During my psychiatry rotation at Queens Hospital Center, I had the opportunity of participating in site visits with Dr. Manuel Saint Martin, an MD, JD. The evaluations, conducted over Zoom, involved presenting cases alongside my colleague, Abbas Aslam, during both the mid and final assessments. Dr. Saint Martin’s engagement and feedback proved to be invaluable, showcasing his genuine interest in our learning and development.

Throughout the evaluations, Dr. Saint Martin consistently encouraged critical thinking and a comprehensive approach to patient care. For instance, he highlighted the importance of checking specific labs such as calcium level in a case involving psychosis, schizophrenia, and hyperparathyroidism. This emphasis on thorough evaluation significantly enhanced our ability to present relevant information. Dr. Saint Martin’s thought-provoking questions went beyond the routine, challenging us to consider alternative treatments for conditions like depression and suicidal ideation. While acknowledging Selective serotonin reuptake inhibitors (SSRIs) as first-line options, he prompted us to think on our feet about immediate interventions and in treatment resistant patients , leading to discussions on treatments like Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (TMS).

One standout aspect was Dr. Saint Martin’s interest in our personal growth. He took the time to inquire about our key takeaways from the rotation, fostering a reflective practice that enhances learning. I particularly appreciated the opportunity to delve into my research on Repetitive Transcranial Magnetic Stimulation (rTMS), which he encouraged and engaged with.

Overall, the time spent with Dr. Saint Martin was not just a routine evaluation but a rich learning experience that will undoubtedly shape my future practice as a PA. His mentorship, emphasis on critical thinking, and encouragement to explore beyond the standard approaches have left a lasting and positive impact on my professional development.

My second rotation in psychiatry, particularly within the Comprehensive Psychiatric Emergency Program (CPEP) at Queens Hospital General, has been a profound and transformative experience. Spanning from February 5 to March 08, 2024, this rotation not only expanded my clinical expertise but also provided invaluable insights into the complex realm of emergency psychiatry. Throughout the rotation, I honed my ability to conduct comprehensive psychiatric evaluations. Encountering patients with schizophrenia, psychosis, depression, and bipolar disorders, I learned to navigate the nuanced management of diverse psychiatric conditions. This experience empowered me to adeptly gather pertinent patient history, assess mental status, and identify potential risk factors, laying a robust foundation for crafting effective treatment plans.

Working in the high-stakes environment of CPEP exposed me to the urgency and precision demanded in managing acute psychiatric crises. Firsthand exposure to protocols for handling situations involving suicidal ideation, severe mood disorders, and psychotic episodes deepened my understanding of crisis management in psychiatry. The collaborative nature of psychiatry became evident as I refined my communication skills while working alongside esteemed professionals such as psychiatrists MD Syed Hasan, Physician Assistants Alie Amil, Jenny Thomas, nurses, and social workers. This interdisciplinary approach underscored the importance of holistic, patient-centered care. Guided by my preceptors, I learned to tailor my focus to the unique needs of each patient. The rotation equipped me with practical crisis intervention techniques, including de-escalation strategies and managing aggressive behaviors. Simultaneously preparing for my Psychiatry end-of-rotation exam, I gained a deeper understanding of psychopharmacology, emphasizing the significance of individualized treatment plans with psychotropic medications.

An essential lesson from this rotation was the paramount importance of accurate and detailed documentation in psychiatry. Improving my documentation skills ensured seamless continuity of care and adherence to legal standards. The rotation also provided a guided exploration of the intricate ethical landscape in psychiatry, navigating challenges such as confidentiality, informed consent, and involuntary hospitalization. This underscored the delicate balance between ethical principles and ensuring patient well-being. Effective communication, extending not only to fellow professionals but also to patients and their families, became a focal point of my development.

In conclusion, my psychiatry rotation at CPEP has been a profound journey, enriching my clinical skills and preparing me for the multifaceted challenges of providing compassionate care in psychiatric emergencies. The experiences gained during this rotation will undoubtedly shape my future practice and contribute significantly to my growth as a healthcare professional.

Name: Abd-Manaaf Bakere
Rotation 2: Psychiatry
Rotation Location: Queens Hospital Center.

Repetitive Transcranial Magnetic Stimulation (rTMS) in Psychiatric and Neurological Disorders

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique used in the treatment of various psychiatric and neurological disorders. This summary provides an overview of the indications, adverse effects, equipment, technique, and the importance of an interprofessional team in utilizing rTMS for conditions such as treatment- resistant depression, PTSD, OCD, Tourette syndrome, and movement disorders.

Indications for rTMS:

rTMS has demonstrated therapeutic potential in conditions such as treatment-resistant depression, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), Tourette disorder, chronic pain syndrome, generalized anxiety disorder (GAD), bipolar disorder, and various movement disorders. The U.S. Food and Drug Administration (FDA) has approved rTMS for major depressive disorder (MDD), and subsequent approvals have expanded its use for other conditions, showcasing its versatility in psychiatric and neurological care.

Adverse Effects and Contraindications:

While rTMS is generally well-tolerated, potential adverse effects include pain at the stimulation site, posttreatment headaches, neck pain, and muscle twitching. Seizures are a rare but significant concern, making it contraindicated for patients with epilepsy. Pre-existing neurological diseases, adolescents, changes in medication regimes, and substance use during rTMS should be considered to prevent lowering the seizure threshold. Awareness of contraindications and potential adverse effects is crucial for safe and effective treatment.

Equipment and Technique:

rTMS relies on the Faraday law of electromagnetic induction, using a coil to generate high- intensity magnetic fields that modulate cortical excitability. The choice of coil, whether round or figure-of-eight-shaped, influences the neural circuit activated. Treatment parameters, including frequency, intensity, and duration, are individualized based on factors such as motor threshold, age, and disease state. The stimulation targets specific brain regions, and the technique involves both low-frequency(<1Hz) and high-frequency(>1Hz) paradigms. Sessions are outpatient procedures where patients experience a tapping sensation on the forehead during stimulation.

Interprofessional Team Coordination:

The successful utilization of rTMS requires an interprofessional team approach. Psychiatrists, psychologists, social workers, nurse practitioners, and primary care providers collaborate to evaluate patients, consider medication trials, and educate patients on the importance of follow-up

sessions. Continuous communication among team members ensures comprehensive patient care. Social workers play a role in managing daily activities, assessing the effectiveness of therapy in routine tasks, and preventing relapse through psychotherapy and medication continuation.

Clinical Significance and Outcomes:

rTMS has shown efficacy in treating treatment-resistant MDD, PTSD, GAD, bipolar depression, stroke complications, and various movement disorders. It is well-tolerated and offers a promising alternative to traditional treatments. Studies suggest positive outcomes in the reduction of depressive symptoms, and its safety extends to stroke-related complications and Parkinson’s disease.

In conclusion, rTMS stands as a valuable non-invasive treatment option for a range of psychiatric and neurological disorders. Its application requires a careful assessment of indications, consideration of contraindications, and collaboration among healthcare professionals to optimize patient outcomes. As research continues, rTMS holds the potential to further enhance healthcare outcomes for individuals with neuropsychiatric conditions.

Summary of the article.

This article discusses three types of benign breast diseases: periareolar mastitis, granulomatous lobular mastitis (GLM), and lymphocytic or diabetic mastopathy. Here is a summary:

Periareolar Mastitis:

Clinical Presentation: Recurrent abscess or sinus at the areolar margin, often in women in their 20s and 30s.

Pathophysiology: Squamous metaplasia of the central duct, causing duct obstruction and subareolar duct ectasia.

Surgical Management: Involves central duct excision, excision of the abscess site, and reconstruction of the subareolar complex.

Granulomatous Lobular Mastitis (GLM):

Clinical Presentation: Palpable breast mass, commonly in Hispanic women around 35 years old. Breast Pain, erythema and skin changes such as warmth and swelling, clear or bloody nipple discharge.

Diagnosis: Imaging (ultrasound) and core needle biopsy to differentiate from carcinoma.

Treatment: Authors recommend avoiding surgical procedures, favoring aspiration, short courses of antibiotics, and observation for milder cases.

Lymphocytic or Diabetic Mastopathy:

Clinical Presentation: Painless breast masses in premenopausal women with long-standing insulin-dependent diabetes.

Diagnosis: Core needle biopsy showing dense keloidal fibrosis and perivascular lymphocytic infiltrate.

Management: No specific interventions after confirmation; patients may develop subsequent masses requiring standard evaluation.

Key Notes:

Periareolar mastitis is often misunderstood, requiring central duct excision for definitive management.

GLM can be challenging, and the treatment strategy focuses on less invasive approaches.

Diabetic mastopathy is associated with insulin-dependent diabetes, and diagnosis involves histopathological examination.

The article emphasizes the importance of accurate diagnosis to distinguish these benign conditions from breast cancer.

In summary, the operative management of periareolar mastitis involves specific surgical procedures, while GLM and diabetic mastopathy are managed with less invasive approaches, including observation and aspiration.