Repeated subcutaneous racemic ketamine in treatment-resistant depression: case series

Interest in the use of parenteral ketamine has been increasing over the last 2 decades for the management of treatment-resistant depression (TRD). While intravenous (IV) ketamine has been the most common parenteral route of administration, subcutaneous (SC) and intramuscular options have been described. We developed a clinical treatment protocol for the use of repeated SC racemic ketamine (maximum six treatments, twice per week) in an inpatient psychiatric care setting with inclusion/exclusion criteria, dosing schedule, and description of treatment, assessment, and monitoring procedures. Results from the first 10 consecutive patients demonstrated the effectiveness of SC racemic ketamine in relieving symptoms of TRD as measured by the Montgomery-Åsberg Depression Rating Scale (MADRS) and Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR 16 ). Response (≥50% reduction in scores from baseline to endpoint) was achieved in 8/10 cases on the MADRS and 6/10 on the QIDS-SR 16 . Remission was achieved in 8/10 (based on MADRS ≤10) and 5/10 (based on QIDS-SR 16 ≤6). Patients tolerated the treatments well with only transient blood pressure changes and dissociative side effects. Repeated SC ketamine treatments could be a safe, feasible, and effective alternative to IV ketamine infusions for patients with TRD.

Characteristics of evidence-based medicine training in Royal College of Physicians and Surgeons of Canada emergency medicine residencies - a national survey of program directors

BACKGROUND

Recent surveys suggest few emergency medicine (EM) training programs have formal evidence-based medicine (EBM) or journal club curricula. Our primary objective was to describe the methods of EBM training in Royal College of Physicians and Surgeons of Canada (RCPSC) EM residencies. Secondary objectives were to explore attitudes regarding current educational practices including e-learning, investigate barriers to journal club and EBM education, and assess the desire for national collaboration.

METHODS

A 16-question survey containing binary, open-ended, and 5-pt Likert scale questions was distributed to the 14 RCPSC-EM program directors. Proportions of respondents (%), median, and IQR are reported.

RESULTS

The response rate was 93% (13/14). Most programs (85%) had established EBM curricula. Curricula content was delivered most frequently via journal club, with 62% of programs having 10 or more sessions annually. Less than half of journal clubs (46%) were led consistently by EBM experts. Four programs did not use a critical appraisal tool in their sessions (31%). Additional teaching formats included didactic and small group sessions, self-directed e-learning, EBM workshops, and library tutorials. 54% of programs operated educational websites with EBM resources. Program directors attributed highest importance to two core goals in EBM training curricula: critical appraisal of medical literature, and application of literature to patient care (85% rating 5 - "most importance", respectively). Podcasts, blogs, and online journal clubs were valued for EBM teaching roles including creating exposure to literature (4, IQR 1.5) and linking literature to clinical practice experience (4, IQR 1.5) (1-no merit, 5-strong merit). Five of thirteen respondents rated lack of expert leadership and trained faculty educators as potential limitations to EBM education. The majority of respondents supported the creation of a national unified EBM educational resource (4, IQR 1) (1-no support, 5- strongly support).

CONCLUSIONS

RCPSC-EM programs have established EBM teaching curricula and deliver content most frequently via journal club. A lack of EBM expert educators may limit content delivery at certain sites. Program directors supported the nationalization of EBM educational resources. A growing usage of electronic resources may represent an avenue to link national EBM educational expertise, facilitating future collaborative educational efforts.