Neurocognitive correlates of metabolic dysregulation in individuals with mood disorders: a systematic review and meta-analysis

Individuals with mood disorders are predisposed to metabolic dysfunction, while those with metabolic dysregulation such as diabetes and obesity experience more severe depressive symptoms. Both metabolic dysfunction and mood disorders are independently associated with cognitive deficits. Therefore, given their close association, this study aimed to explore the association between metabolic dysfunction in individuals with mood disorders in relation to cognitive outcomes. A comprehensive search comprised of these three domains was carried out; a random-effects meta-analysis pooling mean cognitive outcomes was conducted (PROSPERO ID: CRD42022295765). Sixty-three studies were included in this review; 26 were synthesized in a quantitative meta-analysis. Comorbid metabolic dysregulation was associated with significantly lower global cognition among individuals with mood disorders. These trends were significant within each mood disorder subgroup, including major depressive disorder, bipolar disorder, and self-report depression/depressive symptoms. Type 2 diabetes was associated with the lowest cognitive performance in individuals with mood disorders, followed by peripheral insulin resistance, body mass index ⩾25 kg/m2, and metabolic syndrome. Significant reduction in scores was also observed among individual cognitive domains (in descending order) of working memory, attention, executive function, processing speed, verbal memory, and visual memory. These findings demonstrate the detrimental effects of comorbid metabolic dysfunction in individuals with mood disorders. Further research is required to understand the underlying mechanisms connecting mood disorders, metabolism, and cognition.

Effectiveness of emergency department-based and initiated youth suicide prevention interventions: A systematic review

OBJECTIVE

This systematic review examined the effectiveness of Emergency Department-based and initiated youth suicide prevention interventions for suicide attempts, suicidal ideation, hospitalization, family system functioning, and other mental health symptoms.

METHODS

We searched five databases for randomized controlled trial (RCT) studies that examined Emergency Department-based and initiated suicide prevention interventions among youth aged 10 to 18 years old between May 2020 to June 2022. Using Cohen's d and 95% confidence interval as our standardised metrics, we followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) and Synthesis Without Meta-Analysis in Systematic Reviews (SWiM) guidelines when synthesizing, interpreting, and reporting the findings of this review.

RESULTS

Five studies were included in this review. Findings were first synthesized according to the targeted population of the study intervention and this review's outcomes. Two interventions were effective for decreasing depressive symptoms, hospitalization recidivism, and/or increasing family empowerment. There were no interventions that reduced subsequent suicide attempts. A meta-analysis was not conducted due to the heterogeneity of the data.

CONCLUSION

A need exists to develop and evaluate Emergency Department-based and initiated youth suicide prevention interventions that can be successfully and sustainably implemented in practice. Future research should focus on evaluating the components of interventions that effectively mitigate suicide risk among high-risk youth.

Clinical Health Outcomes of Siblings of Children with Chronic Conditions: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of the study was to assess clinical mental and physical health outcomes of siblings of children with chronic health condition(s) compared with siblings of healthy children or normative data.

STUDY DESIGN

We searched Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL through August 9, 2021. We included English-language studies that reported clinically diagnosable mental or physical health outcomes among siblings of children (<18 years old) with a chronic health condition, included a comparison group, and used an experimental or observational study design. Two reviewers extracted data and independently assessed risk of bias using the Newcastle Ottawa Scale.

RESULTS

Of 9899 screened studies, 34 were included; 28 studies reported on mental health, 3 reported on physical health, and 3 reported on mortality. Siblings of children with chronic conditions had greater depression rating scale scores than their comparison groups (standardized mean difference = 0.53; 95% CI = 0.38-0.68; P < .001 [6 studies]), whereas anxiety scores were not substantially increased (standardized mean difference = 0.21; 95% CI = -0.02 to 0.43; P = .07 [7 studies]). The effects for confirmed psychiatric diagnoses (7 studies), mortality (3 studies), or physical health outcomes (3 studies) could not be meta-analyzed given the limited number of studies and between-study heterogeneity.

CONCLUSION

Siblings of children with chronic health conditions may be at an increased risk of depression. Our findings suggest the need for targeted interventions to support the psychological well-being of siblings of children with chronic health conditions.

53 Health Outcomes of Siblings of Children with Chronic Health Conditions: A Systematic Review and Meta-Analysis

Primary Subject area

Mental Health

Background

Chronic childhood health conditions are known to have an impact on the well-being of family members. Parental caregivers face well-defined adverse health outcomes, though less is known about the health impacts on siblings.

Objectives

To assess clinical health outcomes in siblings of children with chronic health condition(s) compared to siblings of healthy children or normative data.

Design/Methods

We searched Ovid MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, PsycInfo, and CINAHL through June 4, 2020. We included English-language studies that: (1) reported clinically diagnosable mental or physical health outcomes of siblings of children (0-18 years old) diagnosed with any childhood chronic health condition; (2) included a comparison group; and (3) used an experimental or observational study design. Risk of bias was assessed using the Newcastle-Ottawa Scale.

Results

We included 28 studies of the 9053 screened, comprising 10 cohort studies and 18 cross-sectional studies. Studies from 11 different countries reported most commonly on siblings of children with disabilities (12 studies), cancer (8 studies), or psychiatric disorders (4 studies). Siblings of children with chronic conditions had greater depression rating scale scores than their comparison groups (standardized mean difference 0.49; 95% CI 0.33-0.65; P &lt; .001 [5 studies]) (Fig. 1), whereas anxiety scores did not differ significantly (standardized mean difference 0.24; 95% CI -0.03-0.52; P = .08 [6 studies]) (Fig. 2). Studies that reported on prevalence of psychiatric diagnoses, rather than rating scale scores, had mixed results, either indicating increased risk (3 studies) or no increased risk (4 studies) among exposed siblings. We did not meta-analyze effects for mortality (3 studies) or physical health outcomes (dental caries [1 study], traumatic brain injury [1 study], sexually transmitted infection [1 study], overweightness/obesity [1 study]) given the limited number of studies and between-study heterogeneity. Included studies were rated as high quality (12 studies) or of moderate quality (16 studies).

Conclusion

Siblings of children with chronic health conditions may be at an increased risk of depression. Our findings suggest the need for targeted interventions to support the psychological well-being of siblings of children with chronic health conditions.

Impacts of the COVID-19 pandemic on youth mental health among youth with physical health challenges

AIM

To examine mental health in conjunction with physical health during the COVID-19 pandemic among youth with physical health conditions compared to those without.

METHODS

A cross-sectional survey of 622 youth aged 14 to 28 was conducted. Analyses were conducted to understand the changes in mental and physical health among youth in four groups: (a) participants with a friend or family member diagnosed with COVID-19, (b) participants with symptoms associated with COVID-19, (c) participants with atopic conditions (asthma and allergies), and (d) participants with other preexisting physical health conditions.

RESULTS

Many participants with physical health concerns met screening criteria for an internalizing disorder, which was significantly higher than the rate found among participants without physical health conditions. Significantly greater declines in self-reported mental health were observed during the COVID-19 period compared to 3 months earlier among youth reporting physical health concerns compared to those without physical health concerns. Substance use does not appear to have been affected.

CONCLUSIONS

Mental health concerns are highly prevalent among youth with physical health concerns, and also appear to be exacerbated by the COVID-19 pandemic. Physical health concerns appear to constitute risk factors for heightened mental health responses to the pandemic situation. System planners striving to adapt mental health services to meet social/physical distancing recommendations are urged to consider youth with physical health conditions and ensure that adequate integrated mental health and physical health supports are available to them.

70 Assessing the Evidence of Micronutrients on Depression among Children and Adolescents: An Evidence Gap Map

Background

Globally, depression is one of the leading causes of illness and disability among adolescents. There is some evidence indicating that nutrition may have the ability to prevent, treat and/or influence the severity of depression. Nutritional interventions may broaden the efficacy of treatment options since they are lower in cost, easily accessible and associated with fewer side effects. This may be of particular importance in many low and middle-income countries where micronutrient deficiencies are common and supplementation may be a cost-effective public health intervention. Before determining the role nutrition interventions play in psychiatry, current research needs a unified direction for the development of effective clinical and population treatments. To be resourceful in this task, evidence gap maps (EGM), which employ a systematic approach to mapping and reporting the current evidence, are of particular usefulness.

Objectives

The aim of this EGM is to offer insight into the potential role of micronutrients in depression treatment and prevention, highlight important gaps in the literature where knowledge is scarce or non-existent, and assist in prioritizing future primary research. It also provides a structured and accessible guide for users to identify the possible efficacy of specific nutrients on depression among those 6-19 years of age.

Design/Methods

We conducted a comprehensive database search of all primary and secondary literature assessing the impact of micronutrients on depression-related outcomes such as unipolar depression, major depressive disorders, dysthymia, acute depression, and mood disorders among those 6-19 years of age. Studies from any setting that assessed the impact of interventions or deficiencies of micronutrients — vitamins and minerals — on depression were included in the EGM. Based upon current literature, the most potentially impactful micronutrients on depression included Vitamins B, C, A, D and E, as well as minerals such as calcium, copper, chromium, iron, magnesium, manganese, phosphate, potassium, selenium, and zinc. Abstracts and full-text articles were dual-screened on the basis of predefined eligibility criteria. Key characteristics of the included publications were extracted. All extracted data was visualized in an evidence matrix.

Results

Our searches identified 7,479 unique citations. After the full-text screening, 30 publications were included in this EGM representing a total of 17,906 participants (58.8% female). Some studies included more than one age range with more reports being among those greater than 10 years of age. About 45% of included studies focused on early adolescents (10-14 years), 35% on late adolescents (15-19 years) and about 20% on children aged 6-9 years. Among studies including adolescents, most studies [n= 22 (73%)] were conducted among boys and girls, seven studies (23.3%) focused exclusively on girls and only one (3%) study targeted only boys. Over half of the evidence was cross-sectional, while the other half was composed of cohort studies, randomized controlled trials and case-control/series studies. Vitamin D (n=8), zinc (n=7), iron (n= 5), folate (n=5), Vitamin A (n=2), and Vitamin B (B1, B12) (n=4) were the most studied micronutrients. There were two studies on magnesium while one study each on Vitamin C, Vitamin E, and copper (some studies examined multiple micronutrients). We did not identify research conducted on any other micronutrients suspected to impact depression.

Conclusion

To our knowledge, this EGM is the first review to map current evidence regarding micronutrients and depression in this age demographic. Currently, there is insufficient evidence to support recommendations for micronutrient supplementation in the management of depression among those 6-19 years of age. More longitudinal studies and trials are needed to confirm a role for micronutrients in the etiology and treatment of depression among children and adolescents.

Association of Parental and Contextual Stressors With Child Screen Exposure and Child Screen Exposure Combined With Feeding

IMPORTANCE

Parents may use screen exposure or screen exposure combined with feeding for infants and toddlers to alleviate their own stress.

OBJECTIVE

To evaluate the association of individual and contextual stressors with child screen exposure (CSE) and CSE combined with feeding (CSE+F) in children aged 7 to 18 months as measured by parent-reported use and variation in quantity of CSE and CSE+F.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, population-based study drew parent-child participants from TARGet Kids, a network of primary health care research settings throughout Toronto, Ontario, Canada, between November 1, 2011, and July 31, 2018. The included children were aged 7 to 18 months. Exclusion criteria were health conditions affecting growth, acute conditions, chronic conditions, severe developmental delay, and families who were unable to communicate in the English language. Data were analyzed from April 1, 2019, to July 31, 2019.

EXPOSURES

Parenting stress, child age, child negative affectivity, family living arrangements, and family income were assessed with parent-completed questionnaires.

MAIN OUTCOMES AND MEASURES

The primary outcome was CSE and the variation in CSE, which represented the amount of background and engaged use of screens (television, videos or DVDs, video games, computers, and mobile devices) in a typical week. The secondary outcome was CSE+F, which represented the frequency of breakfast, lunch, dinner, and snack consumption during screen exposure in a typical week. Both CSE and CSE+F were assessed with the parent-completed Nutrition and Health Questionnaire; Infant Behavior Questionnaire, Revised Very Short; and Parenting Stress Index, Short Form.

RESULTS

The final sample size was 1085 children for the analysis of CSE and 1083 children for the analysis of CSE+F. Among 914 respondents, the children's mean (SD) age was 11.6 (2.3) months, and 478 (52.3%) were male. Among 910 respondents, 839 (92.2%) were mothers, with a mean (SD) age among 873 respondents of 34.4 (4.2) years. In a typical week, 581 of 779 children (74.6%) were reported to have any CSE, and 321 of 874 children (36.7%) had some CSE+F. Higher parenting stress levels (odds ratio [OR], 1.01; 95% CI, 1.00-1.02; P = .04) and older child age (OR, 1.43; 95% CI, 1.01-2.03; P = .04) were associated with CSE. Higher parenting stress levels (incidence rate [IR], 1.00; 95% CI, 1.00-1.01; P = .002) and lower household income (IR, 1.26; 95% CI, 1.10-1.45; P = .01) were associated with increased CSE. Older child age (OR, 1.79; 95% CI, 1.35-2.38; P < .001) and lower household income (OR, 2.54; 95% CI, 1.72-3.74; P < .001) were associated with CSE+F. Lower household income (IR, 1.21; 95% CI, 1.03-1.42; P = .02) was associated with increased CSE+F.

CONCLUSIONS AND RELEVANCE

This study found that parenting stress, income, and child age were associated with CSE, and child age and household income were associated with CSE+F. Given these findings, interventions to improve parental coping mechanisms may decrease child screen exposure.

Le TDAH chez les enfants et les adolescents, partie 1 : l’étiologie, le diagnostic et la comorbidité

Le trouble de déficit de l’attention/hyperactivité (TDAH) est un trouble neurodéveloppemental chronique. La Société canadienne de pédiatrie a préparé trois documents de principes après avoir effectué des analyses bibliographiques systématiques. Leurs objectifs s’établissent comme suit : 1) Résumer les données probantes cliniques à jour sur le TDAH. 2) Établir une norme pour les soins du TDAH. 3) Aider les cliniciens canadiens à prendre des décisions éclairées et fondées sur des données probantes pour rehausser la qualité des soins aux enfants et aux adolescents qui présentent cette affection.

Les thèmes abordés dans la partie 1, qui est axée sur le diagnostic, incluent la prévalence, la génétique, la physiopathologie, le diagnostic différentiel, ainsi que les troubles psychiatriques et les troubles du développement comorbides. En plus des recherches dans les bases de données, les auteurs ont analysé les directives les plus récentes de l’American Academy of Pediatrics , de l’American Academy of Child and Adolescent Psychiatry , du National Institute for Health and Clinical Excellence , du Scottish Intercollegiate Guidelines Network et de l’Eunethydis European ADHD Guidelines Group . Puisque le TDAH est un trouble hétérogène, son évaluation médicale complète devrait toujours inclure une anamnèse fouillée, un examen physique et une évaluation approfondie du diagnostic différentiel et des comorbidités connexes. Les auteurs proposent des recommandations précises sur la récolte d’information, les tests à effectuer et les orientations vers divers services.

ADHD in children and youth: Part 1-Etiology, diagnosis, and comorbidity

Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. Three position statements have been developed by the Canadian Paediatric Society, following systematic literature reviews. Statement objectives are to: 1) Summarize the current clinical evidence regarding ADHD,2) Establish a standard for ADHD care, and3) Assist Canadian clinicians in making well-informed, evidence-based decisions to enhance care of children and youth with this condition. Specific topics reviewed in Part 1, which focuses on diagnosis, include: prevalence, genetics, pathophysiology, differential diagnosis and comorbid psychiatric disorders and developmental disorders. In addition to database searches, the most recent guidelines of the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the National Institute for Health and Clinical Excellence, the Scottish Intercollegiate Guidelines Network, and the Eunethydis European ADHD Guidelines Group, were reviewed. Because ADHD is a heterogeneous disorder, comprehensive medical assessment for ADHD should always include a complete history, a physical examination, and a thorough consideration of differential diagnosis and related comorbidities. Specific recommendations for information gathering, testing, and referral are offered.

Sex differences in brain structure among adolescents with bipolar disorder

OBJECTIVES

Bipolar disorder (BD) is twice as prevalent amongst female as amongst male adolescents. Thus far, little is known regarding the neurostructural substrates underlying this disparity. We therefore examined sex differences in neurostructural magnetic resonane imaging (MRI) phenotypes amongst adolescents with BD.

METHODS

T1-weighted structural MRI was acquired from 44 BD (25 female [F] and 19 male [M]) and 58 (28 F and 30 M) healthy control (HC) adolescents (13-21 years old). Whole-brain and region-of-interest (ROI) analyses examined structural volume and cortical thickness using FreeSurfer. ROIs included the ventrolateral prefrontal cortex (vlPFC), anterior cingulate cortex (ACC), amygdala and hippocampus. General linear models evaluated sex-by-diagnosis interactions, controlling for age and intracranial volume.

RESULTS

Whole-brain analysis revealed sex-by-diagnosis interactions in the left supramarginal gyrus (SMG) (P = .02, η2  = 0.02) and right inferior parietal lobule (IPL) volumes (P = .04, η2  = 0.01). Sex differences in HCs were found in the SMG (M > F) and IPL (F > M). In BD, sex differences were reversed and of smaller magnitude in the SMG (M < F) and of greater magnitude in the IPL (F > M), driven by trends towards smaller SMG and IPL in BD vs HC male participants (P = .05 and .14). Whole-brain analyses for cortical thickness, and ROI analyses for volume and cortical thickness, were not significant.

CONCLUSIONS

Normative sex differences may be disrupted in adolescent BD in the SMG and IPL, heteromodal association network hubs responsible for higher order integration of cognitive and emotional processing. Unexpectedly, these findings may inform our understanding of aberrant brain structure in adolescent BD male patients, rather than female patients. Future work should focus on replication, as well as the impact of puberty status and sex hormones on measures of brain structure and function.

FEASIBILITY OF A MANUALIZED FAMILY-BASED SUICIDE PREVENTION STRATEGY TO REDUCE ADOLESCENT SUICIDE RISK AMONG EMERGENCY DEPARTMENT REFERRED YOUTH: A QUALITY IMPROVEMENT PROJECT

BACKGROUND

Suicide is the second leading cause of death among Canadian children and adolescents. Youth who present at an Emergency Department (ED) for suicidal ideation and risk behaviours (SRB) are at increased risk for eventual suicide. Despite this risk, current approaches to standard of care are referral to community resources or primary care where waitlists are common, and interventions may not be evidence-based or incorporate crisis management or family participation.

OBJECTIVES

To determine the feasibility and acceptability of a manualized, family-centered suicide prevention intervention administered in an outpatient clinic for ED-referred youth.

DESIGN/METHODS

Youth (aged 12 – 18) and parents presenting to the ED for SRB and referred to the Urgent Psychiatry Care clinic were eligible for the QI program, consisting of weekly individual and family sessions delivered over a 6-week period. The therapist addressed common symptoms and concerns of suicidal youth, sources of conflict within the family, and ways to improve communication and ensure patient safety. Patients were excluded if they did not have a parent or caregiver able to participate.

Suicidal ideation and behavior were assessed using youth-report measures, the Suicidal Ideation Questionnaire-Junior (SIQ-JR) and the Harkavy-Asnis Suicide Scale (HASS), at baseline and following program completion. The Mood and Feeling Questionnaire (MFQ) was used to measure depressive symptoms. Participant and therapist feedback was collected at follow-up using quantitative and qualitative measures.

RESULTS

Ten patients were enrolled and completed baseline measures, however four participants withdrew prior to 6 week completion: two withdrew at week 2 and one participant each withdrew at weeks 3 and 6. As such, 7/10 completed 5 weeks of the intervention. Significant improvement in both suicidal ideation (SIQ-JR, x̅ = -16.67; t(5) = 3.125, p = .026) and SRB (HASS, x̅ = -20.17; t(5) = 3.204, p = .024) were observed. Depressive symptoms also decreased (MFQ, x̅ = -15.5, t(5) = 2.724, p = .042). Youth and caregivers rated the program favorably. Improved family communication was most frequently reported by both patients and caregivers as a main benefit of the program.

CONCLUSION

These preliminary data indicate that SRB may be improved by a brief manualized, family-focused therapy. Early data suggest that the protocol is feasible and acceptable for adolescents presenting to the ED with safety concerns, and warrant further examination in a controlled trial.

Child and Adolescent Online Mental Health Information: Parent and Adolescent Perspectives to Inform Development of Canadian Mental Health E-Resources for Paediatrics

BACKGROUND: Parents and adolescents are searching online for information about mental health. Google searches are frequently used, but do not always yield accurate and reliable information that is presented in a user-friendly manner. The first step toward the development of a useful online child mental health resource is to examine existing web content and understand parent and adolescent needs from online mental health material.

OBJECTIVES: The objectives of this study are two-fold (i) To conduct an environmental scan of existing online repositories of child and adolescent mental health information with respect to both parent and adolescent friendly content on three identified topic areas for the initial phase of the project (Anxiety, Eating Disorders, Suicide Prevention) (ii) To determine parent and adolescent needs from, and perspectives about, current web-based information with respect to site design, content and limitations to inform the creation of a pediatric hospital based web site with a broad range of information pertaining to child and adolescent mental health.

DESIGN/METHODS: An environmental scan was conducted to assess available online information about three identified topic areas as described above. As the project continues, the scan will be expanded to include other topic areas in child and adolescent mental health. Parallel parent needs assessment surveys were conducted. As our adolescent section was being developed, adolescents were surveyed for their feedback regarding illustrations and presentation of current content.

RESULTS: The environmental scan identified 17 hospital websites for in-depth review. Although some websites had information on diverse mental health topics, few contained comprehensive information on a broad range of topics. For example, only 9 had information about anxiety disorders. Additionally, an overall lack of adolescent specific content was noted. Parent surveys revealed significant interest in a strong stand-alone site where they could access mental health information. Parents also indicated that they would prefer separate parent and teen content areas.

CONCLUSION: Current websites providing information regarding child and adolescent mental health, while plentiful, lack sufficient scope, adolescent-friendly content, and interactivity that limit their utility for parents and families. Development of a high-quality and accessible child and adolescent mental health website requires an interdisciplinary collaboration of experts in mental health, website design, and knowledge dissemination. This study has informed the development of a new online resource, interactive elements of which will be shared as part of the oral presentation.

Effects of acute aerobic exercise on neural correlates of attention and inhibition in adolescents with bipolar disorder

Executive dysfunction is common during and between mood episodes in bipolar disorder (BD), causing social and functional impairment. This study investigated the effect of acute exercise on adolescents with BD and healthy control subjects (HC) to test for positive or negative consequences on neural response during an executive task. Fifty adolescents (mean age 16.54±1.47 years, 56% female, 30 with BD) completed an attention and response inhibition task before and after 20 min of recumbent cycling at ~70% of age-predicted maximum heart rate. 3 T functional magnetic resonance imaging data were analyzed in a whole brain voxel-wise analysis and as regions of interest (ROI), examining Go and NoGo response events. In the whole brain analysis of Go trials, exercise had larger effect in BD vs HC throughout ventral prefrontal cortex, amygdala and hippocampus; the profile of these effects was of greater disengagement after exercise. Pre-exercise ROI analysis confirmed this 'deficit in deactivation' for BDs in rostral ACC and found an activation deficit on NoGo errors in accumbens. Pre-exercise accumbens NoGo error activity correlated with depression symptoms and Go activity with mania symptoms; no correlations were present after exercise. Performance was matched to controls and results survived a series of covariate analyses. This study provides evidence that acute aerobic exercise transiently changes neural response during an executive task among adolescents with BD, and that pre-exercise relationships between symptoms and neural response are absent after exercise. Acute aerobic exercise constitutes a biological probe that may provide insights regarding pathophysiology and treatment of BD.

Factors Associated with Parental Satisfaction with a Pediatric Crisis Clinic (PCC)

INTRODUCTION

Little is known about parental satisfaction with pediatric crisis clinics (PCCs) that provide a single consultation to families in need of urgent psychiatric care. Parental satisfaction may improve long-term adherence to physician recommendations.

OBJECTIVE

To explore parental satisfaction with a PCC.

METHODS

Parental satisfaction was ascertained by a structured telephone interview following crisis consultation at the PCC of an academic, tertiary care centre.

METHODS

Parents of 71% (n = 124) of 174 pediatric patients seen in the PCC from 2007-2008 participated in the post-consultation interview.

RESULTS

The majority of parents stated they were either somewhat satisfied (49/122, 40.2%) or very satisfied (49/122, 40.2%) with the PCC. Parental satisfaction correlated with time between referral and consultation (p<0.05), the degree to which parents felt listened to by the consultant (p<0.01), the amount of psychoeducation parents felt they received (p<0.01), and appointment length (p<0.001).

CONCLUSIONS

Parents were satisfied overall with an urgent care service model. Satisfaction was correlated with the time between referral and consultation, degree to which they felt their consultant had listened to them, and the amount of information they received at the consultation's conclusion.

[Specialized pain care in Germany]

BACKGROUND

In order to characterize the pain care situation in Germany, a health technology assessment (HTA) was carried out on behalf of the German Institute for Medical Documentation and Information (DIMDI).

METHODS

An up to date literature search was conducted using the database Pubmed. Reviews and studies which describe the pain care in Germany were included. The Physicians' Health Insurance Associations conducted an additional database survey.

RESULTS

Overall 12 studies were included and the results of the analysis showed that there is a lack of some 2,500 curative pain care institutions in Germany. There is also clear under use of inpatient and outpatient institutions in palliative care. The results prove the benefits of the interdisciplinary approach in pain care.

DISCUSSION

Further development should strive to increase the provision of pain and palliative care. There is a great need for pain care research in order to concrete the needs.

[Burnout. Can it be measured?]

Burnout is widely known as a work-related syndrome that is associated by serious individual and social consequences. The aim of the HTA report "Differential diagnostic of the burnout syndrome" published by DIMDI in 2010 was to determine how burnout can be diagnosed and distinguished from other disorders. Based on a systematic literature review of 36 databases, 852 studies published between 2004 and 2009 were identified. After considering inclusion and exclusion criteria, 25 medical and one ethical study remained. The study evidence is predominantly low. Self-assessment tools are mainly used. The analysis showed that no standardized, common valid procedure exists to obtain a burnout diagnosis. Overall the problem is to measure a phenomenon that is not exactly defined. It is primarily important to distinguish burnout from depression, alexithymia, feeling unwell, and the concept of prolonged exhaustion. Beside the need for a valid definition, further research is needed, particularly high-quality, long-term studies, to broaden the understanding of the syndrome. Furthermore, a standardized, internationally accepted and valid procedure for diagnosing burnout is necessary.

Emergency physician referrals to the pediatric crisis clinic: reasons for referral, diagnosis and disposition

OBJECTIVE

To describe the patient population, diagnoses, and disposition of children and adolescents referred by Pediatric Emergency Medicine (PEM) physicians to a Pediatric Psychiatric Crisis Clinic (PCC) for urgent consultation; to describe the percent agreement between PEM physician discharge diagnosis and subsequent child psychiatrist diagnoses.

METHOD

Data were obtained prospectively over a one-year period for consecutive patients referred to the PCC (n=174). Patients and families were contacted for information regarding subsequent emergency department (ED) visitation following PCC consultation.

RESULTS

Referred patients were commonly male (63%) with a mean age of 12.2 ± 3.2 years diagnosed with adjustment disorder (29%), mood disorder (17%) and anxiety disorder (17%) and significant psychosocial stressors. Five percent of patients required hospitalization. PEM physician discharge diagnosis and child psychiatrist diagnosis were in agreement in 21% of cases.

CONCLUSION

Patients referred by PEM physicians for urgent outpatient psychiatric assessment were most commonly early adolescent males. The majority of patients did not require ongoing psychiatric care. Further investigation into the differences between PEM physician and child psychiatrist diagnoses is needed to ensure patients and families receive accurate and consistent mental health information and recommendations from all members of their health care team.

[Increased urinary excretion of transforming growth factor beta and interleukin-6 in patients with diabetic nephropathy]

The purpose of the study was to assess TGF-beta and IL-6 urinary excretion (measured with EIA) in 12 IDDM patients (7 F, 5 M, age 20-49 yrs, mean = 33.08) with albuminuria or microalbuminuria. Control group consists of 27 IDDM patients (12 F, 15 M, age 24-59 yrs. mean = 39.5) without albuminuria or microalbuminuria. Urinary excretion of IL-6 was significantly higher (p < 0.05) in IDDM patients with albuminuria (mean = 7.43 +/- 8.29 pg/mg creatinine) than in control group (mean = 3.74 +/- 2.64 pg/mg creatinine). Urinary excretion of TGF-beta was also higher (but not significantly in IDDM patients with albuminuria or microalbuminuria (mean = 42.0 +/- 30.0 pg/mg creatinine) than in control group (mean = 27.0 +/- 20.0 pg/mg creatinine). The data indicate that IL-6 and TGF-beta could be involved in the development of diabetic nephropathy.

Ureteric stent in severe hydronephrosis of pregnancy

Eleven women (12 pregnancies) were included in the study. A double-pigtail ureteric stent was passed under cytoscopic vision in 8 patients. The mean gestational age on insertion of the stents was 29 weeks (range, 25-35 weeks). Delivery took place at a mean of 39 weeks (range, 35-41 weeks). Stents remained in situ for a mean of 9 weeks (range, 6-14 weeks) before delivery and were removed 4-5 weeks postpartum. Double pigtail ureteric stents did not expose the women to infection. Renal function tests remained within the normal limits. Ureteric stent is an effective method for internal drainage of severe hydronephrosis during pregnancy.

Variability and Circadian Changes in Home Uroflowmetry in Patients with Benign Prostatic Hyperplasia Compared to Normal Controls

We evaluated the variability and circadian changes in consecutive measurements of home uroflowmetry in 32 patients with symptomatic benign prostatic hyperplasia (BPH) and 16 healthy men. In the BPH group 476 uroflow measurements were recorded during 24 to 72 hours (mean 14.9 measurements per patient), and the controls produced 100 flow recordings (mean 6.25 measurements per participant). Great variability between consecutive peak flow rates was observed in the BPH group, ranging from at least 1 standard deviation in 28 of 32 patients (87.5%) to at least 2 standard deviations in 15 of 32 (47%). In 21 of 32 patients (65.6%) the highest recorded peak flow rate was greater than, while the lowest peak flow rate was less than the -2 standard deviations plot in voiding nomograms. In the control group variability between consecutive voiding episodes also was marked, namely at least 1 standard deviation in 8 of 16 men (50.0%) and at least 2 standard deviations in 2 of 16 (12.5%). However, in none of the control men was any peak flow rate measurement less than the -2 standard deviations line. Circadian changes in diurnal and nocturnal measurements of voided volume, interval to maximal flow, flow time, peak flow rate and adjusted peak flow rate were recorded in the BPH group, providing a urodynamic support to a well known clinical observation.

Histopathology of benign prostatic hyperplasia after failure of hyperthermia treatment

We have used a fine morphometric method to evaluate hyperplastic prostate tissue after treatment by local hyperthermia and compare it with untreated specimens. Local hyperthermia was delivered to the prostate gland by a transrectal applicator using microwaves at 915 MHz. Prostatic tissue was obtained from 13 patients who had completed a course of local hyperthermia treatment and who underwent prostatectomy 3 to 12 months later because the treatment had failed. Prostatic tissue from 9 patients who had undergone prostatectomy with no previous treatment served as a control. A significant reduction in the volume fraction of fibrous tissue was found in the study group (37%) compared with the general population (48%). No inter-group difference was observed in the volume fractions of vascular or glandular tissue. We suggest that the difference observed in the fibrous elements may be the reason for the failure of treatment and that the histological composition of the diseased gland may, therefore, be a key factor in determining the outcome.

Isolation of Chlamydia trachomatis from prostatic tissue of patients undergoing transurethral prostatectomy

Chlamydia trachomatis was isolated from three of 100 prostatic tissue specimens obtained from patients undergoing transurethral resection of the prostate. All examined patients were free from symptoms of urethral or prostatic inflammation. Our findings are in accordance with the high incidence of asymptomatic chlamydial infection of the lower genital tract and the increasing evidence that C. trachomatis can cause infection of the prostate.

Serum prolactin levels in patients treated with a gonadotropin-releasing hormone analogue for adenocarcinoma of the prostate

Twenty-six patients with advanced cancer of the prostate were treated with [D-SER(BUt)6]LHRH-(1-9) nonapeptide ethylamide (buserelin). All but 6 patients evidenced signs of metastasis. Blood prolactin levels were measured prior to the initiation of treatment and during a follow-up period of 18 months. A statistically significant (p greater than 0.0005) elevation in serum prolactin levels was observed after 3 months of treatment. Serum prolactin remained elevated for a total of 6 months, after which a decline to pretreatment levels was observed. Our observation of a transient rise in prolactin levels during the chronic administration of buserelin is at variance with previously published data which reported unchanged prolactin levels during such treatment.

Serum prostate specific antigen levels during hyperthermia treatment of benign prostatic hyperplasia

To understand better the tissue and cell changes occurring in the human prostate as a reaction to heat, we used circulating prostate specific antigen as a marker to detect cell injury. The prostate in 18 patients with benign prostatic hyperplasia was heated to 42 +/- 1.5C with local microwaves at 915 MHz. Each treatment sessions lasted 1 hour and the patients underwent 5 treatment sessions. A total of 90 treatment sessions was performed among 18 patients. No significant difference was observed between pre-treatment and post-treatment serum prostate specific antigen levels. We conclude that local hyperthermia is an atraumatic treatment modality that does not exert its effect on the hyperplastic prostate via a cytotoxic insult to prostate epithelial tissues.

Morphometric evaluation of benign prostatic hyperplasia

Resected prostate tissue from 9 patients with benign prostatic hyperplasia was subjected to a morphometric analysis. The relative volume density of 4 prostatic tissue components was determined: fibrous (47%), muscular (8%), vascular (3%), and glandular (18%). The resolution of the stromal portion of the hyperplastic prostate into 3 subcomponents represents a finer level of resolution than that previously reported. This enhanced precision in the determination of tissue composition lends new insight into the etiology of benign prostatic hyperplasia, and provides a basis for the evaluation of novel approaches to its treatment.

[Verrucous carcinoma of the penis]

Malignant tumors of the penis are rare, and constitute only 1% of all tumors in males. The disease is more common in the black population of the USA due to genetic links and the rarity of circumcision. Penile carcinoma is extremely rare in Israel, only 10 cases having been reported during a period of 20 years. Verrucous carcinoma, often called giant condyloma acuminata, constitutes a subgroup of squamous cell carcinoma of the penis. The first description was by Buschke in 1925, and was followed by that of Loewenstein in 1939. The tumor is usually limited to the penile glans and does not invade lymph nodes. We present a 44-year-old Arab with verrucous carcinoma treated by partial amputation of the penis. He had been circumcised 11 years previously. During 18 months of follow-up there was no recurrence.

[The psychological status of acne patients. Personality structure and physician-patient relations]

The results of various studies dealing with the situation and psychological state of acne sufferers and their relationship to their doctors are presented. It was shown that out of approximately 2.7 to 3.5 million acne sufferers, only some 500,000 are presently undergoing medical treatment. Failure to seek medical treatment is closely associated with the fact that acne sufferers for the most part expect to be disappointed with the results. For a number of psychological reasons (self-consciousness, contact difficulties, low level of frustration tolerance) a substantial number of acne sufferers are particularly sensitive to actual or supposed lack of acceptance on the part of their doctors. Greater consideration of their psychological situation might improve the therapeutic outcome, increase compliance, and lead to a greater confidence in the doctor.

[Renal colic and renal calculus]

A positive diagnosis of urinary stone was made in 183 of 407 patients (44.9%) with renal colic seen in the emergency room. 182 (44.7%) had normal intravenous pyelograms, 26 (6.4%) had evidence of dilatation of the urinary system, possibly due to the passage of a stone, and 16 (3.9%) had other pathological urinary conditions, such as double collecting system or cysts. Stones were located in the upper urinary tract in 28.4%, in the midureter in 21.9%, and in the lower ureter in 49.7%. There was a statistically significant correlation between recurrent episodes of left-sided renal colic, erythrocytes in the urine and the presence of a stone in the urinary tract. No ethnic differences were found, nor was there a difference in the rates of stones found in those who were hospitalized and in those who were not.

Endoscopic control during colposuspension procedure for the treatment of stress urinary incontinence

Possible complications during colposuspension for urinary stress incontinence are inadvertent injury to the bladder or ureters. Surprisingly, endoscopic control during the procedure was never described. We suggest the routine use of cystoscopy during colposuspension for the early diagnosis of complications and immediate repair.

Giant obstructing calculus in the distal ureter secondary to obstruction by a ureterocele

A 43-year-old man presented with bilateral simple ureteroceles complicated by calculi. A huge left ureteral calculus subsequently developed, causing nonfunctioning of the left kidney. This is apparently the largest calculus associated with an orthotopic ureterocele ever reported in the literature. Its cause, diagnosis, and treatment are discussed.

Psychosocial factors influencing alcohol problems in West German survey samples

In order to distinguish between different types of people endangered by alcohol, five different indicators were used to classify the degree of alcohol affinity: KFA/Feuerlein, German version of part of the Manson Evaluation, alcohol-in-blood concentration, and frequency and amount of drinking. The degree of alcohol affinity potential is quite different depending on each indicator. All indicators together discriminate between nine independent types (each for men/women) of alcohol-endangered people. Further-more, five independent drinking motivations could be factor analyzed. The diversity in this field was completed by sixteen different therapies used by physicians for alcoholism treatment.

Drug abuse trends among German youth

Data of drug consumption in Baden-Würtemberg, Bavaria and West Germany are presented for the period 1967 to 1977. Two different indicators (representative surveys, and overdose deaths and apprehended illicit drugs) are compared. It can be stated that Germany is now in the third development stage of drug consumption characterized by a decentralizing drug scene and the concentration of a hard core of drug users. More than one-third of the hard core contact physicians three times and then move on. This relationship in particular should be analyzed more deeply in the future.