Patient and contextual factors related to the decision to hospitalize patients from emergency psychiatric services

OBJECTIVE: Mental health care reform has brought an increasing emphasis on community care, with concomitant reductions in inpatient psychiatric resources. Hospitalization remains a necessary and integral component of the mental health care system, but it is taking on a more specialized role. Examining the circumstances in which hospitalization is indicated can help clarify emergency psychiatric practices and determine whether patients' needs are being met within this changing environment. This pilot study examined the impact of selected patient and contextual characteristics on the decision to admit patients to inpatient psychiatric units and assessed the utility of the Severity of Psychiatric Illness (SPI) scale for monitoring clinical practice in emergency psychiatric services. METHODS: Crisis workers in two emergency psychiatric services crisis teams in Toronto, Canada, used the SPI in the assessment of 205 visitors to the services during the winter of 1998-1999. Contextual characteristics, including bed availability, service site, and the admitting physician's level of training, were recorded. Multivariate logistic regression was used to assess the relative contribution of patient and contextual variables in the admission decision. RESULTS: The severity of axis I symptoms and difficulties with self-care were significantly associated with the decision to admit. Site, bed availability, and the admitting physician's level of training did not appear to be associated with clinical decisions. CONCLUSIONS: Patients with the most need are being admitted to inpatient units despite significant systemic pressures on inpatient services. The SPI is a useful and discriminating tool for evaluating clinical practice in emergency services.     

Meiotic double-strand breaks at the interface of chromosome movement, chromosome remodeling, and reductional division

Chromosomal processes related to formation and function of meiotic chiasmata have been analyzed in Sordaria macrospora. Double-strand breaks (DSBs), programmed or gamma-rays-induced, are found to promote four major events beyond recombination and accompanying synaptonemal complex formation: (1) juxtaposition of homologs from long-distance interactions to close presynaptic coalignment at midleptotene; (2) structural destabilization of chromosomes at leptotene/zygotene, including sister axis separation and fracturing, as revealed in a mutant altered in the conserved, axis-associated cohesin-related protein Spo76/Pds5p; (3) exit from the bouquet stage, with accompanying global chromosome movements, at zygotene/pachytene (bouquet stage exit is further found to be a cell-wide regulatory transition and DSB transesterase Spo11p is suggested to have a new noncatalytic role in this transition); (4) normal occurrence of both meiotic divisions, including normal sister separation. Functional interactions between DSBs and the spo76-1 mutation suggest that Spo76/Pds5p opposes local destabilization of axes at developing chiasma sites and raise the possibility of a regulatory mechanism that directly monitors the presence of chiasmata at metaphase I. Local chromosome remodeling at DSB sites appears to trigger an entire cascade of chromosome movements, morphogenetic changes, and regulatory effects that are superimposed upon a foundation of DSB-independent processes.     

Getting a line on CVAD. Central vascular access devices

Covering all types of central lines, these practical guidelines explain how you can protect your patients from complications--and protect yourself from malpractice accusations.     

A practice-based intervention to enhance quality of care in the first 3 years of life: the Healthy Steps for Young Children Program

Context  There is growing concern regarding the quality of health care available in the United States for young children, and specific limitations have been noted in developmental and behavioral services provided for children in the first 3 years of life. Objective  To determine the impact of the Healthy Steps for Young Children Program on quality of early childhood health care and parenting practices. Design, Setting, and Participants  Prospective controlled clinical trial enrolling participants between September 1996 and November 1998 at 6 randomization and 9 quasi-experimental sites across the United States. Participants were 5565 children enrolled at birth and followed up through age 3 years. Intervention  Incorporation of developmental specialists and enhanced developmental services into pediatric care in participants' first 3 years of life. Main Outcome Measures  Quality of care was operationalized across 4 domains: effectiveness (eg, families received =" BORDER="0">4 Healthy Steps–related services or discussed >6 anticipatory guidance topics), patient-centeredness (eg, families were satisfied with care provided), timeliness (eg, children received timely well-child visits and vaccinations), and efficiency (eg, families remained at the practice for =" BORDER="0">20 months). Parenting outcomes included response to child misbehavior (eg, use of severe discipline) and practices to promote child development and safety (eg, mothers at risk for depression discussed their sadness with someone at the practice). Results  Of the 5565 enrolled families, 3737 (67.2%) responded to an interview at 30 to 33 months (usual care, 1716 families; Healthy Steps, 2021 families). Families who participated in the Healthy Steps Program had greater odds of receiving 4 or more Healthy Steps–related services (for randomization and quasi-experimental sites, respectively: odds ratio [OR], 16.90 [95% confidence interval {CI}, 12.78 to 22.34] and OR, 23.05 [95% CI, 17.38 to 30.58]), of discussing more than 6 anticipatory guidance topics (OR, 8.56 [95% CI, 6.47 to 11.32] and OR, 12.31 [95% CI, 9.35 to 16.19]), of being highly satisfied with care provided (eg, someone in the practice went out of the way for them) (OR, 2.06 [95% CI, 1.64 to 2.58] and OR, 2.11 [95% CI, 1.72 to 2.59]), of receiving timely well-child visits and vaccinations (eg, age-appropriate 1-month visit) (OR, 1.98 [95% CI, 1.08 to 3.62] and OR, 2.11 [95% CI, 1.16 to 3.85]), and of remaining at the practice for 20 months or longer (OR, 2.02 [95% CI, 1.61 to 2.55] and OR, 1.75 [95% CI, 1.43 to 2.15]). They also had reduced odds of using severe discipline (eg, slapping in face or spanking with object) (OR, 0.82 [95% CI, 0.54 to 1.26] and OR, 0.67 [95% CI, 0.46 to 0.97]). Among mothers considered at risk for depression, those who participated in the Healthy Steps Program had greater odds of discussing their sadness with someone at the practice (OR, 0.95 [95% CI, 0.56 to 1.63] and OR, 2.82 [95% CI, 1.57 to 5.08]). Conclusion  Universal, practice-based interventions can enhance quality of care for families of young children and can improve selected parenting practices.      

Health literacy of caregivers of adult care recipients: A systematic scoping review

Caregivers play a vital role in providing support to adults with a chronic condition, or cognitive or physical impairment. Low health literacy in caregivers has the potential to impact adequate care provision, and consequently, care recipient health outcomes. The aim of the study was to systematically review literature related to health literacy of caregivers of adult care recipients, and examine its relationship with care recipient, and caregiver, health outcomes. Electronic databases were searched for relevant English‐language publications that assessed health literacy in caregivers. Included studies were abstracted into evidence tables and assessed using an eight‐item quality scale. The search identified 2717 new titles and abstracts, with 67 shortlisted for full review. Twelve papers from 2003 to 2015 met the inclusion criteria. The prevalence of limited health literacy in caregivers ranged from 0% to 52.5% depending on the measure and cut‐off criteria used. Associations were found between low caregiver health literacy and (i) poorer care recipient self‐management behaviours; (ii) increased care recipient use of health services; and (iii) increased caregiver burden. The quality of the studies ranged from fair to excellent. Low health literacy in caregivers differed depending on the measures and scoring criteria used. Evidence to support the relationship between caregiver health literacy and care recipient, and caregiver health outcomes was limited to single studies. Recommendations for further research include: the development of caregiver health literacy measures across different populations; examination of associations between caregiver health literacy and care recipient outcomes; and the development of interventions designed to improve caregiver health literacy.     

Gender Differences in Nonprescribed Psychostimulant Use in Young Adults

Background: In order to better understand the recent rise in nonprescribed use of psychostimulants on college campuses, motives, outcomes, and acceptability of nonprescribed psychostimulants have been evaluated. Despite knowledge that students use nonprescribed medical stimulants for improved academic performance and recreational use, gender differences in these motives have not been examined, despite the fact that the social construction of gender may well affect motives for use. Objectives: The goal of the present study was to examine gender differences in motives, outcomes, and acceptability of nonprescribed psychostimulant use. Methods: 2716 undergraduates (1448 male) between the ages of 17 and 57 years (M = 19.43 years, SD = 1.7 years) completed an online survey examining subjective motives of nonprescribed psychostimulant use, as well as behaviors after use and moral views of nonprescribed use. Results: Consistent with hypotheses and known gender differences in social motivation, results suggested that while females are more likely to use nonprescribed psychostimulants for reasons related to schoolwork, males are typically more likely to use psychostimulants for reasons related to partying and socializing. Additional gender differences were that males are more likely to take part in other risky behaviors after use of psychostimulants, as well as view nonprescribed use as more moral and less physically dangerous than females. Conclusions/Importance: This work suggests that there are striking gender differences in motivation and outcomes of use of nonprescribed psychostimulants, which may have implications for personalized approaches for prevention of nonprescribed psychostimulant use on campuses based on gender.     

Subjective and Neural Responses to Intravenous Alcohol in Young Adults with Light and Heavy Drinking Patterns

Heavy alcohol consumption during young adulthood is a risk factor for the development of serious alcohol use disorders. Research has shown that individual differences in subjective responses to alcohol may affect individuals'' vulnerability to developing alcoholism. Studies comparing the subjective and objective response to alcohol between light and heavy drinkers (HDs), however, have yielded inconsistent results, and neural responses to alcohol in these groups have not been characterized. We performed a double-blind, placebo-controlled, randomized crossover alcohol challenge study comparing functional magnetic resonance imaging and subjective response to intravenously administered 6% v/v ethanol to a target blood alcohol concentration of 0.08% or placebo between HDs and social drinkers (SDs). During the imaging, we presented emotional cues in order to measure how emotion modulated the effects of alcohol on the brain''s reward circuitry. We found that, at equivalent blood alcohol concentrations, HDs reported lower subjective alcohol effects than SDs. Alcohol significantly activated the nucleus accumbens in SDs, but not in HDs. Self-reported ratings of intoxication correlated with striatal activation, suggesting that activation may reflect subjective experience of intoxication. Fearful faces significantly activated the amygdala in the SDs only, and this activation was attenuated by alcohol. This study shows that HDs not only experience reduced subjective effects of alcohol, but also demonstrate a blunted response to alcohol in the brain''s reward system. Our findings indicate that reduced subjective and neural response to alcohol in HDs may be suggestive of either the development of tolerance to alcohol, or of pre-existing decreased sensitivity to alcohol''s effects.     

Development and validation of a scale to assess attitudes and beliefs about menthol cigarettes among african american smokers

To develop more effective smoking cessation interventions for the 70% of African American smokers who smoke menthol cigarettes, it is important to understand smokers' reasons for choosing menthols verses nonmenthols. This study conducted a focus group of African American smokers about their attitudes and beliefs about menthol cigarettes. These attitudes and beliefs, along with others from the literature, were included in a survey of 720 African American smokers in Los Angeles County, California. Five common factors emerged-Medicinal Effects, Image, Less Harmful, Tradition, and Taste/Sensation. Menthol smokers had significantly higher scores on the Taste/Sensation, Medicinal Effects, and Less Harmful scales than nonmenthol smokers did. Men were significantly more likely than women to endorse Medicinal Effects, Image, and Tradition, whereas women were significantly more likely to endorse Taste/Sensation. Education was inversely associated with endorsement of Medicinal Effects, Image, Less Harmful, and Tradition. Respondents aged 40 years or older had significantly higher scores on Medicinal Effects, Image, and Less Harmful, compared with younger respondents. Smoking cessation interventions for African American menthol smokers should address commonly held myths that menthols have medicinal effects and are less harmful than nonmenthols, especially among smokers who are older, male, and/or have low levels of education. The new measures presented in this article could be useful for tailoring cessation interventions to individual smokers' attitudes and beliefs about menthol cigarettes.