Jose R. Maldonado, MD, FAPM, FACFE

All Publications

• Delirium after lung transplantation: Association with recipient characteristics, hospital resource utilization, and mortality. Clinical transplantation Sher, Y., Mooney, J., Dhillon, G., Lee, R., Maldonado, J. R. 2017; 31 (5)

  Abstract

  Delirium is associated with increased morbidity and mortality. The factors associated with post-lung transplant delirium and its impact on outcomes are under characterized.The medical records of 163 consecutive adult lung transplant recipients were reviewed for delirium within 5 days (early-onset) and 30 hospital days (ever-onset) post-transplantation. A multivariable logistic regression model assessed factors associated with delirium. Multivariable negative binomial regression and Cox proportional hazards models assessed the association of delirium with ventilator duration, intensive care unit (ICU) length of stay (LOS), hospital LOS and one-year mortality.Thirty six % developed early-onset and 44% - ever-onset delirium. Obesity (OR 6.35, 95% CI 1.61-24.98) and bolused benzodiazepines within the first post-operative day (OR 2.28, 95% CI 1.07-4.89) were associated with early-onset delirium. Early-onset delirium was associated with longer adjusted mechanical ventilation duration (p=0.001), ICU LOS (p<0.001), and hospital LOS (p=0.005). Ever-onset delirium was associated with longer ICU (p<0.001) and hospital LOS (p<0.001). After adjusting for clinical variables, delirium was not significantly associated with one-year mortality (early-onset HR 1.65, 95% CI 0.67-4.03; ever-onset HR 1.70, 95% CI 0.63-4.55).Delirium is common after lung transplant surgery and associated with increased hospital resources. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/ctr.12966

  View details for PubMedID 28314081

• The intensive care delirium research agenda: a multinational, interprofessional perspective. Intensive care medicine Pandharipande, P. P., Ely, E. W., Arora, R. C., Balas, M. C., Boustani, M. A., La Calle, G. H., Cunningham, C., Devlin, J. W., Elefante, J., Han, J. H., MacLullich, A. M., Maldonado, J. R., Morandi, A., Needham, D. M., Page, V. J., Rose, L., Salluh, J. I., Sharshar, T., Shehabi, Y., Skrobik, Y., Slooter, A. J., Smith, H. A. 2017

  Abstract

  Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.

  View details for DOI 10.1007/s00134-017-4860-7

  View details for PubMedID 28612089

• Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Critical care clinics Maldonado, J. R. 2017; 33 (3): 461?519

  Abstract

  Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.

  View details for DOI 10.1016/j.ccc.2017.03.013

  View details for PubMedID 28601132

• Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes-Beyond Benzodiazepines. Critical care clinics Maldonado, J. R. 2017; 33 (3): 559?99

  Abstract

  Benzodiazepine (BZDP) agents are the standard for the prophylaxis and treatment of all phases of alcohol withdrawal syndrome. However, BZDPs have their drawbacks: cognitive impairment, significant neurologic and medical side effects. There are data suggesting that the alcohol recidivism rate and abuse potential is higher for BZDPs treated patients, compared to alternatives. Clinical and research data demonstrate the efficacy and safety of various pharmacologic alternatives to benzodiazepines for the prevention and management of AWS. This article examines the available published evidence regarding the use of non-BZDP agents compared with conventional treatment modalities. The author's BZDP-sparing protocol is highlighted.

  View details for DOI 10.1016/j.ccc.2017.03.012

  View details for PubMedID 28601135

• Frontal Lobe Epilepsy: A Primer for Psychiatrists and a Systematic Review of Psychiatric Manifestations. Psychosomatics Gold, J. A., Sher, Y., Maldonado, J. R. 2016; 57 (5): 445-464

  Abstract

  Frontal lobe epilepsy (FLE) can masquerade as a primary psychiatric condition, be misdiagnosed in-lieu of a true psychiatric disorder, or may be comorbid with psychiatric illness.To (1) qualitatively review psychiatric manifestations of FLE and (2) to systematically review the cases/case series of psychiatric manifestations of FLE presented in the literature to date.A systematic review of the literature was performed following the PRISMA guidelines and using PubMed/Medline, PsychInfo, and Cochrane database of systematic reviews to identify cases and case series of psychiatric manifestations of FLE.A total of 35 separate articles were identified. Further, 17 patients primarily presented with psychosis, 33 with affective symptoms, and 16 with personality changes. Also, 62% of cases were males and 38% were females. Ages ranged from 2-83 years with the average age of 32.7. Prior psychiatric history was reported in 27.3% of cases. Causes of seizure were known in 53%, with the most common causes being dysplasia and tumor. Only 6 cases (<10%) did not have electroencephalographic correlations. Psychiatric manifestations were primarily ictal in 74.3% of the cases. Associated manifestations included motor (63.6%), cognitive (34.8%), and medical (9.0%) findings. Surgery was required in 31.8% of the cases, whereas others were treated with medications alone. All, but 3, patients were seizure free and saw an improvement in symptoms with treatment.Given the complexity and multifunctionality of the frontal lobes, FLE can present with complex, psychiatric manifestations, with associated motor, cognitive, and medical changes; thus, psychiatrists should keep FLE on the differential diagnosis of complex neuropsychiatric cases.

  View details for DOI 10.1016/j.psym.2016.05.005

  View details for PubMedID 27494984

• Suicide Risk Assessment and Management Clinical Manual of Emergency Psychiatry Maldonado, J. R., Garcia, R. edited by Riba, M., Ravindranath, D., Winder, G. S. American Psychiatric Press Inc. 2016; Second
• Delirium: Prevention and Management Protocols in Critical Care Maldonado, J. R. edited by Rodriguez-Villar, S. Marban. 2016; Third: 930?956
• Valproic Acid for Treatment of Hyperactive or Mixed Delirium: Rationale and Literature Review PSYCHOSOMATICS Sher, Y., Cramer, A. C., Ament, A., Lolak, S., Maldonado, J. R. 2015; 56 (6): 615-625

  View details for Web of Science ID 000366315400002

  View details for PubMedID 26674479

• The Stanford Integrated Psychosocial Assessment for Transplantation: A Prospective Study of Medical and Psychosocial Outcomes PSYCHOSOMATIC MEDICINE Maldonado, J. R., Sher, Y., Lolak, S., Swendsen, H., Skibola, D., Neri, E., David, E. E., Sullivan, C., Standridge, K. 2015; 77 (9): 1018-1030

  View details for DOI 10.1097/PSY.0000000000000241

  View details for Web of Science ID 000364497100007

  View details for PubMedID 26517474

• Adjunctive Valproic Acid in Management-Refractory Hyperactive Delirium: A Case Series and Rationale. journal of neuropsychiatry and clinical neurosciences Sher, Y., Miller, A. C., Lolak, S., Ament, A., Maldonado, J. R. 2015; 27 (4): 365-370

  Abstract

  Patients with delirium may fail to respond to standard therapies. Sixteen patients with management-refractory hyperactive delirium responded to adjunctive valproic acid, with complete resolution of hyperactive delirium in 13 cases. A rationale for using valproic acid in such circumstances is discussed.

  View details for DOI 10.1176/appi.neuropsych.14080190

  View details for PubMedID 25803136

• Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients: A New Scale for the Prediction of Complicated Alcohol Withdrawal Syndrome ALCOHOL AND ALCOHOLISM Maldonado, J. R., Sher, Y., Das, S., Hills-Evans, K., Frenklach, A., Lolak, S., Talley, R., Neri, E. 2015; 50 (5): 509-518

  Abstract

  The prevalence of alcohol use disorders (AUDs) among hospitalized medically ill patients exceeds 40%. Most AUD patients experience uncomplicated alcohol withdrawal syndrome (AWS), requiring only supportive medical intervention, while complicated AWS occurs in up to 20% of cases (i.e. seizures, delirium tremens). We aimed to prospectively test and validate the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), a new tool to identify patients at risk for developing complicated AWS, in medically ill hospitalized patients.We prospectively considered all subjects hospitalized to selected general medicine and surgery units over a 12-month period. Participants were assessed independently and blindly on a daily basis with PAWSS, Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) and clinical monitoring throughout their admission to determine the presence and severity of AWS.Four hundred and three patients were enrolled in the study. Patients were grouped by PAWSS score: Group A (PAWSS < 4; considered at low risk for complicated AWS); Group B (PAWSS ? 4; considered at high risk for complicated AWS). The results of this study suggest that, using a PAWSS cutoff of 4, the tool's sensitivity for identifying complicated AWS is 93.1% (95%CI[77.2, 99.2%]), specificity is 99.5% (95%CI[98.1, 99.9%]), positive predictive value is 93.1% and negative predictive value is 99.5%; and has excellent inter-rater reliability with Lin's concordance coefficient of 0.963 (95% CI [0.936, 0.979]).PAWSS has excellent psychometric characteristics and predictive value among medically ill hospitalized patients, helping clinicians identify those at risk for complicated AWS and allowing for prevention and timely treatment of complicated AWS.

  View details for DOI 10.1093/alcalc/agv043

  View details for Web of Science ID 000363934400004

  View details for PubMedID 25999438

• Prolonged neuropsychiatric effects following management of chloroquine intoxication with psychotropic polypharmacy. Clinical case reports Maxwell, N. M., Nevin, R. L., Stahl, S., Block, J., Shugarts, S., Wu, A. H., Dominy, S., Solano-Blanco, M. A., Kappelman-Culver, S., Lee-Messer, C., Maldonado, J., Maxwell, A. J. 2015; 3 (6): 379-387

  Abstract

  Susceptibility to quinoline antimalarial intoxication may reflect individual genetic and drug-induced variation in neuropharmacokinetics. In this report, we describe a case of chloroquine intoxication that appeared to be prolonged by subsequent use of multiple psychotropic medications. This case highlights important new considerations for the management of quinoline antimalarial intoxication.

  View details for DOI 10.1002/ccr3.238

  View details for PubMedID 26185633

  View details for PubMedCentralID PMC4498847

• The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A Two-Year Follow-Up of a Prospective Study of Medical & Psychosocial Outcomes 35th Annual Meeting and Scientific Sessions of the International-Society-for-Heart-and-Lung-Transplantation Maldonado, J. R., Sher, Y., Tobon, A. ELSEVIER SCIENCE INC. 2015: S174?S174

  View details for Web of Science ID 000353251500449

• Valproic Acid for Treatment of Hyperactive or Mixed Delirium: Rationale and Literature Review Psychosomatics Sher, Y., Cramer, A. C., Ament, A., Lolak, S., Maldonado, J. R. 2015; 56 (6): 615-625
• Delirium Psychiatric Care of the Medical Patient Maldonado, J. R. edited by Fogel, B., Greenberg, D. Oxford University Press. 2015; Third
• Hypnosis in Psychosomatic Medicine Psychiatric Care of the Medical Patient Maldonado, J. R. edited by Fogel, B., Greenberg, D. Oxford University Press. 2015; Third
• Acute Brain Failure: Identification & Management Handbook of Consultation-Liaison Psychiatry Maldonado, J. R. edited by Leigh, H., Streltzer, J. Springer. 2015; Second: 157?188
• An Insatiable Desire for Tofu: A Case of Restless Legs and Unusual Pica in Iron Deficiency Anemia PSYCHOSOMATICS Sher, Y., Maldonado, J. R. 2014; 55 (6): 680-685

  View details for Web of Science ID 000346182000019

  View details for PubMedID 25497506

• The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer. BMC medicine 2014; 12: 141-?

  Abstract

  Delirium is a common and serious problem among acutely unwell persons. Although linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.

  View details for DOI 10.1186/s12916-014-0141-2

  View details for PubMedID 25300023

  View details for PubMedCentralID PMC4177077

• The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): Systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol Maldonado, J. R., Sher, Y., Ashouri, J. F., Hills-Evans, K., Swendsen, H., Lolak, S., Miller, A. C. 2014; 48 (4): 375-390

  Abstract

  To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill.Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool.For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS.The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4.The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.

  View details for DOI 10.1016/j.alcohol.2014.01.004

  View details for PubMedID 24657098

• Dissociative Disorders Psychiatry Maldonado, J. R., Spiegel, D. edited by Tasman, A., Lieberman, J., Riba, M. Wiley. 2014; Fourth
• Dementia: Diagnosis & Management Handbook of Consultation-Liaison Psychiatry Sher, Y. I., Maldonado, J. R. edited by Leigh, H., Streltzer, J. Springer. 2014; Second
• Hypnosis Psychiatry Maldonado, J. R., Spiegel, D. edited by Tasmana, A., Kay, J., Lieberman, J., First, M., Riba, M. Wiley. 2014; Fourth
• Neuropathogenesis of Delirium: Review of Current Etiologic Theories and Common Pathways. American journal of geriatric psychiatry Maldonado, J. R. 2013; 21 (12): 1190-1222

  Abstract

  Delirium is a neurobehavioral syndrome caused by dysregulation of neuronal activity secondary to systemic disturbances. Over time, a number of theories have been proposed in an attempt to explain the processes leading to the development of delirium. Each proposed theory has focused on a specific mechanism or pathologic process (e.g., dopamine excess or acetylcholine deficiency theories), observational and experiential evidence (e.g., sleep deprivation, aging), or empirical data (e.g., specific pharmacologic agents' association with postoperative delirium, intraoperative hypoxia). This article represents a review of published literature and summarizes the top seven proposed theories and their interrelation. This review includes the "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," "neuroendocrine," "diurnal dysregulation," and "network disconnectivity" hypotheses. Most of these theories are complementary, rather than competing, with many areas of intersection and reciprocal influence. The literature suggests that many factors or mechanisms included in these theories lead to a final common outcome associated with an alteration in neurotransmitter synthesis, function, and/or availability that mediates the complex behavioral and cognitive changes observed in delirium. In general, the most commonly described neurotransmitter changes associated with delirium include deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release; and variable alterations (e.g., either a decreased or increased activity, depending on delirium presentation and cause) in serotonin, histamine, and/or ?-aminobutyric acid. In the end, it is unlikely that any one of these theories is fully capable of explaining the etiology or phenomenologic manifestations of delirium but rather that two or more of these, if not all, act together to lead to the biochemical derangement and, ultimately, to the complex cognitive and behavioral changes characteristic of delirium.

  View details for DOI 10.1016/j.jagp.2013.09.005

  View details for PubMedID 24206937

• Broken Heart Syndrome (Takotsubo Cardiomyopathy) Triggered by Acute Mania: A Review and Case Report PSYCHOSOMATICS Maldonado, J. R., Pajouhi, P., Witteles, R. 2013; 54 (1): 74-79

  View details for Web of Science ID 000313609900010

  View details for PubMedID 22795622

• Benzodiazepine loading versus symptom-triggered treatment of alcohol withdrawal: a prospective, randomized clinical trial GENERAL HOSPITAL PSYCHIATRY Maldonado, J. R., Nguyen, L. H., Schader, E. M., Brooks, J. O. 2012; 34 (6): 611-617

  Abstract

  The objectives were to compare the efficacy of a benzodiazepine loading versus a symptom-triggered protocol in the management of alcohol withdrawal.We conducted a prospective, randomized, controlled trial including 47 consecutive patients admitted to one of two tertiary care medical centers who developed alcohol withdrawal syndrome. Patients were randomly assigned to either a benzodiazepine loading protocol or a symptom-triggered treatment protocol. The Clinical Institute Withdrawal Assessment for Alcohol-Revised scale (CIWA-Ar) was recorded throughout the length of stay, along with measures of autonomic system functioning.The average rate of change of CIWA-Ar scores was -1.5 ± 1.3 for the symptom-triggered group and -2.3 ± 2.5 for the loading group. Average rate of change for systolic blood pressure was -2.7 ± 5.3 for the symptom-triggered group and -2.3 ± 6.4 for the loading group. There was no significant difference between the rates of change for either group on either measure. Similarly, there was no significant difference in total benzodiazepine use between groups. Within 72 h of treatment, 69.6% of patients in the loading group were free of withdrawal symptoms versus 41.7% in the symptom-triggered group, a difference not reaching statistical significance.This study did not reveal clear evidence of a clinical advantage for choosing either treatment method.

  View details for DOI 10.1016/j.genhosppsych.2012.06.016

  View details for Web of Science ID 000310672100005

  View details for PubMedID 22898443

• The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A New Tool for the Psychosocial Evaluation of Pre-Transplant Candidates PSYCHOSOMATICS Maldonado, J. R., Dubois, H. C., David, E. E., Sher, Y., Lolak, S., Dyal, J., Witten, D. 2012; 53 (2): 123-132

  Abstract

  While medical criteria have been well established for each end-organ system, psychosocial listing criteria are less standardized. To address this limitation, we developed and tested a new assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT).The SIPAT was developed from a comprehensive review of the literature on the psychosocial factors that impact transplant outcomes. Five examiners blindly applied the SIPAT to 102 randomly selected transplant cases, including liver, heart, and lung patients. After all subject's files had been rated by the examiners, the respective transplant teams provided the research team with the patient's outcome data.Univariate logistic regression models were fit in order to predict the transplant psychosocial outcome (positive or negative) using each rater's SIPAT scores. These results show that SIPAT scores are highly predictive of the transplant psychosocial outcome (P < 0.0001). The instrument has excellent inter-rater reliability (Pearson's correlation coefficient = 0.853), even among novice raters.The SIPAT is a comprehensive screening tool to assist in the psychosocial assessment of organ transplant candidates. Its strengths includes the standardization of the evaluation process and its ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient's candidacy. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used in combination with organ-specific medical listing criteria in order to establish standardized criteria for the selection of transplant recipients.

  View details for Web of Science ID 000301998100003

  View details for PubMedID 22424160

• Empirical findings on legal difficulties among practicing psychiatrists ANNALS OF CLINICAL PSYCHIATRY Reich, J. H., Maldonado, J. 2011; 23 (4): 297-307

  Abstract

  This article reviews the published literature on areas of legal difficulty among practicing psychiatrists.A literature search using PubMed identified studies of malpractice lawsuits or medical board discipline of psychiatrists between 1990 and 2009. Eight studies of physician discipline in the United States and one from the United Kingdom were identified. Information from 3 insurance companies and 3 sets of aggregated insurance company data also were available. One follow-up study of hospitalized psychiatric patients also was reviewed.Studies of medical board discipline indicate that, compared with other specialties, psychiatrists are at an increased risk of disciplinary action. Psychiatrists who were female, board certified, and in practice for a short period of time had a lower chance of medical board discipline. Psychiatry claims accounted for a very small proportion of overall malpractice claims and settlements. The amount of patient disability secondary to alleged malpractice was the most important variable predicting insurance payout.Psychiatrists appear to be disciplined by medical boards at an above-average frequency compared with other medical specialties. However, few malpractice suits reach the courts, and psychiatry represents a very small proportion of overall physician malpractice claims and dollars of settlement.

  View details for Web of Science ID 000297034500009

  View details for PubMedID 22073387

• An Approach to the Patient with Substance Use and Abuse MEDICAL CLINICS OF NORTH AMERICA Maldonado, J. R. 2010; 94 (6): 1169-?

  Abstract

  Substance use is ubiquitous among medically ill patients. The 2008 National Survey on Drug Abuse and Health survey estimated that 20.1 million Americans aged 12 years or older (8% of the US population) had used an illicit drug during the preceding month. Some licit substances also create havoc. The survey found that slightly more than half (56%) of Americans reported being current drinkers of alcohol. A total of 6.2 million (2.5%) Americans used prescription-type psychotherapeutic drugs for nonmedical purposes and 70.9 million Americans (or 28.4%) used tobacco during the survey period. Substance abuse problems were diagnosed in up to 36% of medically hospitalized patients for whom a psychiatric consultation was requested. Given how prevalent the use of substances is among the medically ill and their potential effect on comorbid medical conditions, it is important for physicians to be mindful of their prevalence and presentation. This article covers the presenting symptoms of intoxication and withdrawal states, addresses the acute management of the most commonly encountered substances, and summarizes all others in a table.

  View details for DOI 10.1016/j.mcna.2010.08.010

  View details for Web of Science ID 000284079600009

  View details for PubMedID 20951277

• Post-traumatic stress disorder (PTSD) is not a contraindication to gastric bypass in veterans with morbid obesity SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Ikossi, D. G., Maldonado, J. R., Hernandez-Boussard, T., Eisenberg, D. 2010; 24 (8): 1892-1897

  Abstract

  The veteran population is routinely screened for post-traumatic stress disorder (PTSD). The prevalence of obesity in this population continues to increase. We examined whether weight loss outcomes in veterans with PTSD is comparable to results in veterans who do not suffer from PTSD, after gastric bypass. We also examined the effect of bariatric surgery on PTSD symptoms.This retrospective review of prospective data compares veterans with and without PTSD who underwent laparoscopic gastric bypass. Differences between the means of age, initial BMI, and percent excess weight loss were compared between the groups using a Student's t test. Pearson's chi(2) was used to evaluate the relationship between a diagnosis of PTSD, major depressive disorder (MDD), and other Axis I psychiatric disorders. A similar analysis was done to assess for a relationship between PTSD and obesity-related comorbidities, including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, and GERD.We identified 24 patients who had gastric bypass and a diagnosis of PTSD before surgery and compared them to those without PTSD. Both groups had a similar mean age and initial BMI. There was no significant difference between the percent excess weight lost after 1 year follow-up between the PTSD group (66%) and the non-PTSD group (72%) (p = 0.102). In assessing comorbid conditions, we found a significant association between the diagnosis of PTSD and MDD (p = 0.002), PTSD and other Axis I disorders (p = 0.004), and PTSD and GERD (p = 0.002). However, we saw no significant association between PTSD and DM (p = 0.977), HTN (p = 0.332), and obstructive sleep apnea (OSA) (p = 0.676). The severity of PTSD symptoms fluctuated in the postoperative period.Veterans with PTSD have comparable weight loss to those without PTSD after gastric bypass. In addition, surgery does not seem to have an adverse effect on PTSD symptoms, although PTSD symptomatology tends to fluctuate over time. Further study in this patient population is warranted.

  View details for DOI 10.1007/s00464-009-0866-8

  View details for Web of Science ID 000279488400015

  View details for PubMedID 20063014

• The Impact of Depression in Heart Disease CURRENT PSYCHIATRY REPORTS Sher, Y., Lolak, S., Maldonado, J. R. 2010; 12 (3): 255-264

  Abstract

  Depression and heart disease affect millions of people worldwide. Studies have shown that depression is a significant risk factor for new heart disease and that it increases morbidity and mortality in established heart disease. Many hypothesized and studied mechanisms have linked depression and heart disease, including serotonergic pathway and platelet dysfunction, inflammation, autonomic nervous system and hypothalamic-pituitary-adrenal axis imbalance, and psychosocial factors. Although the treatment of depression in cardiac patients has been shown to be safe and modestly efficacious, it has yet to translate into reduced cardiovascular morbidity and mortality. Understanding the impact and mechanisms behind the association of depression and heart disease may allow for the development of treatments aimed at altering the devastating consequences caused by these comorbid illnesses.

  View details for DOI 10.1007/s11920-010-0116-8

  View details for Web of Science ID 000289731700015

  View details for PubMedID 20425289

• Current approaches to the recognition and treatment of alcohol withdrawal and delirium tremens: "old wine in new bottles" or "new wine in old bottles". Primary care companion to the Journal of clinical psychiatry Stern, T. A., Gross, A. F., Stern, T. W., Nejad, S. H., Maldonado, J. R. 2010; 12 (3)

  View details for DOI 10.4088/PCC.10r00991ecr

  View details for PubMedID 20944765

• Dexmedetomidine and the Reduction of Postoperative Delirium after Cardiac Surgery PSYCHOSOMATICS Maldonado, J. R., Wysong, A., van der Starre, P. J., Block, T., Miller, C., Reitz, B. A. 2009; 50 (3): 206-217

  Abstract

  Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances.The authors investigated the effects of postoperative sedation on the development of delirium in patients undergoing cardiac-valve procedures.Patients underwent elective cardiac surgery with a standardized intraoperative anesthesia protocol, followed by random assignment to one of three postoperative sedation protocols: dexmedetomidine, propofol, or midazolam.The incidence of delirium for patients receiving dexmedetomidine was 3%, for those receiving propofol was 50%, and for patients receiving midazolam, 50%. Patients who developed postoperative delirium experienced significantly longer intensive-care stays and longer total hospitalization.The findings of this open-label, randomized clinical investigation suggest that postoperative sedation with dexmedetomidine was associated with significantly lower rates of postoperative delirium and lower care costs.

  View details for Web of Science ID 000267537700004

  View details for PubMedID 19567759

• Aspects to consider when evaluating a live organ donor Focus: The Journal of Lifelong Learning in Psychiatry Maldonado JR 2009; VII (3)
• Delirium risk factors and treatment algorithm Focus: The Journal of Lifelong Learning in Psychiatry Maldonado JR 2009; VII (3)
• Pathoetiological Model of Delirium: a Comprehensive Understanding of the Neurobiology of Delirium and an Evidence-Based Approach to Prevention and Treatment 20th United States Psychiatric and Mental Health Congress Maldonado, J. R. W B SAUNDERS CO-ELSEVIER INC. 2008: 789-?

  Abstract

  Delirium is the most common complication found in the general hospital setting. Yet, we know relatively little about its actual pathophysiology. This article contains a summary of what we know to date and how different proposed intrinsic and external factors may work together or by themselves to elicit the cascade of neurochemical events that leads to the development delirium. Given how devastating delirium can be, it is imperative that we better understand the causes and underlying pathophysiology. Elaborating a pathoetiology-based cohesive model to better grasp the basic mechanisms that mediate this syndrome will serve clinicians well in aspiring to find ways to correct these cascades, instituting rational treatment modalities, and developing effective preventive techniques.

  View details for DOI 10.1016/j.ccc.2008.06.004

  View details for Web of Science ID 000260863000007

  View details for PubMedID 18929943

• Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin. Maldonado JR. 2008; 24 (4): 657-722
• Delirium following abrupt discontinuation of fluoxetine. Clin Neurol Neurosurg Blum D, Maldonado J, Meyer E, Lansberg M. 2008; 110 (1): 69-70
• Delirium following abrupt discontinuation of fluoxetine CLINICAL NEUROLOGY AND NEUROSURGERY Blum, D., Maldonado, J., Meyer, E., Lansberg, M. 2008; 110 (1): 69-70

  Abstract

  Sudden discontinuation of serotonin reuptake inhibitors (SRI) can lead to a number of psychological (e.g., nervousness, anxiety, crying spells, psychomotor agitation, irritability, depersonalization, decreased mood, memory disturbances, confusion, decreased concentration, and/or slowed thinking) and somatic (e.g., nausea, dizziness, headache) symptoms. Recent studies have shown that withdrawal symptoms are common with paroxetine, venlafaxine and fluvoxamine, but relatively rare and mild with fluoxetine cessation, likely as a result of its longer half-life. We report an unusual case of a patient who developed delirium after abrupt discontinuation of fluoxetine.

  View details for DOI 10.1016/j.clineuro.2007.08.016

  View details for Web of Science ID 000252799500013

  View details for PubMedID 17913343

• Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin Maldonado JR. 2008; 24 (4): 789-856
• Antidepressant and statin interactions: A review and case report of simvastatin and nefazodone-induced rhabdomyolysis and transaminitis PSYCHOSOMATICS Karnik, N. S., Maldonado, J. R. 2005; 46 (6): 565-568

  View details for Web of Science ID 000233116900009

  View details for PubMedID 16288136

• Social support and maladaptive coping as predictors of the change in physical health symptoms among persons living with HIV/AIDS AIDS PATIENT CARE AND STDS Ashton, E., Vosvick, M., Chesney, M., Gore-Felton, C., Koopman, C., O'Shea, K., Maldonado, J., Bachmann, M. H., Israelski, D., Flamm, J., Spiegel, D. 2005; 19 (9): 587-598

  Abstract

  This study examined social support and maladaptive coping as predictors of HIV-related health symptoms. Sixty-five men and women living with HIV/AIDS completed baseline measures assessing coping strategies, social support, and HIV-related health symptoms. The sample was primarily low-income and diverse with respect to gender, ethnicity, and sexual orientation. Three, 6, and 12 months after completing baseline assessments, physical health symptoms associated with HIV disease were assessed. After controlling for demographic characteristics, CD4 T-cell count, and baseline HIV-related health symptoms, individuals reporting lower increase in HIV-related health symptoms used less venting (expressing emotional distress) as a strategy for coping with HIV. However, when satisfaction with social support was added to the model, the use of this coping strategy was no longer significant, and individuals reporting more satisfying social support were more likely to report lower increase in their HIV-related health symptoms, suggesting that social support is a robust predictor of health outcomes over time independent of coping style and baseline medical status. These findings provide further evidence that social support can buffer deleterious health outcomes among individuals with a chronic illness. Future research needs to examine mediating pathways that can explain this relationship.

  View details for Web of Science ID 000232058300006

  View details for PubMedID 16164385

• Differences between long- and short-acting benzodiazepines in the management of alcohol withdrawal J Psychosomatic Research Maldonado JR, Brooks JO, Nguyen LH, Schader M 2005; 58: S61
• Alpha-2 agonist induced sedation prevents ICU delirium in post-cardotomy patients J Psychosomatic Research Maldonado JR, Wysong A, van der Starre PJ, Block T, Reitz B 2005; 58: S61
• Dissociative States in Personality Disorders Textbook of Personality Disorders; Oldham JM, Skodol AE, Bender DS (eds) Maldonado JR, Spiegel D 2005: 493-521
• Dexmedetomidine: can it reduce the incidence of ICU delirium? Psychosomatics Maldonado JR, van der Starre PJ, Block T, Wysong A 2004; 45 (2): 173
• Post-Operative Sedation and the Incidence of Delirium and Cognitive Deficits in Cardiac Surgery Patients Anesthesiology Maldonado JR, van der Starre PJ, Block T, Wysong A 2003; 99: 465
• Selective attention as possible mechanism of symptom production in conversion disorders J Psychosom Research Maldonado JR, Jasiukaitis P 2003; 55: 140
• Evidence of decreased incidence of extra-pyramidal symptoms with intravenous haloperidol J Psychosom Research Maldonado JR, Kang H 2003; 55: 140-141
• Hypnosis Psychiatry, Second Edition; Tashman A, Kay J, Lieberman J (eds) Maldonado JR, Spiegel D 2003: 1807-1837
• Dissociative Disorders Psychiatry; Tashman A, Kay J, Lieberman J (eds) Spiegel D, Maldonado JR 2003: 1452-1470
• Clinical implications of the recognition and management of delirium in general medical and surgical wards Psychosomatics Maldonado JR, Dhami N, Wise L 2003; 44 (2): 157-158
• Predictors of quality of life in HIV-infected individuals: the effects of immunological status and depression J Psychosom Research Maldonado JR, Israelski D, Diamond S, Chapman A, Koopman C, Spiegel D 2003; 55: 140
• Recognition and management of delirium in the medical and surgical intensive care wards J Psychosom Research Maldonado JR, Dhami N 2003; 55 (2): 150
• Postoperative sedation and the incidence of delirium and cognitive deficits in cardiac surgery patients Annals of Neurology Maldonado JR, van der Starre PJ, Block T, Wysong A 2003; 54: S27-28
• Ethical and psychosocial challenges in liver transplantation J Psychosom Research Withers NW, Hilsabeck RC, Maldonado JR 2003; 55: 116
• Liver Transplantation in alcoholic liver disease: selection and outcome J Psychosom Research Maldonado JR 2003; 55: 115-116
• Clinical and Financial Implications of the Timely Recognition and Management of Delirium in the Acute Medical Wards J Psychosom Research Maldonado JR, Wise L 2003; 55 (2): 151
• The role of the novel anesthetic agent dexmedetomidine on reduction of the incidence of ICU delirium in postcardiotomy patients J Psychosom Research Maldonado JR, Wysong A, van der Starre PJ 2003; 55 (2): 150
• Factitious Disorder-By-Proxy: when parents deceive their children?s doctors American Journal of Forensic Psychiatry Maldonado JR 2003; 24 (1): 1-22
• Ethical and clinical implications of liver transplantation in patients on methadone maintenance therapy J Psychosom Research Maldonado JR 2003; 55: 116
• Clinical characteristics, pathophysiology, and treatment of Conversion Disorders: A research based approach Psychosomatics Maldonado JR, Spiegel D 2003; 44 (2): 165
• Psychosomatic aspects in liver disease J Psychosom Research Withers NW, Maldonado JR, Hilsabeck RC, Dishman B 2003; 55: 115
• Acute stress reactions following the assassination of Mexican presidential candidate Colosio 13th Annual Meeting of the International-Society-for-Traumatic-Stress-Studies Maldonado, J. R., Page, K., Koopman, C., Butler, L. D., Stein, H., Spiegel, D. JOHN WILEY & SONS INC. 2002: 401?5

  Abstract

  Considerable evidence suggests that exposure to traumatic events increases the risk of developing anxiety-spectrum disorders in response to later traumatization. We conducted a survey in Guadalajara, Mexico to assess factors associated with acute stress reactions to the assassination of a political figure. Participants included 86 adults who completed the Stanford Acute Stress Reaction Questionnaire (SASRQ) and measures of the perceived impact of the assassination, exhibited emotional behavior following the assassination, and had exposure to a specific prior disaster (a gas pipeline explosion). The results suggest that acute stress reactions can occur in response to an assassination, and that those most susceptible are those most emotionally invested, those who engage in emotional behavioral responses, and those whose lives have been affected by a previous potentially traumatic event.

  View details for Web of Science ID 000177968900008

  View details for PubMedID 12392228

• Dissociative Disorders Textbook of Psychiatry, Fourth Edition; Talbot J, Yudosky S (Eds.) Maldonado JR, Spiegel D 2002: 709-742
• Hypnosis Textbook of Psychiatry, Fourth Edition; Talbot J, Yudosky S (Eds.) Maldonado JR, Spiegel D 2002: 1461-1516
• When patients deceive doctors: a review of Factitious Disorders American Journal of Forensic Psychiatry Maldonado JR 2002; 23 (2): 29-58
• Performance improvement: increasing recognition and treatment of postoperative delirium. Progress in cardiovascular nursing SHINN, J. A., Maldonado, J. R. 2000; 15 (3): 114-115

  View details for PubMedID 10951955

• The relationship between pain and coping styles among HIV-positive men and women PSYCHOLOGY & HEALTH Hart, S., Gore-Felton, C., Maldonado, J., Lagana, L., Blake-Mortimer, J., Israelski, D., Koopman, C., Spiegel, D. 2000; 15 (6): 869-879

  View details for Web of Science ID 000165761600011

• Intravenous versus oral haloperidol: An evaluation of the incidence of extra-pyramidal symptoms Psychosomatics Maldonado JR 2000; 41 (2): 169-170
• Treatment of Dissociative Disorders A Guide to Treatments That Work, 2nd Edition; Nathan PE, Gorman JM (Eds.) Maldonado JR, Butler L, Spiegel D 2000: 463-496
• Dissociation Encyclopedia of Stress; Fink G (Ed) Maldonado JR 2000: 714-722
• Immunological status versus depression as predictors of quality of life in HIV-infected individuals Immunological status versus depression as predictors of quality of life in HIV-infected individuals Maldonado JR, Koopman C, Spiegel D 2000; 41 (2): 186
• Medical Hypnosis Psychiatric Care of the Medical Patient.; Stoudemire A (Ed) Maldonado JR, Spiegel D 2000: 73-90
• The Relationship Between Pain and Coping Styles Among HIV-Positive Men and Women Psychology and Health Hart S, Gore-Felton C, Maldonado J, Lagana L, Koopman C, Blake-Mortimer J, Israelski D, Spiegel D 2000; 15: 869-879
• Hypnosis Effective Treatments for PTSD; Foa EB, Keane TM, Friedman MJ (Eds.) Cardeña E, Maldonado, J, van der Hart O, Spiegel D 2000: 247-279
• Conversion Disorder Review of Psychiatry-Volume 20: Somatoform and Factitious Disorders; Phillips KA (Ed.) Maldonado JR, Spiegel D 2000: 95-128
• Diagnoses of children and adolescents on initial presentation to a Nigerian outpatient psychiatry clinic INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY Lustig, S. L., Maldonado, J. R. 1999; 45 (3): 190-197

  Abstract

  Child and adolescent psychiatry is an underdeveloped specialty in Nigeria, relegated by more entrenched cultural systems, such as traditional healers and syncretic churches, to merely an auxiliary role in child mental health care. Little is therefore known about the epidemiology of childhood disorders as encountered in psychiatric settings. We reviewed the outpatient psychiatric clinic's patient register at the Psychiatric Hospital of Uselu in Benin City, Nigeria, over a twenty-four week period. Fifty-three patients who presented in the twenty-four week index period had definite diagnoses indicated in the register. Of these, 68% had diagnoses denoting significant behavioral disturbances that would motivate their visit to allopathic hospitals after other, more culturally sanctioned healers were of little help. Our findings are compared with similar studies in other cultures.

  View details for Web of Science ID 000083061600006

  View details for PubMedID 10576085

• Dissociative Disorders Textbook of Psychiatry; Talbot J, Yudosky S Spiegel D, Maldonado JR 1999: 711-738
• La Hipnosis y los Trastornos Posttraumáticos Anales de Psicologia Cardeña E, Maldonado JR, Spiegel, D 1999; 15 (1): 147-155
• Diagnoses of children and adolescents on initial presentation to a Nigerian outpatient psychiatry clinic Inter J Soc Psychiatr Lustig SL, Maldonado JR 1999; 45 (3): 190-197
• Immunological status vs. depression as predictors of quality of life in HIV-infected individuals Psychosomatics Maldonado JR, Koopman C, Gore-Felton C, Diamond S, Chapman A, Spiegel D 1999; 40 (2): 160
• Hypnosis Textbook of Psychiatry; Talbot J, Yudosky S (Eds.) Spiegel D, Maldonado JR 1999: 1243-1247
• Manual of Psychiatric Care in the General Hospital: Assesment Tools and Drug Treatment Recommendations & Protocols. Department of Pharmacy, Stanford Health Services. Maldonado JR 1998
• Trauma, Dissociation and Hypnotizability Trauma, Memory and Dissociation; Marmar R, & Bremmer D. (Eds.) Maldonado JR, Spiegel D 1998: 57-106
• Treatment of Dissociative Disorders A Guide to Treatments That Work; Nathan PE, Gorman JM (Eds.) Maldonado JR, Butler L, Spiegel D 1998: 423-446
• Conversion disorder: Are the symptoms the result of pure psychology or true physiological changes? Psychosomatics Maldonado JR 1997; 38 (2): 190-191
• Liver transplantation for alcoholic liver disease: selection and outcome. Clinics of North America: Clinics in Liver Disease W.B.Saunders Co. Maldonado JR, Keeffe EB 1997; 1 (2): 305-321,
• Treatment of dissociative disorders in Nathan PE, & Gorman JM (Eds.) A Guide to Treatments That Work. Oxford Press Maldonado JR, Butler L, Spiegel D. 1997: 423-446
• Hypnosis for Psychiatric Disorders Current Psychiatric Therapy II: Dunner, D (ed) Maldonado JR, Spiegel D 1996: 600-608
• Hypnosis in Tashman A, Kay J, & Lieberman J. (Eds.) Psychiatry. Philadelphia, PA: W. B. Saunders Company Maldonado JR, Spiegel, D 1996: 1475-1499
• The Psychophysiology of Conversion Disorders Psychosomatics Maldonado JR 1996; 37 (2): 216-217
• Hypnosis Psychiatry; Tashman A, Kay J, & Lieberman J. (Eds.) Maldonado JR, Spiegel D 1996: 1475-1499
• Using Hypnosis Women Molested in Childhood; Classen C. (Ed.) Maldonado JR, Spiegel D 1995: 163-186
• Treatment of Post Traumatic Stress Disorder Dissociation: Clinical, Theoretical and Research Perspectives; Lynn SJ, & Rhue J. (Eds.) Maldonado JR, Spiegel D 1994: 215-241