The written report in consultation-liaison psychiatry: a proposed schema

OBJECTIVE: The consultation-liaison psychiatry (CLP) written report serves several crucial functions; it therefore needs to be presented in a meaningful format to its readers. Surprisingly little has been written about its optimal nature. Our aim is to offer a schema which promotes effective communication. METHODS: We have reviewed pertinent literature, consulted with CLP colleagues and convened a focus group that a number of them attended. RESULTS: The core functions of the CLP report are to offer the referrer (and other relevant professionals) key comprehensible findings, recommendations for treatment and advice for follow up. Additional purposes are educational, archival and medico-legal. Our schema contains eight sections: Who is the patient? Why you referred the patient to us at this particular time? What did we find? Who are the patient's family and other supports? How do we understand these findings? What do we recommend regarding management? What further clinical developments have ensued? and What do we recommend regarding psychosocial follow-up? We provide guidelines concerning the content of each section and illustrate the use of the schema with two clinical cases. CONCLUSIONS: The functions of the CLP report are not satisfied through conventional psychiatric-history note taking. Our related yet different framework is inclined to be a more effective means to convey necessary clinical data and treatment recommendations.     

Can we rely on mediastinal widening on chest radiography to identify subjects with aortic injury?

Widening of the mediastinum on chest radiography is widely promoted as a useful criterion for detecting aortic injury. We sought to determine the reliability, sensitivity, and specificity of this sign. The initial chest radiographs from 30 subjects with aortic injury and 47 controls were independently reviewed by six radiologists, who were blinded to diagnosis. The radiologists were asked to decide whether the mediastinum was normal or not normal, as well as whether the mediastinum was widened. Agreement, sensitivity, and specificity were assessed. Agreement for overall assessment of the mediastinum was substantial (kappa = 0.64). Individual radiologists had sensitivity varying from 0.77 to 0.97 and specificity varying from 0.62 to 0.89. For "widening" of the mediastinum, agreement was moderate (kappa = 0.49). "Widening" was less sensitive than the radiologists' overall impression (P = 0.01), varying from 0.50 to 0.83, but no difference was detected in specificity (P = 0.36), varying from 0.81 to 0.94. Mediastinal width has unacceptable sensitivity for predicting aortic injury, with substantial inter-reader variability. Medical education has ingrained the widely promoted concept of mediastinum widening, which may be misleading.     

Type B aortic dissection complicating renal artery angioplasty and stent placement

Percutaneous renal artery stent placement has been demonstrated to improve blood pressure control and stabilize renal function in patients with atherosclerotic renal artery disease. However, this procedure is not without risk of significant morbidity, and its effectiveness, as compared to alternative treatments, has not been adequately established. The authors report a case of acute type B aortic dissection complicating renal artery stent placement. The authors postulate that an intimal disruption occurred during initial balloon angioplasty, and that repeated application of radial, shear, and torque forces during stent placement may have extended the injury. The diagnosis of acute aortic dissection should be considered in patients with suggestive symptoms immediately after stent placement.     

Stent placement in the treatment of pulmonary artery stenosis secondary to fibrosing mediastinitis

This article describes an initial experience with stent placement in three patients with severe pulmonary artery stenosis secondary to fibrosing mediastinitis. All three patients were severely symptomatic on admission and all three were asymptomatic after treatment and remained symptom-free approximately 1 year after treatment.     

Recognition of a dominant epitope in bovine heat-shock protein 70 in inner ear disease

OBJECTIVE: To investigate the specificity of antibodies to heat-shock protein 70 (HSP70) in patients with idiopathic, progressive, bilateral sensorineural hearing loss (IPBSNHL) and Meniere disease. STUDY DESIGN: Test immunoreactivity of patients' sera using recombinant human (rh) and bovine (rb) HSP70, as well as segments representing different regions of bovine HSP70 as antigen. METHODS: Sera were tested by Western blotting. RESULTS: Of 52 patients with IPB-SNHL, 40 sera reacted only with rbHSP70; 12 reacted with both rbHSP70 and rhHSP70. Sera from 13 patients with IPBSNHL and from 8 with Meniere disease were tested on the panel of bovine HSP70 segments. Eleven and 7 samples, respectively, reacted with amino acid segment 427-461 from the carboxy (C)-terminal region of the molecule. CONCLUSION: In IPBSNHL and Meniere disease, antibodies are directed primarily against an epitope(s) within the C-terminal region of HSP70 where diversity in sequence among different species, including possible pathogens, is greatest. These findings may provide clues to the pathogenesis or specific serodiagnosis (or both) of diseases of the inner ear.     

Diagnosis of Huntington disease: A model for the stages of psychological response based on experience of a predictive testing program

Persons diagnosed as affected with Huntington's disease (HD) may have similar stages of psychological response to the clinical presentation of the illness. Here we describe a model of these stages of response based on our experience during a predictive testing program for HD. During the warning Stage, asymptomatic persons are aware of their risk status for HD and develop defenses which favor adaptation to their genetic risk. In response to the initial signs and symptoms of HD (the Incipient Stage) unconscious working through of this realization occurs while it is still kept out of conscious awareness. When symptoms become obvious such that recognition of disease onset is inevitable (Break-through Stage) the possibility of the diagnosis of HD is assimilated. After the delivery of the diagnosis during the Adjustment Stage, short-and long-term adaptive responses to living with HD occur. Recognition of the stage of psychological response of a patient who presents with HD is important prior to delivering a clinical diagnosis. In a significant minority of cases, the psychological readiness lags behind the clinical symptomatology and premature presentation of diagnosis may result in significant untoward adverse events. Understanding of the stages of response may provide a frame-work for evaluating the psychological state of the person with HD and determining their readiness to receiving the diagnosis. This model may have relevance to the psychological responses of patients to the diagnosis of other late onset autosomal dominant disorders. © 1993 Wiley-Liss, Inc.