Needs assessment to improve neonatal intensive care in Mexico.

BACKGROUND: At the time of the research, Dr Weiss was a clinical fellow in neonatal-perinatal medicine at Baylor College of Medicine, Texas Children's Hospital. Dr Profit was on faculty at Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Neonatology. He held a secondary appointment in the Department of Medicine, Section of Health Services Research and conducted his research at the VA Health Services Research and Development Center of Excellence where he collaborated with Dr Kowalkowski.: Improving the quality of neonatal intensive care is an important health policy priority in Mexico. A formal assessment of barriers and priorities for quality improvement has not been undertaken. AIM: To provide guidance to providers and policy makers with regard to addressing opportunities for better care delivery in Mexican neonatal intensive care units. OBJECTIVE: To conduct a needs assessment regarding improvement of quality of neonatal intensive care delivery in Mexico. METHODS: Spanish-language survey administered to a volunteer sample of Mexican neonatal care providers attending a large paediatric conference in Mexico in June 2011. Survey domains included institutional context of quality improvement, barriers, priorities, safety culture, and respondents' characteristics. Results were analysed using descriptive analyses of frequencies, proportions and percentage positive response (PPR) rates. RESULTS: Of 91 respondents, the majority identified neonatology as their primary specialty (n = 48, 65%) and were physicians (n = 55, 73%). Generally, providers expressed a desire to improve quality of care (PPR 69%) but reported notable deterrents. Respondents (n, %) identified family inability to pay (38, 48%), overcrowded work areas (38, 44%), insufficient financial reimbursement (25, 36%), lack of availability of nurses (26, 30%), ancillary staff (25, 29%), and subspecialists (22, 25%) as the principal barriers. Respiratory care (27, 39%)--reduction of mechanical ventilation and initiation of nasal continuous positive airway pressure--and reduction in frequency of late-onset infections (19, 28%) were selected as top clinical priorities. There were substantial opportunities for improving safety (PPR 48%) and teamwork climate (PPR 58%). CONCLUSION: These findings may guide efforts to improving quality of care delivery in Mexican neonatal intensive care units.

Management of anxiety and depression syndromes in the elderly.

Elderly patients are susceptible to disruptions in mood from a variety of sources: primary anxiety or mood disorders, medical illnesses and treatments, and psychosocial stressors. The goals of intervention are to discover reversible etiologies, treat in the least intrusive manner, and improve or restore quality of life. The clinical presentation may vary from typical anxiety or depression, to mixed symptoms, to a highly somatized or dementia-like picture. The most common disturbance is mixed anxiety/depression. Once the threshold is reached for drug therapy, there are safe and effective remedies, including azapirones, short-acting benzodiazepines, serotonin reuptake inhibitors, and others. Because elderly patients are more vulnerable to drug side effects such as sedation and orthostatic hypotension, selection of the therapeutic agent is crucial. Management strategies, therefore, tend to avoid sedating agents and those with strong autonomic effects. Antipsychotic drugs, unless specifically indicated--for example, in cases of delusional depression--are to be avoided in simple anxiety/depression syndromes. Prescribers for patients in nursing facilities must also observe Omnibus Budget Reconciliation Act (OBRA) regulations. These include preference for psychosocial over drug therapies, avoidance of physical and chemical restraint, and minimal use of any psychotropic medication.

Prevalence of anxiety disorder among alcoholics.

A preliminary study of the prevalence of DSM-III anxiety disorders in a group of inpatients treated for alcohol detoxification is presented. The rating was performed in accordance with the Structured Clinical Interview for DSM-III (SCID). The results showed that nineteen of 84 subjects (22.6%) met criteria for one or more anxiety disorders. In 12 of these subjects drinking followed the onset of anxiety by as long as 19 years. No conclusions can be drawn about the etiologic role of anxiety in alcoholism. However, to the extent that patients with treatable phobic and anxious states can be identified, there is a potential for prevention of alcoholism in some of these individuals.

Rapid tranquilization: a comparison of thiothixene with loxapine.

This 6-day study evaluated the efficacy of equivalent doses of loxapine and thiothixene for rapid tranquilization of acutely disturbed, psychotic patients. After initial tranquilization with intramuscular injections for 24 hours, 58 patients were treated for 5 days with oral medication. With both drugs, intramuscular treatment demonstrated clinically significant improvement from baseline on Clinical Global Impressions and Brief Psychiatric Rating scales; this improvement continued during the oral phase. Median time to tranquilization was significantly less with loxapine (60 minutes) than with thiothixene (95 minutes); during the oral phase, there were no significant differences between the two treatment groups. Side effects were minimal during the intramuscular phase; dystonia was most common during the oral phase.

Phenelzine treatment of depression with chronic diarrhea.

The monoamine oxidase inhibitors (MAOIs) have been used increasingly in treating nonendogenous depressions. Patients with psychophysiologic disorders have many characteristics in common with known MAOI responders. The authors present the case of a man who had had diarrhea for 36 years, with an underlying chronic depression. The patient was unresponsive to ECT and tricyclic antidepressants. Phenelzine, 60 mg/day, produced dramatic improvement in the patient's diarrhea and his sense of well-being.

Rapid tranquilization: the efficacy of oral concentrate.

The efficacy of oral concentrate in the rapid tranquilization of 159 acutely disturbed patients in a psychiatric emergency service was evaluated. Patients were randomly assigned to 1 of 10 treatment groups: 7 oral groups and 3 comparison intramuscular groups. Although intramuscular medication produced a faster response, concentrate also proved to be effective for rapid tranquilization. Side effects were benign and minimal. Age, sex, race, and diagnosis had no effect on outcome. The use of concentrate as a paradigm for treating acutely psychotic patients is discussed.

Geriatric psychiatry in the emergency department, II: Evaluation and treatment of geriatric and nongeriatric admissions.

The records of a hospital psychiatric emergency department were reviewed for elderly and middle-aged patients who were diagnosed with organic brain syndrome (OBS) or psychiatric disorder. These records were then compared with those of elderly patients from the medical emergency department. While elderly medical patients received routine physical evaluations and laboratory testing, elderly psychiatric patients with behavioral symptoms were often referred to psychiatry before they received tests necessary to differentiate physical disorders from functional psychiatric disorders. When tests were administered to psychiatric patients, many abnormal results were apparent, indicating the possible presence of physical disease. It is recommended that all elderly patients with psychiatric symptoms undergo adequate medical evaluations to screen for physical causes of the psychiatric symptoms.

Prescription drug abuse.

Prescription drug abuse (PDA) accounts for much drug-related morbidity and mortality. The PDA issue contains several interrelated dimensions: regulatory, practical, and clinical. Historical and current governmental efforts to regulate prescribing practices are reviewed. The authors discuss the many ways that prescription drugs can be diverted for abuse purposes and how potential abuse situations can be identified in the clinical setting. Types of prescribers at risk for promoting PDA are discussed and remedies for PDA are offered in terms of physician and patient education.

Optimal management of anxiety in older patients.

Although the incidence of anxiety disorders diminishes with age, the prevalence of anxiety symptoms among older patients is substantial. These symptoms, which include cognitive and somatic manifestations, are a source of diminished quality of life. The many potential sources of illness- and medication-induced anxiety must be excluded before instituting treatment. The general principles of antianxiety medication treatment in older patients include: (i) symptom relief with minimum sedation; (ii) improvement in sleep; (iii) freedom from autonomic and cognitive toxicities; and (iv) freedom from physical dependence and drug interactions. Older compounds such as the tricyclic antidepressants should be avoided, since more modern agents (e.g. benzodiazepines and buspirone) are well tolerated and effective. Modern antidepressants have also been used to reduce anxiety symptoms, although there is a potential for the opposite effect to occur. The selective serotonin reuptake inhibitors appear to be better suited to treating syndromes such as panic and obsessive-compulsive disorder, whereas nefazodone would be a better choice for generalised anxiety complicated by depression.

Diabetic nephropathy with interstitial nephritis presenting with a false-positive anti-GBM antibody.

A 56-year-old male with DM and HTN presented with flank pain and nausea. Review of systems was negative, physical examination was notable for mild hypovolemia and laboratory revealed BUN 51 mg/dl, creatinine (Cr) 5.1 mg/dl (baseline 1.5), Westergren ESR 122 mm/h, fractional excretion of sodium 0.2% and UA positive for blood and protein. Despite volume resuscitation the Cr continued to rise. Urine sediment analysis revealed granular casts, renal tubular epithelial cells and a negative Hansel's stain. Hemodialysis was initiated with Cr 13.7 mg/ dl for dyspnea and dysgeusia. Subsequent laboratory data revealed 2 separate positive anti-GBM antibody titers and prednisone therapy was initiated. Renal biopsy was performed for further diagnostic, therapeutic and prognostic information and demonstrated interstitial nephritis with linear IgG and albumin deposition consistent with diabetic nephropathy. Follow-up antibody titers were negative. prednisone was discontinued and Cr stabilized with conservative therapy. Anti-GBM antibody disease is characterized by circulating IgG antibodies directed against the glomerular basement membrane, specifically the alpha-3 (IV) collagen chain. Anti-GBM nephritis is a rapidly progressive, isolated glomerulonephritis in association with circulating anti-GBM antibodies. A positive immunofluorescence (IF) test is considered diagnostic in the appropriate clinical setting. Therapies include immunosuppressive agents to suppress new antibody production and plasmapheresis to eliminate circulating antibodies. Anti-GBM antibody is not rapidly cleared by steroid therapy and the recovery of renal function is rare if initiation Cr is greater than 7 mg/dl. This case demonstrates that the current ELISA for alpha-3 (IV) collagen is not pathognomonic for anti-GBM nephritis and that renal biopsy with IF for IgG and albumin may be indicated to prevent administration of potentially toxic treatment.

Correlation of Ki-67 and p53 with the new World Health Organization/International Society of Urological Pathology Classification System for Urothelial Neoplasia.

OBJECTIVE: The present study examines p53 and Ki-67 staining patterns of the diagnostic entities included within the new World Health Organization/International Society of Urological Pathology (WHO/ISUP) classification of urothelial neoplasms. DESIGN: We retrospectively studied 151 bladder biopsies from 81 patients with the following neoplasms: normal urothelium (n = 34 biopsies); low-grade intraurothelial neoplasia (LGIUN; n = 19); high-grade intraurothelial neoplasia (HGIUN; n = 20); papillary hyperplasia (n = 4); papilloma (n = 3); papillary neoplasm of low malignant potential (LMP; n = 12); low-grade papillary carcinoma (n = 28); and high-grade papillary carcinoma (n = 31). Sections were labeled immunohistochemically with antibodies to p53 and Ki-67 (MIB-1). Two hundred cells from each lesion were visually counted, and the percentage of positive cells was tabulated without knowledge of the WHO/ISUP diagnosis. RESULTS: In flat lesions, p53 positivity was of limited diagnostic utility; the marker was present in 6 of 34 benign biopsies, 6 of 19 LGIUNs, and 10 of 20 HGIUNs. In one case in which HGIUN was present elsewhere in the bladder, 29% of the benign urothelial cells were p53 positive. In papillary lesions, p53 positivity was not seen in 4 of 4 cases of papillary hyperplasia, 3 of 3 papillomas, and 8 of 12 LMP tumors. In contrast, p53 was detected in 18 of 28 low-grade and 26 of 31 high-grade papillary urothelial carcinomas. A p53 labeling index (LI) greater than 30% was only seen in HGIUNs and high-grade papillary carcinomas. In flat lesions, an increased Ki-67 LI separated out benign urothelium (mean LI, 0.62%) from dysplasia (mean LI, 3.3%) and HGIUN (mean LI, 11.6%). In papillary lesions, Ki-67 positivity was as follows: papillary hyperplasia (mean LI, 1.1%); papilloma (mean LI, 4.3%); LMP tumors (mean LI, 2.5%), low-grade papillary carcinoma (mean LI, 7.3%); and high-grade carcinoma (mean LI, 15.7%). A Ki-67 LI greater than 10% was seen only in low- and high-grade papillary carcinomas, HGIUN, and single cases of LGIUN and papillary neoplasm of LMP. CONCLUSIONS: An increased proliferative index as demonstrated by immunohistochemical staining for Ki-67 (MIB-1) is most often seen in papillary carcinoma and HGIUN. Marked p53 positivity is also characteristic of carcinoma but may be seen in benign-appearing urothelium, suggesting a "field effect" with occult molecular aberration.

Diagnosis of organic brain syndrome: an emergency department dilemma.

Delirium and dementia frequently pose a diagnostic dilemma for clinicians in the emergency department. The overlap of symptoms between organic brain syndrome and functional psychiatric illness, coupled with a dramatic presentation, often leads to a premature psychiatric diagnosis. In this paper, the authors discuss those symptoms of organic brain syndrome that most frequently generate diagnostic confusion in the emergency department and result in a misdiagnosis of functional illness.

Psychiatric testimony and the "reasonable person" standard.

The aim of this article is to explore the boundaries of psychiatric testimony in criminal cases. In a series of vignettes, the author describes applications of psychiatric testimony in nontraditional areas. These are criminal cases in which the defendant-who was not mentally ill-acted in response to a situation that would tend to trigger violence in many persons: protection of self or others. In scenarios involving self-defense, duress, and passion/provocation, the dynamics involve interpersonal situations that give rise to behavior that may be entirely foreign to the defendant but that could not have been avoided. The law looks at these matters through a "reasonable person" standard: what the ordinary citizen would have done. In principle, there is often no need for expert testimony, because judges and jurors are presumed able to assess reasonableness, justification, or provocation. The trier of fact, however, could use a psychiatric explanation to assess culpability. The author discusses the cases in terms of application and admissibility.

Waiving death row appeals: whose right is it anyway?

Death row prisoners may elect to forgo appeals, thus hastening execution. There are many reasons for such a decision, including depression, psychosis, incompetence, conditions in prison, and others. Due to the gravity of the sentence, and the states' duty to ensure fairness, some jurisdictions impose restrictions on the waiver. An inmate who lacks trial competence may be subject to a habeas corpus hearing and the appointment of a "next friend," often a family member. Moreover, the Constitution forbids execution of the "insane." The decision, then, may be taken out of the inmate's hands. The author outlines the various tests for competence to waive appeals. The Pennsylvania case of Gary Heidnik (In re Heidnik, 112 F.3d 105 (3rd Cir. 1997); and In re Heidnik, 720 A.2d 1016 (Pa. 1998)) illustrates the issues surrounding waiver of appeals that concern psychiatrists, attorneys, and judges. Following a discussion of Heidnik and related cases, the author offers a proposal for a classification of types of inmates requesting waiver.

Anxiety, depression, and diseases of the lower extremities.

There are many physical disorders that have little or no organic basis. Many of these conditions are caused by mental pathology. Certain emotional disorders can magnify the person's ability to perceive pain. Anxiety and depression are often the culprits. It behooves the podiatrist to be aware that anxiety and depression can be a cause of foot and ankle pain or that they can exacerbate true physical symptoms. The podiatrist should be able to perform a rudimentary psychological evaluation in the outpatient clinical setting, and should be prepared to make a timely and proper referral to a mental health professional for additional testing and treatment.

Confronting anxiety and depression in primary care.

Primary care physicians treat many patients with anxiety and depression. These disorders have excellent treatment responses, but can be overlooked due to varied presentations. Physician education concerning anxiety and depression is important.

Treating anxiety in primary care.

Anxiety disorders are a group of highly treatable problems seen in primary care. Physicians wishing to treat panic and generalized anxiety must know differential diagnoses, medications, and patient education strategies.

Prescribing under OBRA. Myth and reality.

The Omnibus Budget Reconciliation Act (OBRA) aims to reduce unnecessary psychotropic drugs in nursing facilities, bringing prescribing practices under scrutiny. Yet, OBRA can be adapted by physicians.