Employing behavioral methods to improve the context of care in a public psychiatric hospital: some applications to health care management

While intervention procedures grounded in behavioral science have proven useful in the provision of direct care and in organizational management, they are seldom used effectively in many psychiatric care organizations. Behavioral practitioners often acknowledge this fact but few have applied their behavior change skills to change the behavior of the organization that is failing. This report outlines several examples of how behavioral technology was employed from an administrative perspective to encourage and strengthen needed changes in the interdisciplinary clinical care procedures of a public psychiatric hospital. The potential of these procedures for administering health care provision as well as the challenges encountered in realizing such applications are discussed.     

Care and problems in intractable neurological diseases--home care of intractable diseases from the view of a practicing physician]

Taking into account how to care patients at home with intractable neurological disease and their family, I have introduced the achievement of the medical caring technique by an aged family member, the risks of the PEG and acute respiratory failures under BiPAP, the problems in home rehabilitation, and the experiences of home terminal care, from the view point of a practicing physician. Home caring pursues to support patients and their family to live peacefully with disease with highest quality of life. Hospice caring is also an important issue. From now on, I would like to try to give even better home care by early recognition of problems and by cooperating with hospitals, clinics and other field workers.     

View from the front line: Diagnosis and treatment of mental health problems among primary care physicians

Summary A self-selected sample of primary care physicians (general practitioners, family specialists, internists, obstetricians/gynecologists) in a southern county completed structured, precoded questionnaires on a random sample of their patients. Approximately 16% of the patients were diagnosed as having mental health problems. Most common were psychological problems coincidental to somatic disorders rather than psychosomatic or primarily psychological problems. Physicians tended to face and deal with the psychological problems by giving counseling. Drugs were prescribed for less than one-third of those with psychological problems and most of these were counselled as well. Few of these patients were referred to other persons or agencies for care. Neither rates of mental health problems nor treatment of them varied by age, race, sex, marital status, or social class. Age, sex and social class significantly affected various measures of extensiveness of the psychological problems and/or specific diagnosis while race and marital status remained nonsignificant.     

Characteristics of double care demanding patients in a mental health care setting and a nursing home setting: results from the SpeCIMeN study

Background: Older patients suffering from a combination of psychiatric disorders and physical illnesses and/or dementia are called Double Care Demanding patients (DCDs). Special wards for DCDs within Dutch nursing homes (NHs) and mental health care institutions (MHCIs) offer a unique opportunity to obtain insight into the characteristics and needs of this challenging population.

Methods: This observational cross-sectional study collected data from 163 DCDs admitted to either a NH or a MHCI providing specialized care for DCDs. Similarities and differences between both DCD groups are described.

Results: Neuropsychiatric symptoms were highly prevalent in all DCDs but significantly more in MHCI-DCDs. Cognitive disorders were far more present in NH-DCDs, while MHCI-DCDs often suffered from multiple psychiatric disorders. The severity of comorbidities and care dependency were equally high among all DCDs. NH-DCDs expressed more satisfaction in overall quality of life.

Conclusions: The institutionalized elderly DCD population is very heterogeneous. Specific care arrangements are necessary because the severity of a patient's physical illness and the level of functional impairment seem to be equally important as the patient's behavioural, psychiatric and social problems. Further research should assess the adequacy of the setting assignment and the professional skills needed to provide adequate care for elderly DCDs.     

Factors influencing the pre- and in-hospital management of acute stroke--data from a Greek tertiary care hospital

In a prospective observational study, data on pre- and in-hospital management of acute stroke patients were collected from 100 consecutive patients admitted to the emergency room (ER) of Papageorgiou Hospital, a tertiary health care facility in Thessaloniki, Greece. Public emergency services were used by 58% of the patients, and 42% were brought by their relatives. 27% of the patients arrived within 1.5 h, 45% within 3 h, and 71% within 6 h from symptom onset. The median interval from ER arrival to examination by a board-certified neurologist was 20 min (range 5-40 min). Time from ER arrival until brain CT scan ranged from 17 min to 28 h, with a median of 1.7 h. The majority (57%) of acute stroke patients reached hospital and received adequate diagnostic and treatment within 6 h, and approximately 30% even within 3 h from symptom onset. Thus, and in contrast to widespread perception, there is a time window for hyper-acute stroke treatment in Greek public hospitals. However, the fraction of patients eligible for acute treatment may be increased by shortening both the interval from symptom onset to hospital arrival, and also the door-to-CT interval.     

Ongoing and planned trials of antiplatelet therapy in the acute and long-term management of patients with ischaemic brain syndromes: setting a new standard of care

Among high vascular risk patients, acetylsalicylic acid (ASA) reduces the relative risk of serious vascular events by about one fifth. However, because ASA fails to prevent four fifths of serious vascular events, more effective, yet equally safe and affordable, antiplatelet regimens are desired. Compared with ASA, clopidogrel alone reduces the odds of serious vascular events by about 10%, and the combination of dipyridamole and ASA reduces the odds of serious vascular events by about 6%. Combining ASA with an orally administered platelet glycoprotein (GP) IIb/IIIa blocker is not effective, and indeed more hazardous than ASA alone. Among patients with non-ST-segment acute coronary syndromes (ACS), the addition of an intravenously administered GP IIb/IIIa receptor antagonist to ASA reduces the risk of vascular events by about 10% compared with ASA, and the addition of clopidogrel to ASA reduces the risk of vascular events by 20% compared with ASA alone. Among patients undergoing percutaneous coronary intervention (PCI), both the addition of an intravenously administered GP IIb/IIIa receptor antagonist to ASA, and the addition of clopidogrel to ASA reduce the risk of vascular events by 30% compared with ASA alone. The greater efficacy of the combinations of ASA with clopidogrel, and ASA with an intravenously administered GP IIb/IIIa receptor antagonist, in patients with ACS and those undergoing PCI has fostered several ongoing and planned trials of these regimens in the acute and long-term management of patients with ischaemic brain syndromes. The combination of ASA and clopidogrel is being compared with ASA alone within 12 h of onset of symptoms of TIA in two trials (FASTER, ATARI), and the use of an intravenously administered GP IIb/IIIa receptor antagonist is being compared with placebo within 6 h of onset of acute ischaemic stroke in two trials (AbESST, AbESST-2). Six trials are assessing the combination of clopidogrel and ASA in the long-term management of patients with ischaemic brain syndromes due to atherothrombosis (MATCH, CHARISMA, ARCH, CARESS, SPS3) or atrial fibrillation (ACTIVE). The MATCH trial of clopidogrel and ASA versus clopidogrel alone in patients with recent TIA or ischaemic stroke is the first which is likely to report its results - in mid 2004. The combination of dipyridamole and ASA is being compared with ASA in the ESPRIT trial and with the combination of clopidogrel and ASA in the planned PRoFESS trial. These ongoing and planned clinical trials of antiplatelet therapy promise to further define the role of combination antiplatelet therapy in the acute and long-term management of patients with ischaemic brain syndromes.     

'Whether you like it or not people with mental problems are going to go to them': a qualitative exploration into the widespread use of traditional and faith healers in the provision of mental health care in Ghana

Limited research has been conducted to explore the factors that support or obstruct collaboration between traditional healers and public sector mental health services. The first aim of this study was to explore the reasons underpinning the widespread appeal of traditional/faith healers in Ghana. This formed a backdrop for the second objective, to identify what barriers or enabling factors may exist for forming bi-sectoral partnerships. Eighty-one semi-structured interviews and seven focus group discussions were conducted with 120?key stakeholders drawn from five of the ten regions in Ghana. The results were analysed through a framework approach. Respondents indicated many reasons for the appeal of traditional and faith healers, including cultural perceptions of mental disorders, the psychosocial support afforded by such healers, as well as their availability, accessibility and affordability. A number of barriers hindering collaboration, including human rights and safety concerns, scepticism around the effectiveness of 'conventional' treatments, and traditional healer solidarity were identified. Mutual respect and bi-directional conversations surfaced as the key ingredients for successful partnerships. Collaboration is not as easy as commonly assumed, given paradigmatic disjunctures and widespread scepticism between different treatment modalities. Promoting greater understanding, rather than maintaining indifferent distances may lead to more successful co-operation in future.     

Continuum of care for patients with obstructive sleep apnea after one year from the COVID-19 pandemic onset: no time for further delays: practical issues for a safe and effective management

Since the SARS-CoV-2 pandemic onset, many routine medical activities have been put on hold and this has deeply affected the management of patients with chronic diseases such as obstructive sleep apnea. Untreated OSA is associated with increased mortality and difficulties in social functioning. A delay in initiating treatment may therefore have harmful consequences. Between February and April 2020, the so-called first wave of the pandemic, the overall activity of sleep centers in Europe was reduced by 80%. As the international infection control authorities released guidelines for SARS-CoV-2 outbreak control, many of the national sleep societies provided strategies for a gradual re-opening of sleep facilities. Most of these strategies were not evidences-based and, in a climate of general concern, worldwide it was strongly advised to post-pone any non-urgent sleep-related procedure. Despite the initial idea that the outbreak could be transient, after one year it is still ongoing and the price we are paying, not only includes deaths caused by COVID-19, but also deaths caused by missed or late diagnosis. As further delays in diagnosing and treating patients with sleep apnea are no more acceptable, a new arrangement of sleep facilities and resources, in order to operate safely and effectively, is now mandatory. In this article, we review most recent literature and guidelines in order to provide practical advice for a new arrangement of sleep laboratories and the care of patients with obstructive sleep apnea after one year from the onset of the COVID-19 pandemic.