Physician Response to Prenatal Substance Exposure

Objectives: To examine physician responses to suspected prenatal substance exposure and the reasons underlying these responses. Methods: National mail survey of practicing obstetricians and pediatricians who see neonates. Response rate: 63%. Results: More than 70% of physicians reported having ever suspected prenatal substance exposure. Response rates did not vary by specialty. Twenty-seven percent reported that they had never suspected prenatal substance exposure. The most common lifetime pattern (60%) was some response whenever prenatal substance exposure was suspected; next most common was no suspicion (27%). Just over 10% had a discretionary response: acting in some cases of suspected prenatal substance exposure but ignoring others. Two percent consistently ignored their suspicions. Getting help for the patient and protecting the fetus were the most common reasons to act. Among those who had ignored their suspicions, lack of sufficient evidence of substance use was the most often cited reason. There were some important specialty differences in reasons for response and non-response and in specific responses likely to be taken. Obstetricians are far more likely to provide the patient with information and get a substance use history; pediatricians are more inclined to involve outsiders. Conclusions: Obstetricians and pediatricians seem quite willing to act on their suspicions of prenatal substance exposure, and generally respond by taking positive actions. Specialty differences are few and reflect practice differences.     

Quality of life of stroke survivors

Adaptation to stroke requires complex, long-term change in stroke survivors' lives. This study aimed at identifying those factors that influence quality of life (QOL) of geriatric stroke survivors 1–3 years post-discharge. The objectives were: to describe the overall quality of life of stroke survivors; to examine the relationships between sociodemographic variables, neurological variables, functional status, social support, perceived health status, depression, and overall QOL; and to determine the best predictors of QOL. Data were collected on 50 stroke survivors using a cross-sectional design and standardized questionnaires, including the Quality of Life Index, the Functional Independence Measure, the Social Support Inventory for Stroke Survivors and the Centre for Epidemiologic Studies Depression Scale. The overall quality of life of the study participants was low. The most important predictors of QOL were depression, marital status, quality of social support, and functional status. Depression was the strongest predictor of QOL. By employing a multi-dimensional perspective, this study confirmed that adaptation to stroke involves much more than physical function. Thus, rehabilitation programs for this group would be more effective if they are based upon a holistic approach.     

Occupational therapy in mental health: challenges and opportunities

The National Mental Health Policy and National Mental Health Plan published in 1992 provided directions for the reform of mental health services in Australia. They stated that mental health services should be part of the mainstream health system and that integrated mental health programmes should be developed to cover the full range of specialist mental health services, focusing on improved quality of service, the consumers, equity of access, continuity of care and redistribution of resources. The Queensland Mental Health Plan published in 1994 set out specific objectives and strategies for implementing mental health service reform in Queensland. In Queensland there has been a concentration on developing core mental health services involving the reorientation of service delivery from institutions to the community, based on the principles of integration, mainstreaming and regional self-sufficiency. Major restructuring of mental health services is taking place, which has meant changes in service development, organizational structures and work practices. There has been a significant impact on the roles and skills required by the mental health workforce in the context of today's mental health services climate. There is a focus on staff providing individualized assessment and continuing treatment using a case management approach, within a continuum of care. Implications for occupational therapists include developing a generic skill base in preparation for broad-spectrum mental health professional roles while maintaining their professional identity. It is recommended that research be conducted to examine the capacity of occupational therapists to adapt to the changing mental health environment. Copyright © 1999 Whurr Publishers Ltd.     

Lorazepam for chronic catatonia: a randomized, double-blind, placebo-controlled cross-over study

Acute catatonic syndromes occurring in the context of various medical and neuropsychiatric conditions, including schizophrenia, have been shown to respond well to benzodiazepines (BZD). However, there have been no studies specifically designed to address the BZD treatment response of persistent catatonic states. Eighteen patients with clinically stable chronic schizophrenia, who also displayed enduring catatonic features, underwent a 12-week long, random assignment, double-blind, placebo-controlled cross-over trial with lorazepam (6 mg/day). A comprehensive assessment, including the subjects’ clinical and motor (catatonic as well as drug-induced movement disorders) condition, was performed at baseline and four weekly intervals thereafter. Pre-existing medication was kept constant throughout the study. Lorazepam had no effect on the subjects’catatonic signs and symptoms, suggesting that acute and chronic catatonic syndromes associated with schizophrenic illness might have a different neurobiological basis. Received: 25 May 1998/Final version: 22 September 1998     

Preoperative ketorolac increases bleeding after tonsillectomy in children

Purpose

To compare the incidence of vomiting following codeine or ketorolac for tonsillectomy in children.

Methods

We had planned to enrol 240 patients, aged 2–12 yr undergoing elective tonsillectomy into a randomized, single-blind study in University Children’s Hospital. The study was terminated, after 64 patients because interim analysis of the data by a blinded non-study scientist concluded that the patients were at undue risk of excessive perioperative bleeding. After induction of anaesthesia by inhalation with N₂O/halothane or with propofol 2.5?3.5 mg· kg^?1 iv, the children were administered 150 μg· kg^?1 ondansetron and 50 μg · kg^?1 midazolam. Maintenance of anaesthesia was with N₂O and halothane in O₂. Subjects were administered either 1.5 mg · kg^?1 codeine im or 1 mg· kg^?1 ketorolac iv before the commencement of surgery. Intraoperative blood loss was measured with a Baxter Medi-Vac® Universal Critical Measurement Unit. Postoperative management of vomiting and pain was standardized. Vomiting was recorded for 24 hr after anaesthesia. Data were compared with ANOVA, Chi-Square analysis and Fisher Exact Test.

Results

Thirty-five subjects received ketorolac. Demographic data were similar. The incidence of vomiting during the postoperative period was 31% in the codeine-group and 40% in the ketorolac-group. Intraoperative blood losses was 1.3 ± 0.8 ml · kg^?1 after codeine and 2.2 ± 1.9 ml · kg^?1 after ketorolac (mean ± SD) P < 0.05. Five ketorolac-treated patients had bleeding which led to unscheduled admission to hospital, P < 0.05, Exact Test.

Conclusion

Preoperative ketorolac increases perioperative bleeding among children undergoing tonsillectomy without beneficial effects.     

Harvard community health plan's mental health redesign project: A managerial and clinical partnership

Harvard Community Health Plan, founded in 1969 as a staff model HMO, is currently a staff and group model HMO with 521,000 members, 19 health centers and 12 independently owned group practices with 26 locations. In 1987, the Plan initiated a review of its mental health benefit and program because its costs were rising, member and clinician dissatisfaction was increasing and many believed the problem was the nature and scope of the benefit. After two years of study, surveys, interviews, cost and utilization analysis, the Plan identified its professional staff as its key asset but recognized many problem areas, including problems with access, variation from site to site, inconsistent service delivery, lack of consistent utilization management and the need for greater diversity along the spectrum of care available to members. From 1989 to 1990, more than 200 clinicians and support staff were engaged in the process of developing a variety of components to the mental health redesign program. Three simultaneous efforts included developing a method of categorizing patients, restructuring the delivery system and redesigning the benefit. A Mental Health Patient Assessment Tool was created which assists clinicians in performing comprehensive evaluations, administers the benefit, measures progress and supports outcomes research. Delivery system changes included the implementation of self-referral, access standards, intake triage functions by non-clinical staff, program development and an outpatient utilization management function.     

The effects of capsaicin upon electrogenic ion transport in rat descending colon

Summary Preparations of rat descending colon mucosa have been used to record changes in short circuit current (SCC) under voltage clamp conditions. When added to the basolateral compartment capsaicin (8-methyl-N-vanillyl-6-nonenamide, 0.1-3 M) caused an initial transient increase in SCC, followed by a more prolonged reduction in SCC, that lasted for 20–30 min.Repeated applications of 3 M capsaicin caused desensitisation of the initial secretory response. The antisecretory effects (i. e. reduction in SCC from the original baseline) remained, although they were significantly reduced. In some preparations described as non-responders, 3 M capsaicin did not elicit a secretory response. No desensitisation of the remaining antisecretory responses was observed in these tissues; in fact these reductions in SCC were consistently larger than those from tissues which responded with a secretory response.Tetrodotoxin (100 nM), hexamethonium (10 M), and yohimbine (50 M) had no significant effect upon either secretory or antisecretory responses. Ruthenium red (10 M) abolished the secretory response to 3 M capsaicin, but had no effect upon the antisecretory responses. Pretreatment of the tissues with 1 M substance P(SP) resulted in significant desensitisation to the peptide and abolished the secretory response to 3 M capsaicin. The antisecretory responses remained, and were significantly larger compared with responses from control tissues. Send offprint requests to H. M. Cox at present address     

Changes in Sexual Patterns Following Vertical Banded Gastroplasty and Weight Loss

Weight loss following vertical banded gastroplasty (VBG) is well established. Herein the effect of weight loss on sexuality was examined. Twenty-seven females and seven males (mean age 39 years) underwent VBG and returned completed questionnaires regarding preoperative and postoperative sexuality. There was a mean interval follow-up of 33 months, with a mean weight loss of 48.6 kg. In general, there was an overall increase in frequency, quality, and enjoyment of sex. Similarly, an improvement in body image, an increase in initiating sexual intercourse, and an increase in the number of sexual partners was found. A small number of patients developed psychosocial problems that limited sexual enjoyment. In conclusion, weight loss after VBG improves sexual life, though not uniformly, as new sexual problems can occur. Decreased sexual inhibition, increased sexual enjoyment and frequency, and increased frequency of orgasm characterizes many of the changes occurring after VBG with resultant weight loss. To help provide a holistic approach to the care of morbidly obese patients after VBG, the potential alterations in their sexual lives should be considered.     

The Role of Therapeutic Alliance in Network Therapy: A Family and Peer Support-Based Treatment for Cocaine Abuse

The therapeutic alliance is a well-studied construct factor that is important to outcome in many forms of individual therapy. Therapeutic alliance has been rarely studied in group therapy and results in addiction treatment have been mixed. In this paper, we studied the presence of a therapeutic alliance in Network Therapy: an approach that uses peer and family support in addiction treatment. Twenty-one participants undergoing Network Therapy for cocaine addiction were observed on videotape, and were rated on therapeutic alliance using the Working Alliance Inventory and the Penn Helping Alliance Rating Scale. Results showed a significant positive correlation between therapeutic alliance and outcome as measured by the percentage of cocaine-free urine toxicology screens and by eight consecutive cocaine-free urines.