Robert M. House

Psychiatric aspects of hepatic transplantation

We conducted formal psychiatric evaluations and extensive chart reviews in a series of 34 patients surviving an average of 5¼ years after hepatic transplantation. Seven of 14 children and 19 of 20 adults exhibited obvious psychiatric disturbances before the operation. (There was not time to evaluate another 5 children and a sixth was an infant; one adult arrived in hepatic coma.) All patients experienced psychiatric problems postoperatively. Organic brain syndromes and apprehensiveness were the most common preoperative problems in pediatric patients, and problems in relationships with family members, anxiety, regression, and helplessness were most common after surgery. In adults, organic brain syndromes, anxiety, and depression were the most common preoperative and postoperative problems. While psychosocial disturbances in liver transplant recipients were similar in many respects to those of the more well-studied kidney homograft patients, a number of important differences emerged: organic brain syndromes, fear of death, severe regression (psychological functioning appropriate to a younger age), worries that a suitable donor would not be found in time, and insomnia were more common, and concerns about the origin of the homograft and about changes in body image were relatively rare postoperatively. These differences seem to be related to the severity of liver disease requiring transplantation, the effects of the illness on the brain, the lack of an alternative means of life support resulting in greater prominence of concerns about survival, the

Can admissions interviews predict performance in residency

ObjectiveThe authors aim to determine whether admission interviews predict performance in residency.MethodsThe authors determined whether interview and other admission data were correlated with performance during postgraduate years 2–4 and with remaining in the residency in 544 residents enrolled in a single psychiatry residency program between 1963 and 2004.ResultsConsidered together, admissions data predicted 13% of the variance in performance ratings in postgraduate year 2 (PGY-2) and 5% in PGY-4. Interview scores were moderately correlated with performance ratings in PGY-2, modestly correlated with performance in PGY-3, and not correlated with performance ratings in PGY-4. Letters of reference were moderately correlated with performance ratings in PGY-2 and modestly correlated with performance in PGY-3 and PGY-4. In PGY-2, interview scores differentiated between the top quartile of performance and the other three quartiles, while letters of reference differentiated performance in the top and bottom quartiles from the middle quartiles. Numerical differences among groups were not great enough to be practically useful, and no variables predicted which residents would leave the program before completing it.ConclusionAs they are currently conducted, application interviews do not have sufficient power to predict performance during residency. Letters of reference may be useful to the extent that they reflect personal experience with the applicant, but differences in ratings of these letters are not great enough to base admission decisions on them. As it is currently performed, the interview process may be more useful as a means of interesting applicants in the program than of evaluating their potential for success in the residency.

Severity of Acute Illness is Associated with Baseline Readiness to Change in Medical Intensive Care Unit Patients with Unhealthy Alcohol Use

BACKGROUND Unhealthy alcohol use predisposes to multiple conditions that frequently result in critical illness and is present in up to one-third of patients admitted to a medical intensive care unit (ICU). We sought to determine the baseline readiness to change in medical ICU patients with unhealthy alcohol use and hypothesized that the severity of acute illness would be independently associated with higher scores on readiness to change scales. We further sought to determine whether this effect is modified by the severity of unhealthy alcohol use. METHODS We performed a cross-sectional observational study of current regular drinkers in 3 medical ICUs. The Alcohol Use Disorders Identification Test was used to differentiate low-risk and unhealthy alcohol use and further categorize patients into risky alcohol use or an alcohol use disorder. The severity of a patients acute illness was assessed by calculating the Acute Physiologic and Chronic Health Evaluation II (APACHE II) score at the time of admission to the medical ICU. Readiness to change was assessed using standardized questionnaires. RESULTS Of 101 medical ICU patients who were enrolled, 65 met the criteria for unhealthy alcohol use. The association between the severity of acute illness and readiness to change depended on the instrument used. A higher severity of illness measured by APACHE II score was an independent predictor of readiness to change as assessed by the Stages of Change Readiness and Treatment Eagerness Scale (Taking Action scale; p < 0.01). When a visual analog scale was used to assess readiness to change, there was a significant association with severity of acute illness (p < 0.01) that was modified by the severity of unhealthy alcohol use (p = 0.04 for interaction term). CONCLUSIONS Medical ICU patients represent a population where brief interventions require further study. Studies of brief intervention should account for the severity of acute illness and the severity of unhealthy alcohol use as potential effect modifiers.

Comparison of self-reports and clinicians' ratings of unipolar major depression.

Recent literature has unfavorably compared self-report measures of depression to clinician-administered measures such as the Hamilton Rating Scale. In the present study, the Beck Depression Inventory and the MMPI D scale were compared to the Hamilton Rating Scale to assess the effectiveness of each measure in discriminating unipolar depressed psychiatric inpatients (n = 26) from inpatients without a major affective disorder (n = 11). Scores on the Beck scale and the MMPI Depression scale but not the Hamilton Rating Scale were significantly related to the diagnosis of unipolar major depression.

Alcohol Use Disorders Affect Antimicrobial Proteins and Anti-pneumococcal Activity in Epithelial Lining Fluid Obtained via Bronchoalveolar Lavage

AIMS Our overall objective was to examine whether characteristics of epithelial lining fluid (ELF) from subjects with alcohol use disorders (AUDs) obtained via bronchoalveolar lavage (BAL) contribute to their predisposition to pneumococcal pneumonia. We sought to compare the anti-pneumococcal activity of acellular human BAL from subjects with AUDs to matched controls. Further, differences in BAL lysozyme activity and lactoferrin concentrations between these two groups were examined to determine the effect of AUDs on these antimicrobial proteins. METHODS BAL was performed in subjects with AUDs and matched controls. Acellular BAL was used at varying concentrations in an in vitro killing assay of Streptococcus pneumoniae, type 2, and the percent kill of organisms per microgram per milliliter total BAL protein was ascertained. Lysozyme activity and lactoferrin concentrations were measured in BAL from subjects and controls at measured concentrations of BAL protein. RESULTS AUD subjects (n = 15) and controls (n = 10) were enrolled in these investigations who were balanced in terms of smoking history. Using a mixed effect model, across the range of BAL protein concentrations, killing of pneumococcus tended to be less potent with BAL fluid from AUD subjects. Additionally, lysozyme activity and lactoferrin concentrations were significantly lower in the AUD group. CONCLUSIONS The predisposition for pneumococcal pneumonia among those with AUDs may be in part mediated through effects of alcohol on substances within ELF that include antimicrobial proteins. Clarifying the composition and activity of ELF antimicrobial proteins in the setting of AUDs via investigations with human BAL fluid can help establish their contribution to the susceptibility for pulmonary infections in these individuals.

Taking Care of Culturally Different and Non-English Speaking Patients

Many physicians evaluate and care for non-English speaking patients and patients from different cultures. If not carefully considered, cultural factors, including language, often interfere with optimal diagnosis and treatment of these patients. In addition to improved clinical care, increased awareness and assessment of these issues will often enhance patient and family satisfaction and cooperation with therapeutic recommendations. A number of cultural examples are given to illustrate various points, which of course cannot be comprehensive, but which should alert the physician for areas to focus upon. The knowledge and skills to perform a sociocultural differential diagnosis and to initiate treatments in these areas are especially important for consultation-liaison psychiatrists.

Acute psychiatric evaluation of self-injuring patients

Abstract Nonlethal self-injurious acts may be a symptom of a number of acute and chronic psychiatric disorders. Emergency room, surgical, primary care, and psychiatric physicians should be particularly alert for self-injury, especially if an unlikely explanation is given for trauma, an unusual type of trauma is present, or a history of multiple traumas is obtained. If self-damaging behavior is suspected, an immediate and thorough psychiatric evaluation should begin. A systematic approach to the psychiatric evaluation of patients suspected of self-injury is presented.

MMPI Results Associated with Abnormal Responses to the DST and TRH Tests

In the present study, it was predicted that psychiatric inpatients who obtained abnormal responses on the Dexamethasone Suppression Test (DST) and the Thyrotropin Releasing Hormone Stimulation Test (TRH) would obtain higher elevations on the MMPI scales associated with depressive symptomatology than inpatients with normal DST and TRH responses. Patients with abnormal DST responses obtained significantly lower scores on the F, Psychopathic Deviate, and Paranoia scales, suggesting that they present themselves on the MMPI as less socially maladjusted, and less alienated from societal values than their depressed inpatient peers who obtained normal DST results. No differences were obtained between abnormal and normal responders on either the DST or TRH with respect to the MMPI scales that are typically associated with depression.

Male genital self-mutilation with maggot infestation in an intoxicated individual

We present the case of a 55-year-old homeless male who presented with penis and scrotal maggot infestation secondary to genital self-mutilation. The patient gave a history consistent with gender identity disorder and indicated that he was intoxicated during the event. The patient had no history of psychosis. He sought medical attention only after he was no longer welcome on public transportation due to the odor emanating from this infection. Untreated gender identity disorder with alcohol dependence in this case led to a drastic behavior with significant consequences.