The working alliance and consumer case management

The Working Alliance Inventory was used to measure the strength of the therapeutic relationship between seriously mentally disabled case management clients and their case managers in a randomized trial of consumer-provided case management services. It was found that while there was no difference in the strength of the alliance between the consumer and nonconsumer teams of case managers, there were positive relationships between alliance and some outcomes, including quality of life, symptomatology, attitudes toward medication compliance, and satisfaction with mental health treatment.     

The efficacy of a consumer case management team: 2-year outcomes of a randomized trial

This article reports the results of a randomized trial of a team of case managers who are mental health consumers compared to a team of nonconsumer. Using a repeated measures MANOVA design, consumer case managers were found to be as effective as a team of nonconsumer case managers in maintaining the stability of severely mentally disabled clients served over a 2-year period. Implications for the employment of consumers in mental health services and the vocational capacity of persons with mental illness are discussed.     

Marijuana use among minority youths living in public housing developments

Youths residing in public housing developments appear to be at markedly heightened risk for drug use because of their constant exposure to violence, poverty, and drug-related activity. The purpose of this study was to develop and test a model of marijuana etiology with adolescents (N=624) residing in public housing. African-American and Hispanic seventh graders completed questionnaires about their marijuana use, social influences to smoke maijuana, and sociodemographic and psychosocial characteristics. Results indicated that social influences, such as friends' marijuana use and perceived ease of availability of marijuana, significantly predicted both occasional and future use of marijuana. Individual characteristics such as antimarijuana attitudes and drug refsul skills also predicted marijuana use. The findings imply that effective prevention approaches that target urban youths residing in public housing developments should provide them with an awareness of social influences to use marijuana, correct misperceptions about the prevalence of marijuana smoking, and train adolescents in relevant psychosocial skills.     

A claims data approach to defining an episode of care.

OBJECTIVE: To utilize health services research techniques in developing an episode of care using an administrative data set. This method is demonstrated for an episodic clinical condition, migraine. DATA SOURCES: Medicaid administrative data set of 3,372 patients with a diagnosis of migraine (ICD-9-CM 346.0, 346.1) in the state of Pennsylvania between May 1990 and March 1992. STUDY DESIGN: The duration of a migraine episode was measured by assessing the magnitude of resource utilization and the proportion of patients with charges in the period after the index migraine as compared to the period before the index migraine. A confidence interval (CI) was developed around each measure using bootstrap techniques. DATA COLLECTION METHODS: All charge data were extracted daily for a 113-day observation period surrounding each index migraine in order to observe the duration of impact of a migraine diagnosis on resource utilization. PRINCIPAL FINDINGS: The lower limits of both the 95% and 99% CIs for the difference in charges are greater than 0 for three weeks. The lower limits of both CIs for the difference in the proportion of patients with charges are above 0 for six weeks. CONCLUSIONS: Our analysis demonstrates that a health services research framework can be used to define an episode of care for a chronic disease category such as migraine. This method can be used to evaluate episodes of care for clinical studies of limited or episodic conditions and to complement clinical expertise in developing time horizons for clinical trials.     

Basal cell carcinoma: what dentists need to know

BACKGROUND: Basal cell carcinoma, or BCC, is a malignant epithelial tumor of the skin, commonly seen in the head and neck. Because dentists routinely evaluate the head and neck, the authors present three examples of BCC of the face and jaw to help clinicians recognize the condition. They also provide a literature review regarding BCC's etiology, classification, treatment and prevention. DESCRIPTION OF THE DISEASE: Sun exposure plays an important role in the development of BCC. The most susceptible people are those with minimal skin pigmentation. BCC is more frequently seen in men than in women. The most common form of BCC is the nodular type, which, if untreated, eventually ulcerates and may result in extensive local tissue destruction. The three cases described in this article highlight the range of BCC severity. CLINICAL IMPLICATIONS: Oral health care providers may play an important role in the recognition and diagnosis of BCC involving the head and neck. Early recognition and diagnosis may lead to management that results in improved cure rates, with reduced morbidity and reduced treatment costs.     

An unusual cause of spinal cord injury: case report and discussion

Traumatic spinal cord injury is a devastating condition that alters every aspect of the victim's life. Motor vehicle accidents cause about half of the cases, whereas others are the result of falls, recreational and sporting accidents, or acts of violence. We report a case of a C3 spinal fracture with a resultant Brown Sequard syndrome, which occurred in a unique manner and could have easily been prevented. There is a need for the medical community to play a more active role in educating the public to prevent accidents that lead to these catastrophic injuries.     

Expression of caspase-3 in brains from paediatric patients with HIV-1 encephalitis

Apoptosis of neurones, macrophages, and microglia occurs in the brains of paediatric patients with human immunodeficiency virus (HIV) type 1 encephalitis, which is often associated with pre-mortem neurological disease (progressive encephalopathy). We have previously reported that TUNEL-positive neurones in brain tissue from paediatric patients with HIV type 1 encephalitis and progressive encephalopathy are strikingly devoid of the pro-apoptotic gene product Bax, in marked contrast to brain-resident macrophages and microglia. Using immunocytochemical methods, the present study demonstrate that neurones in patients with HIV type 1 encephalitis and progressive encephalopathy, as well as macrophages and microglia, but not astrocytes, overexpress caspase-3, a pro-apoptotic enzyme that is proteolytically activated downstream of Bax-Bcl-2 dysregulation. Co-localization of neuronal cytoplasmic caspase-3 and nuclear TUNEL staining, a marker for fragmented DNA, was also infrequently observed in brain tissue from patients with HIV type 1 encephalitis and progressive encephalopathy. These findings suggest that vulnerable neurones in brain tissue from patients with HIV virus type 1 encephalitis and progressive encephalopathy undergo apoptosis by a mechanism that involves upregulation of caspase-3 in a pathway that is independent of Bax-Bcl-2 dysregulation. Furthermore, caspase-3 upregulation in apoptotic neurones likely occurs prior to DNA fragmentation.     

Long-term effects of finasteride on prostate tissue composition

OBJECTIVES: To determine the long-term effects of finasteride treatment on prostate tissue composition; to relate these effects to clinical outcomes; and to test the hypothesis that finasteride exerts a selective or preferential action on the transition zone. METHODS: Nineteen men with symptomatic benign prostatic hyperplasia (BPH) who completed a 6-month double-blind trial of finasteride were enrolled in a 24-month open-label extension study of drug responders. Magnetic resonance imaging and prostate biopsy for morphometric analysis were performed together 70 times: at baseline (n = 19), after treatment periods of intermediate duration (6 to 18 months, n = 32), and after long-term drug treatment (24 to 30 months, n = 19). At baseline, prostate volume averaged 51 cc, of which 57% was transition zone. RESULTS: Decreases in symptom score, dihydrotestosterone and prostate-specific antigen levels, and prostate volume occurred at 6 months (P <0.01), stabilized, and were maintained without further long-term decreases. Prostate epithelium contracted progressively from baseline (19.2% tissue composition; 6.0-cc volume; 3.2 stroma/epithelial ratio) to intermediate (12.5%, 3.3 cc, and 5.6, respectively) to long-term treatment (6.4%, 2.0 cc, and 17.4, respectively, P <0.01 for all). Percent epithelial contraction was similar in the peripheral and transition zones (P = NS). The transition zone remained a relatively constant proportion (53% to 58%) of whole-prostate volume from baseline to long-term observation. CONCLUSIONS: Long-term finasteride treatment (24 to 30 months) results in a marked involution of the prostate epithelium, which continues to progress for many months after clinical effects stabilize. The effect on the epithelium is similar in the peripheral and transition zones for both morphometric and volumetric changes. Progressive contraction of the prostate epithelium appears to constitute the underlying mechanism for sustained action of finasteride.