Identifying Data :

Full Name: Ms. SS

Address: Brooklyn, NY

Date of Birth: 8/6/1984

Age: 37 yo

Date & Time: February 23, 2022 2:00 PM

Location: Woodhull Hospital, Brooklyn NY

Religion: None
Source of Information: Self

Reliability: Good
Source of Referral: Self – admitted with husband to emergency room

Chief Complaint : “Bleeding and hurting so bad after abortion.” x1 day

History of Present Illness

37 yo female patient G2P1011 with PMHx of D&C abortion, spontaneous abortion, anemia, gestational hypertension, and pre-diabetes presents to the Emergency Room complaining of heavy vaginal bleeding and lower abdominal pain after an elective dilation and curretage abortion procedure performed on 2/19/2022. She was discharged home and took Acetaminophen (Tylenol) every 8 hours and Ibuprofen (Mortin) every 6 hours. However, she continued to bleed bright red blood with passage of large clots. Patient says she changes her pads 3 – 4 times a day for the bleeding. The abdominal pain is sharp, constant, and rated an 11/10 that causes her to lie in the fetal position at all times. She describes that the pain intensifies several times a day with an intense throbbing and pulsating sensation. Patient experiences fever and diaphoresis and has to pause several times to deep breathe while accounting symptoms. Denies chest pain, palpitations, shortness of breath, dizziness, headache nausea, vomiting, constipation, diarrhea, or urinary symptoms. Denies recent travels.

Past Medical History

• Anemia
• Gestational Hypertension
• Pre-Diabetic
  

Past Surgical History

•  Dilation & Curettage – 2/19/22
•  3 other termination of pregnancies – Date Unspecified
• Myomectomy for Uterine Fibroids – Date Unknown Medications Currently On :

•  Acetaminophen (Tylenol) 650 mg PO q8 hrs
• Ibuprofen (Motrin) 600 mg PO q6 hrs

Allergies

• No allergies to foods or medications

Family History

• Mother – Aged 60 yo, alive
• Father – Aged 62 yo, alive
• Husband – Aged 38, alive
• Sister – Aged 33, alive
• Daughter, alive
• Son, alive
• Son, alive
• Family history of hypertension and diabetes
• Denies family medical history of cancer or respiratory complications
  

Social History

Patient is a married English & Spanishing speaking 41 yo female who lives with her husband and three children in an apartment in Brooklyn, NY. Patient is currently unemployed and a homemaker. Habits : Patient denies drinking, smoking, and use of drugs.
Travel : Denies recent travel.
Diet : Patient eats a balanced diet of carbs, protein, fruits and vegetables.

Exercise : Patient maintains a sedentary lifestyle. She states that she does not work out and that her physical activity comes from daily steps around the house.

Sexual History : Heterosexual, married, monogomaous, and sexually active. Not currently on birth control and uses condoms occasionally. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears in acute distress and the fetal position due to extraordinary lower abdominal pain. Patient is sweating and moaning with poor pallor. Expresses that she feels very weak. Denies loss of appetite, fever, and chills.

Skin, hair, nails – Presents with sweating. Denies excessive dryness, discolorations, pigmentations, moles, rashes, or pruritus.

Head – Denies headaches, vertigo, head trauma, coma, or fractures.
Eyes – Denies other visual disturbances, use of glasses, lacrimation, photophobia, or pruritus.

Last eye exam – unknown.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction, or epistaxis.

Mouth/throat – Denies bleeding gums, use of dentures, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown.

Neck – Denies localized swelling/lumps. Denies stiffness or decreased range of motion. Breast – Denies lumps, pain, or discharge.

Pulmonary System – Denies shortness of breath that is alleviated with a daily inhaler. Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular System – Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope.

Gastrointestinal System – Denies nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, dysphagia, pyrosis, abdominal pain, diarrhea, hemorrhoids, constipation, rectal bleeding.

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.

Menstrual and Obstetrical — Menarche age 14. Last menstrual cycle – unknown. Presents with heavy bright red vaginal bleeding with passage of clots from incomplete D&C abortion. Denies abnormal vaginal odor or itching.

G6P1051

Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.

Musculoskeletal System – Presents with constant sharp lower abdominal pain. Denies muscle weakness, slowness, aching, swelling, erythema, and stiffness.

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – History of anemia. Denies ecchymosis, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, hypothyroidism, excessive sweating or goiter.

Psychiatric – Denies depression and anxiety. Denies history of speaking with a therapist and psychiatrist. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam

General: Female patient appears in acute distress and the fetal position due to extraordinary lower abdominal pain. Patient is sweating and moaning with poor pallor. Expresses that she feels very weak. Appears well developed and nourished, but poorly hydrated. Appears stated age.

Skin: Poor pallor. Warm, dry, and poor turgor. Non-icteric, no lesions, masses, scars, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, good texture, and good luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.

Visual Acuity : Uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. Lips: Dry, pale. No cyanosis, masses, lesions, swelling, or fissures.

Mucosa: Pink, dry. No masses lesions noted. No leukoplakia. No thrush.
Palate: Pink, dry. No lesions, masses, scars.
Teeth: Teeth intact, no dentures. White and no cavities.
Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge. Tongue: Pink, well papillated. No masses, lesions, or deviation.

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0. Uvula pink, no edema.

Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to palpation. Good range of motion. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds.

Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal: Unable to palpate lower abdomen due to acute distress and severe abdominal pain. Abdomen is round with no striae or pulsations. Bowel sounds normoactive in all four quadrants. No CVA tenderness.

Genitalia : Heavy vaginal bleeding with passage of clots. External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, or erythema. Cervix multiparous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear scheduled for next annual GYN exam. No inguinal adenopathy.

Rectal : Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Neurologic:
Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good

repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract.

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact.

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue.

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact.
CN XII: Tongue is midline with normal movements and no atrophy.

Motor/Cerebellar :

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

Brachioradialis Triceps
Biceps Abdominal

Meningeal Signs :

RL RL

2+ 2+ 2+ 2+ 2+ 2+ 2+/2+ 2+/2+

Patellar
Achilles
Babinski
Clonus negative

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Muscoloskeletal : Unable to palpate lower abdomen due to patient’s acute distress and severe abdominal pain. No erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper extremities and left lower extremities. Full spinal range of motion with no deformities.

Vitals

Blood Pressure – 124/75
Temp – 99.4 °F

SpO2 – 97%

RR – 18

Height – 5’ 7”

Weight – 175 lbs

BMI – 27.4

Assessment & Plan

37 yo female patientwith PMHx of D&C abortion, spontaneous abortion, anemia, gestational hypertension, and pre-diabetes presents to the Emergency Room complaining of heavy vaginal bleeding and lower abdominal pain after an elective dilation and curretage abortion procedure performed on 2/19/2022. Exam is positive for heavy vaginal bleeding and lower abdominal pain and cramping.

Problem List :

• Heavy vaginal bleeding
• Lower abdominal Cramp
• Weakness
• Fever
• Sweating

D/Dx :

1. Incomplete Abortion – The patient is most likely to have an incomplete abortion as she had a D&C 4 days prior to admission to the ED. If there are still products of conception retained in the uterus, they may become infected and lead to fever, sweating, abdominal pain, and continual vaginal bleeding.
2. Endometritis – Endometritis refers to infection of the decidua and is a common cause of postpartum fever and uterine tenderness. The infection may also extend to the peritoneal cavity, causing severe abdominal pain. It is possible that the D&C procedure was not sterile or exposed the uterus and led to infection.
3. Uterine Perforation – There is always a risk of perforation during intrauterine procedures that injures the uterine tissue and blood supply. Complications are likely if the perforation becomes infected. Pelvic
4. Leiomyoma– The patient may also have myomas that can lead to vaginal bleeding and abdominal pain. However, this is lower on the D/Dx list as it would not account for the signs of infection such as fever and sweating. The more likely scenario would be the presence of infection with myomas contributing to vaginal bleeding.
5. Pelvic Inflammatory Disease – There is a possibility that the patient has a history of undiagnosed pelvic inflammatory disease. PID is rare during pregnancy, but can occur in the first 12 weeks of gestation. As a result, there is a possibility that the patient experienced an upper reproductive tract infection that was exacerbated by D&C.

Plan :

Admit the patient for continuous monitoring. Initiate daily blood tests and labs to trend her H/H and ensure that she is hemodynamically stable. Administer IV fluids and consider transfusion. Consult the surgical team for dilation & curettage for incomplete aboration.

1. Transvaginal Sonogram

1. Order sonogram to visualize any remnants of product of conception (POC)

2. Urine Test, EKG, & Labs

1. Rule out urinary tract infection
2. Rule out cardiac complications for surgery
3. Assess for CBC and H/H status for transfusion and IV fluid administration

3. Medications

1. Initiate Medroxyprogesterone (Provera) to minimize bleeding
2. Consider Gentamicin (Garamycin) 5 mg/kg every 24 hours for infection and fever
3. Prepare Packed Red Blood Cell transfusion if Hemoglobin falls < 7 g/dL or presents with unstable signs and symptoms at 7 – 8 g/dL

4. Surgery Consultation

1. Consult surgical team for dilation & curettage if sonogram shows remnants of product of consumption and patient continues to bleed

The OBGYN rotation experience was truly a profound one. The greatest challenge I learned was that to work in OBGYN, a medical provider should embody both intellectual and emotional intelligence. The maternal patient is especially vulnerable during this time as both her mind, body, and emotions are on the line. As a provider ensures the medically safe delivery of the baby, he should also be mindful of the patient needs at this time. 

For example, the patients seen at the OBGYN rotation ranged from miscarriage to labor & delivery to elderly women with fibromas. Each of these scenarios requires a separate set of treatment guidelines as well as empathetic skills to manage the patient. In a patient experiencing miscarriage, I found that the simple act holding her hand greatly impacted the difficult process. The patient is typically alone, in a sterile clinic environment, and experiencing significant loss and bodily pains. It can be especially invasive and foreign to have a transvaginal ultrasound in this time and the act of touch will provide her a sense of comfort and reassurance. Furthermore, the patient often needed longer time after the diagnostic procedure to process her emotions and make any necessary phone calls to family members and friends.

In contrast, patients in labor & delivery required both empathy yet firm guidance. It was important that the patient felt she was cared for. At the same time, she needed encouragement and strength to continue pushing during a long and painful process. Her vitals also had to be monitored regularly to ensure both her and the fetus were stable. Medications such as Butorphanol, Oxytocin, Misoprostol, and Magnesium Sulfate could be administered in order to effectively manage her pain, contractions, cervical ripening, or signs and symptoms of pre-eclampsia. 

For a patient with fibromas, patience and reassurance was necessary in order to explain the condition to her. These patients were typically terrified as fibromas could present with excessive vaginal bleeding for long periods of time.  As a medical professional, we must explain that bleeding is typical complication of fibromas. However, treatment may not be immediate as medications take time to take effect and surgical interventions need to be cleared.

Another aspect I enjoyed immensely about the OBGYN rotation was the hands on approach. I felt very lucky that our rotation site trusted students to be involved in the process such as performing transvaginal ultrasounds, venipunctures, pap smears, STD cultures, and placental removals. I felt that this rotation allowed me to take what I learned through a textbook, apply it hands on, and thoroughly engrain it in my memory for future practice. 

This study looked at women of reproductive age with diabetes mellitus and their responses to different types of contraceptives including combined contraceptive pills, progestogen-only contraceptive pills, transdermal contraceptive patches, combined vaginal rings, combined injectable contraception, intrauterine devices, progestogen-only injectable contraceptives,  and progestogen-only subnormal implants. The results showed that 35 ug of combination contraceptive pills had no effect on glucose concentrations and insulin secretions. Progestogen-only contraceptive pills were found to produce no complications in women with diabetes mellitus of any age. Across the board, long-active reversible contraceptives (IUD, IUS, progestogen-only injectables, subdermal implants, & vaginal ring) were all found to be safe for use in women with diabetes mellitus. The only complication found was an effect on lipid metabolism. However, the benefits of family planning outweighed the impact on lipid metabolism. Overall, the study found that contraceptives of all types were safe to use in women with diabetes mellitus. The main concern was limiting the dosage value of oral combined contraceptive pills to 35 ug and to consider the needs of each patient in determining which type of contraceptive was most suitable. 

This journal article is a systematic review that examines the significance of including grief in the DSM – V. Although grief presents with a specific criteria and unique set of coping strategies, the article argues that the requirements may be too vague and over-diagnose patients. Furthermore, it argues that there may be little benefit in including the diagnosis in the DSM – V as so many symptoms overlap with major depression. Based on the findings of longitudinal cohort studies, the article advocates for the rejection of “complicated grief” and the inclusion of prolonged grief disorder. In doing so, more criteria is included such as identify disruption, marked sense of disbelief about death, avoidance of reminders that person is dead, intense emotional pain related to death, difficulty with reintegration, emotional numbness, feeling that life is meaningless, and intense loneliness must be met. In doing so, this would prevent over-diagnosis. I also believe it is important to distinguish prolonged grief disorder from major depressive disorder as it provides the language for patients and their loved ones to understand what they are going through. A more specific approach in psychotherapy may also be initiated to treat the symptoms of grief such as providing more emotional support and cognitive behavior therapy in preventing ruminating thoughts.

PICO Search Assignment #1

Tiffany Liang

PATIENT PROBLEM/SETTING

40 yo female patient presents to the inpatient psychiatric unit for a schizophrenia episode. Patient has an 18 year history of schizophrenia and currently takes Risperidone 1mg 2x PO q daily.

SEARCH QUESTION: Does the use of dual 2nd generation anti-psychotics reduce the risk of hospital readmissions in schizophrenic patients compared to use of monotherapy 2nd generation anti-psychotics?

QUESTION TYPE: What kind of question is this? (boxes now checkable in Word)

☐Prevalence ☐Screening ☐Diagnosis

☐Prognosis ☒Treatment ☐Harms

• The first choice of study would be a meta-analysis or systematic review as they are regarded as the highest level of study. Meta-analysis systematically reviews the findings of several independent studies. Systematic review is similar in that it proposes a research question and that collects and summarizes all relevant data with eligible criteria. In conclusion, both types of study gathers a larger pool of data to provide more information and greater overview on the topic discussed.

• If these two studies are not available, a randomized control trial would be the next best choice as there is a control and study. In this situation, the control would be one 2nd generation anti-psychotic and the study would be the use of two 2nd generation anti-psychotics. Randomized control trials offers carefully planned experiments and reduces the risk of bias in order to compare the two groups studied and gauge if the study is effective.

PICO SEARCH TERMS:

P	I	C	O
Schiophrenia	Dual 2nd-generation anti-psychotics	2nd-generation anti-psychotic mono therapy	Hospital Readmission
Schizophrenic Patients	Schizophrenia polypharmacy	One 2nd-generation anti-psychotic	Schizophrenic Episode
Psychotic Patients	Risperidone and Ariprazole	Single 2nd-generation anti-psychotic	Reduction in hallucinations
Hallucinatory Patients	Multiple anti-psychotics	Only Risperidone	Relief of hallucinations
Psychosis	Multiple 2nd-generation anti-psychotics	Only Ariprazole	Schizophrenia Relapse

SEARCH TOOLS & RESULTS

PubMed:

• Schizophrenia Dual Anti-Psychotic (Filters : Meta Analysis, Systemic Review, RCT, 2010-present) – 93

• Schizophrenia anti-psychotic combination (Filters : Meta Analysis, Systemic Review, RCT, 2010-present) – 45
• Dual Antipsychotics (Filers : Meta Analysis, Systemic Review, RCT, 2010-present) – 85

Cochrane :

• Dual Therapy Schizophrenia (Filters: Meta analysis, Systemic Review, RCT, 2010-Present) – 26
• Antipsychotic Polypharmacy (Filters: Meta analysis, Systemic Review, RCT, 2010-Present) – 2

JAMA :

• Dual antipsychotics (Filters : Psychiatry) – 0
• Antipsychotic Polypharmacy (Filters : Psychiatry) – 25

Initially, I limited my search parameters to meta-analyses, systematic reviews, and randomized controlled studies as they are considered the highest level of study. A filter for the past ten years was also applied so that the most relevant data could be gathered. However, many of these studies only followed schizophrenia patients for a short period of time. There was no concrete evidence of whether dual anti-psychotic therapy was beneficial in reducing hospital readmission as the subjects were not studied for long enough. This expanded my search to include other types of studies with no date range to see if a study existed to allow for a longer follow-up period.

ARTICLES

1. Clozapine Combined with Different Anti-Psychotic Drugs for Treatment-Resistant Schizophrenia

Citation: Barber S, Olotu U, Corsi M, Cipriani A. Clozapine combined with different antipsychotic drugs for treatment-resistant schizophrenia. Cochrane Database Syst Rev. 2017 Mar 23;3(3):CD006324. doi: 10.1002/14651858.CD006324.pub3. PMID: 28333365; PMCID: PMC6464566.

Type of article:  Meta-Analysis

Abstract:  Background: Clozapine is reserved for treatment-resistant schizophrenia due to its adverse effect profile. However, 40 – 70% of patients continue to not respond to Clozapine. Combination therapy with another 2nd generation anti-psychotic is a suggested alternative treatment strategy.  Materials and Methods: This study used the Cochrane Schizophrenia Group’s Study-Based Register of Trials and MEDLINE to search for randomized control trails exploring combination anti-psychotic therapy with Clozapine and another anti-psychotic. The trial parameters included both genders, aged 18 years or older, and with treatment-resistant schizophrenia. Results were assessed by observing clinical response in mental state and adverse effects (i.e. weight gain).  Results: 5 studies with 309 participants were reviewed. Studies were conducted by comparing dual therapy with Clozapine and a 1st generation anti-psychotic versus Clozapine and a 2nd-generation anti-psychotic. By combining Clozapine with Aripiprazole vs. Clozapine with Haloperidol, the study found no long-term difference in reducing schizophrenia episodes (95% Cl -8.48 to -1.32). Significant benefit in mental status and reduction in adverse effects was only observed when Clozapine was combined with Quetiapine for a short-term period (95% Cl -1.38 to -0.42). Another study combined Clozapine and Risperidone to show no difference in treatment outcome (95% CL 0.40 – 1.68). Conclusion: In this study, it was determined that there was no significant benefit in using dual 2nd-generation anti-psychotic therapy in treatment-resistant schizophrenia patients due to a limited number of studies and inconsistent participation by patients. As several participants left early, the study ultimately showed low-quality evidence.

Key points: In the included studies, there was no clear benefit in taking two 2nd generation anti-psychotics 1/5 studies showed short term benefit in taking Clozapine and Quetiapine for short-term use only 4/5 studies showed no benefit in terms of mental state and reduction in adverse effects Further trials with better experimental setup must be conducted to establish a clear relationship between the use of two 2nd generation anti-psychotics in treating schizophrenia long-term.

Why I chose it: This article was chosen because it clearly pertained to the use of two second generation anti-psychotics for treatment-resistant schizophrenia patients. This proposed a study that matched the clinical question for this PICO study. Furthermore, this article was a meta-analysis conducted in 2017 that included several studies. This allowed for a greater overview of the subject with richer and relevant sources of data.

2. Combining Anti-Psychotic Medication for the Treatment of Schizophrenia

Citation: Ortiz-Orendain J, Castiello-de Obeso S, Colunga-Lozano L, Hu Y, Maayan N, Adams CE. Antipsychotic combinations for schizophrenia. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD009005. DOI: 10.1002/14651858.CD009005.pub2

Type of article:  Meta -Analysis

Abstract:  Objective: This study was performed to see if there was improved patient outcome in using multiple anti-psychotics versus a single anti-psychotic in treating schizophrenia patients.  Materials and Methods: Sixty-Two trails were studied for this review using Randomized Controlled Trials from the Information Specialist of the Cochrane Schizophrenia Group in 2010, 2012, 2016. There was no parameters in terms of age or gender of patient.  Results: The combination of antipsychotics showed some improvement in the treatment of schizophrenia in contrast to taking only one anti-psychotic. The most significant benefit was found using Clozapine and a typical anti-psychotic. However, combination therapy showed no significant benefit in preventing relapse of schizophrenia. Conclusions: This study showed some improvement in the use of combination anti-psychotic therapy for short-term treatment, but not relapse or re-hospitalization. This is likely due to the fact that the study was performed over a short period of time whereas schizophrenia is a long-term disease that requires extensive treatment and observation.

Key points: Combination of Clozapine and typical anti-psychotic showed short-term benefit in treating schizophrenia Combination of two anti-psychotics did not affect relapse and re-hospitalization of schizophrenia patients Study did not provide specific parameters in participants and only looked at short-term outcomes. Conclusion cannot determine the efficacy of using two anti-psychotics in preventing relapses of schizophrenia.

Why I chose it: I chose this article because it specifically looked into the use of two anti-psychotics verse one anti-psychotic and its affects on hospitalization. This specifically looked into the question of whether the use of dual therapy reduced hospital re-admissions instead of only at initial treatment outcomes.

3. Association of Antipsychotic Polypharmacy vs. Monotherapy Psychiatric Rehospitalization Among Adults with Schizophrenia

Citation: Tiihonen J, Taipale H, Mehtälä J, Vattulainen P, Correll CU, Tanskanen A. Association of Antipsychotic Polypharmacy vs Monotherapy With Psychiatric Rehospitalization Among Adults With Schizophrenia. JAMA Psychiatry. 2019;76(5):499–507. doi:10.1001/jamapsychiatry.2018.4320

Type of article:  Cohort Study

Abstract:  Objective: This study was conducted to summarize and compare the efficacy of using a combination pharmacologic approach in contrast to a monotherapy approach to reducing schizophrenia hospital readmissions.  Data Sources: A systemic search of PubMed and PsycInfo was performed leading up to the year of 2014. Methods & Materials : 62, 250 patients were studied. 31,257 were men with a median age of 45.6. They accounted for all persons with schizophrenia treated in an inpatient setting in Finland from 1972-2014. Patients were tracked using the discharge register maintained by the National Institute of Health and Welfare.  Results: The combination of Clozapine and Aripiprazole showed the lowest risk of psychiatric re-hospitalization than just clozapine alone (HR 0.86, 95% Cl 0.75 to 0.89, P < .001) The benefits of dual 2nd generation anti-psychotic therapy was more evident in patients who experienced their first schizophrenic episode (HR 0.78, 95% Cl 0.63 – 0.96). Other drugs combinations studied were clozapine, aripirazole and a partial D2 receptor agonist. This showed an improvement in negative symptoms, reduced weight gian, but presented with increased prolactin level. Another combination studied was of 2 dopamine D2 antagonists. This too, presented with greater prolactin levels but less insomnia.  Conclusions: Combination of Clozapine and Aripiprazole showed the greatest benefit in reducing schizophrenia re-hospitalization. However, this study did not account for additional add-on treatments that may have contributed to the long-term stabilization of the patient.

Key points: All patients with schizophrenia in the country of Finland were followed from 1972 – 2014 Clozapine and Aripiprazole dual therapy showed the greatest efficacy in reducing hospital re-admissions than Clozapine mono therapy (lowered readmission by 14%)

Why I chose it: This article was chosen as it specifically explored antipsychotic polypharmacy vs mono therapy and was able to assess a large group of schizophrenia patients over a long period of time. The combination of Clozapine and Aripiprazole versus Clozapine alone applied directly to the clinical case scenario. However, the main reason this article was valuable was that it was able to follow-up patients through the course of disease. Compared to the previous two articles, this study presented a thorough perspective of whether patients were readmitted during the course of their lifetime for schizophrenia relapse.

What is the clinical “bottom line” derived from these articles in answer to your question?

According to UpToDate, Schizophrenia In Adults : Maintenance Therapy and Side Effect Management, schizophrenia treatment should first be started with the lowest therapeutic dose of a 2nd anti-psychotic medication. 2nd anti-psychotic medications are the first choice as they produce less extrapyramidal symptoms (dystonia, Parkinsonism, akathisia, tardive dyskinesia) due to their lower affinity for dopamine receptors. Risperidone and Aripiprazole are the suggested initial choices of medication as they present with the least adverse effect profile within the class of 2nd generation anti-psychotics. If the trial fails, an alternative anti-psychotic is initiated. Finally, if both trials fail, Clozapine is started. Although Clozapine is highly effective in treating psychotic symptoms, it is reserved for later use due to its severe adverse effect profile such as agranulocytosis and rhabdomyolysis. As schizophrenia is a life-long disease with severely debilitating symptoms, the field of medicine is constantly looking for a better combination of treatment options or new drugs in order to more effectively treat schizophrenia. For this reason, the exploration of using dual 2nd generation anti-psychotic versus a single 2nd generation anti-psychotics is investigated in this PICO study. 

The clinical bottom line of the following studies suggests that there is no concrete correlation in the use of dual 2nd generation anti-psychotics in reducing hospital readmissions for schizophrenia patients. Two of the three articles showed evidence in combining Clozapine and another anti-psychotic in treating schizophrenia patients (Barber 2017; Ortiz-Orendein 2017). However, they both presented with the limiting factor of being conducted over a short period of time. This provides inconclusive evidence as schizophrenia is a long-term disease. The studies weren’t long enough to establish if there was re-hospitalization during a patient’s lifetime. The third article presented with stronger evidence in the benefit of using dual 2nd generation anti-psychotic therapy as it followed patients for the entirety of their life (Tiihonen, 2019). Although there was a correlation between using dual therapy and reduction in hospital readmissions, the sample size was limited to the country of Finland. This is a very small population without a large range of diversity. Therefore, the findings cannot be applied to the general public. In conclusion, these articles suggest that the recommended treatment remains what is advised in UptoDate.  More long-term studies over broader study groups would be needed to provide conclusive evidence that dual 2nd generation anti-psychotic therapy reduces schizophrenia hospital readmissions. 

My inpatient psychiatric unit rotation was truly a memorable one as it exposed me to be an entirely new setting and approach towards patient care. On average, most patients were admitted for a period of two weeks. This provided the rare opportunity to track a patient and progress over time. It was rewarding to observe a patient respond to pharmaceutical therapy in this time. For example, the majority of the patients presented with schizophrenic exacerbations and significant hallucinations. A two-week course of Risperidone and inpatient care ensured that they were compliant with medications. Significant reductions in hallucinations were readily observed. In this process, I also learned to set realistic standards and goals towards psychiatric treatment. Although the ideal situation would be to bring the patient to our version of reality and as a fully functioning individual, we must keep in mind that the goal of treatment is to bring the patient to his level of baseline. This usually means that the patient’s symptoms are managed so that they no longer present as a threat or source of harm to the patient. The best treatment outcome may mean reducing the patient’s suicidal ideations or hallucinations.

Additionally, the psychiatric rotation experience taught me how important the patient interview is. The initial patient interview process often took nearly an hour. This was due to the fact that patient’s were oftentimes slower in thought, experiencing hallucinations, or may present with contradicting information due to personality disorders. It took a much longer time, empathy, and questions to extract the necessary history to diagnose the patient and initiate proper patient. Overall, this experience taught me that extraordinary patience and realistic expectations are needed to provide optimal care for patients.