Integrating Behavioral Healthcare and Primary Care, Appropriate Balance on What Model is Driving Care, and, the Whole Spectrum of Individuals are Coming Through the Door .

With the integration of behavioral health services into primary care and other medical specialties, the community of providers and the public must address a number of questions, including: What models of care are there for these services? What kinds of providers supply these services? Are these providers trained behavioral health providers or extenders in some form? And, as these systems of care are constructed, who makes use of them? The purpose of this study is to address these questions as well as to consider some of the challenges of attending to the spectrum of needs that will arise as integrated healthcare services expand. Consideration of these questions may serve to clarify the impact that these models of healthcare will have in ways that may be readily apparent and, at the same time, in ways that may be subtler and less comprehensible. Addressing these questions is also intended to facilitate discussions within healthcare systems and among providers concerning which models of care best respond to specific populations. In turn, proactively answering these questions will, for the foreseeable future, shape not only behavioral healthcare, in perhaps small or large ways, but also healthcare in general.

Commentary: the use of health and behavior codes in pediatric psychology: where are we now?

This article focuses on the current status of the use of Health and Behavior (H&B) codes by pediatric psychologists. We address the rationale for the use of these codes in a pediatric psychology setting, practice updates since the codes were initiated, and our experience with utilizing these codes in one pediatric hospital. We conclude with a summary of our assertions and future directions for policy and practice.

Implementation of effective treatments of preschool behavior problems in a clinic setting.

Epidemiological data indicate that nearly 20% of preschool aged children have significant behavioral problems. Parents typically consult their child's primary care provider, who frequently refers to child psychologists for treatment regarding these difficulties. Psychologists skilled in providing effective services for young children are in short supply, limiting accessibility, and parents often are reluctant to follow up with a mental health specialist, suggesting low acceptability. The Behavior Consultation Clinic is a structured clinic for preschool children designed to address these issues of effectiveness, accessibility and acceptability. A retrospective review of 550 patients seen over a 5-year period found that half were seen for one therapy session. Review of the remaining patients found that slightly more than half showed improvement (32% successful discharge with improvement, 24% premature discharge with improvement) with a typical range of two to seven half-hour sessions, about a quarter did not improve, and the remaining patients were referred to a higher level of service. These data indicate that a structured, brief clinic that focuses on the needs of preschool children utilizing evidence-based approaches can be effective, acceptable, and accessible. The Behavior Consultation Clinic also serves as a training clinic for psychology interns and pediatric medical residents.

Influence of sphingomyelin and TNF-alpha release on lethality and local inflammatory reaction induced by Loxosceles gaucho spider venom in mice.

It is well known that Loxosceles venom induces local dermonecrosis in rabbits, guinea pigs and humans but not in mice, although, depending on the dose, Loxosceles venom can be lethal to mice. In this work we demonstrate that mice injected intradermally in the dorsal area of the back can survive a lethal dose of Loxosceles gaucho venom and also develop an inflammatory reaction (with infiltration of leukocytes shown by histological analysis) at the local injection site when the venom is co-administered with sphingomyelin. It was observed that more venom was retained for a longer period of time at the local injection site when venom was co-administered with sphingomyelin. The presence of exogenous sphingomyelin did not influence significantly the release of TNF-alpha induced by L. gaucho venom. These results suggest that the action of venom on sphingomyelin, producing ceramide phosphate, causes the development of an inflammatory reaction, which in turn traps the venom in the local area for a long period of time and does not allow it to disperse systemically in a dose sufficient to cause death. Our findings also indicate that the size and availability of the local sphingomyelin pool may be important in determining the outcome of Loxosceles envenoming in different mammalian species.

Effect of Loxosceles gaucho venom on cell morphology and behaviour in vitro in the presence and absence of sphingomyelin.

This study was performed to investigate whether the toxic effects of Loxosceles gaucho venom on cells might be exerted via stimulators of TNF-alpha release generated by sphingomyelinase D--a major component of the venom. It was demonstrated that L. gaucho venom alone is unable to induce TNF-alpha release by J774A.1 cells, while in the presence of exogenous sphingomyelin it induces a high level of TNF-alpha release which is significantly increased by incubation with non-inactivated serum. Ceramide phosphate also induces TNF-alpha release in J774A.1 cells, but (unlike sphingomyelin/sphingomyelinase) the level of release is not influenced by the presence or otherwise of non-inactivated serum. L. gaucho venom does not induce proliferation of J774A.1 cells and even at high concentrations it does not affect their viability. J774A.1 cells, which prior to venom treatment were elongated and clumped, round up after venom treatment, but, revert to their original morphology after incubation with fresh medium. TNF-alpha resistant MRC-5 cells and TNF-alpha sensitive MCF-7 cells are susceptible to the toxic effect of both L. gaucho venom and ceramide phosphate. The results obtained in this study demonstrate that exogenous sphingomyelin can modulate, in vitro, the release of TNF-alpha induced by L. gaucho venom in mouse macrophages. In addition, the results also indicate that ceramide phosphate and L. gaucho venom are toxic to several different cell types, via a variety of mechanisms, some, but not all, of which may involve TNF-alpha as an intermediary.

An immunofluorescent assay for acute promyelocytic leukemia cells.

Sequential treatment with all-trans retinoic acid followed by chemotherapy significantly improves the long-term survival of patients who have acute promyelocytic leukemia (APL). Consequently, a simple and accurate test is needed to establish the diagnosis of APL and to identify those patients having a relapse of the disease. We describe an accurate, 2-hour indirect immunofluorescent assay for identifying APL cells in bone marrow specimens. The assay uses the PML (PG-M3) murine monoclonal antibody that is directed against the amino-terminal portion of the PML gene product. We observed a distinctive, finely speckled pattern of fluorescence in the NB4 cell line (a positive control), as well as in 15 clinical specimens that were confirmed to have APL by cytogenetic, cytochemical, and immunophenotypic studies, including four cases of microgranular variant of APL. By contrast, a coarse globular pattern of fluorescence was observed in 53 other clinical specimens that did not contain APL. When we performed dilution studies using artificial mixtures of APL cells with normal bone marrow cells, we detected as few as 5% APL cells in the mixture. Finally, there was complete concordance between the immunofluorescent assay and a polymerase chain reaction-based assay for the PML-retinoic acid receptor alpha chimeric gene in 12 other clinical specimens. We conclude that the immunofluorescent assay for PML protein is a rapid, sensitive, and accurate method for determining the presence of APL cells in clinical specimens. This assay therefore should be considered as a cost-effective alternative to other diagnostic tests, such as karyotyping or polymerase chain reaction, for the diagnostic evaluation of APL.

Adolescent diabetes management and mismanagement.

OBJECTIVE: To document the existence and prevalence of adolescent-generated diabetes management techniques. RESEARCH DESIGN AND METHODS: One hundred forty-four adolescents completed the confidential questionnaire developed for this study. Glycohemoglobin was also obtained for each individual. RESULTS: Within the 10 days before their clinic visit, many adolescents admitted to engaging in various mismanagement behaviors, with 25% admitting to missing shots. Parents tend to underestimate adolescent mismanagement. Missing shots was significantly related to poor control (P < 0.01). Older adolescents engaged in more mismanagement than their younger cohorts (P < 0.001). The questionnaire factored into two subscales: blatant mismanagement and faking. CONCLUSIONS: This study shows the importance of recognizing the prevalence of mismanagement among adolescents.

Readmissions of children with diabetes mellitus to a children's hospital.

The characteristics of children with diabetes readmitted to Children's Hospital during a 5-year period, 1984 to 1989, were compared with those characteristics of new-onset patients admitted for stabilization and education and to outpatients in the Children's Hospital diabetes program to determine which characteristics were associated with patients who were readmitted. Changes in the frequency of readmissions were examined to determine whether the introduction of a diabetes team and a program that emphasizes the importance of ensuring that patients at risk of readmission consistently received insulin injections resulted in a reduction of readmissions. Readmissions occurred more frequently in patients who were black (71% compared with 38% of new-onset patients and 31% of outpatients) (P less than .001), from one-parent homes (56% compared with 27% of new-onset patients and 24% of outpatients) (P less than .001), and without third-party insurance (45% compared with 18% of new-onset patients and 15% of outpatients) (P less than .001). Readmissions were very common at 14 to 15 years of age (39% of readmissions vs 18% of outpatients) and very uncommon in children younger than age 9 (6% of readmissions vs 27% of outpatients) (P less than .001). Fewer readmissions for ketoacidosis occurred in the summer than in any other season (P less than .05). Readmissions fell by 47% over the 5-year period while new-onset patients increased by 85%. The reduction in frequency of readmissions was due to fewer readmissions for ketoacidosis and fewer readmissions in blacks, in patients from one-parent homes, and in patients without third-party insurance.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatocyte differentiation in vitro: initiation of tyrosine aminotransferase expression in cultured fetal rat hepatocytes.

A fetal rat hepatocyte culture system has been used to study the molecular mechanisms of tyrosine aminotransferase (TAT) gene expression during development. It has previously been shown that TAT activity can be detected in 19-d, but not 15-d, gestation hepatocytes on the first day of culture (Yeoh, G. C. T., F. A. Bennett, and I. T. Oliver. 1979. Biochem. J. 180:153-160). In this study enzyme activity, synthesis, and mRNA levels were determined in hepatocytes isolated from 13-, 15-, and 19-d gestation rats maintained in culture for 1, 2, or 3 d and exposed to dexamethasone. TAT expression is barely detectable in 13-d gestation hepatocytes even after 3 d in culture. Hepatocytes isolated from 15-d gestation fetuses have undetectable levels of enzyme activity and synthesis on the first day of culture; both can be assayed by days 2 and 3. TAT mRNA levels in these hepatocytes, measured by hybridization with a specific cDNA, increase substantially during culture. TAT activity, synthesis, and mRNA are evident on the first and subsequent days of culture in 19-d gestation hepatocytes. Transcription measurements in isolated nuclei indicate that the increase in TAT mRNA in 15- and 19-d gestation hepatocytes is associated with an increase in transcription of the gene. Immunocytochemical studies demonstrated that the increase in TAT expression correlated with an increase in the proportion of hepatocytes expressing the enzyme, rather than a simultaneous increase in all hepatocytes. These results support the proposal that a subpopulation of 15-d fetal hepatocytes undergo differentiation in culture with respect to TAT.

Neurobehavioral anomalies in neonates with seizures.

Neurobehavioral evaluation of the high-risk neonate represents an important advance in early detection of behavioral anomalies which may give rise to later neuropsychological sequelae. In the present study neonates comprising three diagnostic categories (i.e., respiratory distressed, seizure-disordered, normals) were evaluated with the Brazelton Neonatal Behavior Assessment Scale (BNBAS) to determine the extent to which differences in neurobehavioral organization could be detected with the scale, and how they were related to diagnostic classification. Average conceptional age at testing for the three groups was within the range usually considered full term: e.g., 38.81 weeks (respiratory distressed), 40.18 weeks (normal healthy) and 42.54 weeks (seizure disorder). Infants who had been diagnosed with neonatal seizures exhibited consistently less optimal behavior than did either of the other two groups. Infants with respiratory distress and normal controls did not differ significantly on most summary measures of neurobehavioral organization scored with the BNBAS. The study offers support for the discriminative validity of the BNBAS and its potential usefulness in the assessment of clinically ill newborns.

The human lumbar dorsal rami.

The L 1-4 dorsal rami tend to form three branches, medial, lateral, and intermediate, which are distributed, respectively, to multifidus, iliocostalis, and longissimus. The intertransversarii mediales are innervated by a branch of the dorsal ramus near the origin of the medial branch. The L 4 dorsal ramus regularly forms three branches while the L 1-3 levels the lateral and intermediate branches may, alternatively, arise from a short common stem. The L 5 dorsal ramus is much longer than the others and forms only a medial and an intermediate branch. Each lumbar medial branch innervates two adjacent zygapophysial joints and ramifies in multifidus, supplying only those fascicles which arise from the spinous process with the same segmental number as the nerve. The comparative anatomy of the lumbar dorsal rami is discussed and the applied anatomy with respect to 'rhizolysis', 'facet denervation' and diagnostic paraspinal electromyography is described.

The nerve supply to the human lumbar intervertebral discs.

The lumbar intervertebral discs are supplied by a variety of nerves. The posterior aspects of the discs and the posterior longitudinal ligament are innervated by the sinuvertebral nerves. The posterolateral aspects of the discs receive branches from adjacent ventral primary rami and from the grey rami communicantes near their junction with the ventral primary rami. The lateral aspects of the discs receive other branches from the rami communicantes. Some rami communicantes cross intervertebral discs and are embedded in the connective tissue of the disc deep to the origin of psoas. Such paradiscal rami are likely to be another source of innervation to the discs. The anterior longitudinal ligament is innervated by recurrent branches of rami communicantes.