Can We Stay Up To Date? Time Will Tell

Niagara (14)

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I just wanted to share something interesting about what the Academy of Psychosomatic Medicine (APM) is doing to really embody the principle of lifelong learning, in this case for specialists in Psychosomatic Medicine. It’s very difficult to keep up with all of the changes in the medical literature and expert volunteers are using a group process to get a handle on it [1]. Just by reading the abstract, you can get a clear idea of how frustrating it is to stay abreast of all the changes in the evidence  base. If ever there was an argument against Maintenance of Certification (MOC) programs, that’s it. The introduction tells the story about the time commitment. By 2020, it’s estimated that medical knowledge will double every 73 days.

The sheer amount of literature published each year in medicine is overwhelming. Humankind’s collective knowledge is growing exponentially, and medical knowledge has been estimated in 2010 to double every 3.5 years and has been projected to double every 73 days by the year 2020. The area of psychosomatic medicine or consultation-liaison psychiatry is no exception, and it has become all but impossible for practitioners to keep up-to-date on new developments across their field rather than just in a very narrow area of their expertise. Yet, our patients expect us to remain informed about new developments in medicine and practice based on current knowledge.

To help practitioners of psychosomatic medicine keep updated(and to maintain their accreditation) the Academy of Psychosomatic Medicine (APM) in collaboration with its sister organization the European Association of Psychosomatic Medicine (EAPM) established a subcommittee of the APM Research and Evidence-Based Practice Committee, to publish annotated quarterly updates in the field of psychosomatic medicine. This article introduces the group process used to canvass the literature; it provides all references selected by the subcommittee for 2014; and in addition, it further distills the literature related to psychosomatic medicine to provide an overview of important developments in 2014.

Medical students learn early about the time crunch. There is an expectation that doctors know everything there is to know on any topic–and incredibly, we try to live up to it, secretly knowing we can’t possibly do it.

Psychiatric consultants in the general hospital are often expected to diagnose and treat major mental disorders on the spot after a 30 minute interview. Diagnosing some psychiatric disorders requires many followup visits, over weeks and months (sometimes years) before we can be confident enough to drop a psychiatric label on a person whose thoughts, emotions, and behaviors are steadily evolving over time.

Subspecialists can develop a set of lenses that sometimes makes it difficult to identify certain psychiatric syndromes because they don’t see them very often. Much of psychiatric diagnosis is still about behavioral and symptom pattern recognition.

Anyway, the APM expert volunteers work at helping like-minded practitioners stay current. They canvas the studies in the literature using stringent selection criteria including randomized, controlled trials and meta-analyses. They annotate them as well, writing concise summaries, citing strengths and weaknesses including study power and generalizability, as well as commenting on the relevance to psychosomatic medicine.

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Who knows how long they’ll be relevant? Only time will tell. A couple I’ve found helpful are in the Neuropsychiatry and Critical Care categories:

  1. A simple bedside test of attention (months of the year backward) was both sensitive and specific for delirium in hospitalized (but not in intensive care) patients. Quality initiatives in hospitals should pay attention to this simple test–

O’Regan, N. A., et al. (2014). “Attention! A good bedside test for delirium?” Journal of Neurology, Neurosurgery & Psychiatry 85(10): 1122-1131.
Background Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective ‘confusion’.Methods We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method.Results 265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity.Conclusions Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.

APM Annotation:

The Finding: Simple attention screening (months of year backward) is a sensitive and surprisingly specific detector of delirium in hospitalized (nonintensive care) populations. It is enhanced by combining it with screens for subjective confusion or a visuospatial attention task or both.

Strengths and Weaknesses: This article highlighted the continued problems that exist in delirium detection in the general hospital setting, reviewed proposed remedies, and made a convincing argument for a much simpler solution than has been proffered previously. The study design was ambitious (all assessments of the >200 patients took place on the same day; this included screening followed by a second screening with the Confusion Assessment Method, followed by psychiatric assessment) but it appears to have been carried out rigorously. The authors did an excellent job of identifying the potential limiting factors of the study. The biggest quibble is that attention is far from a specific delirium finding and probably ought not be taken as such in a cross-sectional assessment. However, as noted by the authors, very, very few patients with documented dementia in this study did not have delirium. The fact that patients with cognitive impairment were more susceptible to delirium may have mitigated the usual insensitivity of attention impairment as a diagnostic screen. In addition, technically, months of the year backward is not a pure test of attention, as it uses working memory as well.

Relevance: Delirium detection in the general hospital remains poor and is often thought to require significant investment in time and effort. This article may have quality improvement implications as it offers a straightforward and brief bedside method of detecting delirium.

2. This randomized trial found ramelteon to be an effective prevention of delirium in hospitalized patients. Replication is needed before ramelteon can become standard delirium prophylaxis. Whether ramelteon is safer and more effective than melatonin in this setting is also unknown–

Hatta, K., et al. (2014). “Preventive effects of ramelteon on delirium: A randomized placebo-controlled trial.” JAMA Psychiatry 71(4): 397-403.
Importance  No highly effective interventions to prevent delirium have been identified.Objective  To examine whether ramelteon, a melatonin agonist, is effective for the prevention of delirium.Design, Setting, and Participants  A multicenter, rater-blinded, randomized placebo-controlled trial was performed in intensive care units and regular acute wards of 4 university hospitals and 1 general hospital. Eligible patients were 65 to 89 years old, newly admitted due to serious medical problems, and able to take medicine orally. Patients were excluded from the study if they had an expected stay or life expectancy of less than 48 hours.Interventions  Sixty-seven patients were randomly assigned using the sealed envelope method to receive ramelteon (8 mg/d; 33 patients) or placebo (34 patients) every night for 7 days.Main Outcomes and Measures  Incidence of delirium, as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition).Results  Ramelteon was associated with a lower risk of delirium (3% vs 32%; P = .003), with a relative risk of 0.09 (95% CI, 0.01-0.69). Even after risk factors were controlled for, ramelteon was still associated with a lower incidence of delirium (P = .01; odds ratio, 0.07 [95% CI, 0.008-0.54]). The Kaplan-Meier estimates of time to development of delirium were 6.94 (95% CI, 6.82-7.06) days for ramelteon and 5.74 (5.05-6.42) days for placebo. Comparison by log-rank test showed that the frequency of delirium was significantly lower in patients taking ramelteon than in those taking placebo (χ2 = 9.83; P = .002).Conclusions and Relevance  Ramelteon administered nightly to elderly patients admitted for acute care may provide protection against delirium. This finding supports a possible pathogenic role of melatonin neurotransmission in delirium.Trial Registration  University Hospital Medical Information Network Clinical Trials Registry Identifier: UMIN000005591

APM Annotation:

The Finding: In a randomized rater-blinded placebo-controlled trial that was conducted in 4 university hospitals and 1 general hospital involving 67 patients (24 patients in intensive care units and 43 admitted to regular acute care wards) between the ages of 65 and 89 years, ramelteon was associated with a lower risk of delirium (3% vs 32%; p = 0.003). After risk factors were controlled for, ramelteon was still associated with a lower incidence of delirium (p = 0.01; odds ratio = 0.07 [95% CI: 0.008–0.54].

Strength and Weaknesses: The primary strength of this study was its randomized, placebo-controlled design. Despite a relatively low number of patients in the trial, both the groups were reasonably similar concerning risk factors for development of delirium. The limitations of the study included that this was not a double-blind study but was rater-blinded. In addition, although the number of patients enrolled was more than that needed for power analysis, the study had a relatively small sample size. Other weaknesses include the exclusion of patients with hepatic dysfunction, diagnoses of mood disorders (including bipolar mood disorder and depression), and those with psychotic disorders. These groups represented not only those patients who often have sleep/wake dysfunction and circadian rhythm disturbances but also those who have also been shown to be at a higher risk for the development of delirium in the intensive care unit setting; their exclusion from the study deviates from real clinical practice.

Relevance: During the last several years, varying strategies regarding delirium prevention, particularly in intensive care unit patients, have been studied, including use of dopamine antagonists, cholinesterase inhibitors, and even benzodiazepines, all with varying results. This particular study, despite its limitations, was one that is the first to show a significant prophylactic effect on the incidence of delirium in elderly intensive care unit patients with the use of the melatonin analogue ramelteon. Interestingly, no published studies exist to show if ramelteon is more effective (or if more safe) than melatonin is in clinical trials with human subjects.

Don’t forget the APM Annual Meeting in New Orleans!

Reference:

  1. Freudenreich, O., et al. (2015). “Updates in Psychosomatic Medicine: 2014.” Psychosomatics 56(5): 445-459.
    BACKGROUND: The amount of literature published annually related to psychosomatic medicine is vast; this poses a challenge for practitioners to keep up-to-date in all but a small area of expertise. OBJECTIVES: To introduce how a group process using volunteer experts can be harnessed to provide clinicians with a manageable selection of important publications in psychosomatic medicine, organized by specialty area, for 2014. METHODS: We used quarterly annotated abstracts selected by experts from the Academy of Psychosomatic Medicine and the European Association of Psychosomatic Medicine in 15 subspecialties to create a list of important articles. RESULTS: In 2014, subspecialty experts selected 88 articles of interest for practitioners of psychosomatic medicine. For this review, 14 articles were chosen. CONCLUSIONS: A group process can be used to whittle down the vast literature in psychosomatic medicine and compile a list of important articles for individual practitioners. Such an approach is consistent with the idea of physicians as lifelong learners and educators.
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