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Biomedical subjects

J J Strain

Publications and source records attributed to J J Strain.

At least 235 records · Page 13Linked to original sources

The liaison clinic: a model for liaison psychiatry funding, training, and research.

While liaison or similar clinics have existed since at least 1931, they remain uncommon. The Mount Sinai Medical Center Liaison Clinic is presented as a model for psychiatric evaluation and care of medical patients as well as training, research, and funding. In addition, it is a model for linking general and mental health systems in the tertiary care setting. The first year of operation of the clinic is described, including the sources of referral, demographic data, psychiatric, and medical diagnoses, and type of clinic contact. A total of 96 patients were seen in 390 visits, equaling three quarters of a liaison fellow's salary.

Adolescent↗

Do fat cell morphometrics predict weight loss maintenance?

A comprehensive psychosocial approach was used to treat 44 otherwise healthy obese patients, 49-332 percent above desirable weight, whose fat cell morphometrics arbitrarily placed them into three groups: seven with predominant fat-cell hypertrophy, 18 with predominant hyperplasia, and 19 with mixed hypertrophy and hyperplasia. Continuous psychological support was provided to all patients, and life-style was altered by nutrition education and behavior modification. Psychiatric referral was made when indicated. Four of the 45 patients, who were refractory to treatment, were referred for surgery. Successful treatment was defined as maintenance of a weight loss of 18 kg or more for one year. Two of the seven hypertrophic, seven of the 18 hyperplastic, and 11 of the 19 mixed hypertrophic-hyperplastic patients had successful results without surgery. Overall success rate was 45 percent, and did not differ significantly according to fat cell morphometrics. Although greater weight losses were maintained in correlation with the extent of hyperplasia P less than 0.005, the percentage weight change from intake weights was similar. In summary, a program of continuous psychological support, nutrition education, and behavior modification resulted in a substantially higher rate of successful one-year maintenance of weight loss than is generally reported for the treatment of markedly obese patients. Further long-term follow-up is in progress. In contradiction to predictions based on adipose cell morphometrics, those patients with simple hypertrophy of their fat cells were not more successful in maintaining a weight change. Although maintenance varied from 18.2 kg to 52 kg for those successfully treated, a weight loss of approximately 20 percent of the intake was sustained.

Adipose Tissue↗

Self-amputation and restitution.

This paper reports two cases of psychotically induced self-amputation of the hand, and discusses the psychological issues for the patient and staff involved in replantation and adaptation. The psychiatrist's role in facilitating patients' and staffs' utilization of restorative innovative techniques is also addressed.

Adult↗

Care of the psychotic self-amputee undergoing replantation.

The acutely psychotic self-amputee may be brought to the emergency room out of control, refusing treatment. Although these conditions make it difficult for the surgeon to provide restorative surgery, these patients may be quite grateful when resolution of psychosis restores realistic thinking and better judgment. This article describes the treatment of two such patients and provides practical guidelines for general behavioral management. The focal point of the approach is the formation of a surgeon/psychiatrist team that actively and consistently confronts and manages the disturbed behavior from the time the patient arrives in the emergency room until after discharge. Responsibility for deciding to operate when the patient is verbally refusing must be shared by surgeon and psychiatrist. Both surgeon and psychiatrist must be active in the treatment, each contributing his particular expertise to the collaborative effort.

Adult↗

Liaison psychiatry-otolaryngology rounds.

In an attempt to define and resolve patient and staff needs with regard to the psychological, social and economic problems in clinical otolaryngology, psychiatry/otolaryngology rounds were established in the Department of Otolaryngology 18 months ago. These weekly rounds have contributed greatly to improved patient care and better physician-nurse relations. They have also served a significant educational role for residents, medical students and other members of the patient care team. At present the rounds are attended by the inpatient nursing staff, 2 physicians, 6 residents, 3 medical students, an otolaryngologic social worker and the liaison psychiatrist. The meeting begins with a 10 minute discussion and review of current problems among the staff. Attention is then directed to the patient who will be interviewed for the day. The medical and social history are presented. Then the patient is brought in and interviewed in a non-stressful session for 20 minutes. After the patient leaves, the staff discusses the problems which the patient has encountered or poses to them, and the conference participants formulate an appropriate therapeutic plan. Among the problems which have been discussed are noncompliance, organic mental syndromes, hypochondirasis, depression, death and dying, disfigurement, loss of bodily function, and chronic pain. For those patients in whom further psychiatric evaluation and treatment are deemed necessary, the psychiatrist becomes an active participant in their clinical care.

Adult↗

Sex difference in the influence of obesity on the 24 hr mean plasma concentration of cortisol.

The 24 hr mean plasma cortisol concentration was measured in 65 healthy women ranging from 21% below to 218% above desirable weight and in 47 healthy men ranging from 5% below to 330% above desirable weight. In the women, there was a clear-cut inverse linear correlation between the plasma cortisol concentration and the percent deviation from desirable weight (y = 7.5 -- 0.3 x; r = -0.49; p less than 0.001); the relation of free to total cortisol concentration was weight-invariant; the MCR of cortisol in the most obese women was much higher than that of nonobese women (340 +/- 76 versus 211 +/- 31 liters/gm urinary creatinine; p less than 0.01). In the men, the plasma cortisol level and MCR were weight-invariant. To account for the finding in women of a linear correlation of the decrement in plasma cortisol level with the percent deviation from desirable weight (which in turn is nearly perfectly correlated with the total body fat content), we postulate that a given weight of adipose tissue in women takes up a constant amount of cortisol; this in turn suggests that their adipose tissue contains a saturable binding system such as corticosteroid receptor. By the same logic, the weight-invariance of plasma cortisol and MCR in men suggests the absence of significant amounts of corticosteroid receptor in their adipose tissue. The finding that the increased cortisol MCR of obese women results in decreased plasma cortisol levels rather than an increase in cortisol production (the latter, corrected for muscle mass, is normal in obesity: Strain et al, Metabolism 29:980, 1980) suggests a defect in their cortisol ACTH feedback system. Such a defect, presumably hypothalamic, is not unexpected in the light of reports of defective hypothalamic control of prolactin and growth hormone secretion in obesity.

Body Weight↗

Mild Hypogonadotropic hypogonadism in obese men.

To evaluate the pituitary-gonadal axis of obese men, we compared the 24-hour mean plasma concentrations of total and free testosterone and of dihydrotestosterone, FSH, and LH in 21 healthy obese men, aged 18-50, and 24 age-matched healthy nonobese men. In the obese men, we also measured the volume of ejaculate and the number and motility of sperm, and investigated libido by psychiatric interview, and potency by history and by measurement of nocturnal penile tumescence. As a group, the obese men had less than two-thirds the normal mean plasma levels of total testosterone, free testosterone, and FSH; the difference from normal was highly significant for all three. 24 hr LH levels were normal, which is inappropriately low in view of the subnormal testosterone levels. 24 hr mean levels of dihydrotestosterone and spermatogenesis, libido, and potency were essentially normal. Taken together, the findings represent a state of mild hypogonadotropic hypogonadism, which thus appears to be characteristic of obese men. This abnormality probably results from partial suppression of the pituitary by the elevated plasma estrogen levels we and others find in these men.

Adolescent↗

Needs for psychiatry in the general hospital.

Thirty to 60 per cent of the patients in general hospitals suffer from significant psychological dysfunction or psychological dysfunction secondary to their medical illness. In addition to helping medically ill patients adapt to their illness and hospitalization, psychiatrists who work in general hospitals should develop the biopsychosocial model of diagnosis and management and improve the staff's capacity to detect, diagnose, and manage their patients' psychological problems. The author discusses specific needs for consultation-liaison psychiatry in the general hospital such as development of prevention scheme, case detection, continuing education programs for staff, and education groups for patients and families. He also describes structural innovations to meet the increasing demands for psychiatric services in the general hospital setting. These innovations include the establishment of a biopsychosocial data-base system and the use of screening devices, medical-psychiatric inpatient units, and medical-psychiatric aftercare clinics in ambulatory facilities.

Hospitals, General↗

A liaison fellowship on a hemodialysis unit. A self-funded position.

The practice of liaison psychiatry has from its inception been hampered by an inadequate or non-existing funding base. A model is presented for funding an authentic liaison training program, fully supported by consultation-generated revenue. A specific description of the liaison teaching unit is given, which illustrates how the following objectives of the program were successfully met: provision of comprehensive biopsychosocial care, dissemination of psychological skills and knowledge to nonpsychiatrist staff, training of the liaison fellow, and generation of sufficient revenue to offset its costs.

Fellowships and Scholarships↗