Need analysis for a new high acuity medical psychiatry unit: which patients are considered for admission?

BACKGROUND: The study aims were: to estimate the proportion of patients with an indication for admission to a new high acuity Medical Psychiatric Unit (MPU), to explore the reasons for MPU-admission according to different health disciplines, and to check for differences in patient characteristics. The results of this study are to be utilized in the proposed establishment of a high-acuity MPU in a University Medical Center. Such a unit currently does not exist at Erasmus MC. METHODS: Hospital in-patients were included if they received psychiatric consultation from the Psychiatric Consultative Service (PCS). As part of the study protocol, psychiatrists, other medical specialists, and nurses determined the need for admission to the proposed MPU. Patient groups were compared with respect to diagnoses, socio-demographic characteristics and patient routing. RESULTS: One hundred and fifty-one patients were included, 43% had an indication for MPU-admission, for the other patients PCS involvement was sufficient. There was agreement on suicide attempts as a reason for MPU-admission. For psychiatrists, the need for further diagnostic evaluation was a common reason for MPU admission, while other medical specialists more often emphasized the need for safety measures. Patients with an unplanned hospital admission had a higher chance of MPU eligibility (OR = 2.72, 95% CI 1.10-6.70). The main psychiatric diagnoses of MPU-eligible patients were organic disorders (including delirium), mood disorders, and disorders related to substance abuse. The most common diagnoses found were similar to those in previous research on MPU populations. CONCLUSION: Different medical disciplines have different views on the advantages of MPUs, while all see the need for such facilities. The proposed MPU should be able to accommodate patients directly from the Emergency Unit, and the MPU should provide specialized diagnostic care in an extra safe environment.

Subcellular study of sphingoid base phosphorylation in rat tissues: evidence for multiple sphingosine kinases.

The enzymatic phosphorylation of sphingoid bases was analysed in rat tissues, using D-erythro-[4,5-(3)H]sphinganine as substrate. After optimisation of the assay, taking care to block sphingosine-phosphate lyase and sphingosine phosphatase, highest ATP-dependent kinase activities were present in testis, followed by kidney, and intestinal mucosa. Approximately two thirds of the kidney activity were membrane bound, the remaining being cytosolic. Classical cell fractionation studies of kidney and liver did not allow to identify unequivocally the subcellular site of the membrane bound kinase. Separation of a particulate fraction from kidney homogenates by Percoll gradient and sucrose density gradient centrifugation revealed that kinase activities are associated with vesicles derived from the endoplasmic reticulum and the plasma membrane. Based on indirect data, such as the effect of detergents and divalent ions, the cytosolic and both membrane bound activities appear to reside in different proteins. N,N-Dimethylsphingenine was inhibitory to all three different kinases, which were mainly active towards the D-erythro isomers of sphingenine and sphinganine.

Further characterization of rat dihydroceramide desaturase: tissue distribution, subcellular localization, and substrate specificity.

The introduction of the double bond in the sphingoid backbone of sphingolipids occurs at the level of dihydroceramide via an NADPH-dependent desaturase, as discovered in permeabilized rat hepatocytes. In the rat, the enzyme activity, which has now been further characterized, appeared to be mostly enriched in liver and Harderian gland. By means of subcellular fractionation of rat liver homogenates and density gradient separation of microsomal fractions, the desaturase was localized to the endoplasmic reticulum. Various detergents were inhibitory to the enzyme, and maximal activities were obtained in the presence of NADPH and when the substrate was complexed to albumin. In the presence of albumin, the chain length of the fatty acid of the truncated dihydroceramides hardly affected the activity. Finally, in view of a likely evolutionary relationship between desaturases and hydroxylases, the formation of hydroxylated intermediates was analyzed. No evidence for their presence was found under our assay conditions.

Continuous non-invasive blood pressure monitoring: reliability of Finapres device during the Valsalva manoeuvre.

Because of the inherent risks of intra-arterial blood pressure monitoring a new non-invasive device, Finapres, which measures blood pressure continuously in the finger, was evaluated in 14 hypertensive and one normotensive subject. Brachial intra-arterial and finger pressures were compared during a control period and a subsequent Valsalva manoeuvre. Visually, blood pressures measured by Finapres faithfully reproduced the intra-arterial recordings in all subjects. From each pressure signal beat to beat systolic, diastolic, and mean blood pressure values and their differences were obtained and the time course of the response and its characteristic features were analysed. During the control period the Finapres measurements were lower than intra-arterial systolic, mean, and diastolic pressures (mean(SD) 1(9.6), 9(6.8), and 4(6.1) mmHg respectively). During the response to the Valsalva manoeuvre the brachial-finger pressure differences showed limited deviation from those during the control period; median differences were at most 6 mmHg occurring late during the intrathoracic strain period and 7 mmHg during the post-release blood pressure overshoot. In general, the Finapres device reproduced intra-arterial patterns faithfully. This device appears to offer a reliable alternative to intra-arterial blood pressure monitoring.

Accuracy of auscultatory blood pressure measurement with a long cuff.

Intra-arterial blood pressure was compared with simultaneous auscultatory measurements in 37 subjects with a wide range of blood pressures and arm circumferences; six cuffs of various lengths and widths were used. Nineteen subjects had an arm circumference of 34 cm or more (mean 40 cm) and the other 18 were considered to be non-obese and had a mean arm circumference of 30 cm. With each larger cuff, in terms of bladder surface area, auscultatory blood pressure decreased a few mm relative to intra-arterial pressure both for systolic and for diastolic measurements. Apart from diastolic pressure measured with the two 12 cm wide cuffs (12 X 23 cm, 12 X 30 cm) in the obese group all other auscultatory measurements differed less than 5% from intra-arterial pressure, albeit with considerable variability among the subjects. The differences in error among measurements with the four largest cuffs in the obese group (13 X 30 cm, 14 X 30 cm, 14 X 38 cm, and a conical cuff) were clinically irrelevant, and there was even less to choose among all six cuffs in the non-obese subjects. These results suggest that auscultatory blood pressure may be measured with acceptable accuracy with a single long bladdered cuff both in subjects with large arms and in subjects with normal sized arms.

Effects of peripheral vasoconstriction on the measurement of blood pressure in a finger.

Using noninvasive techniques only, the fall in mean pressure and the pulse amplification between brachial and finger arterial pressure were measured in six anaesthetised female subjects during surgery. Brachial pressure was measured every 2 min with an oscillometric technique. Finger pressure was measured continuously using an arterial volume clamp method. In addition changes in the degree of peripheral vasoconstriction were established on an adjacent finger with a photo reflection plethysmograph. On the average finger mean pressure is 10 mmHg below brachial pressure. The difference tends to decrease with increasing constriction. The change in the difference between full constriction and maximal dilatation is 8 mmHg. The average finger to brachial pulse amplitude ratio changes from 110% at maximal dilatation to 170% at full constriction. Finger systolic pressure overshoot is responsible for the pulse wave amplification. On the average it is + 7 mmHg and ranges between maximal dilatation and full constriction over 26 mmHg. The standard error deviation on the volume clamp method could be established at 5% for mean pressure, about equal to that of the oscillometric technique in the literature.

Effects of peripheral vasoconstriction on the blood pressure in the finger, measured continuously by a new noninvasive method (the Finapres).

The authors determined whether vasoconstriction alters the ability of a noninvasive method (Finapres) of continuously measuring arterial blood pressure in the finger to function accurately. They compared the response of the Finapres to blood pressures determined simultaneously by an oscillometric technique (Dinamap) in six anesthetized patients. Vasoconstriction was detected from a photoelectric plethysmogram, which was recorded continuously from an adjacent finger. Vasoconstriction was defined as a decrease in amplitude to less than half of its highest value in one and the same patient. From the 378 paired blood pressure readings obtained in this study, 51% took place in such a vasoconstricted state. The authors found that diastolic and mean blood pressures in the finger were, on the average, 9 mmHg below those in the upper arm and that the systolic pressure was 7 mmHg above that in the upper arm. The authors concluded that the Finapres keeps functioning well during peripheral vasoconstriction and is a recommendable method to monitor arterial blood pressure in the finger.

A study of systolic time intervals during uninterrupted exercise.

A method has been developed for obtaining measurements of the systolic time intervals during uninterrupted graded exercise in the upright position on a bicycle ergometer. The method has been applied to 112 subjects divided into 4 groups: two of normal subjects below and above the age of 40, respectively (mean ages 30 and 48 years), and two of patients (mean ages for each about 50 years), both with coronary insufficiency, but one without and the other with abnormality of left ventricular function as shown by ventriculography. The measurements obtained yield linear relations between total electromechanical systole (QS2) and heart rate, between pre-ejection period (PEP) and RR interval for each subject. The average standard deviation about the regression is less than 6 ms for all three regression lines; the average correlation coefficient is greater than 0-93. The younger group of normal subjects have a significantly shorter PEP compared to the older group. Indices have been derived which separate the patient groups from each other and from the normal subjects. Using these indices 86 per cent of all the subjects were correctly classified according to the group to which they belonged. It is concluded that measurements of STI during uninterrupted exercise offer valuable information in the assessment of cardiac patients.

Automatic determination of systolic time intervals.

Systolic time intervals (STI), measured non-invasively and during uninterrupted exercise, may contain information about cardiac function. A processing system was developed, which determines STI automatically from 8-sec recordings at each load level. A preprocessing unit provides automatic recording and optimal signal-to-noise ratios. One of the main tasks of the computer program, which is modular in structure and written in FORTRAN IV, is to recognize disturbances and artefacts in the signals. After selection of the complexes, usually with some kind of correlation method, a representative beat is found and the inclination points are localized. Besides these points, indicateions of possible errors are given. Preliminary results indicate that the system may be able to replace the human observer in estimating STI.

Pulse wave transmission times in central aorta and peripheral arteries in normal children.

Pulse wave transmission times and pulse wave velocities in central aorta and peripheral arteries were measured in a group of 85 healthy children and adolescents between the ages of 1 and 21 years. A new external plethysmograph is described which gives reliable tracings of external pulsations. A method is given to calculate real pulse wave transmission time from the aortic valves to the groin.