On the road to collaborative treatment planning: Consumer and provider perspectives

Although consumers have made significant gains in having their voices heard in several areas within mental health, they have made less progress in being able to collaborate with their own treaters in setting treatment goals. On the basis of several years of groundwork by staff at the Connecticut Mental Health Center (CMHC), the Patient Care Committee conducted a needs assessment of providers and consumers to assess both groups' current involvement, interest in, and attitudes toward collaborative treatment planning. The results indicate that providers tend to place much of the responsibility for the difficulties in implementing collaborative treatment planning on consumers. Also, providers tend to underestimate consumers' interest in participating in this process. Implications of these findings for the development of an agency-wide training to enhance the collaborative nature of treatment planning are discussed.     

Symphalangism in children. Case report and review of the literature

Symphalangism is an uncommon syndrome characterized by fusion of the interphalangeal joints of the hands and feet. The fusion can involve the proximal or the distal joints; however, involvement of the proximal interphalangeal joints is more common. Symphalangism often is associated with several other skeletal and nonskeletal abnormalities. Analysis of the pedigrees of affected families reveals this trait to be autosomal dominant. The authors present the case of a 9-year-old boy with bilateral symphalangism of the proximal interphalangeal joints in the fingers and toes. His father is affected similarly. A comparison of these cases with those published in the literature indicates that although the radiologic appearance of symphalangism appears disabling, the fused phalanges seldom cause disability or loss of function of the hand. Surgical intervention is not required in most patients. The father and son reported also had capitellar hypoplasia and subluxation of the radial head associated with limitation of elbow flexion and extension.     

Lymph Node Tumor Volumes in Patients Undergoing Sentinel Lymph Node Biopsy for Cutaneous Melanoma

Background: Regional lymph node tumor volumes in patients undergoing sentinel lymph node (SN) biopsy (SNB) for treatment of cutaneous melanoma have not been described. The objectives of this study were to describe the lymph node tumor volumes typically seen in this population and to correlate tumor volumes with tumor thickness and positive SN characteristics.Methods: Review of a consecutive series of patients with clinically localized cutaneous melanoma who underwent SNB of nonpalpable regional lymph node basins followed by complete lymphadenectomy (LND) was performed. Multiple lymph node sections from positive SNs and nonsentinel nodes (NSNs) in LND specimens were examined microscopically. Individual tumor deposit diameters were measured using an ocular micrometer. Aggregate tumor volumes were calculated for SN and LND specimens. Tumor volumes and SN and LND positivity rates were correlated with tumor thickness, the number of positive SNs, and the presence of multiple SN tumor deposits.Results: SNB procedures were performed for 149 melanomas in 189 regional nodal basins. The mean tumor depth was 2.48 mm. The mean number of SNs/basin was 2.1. Thirty-two of 149 SNB procedures (21.5%) revealed a total of 34 nodal basins with at least one positive SN. The median tumor volume in positive SNs was 4.7 mm³ (range, 0.1-3618 mm³; mean, 209 mm³). The median aggregate tumor volume in positive LND specimens was 4.9 mm³ (range, 0.1-3618 mm³; mean, 224 mm³). Six basins (17.6%) contained at least one positive NSN. The regional node aggregate tumor volume correlated weakly with tumor thickness (Pearsons correlation coefficient = .302, P = .0934). NSN positivity was not predicted by tumor thickness, American Joint Committee on Cancer tumor stage, number of positive SNs, or number of metastatic deposits within SNs.Conclusions: Most melanoma-positive SNs contain minute tumor volumes. Tumor thickness and patterns of SN metastases may not be predictive of tumor burden or the presence of positive NSNs.     

Therapeutic Agents of Assertive Community Treatment

The goal of this study was to learn how assertive community treatment (ACT) contributes to the improvement of those with serious mental illness in order to contribute to the growing clinical literature regarding the therapeutic agents of ACT teams. Methods included reviewing the case records of three ACT clients who have improved significantly, as well as interviewing the clients themselves and their clinicians. The results indicated that there was significant agreement among the case records, the clients, and their clinicians in identifying the most useful aspects of assertive community treatment. Primary among these factors were the persistence demonstrated by ACT clinicians in engaging their clients, the trust that clients developed in their clinicians, and as a result, the process by which their clinicians became guides to the world of psychiatric and social services that further facilitated their clients' community adjustment. In closing, we consider implications from these findings both for staff development for ACT team members, and for suggestions toward the development of a model of recovery from serious mental illness.     

Atrial and venous thrombosis secondary to septic arthritis of the sacroiliac joint in a child with hereditary protein C deficiency

Septic arthritis and osteomyelitis in children is seldom accompanied by calf vein thrombosis and rarely by atrial thrombosis. We report the case of an 11-year, 5-month-old boy with septic arthritis and osteomyelitis of the sacroiliac region who developed deep venous thrombosis, in addition to life-threatening right atrial thrombosis. After an intensive hematologic investigation, a hereditary protein C deficiency was revealed. The association of venous thrombosis with septic arthritis or osteomyelitis should raise the possibility of the presence of protein C deficiency.     

Pretreatment bone scan in SCFE: a predictor of ischemia and avascular necrosis

Sixty-two consecutive patients with 73 slipped capital femoral epiphyses (SCFEs) underwent pretreatment planar technetium bone scan to identify the presence of ischemia of the femoral head. The relationship of pretreatment ischemia and the development of avascular necrosis (AVN) was evaluated after a minimum follow-up of 12 months. All patients were treated with spica casting or pinning across the physis. No forceful manipulation was performed. None of the 63 stable SCFEs demonstrated ischemia by bone scan, and none developed AVN. Of the 10 unstable SCFEs, six demonstrated ischemia by bone scan, and five of the six developed AVN. None of the four unstable SCFEs without ischemia on bone scan developed AVN. Pretreatment bone scan is a sensitive predictor for development of AVN in unstable SCFEs and may provide a method for evaluating interventional treatments for AVN associated with SCFE.     

Malarial antibodies in Auckland blood donors.

AIM: To determine the malarial exposure characteristics of "malarial risk" blood donors and measure the potential infectivity of their donations using a commercially available malarial antibody screening kit. METHOD: Malarial risk donors were identified according to standard protocols, questioned as to their degree of exposure to malaria and blood samples were tested for malarial antibodies using an enzyme immunoassay kit. The kit used detects IgG antibodies to P. falciparum, shows 50% crossreactivity with P. vivax and some crossreactivity with P. ovale. Antibody positive samples were further checked by a direct immunochromatographic test for P. falciparum. RESULTS: We found 1.7% of the donors who were classified as a "malarial risk" to be positive for IgG malarial antibodies. None of these antibody positive samples was positive by the direct immunochromatographic test for P. falciparum. CONCLUSION: These results indicate that none of these donors tested were a risk of transmitting P. falciparum, the major and most serious cause of transfusion transmitted malaria. The introduction of malarial testing of malarial risk blood donors in Auckland, currently deferred for plasma donation only, could potentially recover 2300 units of red cells per year.