Serum melatonin and 6-sulfatoxymelatonin in end-stage renal disease: effect of hemodialysis.

The pineal hormone melatonin plays a role in the regulation of hypothalamic-pituitary axis, target gland function, sleep pattern, mood changes, cellular immunity, antibody response, and skin pigmentation, nearly all of which are also affected by renal insufficiency. We measured serum melatonin and its main urinary metabolite, 6-sulfatoxymelatonin (6-SM), by radioimmunoassay in 11 patients with end-stage renal disease (ESRD) between the hours of 6 and 9 a.m. during hemodialysis and again on an off-dialysis day. The results were compared with those obtained in a group of normal control subjects. Predialysis serum melatonin and 6-SM levels obtained at 6 a.m. in the ESRD patients were comparable with those obtained in the normal control group. Serum melatonin concentration in the ESRD group fell approximately 25% during dialysis while 6-SM remained virtually unchanged. The changes observed on the off-dialysis day during the same time period were of nearly the same magnitude as those seen during dialysis (-32% and 1.4%, respectively). No significant difference was found in the concentration of either analyte in the blood entering and leaving the dialyzer. These observations suggest a lack of discernible removal of either compound by hemodialysis. In contrast to the ESRD patients, who showed a slow fall in serum melatonin and no significant change in serum 6-SM on both on- and off-dialysis days, the normal control subjects showed an expected reduction in serum melatonin (-43%) and a sharp fall in serum 6-SM (-53%) between 6 and 9 a.m.(ABSTRACT TRUNCATED AT 250 WORDS)

The pedestrian trauma patient. Perspectives from a psychiatric consultation service.

The hospital course of adult pedestrians injured by automobiles and treated by a university trauma service over a 12-month period was reviewed to evaluate the prevalence, recognition, and intervention of substance use and suicidal behavior. The study showed that the pedestrian trauma patient had a dramatically high rate of substance use and a surprisingly low index of suspicion of suicide attempt by the treatment team as a cause of the accident. Appropriate intervention might greatly reduce the financial and human cost of trauma care, but awareness and identification of these risk factors must be taught first.

Behavioral correlates and staff recognition of alcohol use in a university hospital trauma service.

Hospital course and admission blood alcohol levels were compared in 242 consecutive adult trauma admissions. A 33% overall intoxication rate was found. Intoxicated patients were more likely to be young, male, and Hispanic or black and to be involved in fights, stabbings, and automobile accidents in which they were presumed to be at fault. These patients were also more likely to manifest disruptive behavior in the emergency room. Disruptive behavior on the ward was not correlated with alcohol intoxication at admission, but was correlated with the history of head injury. Staff recognition of intoxication was high, but only about 7% of the patients who were intoxicated at admission were referred to alcohol treatment programs. More frequent referrals for such treatment might decrease trauma center admissions and the high costs associated with them.

Rapid, psychopharmacologically induced improvement can produce new psychological symptoms.

The advent of improved diagnostic criteria, coupled with a refined psychotropic armamentarium, can now produce rapid clinical improvements in clinical psychiatric conditions for which both patients and therapist may be unprepared. The following case report illustrates this problem which will become increasingly important in the practice of psychiatry as further improvements in psychopharmacological therapy occurs.

Linking the public care system and the private practitioner: a study in the use of contracts.

Patients in private practice settings frequently need services such as day hospitalization or vocational rehabilitation, which cannot be provided in a private office. Such services have been demonstrated to be effective and should be available to all patients when clinically indicated. Patients in the public sector are similarly in need of treatment modalities that are not readily available in public facilities; examples include long-term individual psychotherapy and outpatient electroconvulsive therapy. The authors present a contractual model for bridging these gaps. Using case reports, they demonstrate the utility of contracts between public and private providers.

Demographic and clinical characteristics of black psychiatric patients in a private general hospital.

A study of 419 first admissions to a private general hospital psychiatric inpatient unit showed that only 8.8 per cent were blacks, while 23 per cent of the population in the community were blacks. When compared to white patients, blacks were much less likely to be rerred for hospitalization by private sources, were substantially younger, and had shorter hospitalizations. The most common diagnosis for blacks was paranoid schizophrenia. The authors conclude that despite the widespread availability of third-party insurance coverage, blacks use the private general hospital less ofter than whites and their patterns of use are substantially different.