The Educational Value of Outpatient Consultation-Liaison Rotations: A White Paper From the Academy of Consultation-Liaison Psychiatry Residency Education Subcommittee.

BACKGROUND: As mental health services in outpatient medical clinics expand, psychiatrists must be trained to practice in these settings. OBJECTIVES: The Academy of Consultation-Liaison Psychiatry residency education subcommittee convened a writing group with the goal of summarizing the current evidence about outpatient consultation-liaison psychiatry (CLP) training and providing a framework for CLP educators who are interested in developing outpatient CLP rotations within their programs. METHOD: MEDLINE (via PubMed), Embase, and PsycINFO (via OVID) were reviewed each from inception to December 2019, for psychiatric CLP services in ambulatory settings that involved residents or fellows. The CLP education guidelines were reviewed for recommendations relevant to outpatient CLP. We also searched MedEd portal for published curriculums relevant to CLP. The group held 2 conferences to reach consensus about recommendations in setting up outpatient CLP rotations. RESULTS: Seventeen articles, 3 Academy of Consultation-Liaison Psychiatry-supported guidelines, and 8 online didactic resources were identified as directly reporting on the organization and/or impact of an outpatient CLP rotation. These manuscripts indicated that residents found outpatient CLP rotations effective and relevant to their future careers. However, the literature provided few recommendations for establishing formal outpatient CLP training experiences. CONCLUSIONS: Outpatient CLP rotations offer multiple benefits for trainees, including exposure to specific clinical scenarios and therapeutic interventions applicable only in the outpatient setting, increased continuity of care, and the unique experience of providing liaison and education to non-mental health providers. The article outlines recommendations and examples for developing outpatient CLP rotations which CLP educators can incorporate in their programs.

Women With Mental Illness Seeking Assisted Reproduction Considerations in Ethical Candidate Selection.

PURPOSE OF REVIEW: This review aims to provide guidance to clinicians facing requests for assisted reproduction from women with mental illness. RECENT FINDINGS: The paper explores the clinical and safety aspects of initiating fertility treatment in this context, including the use of psychotropic medication and the risk of untreated psychiatric mood or psychotic disorders. It also presents the ethical considerations involved in candidate selection, including treating similar cases equitably to avoid biased decisions based solely on "gut-feelings," respect for women's reproductive autonomy, and an effort to protect patients and prospective fetuses/children from harm by employing optimal strategies regarding medication and psychosocial support. Clinicians ought to be informed regarding recent evidence related to the safety and efficacy of psychopharmacologic treatment of women during pregnancy and the post-partum. They should also carry out a thoughtful ethical analysis to ensure minimal violation of women's reproductive autonomy.

Diagnosis and Treatment of Anxiety in the Aging Woman.

The peri- and postmenopausal periods represent a window of vulnerability for emergence of anxiety symptoms and disorders in the life cycle of adult women. Compared to depression, anxiety symptoms and disorders remain largely unexplored during this phase of a woman's life, despite the significant impact on quality of life if not diagnosed and treated. Here, we review the literature to present our current understanding of the epidemiology, causal factors, diagnosis, and treatment of anxiety in the aging woman.

Assessing decision-making capacity: a primer for the development of hospital practice guidelines.

Decision making capacity (DMC) is a fundamental concept grounding the principle of respect for autonomy and the practice of obtaining informed consent. DMC must be determined and documented every time a patient undergoes a hospital procedure and for routine care when there is reason to believe decision making ability is compromised. In this paper we explore a path toward ethically informed development and implementation of a hospital policy related to DMC assessment. We begin with a review of the context of DMC assessment before discussing some considerations relevant to policy creation by healthcare ethics committees. The discussion concludes in a presentation of a typology of capacity assessment policies, which draws upon a sampling of currently used hospital policies to illustrate relevant ethical considerations.

Attitudes towards euthanasia and assisted suicide: a comparison between psychiatrists and other physicians.

Euthanasia and physician assisted-suicide are terms used to describe the process in which a doctor of a sick or disabled individual engages in an activity which directly or indirectly leads to their death. This behavior is engaged by the healthcare provider based on their humanistic desire to end suffering and pain. The psychiatrist's involvement may be requested in several distinct situations including evaluation of patient capacity when an appeal for euthanasia is requested on grounds of terminal somatic illness or when the patient is requesting euthanasia due to mental suffering. We compare attitudes of 49 psychiatrists towards euthanasia and assisted suicide with a group of 54 other physicians by means of a questionnaire describing different patients, who either requested physician-assisted suicide or in whom euthanasia as a treatment option was considered, followed by a set of questions relating to euthanasia implementation. When controlled for religious practice, psychiatrists expressed more conservative views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated more conservative views. Differences may be due to factors inherent in subspecialty education. We suggest that in light of the unique complexity and context of patient euthanasia requests, based on their training and professional expertise psychiatrists are well suited to take a prominent role in evaluating such requests to die and making a decision as to the relative importance of competing variables.

Portable System for Time-Domain Diffuse Correlation Spectroscopy.

We introduce a portable system for clinical studies based on time-domain diffuse correlation spectroscopy (DCS). After evaluating different lasers and detectors, the final system is based on a pulsed laser with about 550 ps pulsewidth, a coherence length of 38 mm, and two types of single-photon avalanche diodes (SPAD). The higher efficiency of the red-enhanced SPAD maximizes detection of the collected light, increasing the signal-to-noise ratio, while the better timing response of the CMOS SPAD optimizes the selection of late photons and increases spatial resolution. We discuss component selection and performance, and we present a full characterization of the system, measurement stability, a phantom-based validation study, and preliminary in vivo results collected from the forearms and the foreheads of four healthy subjects. With this system, we are able to resolve blood flow changes 1 cm below the skin surface with improved depth sensitivity and spatial resolution with respect to continuous wave DCS.

Deep Brain Stimulation for Alzheimer's Disease: Ethical Challenges for Clinical Research.

Deep brain stimulation (DBS) is an invasive neuromodulation modality that has shown early promise as a novel treatment of Alzheimer's disease (AD). Further clinical research is warranted on the basis of positive results from animal and human studies, as well as the inadequacy of existing treatments in reducing the enormous medical and financial costs of untreated AD. Nevertheless, unique ethical challenges require particular attention to elements of subject enrollment and informed consent. Study protocols should specify robust assessment and regular monitoring of subject decision-making capacity to consent to trial participation. Investigators should also assess for and mitigate therapeutic misconception (the phenomenon whereby a research participant conflates the goals of research with those of clinical treatment) and ensure that all prospective trial participants have adequate post-trial access to treatment and DBS device maintenance. In the following discussion, each issue is summarized and followed by recommendations for proper ethical procedure. We conclude by assimilating relevant ethical considerations into a decision-making algorithm designed to aid future clinical investigators of DBS for AD with the task of ethical subject enrollment.

Preliminary demonstration of an allelic association of the IREB2 gene with Alzheimer's disease.

The role of iron metabolism in Alzheimer's disease (AD) is well documented. Regulation of the proteins that maintain cellular iron metabolism is mediated by two cytoplasmic RNA-binding proteins, the Iron Regulatory Proteins (IRP1 and IRP2), that function through post-transcriptional interactions with RNA stem loop structures called iron-responsive elements. As the primary mediator of iron homeostasis in neuronal cells, IRP2 is a strong candidate for polymorphisms that could impact AD pathogenesis. Thus, we performed a pilot study to assess polymorphisms in the gene encoding IRP2 (IREB2) on clinically well-characterized, post-mortem samples (50 AD and 50 controls). DNA sequence analysis of the IREB2 gene region revealed 14 polymorphisms. Two (rs2656070 and rs13180) showed statistically significant skewing of allelic and genotypic distributions between AD patients and controls. In silico analyses revealed that rs2656070 lies within a probable promoter and disrupts the binding sites of at least two known transcription factors. Though silent and likely not functionally relevant, rs13180 is in complete LD with rs2656070 (D' > 0.999), creating an IREB2-haplotype that is significantly associated with AD. Confirmation of this association in a larger cohort of cases and controls would further support the role of iron regulation in the pathogenesis of this catastrophic and increasingly common neurodegenerative disorder.

Diagnosing, Disclosing, and Documenting Borderline Personality Disorder: A Survey of Psychiatrists' Practices.

Borderline personality disorder (BPD) is a valid and reliable diagnosis with effective treatments. However, data suggest many patients remain unaware they carry the diagnosis, even when they are actively engaged in outpatient psychiatric treatment. The authors conducted a survey of 134 psychiatrists practicing in the United States to examine whether they had ever withheld and/or not documented their patients' BPD diagnosis. Fifty-seven percent indicated that at some point during their career they failed to disclose BPD; 37 percent said they had not documented the diagnosis. For those respondents with a history of not disclosing or documenting BPD, most agreed that either stigma or uncertainty of diagnosis played a role in their decisions. The findings highlight the need for clinical training programs to address these issues. The research also invites further research to identify other reasons why psychiatrists are hesitant to be fully open about the diagnosis of BPD.

Temporal comparison of functional brain imaging with diffuse optical tomography and fMRI during rat forepaw stimulation.

The time courses of oxyhaemoglobin ([HbO2]), deoxyhaemoglobin ([HbR]) and total haemoglobin ([HbT]) concentration changes following cortical activation in rats by electrical forepaw stimulation were measured using diffuse optical tomography (DOT) and compared to similar measurements performed previously with fMRI at 2.0 T and 4.7 T. We also explored the qualitative effects of varying stimulus parameters on the temporal evolution of the hemodynamic response. DOT images were reconstructed at a depth of 1.5 mm over a 1 cm square area from 2 mm anterior to bregma to 8 mm posterior to bregma. The measurement set included 9 sources and 16 detectors with an imaging frame rate of 10 Hz. Both DOT [HbR] and [HbO2] time courses were compared to the fMRI BOLD time course during stimulation, and the DOT [HbT] time course was compared to the fMRI cerebral plasma volume (CPV) time course. We believe that DOT and fMRI can provide similar temporal information for both blood volume and deoxyhaemoglobin changes, which helps to cross-validate these two techniques and to demonstrate that DOT can be useful as a complementary modality to fMRI for investigating the hemodynamic response to neuronal activity.

Genomic and Proteomic Biomarker Discovery in Neurological Disease.

Technology for high-throughout scanning of the human genome and its encoded proteins have rapidly developed to allow systematic analyses of human disease. Application of these technologies is becoming an increasingly effective approach for identifying the biological basis of genetically complex neurological diseases. This review will highlight significant findings resulting from the use of a multitude of genomic and proteomic technologies toward biomarker discovery in neurological disorders. Though substantial discoveries have been made, there is clearly significant promise and potential remaining to be fully realized through increasing use of and further development of -omic technologies.

In vitro characterization of a compliant biodegradable scaffold with a novel bioreactor system.

The influence of scaffold compliance on blood vessel tissue engineering remains unclear and compliance mismatch issues are important to an in vivo tissue-engineering approach. We have designed and constructed a modular bioreactor system that is capable of imparting pulsatile fluid flow while simultaneously measuring vessel distension with fluid pressure changes in real time. The setup uses a pneumatic PID control system to generate variable fluid pressure profiles via LabVIEW and an LED micrometer to monitor vessel distension to an accuracy of +/-2 microm. The bioreactor was used to measure the compliance of elastomeric poly(1,8-octanediol citrate) (POC) scaffolds over physiologically relevant pressure ranges. The compliance of POC scaffolds could be adjusted by changing polymerization conditions resulting in scaffolds with compliance values that ranged from 3.8 +/- 0.2 to 15.6 +/- 4.6%/mmHg x 10(-2), depending on the distension pressures applied. Furthermore, scaffolds that were incubated in phosphate-buffered saline for 4 weeks exhibited a linear increase in compliance (2.6 +/- 0.9 to 7.7 +/- 1.2%/mmHg x 10(-2)) and were able to withstand normal physiological blood pressure without bursting. The ability to tailor scaffold compliance and easily measure vessel compliance in real time in vitro will improve our understanding of the role of scaffold compliance on vascular cell processes.

Evidence that cerebral blood volume can provide brain activation maps with better spatial resolution than deoxygenated hemoglobin.

With the aim of evaluating the relative performance of hemodynamic contrasts for mapping brain activity, the spatio-temporal response of oxy-, deoxy-, and total-hemoglobin concentrations were imaged with diffuse optical tomography during electrical stimulation of the rat somatosensory cortex. For both 6-s and 30-s stimulus durations, total hemoglobin images provided smaller activation areas than oxy- or deoxy-hemoglobin images. In addition, analysis of regions of interest near the sagittal sinus vein show significantly greater contrast in both oxy- and deoxy-relative to total hemoglobin, suggesting that oximetric contrasts have larger draining vein contributions compared to total hemoglobin contrasts under the given stimulus conditions. These results indicate that total hemoglobin and cerebral blood volume may have advantages as hemodynamic mapping contrasts, particularly for large amplitude, longer duration stimulus paradigms.

Volumetric diffuse optical tomography of brain activity.

We present three-dimensional diffuse optical tomography of the hemodynamic response to somatosensory stimulation in a rat. These images show the feasibility of volumetrically imaging the functional response to brain activity with diffuse light. A combination of positional optode calibration and contrast-to-noise ratio weighting was found to improve imaging performance.