Evaluating the first 1000 patients referred to a specialist depression clinic: a case for tertiary referral facilities.

BACKGROUND: We report on the assessment and outcome of the first 1000 patients referred to a tertiary referral depression clinic established to assess the utility of diagnostic sub-typing on clinical course of illness. METHODS: Diagnostic, treatment recommendations, prognostic judgments and 12-week outcome data were examined. RESULTS: Nearly 40% of those with a primary mood disorder were diagnosed with bipolar disorder, of whom three-quarters received such a diagnosis for the first time. Alternative diagnoses or formulations were provided for 68% of the total sample, with the therapeutic paradigm altered for the majority (86%) of patients. Improvement rates were indicative of a higher level of improvement in those diagnosed with bipolar disorder (some 70%) compared to those with unipolar disorders (some 60%). Overall, however, rates of 'full remission' were low, being 2% and up to 12% for bipolar and unipolar patients respectively and perhaps reflecting the tertiary nature of the assessing clinical facility. Baseline clinician predictions were in the order of 60% accuracy in predicting outcome, irrespective of diagnostic grouping. LIMITATIONS: Anticipation factors (e.g. attending a specialist tertiary referral service) may have contributed non-specifically to outcome. Use of clinician-derived diagnoses rather than strict DSM-IV criteria limits comparisons to other studies. CONCLUSIONS: The high rates of a first-time bipolar diagnosis suggest that detection and diagnosis of this condition continues to be problematic. Low remission rates underline the chronic nature of many mood disorders, and the need for ongoing management given the high risk of relapse. Our findings offer support for the importance of identifying bipolar disorder and distinguishing depressive sub-types in order to shape more targeted treatments, a task that might be advanced by the establishment of more tertiary referral services.

Renal cell carcinoma in a horseshoe kidney presenting as an acute, left sided varicocele.

We present a rare case of renal cell carcinoma (RCC) in a horseshoe kidney presenting as an acute left sided varicocele. A left sided varicocele is a well-described presentation of RCC, usually caused by tumour thrombus extending along the renal vein with resultant testicular vein occlusion. However, in our case a tumour in the lower pole of a horseshoe kidney caused an acute varicocele by direct involvement and occlusion of the testicular vein.

Laser treatment of psoriasis.

In psoriasis, the earliest observable electron microscopic changes are in the dermal papillary vasculature. The flashlamp-pumped pulsed tunable dye laser can achieve selective photothermolysis of the dermal vasculature. This laser was used to treat eight patients with chronic plaque psoriasis, as it was hypothesized that the ablation of dermal papillary vasculature would arrest the early events leading to the evolution of psoriasis, and produce resolution of the plaques. At the final assessment, performed 10 weeks after three fortnightly laser treatments, five of the eight patients recorded an improvement of > or = 50%, and one showed complete resolution of the treated plaques of psoriasis. Although not practicable in the treatment of widespread psoriasis, we conclude that selective photothermolysis of the dermal vasculature by pulsed tunable dye laser offers an alternative new therapy for chronic plaque psoriasis, and also demonstrates the pivotal role of the vasculature in the pathogenesis of psoriasis.

Communication in the physician-patient relationship.

Political, legal, ethical, social, economic, and technological changes in the twentieth century have produced a profound effect on the health care and health status of Americans and the way in which physicians and patients communicate. In the latter half of this century, the responsibility for individual health care has shifted from a physician-oriented, paternalistic approach to a patient-centered one. Patients now assume two identities: health consumers and active participants in the medical decision-making process. This phenomenon has created an environment where consumer demand for information has shifted from a single focus on symptoms, diagnosis, and treatment of diseases to an increasing preoccupation with cost, quality, and access to health care. This shift emphasizes the critical role played by medical librarians in the dissemination of needed information, and it challenges librarians to take a leadership role in opening newer channels of communication between physicians and patients. The 1992 Janet Doe Lecture analyzes the evolutionary change in the physician-patient relationship and its modes of communication, projects future roles for medical librarians, and provides an extensive list of references for further reading.

Characteristics, content, and significance of the popular health periodicals literature.

An analysis of the content of sixty popular health periodicals covered in 1986 by the Consumer Health & Nutrition Index was made to identify the characteristics and concerns of popular health magazines and newsletters. The literature mirrors the health values and anxieties of the American public. While some of the literature diverges from mainstream allopathic medicine, most popular publications succeed in presenting coherent, reasoned, and documented viewpoints. Because there is no consensus on many medical problems, it is important that individuals have the freedom to read dissenting and alternative points of view and consider multiple options before making informed and reasoned health decisions. The popular literature is a valuable yet inexpensive source of reliable information on topics of current concern. The publications are not as well known as they deserve to be because they have not been adequately indexed, while they have not been indexed because they are not well known. The Consumer Health & Nutrition Index now provides expanded subject access to sixty health-related periodicals plus all health-related articles in sixteen general interest magazines.

Health sciences libraries in the United States: II. Medical school libraries, 1960-1980.

Surveys of medical school libraries made over a twenty-year period (1960-61 through 1980-81) were analyzed. As indicated by growth in both number and support, medical school libraries have evolved from a period of stability through expansive growth and subsequent leveling off. Expenditures and resource development have been affected by historical developments, especially recent massive federal and state aid to medical education.

Obliterative bronchiolitis in rheumatoid arthritis.

Two patients with rheumatoid arthritis who developed obliterative bronchiolitis are described. Both patients had received penicillamine. The first patient died in respiratory failure 4 months after the onset of her breathlessness and the diagnosis was confirmed at post-mortem. The second patient was diagnosed with appropriate lung function tests and has been started on azathioprine. Although she is still disabled by breathlessness 12 months after presentation, her condition has stabilised.

Routine preoperative chest radiography in non-cardiopulmonary surgery.

Preoperative radiography was performed on 667 consecutive patients undergoing elective non-cardiopulmonary surgery in a large hospital in Wales. Of all significant findings reported 54% were due to cardiomegaly and 19% to chronic respiratory disease, and no appreciable abnormality was found in any patient under 30. Out of a subsample of 152 examined prospectively, 38% had received a chest radiograph within the last year, and the maximum marrow dose had been exceeded in 12-5%. It is concluded that the procedure, as presently practised, is not only being considerably overused but is also exposing many recipients to the potentially harmful effects of over-irradiation. The findings provide further evidence in support of the Royal College of Radiologists' proposal that a national multicentre study of diagnostic radiology should be set up with some urgency.

The involvement of receptro sulphydryl groups in the binding of steroids to the cytoplasmic glucocorticoid receptor from rat thymus.

The glucocorticoid receptor protein present in the high-speed supernant fraction of rat thymus tissue is extremely unstable, having a half-life of about 2 h at 4 degrees C. It was found that the decline in steroid-binding capacity could be slowed, though not arrested completely, by the addition of sulphydryl-protecting agents such as 2-mercaptoethanol or dithiothreitol, and by EDTA. The inactivation was also partly reversed by these agents. 0.5 mM N-ethylmaleimideor p-chloromercuriphenylsulphonic acid inactivated the recptor at 4 degrees C, but the presence of bound steroid protected the receptor against this inactivation. Bound steroid did not protect the receptor against the action of higher concentrations of these reagents. Treatment of intact thymus cells with 2,4-dinitrophenol resulted in a reduction in the steroid-binding capacity of the supernatant fraction derived from these cells. This effect of 2,4-dinitrophenol could not be reversed by the presence of dithiothreitol in the extraction buffer. It is concluded that the inactivation of the receptor in vitro is at least partly due to the oxidation of one or more sulphydryl groups necessary for steroid binding; the process of oxidation does not account for the reduction in steroid binding observed in intact thymus cells under conditions of energy deprivation.

An Investigation of the Educational Needs of Health Sciences Library Manpower: Part VII: Summary and Conclusions.

The major findings and conclusions of a survey of manpower in health sciences libraries of the United States in 1969 are summarized. Although there does not appear to be a serious manpower shortage in terms of budgeted positions which are unfilled (demand), the manpower situation can still be considered serious when we introduce into our evaluation of the situation the question of existing levels of training and the urgent requirement (need) to bring manpower levels to a point at which adequate information services can be provided to the whole health sciences community. This is the final paper in a series of papers on a manpower study which also summarizes and analyzes the manpower data obtained by the American Hospital Association survey of 1968 and presents a number of general conclusions and recommendations for manpower planning for health sciences libraries.