Psychiatric consultation on an otolaryngology liaison service

Otolaryngology patients (especially those with tracheostomies) present a significant challenge to psychiatrists from both a diagnostic and therapeutic standpoint. To date, no study has been made of psychiatric disorders among this important group of patients. At the Mount Sinai Medical Center, a liaison psychiatrist has been involved with a specialized otolaryngology cluster unit since 1979. Using a 384-item computerized database protocol developed at Mount Sinai, data on 139 otolaryngology patients were recorded and compared with 1662 "Other" inpatient psychiatric consultations on the medical and surgical services during 1980-1987. The otolaryngology patients as a group were more likely to be male (p = 0.011), married (p = 0.001) and employed (p less than 0.001). Cancer was the most common medical disorder, and the average level of stress as reported on DSM-III's Axis IV (5.1, severe) was significantly greater (p less than 0.0001) than that for the "Other." The most common psychiatric response was adjustment disorder (36%). The length of stay of those ENT patients seen in psychiatric consultation was 26.4 days, in contrast to 11.1 days for all ENT patients. However, the length of stay of those patients on ENT receiving a psychiatric consultation was not different from the "Other" psychiatric consultation cohort (26.3 days). Despite the higher level of stress, the incidence of significant psychiatric morbidity was lower for the ENT cohort. The primary effect of the liaison psychiatrist was to lower the threshold for case identification that enhanced the referral rate on the ENT unit.

Effects of copper deficiency on hepatic and cardiac antioxidant enzyme activities in lactose- and sucrose-fed rats

1. A number of dietary sugars are known to mediate the effects of copper deficiency. The effects of lactose (compared with sucrose) and a dietary Cu deficiency on hepatic and cardiac antioxidant enzyme activities and tissue mineral element status were investigated in the rat. 2. Groups (n 6) of male weanling Wistar rats were provided ad lib. with deionized water and diets containing sucrose (580 g/kg) or sucrose and lactose (387 g/kg and 193 g/kg respectively) with either control (12.0 mg/kg) or deficient (1.5 mg/kg) quantities of Cu for 77 d. 3. Animals consuming the low-Cu diets exhibited significantly decreased tissue Cu levels (P less than 0.01), hepatic and cardiac cytochrome c oxidase (EC 1.9.3.1, CCO) activities (P less than 0.01 and P less than 0.001 respectively) and hepatic Cu-zinc superoxide dismutase (EC 1.15.1.1, CuZnSOD) activity (P less than 0.05). The low-Cu diets also significantly decreased cardiac manganese superoxide dismutase (EC 1.15.1.1, MnSOD), catalase (EC 1.11.1.6) and glutathione peroxidase (EC 1.11.1.9, GSH-Px) activities (P less than 0.01, P less than 0.05 and P less than 0.001 respectively). 4. Hepatic Mn was significantly increased in both lactose-fed (P less than 0.001) and Cu-deficient (P less than 0.01) animals. These increases were unrelated to hepatic MnSOD activity. Cardiac Zn was significantly (P less than 0.01) increased in Cu-deficient animals. 5. Lactose feeding resulted in significantly increased cardiac CCO activity (P less than 0.001) but significantly decreased hepatic CuZnSOD (P less than 0.05), catalase (P less than 0.01) and GSH-Px (P less than 0.001) activities. 6. The activities of lactose dehydrogenase (EC 1.1.1.27, LDH) and glucose-6-phosphate dehydrogenase (EC 1.1.1.49, G6PDH) were found to be significantly (P less than 0.05 and P less than 0.01 respectively) increased in Cu-deficient animals and G6PDH activity was significantly (P less than 0.01) decreased as a result of lactose consumption. 7. The observed changes in antioxidant enzyme activities associated with both Cu deficieny and lactose consumption may have important implications for the development of free radical mediated cell damage. However, no significant differences in either hepatic or cardiac levels of thiobarbituric acid reactive substances, a measure of lipid peroxidation, were found.

Reliability, validity, and temporal stability of the geriatric depression scale in hospitalized elderly

The reliability, validity, and temporal stability of the Geriatric Depression Scale (GDS) were studied in sixty-nine elderly patients who had their broken hips surgically repaired. The GDS demonstrated internal consistency reliability and concurrent validity with the Hamilton Depression Rating Scale. In addition, the GDS was stable across the hospital stay and thus appeared to be less influenced by the patients' acute health status.

Increased hepatic lipid peroxidation with methionine toxicity in the rat

Consumption of excess methionine by rats is known to cause membrane damage, liver enlargement and accumulation of iron in the spleen. In this study two groups (n = 5) of male, Wistar rats were pair-fed either a methionine supplemented (20.0 g/kg) or control (2.0 g/kg) diet for 7 weeks. Hepatic and erythrocyte copper-zinc superoxide dismutase activities were significantly reduced (P less than 0.05 and P less than 0.001 respectively) by methionine supplementation while the activities of catalase (P less than 0.01 and 0.05) and glutathione peroxidase (P less than 0.05) were significantly increased. Methionine supplementation also increased hepatic lipid peroxidation (P less than 0.01), as measured by the level of thiobarbituric acid reactive substances, and iron (P less than 0.001) concentrations. These changes are indicative of increased oxidative stress resulting from methionine toxicity.

Psychiatric consults on medical and surgical wards: a six year study

Using a psychiatric consultation database 1,463 consults were completed over a six-year period (1980 to 1986). Many variables were studied, including demographics, who requested the consults, the reasons for consultation, DSM-III diagnoses, and treatment recommendations. Most variables were unstable from year to year despite thorough and consistent supervision. This study demonstrates the vulnerability of traditionally reported consultation data in establishing norms for defining psychiatric morbidity in the hospital. Future recommendations are discussed.

A reassessment of diet and osteoporosis--possible role for copper

Much emphasis has centred on the role of dietary calcium and calcium supplementation in the pathophysiology and prevention of osteoporosis. Yet there is accumulating evidence that current recommendations on preventive measures are at best of little value and are inconsistent with the available epidemiological data. It is proposed that more attention should be given to dietary trace elements, especially copper, in the aetiology of post-menopausal osteoporosis. Osteoporotic lesions attributable to copper deficiency have been described in both man and animals and the hypothesis that a mild dietary copper deficiency may be implicated in the onset and progression of osteoporosis is also consistent with the epidemiological evidence. Many western diets are low in copper but in addition milk and milk products are amongst the poorest sources of copper and lactose may interfere with copper metabolism. Current recommendations, therefore, for the prevention of osteoporosis may actually be detrimental to health.

Treatment opportunities on a consultation/liaison service

The amount of time consultation psychiatrists in a large metropolitan teaching hospital spent providing direct services was studied over 1,104 consecutive consultation cases. Although the majority of cases required less than 5 hours of psychiatric time apiece, more than 10% of these cases each received more than 10 hours of direct services. This finding has important implications for understanding the types of psychiatric services provided to hospitalized medical/surgical patients.

Interventions in consultation-liaison psychiatry: the development of a schema and a checklist for operationalized interventions

A literature review and pilot investigations reveal that (ward-) management consultation-liaison (C/L) psychiatry recommendations are infrequent and unsystematically used. Furthermore, the communication with the operational group as defined by Meyer and Mendelson is not sufficiently activated. The major focus of the consultation is the first contact, but follow-up is infrequent. With the exception of biologic recommendations and disposition, chart notes by psychiatric consultants do not sufficiently specify the actions to be taken by the ward staff in a general hospital. A schema for the systematic organization of the intervention was developed. A checklist of operationalized C/L interventions is reported. This combination provides a tool for the systematic use of strategic ward management and discharge recommendations. Its basic structure is currently integrated in MICRO CARES [Hammer et al, SCAMC]. The impact on clinical care, education, and research is described.

Milk consumption, lactose and copper in the aetiology of ischaemic heart disease

Milk is a poor source of copper--a nutrient which is known to be limiting or marginal in many western diets. Lactose (a major nutritional constituent of milk) may interfere with copper utilization in milk and in the overall diet. It is postulated that the strong association between the consumption of milk and dairy products (especially fresh milk and non-fermented milk products) and the incidence of ischaemic heart disease (IHD) indicates a central role for a dietary copper deficiency in the aetiology of this disease.

Screening devices for diminished cognitive capacity

This study compares three commonly used tests to detect organic mental disorders: the Mini-Mental State (MMS), Cognitive Capacity Screening Examination (CCSE), and Tachistoscope (T-Scope). Ninety-seven medical-surgical inpatients at the Mount Sinai Hospital referred for psychiatric consultation had a Missouri Mental Status Examination performed by a psychiatrist who also rated the patients' organic mental disorder as "none," "mild," "moderate," or "severe." The CCSE, MMS, and T-Scope, respectively, showed: sensitivity--0.54, 0.52, 0.68; specificity--0.85, 0.76, 0.79; and positive predictive value--0.83, 0.74, 0.79. False negatives occurred more often among those patients with mild organic mental disorders with all instruments (p = 0.05), while the T-Scope could not be administered in 27% of the patients. Screening instruments with increased acceptability, sensitivity, and specificity need to be developed to identify a potentially life-threatening disorder.

Chronic occupational exposure to asbestos: more than medical effects?

One hundred and twenty-nine workers chronically exposed to asbestos were interviewed regarding their perceived health status and concerns, their health behaviors, particularly their smoking behavior, and their psychologic well-being. In contrast to a non-exposed comparison group of postal workers, asbestos workers exhibited significantly elevated levels of somatic concern (P less than .03), and significantly lower levels of mental health functioning only when experiencing high levels of stress (P less than .01). Despite feeling significantly more susceptible to developing cancer (P less than .0001), 34% of asbestos workers were cigarette smokers (compared to 32% of the postal group) and long-term mask usage was minimal. Asbestos workers' increased sensitivity to stress and changes in health status along with the lack of adaptation of health-promotive behaviors indicate the need for interventions to attend to the psychologic effects of increased risk status.

Appraisal of marketing approaches for consultation-liaison psychiatry

The high prevalence of undetected and undertreated mental disorders in the general health care sector suggests that the active "marketing" strategies proposed in these articles are overdue. However, a more extensive data base that documents the need for psychiatric involvement in the medical setting and assesses the capacities of other mental health professionals to substitute for consultation-liaison (C-L) psychiatrists in clinical care, teaching, and research is urgently needed and will prove to be the most potent marketing tool available to the specialty.

Impact of psychiatric comorbidity on length of hospital stay for medical/surgical patients: a preliminary report

The impact of psychiatric comorbidity on the length of hospital stay was addressed in a study of all medical/surgical patients discharged in 1984 from the Mount Sinai Hospital in New York City (N = 37,370) and Northwestern Memorial Hospital in Chicago (N = 21,889). At both hospitals the mean +/- SD length of stay of the patients with psychiatric comorbidity was significantly longer than that of the other patients: 19.8 +/- 33.3 versus 9.2 +/- 15.3 days at Mount Sinai Hospital and 13.7 +/- 27.7 versus 8.3 +/- 13.2 days at Northwestern Memorial Hospital. Early identification of patients with psychiatric comorbidity would permit appropriate psychosocial intervention, which might shorten their hospital stays.

Ombudsman Rounds on the otolaryngology service

An attempt to enhance psychiatric teaching on the Otolaryngology Service was undertaken by employing the vehicle of Ombudsman Rounds. The structure of these rounds is dictated by its major goal of maximizing the relationship of the surgeon and liaison psychiatrist as coteachers among the staff of the ENT surgical unit. Surgical residents, surgical clerks, nurses, and the social worker meet with the Chairman of the ENT Department and the liaison psychiatrist in a scheduled weekly conference, which addresses both staff and patient needs on the in-patient surgical service. Through patient interviews, multidiscipline staff presentations, chief of service surgical and prognostic summaries, and liaison psychiatrists' formulations, group discussions are undertaken. Through such an experience the staff become aware of the patient's feelings and understandings about their illness and care. The goal of Ombudsman Rounds is to enhance patient care, advance psychiatric knowledge of the multidiscipline staff, and provide an ongoing vehicle to change attitudes so that they incorporate a biopsychosocial approach to patient management on the ENT Service.

Models of mental health training for primary care physicians: a validation study

Since the majority of persons with alcohol, drug abuse, and/or mental disorders (19%) of Americans during any 6-month period are seen exclusively within the general health sector, it is imperative to know the quality and quantity of mental health training for primary care residents. In this study, the five program training model types previously described--Consultation, Liaison, Bridge, Hybrid, Autonomous--are validated by a random sampling technique using a structured instrument to test eight hypotheses developed before data collection to preclude post hoc interpretations. Of 250 programs, 147 responded (60%): 67 Family Practice, 42 Primary Internal Medicine, and 38 Internal Medicine. Since all eight hypotheses were supported by the data, the construct validity of the program model types is significantly substantiated. Multiple discriminant analysis revealed that the relationships between twelve training program characteristics and the five program model types were such that the former could explain 57% of the variance in the latter and correctly classify 89% of the programs.

Consortium-based consultation/liaison research: commentary and perspective

Although a consortium approach for clinical trials is a common research strategy which has made important contributions in other disciplines in medicine, to date it has not been employed for research efforts in the consultation/liaison setting. There are several reasons for this: the relative newness of the field, lack of administrative control over patient care, and the unavailability of a standard methodology that could be adapted to multiple sites. Four basic research strategies can be employed within the framework of a research consortium to advance scientific knowledge in consultation/liaison psychiatry: 1) prevalence studies of psychiatric morbidity in medical settings; 2) interrelationship among psychiatric and medical conditions; 3) the outcome of psychiatric interventions within medical milieu; and, 4) cost-benefit evaluation. A field-tested computerized database protocol and a software system usable on an office-based microcomputer were employed to obtain standardized data across multiple training sites. The advantages and disadvantages of consortium studies are described.

Psychiatric emergencies in the general hospital

Using a psychiatric consultation data base, 1257 referrals were classified into "stat" (14%), "today" (44%), and "routine" (42%) status of urgency. "Stat" referrals compared to the "today" and "routine" group were more likely to be male, highly educated, and 20-39 years old or over 80 years of age. The "stat" group was referred more often for the management of behavior and suicide risk evaluation, and received more diagnoses of organic mental disorders than the other referrals. An increased number of "stat" patients required constant observation on the medical/surgical ward, narcotic or neuroleptic administration, and inpatient psychiatric treatment.

The role of psychiatry in the training of primary care physicians

The question of psychiatry's role in medicine, and in particular its role in the training of primary care physicians (PCPs), is heightened by the knowledge that 60% of the 15% of patients who have DSM-III diagnosable alcohol, drug abuse, and mental health (ADM) disorders are seen exclusively in the general health sector. In addition, although PCPs have a low recognition rate of ADM disorders and are pessimistic about their outcome even with treatment, they prescribe the majority of tricyclic and anxiolytic medications. Models of mental health training for PC residents in training are examined, with particular emphasis on competencies taught, pedagogic vehicles, disciplines of the mental health teacher, and the relationship to departments of psychiatry. A computerized approach to assist the mental health training of primary care physicians developed at the Mount Sinai School of Medicine and Northwestern is presented. Finally, critical policy issues with regard to psychiatry's future role in training is described.

The timing of psychiatric consultation in the general hospital and length of hospital stay

Four hundred nineteen consecutive consult cases were studied to determine the relationship of the timing of the consult to hospital length of stay. Results indicated that earlier consultations predicted shorter lengths of stay. Applications of the present methodology to more complex evaluations of psychiatric consultation are discussed.

The problem of alcohol in the medical/surgical patient

The authors report the results of a computerized data-based study of 845 general hospital patients seen by a consultation-liaison psychiatry service in a major urban hospital. The findings indicate that only 5.2% of the referrals were for the problem of alcohol. Furthermore, the detection rate of an alcohol problem by both the referring physicians and the psychiatric consultants was low (8.3%) as compared with the literature's reported prevalence rate of alcoholism in the general hospital (8.7%-55%). The problem of recognition of an alcohol problem in the medical/surgical patient is explored with particular emphasis on the obstacles to diagnosis--masking of alcoholism by other major psychiatric disease, the categorization of patients by symptom rather than underlying causation, and the lack of sufficient employment of useful diagnostic screening devices.

Consultation-liaison psychiatry and cost-effectiveness research. A review of methods

In light of the increasing emphasis on cost-effectiveness evaluations of consultation-liaison interventions, it becomes important for researchers to be cognizant of the available statistical methods. With this in mind, the present article reviews eight strategies of cost-effectiveness research and discusses their relative strengths and liabilities.

Toward the integration of psychosocial services in the general hospital. The human services department

This article describes an innovative administrative organization for the delivery of psychologic care in the contemporary teaching hospital that, by combining services under medical leadership, takes an evolutionary beyond multidisciplinary team approaches. The long-range goal of this organization is to provide cost-effective psychosocial services in the general hospital while maintaining the unique role contributions of the participating disciplines. To allow for informed decision making in this process, the initial step has been to establish a collaborative data base for patient and staff tracking, program planning, and evaluation.

Informed consent--mandating the consultation

This article illustrates how a mandatory consult procedure identified treatable psychiatric problems. Using a computerized data-based format, 372 (37.4%) patients (the "judgment" group) of 996 psychiatric consultations were identified as referred to assess the patient's capacity to execute a consent form for a medical or surgical procedure. One hundred twenty-nine (35%) of the 372 patients thus referred by hospital mandate were given psychiatric diagnoses (DSM-II) by the consultant and received recommendations for primary psychiatric treatment. The "judgment" group had significantly more organic brain syndrome and psychoses associated with CNS conditions (p less than 0.001), whereas the "nonjudgment" group was diagnosed as exhibiting significantly more neurosis, alcoholism, psychophysiologic disorders, transient situational reactions, and personality disorders (p less than 0.001). Without a required psychiatric consultation sanctioned by administrative hospital mandate, the majority of the "judgment" cases with major psychopathology would not have been identified. The use of the mandated psychiatric consultation in the general hospital is discussed.

Medical and surgical inpatients who referred themselves for psychiatric consultation

Medical and surgical inpatients who referred themselves for psychiatric consultation are characterized. The 25 "self-referred" compared to 787 "others" referred to the Consultation-Liaison Psychiatry Division were more likely to state depression (52%/25%) and anxiety (36%/11%) as reasons for referral. "Self-referrals" were less likely to be referred by physicians for behavior management (8%/23%), general diagnosis (4%/22%) or suicide evaluation (4%/25%). The "self-referral" represents a challenge to the current medical model referral mechanism in which the physician controls access to consultants. The data indicate that there should be a mechanism for the patient's contribution to the referral process and that increased sensitivity to psychologic difficulties in coping with medical illness would improve the use of psychiatric consultation in the medical setting.

Microcomputers and consultation psychiatry in the general hospital

The microcomputer allows for the design of a system that functions integrally with both the day-to-day and long-term needs of a consultation-liaison psychiatric service. This article describes a microcomputer system and data structure that can accomplish many of the same research tasks as a minicomputer system. In addition, the same data item inputs can be used to develop management reports that can facilitate the administrative as well as the pedagogic needs of a consultation-liaison service. Because of the daily availability and review of output reports, supervisors' corrections are made that enhance the reliability of the data. The program format provides 1) an intake form with pertinent identifying demographic data; 2) an activity file that contains every encounter between the consultant and the patient as well as research, supervisory, and liaison activities (which permit cost-effectiveness analysis); 3) a master clinical data base containing 255 variables for each case seen; 4) a computer-generated chart note; 5) letters to referring physicians; 6) clinical activity descriptions for billing; and 7) a file for pertinent literature searches. Since certain analyses may be limited in the microsystem, its interactive capacity with mainframe computers allows for complex functions. The microsystem described presently emphasizes flexibility, accessibility, and step-by-step development of files as needed by a particular consultation-liaison service. Finally, microcomputers are available at a fraction of the cost of the minicomputer or mainframe systems.

A minicomputer approach to consultation-liaison data basing: Pedagog-Admin-CLINFO

Minicomputer systems have been designed for researchers who have no prior computer experience and, therefore, require no computer training, that is, programming knowledge. Such systems allow immediate access to the data, their retrieval, reduction, and analysis, and the retention of direct control over the data base by the researcher. In addition, CLINFO offers a wide range of calculations and statistical procedures. The three-dimensional, time-oriented data-base format of CLINFO allows for a longitudinal study of a particular variable, and its repeated measure over time in the same patient. This system has been adapted for use in the consultation-liaison setting to provide pedagogic, research, and administrative functions from a field-tested data base.

Models of mental health training for primary care physicians

Of the 15% of the population with DSM III diagnosable disorders, 54% are seen exclusively by their primary care physician or by other health professionals. To understand how primary care physicians are prepared for this task the authors attempted to develop a taxonomy of mental health training programs for primary care physicians by: review of the literature, interviews with program sponsors, review of NIMH training grants, and site visits to teaching programs. From this process six program types were defined: consultation, liaison, bridge, hybrid, autonomous, and postgraduate specialization. The characteristics and emphasis of these model types are described as well as program needs for future training. Competence in psychosomatic medicine, psychophysiologic reactions, and the interactions of biologic, psychologic, and social factors in health and disease can be imparted to primary care physicians by such mental health training program designs.

L-tryptophan does not increase weight loss in carbohydrate-craving obese subjects

Eight subjects, aged 26 to 50 years, who had long histories of carbohydrate (CHO) craving and were more than 45 kg above desirable body weight participated in a randomized, double-blind, crossover pilot study on the effects of L-tryptophan on weight loss and mood state. One g of tryptophan with 10 g of CHO was administered three times a day, 30 min before meals, as an adjunct to a weight-loss protocol that included nutritional consultation teaching low fat, high fiber diets ranging from 1200-1600 kcals/day, behavior modification, and supportive therapy. During the pretreatment period, body weight and plasma tryptophan levels were measured and the Beck Depression Inventory, SCL 90 rating, and Profile-of-Mood State (POMS) were used to assess mood. During the treatment periods, subjects kept daily records of food intake and the timing of medication. All patients were seen at least biweekly. After six weeks on medication, baseline measurements were repeated and the crossover between tryptophan and placebo was implemented. After an additional six weeks on placebo or tryptophan, the same measurements were repeated. For the eight patients who completed the three-month protocol, the mean weight loss for six weeks on placebo was 1.14 kg and for six weeks on tryptophan was 2.3 kg. Mean Beck scores were 8.8 during the control period, 8.3 on placebo, and 10.9 on tryptophan. Mean SCL 90 ratings were 69.2 during the control, 54.6 on placebo, and 64.2 on tryptophan. Mean scores for total mood disturbance on the POMS were 48 during the control period, 43 on placebo, and 52 on tryptophan.(ABSTRACT TRUNCATED AT 250 WORDS)

The liaison clinic: a model for liaison psychiatry funding, training, and research

While liaison or similar clinics have existed since at least 1931, they remain uncommon. The Mount Sinai Medical Center Liaison Clinic is presented as a model for psychiatric evaluation and care of medical patients as well as training, research, and funding. In addition, it is a model for linking general and mental health systems in the tertiary care setting. The first year of operation of the clinic is described, including the sources of referral, demographic data, psychiatric, and medical diagnoses, and type of clinic contact. A total of 96 patients were seen in 390 visits, equaling three quarters of a liaison fellow's salary.

Do fat cell morphometrics predict weight loss maintenance?

A comprehensive psychosocial approach was used to treat 44 otherwise healthy obese patients, 49-332 percent above desirable weight, whose fat cell morphometrics arbitrarily placed them into three groups: seven with predominant fat-cell hypertrophy, 18 with predominant hyperplasia, and 19 with mixed hypertrophy and hyperplasia. Continuous psychological support was provided to all patients, and life-style was altered by nutrition education and behavior modification. Psychiatric referral was made when indicated. Four of the 45 patients, who were refractory to treatment, were referred for surgery. Successful treatment was defined as maintenance of a weight loss of 18 kg or more for one year. Two of the seven hypertrophic, seven of the 18 hyperplastic, and 11 of the 19 mixed hypertrophic-hyperplastic patients had successful results without surgery. Overall success rate was 45 percent, and did not differ significantly according to fat cell morphometrics. Although greater weight losses were maintained in correlation with the extent of hyperplasia P less than 0.005, the percentage weight change from intake weights was similar. In summary, a program of continuous psychological support, nutrition education, and behavior modification resulted in a substantially higher rate of successful one-year maintenance of weight loss than is generally reported for the treatment of markedly obese patients. Further long-term follow-up is in progress. In contradiction to predictions based on adipose cell morphometrics, those patients with simple hypertrophy of their fat cells were not more successful in maintaining a weight change. Although maintenance varied from 18.2 kg to 52 kg for those successfully treated, a weight loss of approximately 20 percent of the intake was sustained.

Self-amputation and restitution

This paper reports two cases of psychotically induced self-amputation of the hand, and discusses the psychological issues for the patient and staff involved in replantation and adaptation. The psychiatrist's role in facilitating patients' and staffs' utilization of restorative innovative techniques is also addressed.

Care of the psychotic self-amputee undergoing replantation

The acutely psychotic self-amputee may be brought to the emergency room out of control, refusing treatment. Although these conditions make it difficult for the surgeon to provide restorative surgery, these patients may be quite grateful when resolution of psychosis restores realistic thinking and better judgment. This article describes the treatment of two such patients and provides practical guidelines for general behavioral management. The focal point of the approach is the formation of a surgeon/psychiatrist team that actively and consistently confronts and manages the disturbed behavior from the time the patient arrives in the emergency room until after discharge. Responsibility for deciding to operate when the patient is verbally refusing must be shared by surgeon and psychiatrist. Both surgeon and psychiatrist must be active in the treatment, each contributing his particular expertise to the collaborative effort.

Needs for psychiatry in the general hospital

Thirty to 60 per cent of the patients in general hospitals suffer from significant psychological dysfunction or psychological dysfunction secondary to their medical illness. In addition to helping medically ill patients adapt to their illness and hospitalization, psychiatrists who work in general hospitals should develop the biopsychosocial model of diagnosis and management and improve the staff's capacity to detect, diagnose, and manage their patients' psychological problems. The author discusses specific needs for consultation-liaison psychiatry in the general hospital such as development of prevention scheme, case detection, continuing education programs for staff, and education groups for patients and families. He also describes structural innovations to meet the increasing demands for psychiatric services in the general hospital setting. These innovations include the establishment of a biopsychosocial data-base system and the use of screening devices, medical-psychiatric inpatient units, and medical-psychiatric aftercare clinics in ambulatory facilities.

Mild Hypogonadotropic hypogonadism in obese men

To evaluate the pituitary-gonadal axis of obese men, we compared the 24-hour mean plasma concentrations of total and free testosterone and of dihydrotestosterone, FSH, and LH in 21 healthy obese men, aged 18-50, and 24 age-matched healthy nonobese men. In the obese men, we also measured the volume of ejaculate and the number and motility of sperm, and investigated libido by psychiatric interview, and potency by history and by measurement of nocturnal penile tumescence. As a group, the obese men had less than two-thirds the normal mean plasma levels of total testosterone, free testosterone, and FSH; the difference from normal was highly significant for all three. 24 hr LH levels were normal, which is inappropriately low in view of the subnormal testosterone levels. 24 hr mean levels of dihydrotestosterone and spermatogenesis, libido, and potency were essentially normal. Taken together, the findings represent a state of mild hypogonadotropic hypogonadism, which thus appears to be characteristic of obese men. This abnormality probably results from partial suppression of the pituitary by the elevated plasma estrogen levels we and others find in these men.

Sex difference in the influence of obesity on the 24 hr mean plasma concentration of cortisol

The 24 hr mean plasma cortisol concentration was measured in 65 healthy women ranging from 21% below to 218% above desirable weight and in 47 healthy men ranging from 5% below to 330% above desirable weight. In the women, there was a clear-cut inverse linear correlation between the plasma cortisol concentration and the percent deviation from desirable weight (y = 7.5 -- 0.3 x; r = -0.49; p less than 0.001); the relation of free to total cortisol concentration was weight-invariant; the MCR of cortisol in the most obese women was much higher than that of nonobese women (340 +/- 76 versus 211 +/- 31 liters/gm urinary creatinine; p less than 0.01). In the men, the plasma cortisol level and MCR were weight-invariant. To account for the finding in women of a linear correlation of the decrement in plasma cortisol level with the percent deviation from desirable weight (which in turn is nearly perfectly correlated with the total body fat content), we postulate that a given weight of adipose tissue in women takes up a constant amount of cortisol; this in turn suggests that their adipose tissue contains a saturable binding system such as corticosteroid receptor. By the same logic, the weight-invariance of plasma cortisol and MCR in men suggests the absence of significant amounts of corticosteroid receptor in their adipose tissue. The finding that the increased cortisol MCR of obese women results in decreased plasma cortisol levels rather than an increase in cortisol production (the latter, corrected for muscle mass, is normal in obesity: Strain et al, Metabolism 29:980, 1980) suggests a defect in their cortisol ACTH feedback system. Such a defect, presumably hypothalamic, is not unexpected in the light of reports of defective hypothalamic control of prolactin and growth hormone secretion in obesity.

Liaison psychiatry-otolaryngology rounds

In an attempt to define and resolve patient and staff needs with regard to the psychological, social and economic problems in clinical otolaryngology, psychiatry/otolaryngology rounds were established in the Department of Otolaryngology 18 months ago. These weekly rounds have contributed greatly to improved patient care and better physician-nurse relations. They have also served a significant educational role for residents, medical students and other members of the patient care team. At present the rounds are attended by the inpatient nursing staff, 2 physicians, 6 residents, 3 medical students, an otolaryngologic social worker and the liaison psychiatrist. The meeting begins with a 10 minute discussion and review of current problems among the staff. Attention is then directed to the patient who will be interviewed for the day. The medical and social history are presented. Then the patient is brought in and interviewed in a non-stressful session for 20 minutes. After the patient leaves, the staff discusses the problems which the patient has encountered or poses to them, and the conference participants formulate an appropriate therapeutic plan. Among the problems which have been discussed are noncompliance, organic mental syndromes, hypochondirasis, depression, death and dying, disfigurement, loss of bodily function, and chronic pain. For those patients in whom further psychiatric evaluation and treatment are deemed necessary, the psychiatrist becomes an active participant in their clinical care.