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Background To address a rising trend of emergency department (ED) visits for mental disorders (VMD), our ED implemented a child guidance model for their efficient evaluation and disposition. Objectives The main objective of our study was to evaluate the impact of the child guidance model on the ED length of stay (LOS) and ED costs on children with VMD. Methods We conducted a retrospective chart analysis on 1031 VMD visits made to an inner-city tertiary care pediatric ED in 2002 (1.4% of the total 2002 ED visits). We collected demographic and LOS information on all VMD visits. The child guidance model was implemented June 2002, after which we divided the VMD cases into 2 groups based on the presence or absence of the model. We performed a cost analysis to assess the impact of the model on LOS and determined the opportunity costs of prolonged LOS of the VMD visits as compared with 500 non-VMD visits. Results The average LOS of VMD visits was longer than that of the 500 non-VMD visits (236.04 minutes +/- 162.82 vs. 134.69 minutes +/- 95.19; mean difference, 101.34 minutes; P = 0.001). The LOS was significantly reduced after the model was implemented (259.49 minutes +/- 171.12 vs. 216.39 +/- 152.95 minutes, P = 0.00). The lost revenue due to extended VMD LOS was calculated as opportunity costs of $201,173.30, whereas the cost savings during the study period due to reduced LOS after the model was implemented was $10,651. Conclusions This study suggests that children with VMD visits contribute a substantial resource burden in the ED, and focused interventions such as the child guidance model in the ED can significantly decrease LOS and reduce ED costs.

Because parents assume the primary responsibility for pro- viding ambulatory post-transplant care to pediatric patients, pretrans- plant psychosocial evaluation in these recipients is usually focused on parents rather than on patients themselves. We sought to determine whether pretransplant parental psychosocial evaluation predicts post- transplant medical outcome at current levels of psychosocial support. We compared relative risk (RR) of rejection and hospitalizations (days of all-cause hospitalization) following initial discharge in patients in risk and control groups defined by their pretransplant parental psy- chosocial evaluation. We also compared the two groups of patients for the proportion of all outpatient trough cyclosporine A (CSA) or tac- rolimus (FK) levels that were

We assessed the long-term functional, social and psychosexual outcome in children who underwent vaginal reconstruction.We interviewed and assessed the psychological development of 16 women 17 to 28 years old (mean age 22) who underwent vaginal reconstruction only or in combination with other urogenital reconstructive procedures at ages 11 months to 18 years (mean 8.8). Psychological measures included the Beck Depression Inventory, Draw-a-Person test and Linkowski acceptance of disability scale as well as a standard questionnaire evaluating the sexual adjustment, social adjustment and ability for self-support of these women.Mean Beck Depression Inventory was 8.5 with less than 9 defined as minimal depression. Mean acceptance of disability score was 83.9 (range 54 to 94), indicating that patients were well adjusted with respect to the disability. Functionally 10 women were satisfied with the appearance of the vagina, 4 were neutral and 2 were dissatisfied. A total of 12 patients had no doubts about their female identity but 2 had occasional, 1 had significant and 1 had chronic doubts. Of the 16 patients 12 have completed high school, 3 are still in high school and 1 has withdrawn from high school. Of the 12 women who have completed high school 9 are currently in college and 3 have completed college. Socially all 16 participants rated family relationships as good and 13 were at least satisfied with their social life. Of the 16 women 12 have had a sexual encounter, including 1 who did not achieve orgasm. Six women are involved in long-term relationships, of whom 1 is married. In regard to the future all patients believe that they will be independent and financially stable with a fulfilling career.While women who have undergone vaginal reconstruction may be at risk for avoiding interpersonal relationships and sexual intimacy, we did not note this finding in our series. The majority of these patients were well adjusted to their physical condition, and had a high level of education and a stable family life.

A number of organizations have advised against the use of placebo substitution, including the American Pain Society, Agency for Healthcare Policy and Research, World Health Organization, Healthcare Facilities Accreditation Program, Joint Commission on Accreditation of Healthcare Organizations, Education for Physicians on End-of-Life Care Project (cosponsored by the American Medical Association and The Robert Wood Johnson Foundation), American Nursing Association, and the American Society of Pain Management Nurses. This white paper describes the literature and rationale in support of the American Osteopathic Association's (AOA's) position on the controversial subject of the use of placebos for pain management in terminally ill patients.

Pain management in end-of-life care presents a unique set of opportunities for patients and physicians. Physicians will encounter patients at the end of life regardless of type of specialty practice. Symptom relief is the concern of all physicians. Knowledge of "total pain" concepts along with basic end-of-life pain management offers much to patients and their families. Osteopathic principles and treatment philosophy complement quality pain management in end-of-life care. Physicians providing supportive care can assist patients and their families with comfort at the end of life. Good pain management at the end of life enhances the patient-physician relationship.

The relationship of cognitive impairment to the course of schizophrenia remains uncertain. By studying psychotic adolescents, 90% of whom were hospitalized for the first time, we hoped to reduce the influence of such confounding variables as lengthy disease process, neuroleptic treatment, and institutionalization. 39 psychotic adolescent subjects who fulfilled DSM-III criteria for schizophrenia, schizophreniform psychosis, paranoid schizophrenia, or atypical psychosis were compared to 41 non-psychotic adolescent psychiatric controls. Subjects were administered the Wechsler Intelligence Scale for Children-Revised, Peabody Individual Achievement tests of reading, reading comprehension, and mathematics, Bender-Gestalt, and Purdue Pegboard test within 3 weeks of admission to a psychiatric hospital. Performance IQ was significantly lower in the psychotic group (72 versus 93, P = 0.03). Thus, the IQ pattern in adolescent psychotic patients at an early stage in their illness was similar to the pattern displayed by chronic adult schizophrenic patients. Results were not consistent with theories of left hemisphere involvement in schizophrenia. Academic achievement was similar in both groups despite marked differences in performance IQ. Psychotropic medication had no significant impact on the results. In summary, deficits in processing novel material seem at the very least to be present at the onset of the psychotic disorder, though they may be non-progressive thereafter.

Blink rate, a putative noninvasive measure of central dopaminergic activity, was observed in developmentally disabled children. Autistic subjects had elevated blink rates when compared with normal subjects. These results are consistent with research that suggests that autism is associated with brain dopaminergic hyperactivity. The findings of diminished blink rate in mentally retarded children may not be related to dopaminergic activity and raise questions about what alternative mechanisms might be responsible.

Increased blink rate, a putative correlate of central dopaminergic activity, may be elevated in patients with chronic schizophrenia. In an effort to determine whether this elevation is due to iatrogenic factors, blinking was examined in medication-naive adolescent psychiatric inpatients undergoing their first hospitalization. The mean (±SD) blink rate of patients with psychosis (n = 13, 16 ± 9 blinks/minute) was significantly greater than that of the nonpsychotic control inpatients (n = 35, 10 ± 6 blinks/minute). Thus, elevated blink rate may be a feature of psychosis that is not necessarily caused by neuroleptic treatment or psychiatric hospitalization.