A cost-effectiveness comparison of supported employment and rehabilitative day treatment

Recent research suggests that, for some people with severe mental illness, supported employment could improve vocational outcomes for little additional expense. This study describes the costs and client outcomes in one mental health center that converted two rehabilitative day treatment programs to supported employment. Converting from day treatment to supported employment improved vocational outcomes significantly without increasing costs. Although total costs for community treatment were lower in both sites after implementing supported employment, differences appeared to be due to decreasing unit costs over the study period. Results illustrate the importance of testing the effects of cost estimation methods on findings.This study was supported by West Central Services, the New Hampshire Division of Mental Health and Developmental Services, and NIMH grant K02-MH-00839. The authors are grateful to Jesse Turner and Phil Wyzik for facilitating the research.     

Causes of Alcoholism: A Qualitative Study of Traditional Muscogee (Creek) Indians

Abstract Traditional Native American people are experiencing serious health, economic, and social problems resulting from alcoholism. Native Americans maintain a worldview of health and illness that conflicts with the dominant culture's approach to treatment. The purposes of this study were to describe the health beliefs of traditional Muscogee (Creek) Indians concerning the causes of illness and learn how these beliefs relate to alcoholism. The researchers conducted in-depth interviews of 55 traditional Muscogee (Creek) participants to learn traditional beliefs about illness and alcoholism. Data were analyzed using content analysis. Results indicate that both illness and alcoholism are perceived as having natural and unnatural (supernatural) causes. A challenge facing nurses is how to provide culturally sensitive care when clients' and nurses' beliefs about the cause of alcoholism may be in conflict. The authors discuss preservation, accommodation, and repatterning of health care beliefs as a basis for planning culturally sensitive nursing care.     

Contralateral reinnervation of midline muscles in nonidiopathic facial palsy.

The purpose of this study was to analyze contralateral reinnervation of the facial nerve in eight patients with complete facial palsy after surgery or trauma and seven healthy volunteers. All patients had contralateral reinnervation of facial muscles as demonstrated by electrical nerve stimulation versus none of the control subjects. Four patients had facial muscle movements at the site of the damaged nerve. In one patient this was entirely the result of contralateral reinnervation, whereas the other three patients had innervation both ipsilaterally and contralaterally. This implies that renewed facial muscle activity should be examined considering the origin of the reinnervation, either contralateral or ipsilateral. Contralateral reinnervation is a common phenomenon after total facial palsy and can occur alongside ipsilateral reinnervation. It can be mistaken for adequate reinnervation of the damaged nerve, causing postponement of dynamic reconstruction therapy.     

Invasive ventilation in the emergency department: Part 2: Implications for patient safety

The use of mechanical ventilation in the Emergency Department requires adequate resources in order to maintain patient safety and avoid potential risks. Moreover, developments in technology require increased knowledge of mechanical ventilation techniques to address the complexity of decision-making involved. Organisational issues and system factors have the potential to negatively impact on the ability of the emergency service to provide optimum care to patients receiving mechanical ventilation. These issues include staffing and skill-mix, demand on emergency services, role-delineation, scope of practice, and current mechanisms for monitoring of quality and safety. Furthermore, in response to advances in ventilator technology, current education programs for both nursing and medical staff require review to ensure that they provide comprehensive information about the types of ventilation techniques now available and the relative risks and benefits associated with their application.This article is the second in a two-part series and explores the educational and organisational factors that impact upon safety and quality of care delivered to patients receiving mechanical ventilation in the emergency department. Recommendations for future policy development, curriculum review and reporting mechanisms to support further research in the application of mechanical ventilation in the emergency department are made.     

Group excellence: A model for the application of Japanese Management to Mental Health Centers

Mental health centers and other government sponsored service organizations need highly effective management techniques. In this era of tightening budgets, the Japanese Management System may be a way of increasing both excellence and employee satisfaction. Managers who choose to explore this system may need a concise, written model as a guide to the ingenious, extensive, and paradoxical Japanese Management System. The System centers around quality control circles—autonomous problem-solving groups that strive for excellence. Composed of hierarchically interlocking groups, it uses a wide selection of group cohesion techniques to inspire esprit de corps, and an interlocking set of rewards governs behavior at every level. Decision making is collective (although supervisors retain veto power), and execution of ideas, once agreed upon, is quick and consistent. The System operates holistically, enthusiastically, with a high degree of excellence and mutual concern.     

Predicting survival and recurrence in localized melanoma: A multivariate approach

Several clinical and pathologic factors appear to affect melanoma recurrence and survival. While much attention has been directed at identifying prognostic factors, few researchers have developed predictive models for survival and recurrence. Two major clinical questions are of interest in the management of melanoma: 1) what is the patient's chance of surviving for a given period, e.g., 5 or 10 years, after diagnosis of melanoma; and 2) after a patient has been disease free for a period of time, e.g., 5 years, what is his or her chance of melanoma recurrence or death in the following interval, e.g., 5 years or 10 years. In this paper, a generalized multivariate prognostic model to address both of these clinical questions is presented.Tables of the estimated probabilities of melanoma recurrence and death for prognostic subgroups are shown to facilitate prediction of an individual patient's outcome. The model was based on a database of 4,568 patients with localized melanoma, one of the largest melanoma databases in the world with detailed clinical and pathologic information, and long-term follow-up. Tumor thickness at diagnosis was the single most important prognostic factor for all outcomes. Tumor ulceration, Clark's level, lesion location, and sex had an impact on overall survival from diagnosis for some of the subgroups defined by tumor thickness. Tumor thickness at diagnosis was strongly indicative of melanoma recurrence and death even after a disease free interval of 2, 5, or 10 years. Lesion location and ulceration were of prognostic importance after disease free intervals up to 5 years, but their impact on melanoma recurrence and death diminished after longer disease free intervals.Prediction models for melanoma outcome at diagnosis and after a disease free period can provide useful information to clinicians in the management of melanoma patients. Utilization of the model will be valuable in identifying patients at high risk for melanoma recurrence and death.

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Resumen Diversos factores clínicos y patológicos parecen afectar las tasas de recurrencia y mortalidad del melanoma. En tanto que se ha dispensado bastante atención en cuanto a identificar factores de pronóstico, pocos investigadores han desarrollado modelos de predicción de sobrevida y de recurrencia. Dos interrogantes principales son de interés en cuanto al manejo del melanoma: 1) cual es la probabilidad del paciente de sobrevivir un determinado período, por ejemplo 5 o 10 años, después del diagnóstico de melanoma; y 2) después de que el paciente se ha mantenido libre de enfermedad por un período de tiempo, por ejemplo 5 años, cual es su probabilidad de recurrencia del melanoma o de muerte en el siguiente período de tiempo, por ejemplo 5 o 10 años. En este artículo se presenta un modelo generalizado y multivariable de pronóstico para enfrentar estos interrogantes clínicos.Se presentan tablas para estimar las probabilidades de recurrencia y de muerte en divesos subgrupos de pronóstico que facilitan la predicción del destino final de un individuo. El modelo se fundamentó en una base de datos de 4568 pacientes con melanomas localizado, una de las más grandes bases de datos de melanoma existentes en el mundo, con detallada información clínica y patológica y con seguimiento a largo plazo. El espesor del tumor en el momento del diagnóstico apareció como el factor individual de pronóstico de mayor importancia. La ulceración del tumor, el nivel de Clark, la ubicación de la lesión y el sexo exhibieron importancia en cuanto a la sobrevida para algunos de los subgrupos definidos según el espesor del tumor. El espesor del tumor en el momento del diagnóstico fue un factor fuertemente indicativo de recurrencia y de muerte, aún después de un intervalo libre de enfermedad de 2, 5 o 10 años. La ubicación de la lesión y la ulceración aparecieron como de importancia en cuanto el pronóstico después de intervalos libres de enfermedad hasta de 5 años, pero tal importancia disminuyó después de intervalos libres de enfermedad de mayor duración.Los modelos de predicción del resultado final en el melanoma aplicados en el momento del diagnóstico y después de un período libre de enfermedad pueden proveer información útil para el manejo clínico de pacientes con melanomas. La utilización del modelo es de valor en la identificación de pacientes con mayor riesgo de recurrencia y muerte por melanoma.

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Résumé Plusieurs facteurs cliniques et anatomopathologiques semblent déterminer la récidive et la survie des mélanomes. De nombreux auteurs se sont intéressés à l'identidification des facteurs de pronostic, mais peu d'équipes ont essayé d'élaborer un modèle permettant de prédire survie et récidive. Deux problèmes restent à résoudre dans le traitement des mélanomes: 1) quelles sont les chances de survie après le diagnostic de mélanome pour un patient donné, pendant une période donnée, par exemple 5 à 10 ans et 2) quels sont les risques de récidive ou de décès dans les 5 à 10 ans qui suivent une période donnée (par exemple 5 ans) où un patient semblait en rémission. Dans cet article, nous avons créé un modèle d'évaluation pronostique multifactorielle pour tenter de répondre à ces 2 questions.Des tables montrant les probabilités de récidive et de décès par mélanome, calculées à partir de sous groupes différents, peuvent aider à déterminer le pronostic. Ce modèle repose sur une banque de données de 4568 patients atteints de mélanome non disséminé. Il s'agit d'une des plus grandes banques de données au monde contenant des informations cliniques, anatomopathologiques et sur l'évolution à long terme. L'épaisseur de la tumeur au moment du diagnostic était le facteur pronostic le plus important pour déterminer l'évolution. Le caractère ulcéré, le stade de Clark, la localisation de la lésion et le sexe avaient tous une importance pronostique, influant sur la survie globale liée à l'épaisseur de la tumeur. L'importance de l'épaisseur de la tumeur au moment du diagnostic était un facteur de récidive et mortalité même après un intervalle long de 2, 5 ou 10 ans. Le site de la tumeur et son caractère ulcéré étaient également des facteurs associés à un risque de récidive tumorale ou de décès après une rémission de 5 ans. L'influence de ces facteurs diminuait en cas de rémission plus prolongée.Les modèles permettant d'évaluer l'évolution du mélanome malin au moment du diagnostic et apreès un intervalle de rémission sont utiles au cours du traitement du mélanome. Ils doivent permettre d'identifier les patients à risque de récidive et de décès.

     

Osteocalcin 24-hour profiles during normal pregnancy.

The interpretation of previous data on osteocalcin during pregnancy has been complicated by the fact that serum levels, at least in nonpregnant women, display a significant circadian variation. In the present study, serum concentrations of osteocalcin were recorded for 24 h in 12 individual women. In 4 nonpregnant women, there were striking diurnal fluctuations during the sampling period, with values ranging from 0.5 to 4.0 ng/ml. One woman who was investigated in the 11th week of pregnancy showed similar fluctuations in osteocalcin concentrations whereas in the 15th and 17th week values were much lower with minor fluctuations. In 4 women investigated during late pregnancy (weeks 34-38), osteocalcin serum levels were extremely low (range 0.2-0.4 ng/ml), often below the detection limit of the assay, and there was no diurnal variation. Also, in 1 lactating woman, osteocalcin serum levels were low (0.3-0.8 ng/ml) and stable. Low osteocalcin values during pregnancy may indicate a reduced bone turnover possibly mediated via an altered estrogen and growth hormone secretion.     

Evaluation of diagnostic criteria for borderline personality disorder

A comparison of 17 narrowly defined borderline patients with 20 nonpatient control subjects indicated that certain individual and combinations of criteria may be more highly correlated with the disorder than others. Requiring any four or certain specific combinations of two or three of the five most discriminating criteria provided the optimal balance of sensitivity, specificity, predictive power, and diagnostic efficiency considerations. Fewer than five DSM-III-R criteria adequately identified the patients.     

Is Functional Dyspepsia of Particular Concern in Women? A Review of Gender Differences in Epidemiology, Pathophysiologic Mechanisms, Clinical Presentation, and Management

Dyspepsia is a remarkably common symptom in the general population. Although multiple definitions have been used to describe the symptom, the most common explanation is that of chronic or recurrent pain or discomfort (a subjective negative feeling that may be associated with early satiety, fullness, bloating, or nausea) centered in the upper abdomen. When a thorough evaluation of a dyspeptic patient fails to identify a cause for her symptoms, the label of nonulcer or functional dyspepsia is applied. Functional dyspepsia is a heterogeneous disorder characterized by relapsing and remitting symptoms. Treatment strategies should focus on alleviating the most bothersome symptom and can be based on the proposed underlying pathophysiology. The effect of gender on mechanisms of disease, symptom presentation, and treatment response is an area of increasing interest and study. As with other functional gastrointestinal disorders, there appear to be some gender-specific features of functional dyspepsia. Specifically, gender-related differences have been observed in some studies of both the prevalence of individual dyspepsia symptoms, and in gastric emptying and proximal gastric motor function. There also appear to be gender differences in the psychosocial realm, with dyspeptic women experiencing a lesser sense of well-being than dyspeptic men, as well as an association of an abuse history with functional dyspepsia. This review will highlight specific gender differences related to the symptom presentation, pathophysiology, and approach to treatment of functional dyspepsia, while noting where differences have not been found and where further investigation is warranted.