Assessment of health-related quality of life in patients with cystinuria on tiopronin therapy

Cystinuria comprises less than 1% of kidney stones and is associated with impaired health-related quality of life (HRQOL). Limited evidence is available regarding HRQOL of patients with cystinuria treated with tiopronin (Thiola^®). The objective of this study was to assess the HRQOL of patients with or without tiopronin treatment. For this cross-sectional survey, patients on tiopronin treatment were recruited through the “Thiola^® Total Care Hub,” a specialty pharmacy used to dispense tiopronin, and compared with patients not taking tiopronin (non-tiopronin group) who were identified from the Cystinuria Contact Registry at New York University School of Medicine. Consented patients responded to a survey that included questions about their experiences with kidney stones, the Wisconsin stone quality of life (WISQOL) (disease-specific) questionnaire, and the short form-36 version 2 (SF-36v2) (generic) HRQOL questionnaire. Statistical analyses included independent-sample t tests, one-way analysis of variance (ANOVA), and correlations. The survey was completed by 312 patients: 267 in the tiopronin group (144 male, 123 female; mean 49 years) and 45 in the non-tiopronin group (10 male, 35 female; mean 48 years). Both groups utilized pain medications similarly (24% overall). Patients on tiopronin had a significantly better HRQOL than patients not on tiopronin for all WISQOL domains (p < 0.001) and all but the physical functioning SF-36v2 domain (p < 0.001), where both groups approached the US normative mean, when controlling for the last stone event. Compared with patients in the non-tiopronin group, patients taking tiopronin reported better HRQOL on both the WISQOL and SF-36v2.

Clinical factors associated with C-reactive protein in chronic spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Determine clinical factors associated with plasma C-reactive protein (CRP) in persons with chronic spinal cord injury (SCI).

SETTING

Veterans Affairs Medical Center in Boston, MA, USA.

METHODS

Participants provided a blood sample, completed a respiratory health questionnaire and underwent dual X-ray absorptiometry (DXA) to assess total and regional body fat. Linear regression models were used to assess cross-sectional associations with plasma CRP.

RESULTS

In multivariable models, factors associated with a higher CRP included a greater BMI, urinary catheter use, a respiratory illness in the past week and non-white race. Mean CRP also increased with decreasing mobility (motorized wheelchair >hand-propelled wheelchair >walk with an assistive device >walk independently). Results were similar when adjusting for percentage android, gynoid, trunk or total fat mass in place of BMI. Level and completeness of SCI was not associated with CRP in multivariable models.

CONCLUSIONS

Clinical characteristics common in chronic SCI are associated with plasma CRP. These factors are more important than the level and completeness of SCI and some are potentially modifiable.

Paranoids in the legal system. The litigious paranoid and the paranoid criminal

Paranoid symptomatology involving suspicions, a sense of being wronged and persecuted, along with an implacable will to retaliate against one's enemies, often translates into litigious struggles. Paranoids resort to the judicial arena to act out their own internal psychopathologic needs. Examples are offered of the many ways litigious paranoids may present within the legal system, as well as how interventions by the psychiatrist may be useful. Criminal behavior by paranoids, under the sway of full-blown delusions of various types, is discussed and analyzed. Historical cases are described (Hadfield, M'Naghten), and more contemporary cases are discussed according to diagnostic subtypes. The central importance of paranoid delusions in insanity defense cases and the exculpatory effect of various delusional subtypes are examined.

Medical malpractice in the absence of a doctor-patient relationship: the potential liability of psychiatric examiners in New York State

In New York, psychiatrists (and all physicians) have a duty, in every circumstance with respect to such functions as they are required to undertake, to conduct themselves and all their examinations in a thorough and proper manner. Especially in a forensic setting, psychiatrists must bear in mind that they have a legal duty to perform a competent examination before they render an opinion. It is well established that malpractice liability does not require the preexistence of a doctor-patient relationship based on an undertaking for the purpose of treatment. The author discusses a long line of cases in New York State which holds that psychiatric examiners are potentially liable in malpractice for any breach of duty with respect to those functions that are undertaken. Failure to conduct a proper, careful, and competent examination may result in liability in a variety of areas: competency examinations, commitment proceedings, workers' compensation claims, and so on. Limitations on such malpractice liability are discussed. Unlike some jurisdictions, New York does not accord judicial immunity to psychiatric examiners.

When doctors divulge: is there a "threat from within" to psychiatric confidentiality?

Psychiatrists, as a profession, have always asserted the central importance of confidentiality. The American Psychiatric Association (APA), in its recently released "Guidelines on Confidentiality," reaffirms this position. In an age of progressive erosion of the traditional psychiatrist-patient confidentiality, the threat to confidentiality is invariably perceived as exogenous, emanating from external sources such as the legal system, third-party payers, and peer review organizations. In rare instances, there appears to be a threat from within, when the psychiatrist (or nonpsychiatrist physician dealing with a psychiatric patient) deliberately chooses to divulge the patient's confidential communications in the absence of any clearcut legal requirement to do so (and against the express wishes of the patient). Four case examples of these unusual breaches of confidentiality are presented. The author concludes that although significant assaults on patient confidentiality are occurring from without, it is quite rare for such violations to come from within the profession itself.

Consequences of surveillance of the forensic psychiatric examination: an overview

Lawyers have argued that surveillance of the forensic psychiatric examination (either direct observation by a lawyer or recording of the examination) is necessary under certain circumstances to protect clients' rights and ensure more accurate reporting of the findings. Psychiatrists are concerned that surveillance could disrupt such examinations and impair their validity. The author reviews and extrapolates from available data on the effects of tape recording on clinical examinations and psychotherapy and concludes that the current state of scientific knowledge does not allow confident assessment of whether the perceived need for surveillance outweighs the possible impairment of the validity of forensic psychiatric examinations.

Litigious paranoids and the legal system: the role of the forensic psychiatrist

Forensic psychiatrists should be aware of the many ways that paranoid individuals may present within the legal system. Litigious paranoids often utilize the legal system as a vehicle to act out their fantasies and delusional preoccupations. Imaginary grievances, accusations based on delusional ideation, and irrational vindictiveness toward imagined persecutors may find full expression in any number of legal contexts. They can defeat the rational and legitimate objectives of the legal system, enmesh innocent and unsuspecting victims in nightmarish legal entanglements, and subvert the process of justice. The forensic psychiatrist can assist the court by alerting it to the presence of paranoid illness in parties or witnesses and by clarifying what the effects of such psychopathology are and what the most favorable response should be. Three legal contexts wherein paranoid individuals may present within the legal system are discussed: the "hypercompetent" defendant, the paranoid party in a divorce proceeding, and the paranoid complaining witness. Case illustrations are presented for each legal context. Two issues are discussed: the dividing line between paranoid ideation (and its impact on the legal process) and so-called "normal" thinking (and its objective to use the legal process to obtain certain ends); and the degree to which psychiatric opinions in this area should influence the way an individual's case is handled by the legal system. The author concludes that, despite the costs involved, it is preferable that even paranoids have their "day in court."

The psychiatrist's role in retrospective determination of suicide: an uncertain science

Psychiatrists have made significant contributions to our understanding of the phenomenon of suicide and are generally regarded as experts in all matters relating to suicide. When a legal determination must be made as to whether an individual has died as a result of suicide or by accidental (or any other) means, psychiatrists are often called upon to proffer their expert opinion to assist the courts to resolve the matter. Two case illustrations are presented and analyzed in which psychiatrists were called upon to make such retrospective determinations of suicide. The question is raised as to whether psychiatrists may sometimes exceed the limits of their scientific expertise in making such determinations.

Functional outcomes following medical intensive care

This study describes the long-term functional outcomes of a medical and coronary care ICU population. Baseline and 1-yr follow-up data were collected prospectively from all 2213 patients admitted during a 2-yr period. Patients were stratified into three groups based on their preadmission functional status: active (n = 917), sedentary (n = 1017), or severely limited (n = 279). Those with severe functional limitation before admission were twice as likely to undergo major interventions (p less than .005). This group also had a significantly (p less than .001) higher mortality and incurred significantly (p less than .01) higher hospital charges than the other two groups, even though hospital lengths of stay were similar. Finally, cumulative mortality was significantly (p less than .001) greater for the severely limited patients: 33% expired in the ICU, 42% died while still in the hospital, and 63% died after discharge. Most survivors regained their preadmission functional status, with 60% of the previously employed returning to work. However, even for hospital survivors, mortality was high and was related to prior functional status: active 7%, sedentary 20%, severely impaired 37%.

Clinical utility of serum digoxin level tests in hospitalized elderly patients

To assess the clinical utility of serum digoxin tests in the elderly and to ascertain the use by physicians of test results, digoxin levels were obtained from 77 consecutive, elderly patients (means age 72 years) taking digoxin on admission to a rehabilitation hospital. Blood samples were drawn the morning following admission (prior to the administration of digoxin) and were repeated in two weeks. Signs or symptoms of digoxin toxicity were seen in all 13 patients with levels above the therapeutic range. Of 38 patients with therapeutic levels, 16 had signs or symptoms compatible with underdigitalization or digoxin toxicity. Physicians were significantly more likely to respond to both the initial and follow-up serum digoxin test result when the first test result was above the therapeutic range.

Hospital readmissions among survivors six months after myocardial revascularization

One neglected but important measure of early morbidity after coronary artery bypass graft (CABG) operations is rehospitalization. As part of a prospective study of recovery after elective CABG procedures conducted at four academic medical centers, data from all readmissions occurring within the first six postoperative months were collected for 326 patients. A total of 24% of patients had readmissions. The most common categories of readmission discharge diagnoses were cardiac (57%), noncardiac (26%), and surgical sequelae (17%). Factors from the initial hospitalization identified as risk factors for rehospitalization included: length of stay in intensive care unit after surgery, severe noncardiac complications, duration of preoperative cardiac symptoms, intra-aortic balloon insertion, and preoperative resting angina. These findings help to identify a subset of at risk patients for whom more careful surveillance might be beneficial.

Nursing home patients admitted to a medical intensive care unit

To investigate admissions from nursing homes to a medical intensive care unit (ICU), the authors detailed the major interventions, costs, and outcomes for such patients (n = 67) over a 3-year period and then compared them with those for ICU patients receiving home care or visiting nurse services (240 patients) before admission and all others older than 65 years of age (949 patients). These three groups comprised 37% of total ICU admissions. In contrast to younger patients admitted primarily with acute ischemic heart disease, nursing home patients were more likely to be admitted with cardiopulmonary arrest, infection, and gastrointestinal bleeding. Major interventions of intubation and mechanical ventilation were most frequent for nursing home patients, but total hospital charges differed little among the groups. In-hospital mortality for the nursing home group (28%) was significantly higher than for the home care group (7%) and others older than 65 years of age (7%). Cumulative mortality for the nursing home group reached 66% by 8 months, versus 32% and 26% in the other groups, respectively.

The automatic call distributor: one answer to appointment-making problems

This case study addresses one problem brought on by a significant increase in patient volume: the inability of appointment desk clerks to answer the telephone within a reasonable amount of time. In response to mounting complaints from both patients and clinic staff, conversion to a computerized appointment system was undertaken. However, when the conversion led to no immediate relief of the problems at hand, an automatic call distributor was installed. Though this experience in instituting two new systems simultaneously was not without its problems, it did prove successful in effectively smoothing clinic operations.

Predictors of employment status after cardiac surgery

Preoperative predictors of postoperative employment status were studied in 228 patients (aged 25 to 64 years) who underwent cardiac surgery. Of the 150 patients working in the year before surgery, 73% returned within six months. Of those not so employed, 18% started working. Patients who expected preoperatively to return to work did so at an 82% rate compared with 39% of the others. This was a strong predictor in the multiple regression analysis. Educational level and family income were stronger predictors than occupation or level of physical exertion required. Rates of return were higher in patients with less severe angina and less fatigue preoperatively, but did not differ significantly by sex, surgical procedure, or duration of illness. Seven variables predicted work status correctly for 86% of persons. These results suggest that determinants of return to work are largely present before surgery and that patients' attitudes and expectations play an important role.

Passive mode locking of lasers with a tunable dye cell

A laminar-flow dye cell with continuously variable thickness (tunable without removal of the dye solution) provides an excellent way of optimizing passively mode-locked lasers. Varying the cell thickness adjusts low-light-level transmittance to match the total cavity and excitation energy conditions and also varies pulse duration. Acceptable cell thicknesses and dye concentrations can be calculated theoretically using well-known parameters. The cell can be conveniently retuned to compensate for dye degradation or to provide conditions for Q switching. Experimental evidence is presented for a Nd:YAG laser.

Medical intensive care for the elderly. A study of current use, costs, and outcomes

All admissions (2,693) to a medical intensive and coronary care unit (ICU/CCU) during a two-year period were reviewed to compare indications for admission, major interventions, and outcomes for elderly patients with those for younger patients. Once admitted to the ICU/CCU, older patients were more likely to receive major life-support interventions such as mechanical ventilation but less likely to survive. Major interventions were used in 32% of patients aged 75 years or older, in 26% of those 65 to 74 years, and in 22% of those 55 to 64 years. Nonetheless, elderly patients had no longer mean lengths of stay and no greater mean hospital charges. Hospital mortality for the oldest patients was 16%, compared with 14% and 8% for the younger age groups. Cumulative mortality one year after discharge for those older than 75 years was 44%. Elderly hospital survivors returned to their preadmission living situation but did not regain their preadmission activity level.

Credibility and incredibility: the psychiatric examination of the complaining witness

Psychiatrists are called on to evaluate the credibility (and incredibility) of complaining witnesses in criminal proceedings despite a longstanding controversy about their ability to accurately make such determinations. The author discusses the history of such psychiatric activity from Freud through the Alger Hiss prejury trial, its current status in terms of benefits to the criminal justice system, the legal and social questions it raises (e.g., the competing issue of the complainant's right to privacy), andthe court's restrictions on the psychiatrists. He presents two illustrative case histories.

Medical intensive care: indications, interventions, and outcomes

To evaluate current practices regarding intensive-care units (ICU's), we collected data on 2693 consecutive admissions to a medical ICU during a two-year period and studied indications for admission, specific interventions, costs, and outcomes. The need for noninvasive monitoring rather than immediate major interventions prompted 77 per cent of the admissions. Only 10 per cent of monitored patients had subsequent indications for major interventions. The 23 per cent who required immediate interventions accounted for disproportionate shares of total charges (37 per cent) and deaths during hospitalization (58 per cent). Demographic and diagnostic data indicate that the aged and chronically ill have become the principal consumers of intensive care. Overall mortality during hospitalization was 10 per cent; cumulative mortality during follow-up study (mean duration, 15 months) was 25 per cent. We conclude that identification of sensitive predictors of complications and specific predictors of mortality can lead to more efficient and effective ICU practices.

Data for peer review: acquisition and use. Results in the experimental medical care review organization program

Nine Experimental Medical Care Review Organizations (EMCROs) review the process and outcome of medical care, using insurance billing claims or medical record abstracts as the data source. The cost of EMCRO insurance billing claims processing in 1972, including peer review, ranged from $0.47 to $2.50 per claim. Three EMCROs reviewed the necessity for elective hospital admission prospectively for $2.50, $8.50, and $10.02 per case. The EMCROs developed innovative methods for abstracting hospital, nursing home, and ambulatory medical records at a cost of $0.40 to $4.00 per abstract. These EMCRO cost estimates were not derived from uniform accounting methods. Problems of accuracy and comparability of data for peer review are discussed. The EMCRO experience may aid local implementation of Professional Standards Review Organizations (PSROs).