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Funding for psychiatric consultation-liaison (C-L) services has been a difficult problem. It has been suggested that the identification of psychiatric co-morbidities in Medicare patients on medical services could generate incremental hospital revenue by moving patients from a lower to a higher paying Diagnostic Related Group (DRG). This increased revenue could be used as a means of supporting the psychiatric C-L service. This study documents the financial impact of screening for and documenting psychiatric co-morbidities on a general acute medical service. We clinically assessed 100 consecutive Medicare admissions and found 25 psychiatric co-morbidities in 20 patients. In only one case did the psychiatric diagnosis result in moving the case to a higher DRG. However, the need for psychiatric consultation remains evident as there was significant lack of recognition and documentation of the psychiatric diagnoses by the medical team. The authors discuss both the financial and clinical implications of screening medical inpatients for psychiatric co-morbidities and propose directions for further studies in this area.

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In a prior study, delirium and plasma anticholinergic drug levels were significantly correlated in 9 of 25 surgical intensive care patients. The present study, using cumulative anticholinergic effects of parent compounds of these patients' medications, found that delirious patients' medication combinations had significantly higher cumulative anticholinergic effects than those of nondelirious patients.

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Delirium is a common and often unrecognized syndrome in hospitalized surgical patients. It can be caused by many different physical abnormalities, which are potentially correctable. Frequently, several etiologies coexist. It is associated with high morbidity and mortality rates. Delirium might be recognized (and its associated serious physical disorders corrected) earlier and more frequently if the diagnosis is considered whenever a patient has mental or behavioral abnormalities.

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Requests for inpatient psychiatric consultations at a general hospital over a three-year period were reviewed. Of 2,423 referrals, 79 (3.3%) were specifically for evaluation of competency, and 78.5% of those cases resulted in a diagnosis of an organic mental disorder. The proportion of referrals with organic mental disorder was significantly greater than it was in a control population of patients referred for consultation for any reason. Patients with organic mental disorder who were referred for competency evaluation had greater cognitive impairment than did control subjects.

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In a surgical intensive care unit, plasma anticholinergic activity was significantly higher in nine delirious patients than in 16 patients without delirium. The delirium may have been related to medications that are known to be associated with delirium and/or anticholinergic activity.

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All 150 psychiatric consultations performed upon patients hospitalized on the Surgery service at The Johns Hopkins Hospital during a period of two years were studied with particular attention to delirium which was found in 20.7 per cent of the patients. Delirium was the most common psychosis in elderly and postoperative patients. Mood disturbance was the most common reason given for request for psychiatric consultation (39.3 per cent). Delirium was diagnosed in 26.3 per cent of those patients. Delirium is a common syndrome and presents as altered consciousness with cognitive impairment. It is often not appreciated by the surgeon because of the impressive nature of associated symptoms which might be given undue emphasis. Assessment of consciousness and cognitive function should be performed promptly whenever psychiatric disorders are suspected.

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A review of the cases of major inflammatory disease of the breast seen during an 11-year period found that 49 (77%) of the 64 cases that required hospitalization were not associated with pregnancy or lactation. In such cases, an aggressive surgical approach including excision of central nipple ducts revealed a variant of mammary duct ectasia in 13 of the 14 patients operated on. We believe that when surgery is required for treatment of mastitis, it should include nipple duct excision.

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Twenty-eight women participating in a screening program had a breast cancer diagnosed subsequent to the report of a negative mammogram which was read by only one of a group of radiologists. Fourteen occurred prior to a scheduled routine screening visit (interval cancers) and 14 were detected during such an examination. The negative mammograms from the 28 cancer patients, together with those from 120 women without cancer (controls) were independently reviewed by each member of a panel of three radiologists. Forty-six percent of the cancer cases and 5.8% of the controls were interpreted as positive by two or more of the radiologists. These findings suggest that agreement among several independent reviewers enchances the value and accuracy of mamography by reducing the number of false negative interpretations.

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Using a standard heterologous assay in which lymphokines alter guinea pig peritoneal macrophage migration, it was found that regional lymph node cells (RLNCs) from patients with primary breast cancer elaborate soluble factors which variably affect such migration. Variation of migration resulted when soluble factors employed were obtained from different nodes in the same patient as well as from nodes from different patients. Some nodes from a patient elaborated migration inhibition factors (MIF) and other migration enhancing factors (MEF). The findings are in keeping with others obtained by us relative to the variation in lymphocyte transformation and thymidine uptake by RLNCs and further emphasize that all RLNs in patients with breast cancer are not biologically similar. They lend support to our previous hypothesis that the reason why some RLNs contain metastases and others do not is more likely due to biological differences than because of anatomical happenstance, i.e., transport of tumor cells to some nodes and not to others.

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Serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, testosterone, estrone, and estradiol were measured weekly for 1 month in 12 menstruating women with fibrocystic mastopathy. LH levels were abnormally elevated. The remainder of hormone levels were essentially normal. Elevated serum LH may be secondary to hypothalamic-pituitary, ovulatory, or corpus luteum dysfunction. The roles of hormonal abnormalities in the pathogenesis of fibroycstic mastopathy are not known.

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There is some reason to believe that common benign diseases of the breast are in great part caused by abnormalities of the hormonal milieu in which the breasts exist. Relative hyperestrinism by itself may cause mammary dysplasia, but it is likely that etiologic contributions are required from genetic factors within the cells of the mammary gland, from abnormalities of pituitary mammotropic hormone activity and from surplus or deficit of other circulating nongonadal factors.

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Tumor cells were identified in mammary vein blood in ten of 38 (26.6%) patients during total mastectomy with axillary dissection performed as the primary therapy for breast carcinoma (pathological stages I and II). This finding was analyzed with respect to 35 histological characteristics of the primary tumors. The presence of blood-borne tumor cells was inversely related to perineural space invasion, whereas there was no apparent relationship with the remaining 34 characteristics. The significance of blood-borne tumor cells remains unknown.

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