Non-attendance at psychiatric outpatient clinics: comparison of clinical, risk and demographic factors between attenders and non-attenders

AimsWith an overarching aim of decreasing the incidence of non-attendance in psychiatric outpatient clinics, this service evaluation was intended to explore the profile of non-attenders. Specifically, the clinical, risk and demographic features of patients who did not attend their psychiatric outpatient appointments were compared with those of attenders. The outcome of patients who did not attend was also studied.MethodAll the consecutive non-attenders (n = 32) in November 2020 in a psychiatric outpatient clinic were compared with 32 consecutive attenders. The groups were compared based on clinical features (diagnosis, medical treatment, psychological treatment, care programme approach, first contact), risk profile (self or others) and demographic features (age, gender, ethnicity, accommodation, occupation, benefits). The non-attender sample was also analysed to consider the outcome after their missed appointment, following local Trust protocols.ResultThe overall rate of patients who did not attend their appointment was 22%. There was a statistically significant difference between the age and gender of non-attenders. Males were less likely to attend their appointment than females (p = 0.024). The mean age of patients who did not attend their appointment was 36.4 compared with 44.8 years in the attenders (p = 0.005). There were a few clinically relevant findings. Around one third (34%) of patients who did not attend their appointments had a history of risk of self-harm noted in previous appointments. The results also showed that 75% of individuals who did not attend their outpatient appointments were unemployed. There were no significant differences based on the type of treatments (depot injections, lithium, clozapine, antipsychotics or antidepressants) patients received. Patients who did not attend were more likely to have a mood disorder (59% compared with 40%), and less likely to have a psychotic disorder (25% compared with 44%). Of the patients who did not attend, all were appropriately contacted as per the local Trust guidelines via a letter, and were provided with appointments where appropriate; 34% of non-attenders were discharged from services.ConclusionNon-attendance at psychiatric outpatient appointments is a concern, particularly for younger and male patients. Considering the clinical risks associated with this patient population, efforts need to be taken to improve their engagement with mental health services. Future studies may explore patients’ perspectives of non-attendance and how to ameliorate any hindrances to attending.

A Rare Case of Autoimmune Progesterone Disease

Background: Autoimmune progesterone disease is a rare disease, with fewer than 200 reported cases. Unfortunately, there are no published estimates of incidence or prevalence. Clinical Case: A 24 year-old woman with no significant past medical history presented with sudden and new onset swelling of the lips which was unresponsive to Benadryl and prednisone. Swelling eventually progressed into blistering over the lips, oral, pharyngeal mucosa and tongue. She was admitted to the hospital for suspicion of Steven Johnson syndrome and was discharged after resolution of skin and oral lesions following treatment. She presented again in 3 months with full body rash and blisters now involving oral and vaginal mucosa. She underwent biopsy of these lesions during this admission and findings were suspicious for drug eruption vs erythema multiforme. Unfortunately, inciting drug or event could not be associated even with pathological diagnosis. She continued to have mucocutaneous flare every month for the next 8 months with multiple hospitalizations and was treated with antibiotics during these admissions. Over the course of her evaluation, it was noted that her symptoms seemed to coincide with her menstrual cycles. Her IUD was removed and she was started on OCPs but her symptoms persisted without any improvement. She underwent intradermal progesterone challenge test at tertiary center for ongoing cyclical dermatitis and tested positive for progesterone sensitivity. She was diagnosed with Autoimmune Progesterone dermatitis. She had to ultimately undergo total abdominal hysterectomy and bilateral salphingo-oophorectomy as she failed OCPs and had adverse effects to progesterone desensitization including full body rash and blisters. Post operatively, she has been started on IM depot injections of estrogen and vaginal estrogen cream. Conclusion: Autoimmune progesterone disease also known as progesterone dermatitis or progesterone hypersensitivity is not associated with other autoimmune diseases and usually affects women of reproductive age. It is a rare disorder with variable presentation and often overlaps with other forms of dermatosis. It is commonly underdiagnosed or misdiagnosed and appropriate treatment is often delayed. High clinical suspicion for symptoms of cyclical nature is necessary for making the diagnosis.

Emergency contraception using progestin drugs in domestic cats

Today, in conditions of strict quarantine, when it is not always possible to carry out surgery in cats, some methods of emergency drug contraception can be used. Over the years, many contraceptive medications have been developed for companion animals, but many secondary adverse effects have limited their use. However, in all species, the secondary adverse effects of progesterone-type drugs limit their use and vary depending on when treatment is given in relationship to the stage of the estrous cycle. An ideal non-surgical sterilant would be safe, effective, permanent, administered as a single injection and capable of being manufactured inexpensively. Contraceptives are used for cats, as a method of renewable fertility over time for breeding animals, as a method of suppressing sexual function for animals at risk for surgery, and to prevent over populations in stray cats. The use of non-surgical, safe and effective methods of suppression of sexual function in cats eliminates traumatization, anesthesia and complicated postoperative period in animals, which in some cases are impossible in the state of health, etc. The most common and affordable method of medical contraception is progestins, such as megestrol acetate, medroxyprogesterone acetate, proligestone (used orally or as a depot injection). These drugs are effective in inhibiting sexual function. Contraceptives for felids are available as implants, depot injections, and pills or liquid for oral administration, powder for mixing with food, or as vaccines. Regimens may differ according to the timing of first treatment, whether coinciding with the active reproductive period, preceding this period, or during anestrus. Ideally, the treatment regimen is initiated during anestrus to minimize the dose needed for reproductive suppression and to avert exposure to endogenous steroids that can cause lesions in reproductive organs.

NEOADJUVANT AND ADJUVANT CHEMOHORMONAL THERAPY IN PATIENTS WITH HIGH-RISK AND VERY HIGH-RISK PROSTATE CANCER: OUR EXPERIENCE

Background. The approach to the management of prostate cancer with lymph node metastases has recently moved towards aggressive multimodal treatment with the use of the most rational combinations that are currently available.Objective: to assess the efficacy and tolerability of chemohormonal therapy (CHT) in patients with high-risk and very high-risk prostate cancer.Materials and methods. An open prospective clinical trial evaluating the efficacy and tolerability of neoadjuvant and adjuvant CHT in patients with high-risk and very high-risk prostate cancer was initiated in 2016 at the P.A. Herzen Moscow Oncology Research Institute. Patient recruitment is still ongoing.A total of 64 patients with high-risk and very high-risk prostate cancer (сT3N0–T3N+М0, prostate specific antigen (PSA) ≥20 ng/mL, and Gleason score of 8–10) were recruited since July 2016. All patients were examined prior to treatment initiation and after 3 and 6 courses of therapy. The examination included pelvic magnetic resonance imaging, ultrasound imaging of the abdominal cavity and retroperitoneal space, transrectal ultrasound imaging, and chest radiography or computed tomography. Serum PSA level was evaluated before each course of therapy. Bone scintigraphy was performed before treatment and after its completion. Study participants were divided into two groups. Group A included patients that initially underwent surgical treatment and then 6 courses of CHT no later than 6 weeks after surgery: docetaxel 75 mg/m2 given intravenously on day 1 of a 21-day cycle and oral prednisolone 10 mg/day. Patients also received hormonal therapy with luteinizing hormone-releasing hormone analogue (aLHRH) given in depot injections every 28 days.Group B included patients that initially received 6 courses of CHT: docetaxel 75 mg/m2 given intravenously on day 1 of a 21-day cycle and oral prednisolone 10 mg/day. After that, patients underwent radical prostatectomy with pelvic lymphadenectomy no later than 4 weeks after the completion of chemotherapy. Patients also received hormonal therapy with aLHRH given in depot injections every 28 days. The total treatment duration was 6 months.Results. The group of adjuvant CHT included 24 patients with high-risk prostate cancer (T3b–4N+М0 with at least 5 regional lymph node metastases detected by morphological examination of surgical specimens). All patients had Gleason score 8–10 tumors. Mean age of patients was 63.0 ± 7.7 years (range: 46–72 years). In total, all patients received 142 courses of CHT. By the time of publishing this article, 23 (96 %) of patients completed their treatment.The group of neoadjuvant CHT included 40 patients with very high-risk prostate cancer (T3b–4N+М0 with metastases to pelvic and retroperitoneal lymph nodes detected by instrumental examination). All patients had Gleason score 8–10 tumors. Mean age of patients was 61.0± 6.4 years (range: 43–69 years). In total, all patients received 236 courses of CHT. By the time of publishing this article, 36 (90 %) of patients completed their treatment. Thirty-five patients (87 %) underwent radical prostatectomy with extensive pelvic and paraaortic lymphadenectomy. Routine pathological examination demonstrated that all patients had signs of tumor destruction. Thirty-three participants (94 %) had grade II therapeutic pathomorphosis, whereas 2 patients (6 %) had grade III therapeutic pathomorphosis.Median PSA relapse-free survival (PSA-RFS) rate in the neoadjuvant CHT group was 10 months. Serum PSA of 0.1 ng/mL 1 month postoperatively correlated with longer RFS (р = 0.04). Biochemical relapse (PSA level >0.2 ng/mL) was observed in 6 patients (15 %) from this group. Later these patients received hormonal therapy with aLHRH. Median PSA-RFS in the adjuvant CHT group was 11 months.The main adverse events in the two groups were hematological toxicity, observed in 24 patients (34.29 %), and gastrointestinal toxicity, observed in 9 patients (12.86 %) (diarrhea (n = 6) and stomatitis (n = 3)). Only grade I–II toxicity was registered so far. Two patients (3.1 %) had febrile neutropenia, which required cytostatic dose reduction by 20 %. Relatively good tolerability and acceptable quality of life allowed the vast majority of patients to be treated on an outpatient basis.Conclusion. So far, we can make only a preliminary conclusion that adjuvant and neoadjuvant CHT is a promising treatment strategy for high-risk and very high-risk prostate cancer.