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A 20-year-old woman with no prior psychiatric and medical history presented with acute autobiographical memory loss and a psychogenic tremor. Her laboratory and imaging work-up revealed no infectious, inflammatory, or other organic etiologies. A lorazepam infusion-assisted interview successfully facilitated recovery of memories and elucidated precipitating events. We discuss the utility of drug-assisted interviews and the safety of benzodiazepine infusions for dissociative amnesia.

Background Valerian root is an herbal supplement used for its anxiolytic and sedative properties. Its extract is thought to serve as an allosteric modulator of gamma-aminobutyric acid A, which can cause delirium due to its influence on the nervous system’s inhibitory tone and its effect on the sleep-wake cycle. Objective This report presents a patient who developed delirium secondary to withdrawal from valerian root. Conclusion This report emphasizes the importance of screening for use and abstinence of herbal supplements when delirium develops, as herbal supplement withdrawal can be an uncommon and overlooked etiology of delirium.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Heart disease is a chronic condition that affects millions of people worldwide. Research has led to improvements in treatment and increased longevity for patients. Heart disease is comorbid with many psychiatric illnesses that psychiatrists encounter in everyday practice. Thus, it is important for clinicians to have a basic understanding of heart disease, and its impact on their patients and their patients' treatments. In this article, we review the basic pathophysiology, epidemiology, and treatments for heart disease, and then describe a framework for managing the affective, behavioral, and cognitive considerations for patients with heart disease. We emphasize the identification of comorbid psychiatric illnesses and symptoms that directly or indirectly result from heart disease. Finally, we outline treatment strategies to improve overall cardiac health. [ Psychiatr Ann . 2019;49(2):55–59.]

The number of people who are overweight and obese has reached epidemic proportions in the United States. Estimates show that 78% of the adult population is either overweight, obese, or extremely obese. This represents a substantial increase from recent decades. Overwhelming scientific evidence links an increasing body mass index to increasing morbidity and mortality. Although numerous treatments for obesity are available, the cornerstone of treatment is behavioral modification, focusing on diet changes and exercise regimens. Additional therapies include a growing array of medications and surgeries. To improve care for patients who are overweight or obese, mental health providers should have a thorough understanding of overweight and obesity and its treatment to effectively address this topic with their patients. In addition, they must recognize that recidivism and failure to maintain weight loss is quite high, and that successful treatment requires a concerted and sustained effort. [ Psychiatr Ann . 2019;49(2):65–77.]

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

BACKGROUND: Medicine relies on education of trainees for growth of the field. Medical education has benefitted from a rapid pace of innovation, but due to the coronavirus disease 2019 (COVID-19) pandemic, many paradigms underpinning the medical education of trainees shifted-rendering numerous teaching modalities unusable. The COVID-19 pandemic, however, accelerated the development of novel teaching methodologies, which our trainees are now adapting to. We sought to examine emerging teaching methodologies to understand the opportunities available for medical education to innovate our teaching practices for learners in the midst of the COVID-19 pandemic. METHODS: In this narrative review, we drew upon the experiences of the authors as both life-long learners and educators. We then reviewed literature pertaining to novel teaching methodologies developed in medical education since the start of the COVID-19 pandemic. RESULTS: Several medical specialties have employed novel teaching methodologies including use of telemedicine, remote teaching, online curricula, virtual rotations, virtual conferences, simulations, and learning consortia to continue engaging trainees during the COVID-19 pandemic. There is a paucity of literature that addresses efficacy of novel teaching methodologies compared to more traditional teaching methodologies. CONCLUSIONS: The COVID-19 pandemic presents an opportunity for medical education to combine new and innovative teaching methodologies to create novel, accessible, and engaging learning opportunities for our trainees.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Approximately 637,000 lesbian, gay, bisexual, or transgender (LGBT)-identified documented adult immigrants live in the United States. LGBT people face persecution in dozens of countries around the world, where having an LGBT identity may be criminalized or even punishable by death. LGBT immigrants have often survived traumatic experiences in their countries of origin. In the United States, both LGBT non-immigrants and immigrants may experience significant stigma-related health disparities, which range from mental health problems to sexually-transmitted infections. LGBT immigrants in particular face challenges accessing culturally-competent health care, which has the potential to reduce health disparities. Trauma-informed approaches and an understanding of intersecting cultural identities can enable staff in health centers and clinics to support LGBT immigrants in overcoming health disparities, through implementation of best practices that meet the unique needs of these communities and improve engagement of LGBT immigrants in affirming and high-quality primary care and psychiatric care (i.e., collaborative care).

Background Delirium is an acute confusional state, associated with morbidity and mortality in diverse medically ill populations. Delirium is preventable and treatable when diagnosed but the diagnosis is often missed. This important and difficult diagnosis is an attractive candidate for computer-aided decision support if it can be reliably identified at scale. Objective Here, using an electronic health record–based case definition of delirium, we characterize incidence of this highly morbid condition in 2 large academic medical centers. Methods Using the electronic health record of 2 large New England academic medical centers, we calculated and compared the rate of the diagnosis of delirium using a range of administrative and discharge summary text-based case definitions over an 8-year period. Results Depending on case definitions, the overall delirium rate ranged from 2.0–5.4% of 809,512 admissions identified. The identified rate of delirium increased between 2005 and 2013, such that by the final year of the study, one of the two sites reported delirium in 7.0% of cases. The concordance between case definitions was low; only half of the cases identified by text analysis were captured by administrative data. Conclusion Delirium may be better captured by composite outcomes, including both administrative claims data and elements drawn from unstructured data sources. That the rate of delirium observed in this study is far lower than the current literature estimates suggests that further work on case definitions, identification, and documented diagnosis is required.

Background An increasing number of patients are admitted to general hospitals for injuries sustained in suicide attempts and for assessment of their ongoing risk for suicide. However, clinical staff may lack knowledge and expertise in the provision of a safe environment for potentially suicidal patients. Objective In an effort to follow the Joint Commission's recommendations on the care of suicidal patients, a Suicide Prevention Interdisciplinary Task Force was created. The task force sought to design and implement a suicide checklist that would facilitate creation of a safe environment for potentially suicidal inpatients on nonpsychiatric units in a general hospital. Methods We describe the development and implementation of a Care of the Suicide and Self-Injury Patient Checklist and report on data derived from incident reports related to self-harm/suicide attempts over a 4-year period. We also report results of a Research Electronic Data Capture survey of nurses' feedback on the checklist. Results After implementation of the Care of the Suicide and Self-Injury Patient Checklist, a total of 47 incidents of patient self-injury were reported over 4 years on nonpsychiatric inpatient units at a large general hospital; only three sustained permanent or serious harm. The Research Electronic Data Capture survey revealed that 88% of responding nurses believed that the Care of the Suicide and Self-Injury Patient Checklist guided creation of a safe environment and 90% believed that it supported consistent practice. Conclusions The Care of the Suicide and Self-Injury Patient Checklist contributed to the creation of a safe environment while caring for potentially suicidal patients on nonpsychiatric inpatient units and guided clinicians on the management of potentially self-injurious individuals.

Idiosyncratic adverse events related to psychotropic medications are prevalent and problematic, and they are the most frequent cause of postmarketing (or black-box) warnings and withdrawals of drugs from the market. This review examines the clinical nature of idiosyncratic adverse events, predictors of their onset, and the role of clinician awareness in avoiding irreversible and serious injury from medications prescribed for psychiatric conditions. Idiosyncratic reactions can be minimized or avoided by knowledge of risk factors, cautious use (or avoidance) of specific agents in subpopulations at risk, informed dose titration, and careful monitoring of clinical response. [ Psychiatr Ann . 2016;46(8):456–465.]

Received July 11, 2015; revised August 11, 2015; accepted August 12, 2015. From Harvard Medical School, 260 Longwood Avenue, Suite 168, Boston, MA 02115 (NE); Psychiatry Department, Massachusetts General Hospital, Boston, MA (DEM, TAS). Send correspondence and reprint requests to Neir Eshel, Ph.D., Massachusetts General Hospital, 260 Longwood Avenue, Suite 168, Boston, MA 02115; e-mail: Neir_Eshel@hms.harvard.edu & 2016TheAcademy of PsychosomaticMedicine. Published by Elsevier Inc. All rights reserved. Introduction

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.

Background Numerous currently available medications that act in the central nervous system can be delivered transdermally. Such medications include cholinesterase inhibitors for dementia, methylphenidate (MPH) for attention-deficit hyperactivity disorder, monoamine oxidase inhibitors (MAOIs) for depression, dopamine agonists for Parkinson disease and restless leg syndrome, and clonidine for attention-deficit hyperactivity disorder and impulse-control disorders. Objective This article aims to review the literature related to transdermal delivery systems from the perspective of clinical practice and research related to their use in the treatment of psychiatric conditions. Results Most of the currently available transdermal systems have psychotropic properties or utility in the behavioral health arena and, therefore, are of clinical relevance to consultation-liaison psychiatrists or practitioners of psychosomatic medicine. We discuss their efficacy and safety profiles. We provide a table of these agents and their uses. Conclusions Transdermal delivery (i.e., patches) for medicines with psychotropic properties allows mental health providers to customize therapy for patients by altering the duration of therapy, minimizing first-pass metabolism and the potential for drug–drug interactions, and decreasing the risk for gastrointestinal irritation.

Although rabies is rare in the United States, infection with the virus must be considered and treated soon after viral transmission; failure to diagnose and to intervene will usually result in disease progression and death. Typically transmitted often through an unrecognized bite of an infected animal (e.g., dog or bat), the clinical course is characterized by 5 phases (the incubation period, the prodrome, an acute neurologic phase, coma, and death). We present the case of a man with rapidly progressive and seemingly disparate somatic symptoms (including muscles aches, difficulty swallowing, and apprehension) and discuss the differential diagnosis, the evaluation, and the treatment approaches.

Background: While the number of Deaf and hard-of-hearing patients worldwide is estimated at six hundred million, few specialized psychiatric services or training resources exist to support the provision of mental health care to this population. This presents a particularly acute problem in the general hospital, where the consultant psychiatrist is likely to be confronted with the challenges of providing comprehensive psychiatric evaluation, diagnosis and treatment to patients with whom he or she may have limited experience or confidence. Method: We review critical considerations in the work-up, differential diagnosis, and management of commonly-presenting psychiatric disorders among Deaf patients in the general hospital setting.

Each year, 5000-6000 individuals undergo orthotopic liver transplantation (OLT) in the United States, and of these, nearly 18% have alcoholic liver disease. Relapse to alcohol occurs in more than 40% of patients with OLT for alcoholic liver disease.We sought to identify factors that predict relapse to alcohol or medication nonadherence following OLT in patients with alcoholic liver disease and to review what randomized clinical interventions have addressed these factors following OLT. Our hypothesis was that there would be factors before and after OLT that predict relapse to alcohol following OLT, and that these, if targeted, might improve sobriety and associated outcomes of adherence with medications and appointments.We performed a review (focusing on articles published since 2004) with PubMed and MEDLINE searches using the following search terms: liver transplantation, recidivism, alcohol relapse, and predictors of alcohol relapse. We supplemented the online searches with manual reviews of article reference lists and selected relevant articles for further review by author consensus.In largely white populations, prospective studies document that shorter length of pretransplantation sobriety is a significant predictor of time to first drink and time to binge use. Presence of psychiatric comorbidity, high score on standardized High-risk Alcoholism Relapse Scale, and diagnosis of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) alcohol dependence are predictive of posttransplantation alcohol relapse. Pretransplantation alcohol use history variables (e.g., family history of alcoholism) reliably discriminate between complete abstainers and those who drink, while medical and psychosocial characteristics at early post-liver transplantation period (e.g., more bodily pain) maximally discriminate patterns of alcohol use. Alcoholic individuals with early-onset, rapidly accelerating moderate use and early-onset, continuously increasing heavy use have more than double the prevalence of steatohepatitis or rejection on biopsy and graft failure and more frequent mortality resulting from recurrent alcoholic liver disease than late-onset (i.e., peak of heaviest drinking at 6y posttransplantation) alcohol users do. Fortunately, pretransplantation screening combined with a structured pretransplantation management program and a 12-step program attendance reduced recidivism. No randomized clinical trials have been performed that target pretransplantation risk factors in individuals with alcoholic liver disease before or after OLT to improve post-OLT outcomes.Recent research findings suggest that screening can reveal individuals who are vulnerable to alcohol relapse and targeted intervention can prevent their relapse to alcohol. Based on existing addiction treatments (e.g., relapse prevention plan construction), randomized clinical trials tailored to post-OLT patients should be conducted to improve their survival and quality of life.

Background The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education. Objective As the APM owns the journal, Psychosomatics , we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence. Methods We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered. Results In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often. Conclusions Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.

Background Lyme disease, a tick-borne illness transmitted to humans, has become increasingly recognized. Objective Given the myriad neurovegetative and neuropsychiatric symptoms that can be associated with Lyme disease, we sought to review the epidemiology, evaluation, and treatment of the disorder. Methods A case vignette that highlights manifestations of the condition and dilemmas associated with its treatment is presented. Conclusions Knowledge about its symptoms, its abnormal laboratory tests, and its course can help to guide the timely and appropriate management of this spirochetal infection.

Background Although anesthetics have been used for more than a century, their mechanisms of action remain poorly understood. Given that a number of intraoperative and postoperative neuropsychiatric syndromes have been linked to the use of anesthetics, practitioners should familiarize themselves with these conditions. Methods Basic concepts about anesthesia are reviewed and neuropsychiatric syndromes associated with anesthesia exposure described. Conclusions Emergence delirium, postoperative delirium, postoperative cognitive dysfunction, and intraoperative awareness can develop in association with use of inhalation anesthetics and intravenously administered anesthetics.

Background Delirium is an acute neuropsychiatric syndrome that portends poor prognosis and represents a significant burden to the health care system. Although detection allows for efficacious treatment, the diagnosis is frequently overlooked. This underdiagnosis makes delirium an appealing target for translational predictive algorithmic modeling; however, such approaches require accurate identification in clinical training datasets. Methods Using the Massachusetts All-Payers Claims Database, encompassing health claims for Massachusetts residents for 2012, we calculated the rate of delirium diagnosis in index hospitalizations by reported ICD-9 diagnosis code. We performed a review of published studies formally assessing delirium to establish an expected rate of delirium when formally assessed. Secondarily, we reported a sociodemographic comparison of cases and noncases. Results Rates of delirium reported in the literature vary widely, from 3.6-73% with a mean of 23.6%. The statewide claims data (Massachusetts All-Payers Claims Database) identified the rate of delirium among index hospitalizations to be only 2.1%. For Massachusetts All-Payers Claims Database hospitalizations, delirium was coded in 2.8% of patients >65 years old and for 1.2% of patients ≤65. Conclusion The lower incidence of delirium in claims data may reflect a failure to diagnose, a failure to code, or a lower rate in community hospitals. The relative absence of the phenotype from large databases may limit the utility of data-driven predictive modeling to the problem of delirium recognition.

Objective To assess whether and how effectively an interactive presentation about lifestyle medicine could impact the knowledge and attitudes of medical students to prepare them for managing chronic conditions in their patients. Chronic diseases are increasingly prevalent and problematic. Although chronic disease management involves lifestyle modification, few physicians are adequately trained in effective motivational interventions. Methods We surveyed first- and second-year Harvard Medical School students in October 2015 before and after a presentation on lifestyle medicine and quantified changes in their knowledge, attitudes/confidence, and skills. Results Medical students learned the basics of behavioral change after a 1-hour presentation, and their confidence with regard to implementing interventions increased. Median scores of confidence in counseling patients on lifestyle changes improved as did their ability to counsel patients on exercise, nutrition, sleep, stress management, and smoking cessation. Conclusions After a brief intervention, medical students can learn principles of behavioral management and how to implement the skills with patients suffering from chronic illnesses.

The Composite Beam Roll-out Array (COBRA) structurally integrates the photovoltaic assembly with a deployable boom. By combining the array with the deployment structure, a simple and effective deployable power generation subsystem is created that adds an effective back-side thermal control surface and shielding surface to the solar cell array, while the PVA provides additional stiffness and structural stability to the composite boom. This paper describes results of structural configuration trades and analysis for a COBRA deployable array designed to meet typical space mission environments. The analysis shows that a deployable array of this design can meet typical structural requirements with improved specific power, mass and volume metrics.

Background The presence of primitive reflexes (PRs) may have diagnostic or prognostic value in the evaluation of cognitive impairment. Objective We hypothesized that the presence of preoperative PRs would predict the development of postoperative delirium and that the emergence of PRs postoperatively would be positively associated with the emergence of delirium. Methods Patients participating in a larger study on the prophylaxis of postoperative delirium were evaluated for the presence of six PRs (grasp reflex [left and right], palmomental reflex [left and right], glabellar tap, and snout reflex), preoperatively and postoperatively. The presence of PRs was then correlated with the development of delirium. Results Of the 79 patients studied, 29% (n = 23) developed delirium during the postoperative period. The preoperative presence of one PR did not predict the development of delirium, but the only patient with >1 PR preoperatively went on to develop delirium in the postoperative period. Similarly, having one frontal release sign in the postoperative period did not correlate with delirium, while the appearance of more than one PR was associated with a greater likelihood of delirium. Of the 11 patients who had two or more frontal release signs during one postoperative examination, six (55%) developed delirium. Of the five patients who showed three or more frontal release signs, 4 (80%) developed delirium. Conclusion Our study is the first to investigate the relationship between the appearance of PRs and the development of delirium. We have provided some evidence that PRs are associated with acute CNS dysfunction.