Improving bone marrow biopsy quality through peer discussion and data comparisons: A single institution experience.

INTRODUCTION: Bone marrow biopsy (BMB) is crucial for the diagnosis, staging, and monitoring of a variety of hematologic diseases. Obtaining an adequate BMB can be challenging given the need to balance patient comfort with acquisition of high quality specimens. We had observed variable BMB quality at our institution with poor quality specimens sometimes affecting diagnosis. We thus undertook this quality improvement (QI) project to improve the quality of diagnostic BMB specimens. METHODS: We used an A3 QI process to identify factors possibly influencing BMB quality. We collected baseline data on 211 BMB, with short and long-term follow-up data on a further 382 cases. We used clinical conferences to discuss data, perform peer comparisons and identify strategies to create a sustainable improvement in BMB quality. RESULTS: Baseline data showed that BMB length was influenced most by the individual performer, with some influence of needle gauge. Other factors such as sedation, BMB indication were noncontributory. BMB lengths improved following performer education and individual performer data comparisons (15.2 mm post vs 12.8 mm baseline, P < .0001) and with use of an 8- rather than 11-gauge needle (18.3 mm 8-gauge vs 13.3 mm 11-gauge P < .0001), and were sustained over the long term. CONCLUSIONS: Education on BMB standards, sharing of performer data, and changing needle gauge are relatively straightforward methods to improve BMB quality, leading to easier pathology diagnosis.

Psychiatric disorders in children with speech and langauge retardation. Factors associated with development.

One hundred children (mean age, 5 to 6 years) who were seen consecutively at a suburban speech and hearing clinic were systematically evaluated for speech and language disorders and psychiatric disorders. Fifty-three were found to have a psychiatric illness. The three groups were compared with the psychiatrically well group to ascertain factors associated with the presence of a psychiatric disorder. Significantly differentiating the ill group were more academic and classroom behavior problems and the presence of both speech and language problems. The two groups were not significantly different in intellectual retardation, hearing impairment, medical factors, nonlanguage development disorders, and a variety of family and demographic factors. Common in both groups were psychiatric illness in parents and first-degree relatives. The data indicate that children with speech and langauge disorders are highly at risk for the development of significant psychiatric problems, which suggests the need for proper screening and multimodal treatment planning.

A comparison of DSM-II and DSM-III in the diagnosis of childhood psychiatric disorders. I. Agreement with expected diagnosis.

This study was conducted to compare DSM-II and DSM-III in the diagnosis of childhood and adolescent psychiatric disorders. Twenty psychiatrist-raters completed standardized diagnostic questionnaires for 24 actual case histories. This report, the first of four, presents the rater agreement with the "expected diagnosis," ie, the diagnosis that we considered most appropriate for each case. The average rater agreement with the expected diagnosis was less than 50%. It was highest in cases of mental retardation, psychosis, hyperactivity, and conduct disorder. In only five cases did the most common diagnosis of the raters differ from the expected diagnosis. Analyses of these cases and those we selected to present specific diagnostic problems to the raters have produced suggestions to improve the reliability of DSM-III.

A comparison of DSM-II and DSM-III in the diagnosis of childhood psychiatric disorders. II. Interrater agreement.

A case-history format was utilized to compare interrater agreement on childhood and adolescent psychiatric disorders, using DSM-II and DSM-III. The average interrater agreement was 57% for DSM-II and 54% for axis I (clinical psychiatric syndrome) of DSM-III. There was high agreement in both systems on cases of psychosis, conduct disorder, hyperactivity, and mental retardation, with DSM-III appearing slightly better. There was noteworthy interrater disagreement in both systems for "anxiety" disorders, complex cases, and in the subtyping of depression. Overall, the reliability of DSM-III appears to be good and is comparable with that of DSM-II and other classification systems of childhood psychiatric disorders.

A comparison of DSM-II and DSM-III in the diagnosis of childhood psychiatric disorders. III. Multiaxial features.

A major feature of DSM-III is its multiaxial format. One purpose of this study was to examine the purported advantages of a multiaxial system as compared to those of a multicategory system, eg., DSM-II. We found that the multiaxial system led to a more complete and reliable diagnosis of complex clinical cases. Concomitant medical disorder and psychosocial stressors were coded with high levels of interrater agreement. We conclude that the multiaxial framework is a major strength of DSM-III.

Ultrastructure and histochemistry of the digestive tract of juvenile Paramphistomum epiclitum (Paramphistomidae: Digenea) during migration in Indian ruminants.

The digestive tract of juvenile Paramphistomum epiclitum consists of a foregut with a highly muscular terminal pharynx and an oesophagus, which leads to a pair of unbranched and blind-ending intestinal caeca. A syncytium lining the foregut is continuous with the external tegument and displays similar sensory papillae and secretory bodies (T1 and T2). A third type of secretory body (T3) is confined to the oesophageal cytons of newly excysted juveniles and is first evident in the syncytium by day 14 of migration. An epithelium lining the caeca is composed of a single layer of morphologically uniform cells whose apical surface is amplified by microvilli. Dense secretions synthesized in the caecal epithelium of mature cercariae are released during migration by a mechanism resembling modified apocrine discharge. The caecal epithelium of migrating juveniles undergoes a 10-fold increase in surface amplification (irrespective of growth) during its transition from a primarily secretory tissue to one apparently specialized for absorption.

Ultrastructure and histochemistry of the protonephridial system of juvenile Paramphistomum epiclitum and Fischoederius elongatus (Paramphistomidae: Digenea) during migration in Indian ruminants.

The protonephridial system of juvenile Paramphistomum epiclitum and Fischoederius elongatus consists of a bilaterally symmetrical arrangement of primary, secondary and tertiary ducts which connect individual flame cells with a simple common bladder. Primary and secondary ducts are formed from columns of adjoining cells which provide an epithelial lining, whose luminal surface is elaborated with either short tubercles or lamellae. Groups of cilia project from the luminal surface at frequent intervals along secondary ducts. By contrast, the tertiary ducts and bladder are lined with a nucleated syncytium which ends at a junctional complex formed with the terminal canal. The latter is continuous with the tegumental syncytium and opens at a nephridiopore on the postero-dorsal surface. Tertiary ducts of mature cercariae contain concretions which are voided by migrating juveniles in whose tertiary ducts lipids are progressively accumulated. Evidence for the role of protonephridia in excretion and possibly in osmoregulation and ionic balance is currently examined.

Ultrastructure and histochemistry of the lymph system and parenchyma of juvenile paramphistomes (Paramphistomidae: Digenea) during migration in Indian ruminants.

The lymph system of juvenile Paramphistomum epiclitum and Fischoederius elongatus consists of a single pair of longitudinal primary vessels from which sub-dividing branches extend laterally to associate with most major tissues and organs. The system originates shortly after excystation in the definitive host and is fully developed in day 14 juveniles. Lymph vessels are syncytial and membrane limited, with a matrix which contains autophagic-like inclusions, clusters of SER and free nuclei. Similar organelles are evident in the matrix of parenchyma and specialized cells juxta-posing the pharynx (JP cells). These tissues are intimately associated and perhaps functionally integrated. Parenchyma represents a major site for carbohydrate storage and turnover, whilst the lymph appears to perform a similar role for proteins. The JP cells of juveniles display prolific autophagic-like activity only during migration, which coincides with the depletion of carbohydrate reserves in parenchyma. Key mitochondrial enzymes were histochemically demonstrated in the lymph despite the apparent absence of mitochondria from this system in post-day 14 juveniles. Succinate dehydrogenase activity was cytolocalized in mitochondria, whilst attempts to perform a similar localization of this enzyme in lymph were unsuccessful. The possibility of non-enzymatic interference in the histochemical demonstration of dehydrogenase is examined.

Suicide and other consequences of childhood and adolescent anxiety disorders.

The increasing risk of suicide among children and adolescents makes imperative the development of a set of appropriate and clinically significant predictors of suicide risk for that group. Of particular concern is the need to understand the role of anxiety psychopathology in suicidal children and the occurrence of suicidal behaviors in children with anxiety disorders. The author reviews the recent investigations assessing childhood and adolescent suicide risk and emphasizes the need to update our current methods in assessing both suicidal behavior and anxiety. Furthermore, he points out the need for prospective studies of anxiety disorders in children and adolescents to identify those children at risk for suicide and other psychopathology as they mature.

DSM-III in the clinical practice of child psychiatry.

The clinical usefulness of DSM-III was assessed by examining its inclusiveness, its correspondence to DSM-II, and difficulties encountered in its use in evaluations of 108 children. DSM-III covered adequately a wide range of diagnostic entities, showed relatively good correspondence to DSM-II with some exceptions, and presented relatively few major difficulties in a child psychiatry clinic setting. DSM-III seems likely to be accepted and used by a majority of practicing child psychiatrists.

The predatory soil flagellate Heteromita globosa stimulates toluene biodegradation by a Pseudomonas sp.

A model food chain was established to investigate the influence of grazing by flagellates on bacteria degrading toluene in batch culture. The rate of toluene consumed by a Pseudomonas sp. strain PS+ (max. 0.37 fmol cell(-1) h(-1)) was significantly higher in the presence of the bacterivorous flagellate Heteromita globosa (max. 1.38 fmol cell(-1) h(-1)). A maximum increase of up to 7.5 times was observed in the rate of toluene consumed by these bacteria during exponential growth of this flagellate. Carbon conversion efficiency (CCE) of bacteria to flagellate biomass was estimated to be 33.4% based on measured biovolumes and published values for carbon contents. However, the CCE for toluene-derived carbon was lower (max. 4.9%) when calculations were based on incorporation of [ring-U-(14)C]toluene into biomass of flagellates grazing on labelled bacteria. The findings suggest a potential role for flagellates in bioremediation processes.

School consultation: a review of research on issues unique to the school environment.

OBJECTIVE: To provide clinicians with current information to assist in their consultations to schools on 4 major topics that are unique to the school environment and of serious concern to educators: absenteeism, disciplinary referrals, retention (non-promotion), and dropping out. METHOD: Computer literature searches and the major journals of the various school disciplines were used to identify empirically based articles with sound methodology. Information on each of the 4 issues is presented as general characteristics, characteristics of psychopathology, prevention and treatment, and implications for consultation. RESULTS: Findings are largely general, with little specific information on level of intelligence, learning disorders, psychopathology, or family stressors. Students under each topic have varied presentations. However, many pupils with absenteeism, disciplinary referrals, or retention appear to be characterized by chronic and serious academic and/or behavior problems, all of which can predate dropping out. CONCLUSIONS: Considerable research is still needed on all 4 school issues, especially psychopathology. Nevertheless, consultants can reasonably first help schools to identify students at risk for the 4 outcomes, followed by appropriate screening/evaluation to indicate more clearly their true intervention needs. The ongoing process can further educate school staff about psychiatric disorders in their most problematic students.

Long-term stability of Child Behavior Checklist profile types in a child psychiatric clinic population.

OBJECTIVE: To study the long-term stability of Child Behavior Checklist (CBCL) profile types, which represent children's overall patterns of single and comorbid scale elevations. METHOD: Profile types were determined for 623 outpatient children at referral and then at mean follow-up 4.8 years later, and their continuity was determined. RESULTS: At baseline 37.5% of the children were classified by a profile type, and 41.9% of these originally classified children continued to be classified at follow-up. The average odds ratio for a child continuing as a specific CBCL profile type from baseline to follow-up was 8.2. When children changed from one specific profile type to another, they usually continued in the same broad externalizing or internalizing category. Children who were not classified by a profile type at baseline generally remained unclassified. CONCLUSIONS: Stability findings for CBCL profile types appeared good and were similar to past longitudinal results for CBCL scales and DSM diagnoses. These profile types may prove an important empirical method for addressing the problem of comorbid clinical pictures.

Adolescent schoolboys in SED classes: implications for child psychiatry.

OBJECTIVE: The primary purpose of this study was to determine basic psychosocial characteristics for adolescent socially and emotionally disturbed (SED) boys. METHODS: Boys aged 12 to 16 years who were recommended for SED placement were compared with same-aged boys recommended for other educational intervention. The main measures were the Kiddie SADS-E interview and Achenbach's parent Child Behavior Checklist and Teacher Report Form scales. RESULTS: The adolescent SED boys were found to have normal intelligence, high rates of family stressors, predominantly DSM-III externalizing disorders, serious dysfunction according to checklist ratings by both teachers and parents, and little current community mental health intervention. They were significantly different from the comparison group on several variables: lower socioeconomic status, more abuse experience, greater diagnostic comorbidity, higher Axis V clinician ratings, and higher teacher ratings on externalizing scales. CONCLUSIONS: Findings are similar to those for other age-gender groups of SED students. One implication is the need for more private child psychiatrists to become involved in the collaborative treatment of this complex and seriously ill group of special education students. Consequently, a second implication is to increase the experience of child psychiatry trainees in dealing with the many consultative needs of SED students and staff.

Use of psychotropic medications in special education students with serious emotional disturbance.

The three-year usage of psychotropic medication was investigated for the first time in elementary school students classified by the special education category serious emotional disturbance. Almost 40% of the original 89 students were on a medication at baseline, primarily stimulants (26%), and multiple medications were not common (17%). Over the three time points of followup, 52% of the constant 54 students used a medicine at least once, principally stimulants followed by, in descending order, antipsychotics, antidepressants, and Clonidine. The order of distribution was constant at each point of follow-up. Only 24% received a medication at all three time points (rarely the same specific medicine), and only 9% received therapy at each time. Overall, 41% of the ongoing students received no medication or therapy over the course of the study. The medication needs, as well as the therapy needs, of this highly dysfunctional group of students appear unmet.

Child behavior profile types in a general population sample of boys 6 to 11 years old.

Characteristics of Child Behavior Profile (CBP) types were studied in a general population sample of 202 boys aged 6 to 11 years. Parents completed the Child Behavior Checklist and teachers simultaneously rated the Teacher's Report Form. Overall, 39.7% of the boys were classified within a CBP type: 28.8% Internalizing and 10.9% Externalizing. The most common specific type was Somatic Complaints. Teachers rated the Externalizing CBP boys as showing robust externalizing behaviors in school. Also, boys with Externalizing profile types showed severe degrees of psychopathology in both home and school environments. An intraclass correlation of .35 or greater was found to identify boys with sufficiently severe psychopathology to warrant further clinical evaluation. Findings in this general population sample appear consistent with previous results in outpatient samples, and extend our understanding of the validity and clinical value for CBP types.

Diagnostic importance of combined parent and teacher ratings on the Revised Behavior Problem Checklist.

The Revised Behavior Problem Checklist (RBPC) was completed by parents and teachers for 105 child psychiatry outpatient boys aged 6 to 12 years. In addition, DSM-III diagnoses were determined independent of checklist results, and the children were divided into major diagnostic groups of externalizing, internalizing, and mixed disorders. Combined parent and teacher ratings proved more effective than separate ratings in distinguishing the externalizing and mixed groups from the internalizing group on the RBPC externalizing factors. The overall classification of individual boys with discriminant function analysis increased from 72% to 83% when the ratings of both parents, rather than one parent, were combined with teacher ratings. Enhancing diagnostic accuracy of type of psychiatric disorder by using combined parent and teacher behavior checklist ratings is discussed.

Behavior problems in children with pure speech disorders and in children with combined speech and language disorders.

Forty-six children with pure speech disorders and 53 children with disorders of both speech and language were rated by parents and teachers for behavioral problems. Both parents and teachers rated the speech- and language-disordered children as having more severe and more frequent behavioral abnormalities, particularly hyperactive behaviors and developmental problems. Somatic complaints were more pronounced in the pure speech group. Conduct disorders, emotional problems, and poor relationships did not distinguish between the two groups. The importance of these findings for speech therapists and individuals working with speech- or language-impaired children is discussed.

Dimensions of behavior in children with speech andlanguage disorders.

The behavioral symptoms of a population of children with speech and language disorders (with a mean age of approximately 6 years) were studied with a teacher and a parent questionnaire. A factor analysis produced similar factors for both questionnaires: Hyperactivity-Conduct, Affect, and Language. An Asocial factor was also found with the teacher questionnaire. The factors of this study were in good agreement with the general factors of "Aggression" and "Withdrawal" found in other quantitative studies. Mean factor score profiles were reported for this unique population of children.

A practical method for screening psychiatric disorder in children with speech and language disorders.

Children with speech and language disorders have been found to have a prevalence rate of psychiatric disorder of 50%. The authors sought to develop an efficient screening procedure to distinguish such children who have psychiatric disorder and those who do not. Cutoff scores for easily administered parent and teacher behavior rating questionnaires were investigated in a population of 256 children with speech and language disorders and known presence or absence of psychiatric disorder. It was learned that when the questionnaires are used together, a cutoff score of 31 or greater on either questionnaires are used together, a cutoff score of 31 or greater on either questionnaire has a positive predictive value of 74.1% and a negative predictive value of 76.1%. This screening method shows promise in assisting speech pathologists in comprehensive evaluation and treatment planning for children with speech and language disorders.