Child psychiatry education for general residents

There is continuing debate about what child psychiatry experiences should be included in a general residency. The author describes the program at the University of Michigan in an effort to provide some insights into the interface between child psychiatry and general residency training. This program is unique in several respects: a 12-month rotation in child psychiatry is offered, and the faculty size and budget of the youth services are comparable to those of the adult services. A survey of all residents and faculty pointed up numerous disagreements as to the length of the rotation and priorities in curriculum. The author discusses the influence of the various competitive processes on the educational program.     

Child, adolescent and general psychiatry

The incidence and characteristics of hepatic tumors -primitive or secondary- were analyzed in a series of 596 patients with cirrhosis and on whom an autopsy was carried out. A hepatic tumor was discovered in 43.6%: 96.5% with histological findings of malignant disease and only 3.4% with benign disease. The tumors discovered showed the following in order of frequency: hepatocellular carcinoma (90.3%), hepatic metastases (4.2%), cholangiocarcinoma (2.3%), adenoma (1.5%), hemangioma (1.2%) and hamartoma (0.8%). Therefore, 10% of the neoplasms located in the cirrhotic liver were different from the hepatocellular carcinoma. In 2% of the subjects with hepatic tumors, two histologically different lesions were found to co-exist in the liver, and in every case it was found to be a hepatocellular carcinoma related to another tumor, which further complicated the diagnosis. The most frequent type of hepatocellular carcinoma was multinodular, although diffuse tumors most frequently developed metastases. When the hepatocellular carcinoma was uninodular and small, distal spread was exceptional. Metastatic infiltration of the liver by neoplasms of different origin, characteristically infrequent in cirrhosis, was always accompanied by spread to other organs and did not appear as a single nodule in any case. We conclude that the correct diagnosis of tumor-related lesions located, in a cirrhotic liver is occasionally difficult during life, especially when the neoplasms are different from the hepatocellular carcinoma.     

Children referred for specialist care: a nationwide study in Dutch general practice

BACKGROUND: Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available. AIM: To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice. METHOD: From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care. RESULTS: The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals. CONCLUSIONS: The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred.     

An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice

OBJECTIVE: This study evaluated the 6-month outcome of patients referred by their general practitioner (GP) to a consultation-liaison (C-L) psychiatry service provided to eight group general practices. METHOD: Over a 12-month period, there were 307 referrals to the C-L psychiatry service of whom 86 consented to take part in an outcome study. Two different control groups were examined comprising patients seen by the same GPs but not referred to the C-L service, who were matched with the C-L referrals on the basis of either demographic characteristics (n = 86) or initial symptomatology (n = 59). Clinical interviews were conducted at recruitment to the outcome study using the Composite International Diagnostic Interview (CIDI), while postal questionnaires were used at both the initial and 6-month assessments. RESULTS: Data reported include DSM-III-R clinical audit and CIDI diagnoses, changes in current symptomatology (SCL-90-R) and changes in global ratings of physical health, emotional health, social relationships and ability to perform everyday duties. Consultation-liaison referrals without symptom-matched controls (n = 27), being patients with higher levels of symptoms initially, were more likely to be referred to other psychiatric services for treatment. They also showed more marked improvement over time on the selected outcome measures. However, there were no significant differences in the patterns of change over time between symptom-matched C-L referrals and their non-referred controls. CONCLUSIONS: The findings from the 6-month outcome study raise doubts about the overall benefit of the current C-L service relative to usual GP care. Improving the quality of psychiatric care in general practice is likely to require a range of interrelated strategies, including C-L psychiatry services, GP education and well-functioning links with public mental health services.     

The psychologist as front-line mental health consultant in a general hospital.

Describes the experiences and diverse functions of a psychologist who acts as an independent mental health consultant in a general hospital. Particular attention is paid to problems that arise when psyche and soma interface, because these problems require knowledge of biology as well as of psychology. The appropriateness of this role for the psychologist and its acceptability to referring physicians are examined. The particular strengths of the psychologist as a behavioral scientist and the need for continuing education in differential diagnosis when psychological and physiological factors interact are also explored. Professional boundaries and role relations between psychology and related professions are reviewed. (25 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Child psychiatry. The family: a valuable partner]

Plasma chemistry and haematological studies were conducted on chickens with coccidiosis. Male White Leghorn chickens, of two weeks old, were inoculated with 5 x 10(4) Eimeria tenella sporulated oocysts or with 1 x 10(6) E acervulina sporulated oocysts. Blood samples were taken four, seven and 11 days after inoculation. A wet chemistry system was applied to measure the plasma activities of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma glutamyltransferase, creatine kinase, amylase and lactate dehydrogenase and the concentrations of creatine, total bilirubin, urate, total cholesterol, total protein, albumin, glucose and triglycerides. A dry chemistry system was applied to measure sodium, potassium, chloride and calcium. The number of red blood cells and packed cell volume were determined by a micro cell counter and blood pH was measured with a blood gas analyser. The erythrocyte count, packed cell volume, sodium and chloride levels in the chickens infected with E tenella were significantly (P < 0.05) lower than those of the uninfected controls. The significant decrease in blood pH of the chickens infected with E acervulina suggests malabsorption associated with duodenal lesions induced by the infection.     

A comparison of consecutive orthodontic referrals seen by a consultant unit and specialist orthodontic practitioners

We evaluated urokinase-type plasminogen activator (uPA) expression with immunohistochemistry in 90 cases of colorectal cancer and compared it with the clinicopathological findings. Patients who had cancer cells which were stained intensively relative to the background were recognized as uPA-positive patients. The uPA-positive rate was 36.7% (33/90) in total cases. There was a significant correlation was also seen between uPA expression and liver metastasis. Prognosis was poorer in the uPA-positive patients than in the uPA-negative patients. Therefore, uPA may be a good predictor of metastasis and prognosis.     

Self-in-relation theory and the role of the clinical nurse specialist. Part II: Application to advanced nursing roles in a professional practice model

CONCEPTS AND ASSUMPTIONS of self-in-relation theory of women's development, as proposed by feminist scholars at the Stone Center in Wellesley, Massachusetts, are applied in this article. This theory was used as a framework to guide staff development and mentorship roles of advanced practice nurses. How the theory served to direct these roles and assisted in development of a professional practice model is discussed. Exemplars from the authors' practices and professional practice outcomes after 2 years of theory implementation are presented.     

The scope of professional practice in specialist practice

The Scope of Professional Practice (UKCC, 1994a) now offers nurses, midwives and health visitors new opportunities to develop their clinical role. Role expansion is at the centre of debate in the health service. In the spirit of Scope, trusts and regional health authorities have been experimenting with new roles that combine medical and nursing practice in order to promote a holistic approach to health care. Education, experience and the appropriate clinical competency are the foundations for role expansion and the development of professional practice. However, some of the new roles and innovative practices have also been targeted at reducing junior doctors' hours (Read and Graves, 1994). New roles must be evaluated before they are allowed to develop and there is an urgent need for national evaluation of the initiatives underpinning Scope. This article examines the changing role of practitioners in specialist practice. The ethical, professional and legal issues surrounding these changes will also be considered.     

Structured patient education for out-patients with hypertension in general practice: a model project in Germany

In a model project, office-based physicians in two regions of Germany provided a structured treatment and teaching programme for out-patients with hypertension. The project was carried out in co-operation with the German Hypertension League and designed to evaluate the practicability and efficacy of the implementation in routine primary health care. A total of 111 primary health care practices in two German districts who had participated in a training course were interviewed. In 43 of these offices documented data of all patients who had received the standardised treatment and teaching were evaluated. The programme was well received by the physicians of which 81% rated the training course and 93% the teaching material as 'very good' or 'good'. A total of 466 patients were trained. Data collected on 272 patients (22 weeks after the intervention) demonstrated the efficacy of the programme at treatment level: reduction of body weight (2 kg, P < 0.001) and blood pressure (from systolic 158+/-18 to 148+/-17 mm Hg, P < 0.001; diastolic 91 +/-9 to 86+/-9, P < 0.001). Sixty-five per cent of patients learned for the first time how to perform blood pressure self-monitoring during the programme. The number of blood pressure readings by the patients' increased significantly from 1+/-3 measurements per week before, to 8+/-7 measurements per week after the programme (P < 0.001). The results of the study demonstrate the practicability and efficacy of the implementation of the programme for patients with hypertension into routine primary health care.     

Child psychiatry perspectives. After the "civilized" divorce

The sorption of bile acids, bilirubin, bilirubin glucuronates and cholesterol on ion-exchange resin is described. After some successful attempts of sorption of these substances from human and animal bile in vitro, this exchanger has been used in human therapy. Positive results obtained showed the usefulness of the method. The purpose of the experiments was to study the usefulness of ion-exchangers for sorption of bile components of bile acids, bilirubin, bilirubin glucuronates and cholesterol. First sorption was carried out on human and animal bile, on Zerolit-FS-ip, in cycles (OH-) and (Cl-), by passing through glass columns downwards and some of them by mixing the bile with ion-exchange resin. Zerolit FS-ip is an organic sorbent, a scavenger, a strongly basic macroporous, anion exchanger. Positive results of these sorptions indicated the possibility of using this method in therapy of disturbed lipid conditions.     

Child custody cases: A content analysis of evaluations in practice.

Guidelines for custody evaluations recommend multiple ways for assessing the parent-child relationship and outline appropriate means of assessing special issues such as domestic violence, child abuse, and substance use. However, little is known about the implementation of these guidelines in practice. This study examines 60% of custody evaluations in one circuit court over a 2-year period. Custody evaluations were examined for adherence to guidelines and for differences based on evaluator training. This analysis suggests much variety in techniques used and a lack of consistency between guidelines and clinical practice. The findings suggest a need for more standardized approaches to conducting custody evaluations as well as the assessment of domestic violence, child abuse, and substance abuse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)