Liaison Psychiatry on a Coronary Care Unit

Abstract

This paper presents several of the author's experiences as a liaison psychiatrist on coronary care units. Technological and pharmacological advancements over the past decade have made major contributions toward reducing the psychological stress of patients admitted to these units. The psychiatrist's main liaison role is in assisting with patient education and rehabilitation efforts. Examples are given of a patient education program and reasons for systematic evaluations for such programs. The psychiatrist also can aid in patient rehabilitation efforts carried out in the outpatient clinic. Results are given from an experimental program of group therapy as an adjunct to the treatment of post-myocardial infarction patients. Finally, two case histories are briefly presented which exemplify subjects' serum uric acid and serum cholesterol variability associated with psychological stresses encountered during their hospitalizations following a myocardial infarction.     

Utilization of computed tomography imaging in the pediatric emergency department

Background

In recent years, there has been a movement toward more judicious use of computed tomography (CT) imaging in an attempt to limit exposure of pediatric patients to ionizing radiation. The Image Gently Alliance and like-minded movements began advocating for safe and high-quality pediatric imaging worldwide in the late 2000s.

Objective

In the context of these efforts, we evaluate CT utilization rates in the pediatric emergency department at a major academic medical center.

Materials and methods

We tracked utilization in several categories of CT, magnetic resonance imaging (MRI) and ultrasonography (US) between July 2008 and June 2017 and compared them with utilization rates from 2000 to 2006.

Results

A total of 4,955 pediatric patients underwent a total of 5,973 CT scans, 2,775 US studies and 293 MRI scans while in the pediatric emergency department during the 2008–2017 study period. We observed decreases in CT scans across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT scans were observed in patients younger than 3 years of age as compared to older children and adolescents. Abdominal and pelvic US increased. Brain MRI also increased over the final two years of the study.

Conclusion

CT utilization decreased throughout the 2008–2017 study period.

     

A comparison of the socio-demographic and clinical characteristics of private household and communal establishment residents in a multi-ethnic inner-city area

This study compares the socio-demographic, physical and psychiatric profiles of representative samples of adults resident in communal establishments (n=170) with those living in private households (n=544) in a deprived multi-ethnic inner-city health district. Respondents were interviewed about their psychiatric and physical health as well as their early life experiences, close personal relationships, experiences of police contact and episodes of deliberate self-harm. Communal establishment residents were more likely to be single, white men and to be out of work than those in the private household sample. They typically left school at an earlier age, had a more disrupted upbringing, were less likely to have close personal relationships and reported more contact with the police. Both physical and psychiatric morbidity were substantially higher in the communal establishment residents than among those living in private households (especially for psychotic disorders). In contrast to these findings, comparisons between communal establishment residents with and without mental health problems revealed few differences. Our data highlight the extensive needs of those living in communal establishments and the need for a wide range of agencies to co-ordinate their efforts effectively if services to this population are to be effective.     

Looking for points of attack in signal transduction pathways

Patients with colorectal cancer can expect an increased likelihood of survival if they are given an autologous tumour-cell vaccine after surgery, compared with undergoing surgery alone, according to the results of a phase III study. The results of this European trial are more encouraging than the results of a similar, earlier trial conducted in the US. This may be due to greater quality control of the vaccine in the European study, suggested Dr Michael Hanna from Perimmune, Rockville, US, or to the addition of an additional booster dose. Dr Hanna presented the results of the trials at the IBC USA’s 2nd Annual Meeting on ‘Immunotherapeutic Strategies for Cancer’ [ San Diego, US; November 1996 ].     

The pseudotransition zone in long segment Hirschsprung's disease

Two cases of Hirschsprung's disease with pseudotransition zones are presented. The location and appearance of the transition zone, transverse contractions proximal to the radiographic transition zone, and a delayed film aid in distinguishing a false transition zone from a true transition zone.     

Psychiatric and social consequences of liver transplantation.

We assessed the prevalence of psychiatric morbidity and level of social adjustment in 32 of 34 adults who received liver transplants between 1 August 1987 and 31 July 1988 and who survived more than 6 months postoperatively. The prevalence of psychiatric morbidity was comparable with that found in the general population. Subjective complaints of cognitive impairment were common (40.6%). Liver transplant recipients were not significantly more handicapped in overall social functioning, but did show significant impairment in several role areas when compared with a community sample. Psychiatric morbidity was associated with greater social impairment, whereas liver function and other medical problems were not. We suggest that identification and treatment of psychiatric illness following transplantation needs to be better established as part of the treatment program.     

Genetic Modifiers of Cystic Fibrosis–Related Diabetes

Diabetes is a common age-dependent complication of cystic fibrosis (CF) that is strongly influenced by modifier genes. We conducted a genome-wide association study in 3,059 individuals with CF (644 with CF-related diabetes [CFRD]) and identified single nucleotide polymorphisms (SNPs) within and 5′ to the SLC26A9 gene that associated with CFRD (hazard ratio [HR] 1.38; P = 3.6 × 10⁻⁸). Replication was demonstrated in 694 individuals (124 with CFRD) (HR, 1.47; P = 0.007), with combined analysis significant at P = 9.8 × 10⁻¹⁰. SLC26A9 is an epithelial chloride/bicarbonate channel that can interact with the CF transmembrane regulator (CFTR), the protein mutated in CF. We also hypothesized that common SNPs associated with type 2 diabetes also might affect risk for CFRD. A previous association of CFRD with SNPs in TCF7L2 was replicated in this study (P = 0.004; combined analysis P = 3.8 × 10⁻⁶), and type 2 diabetes SNPs at or near CDKAL1, CDKN2A/B, and IGF2BP2 were associated with CFRD (P < 0.004). These five loci accounted for 8.3% of the phenotypic variance in CFRD onset and had a combined population-attributable risk of 68%. Diabetes is a highly prevalent complication of CF, for which susceptibility is determined in part by variants at SLC26A9 (which mediates processes proximate to the CF disease-causing gene) and at four susceptibility loci for type 2 diabetes in the general population.Cystic fibrosis (CF) is a common life-limiting monogenic disease in Caucasians caused by defects in an epithelial chloride channel, CF transmembrane regulator (CFTR), which is expressed across tissues, including sweat glands, pancreas, and lung. Diabetes is an age-dependent complication of CF that affects 19% of adolescents and 40–50% of adults with CF (1). CF-related diabetes (CFRD) is associated with worse lung disease, malnutrition, and mortality (2), and treating CFRD substantially improves outcomes (1,3). Risk factors for CFRD include pancreatic exocrine insufficiency (4), female sex (5), and liver disease (6). Genetic modifiers (genes other than CFTR) contribute to the risk of CFRD (7), and identification of these modifiers could give insight into the pathophysiology of CFRD.The clinical and histologic features of CFRD share some similarities with other forms of diabetes in the general population, but there are also distinct differences. For example, type 2 diabetes and CFRD are associated with a subacute decline in β-cell function and production of islet amyloid (8,9). In contrast, insulin sensitivity is reduced in type 2 diabetes but is generally normal in CFRD (except during exacerbations or glucocorticoid treatment) (1). These findings suggest that CFRD and type 2 diabetes have both common and distinct mechanisms; therefore, dissection of the contributing pathways could be informative for both conditions.Identification of genes that confer risk for CFRD can address the degree of overlap with type 2 diabetes. There is a reasonable basis for a genetic approach as follows: >50 common gene variants associate with type 2 diabetes (10); a family history of type 2 diabetes (i.e., diabetes in non-CF family members) approximately triples the risk for CFRD (11); and in a total of 1,745 CF individuals, we previously demonstrated that TCF7L2, a susceptibility gene for type 2 diabetes, confers risk for CFRD (11). The formation of the CF Genetic Modifier Consortium and genome-wide single nucleotide polymorphism (SNP) typing of ∼3,500 CF patients (12) afforded an opportunity to search for unique and shared risk factors using genome-wide association analysis. To increase the power for detecting variants affecting both CFRD and type 2 diabetes, we also tested candidate type 2 diabetes SNPs at 7 loci for association with CFRD.