Referral patterns to and from inpatient psychiatric services: a social network approach.

Interorganizational linkages have assumed more import for mental health service systems during the past three decades because of increased levels of complexity in service delivery patterns. This analysis examines these linkages from a relational perspective, with network of patient referral patterns as the basic unit. Multidimensional scaling is employed to discern patterns of interorganizational linkages in national patient referral data collected by the National Institute of Mental Health in 1975 and 1980 for patient samples from inpatient psychiatric services of state and county mental hospitals, private psychiatric hospitals, and public and nonpublic general hospitals. The multidimensional scaling techniques distinguish two structural characteristics of the interorganizational linkages of psychiatric inpatient services--public vs private services, and drift over time in referral patterns. Public and private inpatient psychiatric services are differentiated principally in terms of degree of interaction with legal agencies and private practice psychiatrists. Chronological change in referral patterns is characterized principally by changes in the degree of interaction with other inpatient or outpatient psychiatric services. Methodologically and theoretically, the techniques and findings described can enhance our understanding of interorganizational linkages and dynamics.     

Thrombosis at venous insertion sites after inferior vena caval filter placement

Color Doppler flow imaging or compression ultrasound (US) was used to prospectively determine frequency of thrombosis at 54 venous insertion sites (47 in common femoral veins, seven in right internal jugular veins) after percutaneous placement of Greenfield filters for interruption of the inferior vena cava. Fifty-one filters were successfully placed in 51 patients with a dilator set or a balloon angioplasty catheter. Nine focal thrombi were detected in the common femoral vein (19%) and one in the right internal jugular vein (14%). Use of dilators induced eight thrombi (24%), compared with two (10%) from balloon catheters. The left common femoral vein had a high frequency of thrombosis, regardless of dilation technique (five of nine). Of nine patients with acute common femoral vein thrombosis, four became symptomatic within 10 days after the procedure. Patients may remain asymptomatic or have delayed symptoms; thus, US is valuable for determining patients at risk of thrombosis of the common femoral vein.     

Pyoderma gangrenosum complicating Felty's syndrome

The case of a 54-year-old woman with Felty's syndrome whose course was complicated by mucocutaneous lesions clinically typical of pyoderma gangrenosum is described. Necrotizing sinusitis and saddle nose deformity were distinctive clinical features. Lymphocytic vasculitis and rheumatoid nodule formation observed within panniculus at the base of a cutaneous lesion and in a nasal mucosal lesion were unexpected histopathologic findings.     

Measuring the benefits of clinical decision support: return on investment.

In an effort to provide high quality care in a more cost-effective manner, health care providers have found it necessary to implement a series of decision support strategies designed to improve outcomes of care. While each of these strategies has measurable benefits, they each come along with additional costs. This article will describe a methodology for measuring the costs and direct and indirect benefits from decision support activities.     

Acute central nervous system symptoms caused by ibuprofen in connective tissue disease

We describe 2 cases of acute encephalopathy in patients with connective tissue disease caused by small doses of ibuprofen. In addition to aseptic meningitis, both patients had altered mental status and focal neurologic signs, ophthalmoplegia in one and hemiparesis in the other. The spectrum of neurologic manifestations of ibuprofen hypersensitivity is reviewed.     

The use of metabolic inhibitors to compare the excision repair of pyrimidine dimers and nondimer DNA damages in human skin fibroblasts exposed to 254-nm and sunlamp-produced greater than 310-nm ultraviolet radiation

Normal human skin fibroblasts were exposed to either 0-5 J/m2 of 254-nm ultraviolet (UV) radiation or 0-50 kJ/m2 of the Mylar-filtered UV (greater than 310 nm) produced by a fluorescent sunlamp. These cells were then incubated for 0-20 min in medium containing 10 mM hydroxyurea (HU) and 0.1 mM 1-beta-D-arabinofuranosyl cytosine (ara C), and the yield of DNA strand breaks was measured by means of the alkaline elution technique. For cells irradiated with 254-nm UV, which results primarily in the formation of cyclobutane pyrimidine dimers, a rapid increase in DNA strand breaks was detected following incubation with these metabolic inhibitors. In contrast, only a low level of strand breaks formed in cells incubated with HU and ara C after irradiation with approximately equitoxic fluences of sunlamp UV greater than 310 nm, which mainly causes the induction of nondimer DNA lesions. Hence, these results are consistent with the conclusion that the pathways involved in the repair of nondimer DNA damages induced by UV wavelengths greater than 310 nm differ from the repair of pyrimidine dimers.     

Consistency in platelet morphology in whole blood

The morphology of instantaneously fixed platelets in whole blood was assessed for intra-subject consistency in 24 subjects; 10 were healthy and 14 had metastatic carcinoma. In both groups two samples were obtained from each subject. The time between samples varied for the normal group from 1 to 17 months (average of 6 months) and for the cancer group from 13 to 39 days (average of 14 days). Analysis of variance pertaining to unactivated discs (i.e., discs without pseudopods) revealed that a factor that differs among individuals rather than any uncontrolled artifact probably accounts for the large range of values obtained. Additionally, it appears that, in a given individual, platelet morphology in whole blood, expressed as % discs, remains fairly constant over a period of weeks or months. These findings suggest that characteristic levels of unactivated platelet forms exist in whole blood and that these levels reflect in vivo conditions.     

T1 stage breast cancer: adjuvant hypofractionated conformal radiation therapy to tumor bed in selected postmenopausal breast cancer patients--pilot feasibility study.

PURPOSE: To explore the feasibility of a short course of hypofractionated conformal radiation therapy to the tumor bed as part of a breast preservation protocol in postmenopausal patients with nonpalpable pT1N0 stage breast cancer. MATERIALS AND METHODS: The tumor bed was imaged at computed tomography (CT) in the prone position on a dedicated table. The same table and position were used for treatment with a 4-MV linear accelerator. The planning target volume was the tumor bed plus a 1-2-cm margin defined at postmastectomy CT. A regimen of five fractions was tested in this pilot dose study. Cosmesis was assessed by patients and physicians before treatment and 36 months after treatment. RESULTS: Ten consecutive patients who were eligible for the study were assigned to one of three dose-per-fraction regimens; nine were treatable with the proposed technique on the basis of CT findings. Patients received five fractions over 10 days (total dose range, 25-30 Gy): Three received 5.0 Gy per fraction; four, 5.5 Gy; and two, 6.0 Gy. At minimum follow-up of 36 months (range, 36-53 months), all patients were alive and disease free with good to excellent cosmesis. CONCLUSION: Hypofractionated conformal breast radiation therapy is feasible. Further studies are warranted.