This case report describes a woman with no psychiatric history and previously diagnosed Hashimoto’s thyroiditis who presented to the psychiatric emergency department with a first episode of psychosis. The initial workup for organic causes of psychosis revealed an astronomically high thyroid stimulating hormone (TSH) (> 1,000 μIU/mL) out of proportion to the patient’s minimal physical symptoms of hypothyroidism. Additionally the patient’s head imaging showed an enlarged pituitary, a rare, but reversible, presentation of chronically untreated primary hypothyroidism. The patient was transferred to a medical unit to receive IV thyroid hormone replacement as well as an adjunctive antipsychotic to assist with remission of her distressing auditory hallucinations and persecutory delusions. This case highlights the importance of a thorough medical workup for causes of new onset psychosis and the need for further consensus in the literature regarding choice of antipsychotic and duration of treatment for psychosis secondary to hypothyroidism.

A 64-year-old patient with long-standing type 2 diabetes and a history of myocardial infarction expressed frustration with his elevated blood glucose level and inability to lose weight. He was taking metformin but wondered if he needed another medication. We discussed treatment options and he became interested in starting treatment with a glucagon-like peptide-1 receptor agonist (GLP-1 RA), but he wanted to make sure it had a good track record of safety.Glucagon-like peptide-1 receptor agonists have emerged as attractive therapies for patients with type 2 diabetes or obesity. For type 2 diabetes, GLP-1 RAs use has been shown to reduce levels of glycated hemoglobin (HbA 1c ; mean difference, −0.9% after 6 months) and promote weight loss (mean difference, −1.5 kg after 6 months). 1 With obesity, GLP-1 RA use is associated with more substantial weight loss (mean difference, −12.7 kg after 68 weeks for semaglutide vs placebo). 2 In addition, multiple trials have demonstrated that GLP-1 RA use in patients with type 2 diabetes was associated with reductions in major cardiovascular events, which appear to be unrelated to how GLP-1 RAs affect HbA 1c levels. 1 The relative effects of GLP-1 RAs on cardiovascular outcomes are consistent across patients with different levels of baseline risk for cardiovascular events; thus, the absolute effects are primarily driven by the patient's individual risk. Accordingly, current guidelines for diabetes management recommend 3 or suggest 4 the use of GLP-1 RAs, irrespective of HbA 1c levels, in individuals with type 2 diabetes at high risk for or with established atherosclerotic cardiovascular disease.Although GLP-1 RAs have a track record of cardiovascular safety, they are associated with gastrointestinal adverse effects, 3 which often limits their use in clinical practice. Mild, transient gastrointestinal adverse effects, such as nausea, are common but tend to resolve over time. Rates of severe nausea and vomiting vary depending on the dose and type of GLP-1 RA but are generally 10% or less. Early safety concerns that emerged with GLP-1 RAs included the risk of pancreatitis, pancreatic cancer, and retinopathy, complications that are now designated as key safety outcomes and are being tracked by subsequent clinical trials. Reassuringly, in recent meta-analyses, none of these adverse events were significantly associated with GLP-1 RA use. 1,4 Less is known about the risk of cholecystitis or cholelithiasis associated with the use of GLP-1 RAs. Early studies raised concerns about increased risk of these events. 5,6 There are at least 2 potential mechanisms that may connect GLP-1 RA use with these complications. First, GLP-1 RAs may directly inhibit gallbladder and biliary duct motility, which may lead to sludging and stone formation. Second, rapid weight loss associated with GLP-1 RA use may lead to supersaturation of cholesterol in the bile and gallstones. Gallstones have been re-

Purpose: Diabetes care has largely focused on reducing the risk of complications by achieving hemoglobin A1c (HbA1c) targets; yet, whole-person care may be more effective and desirable. We sought to determine the nature of discussions about quality of life, burden of treatment, hypoglycemia, sexual function, and social support during diabetes-focused clinical encounters. Methods: We analyzed 41 previously recorded clinical encounters with patients with type 2 diabetes from the control arms of practice-based trials of shared decision making. Two coders evaluated videos for discussions about aspects of life with diabetes: quality of life, burden of treatment, hypoglycemia, sexual function, and social supports. When an aspect was raised, coders evaluated the nature of the conversation, clinician responses, and time spent on discussing the aspect.Results: Median length of the encounter was 15 minutes, 6 seconds (IQR: 11:16 -20:23 minutes). Thirty ve of 41 encounters (85.4%), included some discussion of quality of life (58.5%), burden of treatment (51.2%), social support (2.4%), or hypoglycemia (9.8%). Sexual function was not discussed. On average, 4.5% (1.4%-5.5%) of the encounter time involved conversations about HbA1c whereas 15.0% (0%-25%) of the encounter was spent on some aspect of quality of life, burden of treatment, social support, or hypoglycemia. If a topic related to quality of life was raised, clinicians most often responded by acknowledging patient's concern without providing a solution (45.8%).Conclusions: A signi cant part of the patient-clinician encounter involves discussion of quality of life and burden of treatment, but clinicians rarely address these issues by providing solutions.

Background Diabetes care has been traditionally focused on targeting certain levels of glycemic control. This narrow emphasis may impose burdens on patients, including high treatment costs, illness-related work, or side effects from medications, while leaving other patient needs and goals under-addressed. The authors aim to shift the paradigm of care for people with diabetes, to focus on quality of life, burden of treatment, safety, and avoidance of future events: the QBSAfe domains. Methods We describe a single-arm pilot study to assess the feasibility and acceptability of using the QBSAfe agenda setting kit (ASK) during routine clinical visits. The set of 14 conversation aid cards was co-developed with patients, family caregivers, and clinicians. The ASK will be used in the context of a clinic visit, which will be recorded by members of the study team to identify patterns of clinician-patient conversations. Feasibility will be measured by the number of participants recruited, time to goal accrual, and completeness of data collection; acceptability will be assessed using post-visit surveys of patients and clinicians. A subgroup of patients will be invited to participate in post-visit qualitative semi-structured interviews for additional feedback. This study will be conducted across three medical centers in the Midwest and East Coast of the USA. Discussion Current healthcare infrastructure and associated demands and pressures on clinicians make changes in care difficult. However, this intervention has the potential to shift conversations during clinical encounters so they can address and directly respond to patient needs, symptoms, and capacity. As part of the QBSAfe ASK, the authors are also actively collaborating with a variety of stakeholders to create tools to help clinicians respond more effectively to patient concerns as they are raised during the clinical encounters. Additional insights about the use of the QBSAfe approach in the virtual space will be gathered during the process of our study due to restrictions imposed upon face to face visit during the COVID-19 pandemic. Trial registration ClinicalTrials.gov, NCT04514523. Registered 17 August 2020—retrospectively registered.

Objectives: Diabetes care has traditionally focused on target A1c, leaving other patient goals and needs under-addressed. We assessed the feasibility and acceptability of conversation cards (QBSAFE agenda setting kit) during routine clinic visits. Methods: We recruited clinicians and their patients with diabetes into a single-arm intervention study. The intervention consisted of a set of 14 conversation cards (QBSAFE ASK) describing diabetes-related topics. The cards were presented to patients and asked to select 0-3 cards for discussion. Clinicians and patients completed post-encounter acceptability surveys. Feasibility was assessed based on participant enrollment, time to enrollment, and percent who completed study procedures. Encounters were recorded and analyzed to describe the cards selected and clinician responses to the cards. Results: A total of 85 patients (63yo ± 14.7, 43.5% female, and 84.5% white) and 7 clinicians were recruited over 5 months. Among 85 patients, 68.2% completed all study procedures. Most patients (63.8%) agreed the cards helped discuss their situation, 77.6% agreed other patients could benefit from them, but only 37.9% would use the cards again. Clinicians felt confident responding to issues raised by the cards during 89.9% of encounters and would recommend the cards to their colleagues (82.4%). Based on video analysis, 83.3% of patients selected at least 1 card, with the common being “I have difficulties with diet and exercise” (34.5%). Clinicians most often responded by asking elaborating questions (81.8% of encounters) followed by change in treatment (34.5%). The tool often elicited collaborative conversations between clinicians and patients (58% of encounters). Conclusions: QBSAFE ASK can be feasibly implemented into clinical care, is generally acceptable, and holds promise in helping patients discuss their situation with clinicians and in eliciting collaborative problem-solving. Disclosure S.Haider: None. K.J.Lipska: Other Relationship; UpToDate. C.Gonzalez lopez: None. J.Clark: None. D.L.Gravholt: None. M.Breslin: None. K.Boehmer: None. S.A.Hartasanchez: None. B.B.M.Sanchez: None. V.M.Montori: None. Funding National Institute on Aging (5R21AG061427)