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Confrontsred Tape IPS: THE MENTAL HEALTH SERVICES CONFERENCE Oct. 8-11, 2015 • New York City When Good Care Confronts Red Tape Navigating the System for Our Patients and Our Practice New York, NY | Sheraton New York Times Square POSTER SESSION OCTOBER 09, 2015 POSTER SESSION 1 P1- 1 ANGIOEDEMA DUE TO POTENTIATING EFFECTS OF RITONIVIR ON RISPERIDONE: CASE REPORT Lead Author: Luisa S. Gonzalez, M.D. Co-Author(s): David A. Kasle MSIII Kavita Kothari M.D. SUMMARY: For many drugs, the liver is the principal site of its metabolism. The most important enzyme system of phase I metabolism is the cytochrome P-450 (CYP450). Ritonavir, a protease inhibitor used for the treatment of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), has been shown to be a potent inhibitor of the (CYP450) 3A and 2D6 isozymes. This inhibition increases the chance for potential drug-drug interactions with compounds that are metabolized by these isoforms. Risperidone, a second generation atypical antipsychotic, is metabolized to a significant extent by the (CYP450) 2D6, and to a lesser extent 3A4. Ritonavir and risperidone can both cause serious, and even life threatening, side effects. An example of one such rare side effect is angioedema which is characterized by edema of the deep dermal and subcutaneous tissues. Here we present three cases of patients residing in a nursing home setting, diagnosed with HIV/AIDS and comorbid psychiatric illness. These patients were all on antiretroviral medications such as ritonavir, and all later presented with varying degrees of edema after long term use of risperidone. We aim to bring to awareness the potential for ritonavir inhibiting the metabolism of risperidone, thus leading to an increased incidence of angioedema in these patients. P1- 2 EVIDENCE BASED ASSESSMENT IN CHILD AND ADOLESCENT PSYCHIATRY: BRINGING SYSTEMATIC ASSESSMENT AND MONITORING FROM THE IVORY TOWER TO THE TRENCHES Lead Author: Lila Aboueid, D.O. Co-Author(s): Cathryn A. Galanter, M.D. SUMMARY: Background: Over the past several decades, investigators have developed standardized assessment tools that have led to increased diagnostic accuracy in clinical and epidemiological studies. However, these assessment methods are rarely utilized in everyday community clinical practice. Objective: We argue for further study of implementation of evidence based assessment and systematic monitoring of symptoms and adverse effects in clinical practice. Methods: Review of literature on misdiagnosis as a medical error, standardized assessment and monitoring of symptoms and adverse effects, their implementation in the community, barriers to their implementation, the role of monitoring in health care reform and recommendations for future research. Conclusions: Although the field of child and adolescent psychiatry has been rapidly evolving, the method and extent of systematic assessment and monitoring has not been fully established. Research is needed to establish whether evidence based assessment and monitoring tools are feasible, valid, reliable, and demonstrate improved outcomes following administration. P1- 3 ENHANCING RECOVERY THROUGH AN INTEGRATED INDIVIDUAL AND FAMILY MODEL FOR TREATING TRAUMA IN SERIOUS MENTAL ILLNESS Lead Author: Madeleine S. Abrams, L.C.S.W., M.S.W. Co-Author(s): Kristina Muenzenmaier, M.D., Joseph Battaglia, M.D., Ayol Samuels, M.D., Michelle To, M.D., Tali Tuvia, M.D. SUMMARY: Historically, and even currently despite its lack of political correctness, families have been blamed and stigmatized for serious mental illness in a family member. This attitude is even more exaggerated in cases of trauma, particularly when it occurs within the family. Thus, families with both serious mental illness and trauma frequently have been ignored, dis- empowered, and marginalized. In working with this population, we have seen how the exclusion of the family has contributed to lack of progress in working with an individual coping with serious mental illness and trauma. When the family has been integrated into the treatment, we have seen evidence that the individual progresses and the family suffering and guilt are alleviated. Whenever possible, families are able to be reconnected in a more positive manner. Family involvement contributes to reintegration of the individual into the community. This poster will outline a four phase model developed in our program for working with families coping with trauma and serious mental illness. Central to constructing the model are several premises and assumptions that we consider to be basic to an understanding of the experience of families fitting these criteria. The model consists of strategies for engagement, interventions, reintegration of the family, and consolidation, thus enabling the development of improved relationships. Application of the model will be discussed and reinforced with clinical illustrations. This model can be used for training service providers in community settings. P1- 4 PHENOMENOLOGICAL DILEMMA: THOUGHT DISORDER OR APHASIA IN A PATIENT WITH SCHIZOPHRENIA AND A LEFT TEMPORAL LOBE GLIOBLASTOMA? Lead Author: Alicia Adelman, M.S. Co-Author(s): Christine Winter, D.O., David Williamson, M.D. SUMMARY: Introduction: Language and the ability to communicate is an essential social competency. Neurologists and psychiatrists use different nosology to describe impairment of spoken language. When there is a lesion in language regions of the brain, such as a stroke or tumor, the result is called aphasia. When mental illness interferes with our communication abilities, it is called thought disorder. Clinically, it can be hard to differentiate neurological and psychiatric causes of disordered language. Case: The patient is a 56-year-old right-handed Caucasian male with a thirty-year history of schizophrenia. He had been stable on clozapine for several years and was the caregiver for his elderly mother. The patient and his family noticed cognitive and speech changes over several weeks, which prompted him to present to the emergency department. He had tangential thought processes, and displayed elements of fluent aphasia, notably anomia and neologistic paraphasic language. Imaging revealed a tumor in the anterior medial portion of the left temporal lobe. Histology confirmed the tumor was a glioblastoma and he underwent surgery. Two weeks following surgical resection, he was transferred to the neuropsychiatric inpatient unit for cognitive rehabilitation, management of his schizophrenia and further treatment of his tumor. Because of the risk of bone marrow suppression with clozapine, an alternative antipsychotic was necessary. Ziprasidone was chosen as the patient had been cross tapering from clozapine to ziprasidone prior to hospitalization. Two days after discontinuing clozapine, the patient began ziprasidone. During this time, he began to display increased language disorganization, perseverating on his "situation," and showing loose associations. Over several days, the patient became increasingly agitated, was no longer able to be re-directed to complete tasks and was unable to answer yes/no questions. Ten days after discontinuing clozapine, risperidone was added. Following the addition of risperidone to ziprasidone, the patient's sensorium began to clear. Although he continued to remain slightly aphasic, he was able to speak in sentences and participate in his treatment plan decisions. Discussion: This case illustrates how complex the differential diagnosis can be for patients who present with disorders of language. It initially appeared as if the patient's left-sided temporal lobe tumor may have been causing the patient's worsening aphasia. However, the patient showed an improvement in speech after beginning risperidone, suggesting that exacerbation of his schizophrenia during the transition from clozapine to ziprasidone and risperidone may have been the underlying cause of the patient's language abnormalities. Clinically his presentation was consistent with a fluent aphasia. This case illustrates that aphasia and thought disorder may describe the same clinical presentation and different nosological systems describe the same clinical findings P1- 5 FACTITIOUS FLORA; A RARE CASE OF SELF INDUCED BACTEREMIA. Lead Author: Saba Afzal, M.D. Co-Author(s): Humaira Shoaib, MD, Rashi Aggarwal, MD. SUMMARY: Introduction: Factitious disorder (FD) is a condition in which a person acts as having an illness by deliberately producing, feigning or exaggerating symptoms. Different presentations have been reported. Episodes of multiorganism bacteremia (MOB) in psychiatric patient have also been reported but are rare. Patients without any psychiatric history and treatment across different hospitals make diagnosis challenging. We hereby report a case of a patient without any known psychiatric illness who was admitted with bacteremia and was found to have MOB without any identifiable organic cause. Case Presentation:50 year old male with chronic lower extremity (LE) erythema, recurrent episodes of right knee septic arthritis (SA), requiring multiple incision drainage procedures and recent placement of antibiotic spacer, presented to emergency room (ER) for evaluation of acute kidney injury (AKI) and worsening bilateral (B/L) LE erythema. In ER, he had edema, erythema and tenderness of B/L LEs with stable vital signs, elevated creatinine and leukocytosis. Orthopedics consult and LE imaging ruled out SA. Blood cultures (BC) were sent; empiric antibiotics and IV fluids were started and he was admitted to hospital.
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