RESUMEN
OBJECTIVE: this article reviews the current status and recent trends in the American Board of Psychiatry and Neurology (ABPN) psychiatric subspecialties and discusses the implications of those trends as well as several key questions whose answers may well determine subspecialty viability. METHODS: data are presented on specialty and subspecialty programs; graduates; and ABPN certification candidates and diplomates drawn from several sources, including the records of the ABPN, the websites of the Accreditation Council for Graduate Medical Education and the American Medical Association, and the annual medical education issues of JAMA. RESULTS: fewer than half of psychiatry graduates pursue subspecialty training. While most recent specialty graduates attempt to become certified by the ABPN, many subspecialists elect not to do so. There have been recent decreases in the number of fellowship programs and trainees in geriatric psychiatry and addiction psychiatry. The pass rates for fellowship graduates are superior to those for the "grandfathers" in all of the newer psychiatric subspecialties. Lower percentages of subspecialists than specialists participate in maintenance of certification, and maintenance of certification pass rates are high. CONCLUSION: the initial interest in training and certification in some of the ABPN subspecialties appears to have slowed, and the long-term viability of those subspecialties may well depend on the answers to a number of complicated social, economic, and political questions in the new health care era.
Asunto(s)
Neurología/educación , Psiquiatría/educación , Especialización , Participación de la Comunidad , Recolección de Datos , Economía , Educación , Educación de Postgrado en Medicina , Humanos , Política , Desarrollo de Programa , Especialización/tendencias , Consejos de Especialidades/tendencias , Estados UnidosRESUMEN
Tetrahydrobiopterin (BH(4)) is a vital cofactor maintaining availability of the amine neurotransmitters [dopamine (DA), noradrenaline (NA), and serotonin (5-HT)], regulating the synthesis of nitric oxide (NO) by nitric oxide synthase (NOS), and stimulating and modulating the glutamatergic system (directly and indirectly). These BH(4) properties and their potential relevance to schizophrenia led us to investigate the hypothesis of a study group (healthy controls, n=37; schizophrenics, n=154) effect on fasting plasma total biopterin levels (a measure of BH(4)). Study analysis showed a highly significant deficit of total biopterins for the schizophrenic sample after partialling out the effects of potential confounds of gender, age, ethnicity, neuroleptic use history and dose of current use, 24-hour dietary phenylalanine/protein ratio (a dietary variable relevant to BH(4) synthesis), and plasma phenylalanine (which stimulates BH(4) synthesis). A mean decrement of 34% in plasma total biopterins for schizophrenics from control values supports clinical relevance for the finding. In a subsample (21 controls and 23 schizophrenics), sequence analysis was done of the GTP cyclohydrolase I feedback regulatory gene and no mutations were found in the coding region of the gene. A deficiency of BH(4) could lead to hypofunction of the systems of DA, NA, 5-HT, NOS/NO, and glutamate, all of which have been independently implicated in schizophrenia psychopathology. Further, evidence has been accumulating which implicates the critical interdependence of these neurotransmitter systems in schizophrenia; this concept, along with the present study finding of a biopterin deficit, suggests that further study of the BH(4) system in schizophrenia is warranted and desirable.
Asunto(s)
Biopterinas/análogos & derivados , Esquizofrenia/metabolismo , Adulto , Biopterinas/biosíntesis , Biopterinas/sangre , Biopterinas/deficiencia , Demografía , Femenino , GTP Ciclohidrolasa/genética , GTP Ciclohidrolasa/metabolismo , Regulación Enzimológica de la Expresión Génica/genética , Variación Genética , Genotipo , Humanos , Péptidos y Proteínas de Señalización Intracelular , Masculino , Óxido Nítrico/metabolismo , Fenilalanina/sangre , Proteínas/genética , Esquizofrenia/enzimología , Esquizofrenia/genética , Análisis de Secuencia de ADNRESUMEN
Debate continues about whether clear nosologic boundaries can be drawn between schizoaffective disorder (SA), schizophrenia (SP), and bipolar disorder (BPD). This study attempted to clarify these boundaries. A retrospective review of the records of adult psychiatric inpatients with DSM-IV diagnoses of SA (n = 96), SP (n = 245), and BPD (n = 203) was conducted. Patients were assessed at admission and discharge using standardized rating scales (completed by physicians and nurses) and self-report inventories. Differential improvement over time also was examined. Significant differences were found for gender, legal status at admission, age, LOS, episode number, and ethnicity. Overall, SA was rated by clinicians as intermediate between SP and BPD, although SA rated themselves as the most severe. SA was similar to SP on positive symptoms, intermediate on negative symptoms, and similar to BPD on mood- and distress-related symptoms. Independent of diagnosis, differences in change scores from admission to discharge were related to severity level at admission. Although several differences were found in symptom severity across domains, no syndrome was identifiable associated with the diagnosis of SA and the diagnosis was unstable over time, thereby bringing into question the validity of SA as a diagnostic entity.
Asunto(s)
Trastornos Psicóticos/diagnóstico , Escalas de Valoración Psiquiátrica Breve , Diagnóstico Diferencial , Humanos , Variaciones Dependientes del Observador , Enfermería Psiquiátrica/métodos , Trastornos Psicóticos/epidemiología , Trastornos Psicóticos/psicología , Reproducibilidad de los Resultados , Estudios Retrospectivos , Autoevaluación (Psicología) , Encuestas y CuestionariosRESUMEN
Nowadays, managed care has taken over the management of the Medicaid program in most states of the nation. The patients treated in the public sector managed care system are very vulnerable and at high risk. Thus, we decided to measure the impact of managed care in the public-sector population of Texas. To this end, we assessed the treatment outcome at the Harris County Psychiatric Center (HCPC). Our results showed that after the implementation of the Medicaid managed care program in Houston, the bed utilization at HCPC decreased by 32% and the readmission rate increased by 21%; concomitantly, the length of stay decreased from 15.6 days to 9.3 days. Additionally, African-American and Hispanic-American patients were more negatively affected than Caucasian patients. Undoubtedly, the implementation of the Medicaid managed care system in Texas has led to untoward effects in the quality of care provided to the most disadvantaged population of the state.