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White G, Adessky N, Chen FW, Regazzoni A, Tourian L, Chagnon M, Gursahaney A, Alharbi M, Williamson D, Perreault MM. Valproic acid for agitation in the intensive care unit: an observational study of psychiatric consults. Int J Clin Pharm 2024; 46:177-185. [PMID: 38071694 DOI: 10.1007/s11096-023-01661-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/09/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Agitation is a common clinical problem encountered in the intensive care unit (ICU). Treatment options are based on clinical experience and sparse quality literature. AIM The aim of this study was to describe the effect of valproic acid (VPA) as adjuvant treatment for agitation in the ICU, identify predictors of response to VPA and evaluate the independent effect of VPA on agitation compared to standard of care (SOC). METHOD This retrospective single center observational study evaluated adult patients admitted to the ICU for whom a psychiatric consultation was requested for agitation management, with agitation defined as a Richmond Agitation Sedation Score of 2 or greater. A descriptive analysis of the proportion of agitation-free patients per day of follow-up, the incidence of agitation-related-events, as well as the evolution of co-medications use over time are presented. A logistic regression model was used to assess predictors of VPA response, defined as being agitation-free on Day 7 and generalized estimating equations were used to evaluate the independent effect of VPA as adjuvant therapy for agitation in the critically ill. RESULTS One hundred seventy-five patients were included in the study with 78 receiving VPA. The percentage of agitation-free patients on VPA was 6.5% (5/77) on Day 1, 14.1% (11/78) on Day 3 and 39.5% (30/76) on Day 7. Multivariate regression model for clinical and demographic variables identified female gender as predictor of response on Day 7 (OR 6.10 [1.18-31.64], p = 0.03). The independent effect of VPA was non-significant when compared to SOC. CONCLUSION Although VPA used as adjuvant treatment was associated with a decrease in agitation, its effect when compared to SOC did not yield significant results.
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Affiliation(s)
- Geneviève White
- Department of Pharmacy, Réseau local de Gaspé, CISSS de la Gaspésie, 215 Boul York W, Gaspé, QC, G4X 2W2, Canada.
| | - Noah Adessky
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Fei-Wen Chen
- Department of Pharmacy, CIUSSS Centre-Sud-de-l'île-de-Montréal, Hôpital Notre-Dame, 1560 Sherbrooke St E, Montreal, QC, H2L 4M1, Canada
| | - Anne Regazzoni
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Leon Tourian
- Department of Psychiatry, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistic, University of Montreal, 2920 Chemin de la Tour, Montreal, QC, H3C 3J7, Canada
| | - Ashvini Gursahaney
- McGill University Health Centre, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Department of Medicine and Critical Care, McGill University, Montreal, Canada
| | - Majed Alharbi
- Department of Psychiatry, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Department of Adult Mental Health, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - David Williamson
- Department of Pharmacy and Research Center, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, QC, H4J 1C5, Canada
- Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Marc M Perreault
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
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Zhang Y, Langlois LP, Mesli N, Ware J, Tourian L, Martel MO. Interrelations Between Generalized Anxiety Disorder Symptoms And Anhedonia Among Patients With Chronic Pain: Insights From A Network Approach. The Journal of Pain 2023. [DOI: 10.1016/j.jpain.2023.02.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
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Thoma B, Karwowska A, Samson L, Labine N, Waters H, Giuliani M, Chan TM, Atkinson A, Constantin E, Hall AK, Gomez-Garibello C, Fowler N, Tourian L, Frank J, Anderson R, Snell L, Van Melle E. Emerging concepts in the CanMEDS physician competency framework. Can Med Educ J 2023; 14:4-12. [PMID: 36998506 PMCID: PMC10042782 DOI: 10.36834/cmej.75591] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background The CanMEDS physician competency framework will be updated in 2025. The revision occurs during a time of disruption and transformation to society, healthcare, and medical education caused by the COVID-19 pandemic and growing acknowledgement of the impacts of colonialism, systemic discrimination, climate change, and emerging technologies on healthcare and training. To inform this revision, we sought to identify emerging concepts in the literature related to physician competencies. Methods Emerging concepts were defined as ideas discussed in the literature related to the roles and competencies of physicians that are absent or underrepresented in the 2015 CanMEDS framework. We conducted a literature scan, title and abstract review, and thematic analysis to identify emerging concepts. Metadata for all articles published in five medical education journals between October 1, 2018 and October 1, 2021 were extracted. Fifteen authors performed a title and abstract review to identify and label underrepresented concepts. Two authors thematically analyzed the results to identify emerging concepts. A member check was conducted. Results 1017 of 4973 (20.5%) of the included articles discussed an emerging concept. The thematic analysis identified ten themes: Equity, Diversity, Inclusion, and Social Justice; Anti-racism; Physician Humanism; Data-Informed Medicine; Complex Adaptive Systems; Clinical Learning Environment; Virtual Care; Clinical Reasoning; Adaptive Expertise; and Planetary Health. All themes were endorsed by the authorship team as emerging concepts. Conclusion This literature scan identified ten emerging concepts to inform the 2025 revision of the CanMEDS physician competency framework. Open publication of this work will promote greater transparency in the revision process and support an ongoing dialogue on physician competence. Writing groups have been recruited to elaborate on each of the emerging concepts and how they could be further incorporated into CanMEDS 2025.
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Affiliation(s)
- Brent Thoma
- University of Saskatchewan, Saskatchewan, Canada
- Royal College of Physicians and Surgeons of Canada, Ontario, Canada
| | - Anna Karwowska
- University of Ottawa, Ontario, Canada
- Association of Faculties of Medicine of Canada, Ontario, Canada
| | - Louise Samson
- Université de Montréal, Quebec, Canada
- Collège des médecins du Québec, Quebec, Canada
| | | | | | | | | | - Adelle Atkinson
- Royal College of Physicians and Surgeons of Canada, Ontario, Canada
- University of Toronto, Ontario, Canada
| | | | - Andrew K Hall
- Royal College of Physicians and Surgeons of Canada, Ontario, Canada
- University of Ottawa, Ontario, Canada
| | | | - Nancy Fowler
- McMaster University, Ontario, Canada
- College of Family Physicians of Canada, Ontario, Canada
| | | | | | - Rob Anderson
- Royal College of Physicians and Surgeons of Canada, Ontario, Canada
- NOSM University, Ontario, Canada
| | - Linda Snell
- Royal College of Physicians and Surgeons of Canada, Ontario, Canada
- McGill University, Quebec, Canada
| | - Elaine Van Melle
- Royal College of Physicians and Surgeons of Canada, Ontario, Canada
- Queen’s University, Ontario, Canada
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Affiliation(s)
- Jena Hall
- University of Calgary, Alberta, Canada
| | | | | | | | - Brent Thoma
- University of Saskatchewan, Saskatchewan, Canada
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Kudrina I, Bartlett G, Pagé MG, Shir Y, Tourian L, Choinière M, Vedel I. Transitional Pain Care in Quebec: Did We Forget Our Youths? A Brief Research Report. Front Pain Res 2022; 3:885570. [PMID: 35712447 PMCID: PMC9197181 DOI: 10.3389/fpain.2022.885570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Adolescents and young adults (AYAs) represent a unique population with distinct psycho-social risks and care needs. About 10% of AYAs live with chronic pain (CP) and transition to adult pain care between 16 and 25 years of age. These transitions in care happen simultaneously with other bio-psycho-social changes and require flexible multi-disciplinary support models. As it stands, transitional pain care appears suboptimal, fragmented, and opportunistic in Quebec (Canada). The objective of this Brief Report is, therefore, to present our study findings and propose a multi-disciplinary transitional framework vision applicable to AYAs living with CP. Data were collected using a sequential-consensual qualitative design with a longitudinal participatory component. The consecutive stages of this work included an exploratory stage, semi-structured interviews with primary care providers, and inter-disciplinary deliberative stakeholder consultation groups. The deductive inductive thematic approach and the three-level Health Care Transition Research Consortium's theoretical framework were used to analyze the data. A representative group of stakeholders discussed findings from the first two steps, made fifteen actionable recommendations and formulated their vision of a transitional pain care model that can be further adapted in other settings. The study results present important insights into various psycho-social factors associated with transitional pain care for AYAs.
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Affiliation(s)
- Irina Kudrina
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
- *Correspondence: Irina Kudrina
| | - Gillian Bartlett
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Family and Community Medicine, School of Medicine, University of Missouri, Columbia, MO, United States
| | - M. Gabrielle Pagé
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center of the Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Yoram Shir
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
| | - Leon Tourian
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
- Department of Psychiatry, McGill University Health Center, Montreal, QC, Canada
| | - Manon Choinière
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center of the Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, QC, Canada
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AlSalem M, AlHarbi MA, Badeghiesh A, Tourian L. Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review. Medicine (Baltimore) 2020; 99:e23708. [PMID: 33371117 PMCID: PMC7748330 DOI: 10.1097/md.0000000000023708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/17/2020] [Indexed: 12/03/2022] Open
Abstract
Despite the increased morbidity and mortality associated with psychiatric illnesses, there remains a substantial level of inaccuracy of the initial psychiatric diagnoses given by nonpsychiatric physicians. This study examines the accuracy of initial psychiatric diagnoses by non-psychiatric physicians at the McGill University Health Center (MUHC).We conducted a retrospective chart review for all consultations requested from the consultation-liaison psychiatry service at MUHC. We included all the consultations from January 1, 2018, to December 30, 2018, and excluded patient data with established psychiatric diagnoses. In all requested consults, each diagnosis of a referring physician was compared with the final diagnosis given by the C-L psychiatry team. Conformity between the 2 was validated as accurate.Of the 980 referred inpatients, 875 were enrolled. Patients ranged in age and those older than 70 years constituted the largest group: 54.4% were male. For 467 patients (55.20%), the initial diagnostic impression given by the referring physicians agreed with the final diagnosis made by the C-L psychiatry team, while in 379 patients (44.80%), the initial diagnostic impression was not consistent with the final diagnosis made by the C-L team.Diagnostic impressions of neurocognitive and substance use disorders were highly accurate, but this was not the case when the referring physicians suspected depression or bipolar, personality, or psychotic disorders. This study shows that around half of the referrals were accurately diagnosed, which evinces that nonpsychiatric physicians' knowledge regarding psychiatric conditions is not optimal and that might negatively impact screening and treating these conditions.
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Affiliation(s)
- Moayyad AlSalem
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
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Claudio F, Aalamian A, Cummings BA, Hannouche M, Zanelli P, Tourian L. Residency redeployment during a pandemic: Lessons for balancing service and learning. Can Med Educ J 2020; 11:e132-e133. [PMID: 33062109 PMCID: PMC7522867 DOI: 10.36834/cmej.70267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Medical students often have difficulty selecting a residency training program. The internal medicine clerkship rotation occurs primarily on the general internal medicine ward, making it difficult for students to experience the breadth of IM subspecialties prior to making career decisions. Herein, we describe a two-week student-led program (IMED: Internal Medicine Enrichment and Development) designed to give interested pre-clerkship students an overview of the internal medicine subspecialties in order to broaden their understanding of the opportunities within the field. We believe that medical students across the country would benefit from such exposure in order to make more informed decisions about residency.
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Barrett-Bernstein M, Carli F, Gamsa A, Scheede-Bergdahl C, Minnella E, Ramanakumar AV, Tourian L. Depression and functional status in colorectal cancer patients awaiting surgery: Impact of a multimodal prehabilitation program. Health Psychol 2019; 38:900-909. [PMID: 31380686 DOI: 10.1037/hea0000781] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Depression and poor functional status (FS) frequently co-occur. Though both predict adverse surgical outcomes, research examining preoperative functional performance (FP; self-reported) and functional capacity (FC; performance-based) measures in depressed cancer patients is lacking. Prehabilitation, a preoperative intervention including exercise, nutrition, and stress-reduction, may improve FC; however, whether depressed patients benefit from this intervention remains unknown. The primary objectives were to (a) assess differences in FP and FC and (b) explore the impact of prehabilitation on FC in individuals with depressive symptoms versus those without. METHOD A secondary analysis was conducted on 172 colorectal cancer patients enrolled in three studies comparing prehabilitation with a control group (rehabilitation). Measures were collected at 4 weeks pre- and 8 weeks postoperatively. FP, FC, and psychological symptoms were assessed using the 36-Item Short Form Health Survey, Six-Minute Walk Distance (6MWD), and Hospital Anxiety and Depression Scale (HADS), respectively. Subjects were divided into three groups according to baseline psychological symptoms: no psychological-symptoms (HADS-N), anxiety-symptoms (HADS-A), or depressive-symptoms (HADS-D). Main objectives were tested using analyses of variance, chi-square tests, and multivariate logistic regression. RESULTS At baseline, HADS-D reported lower FP, had shorter 6MWD, and a greater proportion walked ≤ 400 m. Prehabilitation was associated with significant improvements in 6MWD in HADS-D group but not in HADS-N or HADS-A groups. CONCLUSION Poorer FS was observed in subjects with depressive symptoms, and these subjects benefited most from prehabilitation intervention. Future research could examine whether severity of depression and co-occurrence of anxiety differentially impact FS and whether prehabilitation can improve psychological symptoms and quality of life. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Tourian L, LeBoeuf A, Breton JJ, Cohen D, Gignac M, Labelle R, Guile JM, Renaud J. Treatment Options for the Cardinal Symptoms of Disruptive Mood Dysregulation Disorder. J Can Acad Child Adolesc Psychiatry 2015; 24:41-54. [PMID: 26336379 PMCID: PMC4357333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 12/18/2014] [Indexed: 06/05/2023]
Abstract
OBJECTIVE DSM-5 has added a new developmentally appropriate child and adolescent mood disorder subtype called disruptive mood dysregulation disorder (DMDD). The core features of DMDD are temper outbursts (manifested by either verbal rages and/or physical aggression) and unrelenting irritability or anger. Currently, the literature is lacking a thorough review of the possible treatment options for the cardinal symptoms constituting DMDD. The objective of this article is to provide a thorough review of peer-reviewed studies on the subject of pharmacological treatment options for children and adolescents with the cardinal symptoms of DMDD. METHODS Relevant articles for this study were obtained through Pubmed, Medline, PsychINFO and PsychINDEXplus using the key words: "adolescents," "children," "paediatric," "youth," "irritability," "temper outbursts," "aggression," "rage," "disruptive behaviour," "treatment," "dysphoria," "autism," "mental retardation/intellectual disability," "impulsivity," "ADHD," "oppositional defiant disorder," and "conduct disorder." A total of 823 studies were generated; only English studies focusing on pharmacological treatment were retained. RESULTS Currently there are no established guidelines or thorough reviews summarizing the treatment of DMDD. Pharmacotherapeutic treatment options of both aggression and chronic irritability include: antidepressants/selective norepinephrine reuptake inhibitors, mood stabilizers, psychostimulants, antipsychotics, and alpha-2 agonists. CONCLUSION Treatment options of severe, persistent irritability in youth are numerous, and a consensual treatment algorithm has not yet emerged from the literature. Further studies and clinical trials are warranted to determine efficacious and safe treatment modalities.
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Affiliation(s)
- Leon Tourian
- McGill University – Douglas Mental Health University Institute, Montreal, Quebec
| | - Amélie LeBoeuf
- McGill University – Douglas Mental Health University Institute, Montreal, Quebec
| | | | - David Cohen
- Université Pierre et Marie Curie, - GH Pitié Salpêtrière, Paris, France
| | - Martin Gignac
- Institut Philippe Pinel – Université de Montréal, Montreal, Quebec
| | - Réal Labelle
- Université du Québec à Montréal – Psychology, Montreal, Quebec
| | | | - Johanne Renaud
- McGill University – Douglas Mental Health University Institute, Montreal, Quebec
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Tourian L, Zhao H, Srikant CB. p38alpha, but not p38beta, inhibits the phosphorylation and presence of c-FLIPS in DISC to potentiate Fas-mediated caspase-8 activation and type I apoptotic signaling. J Cell Sci 2004; 117:6459-71. [PMID: 15572410 DOI: 10.1242/jcs.01573] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pharmacological inhibitors of JNK (SP600125) and p38 (PD169316) sensitize tumor cells to Fas-mediated apoptosis. PD169316 is less potent than SP600125 and diminishes its effect when present together. Because the p38 isoforms that promote (p38alpha) or inhibit (p38beta) apoptosis are both suppressed by PD169316, we investigated their regulatory involvement in Fas-signaling. We report here, that p38alpha, but not p38beta, exerts its proapoptotic effect by inhibiting the phosphorylation and presence of c-FLIPS, but not c-FLIPL, in the DISC to promote caspase-8 activation and type I signaling in Fas-activated Jurkat cells. Its effect was enhanced by enforced expression of Flag-tagged p38alpha and was attenuated by its inactive mutant (p38alpha-AGF) or by translational silencing. By contrast, type II signaling was facilitated by p38alpha-dependent mitochondrial presence of tBid and inhibition of Bcl-2 (Ser70) phosphorylation as well as by p38alpha/beta-dependent mitochondrial localization of Bax and inhibition of phosphorylation of Bad (Ser112/Ser155). Potentiation of Fas-mediated apoptosis by the inhibition of JNK1/2 correlated with the loss of Bad (Ser136) phosphorylation and was dependent on the stimulatory effect of p38alpha on DISC and the downstream effects of both p38alpha and p38beta. These data underscore the need to reassess the findings obtained with pan-p38 inhibitors and suggest that activation of p38alpha coupled with targeted inhibition of p38beta and JNK1/2 should optimally sensitize tumor cells to Fas-mediated apoptosis.
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Affiliation(s)
- Leon Tourian
- Fraser Laboratories, Department of Medicine, McGill University Health Centre and Royal Victoria Hospital, Montreal, Quebec, H3A 1A1, Canada
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