Psychiatric emergency services and the system of care

OBJECTIVE: Admissions to psychiatric emergency services have frequently been cited as a gauge of how well a mental health system manages behavioral disorders. However, few measurements of the longitudinal association between psychiatric emergencies and characteristics of a mental health system have been described. The purpose of this study was to assess whether weekly admissions to psychiatric emergency services would increase when outpatient services were reduced, whether weekly admissions would increase when greater effort was made to identify and treat persons with acute mental illness, and whether weekly admissions would decrease when emergency services were enhanced to include postrelease case management. METHODS: Time-series methods were applied to approximately 29,010 admissions to three psychiatric emergency services of the San Francisco Department of Public Health over a 180-week period. RESULTS: Reduced outpatient services, efforts to identify acutely ill persons, and changes in emergency services themselves were found to affect admissions to emergency services. However, community events such as extreme weather, holidays, job loss, and the scheduling of receipt of income also affected the workload of the emergency service. CONCLUSIONS: The causes and course of mental illness inextricably tie a psychiatric emergency service to the overall mental health system and to events in the community it serves. These connections make it possible for managers to anticipate the use of emergency services and to detect disruptions in the remainder of the mental health services systems.     

Development of a biophysical model for vestibular prosthesis research

Physiologic properties of primary vestibular neurons are compared and contrasted with properties of primary auditory neurons. The differences and similarities suggest possible coding strategies for a vestibular implant. The degree of spike rate variability, or coefficient of variation (CV), is a prominent physiological property of vestibular neurons with undetermined functional significance. At the very least, CV is highly correlated with threshold to electrical stimulation in the intact vestibular labyrinth. If CV is also important for vestibular coding, then electrical stimulation strategies should be designed to restore relatively physiologic patterns of CV. Simulations using a stochastic model of primary afferent vestibular neurons reveal that this should be possible using combinations of low and high-rate pulsatile stimulation. They also demonstrate that differences in the number and independence of synaptic inputs can significantly affect CV.     

Fallopian tube carcinoma presenting with a brain metastasis

BACKGROUND: Fallopian tube carcinoma is a rare gynecologic cancer. An extensive literature search reveals no previous case report of fallopian tube carcinoma presenting with a brain metastasis. CASE: A 63-year-old woman presented with 3 weeks of progressive left-sided weakness. CT scan of the brain revealed a solitary lesion in the right parietal lobe. The patient underwent a complete resection, followed by whole-brain radiation therapy. Pathologic review demonstrated adenocarcinoma with follicular structures. A directed workup revealed a large right adnexal mass. She underwent resection of a large fallopian tube carcinoma with normal ovaries. She recovered from surgery and is receiving combination chemotherapy. CONCLUSION: This is the first case report of a fallopian tube carcinoma presenting as a brain metastasis.     

An analysis of orthopaedic residency selection criteria

The lack of literature on residency selection criteria used by orthopaedic program directors has left medical students in the position of relying on rumor and anecdotal information as to what program directors value most highly when sorting through large candidate pools. The purpose of this study was to compare the perspectives on resident selection criteria solicited from orthopaedic program directors and residency applicants. A power analysis was done to determine adequate sample size. A 26-item questionnaire was mailed to 98 residency applicants who interviewed at our program and 156 orthopaedic program directors. The program directors were also asked to elaborate on those factors that were most important in their selection process. A two-tailed Student's t-test was employed to compare the two groups. Significance was set at p < 0.05. Statistically significant differences between applicant and program director ratings were found in 12 of the 26 questionnaire items. Applicants (n = 91) ranked the following criteria as most important: a letter of recommendation from an orthopaedic surgeon (8.6 on a scale of 1 to 10, 10 being most important), USMLE I score (7.7), and rank in medical school (7.6). The most important criteria for the directors (n = 109) were: the applicant performed a rotation at the director's program (7.9), USMLE I score (7.8), and rank in medical school (7.8). This study provides the most comprehensive empirical data to date as to the factors which orthopaedic program directors consider most important during the residency selection process. To our knowledge, this is the first study in the orthopaedic literature that compares the program directors 'and residency applicants' views on resident selection criteria. Significant differences were found between applicant and program director views on resident selection criteria.     

A comparison between forefoot plaster and wooden soled shoes following Mitchell's osteotomy for hallux valgus

Between 1 October 1997 and 1 November 1998, 43 patients (59 feet) were treated with a standard Mitchell's osteotomy for hallux valgus. Of these, 26 patients (36 feet) were treated postoperatively in a forefoot plaster. The other 17 patients (23 feet) were treated with a wooden soled shoe. There was no significant difference between the 2 groups for age, indication for surgery, pre-operative deformity or grade of the operating surgeon. There was no significant difference in the mean time immobilised, mean time to union or complications. The patients were interviewed by telephone after a mean follow-up of 9.4 months. There was no significant difference in results between the 2 groups. This suggests that a forefoot plaster following Mitchell's osteotomy is unnecessary. Postoperative mobilisation in a wooden soled shoe can be used as an alternative.     

Mitoxantrone plus vinorelbine with granulocyte-colony stimulating factor (G-CSF) support in advanced breast cancer patients. A dose and schedule finding study

Summary Mitoxantrone (MTZ) and vinorelbine (VNR) have shown a good efficacy in advanced breast cancer. We conducted a phase I-II trial to determine the MTDs and best schedule of these drugs, in advanced breast cancer patients, when granulocyte-colony stimulating factor (G-CSF) support was given. The starting dose-intensity level was MTZ 3 mg/m²/week + VNR 15 mg/m²/week; dose was escalated at each step by 1 mg/m²/week for MTZ and 5 mg/m²/week for VNR, until dose limiting toxicity (DLT) developed in 33% or more of the patients at the first course. G-CSF 5 µg/kg/day d 3–13 was administered at each cycle from dose level 2 on. For each dose step we planned 3 different schedules (a = total dose of MTZ on day 1; b = total dose d 1 and 8; c = weekly schedule). At the time of this analysis (December 1993) 43 patients with locoregionally advanced or metastatic breast cancer have entered this study, 23 of whom had received prior chemotherapy other than adjuvant. Toxicity has been primarily hematologic. Non hematologic toxicity never caused interruption of dose escalation.Overall 8 patients developed DLT at the first course. Dose escalation was stopped at level 3 in patients receiving schedules a or b, and in those receiving schedule c the dose was escalated until level 5. The MTD was MTZ 6 mg/m² and VNR 30 mg/m² weekly. Age, dose level, and PS were found to be correlated with neutrophil and platelet nadirs, but dose level was the only independent variable predictive of myelotoxicity at multiple regression analysis.Forty-one patients were evaluable for response. Five complete and 16 partial responses were recorded for a 51% [35–67] overall response rate. This was 67% (12/18) in chemotherapy naive patients as compared to 39% (9/23) in those who had been pretreated.Seven of 21 (33%) patients receiving dose level 1 and 2 responded as compared to 14/20 (70%) patients who received higher dose-intensity (p = 0.02). Dose level and pretreatment were the only variables significantly associated with response rate at multiple logistic analysis.The median TTP was 9.5 months for the entire group. It was significantly better in patients who received a dose level > 2 (15 vs. 7; p = 0.015). However, the chemotherapy dose level did not significantly predict outcome after correction for pretreatment (yes vs. no), at multivariate Cox analysis.In conclusion, G-CSF support allows us to achieve a high dose-intensity of MTZ and VNR. Weekly administration of mitoxantrone is recommended to achieve the maximum dose level.Dose escalation seems to provide a significant gain in terms of response rate, although the low number of patients enrolled and the short follow-up prevents us from drawing any conclusion on its effects on TTP and survival. Further controlled trials of this combination in unpretreated patients with advanced breast cancer are needed to determine whether dose escalation can really improve prognosis.     

Whole brain apparent diffusion coefficient histogram: a new tool for evaluation of leukoaraiosis

PURPOSE: To test whole brain apparent diffusion coefficient histogram analysis as an alternative approach to visual score for the assessment of leukoaraiosis (LA). MATERIALS and METHODS: T2 and diffusion weighted images were obtained in 15 elderly patients. LA extension was assessed on T2 weighted images by two observers using a semiquantitative visual score. Apparent diffusion coefficient (ADC) maps of the entire brain were generated and, after exclusion of the skull with manual tracing and of the cerebrospinal fluid (CSF) by application of a threshold value, whole brain (WB)-ADC histogram was obtained. Moreover, a brain volume index (BVI) was calculated on ADC maps as (intracranial volume - CSF volume) /intracranial volume. RESULTS: The kappa inter-observer agreement for LA scoring was 0.69. Manual segmentation of the skull showed a mean inter-operator coefficient of variation below 3%. The median value of whole brain ADC histogram directly correlated with LA extension (P = 0.013). Moreover a significant inverse correlation (P = 0.002) was found between WB-ADC median value and BVI. CONCLUSION: WB-ADC histogram is a reproducible alternative tool for assessing LA extension and severity.