Volume 109, Issue 7

Context: Suicide risk assessment in the emergency department is a challenging task for psychiatrists and is further complicated when patients are admitted involuntarily. Objective: To evaluate the quality of suicide risk assessments in the psychiatric emergency setting by reviewing physician documentation of process indicators. Methods: A retrospective review of medical records for patients who were admitted involuntarily to the Kern Medical Center Psychiatric Emergency Service in Bakersfield, Calif. All patients were deemed a “danger to self” as defined by California Law and were admitted for evaluation in June 2006. Medical records were reviewed for 19 process indicators, which were identified from risk factors and treatment guidelines described in the literature. Documentation that a process indicator was not met by a patient was included in the data. Patients were then separated into two study groups: those who were admitted to the inpatient psychiatric unit, and those who were released. Data were analyzed using t tests for continuous variables and χ 2 tests for categorical variables. Results: The medical records of 145 patients were reviewed. None of the suicide risk assessments documented all 19 process indicators. The three most commonly documented process indicators were access to firearms (75.9%), recent stressful life events (75.2%), and “contract for safety” (74.5%). According to medical records, patients admitted to the inpatient unit were more likely than patients released to home care to have been assessed for command auditory hallucinations ( P =.02) or prior psychiatric diagnoses ( P =.001). Discharged patients were more likely to have been assessed for a family history of suicide ( P =.001) or symptoms of major depressive disorder ( P =.02). Conclusion: Many important risk factors for suicide were not documented in emergency department assessments, suggesting that overall quality of psychiatric risk assessments was not optimal. This lack of documentation has important implications from a treatment and medicolegal perspective.

Context: The academic credential awarded to osteopathic physicians is the doctor of osteopathy or doctor of osteopathic medicine (DO) degree. Public recognition of the degree has been disappointingly low, however, leading some members of the profession to argue for a change in the degree's name and formal designation. Objectives: To investigate antecedents to the desire among osteopathic medical students to change vs retain the DO degree designation and maintain “the DO difference.” Methods: A self-administered cross-sectional 38-item electronic survey was distributed to 480 students at an osteopathic medical school in the Midwestern United States. The instrument included knowledge-based items about osteopathic principles and practice (OPP) as well as items designed to assess attitudes, subjective norms, perceived behavioral control, and intention to support a proposed degree change. Results: An overall response rate of 45% was achieved (n=214). Structural equation modeling revealed that low levels of OPP knowledge were associated with positive attitudes and subjective norms favoring a degree change with the reverse true for opposing students. Knowledge did not influence perceived behavioral control. Attitudes were the best predictor of intention to vote with 85% variance predicted in our models; perceived behavioral control was the best predictor of intention to debate with approximately 38% variance observed. Conclusions: As a result of diminished use of palpation and osteopathic manipulative treatment—two historic markers of professional identity among osteopathic physicians—the DO degree designation as an indicator of difference has received increasing scrutiny. Improved student awareness of OPP is essential to maintaining the DO difference in clinical practice and with regard to the DO degree designation.

Unlike systemic amyloidosis, the diagnosis of brain amyloidoma without systemic manifestations is clinically challenging. Despite the availability of advanced brain imaging technology, such conditions are difficult to ascertain without brain biopsy or autopsy. We report the case of a 64-year-old woman who presented with frontal lobe syndrome with abnormal linear enhancement on brain magnetic resonance imaging. Results from a stereotactic biopsy revealed λ-positive protein deposition in the brain parenchyma. During the course of illness, the patient had an acute cerebral hemorrhage, which manifested with hemiparesis, dysarthria, and pathologic crying. Review of the literature revealed 15 cases of primary brain amyloidoma. Patients had similar protein deposits but in different regions of the brain and therefore presented with various neurologic symptoms.