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PubMed2005

Dimensionality of somatic complaints: factor structure and psychometric properties of the Self-Rating Anxiety Scale.

Somatic complaints are often key features of anxiety pathology. Although most measures of anxiety symptoms capture somatic complaints to some degree, the Self-Rating Anxiety Scale (SAS) was developed primarily as a measure of somatic symptoms associated with anxiety responding. We evaluated the psychometric properties and factor structure of the SAS in two large undergraduate samples who completed the SAS and measures of anxiety and depression. Exploratory factor analysis revealed four lower-order SAS factors in both samples: (1) anxiety and panic; (2) vestibular sensations; (3) somatic control; and, (4) gastrointestinal/muscular sensations. The SAS demonstrated good reliability in both samples, and the correlations between the SAS factors and other anxiety variables provide supportive evidence for convergent validity, though evidence for discriminant validity was limited. The strengths and limitations of the SAS are offered as well as the implications of our findings for the nature and assessment of somatic complaints in anxiety disorders.

Adult↗
PubMed2005

Application of bioreactor system for large-scale production of Eleutherococcus sessiliflorus somatic embryos in an air-lift bioreactor and production of eleutherosides.

Embryogenic callus was induced from leaf explants of Eleutherococcus sessiliflorus cultured on Murashige and Skoog (MS) basal medium supplemented with 1 mg l(-1) 2,4-dichlorophenoxyacetic acid (2,4-D), while no plant growth regulators were needed for embryo maturation. The addition of 1 mg l(-1) 2,4-D was needed to maintain the embryogenic culture by preventing embryo maturation. Optimal embryo germination and plantlet development was achieved on MS medium with 4 mg l(-1) gibberellic acid (GA(3)). Low-strength MS medium (1/2 and 1/3 strength) was more effective than full-strength MS for the production of normal plantlets with well-developed shoots and roots. The plants were successfully transferred to soil. Embryogenic callus was used to establish a suspension culture for subsequent production of somatic embryos in bioreactor. By inoculating 10 g of embryogenic cells (fresh weight) into a 3l balloon type bubble bioreactor (BTBB) containing 2l MS medium without plant growth regulators, 121.8 g mature somatic embryos at different developmental stages were harvested and could be separated by filtration. Cotyledonary somatic embryos were germinated, and these converted into plantlets following transfer to a 3l BTBB containing 2l MS medium with 4 mg l(-1) GA3. HPLC analysis revealed that the total eleutherosides were significantly higher in leaves of field grown plants as compared to different stages of somatic embryo. However, the content of eleutheroside B was highest in germinated embryos. Germinated embryos also had higher contents of eleutheroside E and eleutheroside E1 as compared to other developmental stages. This result indicates that an efficient protocol for the mass production of E. sessiliflorus biomass can be achieved by bioreactor culture of somatic embryos and can be used as a source of medicinal raw materials.

Bioreactors↗
PubMed2006

Improving outcomes in depression: a focus on somatic symptoms.

BACKGROUND: It is hypothesized that somatic symptom alleviation is a significant predictor of overall outcome in depressed primary care patients. METHODS: Depressed primary care patients (N=205) meeting DSM-IV-TR criteria received open-label antidepressant therapy. The primary symptom measurement tool used was the 17-item Hamilton Depression Rating Scale (HAMD-17), with the Montgomery-Asberg Depression Rating Scale (MADRS) and the Clinical Global Impression Improvement/Severity (CGI-I/S) used as secondary measures. As proxies for somatic symptoms, 8 items from the HAMD-17 (HAMD-S) and 3 items from the MADRS (MADRS-S) that measure somatic symptoms were identified and extracted. RESULTS: There was a significant correlation between improvement on the HAMD-S score and overall reduction on the MADRS total score (r=.766, P<.001), response (r=.594, P<.001), and remission (r=.552, P<.001). Improvement on the MADRS-S also correlated with overall HAMD-17 improvement (r=.782, P<.001), along with response (r=.649, P<.001) and remission (r=.539, P<.001) rates. Both the HAMD-S and the MADRS-S correlated with global improvement as measured by the CGI-I/S (P<.001). CONCLUSIONS: A reciprocal interaction between somatic symptoms and other depressive-symptom domains is implied by this analysis. Clinicians are encouraged to identify, track, and target the somatic symptoms of depressive illnesses.

Adult↗
PubMed2006

Bicuspid aortic valve and ascending aortic aneurysm are not associated with germline or somatic homeobox NKX2-5 gene polymorphism in 19 patients.

BACKGROUND: Bicuspid aortic valve is the most common congenital anomaly, occurring in 1% to 2% of the population. It is the most common reason for aortic valve replacement, and such individuals are at significantly increased risk of aortic complications. Despite the clinical significance of bicuspid aortic valve, its genetic basis remains unclear. The homeobox gene NKX2-5 occupies a central position in the hierarchy of cardiac determinants, and mutations in this gene are associated with bicuspid aortic valve in mice. We therefore investigated the presence of mutations in NKX2-5 among patients with bicuspid aortic valve and associated aneurysm. METHODS: Germline DNA was extracted from peripheral blood leukocytes and somatic DNA from diseased aortic tissues of 19 patients with bicuspid aortic valve and associated aortic aneurysm. Three patients with trileaflet aortic valve and aneurysm served as control subjects. The entire NKX2-5 coding sequence, including intron-exon boundaries, was screened for mutation by means of polymerase chain reaction, followed by DNA sequencing. RESULTS: Direct sequencing revealed a change in somatic (aortic) DNA 239A-->G, leading to synonymous amino acid alteration of Glu21Glu in one patient with bicuspid aortic valve and 1 control subject. There were no other alterations detected in the coding regions of germline or somatic genes. A known polymorphic change in the 3' untranslated region adjacent to exon 2 was detected in both bicuspid aortic valve and control samples. Discrepancies between germline and somatic DNA sequences were observed. CONCLUSION: Our study fails to demonstrate an association between bicuspid aortic valve and NKX2-5 mutation, as has been seen in mice. Our findings support the importance of sequencing somatic, as well as germline, DNA.

Aortic Aneurysm, Thoracic↗
PubMed2004

Somatic mitochondrial DNA mutations in single neurons and glia.

Somatic mitochondrial DNA (mtDNA) point mutations reach high levels in the brain. However, the cell types that accumulate mutations and the patterns of mutations within individual cells are not known. We have quantified somatic mtDNA mutations in 28 single neurons and in 18 single glia from post-mortem human substantia nigra of six control subjects. Both neurons and glia contain mtDNA with somatic mutations. Single neurons harbor a geometric mean (95% CI) of 200.3 (152.9-262.4) somatic mtDNA point mutations per million base pairs, compared to 133.8 (97.5-184.9) for single glia (p=0.0251). If mutations detected multiple times in the same cell are counted only once, the mean mutation level per million base pairs remains elevated in single neurons (146.9; 124.0-174.2) compared to single glia (100.5; 81.5-126.5; p=0.009). Multiple distinct somatic point mutations are present in different cells from the same subject. Most of these mutations are individually present at low levels (less than 10-20% of mtDNA molecules), but with high aggregate mutation levels, particularly in neurons. These mutations may contribute to changes in brain function during normal aging and neurodegenerative disorders.

Adult↗
PubMed2005

The effect of osmoticum on ascorbate and glutathione metabolism during white spruce (Picea glauca) somatic embryo development.

Water stress is an important factor which regulates organized development of both zygotic and somatic embryos. Somatic embryos of white spruce were cultured in the presence of polyethylene glycol (PEG), a non-plasmolyzing agent which increases embryo quality and number, and mannitol, a plasmolyzing agent. The effects of these two compounds on both ascorbate and glutathione metabolism were investigated at different stages of embryo development. Compared to control and mannitol-treated embryos, embryos treated with PEG accumulated higher levels of endogenous ascorbate (ASC) in its reduced form, especially during the first half of the maturation period. This increase, also observed in immature seeds, was mainly the result of two different processes: activation of the de novo ASC machinery, and recycling of ASC from ascorbate free radicals (AFR) which was modulated by the activity of ascorbate free radical reductase (AFRR, EC. 1.6.5.4). The activity of this enzyme increased during the early phases of development in both PEG-treated somatic embryos and seeds. Compared to control somatic embryos, mannitol and PEG were shown to change the levels of reduced (GSH) and oxidized glutathione (GSSG). In particular, a constant decline in the GSH/GSSG ratio was observed in the presence of PEG. This pattern was also observed in maturing white spruce seeds. Overall, these data indicate that applications of non-plasmolyzing agents in the culture medium of spruce somatic embryos result in seed-like fluctuations of the ascorbate-glutathione metabolism, which may have a positive effect on embryo yield.

Ascorbic Acid↗
PubMed2005

The cell agglutination agent, phytohemagglutinin-L, improves the efficiency of somatic nuclear transfer cloning in cattle (Bos taurus).

One of the several factors that contribute to the low efficiency of mammalian somatic cloning is poor fusion between the small somatic donor cell and the large recipient oocyte. This study was designed to test phytohemagglutinin (PHA) agglutination activity on fusion rate, and subsequent developmental potential of cloned bovine embryos. The toxicity of PHA was established by examining its effects on the development of parthenogenetic bovine oocytes treated with different doses (Experiment 1), and for different durations (Experiment 2). The effective dose and duration of PHA treatment (150 microg/mL, 20 min incubation) was selected and used to compare membrane fusion efficiency and embryo development following somatic cell nuclear transfer (Experiment 3). Cloning with somatic donor fibroblasts versus cumulus cells was also compared, both with and without PHA treatment (150 microg/mL, 20 min). Fusion rate of nuclear donor fibroblasts, after phytohemagglutinin treatment, was increased from 33 to 61% (P < 0.05), and from 59 to 88% (P < 0.05) with cumulus cell nuclear donors. The nuclear transfer (NT) efficiency per oocyte used was improved following PHA treatment, for both fibroblast (13% versus 22%) as well as cumulus cells (17% versus 34%; P < 0.05). The cloned embryos, both with and without PHA treatment, were subjected to vitrification and embryo transfer testing, and resulted in similar survival (approximately 90% hatching) and pregnancy rates (17-25%). Three calves were born following vitrification and embryo transfer of these embryos; two from the PHA-treated group, and one from non-PHA control group. We concluded that PHA treatment significantly improved the fusion efficiency of somatic NT in cattle, and therefore, increased the development of cloned blastocysts. Furthermore, within a determined range of dose and duration, PHA had no detrimental effect on embryo survival post-vitrification, nor on pregnancy or calving rates following embryo transfer.

Animals↗
PubMed2000

Germline and somatic mutation analysis of MLH3 in MSI-positive colorectal cancer.

Microsatellite instability (MSI) is characteristic of hereditary nonpolyposis colorectal cancer, and occurs in a subset (10 to 15%) of unselected colorectal cancer cases. In hereditary nonpolyposis colorectal cancer, MSI is caused by defects in five mismatch repair genes, and in sporadic cases the main cause seems to be somatic MLH1 promoter methylation. Most likely additional hereditary nonpolyposis colorectal cancer genes remain to be discovered. Genes with simple repeats in their coding region are often targets for deletions in MSI-positive tumors. Several genes (TGFbeta RII, IGFIIR, MSH3, MSH6, BAX, MBD4) with significance in tumorigenesis harbor repeats in their coding regions and are often somatically inactivated because of deletions causing frameshifts. Recently, a novel human mismatch repair gene, MLH3, was cloned and shown to be involved in mammalian mismatch repair. To evaluate the possible role of MLH3 in hereditary cancer, we performed germline single-strand conformation polymorphism-analysis for 52 patients displaying features of inherited colorectal cancer. Forty-six of these had been diagnosed with MSI-positive tumors. No germline mutations were found. Similar to MSH3 and MSH6, MLH3 harbors mononucleotide repeats, ie, (A(6))-(A(9)), in its coding region, which makes it a putative target for somatic mutations in MSI-positive tumors. To evaluate its somatic inactivation we performed a deletion search focusing on eight exonic MLH3 mononucleotide repeats in a series of 93 MSI-positive tumors. Somatic deletions were found in 8.6% of the samples, a frequency similar to one detected in neutral noncoding mononucleotide repeats. No evidence of involvement of MLH3 in MSI tumorigenesis was obtained.

Amino Acid Substitution↗
PubMed2000

Fundic gland polyps in familial adenomatous polyposis: neoplasms with frequent somatic adenomatous polyposis coli gene alterations.

Fundic gland polyps (FGPs) are the most common gastric polyps in patients with familial adenomatous polyposis (FAP). FGPs have traditionally been regarded as nonneoplastic, possibly hamartomatous lesions, but the pathogenesis of FGPs in both FAP and sporadic patients remains unclear. FGPs in FAP can show foveolar dysplasia, and rarely invasive gastric adenocarcinoma has been reported in patients with FAP and fundic gland polyposis. Using direct gene sequencing and allelic loss assays at 5q, we analyzed somatic adenomatous polyposis coli (APC) gene alterations in 41 FAP-associated FGPs (20 with foveolar dysplasia, six indefinite for dysplasia, and 15 nondysplastic) and 13 sporadic FGPs. The foveolar epithelium and dilated fundic glands of the polyps were separately microdissected and analyzed in 25 of 41 FAP-associated FGPs and 13 of 13 sporadic FGPs. Somatic APC gene alterations were identified frequently (21 of 41 cases, 51%) in FAP-associated FGPs. Both the foveolar epithelium and the dilated fundic gland epithelium comprising the FGPs were shown to carry the same somatic APC gene alteration in 24 (96%) of 25 cases. Furthermore, there was no difference in the frequency of somatic APC gene alterations between FGPs with foveolar dysplasia (10 of 20, 50%), indefinite for dysplasia (four of six, 67%), and nondysplastic (seven of 15, 47%) in FAP patients (P: = 0.697). In contrast, FGPs from non-FAP patients showed infrequent (one of 13, 8%) APC gene alterations (P: = 0.008). These results show that FGPs in FAP patients are pathogenetically distinct from sporadic FGPs. Somatic, second-hit APC gene alterations, which precede morphological dysplasia in many FAP-associated FGPs, indicate that FGPs arising in the setting of FAP are neoplastic lesions.

Adenomatous Polyposis Coli↗
PubMed2003

Alternative patterns of transcription and translation of the ribosomal protein L32 mRNA in somatic and spermatogenic cells in mice.

The patterns of transcription and translation of the ribosomal protein L32 (Rpl32) mRNA differ greatly in adult testis and somatic tissues. Northern blots reveal that the levels of Rpl32 mRNA are four- to five-fold higher in prepubertal and adult testes, and purified pachytene spermatocytes and round spermatids than in a variety of nongrowing adult somatic tissues. 5' RACE demonstrates that transcription in 8-day prepubertal testis, which lacks meiotic and haploid cells, strongly prefers the same start site in the 5' terminal oligopyrimidine tract (5' TOP) that is used is somatic cells. The 5' TOP is a cis element that inhibits translation of many mRNAs in nongrowing somatic cells. Although the sizes of deadenylated Rpl32 mRNAs are indistinguishable in somatic and spermatogenic cells, transcription initiates at 11 sites over a 31-nt segment in adult testis and approximately 62% of Rpl32 mRNAs lack a 5' TOP. In agreement with previous studies, low levels of cycloheximide increase the proportions and sizes of polysomes in absorbance profiles, and increase the proportions and sizes of polysomes translating four 5' TOP mRNA species including the Rpl32 mRNA in 8-day seminiferous tubules. In contrast, cycloheximide has little or no effect on the absorbance profiles and distribution of Rpl32 mRNA and 5' TOP mRNAs in adult seminiferous tubules. The failure of cycloheximide to increase the size of polysomes in adult seminiferous tubules implies a block in the pathway by which ribosomes are recruited onto translationally active mRNAs.

Aging↗
PubMed1991

Relationships of somatic symptoms to behavioral and emotional risk in young adolescents.

Junior high students (n = 1508) from a midwestern community completed a health behavioral questionnaire that asked the frequency of headache and abdominal pain and of a number of behavioral and emotional risk indicators. Headache (24%) and abdominal pain (13%) were frequently reported among these young adolescents, particularly among girls. Those reporting frequent somatic complaints also reported significantly more behavioral and emotional symptoms indicative of risk (p less than 0.001). Further, the interaction between somatic complaint and gender significantly affected risk status (p less than 0.01). This interaction was greater with behavioral risk: boys with both abdominal pain and headaches reported higher behavioral risk than all other groups (p less than 0.0001). Somatic symptoms continued to account for a significant amount of variance in behavioral risk after the effects of emotional risk and age were removed. This suggests that behavioral risk and emotional risk are independently associated with somatic complaints. The evaluation of persistent somatic complaints in adolescents, particularly in boys with abdominal symptoms, should include careful examination of emotional risk factors and other health-endangering behaviors such as substance use, early sexual activity, and delinquency.

Abdominal Pain↗
PubMed2001

Feeling your body or feeling badly: evidence for the limited validity of the Somatosensory Amplification Scale as an index of somatic sensitivity.

OBJECTIVE: The Somatosensory Amplification Scale (SSAS) purports to measure the extent to which individuals are sensitive to their bodies. The present study examined the psychometric properties of the SSAS in two studies with university students. METHODS: Participants completed the SSAS, various cross-sectional measures of somatic and psychological distress, longitudinal measures of somatic symptoms, daily hassles and mood, and participated in a heartbeat detection task (Study 2 only). RESULTS: The SSAS was correlated with cross-sectional measures of somatic symptom reporting, but not with somatic symptoms reported on a daily basis nor with an index of interoceptive sensitivity. The SSAS was also correlated with several indices of general distress including anxious and depressive symptoms, daily hassles, and negative emotionality. CONCLUSION: Taken together, the results suggest that the SSAS is more likely an index of negative emotionality and general distress than a valid measure of somatic sensitivity per se.

Adolescent↗
PubMed2003

Alexithymia in insulin-dependent diabetes mellitus is related to depression and not to somatic variables or compliance.

OBJECTIVES: To assess the prevalence of alexithymia in insulin-dependent diabetic mellitus (IDDM) outpatients. To examine whether alexithymia is associated with diabetic somatic variables, depression, and compliance. METHOD: Our sample comprised 69 diabetic outpatients followed in a university hospital. We assessed the prevalence of alexithymia (26-item Toronto Alexithymia Scale, TAS-26) and the relationships among alexithymia, depression (13-item Beck Depression Inventory, BDI-13), somatic diabetic variables (glycosylated hemoglobin, number of mild or severe hypoglycemia, somatic complications), and compliance (observer-rater scale completed by diabetologist). RESULTS: The prevalence of alexithymia in IDDM patients was low (14.4%). Alexithymia and depression, as measured by TAS-26 and BDI-13 scores, respectively, correlated with each other. Alexithymia was not correlated with glycemic control, somatic complications, or compliance. CONCLUSION: In our sample, alexithymia was related to depression and not to somatic factors or compliance.

Adult↗
PubMed2004

Effect of psychotherapy and relaxation on the psychosocial and somatic course of Crohn's disease: main results of the German Prospective Multicenter Psychotherapy Treatment study on Crohn's Disease.

OBJECTIVE: Few studies have been published on the influence of psychotherapy on the physical and psychosocial course of Crohn's disease (CD). METHODS: The present study, a prospective, randomized multicenter investigation conducted with 108 of 488 consecutive CD patients, was designed to investigate the influence of short-term psychodynamic therapy and relaxation in addition to a standardized glucocorticoid therapy on the somatic course of the disease as well as on patient psychosocial status. Based on the same standardized somatic treatment, the psychotherapy and control groups were compared after a 1-year treatment period and a follow-up of another year with regard to somatic course and psychosocial situation. RESULTS: A total of 81 (75%) of 108 randomized patients completed the psychosocial follow-up. The comparison between the therapy groups after 1 year showed no significant differences in the four main target criteria of psychosocial status (depression, anxiety, psychosocial-communicative status and health-related quality of life). The mean Beck's Depression Inventory (BDI) score at admission was 12.3 in the psychotherapy group and 8.7 in the control group. At the 1-year follow-up, the scores for depression have been 7.8 (psychotherapy group) and 7.8 (control group). In the 2-year follow-up, 84 patients were classified into four groups on the basis of somatic course; 23% of the control group and 30% of the psychotherapy group showed episode-free courses, 29% and 17% respectively underwent surgery due to failure of immunosuppressive or medical therapy, and a further subranking showed no significant differences between the two groups (P=.125). At the 1-year follow-up, the scores for depression of patients with an active episode respective remission were 14.6 vs. 5.8. From the patient's point of view, at the end of the 2-year follow-up, the overall subjective evaluation of the effectiveness of psychotherapy was positive. CONCLUSION: The patients included showed no psychosocial disturbances of clinical relevance. Although a tendency toward fewer surgical interventions, fewer relapses and reduction of depression was noted, the analysis was unable to demonstrate any benefit from psychosocial intervention on hypothesized parameters of psychosocial status and somatic course. Further studies should be performed to identify patient subgroups that may benefit from psychosocial intervention.

Adult↗
PubMed2001

Decision making in patients with spinal cord damage: afferent feedback and the somatic marker hypothesis.

Damasio has proposed an influential model of human decision making - the somatic marker hypothesis (Damasio AR. Descates' Error. London: Papermac/Macmillan, 1994), where he argues that somatic feedback to the brain influences decision making in man. It is proposed that when choosing between options that differ in relative risk, a somatic marker (e.g. a 'gut feeling') feeds back to the brain and influences cognitive appraisal. In the present study patients who had suffered a complete tetraplegia at the level of the sixth cervical vertebra were compared with matched healthy control subjects. As the spinal injury group have reduced somatic/peripheral feedback via the spinal cord, it was predicted, based on the somatic marker hypothesis, that they may demonstrate riskier behaviour than controls. All subjects completed the Iowa Gambling Task, a computerised card playing game where the player is instructed to try and win as much money as possible over 100 selections from one of four decks. The rules are not disclosed in advance, and the player gradually 'learns' that two of the decks are 'high risk' and lead to significant financial losses. Healthy individuals have previously been shown to learn to avoid the risky decks, whereas patients with medial frontal lobe damage (Bechara A, Damasio AR, Damasio H, Anderson SW. Insensitivity to future consequences following damage to human prefrontal cortex. Cognition 1994;50:7-15) and those with peripheral neuropathy (Bechara A, Tranel D, Wilson J, Heberlein AS, Ross M, Damasio AR, 1998. Impaired decision-making in peripheral neuropathy. Society for Neuroscience Abstracts 24:1176) select an excessive number from the risky decks, and consequently lose money. In the present study there were no significant differences between the spinal sectioned and healthy control groups in either card selection strategy or net financial outcome. This result suggests that in terms of the somatic marker hypothesis, feedback to the brain from the periphery via the cranial vagus and other nerves and the hormonal route may be equally or more influential than afferent feedback transmitted via the spinal cord.

Adult↗
PubMed1989

Somatic symptoms in multiple personality disorder.

A structured interview, the Dissociative Disorders Interview Schedule, was administered to 20 patients with multiple personality disorder, 20 with panic disorder, 20 with eating disorders, and 20 with schizophrenia. The frequencies of somatization disorder and of individual somatic symptoms in the four groups were compared. The multiple-personality patients reported more somatic symptoms than the other groups. Of the 20 multiple-personality patients, seven met the criteria for somatization disorder. The average number of somatic symptoms per multiple-personality patient was 13.5.

Adult↗
PubMed1992

The recognition and management of somatization. What is needed in primary care training.

This article addresses the medical education issues associated with teaching primary care residents about somatization. Specific training designed to recognize and manage somatization involves a hierarchical series of five knowledge domains with associated discrete skills. As a foundation, a biopsychosocial model must be embraced by the medical leadership of the training program. Second, because psychosocial stresses play a critical etiologic role in somatization, the ability to identify relevant psychosocial issues during medical interviewing is a fundamental skill. Third, basic psychiatric diagnostic areas (depression and anxiety) must be mastered as a prerequisite for identifying somatization. Specific interviewing and management techniques are reviewed, along with two current programmatic approaches. Finally, the concept of physician countertransference also must be explicitly addressed as part of the curriculum. Without assuring that these building blocks are in place, residents are likely to become overwhelmed by the management of somatizing patients and continue the pattern of frustration associated with these patients.

Curriculum↗
PubMedDate not supplied

Health care utilization of somatizing patients in a pulmonary subspecialty clinic.

Somatizing patients present with medically unexplained physical complaints, repeat clinic visits, and a history of prior extensive testing. The authors reviewed 1,908 pulmonary consultation reports for 1990-1991 for evidence of somatization, yielding a group of 41 (2%) patients for study. Billing records were obtained and were compared to asthmatic patients and those in a health maintenance organization (HMO). Health care costs for the somatizing patients were significantly higher than the average cost for HMO patients and comparable to the health costs for patients with asthma. Half of the somatizing patients had psychological problems indicated in their medical records, but few received psychiatric referral or treatment. Management of the somatizing patient within the specialty clinic and on-site psychiatric treatment are suggested as ways to decrease unnecessary health care utilization.

Adolescent↗