Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review

Despite the increased morbidity and mortality associated with psychiatric illnesses, there remains a substantial level of inaccuracy of the initial psychiatric diagnoses given by nonpsychiatric physicians. This study examines the accuracy of initial psychiatric diagnoses by non-psychiatric physicians at the McGill University Health Center (MUHC).We conducted a retrospective chart review for all consultations requested from the consultation-liaison psychiatry service at MUHC. We included all the consultations from January 1, 2018, to December 30, 2018, and excluded patient data with established psychiatric diagnoses. In all requested consults, each diagnosis of a referring physician was compared with the final diagnosis given by the C-L psychiatry team. Conformity between the 2 was validated as accurate.Of the 980 referred inpatients, 875 were enrolled. Patients ranged in age and those older than 70 years constituted the largest group: 54.4% were male. For 467 patients (55.20%), the initial diagnostic impression given by the referring physicians agreed with the final diagnosis made by the C-L psychiatry team, while in 379 patients (44.80%), the initial diagnostic impression was not consistent with the final diagnosis made by the C-L team.Diagnostic impressions of neurocognitive and substance use disorders were highly accurate, but this was not the case when the referring physicians suspected depression or bipolar, personality, or psychotic disorders. This study shows that around half of the referrals were accurately diagnosed, which evinces that nonpsychiatric physicians’ knowledge regarding psychiatric conditions is not optimal and that might negatively impact screening and treating these conditions.     

Brief integrated outpatient dual-diagnosis treatment reduces psychiatric hospitalizations

A retrospective pilot study was conducted to determine whether a relatively brief integrated outpatient treatment for patients with dual disorders reduced inpatient hospital service utilization. Outpatients (n=44) with substance dependence and either comorbid schizophrenia, major depressive disorder, or bipolar disorder were studied. A multidisciplinary team provided relatively brief (up to 24 weeks), integrated, dual-diagnosis outpatient treatment. A significant 60% reduction in the number of psychiatric hospitalization days was found for the year after treatment as compared to the year before. Patients with schizophrenia showed the greatest reduction (74%) in hospitalization days. Thus, even brief integrated outpatient dual-diagnosis treatment can reduce inpatient psychiatric hospitalizations.     

The identification of psychiatric illness by primary care physicians

Objective:This study tested several hypotheses about why women are more likely than men to have psychiatric disorders noted by their primary care physicians. Design:Patients were screened for mental disorders using the General Health Questionnaire. A stratified sample was assessed using the Schedule for Affective Disorders and Schizophrenia. Information on utilization and identification of mental bealth problems was abstracted from the medical records. Setting:The study was conducted at a multispecialty group practice in a semirural area of Wisconsin. Patients:Study participants consisted of a stratified probability sample of 247 patients seeking primary care. Results:Patients with a psychiatric illness who were relatively frequent users of the clinic were most likely to be identified by a physician as having a mental health problem. When psychiatric illness and utilization rates were statistically controlled, men and women had comparable identification rates. Supported in part by a contract (DBE-77-0071) and grant from the National Institute of Mental Health (MH-33940) and a grant from the Robert Wood Johnson Foundation.     

Diagnosis and management of hypertension by physicians in the Federal Republic of Germany.

Diagnosis and management of hypertension by physicians in two large cities in the northwest of Germany were studied in 1988. Three hundred and fifteen out-of-hospital physicians (71%) responded to a mailed questionnaire. Sixty-eight per cent reported measuring blood pressure at almost each patient visit and 36% involved allied health professionals in the measurement process. Only 63% used disappearance of sound for the diastolic reading (phase V). A comparison with US data from 1987 showed that German physicians started drug therapy at higher levels of diastolic blood pressure than their American colleagues. Only 43% of the German physicians initiated antihypertensive medication at diastolic blood pressure values below 100 mmHg; this compares with 92% for US physicians. In Germany, beta-blockers were clearly preferred as step-one therapy for young patients, while diuretics were prescribed for the majority of the older patients. Forty per cent reported reducing or stopping antihypertensive medication when the blood pressure was controlled.     

New transient ischemic attack and stroke: outpatient management by primary care physicians

BACKGROUND: Patients with transient ischemic attack (TIA) or stroke frequently first contact their primary care physician rather than seeking care at a hospital emergency department. The purpose of the present study was to identify a group of patients seen by primary care physicians in an office setting for a first-ever TIA or stroke and characterize their evaluation and management. METHODS: Practice audit based on retrospective, structured medical record abstraction from 27 primary care medical practices in 2 geographically separate communities in the eastern United States. RESULTS: Ninety-five patients with a first-ever TIA and 81 with stroke were identified. Seventy-nine percent of those with TIA vs 88% with stroke were evaluated on the day their symptoms occurred (P =.12). Only 6% were admitted to a hospital for evaluation and treatment on the day of the index visit (2% TIA; 10% stroke; P =.03); only an additional 3% were admitted during the subsequent 30 days. Specialists were consulted for 45% of patients. A brain imaging study (computed tomography or magnetic resonance imaging) was ordered on the day of the index visit in 30% (23% TIA, 37% stroke; P =.04), regardless of whether the patient was referred to a specialist. Carotid ultrasound studies were obtained in 28% (40% TIA, 14% stroke; P<.001), electrocardiograms in 19% (18% TIA, 21% stroke; P =.60), and echocardiograms in 16% (19% TIA, 14% stroke; P =.34). Fewer than half of patients with a prior history of atrial fibrillation (n = 24) underwent anticoagulation when evaluated at the index visit. Thirty-two percent of patients (31% TIA, 33% stroke; P =.70) were not hospitalized and had no evaluations performed during the first month after presenting to a primary care physician with a first TIA or stroke. Of these patients, 59% had a change in antiplatelet therapy on the day of the index visit. CONCLUSIONS: Further primary care physician education regarding the importance of promptly and fully evaluating patients with TIA or stroke may be warranted, and barriers to implementation of established secondary stroke prevention strategies need to be carefully explored. Arch Intern Med. 2000;160:2941-2946     

失眠的中医治疗

失眠中医多称为“不寐” ,还有称“目不冥、不得眠、少睡、少寐、不睡、不眠”等 ,是指 :入睡困难、睡眠浅而易醒、或时寐时醒、自觉多梦早醒、醒后不易入睡、醒后仍感倦怠乏力、头昏思睡 ,严重者整夜不能入寐。1　睡眠生理有关中医睡眠生理主要有以下 4种理论 :1.1　阴阳消长论　认为睡眠是阴阳之气相互潜藏出入的过程 ,它与人体的卫气循行和昼夜节律的阴阳盛衰有密切关系。人的白昼醒觉属阳 ,夜间睡眠属阴。正常睡眠是由阳转阴 ,阳潜于阴的生理过程。1.2　营卫循行论　认为卫气运行日夜不休 ,昼行于阳在表 ,夜行于营阴在里而寤寐交替。1.3…     

Drug use by alcoholics in outpatient treatment

Although increasing attention has been paid to the problems of combined and sequential alcohol and drug abuse, data about drug use by alcoholics during the course of outpatient treatment are not available. Urine testing for commonly abused drugs was obtained on 112 alcoholic outpatients during a 2-week period. Ten urine samples were positive for abuseable drugs. Patients' age, length of treatment involvement, and history of drug use prior to treatment appeared to affect drug use during treatment. At 4 month follow-up of the 10 patients with positive urine tests, five were drug free, three had discontinued but then returned to drug use, and two had been discharged. Given the limitations of such a cross-sectional study, the incidence of drug use by alcoholics during outpatient treatment seems high enough to warrant further study.     

Screening and treatment of diabetic nephropathy by primary care physicians

OBJECTIVE: To describe the practices of Indiana primary care physicians related to diabetic nephropathy screening and management. DESIGN: Cross-sectional, observational. SETTING: The state of Indiana. PARTICIPANTS: Active primary care physicians (defined as general internists, family practitioners, and general practitioners) in Indiana who provided care for diabetic patients at the time of the survey (n = 1,018) MEASUREMENTS AND MAIN RESULTS: Practice patterns relevant to microalbuminuria and overt albuminuria screening and management were assessed along two dimensions: the percentage of patients to whom the practices were applied and the frequency with which the practices were performed. Of 1,141 physicians who responded to the survey, 1,018 were eligible for analysis. Eighty-six percent of physicians reported screening more than half of their patients with type 1 diabetes for overt albuminuria, as did 82% of physicians for their patients with type 2 diabetes. Only 17% of physicians indicated performing microalbuminuria testing on more than half of their type 1 patients. Angiotensin-converting enzyme inhibitor agents were used frequently to treat abnormal urinary albumin excretion when hypertension was present, but less often when hypertension was absent. Physician specialty, year of graduation from medical school, practice location, and familiarity with the results of the Diabetes Control and Complications Trial were significant predictors of screening and treatment practice patterns. CONCLUSIONS: Primary care physicians report practices that allow them to detect overt albuminuria but not microalbuminuria. Angiotensin-converting enzyme inhibitors are frequently used by physicians who test for microalbuminuria, but efforts to increase the detection of early renal damage are needed so that these agents and other therapeutic strategies may be employed at the earliest opportunity.     

Cocaine-induced mood disorder: prevalence rates and psychiatric symptoms in an outpatient cocaine-dependent sample.

This paper attempts to examine and compare prevalence rates and symptom patterns of DSM substance-induced and other mood disorders. 243 cocaine-dependent outpatients with cocaine-induced mood disorder (CIMD), other mood disorders, or no mood disorder were compared on measures of psychiatric symptoms. The prevalence rate for CIMD was 12% at baseline. Introduction of the DSM-IV diagnosis of CIMD did not substantially affect rates of the other depressive disorders. Patients with CIMD had symptom severity levels between those of patients with and without a mood disorder. These findings suggest some validity for the new DSM-IV diagnosis of CIMD, but also suggest that it requires further specification and replication.     

Lingual thyroid. Diagnosis and treatment

We describe four patients who presented with a lingual thyroid condition (three females and one male, aged between 7 and 22 years). Only the male patient was symptomatic with mild dysphagia and hemoptysis. The diagnosis was suspected in three patients, and was confirmed by iodine 123 or 131 scanning in all patients and by a computed tomographic scan in the one patient studied. The patient with dysphagia received a 10-mCl therapeutic dose of iodine 131 before thyroxine replacement was started. The diagnosis and management of lingual thyroid is discussed. All patients need lifelong thyroxine suppression. Unenhanced computed tomographic scans have a diagnostic appearance due to the iodine content of the ectopic thyroid tissue.     

急性胆源性胰腺炎的诊断和治疗

急性胆源性胰腺炎(Acute gallstone pancreatitis,AGP)是中国最常见的胰腺炎之一。AGP的诊断主要依靠病史、临床症状、体征以及辅助检查,其中辅助检查在AGP的诊断中具有重要的作用,如肝功能异常,以丙氨酸氨基转移酶(ALT)、胆红素升高,以及磁共振逆行胰胆管造影(MRCP)检查提示胆管扩张或梗阻等影像学主要表现。AGP的治疗临床上主要包括内科保守治疗、微创治疗和外科治疗等。迄今,内镜微创治疗已逐渐取代外科手术治疗成为AGP的一线治疗方法,如胆管梗阻应尽量早期行内镜下逆行胰胆管造影(ERCP);对有症状且并发感染坏死的AGP,微创坏死组织清除术优于开放手术。     

Diagnosis and treatment of diffuse ileojejunitis.

Thirteen patients with diffuse ileojejunitis have been diagnosed and treated by us over the past ten years. The disease bears close resemblance to Crohn's disease and may represent a variant of it. No clearcut relationship to celiac sprue was observed in this group of patients. Therapeutic success was obtained in the majority of patients treated with the anti-inflammatory drugs, sulfasalazine and steroids, with four patients requiring resectional surgery, all others manageable by nonsurgical means. There was no mortality in this series of patients.