Outpatient Specialty Clinic Research Articles

W1243 Concomitant Use of Immunosuppressive Therapy in An Outpatient IBD Subspecialty Clinic Results in Rates of Response Higher Than Those Seen in the Infliximab Randomized Controlled Trials

(Background: for bold) Infliximab has confirmed efficacy from RCTs for the induction and maintenance of remission of active luminal and fistulizing Crohn's disease (CD). What have been less clearly described are the long-term outcomes of maintenance infliximab therapy outside of the rigors of a clinical trial setting and in actual clinical practice. (Aims: for bold) The objective of this cohort study was to examine, in an outpatient IBD specialty clinic, the induction and maintenance responses to infliximab in patients with moderately severe active CD. (Methods: for bold) A retrospective chart review was conducted of all Crohn's disease patients treated at a large, urban university hospital that serves as a quaternary IBD referral center. All patients treated with induction and maintenance dosing of infliximab were identified and their records reviewed for patient demographics, and clinical responses. Clinical response was defined by physician global assessment and off corticosteroids. (Results: for bold) 151 patients were identified of whom 133 had sufficient records to be entered into the analysis. The study population was 53% female; 98% Caucasian; mean age at initiation of therapy was 36.5 yrs; mean duration of disease from diagnosis to infliximab treatment was 11.5 yrs. Anatomic distribution of CD was 36% ileal, 32% colonic and 32% ileo-colonic. 117/133 (89%) of patients had a clinical response to induction and continued with maintenance infliximab therapy. 105/117 (90%) patients were on concomitant immunomodulatory therapy: azathioprine/6-MP 81/105 (69%); methotrexate 24/105 (21%). The mean duration of clinical response was 94.0 wks (95% CI 78.8-109.2). The proportion of patients with an ongoing clinical response at week 30 was 83.2%, at week 54 was 63.6% and at week 104 was 44.9%. In all, 36 (30.8%) patients lost response (LR) defined as worsening of symptoms, initiation of new CD therapy, or need for surgery. The mean time to LR was 63.8 weeks (95% CI 49.4-78.2). 15/117 (12.8%) patients experienced an adverse event (AE), resulting in the discontinuation of infliximab in 7 (6.0%) patients. AE's included 9 infusion reactions, 4 serum sickness-like reactions, 1 rash of unknown significance and 1 serious infection (osteomyelitis of the jaw). There were no cases of malignancy or death. (Conclusions: for bold) Patients starting infliximab in an IBD outpatient specialty clinic were demographically similar to those in the RCTs. Nevertheless, a higher number were using concomitant immunosuppressive therapy and demonstrated higher induction and maintenance of response rates.

Specific mutations in Methyl-CpG-Binding Protein 2 confer different severity in Rett syndrome

To determine if a relationship exists between the clinical features of Rett syndrome, an X-linked dominant neurodevelopmental disorder, and specific mutations in MECP2. Cross-sectional study of 245 girls and women with typical Rett syndrome seen between 1990 and 2004 in tertiary academic outpatient specialty clinics and who had complete MECP2 mutation analysis. A structured clinical evaluation was completed for each participant. The results were grouped by MECP2 mutation and compared. Participants with the R133C mutation are less severely affected than those with R168X or large DNA deletions (p < 0.05). Likewise, individuals with the R168X mutation are more severely affected than those with R294X and late carboxy-terminal truncating mutations (p < 0.05). Clinical differences are notable in ambulation, hand use, and language (p < 0.004), three cardinal features of Rett syndrome. Individuals with R168X are less likely to walk (p = 0.008), retain hand use (p = 0.002), or use words (p = 0.001). In contrast, those with carboxy-terminal truncations are more likely to walk (p = 0.007) and use words (p < 0.001). The R306C mutation, previously found to confer milder features, adversely affects only one clinical feature, language (p < 0.05). Specific mutations in MECP2 confer different severity. These results allow the design of therapies targeted toward the amelioration of expected problems. Furthermore, the distinct effects of MECP2 mutations on clinical severity must be considered in clinical intervention trials.

Implementation and outcomes of group medical appointments in an outpatient specialty care clinic

To describe the outcomes of a nurse practitioner (NP)-facilitated group medical appointment (GMA) intervention for chronic obstructive pulmonary disease (COPD) clients in a pulmonary practice in the Midwest. Medical records from a convenience sample of six established pulmonary patients in a Midwest specialty clinic who received care in a group format were retrospectively audited. Outcome measures included examination of changes in the utilization of healthcare services, exercise tolerance, and use of nonpharmacological and pharmacological interventions pre- and postparticipation in the GMA program. NP-facilitated GMAs are feasible and can help improve health outcomes. Results showed a significant increase in exercise tolerance measured by 6-min walk distance. Anecdotally, patient and provider response to the GMA was very positive. The GMA format is an innovative solution for the management of chronic disease patients that is comprehensive, time efficient, reimbursable, and well suited to NP practice. GMAs can be implemented in most practice settings.

Biomedical markers and psychiatric morbidity of neurasthenia spectrum disorders in four outpatient clinics in India

Context:Disorders of unexplained fatigue are researched globally and debated prominently concerning their biomedical and psychiatric comorbidity. Such studies are needed in India.Aims:To identify biomedical markers and psychiatric morbidity of disorders of severe unexplained fatigue or weakness with disability, designated neurasthenia spectrum disorders (NSDs). To compare biomedical markers of patients with controls. To study correlation between biomedical markers and psychiatric morbidity.Settings:Four specialty outpatient clinics of Psychiatry, Medicine, Dermatology, and Ayurved of an urban general hospital.Design:Case-control study for biomedical markers. Diagnostic interviews for assessment of psychiatric morbidity.Materials and Methods:Patients (N = 352) were recruited using screening criteria and Structured Clinical Interview for DSM-IV screening module. They were compared with controls (N = 38) for relevant biomedical markers. Psychiatric morbidity was assessed with SCID-I interviews, Hamilton scales, and Symptom Check List-90 (SCL-90). Correlations between a nutritional index and axis I morbidity were studied.Statistical Analyses:Frequencies and means of biomedical markers and psychiatric diagnoses were compared and associations assessed with regression analysis.Results:Corrected arm muscle area (CAMA) was significantly lower among patients (P < 0.001), but not anemia. Anxiety (73.0%) and somatoform (61.4%) disorders, especially nonspecific diagnoses, were more frequent than depressive disorders (55.4%). Generally, Hamilton and SCL scores were lowest in Ayurved clinic, and highest in Psychiatry clinic. Presence of Generalized Anxiety Disorder (GAD) and adjustment disorders correlated with low nutritional index.Conclusions:Malnutrition or de-conditioning that may explain weakness need to be considered in the management of NSDs in India, particularly with comorbid GAD or adjustment disorders. Weakness and anxiety, rather than fatigue and depression, are distinct features of Indian patients. SCL may be more useful than categorical diagnoses in NSDs. NSDs are an independent entity with nonspecific psychiatric comorbidity. Cross clinic differences among patients with similar complaints highlight need for idiographic studies.

Pediatric Trichotillomania: Descriptive Psychopathology and an Open Trial of Cognitive Behavioral Therapy

In study 1, 46 children and adolescents with trichotillomania who sought treatment at 2 specialty outpatient clinics were assessed. Most children reported pulling hair from multiple sites on the body, presented with readily visible alopecia, reported spending 30–60 minutes per day pulling or thinking about pulling, and reported experiencing significant distress about their symptoms. Most were described by their parents as having significant problems in school functioning. Few children met criteria for obsessive‐compulsive disorder or tic disorder. Child and family rates of other forms of psychopathology were high. In study 2, 22 of these children were enrolled in an open trial of individual cognitive behavioral therapy with particular attention to relapse prevention. Trichotillomania severity decreased significantly and 77% of children were classified as treatment responders at post‐treatment and 64% at 6‐month follow‐up.

Clinical and epidemiological characteristics of Helicobacter pylori infection among patients in specialty outpatient clinics at Faculdade de Medicina ABC

Clinical and epidemiological characteristics of Helicobacter pylori infection among patients in specialty outpatient clinics at Faculdade de Medicina ABC

Assessing Readiness to Change among Clients Seeking Help for Hypersexual Behavior

Mental health professionals may erroneously assume that clients seeking help for hypersexual behavior are ready to begin working on their issues at the outset of treatment. Prochaska and DiClemente (e.g., 1983, 1984) proposed the transtheoretical model (TTM) stages of change to advance their belief that clients move through several stages when attempting to alter specific target behaviors. If a clinician gets ahead of a client by administering interventions that are improperly matched with the client's readiness to change, treatment may be prematurely terminated or high levels of resistance may be encountered during therapy. In this study, clients (N = 67) who were referred for treatment in a specialty outpatient clinic for hypersexual behavior completed the Sexual Compulsivity Scale (Kalichman et al., 1994; Kalichman & Rompa, 1995, 2001) and the Stages of Change Scale (McConnaughy, DiClemente, Prochaska, & Velicer, 1989; McConnaughy, Prochaska, & Velicer, 1983). The data collected from these measures revealed that 70% (n = 47) of clients who expressed an interest in receiving help with issues related to hypersexuality also had high levels of ambivalence about the changes they desired to make and that individuals with ADHD were significantly (chi-square, p ≤ .001) more likely to be in the contemplation stage than subjects presenting with alternative diagnoses. Implications for these finding are discussed and suggestions for future research are offered.

Dialectical Behavior Therapy for Adolescents With Bipolar Disorder: A 1-Year Open Trial

To describe an adapted version of dialectical behavior therapy for adolescents with bipolar disorder. The dialectical behavior therapy intervention is delivered over 1 year and consists of two modalities: family skills training (conducted with individual family units) and individual therapy. The acute treatment period (6 months) includes 24 weekly sessions; sessions alternate between the two treatment modalities. Continuation treatment consists of 12 additional sessions tapering in frequency through 1 year. We conducted an open pilot trial of the treatment, designed as an adjunct to pharmacological management, to establish feasibility and acceptability of the treatment for this population. Participants included 10 patients (mean age 15.8 +/- 1.5 years, range 14-18) receiving treatment in an outpatient pediatric bipolar specialty clinic. Symptom severity and functioning were assessed quarterly by an independent evaluator. Consumer satisfaction was also assessed posttreatment. Feasibility and acceptability of the intervention were high, with 9 of 10 patients completing treatment, 90% of scheduled sessions attended, and high treatment satisfaction ratings. Patients exhibited significant improvement from pre- to posttreatment in suicidality, nonsuicidal self-injurious behavior, emotional dysregulation, and depressive symptoms. Dialectical behavior therapy may offer promise as an approach to the psychosocial treatment of adolescent bipolar disorder.

Interactional styles of out-patients with poor adjustment to chronic illness receiving problem-solving counselling

A sample of subjects with poor to fair adjustment to chronic illness is described according to three interactional styles distinguished by patterns of beliefs about the self in relation to others along an axis of purpose, dependency and self-concept. Further, the question of whether differences in style are related to quantitative measures of adjustment, purpose in life, and health and social service consumption is addressed. A randomized controlled trial was set up involving adult subjects (Roberts et al. 1995a), who were not adjusting well to their illness as determined by the Psychosocial Adjustment to Illness Scale-Self Report (PAIS-SR; Derogatis & Lopez 1983), and who were referred to one of nine specialty out-patient clinics in a large urban health care centre in southern Ontario. The subjects received a problem-solving intervention (experimental group) by random assignment to help improve psychosocial adjustment to chronic illness and reduce health care utilization. The nurse counsellors, using grounded theory, compiled descriptive formulations for 96 experimental subjects who were receiving problem-solving counselling intervention. In this group, three core interactional styles emerged. According to descriptions predominating in the formulations written by nurses, subjects were placed along a continuum from least to most effective in fostering social relationships and having needs met. The subjects were respectivley labelled “resigned”, “survivors” and “resourceful”. When these categories were compared for improvement in psychosocial adjustment, “resourceful” individuals had a clinically important (defined as 10 points) gain in their adjustment immediately following counselling. “Resourceful” individuals were able to maintain their gains in adjustment even 6 months after counselling (P=0.03). In contrast “resigned” individuals despite a slight gain with counselling continued in a trend toward their baseline poor adjustment status when counselling ended. “Resourceful” individuals were higher in their purpose-in-life score (PIL) at the outset and maintained that high purpose after counselling compared with “Resigned” individuals (P=0.03) who improved somewhat and then returned to low levels of purpose. All types of subjects with chronic illness were similar at the outset in their consumption of all health services. However, during the period of counselling, although not statistically significant an administratively important higher per person annual expenditure for services was generated by “Resourceful” individuals (P=0.11) followed by a marked reduction in their service consumption 6 months after counselling compared to consumption trends exhibited by “Resigned” and “Survivor” individuals.

Diagnostic concordance of neurasthenia spectrum disorders in Pune, India

Clinically significant fatigue or weakness is a common but understudied clinical problem in India. The applicability and relevance of Western clinical criteria in this setting are not studied. Alternative criteria sets used in different clinical contexts suggest a range of conditions constituting neurasthenia spectrum disorders (NSDs). We therefore aimed to determine frequency of patients with these complaints in four specialty outpatient clinics of an urban general hospital. We compared the concordance of four diagnostic criteria sets of fatigue disorders among the same patients. Patients from the clinics of Psychiatry, Medicine, Dermatology, and Ayurved were screened for clinically significant fatigue or weakness and assessed for CFS, ICD-10 neurasthenia, DSM-IV draft criteria for neurasthenia, and CCMD-2 neurasthenia. For 352 patients, sensitivity of CDC criteria for CFS (13.4%) was poorest. CFS was most frequent in the Medicine clinic. CCMD-2 criteria were the most frequently met (77.6%) with no significant difference across clinics. Two-way concordance of neurasthenia categories was no better than fair (< or =0.4) and few patients (8.0%) met criteria for all four categories. Four NSD criteria sets identified different clinical subgroups. CFS, considering fatigue and ignoring weakness, was least relevant for identifying NSD patients in these clinics. Poor concordance among the four diagnostic systems studied indicates the need for reviewing the nosology of these disorders. Focus on clinical significance alone is likely to avoid the discordant confusion arising from cross-cultural differences.

Survivors of violence-related facial injury: psychiatric needs and barriers to mental health care

Objective This study examined mental health needs, receptivity to psychosocial aftercare, and barriers to care among survivors of violence-related facial injuries. Methods Face-to-face interviews were conducted with 25 consecutively treated individuals at a hospital-based specialty outpatient clinic one month after a violence-related facial injury. To participate in the study, patients had to screen positive for an alcohol use disorder (AUD), major depression or posttraumatic stress disorder (PTSD). Participants were questioned about receptivity to an aftercare program and perceived barriers to care. Results Of those screened for study eligibility ( n=62), a substantial proportion met probable criteria for AUD (31%), PTSD (34%) and major depression (35%). Among those completing the core interview ( n=25), 80% met probable criteria for two or more psychiatric disorders. The majority (84%) expressed interest in psychosocial aftercare. However, barriers such as cost, insufficient information about counseling and obtaining services, transportation and preferences for self-reliance were commonly endorsed. Conclusions Survivors of violence-related facial injuries have substantial mental health needs and appear receptive to psychosocial aftercare. However, significant treatment barriers must be addressed. Findings underscore the value of a collaborative care model for treating violence-related facial trauma patients seeking care in specialty outpatient oral and maxillofacial clinics.

ESTABLISHING THE FEASIBILITY OF DIRECT OBSERVATION IN THE ASSESSMENT OF TICS IN CHILDREN WITH CHRONIC TIC DISORDERS

Behavior analysis has been at the forefront in establishing effective treatments for children and adults with chronic tic disorders. As is customary in behavior analysis, the efficacy of these treatments has been established using direct-observation assessment methods. Although behavior-analytic treatments have enjoyed acceptance and integration into mainstream health care practices for tic disorders (e.g., psychiatry and neurology), the use of direct observation as a primary assessment tool has been neglected in favor of less objective methods. Hesitation to use direct observation appears to stem largely from concerns about the generalizability of clinic observations to other settings (e.g., home) and a lack of consensus regarding the most appropriate and feasible techniques for conducting and scoring direct observation. The purpose of the current study was to evaluate and establish a reliable, valid, and feasible direct-observation protocol capable of being transported to research and clinical settings. A total of 43 children with tic disorders, collected from two outpatient specialty clinics, were assessed using direct (videotape samples) and indirect (Yale Global Tic Severity Scale; YGTSS) methods. Videotaped observation samples were collected across 3 consecutive weeks and two different settings (clinic and home), were scored using both exact frequency counts and partial-interval coding, and were compared to data from a common indirect measure of tic severity (the YGTSS). In addition, various lengths of videotaped segments were scored to determine the optimal observation length. Results show that (a) clinic-based observations correspond well to home-based observations, (b) brief direct-observation segments scored with time-sampling methods reliably quantified tics, and (c) indirect methods did not consistently correspond with the direct methods.

Complementary treatments for tobacco cessation: A survey

Little information is available regarding the prevalence of use and interest in future use of complementary and alternative medicine (CAM) for tobacco cessation among tobacco users. We conducted a self-administered anonymous survey among 1,175 patients seen at a midwestern outpatient tobacco treatment specialty clinic between November 2003 and July 2005. Patient use of CAM for tobacco cessation, perceived efficacy of these treatments, and interest in future use of CAM were ascertained. Data were summarized using descriptive statistics, and logistic regression models were used to determine the characteristics associated with past CAM use or interest in future use of CAM for tobacco cessation. All of the patients who received the survey completed it. A total of 27% of patients reported previous use of CAM for tobacco cessation. The interventions most commonly used were hypnosis, relaxation, acupuncture, and meditation. CAM treatments most commonly perceived to be efficacious were yoga, relaxation, meditation, and massage therapy. A total of 67% of the patients reported interest in future use of CAM for tobacco cessation. The treatments of greatest interest for use in the future were hypnosis, herbal products, acupuncture, relaxation, and massage therapy. Female gender, previous use of conventional tobacco cessation products, previous use of CAM treatments, and a higher level of education were significantly associated with interest in future CAM use. The high level of interest in CAM among tobacco users underscores the need to conduct further research in this field.

PR_175: Arterial Micro-Embolism Following Carpal Tunnel Injection: A Case Report

Setting: Outpatient hand specialty clinic. Patient: A 51-year-old woman with bilateral carpal tunnel syndrome. Case Description: The patient described paresthesias in her right thumb, index and middle fingers. Examination demonstrated a positive Phalen sign, carpal tunnel compression, and Tinel sign on the right. Electromyography showed bilateral median neuropathies, moderately severe on the right and mild on the left. Using sterile technique, a 25-gauge, 3.2-cm (1.25-in) needle was introduced to the ulnar side of the palmaris longus tendon, proximal to the distal wrist crease. The needle was directed toward the carpal tunnel at a 45° angle. A mixture of 1.5mL of 40mg of triamcinolone (Kenalog) and 1.5mL of lidocaine was injected. After injection, the patient’s right hand exhibited signs of ischemia including coolness and discoloration of the entire hand and all the digits. Her hand was dipped in paraffin 5 times and warmth was maintained for 20 minutes. She regained normal color in the hand but described coolness. Assessment/Results: At follow-up visits, the patient described burning in the hand and blotchiness and superficial skin necrosis of the digits was noted. Magnetic resonance angiogram of the right wrist and vascular medicine consult were normal. She underwent an open carpal tunnel release approximately 6 weeks postinjection. Surgical exploration demonstrated no evidence of needle tracking near the median nerve nor the ulnar or radial arteries. The ischemic changes were presumed to be due to microvascular emboli. Discussion: To our knowledge, this is the first reported case of arterial microembolism following carpal tunnel injection. The exact etiology of the microembolism is unclear, but may be related to vasospasm as has been described in the spine injection literature. Conclusions: This case illustrates an uncommon adverse event in a commonly performed procedure and raises questions for further review.

43 Sacrosidase in the Treatment of Chronic Nonspecific Diarrhea in Children.

Context: Chronic nonspecific diarrhea in children, also known as toddler's diarrhea, is a frequently encountered disorder in clinical practice. It tends to cause significant parental anxiety and frustration leading to frequent health care visits.Objective: We investigated the usefulness of sacrosidase (Sucraid®) in children with toddler's diarrhea. The primary outcome was the proportion of patients who responded to sacrosidase supplementation. Secondary outcome measures included safety and potential adverse effects.Population: Children 1 to 6 years of age with a current history of toddler's diarrhea (≥ 3 loose stools per day for ≥ 3 months) were enrolled in a prospective trial from our outpatient specialty clinic. Exclusion criteria included a history consistent with infection, inflammation, malnutrition or the use of motility altering agents. Patients were also excluded if they had abnormal screening tests including the presence of anemia, elevated inflammatory markers, positive celiac disease antibodies or infectious stool studies.Design: Baseline defecation patterns (stool frequency and consistency) were obtained using daily diaries filled by caregivers over 1 week prior to any intervention. Patients with baseline defecation patterns that satisfied the definition of toddler's diarrhea (≥ 3 stools daily) were placed on sacrosidase supplementation with all snacks and meals. Caregivers filled similar daily diaries for 2 weeks. We defined clinical response as a decrease in daily stool frequency by 50% and/or a decrease of ≥ 2 points on the stool consistency scale while on sacrosidase supplementation.Results: Between September 2005 and July 2006, 37 children presented for evaluation of diarrhea, of which 20 were eligible for the study. Of those eligible, 12 were enrolled (average age 31.6 months, range 41 to 23 months). One subject was excluded from analysis for noncompliance and three subjects were not kept in the study due to normal defecation patterns in the baseline period. Four of the remaining eight patients (50%) who finished the study were clinical responders. In the responder group, the average daily stool frequency decreased from 5.2 to 1.9 and the stool consistency scale decreased from a mean of 4.5 to 2.5 points. In the non-responder group, the average daily stool frequency and stool consistency remained unchanged. There were no complications reported.Conclusions: Sacrosidase supplementation demonstrated a potential benefit in children with toddler's diarrhea by decreasing defecation frequency and improving stool consistency. This may be due to excessive sucrose in children's diet or to unrecognized partial sucrase deficiency. A larger scale study with longer patient follow up is needed to further assess the benefit of such an intervention.

Disability, Psychosocial, and Demographic Characteristics of Abused Women With Physical Disabilities

In a sample of 415 predominantly minority women with physical disabilities recruited from private and public specialty outpatient clinics, we examined experiences of physical, sexual, and disability-related abuse within the past year and its associations with demographic, disability, and psychosocial characteristics. Logistic regression analyses identified 27% of the variance and indicated that women with disabilities who were younger, more educated, less mobile, more socially isolated, and who had higher levels of depression may have a higher likelihood of having experienced abuse in the past year. This model correctly identified 84% of the abused women with disabilities. Questions of directionality, the role of disability, and validity testing are discussed.

Inside Look

Children's Hospital of Wisconsin, located near Milwaukee, is a private, independent, not-for-profit center for pediatric healthcare. The only hospital in Wisconsin dedicated solely to the care and treatment of children, the facility provides inpatient care, including transport of critically ill or injured children and intensive care services. It includes more than 70 specialty outpatient clinics that care for the full range of pediatric healthcare needs.The facility, which treats thousands of children each year, was originally founded in 1894 by seven Milwaukee women who saw an urgent need to establish a hospital for children, especially those from poor immigrant families who had made Milwaukee their home.Today, Children's Hospital is recognized as a leader in bone marrow transplants, particularly between unrelated donors and recipients, and in the care of critically ill newborns.Recognizing the critical nature of inspecting the hospital's equipment in a timely fashion, Terry Hensler—clinical engineering manager at Children's Hospital—and his staff developed a proactive plan for staying ahead of inspection schedules. The plan is built upon the principles of planning ahead, prioritization, and teamwork with other departments.“We've developed close working relationships with the clinical staff, which has helped tremendously,” says Hensler. “If a ventilator that is coming due for preventive maintenance is in use and is expected to be in use for some time, you need to be able to communicate with the nurses and doctors to develop a solution that works for everyone involved.”That teamwork paid off recently when one of the facility's external pacemakers that was coming due for inspection went missing.“Small devices such as external pacemakers can be misplaced or stashed somewhere,” says Hensler. “So when that happened to us, particularly since it was a life support device, we sent out an e-mail, including a photo of the device, to the entire hospital staff. The device was located within a couple of days.”In addition to developing strong relationships with other departments, Hensler says that his department's unique way of charting upcoming preventive maintenance jobs has been successful as well.“A common practice in clinical engineering is to list on a chart the preventive maintenance jobs that are due to be done that month,” says Hensler. “But some months are heavier than others. So we developed a three-month ‘predictor’ list that outlines what's coming due over the next three months. We also mark certain items on the chart in bold or in red to denote priority. The chart prevents us from being surprised by a heavy month, and helps us to prioritize what is most urgent.”Other highlights of the department's inspection timeliness plan include:

Effectiveness of Cognitive-Behavioral Therapy for Adolescent Depression: A Benchmarking Investigation

In this study, we examined the effectiveness of cognitive-behavioral therapy (CBT) for adolescent depression. Outcomes of 80 youth treated with CBT in an outpatient depression specialty clinic, the Services for Teens at Risk Center (STAR), were compared to a “gold standard” CBT research benchmark. On average, youths treated with CBT in STAR experienced significantly slower symptom improvement than youths in the CBT benchmark. However, outcomes for STAR teens were more similar to the research benchmark when accounting for differences in referral source (clinical versus advertisement) between the datasets. Results support further efforts to test the effectiveness of CBT in clinically representative community practice settings and samples.

A Model for Primary Care Psychology With General Thoracic Surgical Patients

This study examined a model for brief psychological assessment for providing primary psychological care to patients within a surgical, specialty outpatient clinic to provide early and accurate detection of psychological distress in patients to increase compassionate care. Questionnaires were completed by 351 outpatients and 227 of these outpatients were provided a model of primary care (brief psychological intervention). Patients were assessed and provided coping strategies, patient education, and a brief evaluation of anxiety and depressive symptoms. Psychologists, in a brief interview (mean = 12 min) identified individuals experiencing significant psychological distress. The ratings of emotional status also predicted health quality of life and anxiety. Younger individuals presenting for medical care appear to be more vulnerable to psychological distress. Brief psychological interventions provide accurate, efficient assessment of psychological distress and can be an effective way of increasing compassionate care. The results support the use of primary care psychology and brief psychological interventions in the management of medical patient care.

Aeroallergen sensitization in pediatric allergic rhinitis in Singapore: is air-conditioning a factor in the tropics?

Singapore is a unique blend of a tropical environment with a high standard of hygiene and public health care. The objective was to define the prevalence, clinical characteristics, and environmental risk factors of specific aeroallergen sensitization in pediatric allergic rhinitis patients in this unique environment. The method adopted was a retrospective analysis of allergic rhinitis patients, undergoing aeroallergen skin prick testing (SPT), in the outpatient specialty clinic of the KK Children's hospital, from July 2001 to June 2002. A total of 202 patients were included, 161 (80%) males, 167 (83%) Chinese, age mean 7.6 yr (range 2-14 yr). The most prevalent clinical symptoms were: watery rhinorrhea 61%, blocked nose 61%, sneezing 52%, snoring 17%, and epistaxis 12%. SPT results were positive for house dust mites in 97% of children, pets (20%), molds (19%), pollens (15%), and kapok (10%). Mold sensitization was significantly more prevalent in households without air-conditioning (aircon), 49% vs. 10% with aircon (odds ratio 9.4, 95% CI 3.8-22.9). Polysensitization (sensitization to three or more allergens) was similarly more prevalent in households without aircon, 51% vs. 14% with aircon (odds ratio 6.4, 95% CI 2.8-14.7). It was concluded that indoor aeroallergen sensitization is the major associated factor with clinical allergic rhinitis in children in Singapore. Patients living in households without air-conditioning are at increased risk of mold sensitization and polysensitization.