Successful program maintenance when federal demonstration dollars stop: the ACCESS program for homeless mentally ill persons

A major issue that has long dogged federal human services demonstration programs is the perception that when federal dollars end, the programs end—regardless of any proven successes. Access to Community Care and Effective Services and Supports (ACCESS) was a 5-year federal demonstration project to foster partnerships between service providers for homeless people with serious mental illness and co-occurring substance abuse disorders; and to identify effective, replicable systems integration strategies. After federal funding ended, research teams visited the ACCESS sites to determine which project elements remained and which strategies were used by the sites to continue ACCESS. This article describes ACCESS services and systems integration activities retained by the sites, new funding streams, and strategies used to obtain continued funding.     

Cross-modal neuroplasticity in neonatally enucleated hamsters: structure, electrophysiology and behaviour

Potential auditory compensation in neonatally bilaterally enucleated Syrian hamsters was explored anatomically, electrophysiologically and behaviourally. Gross morphology of the visual cortex appeared normal and no obvious cytoarchitectural malformation was discerned. However, enucleation induced a significant increase in the spontaneous firing rate of visual cortex cells. Further, auditory stimuli elicited field potentials and single unit responses in the visual cortex of enucleated, but not normal, animals. About 63% of the cells isolated in the visual cortex of 16 enucleated hamsters responded to at least one type of auditory stimulus. Most of the responses were less vigorous and less time-locked than those of auditory cortex cells, and thresholds were typically higher. Projection tracing with WGA-HRP disclosed reciprocal connections between the visual cortex and the dorsal lateral geniculate nucleus in both intact and enucleated animals. However, in the enucleated animals retrogradely labelled cells were also found in the inferior colliculus, the major midbrain auditory nucleus. Behaviourally determined auditory sensitivity across the hearing range did not differ between enucleated and intact hamsters. Minimum audible angle, as determined by a conditioned suppression task, ranged from around 17 to 22 degrees, with no significant difference between normal and enucleated animals. The two groups also did not differ with regard to the direction of their unconditioned head orientating response to intermittent noise. However, the enucleated animals showed a more vigorous response and were slower to habituate to the noise. These results show that bilateral enucleation of newborn hamsters results in auditory activation of visual targets, in addition to the typical activation of the intact auditory pathway. Behaviourally it appears that enucleated hamsters, compared with their normal littermates, are slower to habituate in their response to an unexpected source of sound.     

Functional outcome after gamma knife surgery or microsurgery for vestibular schwannomas

OBJECT: Microsurgical excision is an established treatment for vestibular schwannoma (VS). In 1992 the authors used a patient questionnaire to evaluate the functional outcome and quality of life in a series of 224 consecutive patients. In addition, starting with gamma knife surgery (GKS) in 1992, the authors decided to use the same methodology to evaluate prospectively the results of this modality to compare the two alternatives. METHODS: Among the 500 patients who were included prospectively, the authors only evaluated patients in whom GKS was the primary treatment for unilateral VS. Four years of follow up was available for the first 104 consecutive patients. Statistical analysis of the GKS and microsurgery populations has shown that only a comparison of Stage II and III (according to the Koos classification) was meaningful in terms of group size and preoperative risk factor distribution. Objective results and questionnaire answers from the first 97 consecutive patients were compared with the 110 patients in the microsurgery group who fulfilled the inclusion criteria. Questionnaire answers indicated that 100% of patients who underwent GKS compared with 63% of patients who underwent microsurgery had no new facial motor disturbance. Forty-nine percent of patients who underwent GKS (17% in the microsurgery study) had no ocular symptoms, and 91% of patients treated with GKS (61% in the microsurgery study) had no functional deterioration after treatment. The mean hospitalization stay was 3 days after GKS and 23 days after microsurgery. All the patients who underwent GKS who had been employed, except one, had kept the same professional activity (56% in the microsurgery study). The mean time away from work was 7 days for GKS (130 days in the microsurgery study). Among patients whose preoperative hearing level was Class 1 according to the Gardner and Robertson scale, 70% preserved functional hearing after GKS (Class 1 or 2) compared with only 37.5% in the microsurgery group. CONCLUSIONS: Functional side effects happen during the first 2 years after radiosurgery. Findings after 4 years of follow up indicated that GKS provided better functional outcomes than microsurgery in this patient series.     

Post-exposure rabies treatment in pigs

A rabid dog invaded a Thai pig farm and severely mauled 11 adult pigs. This offered an opportunity to study efficacy of a human type post-exposure vaccine regimen with and without rabies immunoglobulin. A commercial veterinary tissue culture rabies vaccine and equine rabies immune globulin were used. All pigs survived for 1 year following the exposure. All animals developed detectable rabies neutralizing antibodies on day 7 and levels over 0.5IU/ml on day 14. This small study suggests that post-exposure rabies treatment using a proven human regimen, applied to valuable farm animals, can be safe and effective.     

College students' drinking: master's in social work compared with undergraduate students

The article is based on the supposition that personal experiences with alcohol influence how master's of social work (MSW) students interact with problem-drinking clients and their significant others. The study compared self-report drinking practices of 413 MSW students with 552 undergraduate college students from universities in the Northeast. The variables were having five or more drinks during the past two weeks, feeling the need to cut down, having an alcohol problem, recovering, and consuming the student's last drink. The MSW students, within age and gender categories, did not drink as excessively as the undergraduate students, although a greater percentage were recovering, a finding of high relevance for the training of these students.     

Current Options for the Treatment of Neoplastic Meningitis

Neoplastic meningitis, which is the diffuse involvement of the leptomeninges by infiltrating cancer cells, may be caused by many systemic tumors. The treatment options for neoplastic meningitis disease remain unsatisfactory. In this review article, we discuss the pathogenesis and cytology of neoplastic meningitis and the options for treatment, including intrathecal chemotherapy, systemic chemotherapy, and newer agents such as cytokines and monoclonal antibodies.     

Approach to Hodgkin's lymphoma in the new millennium

Approximately 75% of patients with Hodgkin's lymphoma can be cured with modern chemotherapy and radiation. Most patients are treated according to clinical stage and the associated prognostic factors. For patients with limited stage Hodgkin's lymphoma, combined modality treatment has replaced subtotal nodal irradiation as the preferred treatment option. This approach eliminates laparotomy and potentially decreases the long-term toxicity secondary to extended field irradiation and splenectomy. Furthermore, recent studies suggest that it may improve disease control and possibly survival. Multiple novel regimens have been tested in the past 20 years in patients with advanced Hodgkin's lymphoma including dose-intense regimens, but current evidence suggests that ABVD remains the treatment of choice outside clinical trials. Over the past decade, the treatment-related morbidity and mortality associated with autologous stem cell transplantation have reduced significantly and stem cell transplant is becoming the treatment of choice for most patients with primary refractory or recurrent Hodgkin's lymphoma. With longer follow-up, long-term complications, in particular secondary malignancy have become the leading cause of late treatment failure for patients with Hodgkin's lymphoma. To improve the overall outcome of patients with Hodgkin's lymphoma, future studies need to focus on reducing the therapy-related toxicity for patients with good risk disease as well as improving disease control for patients with poor risk disease through a risk-adapted approach.     

Phase II study of irinotecan (CPT-11) in children with high-risk malignant brain tumors: the Duke experience

A phase II study of irinotecan (CPT-11) was conducted at Duke University Medical Center, Durham, NC, to evaluate the activity of this agent in children with high-risk malignant brain tumors. A total of 22 children were enrolled in this study, including 13 with histologically verified recurrent malignant brain tumors (glioblastoma multiforme [GBM] 4, anaplastic astrocytoma 1, ependymoma 5, and medulloblastoma/primitive neuroectodermal tumor 3), 5 with recurrent diffuse pontine glioma, and 4 with newly diagnosed GBM. All patients with recurrent tumor had prior chemotherapy and/or irradiation. Each course of CPT-11 consisted of 125 mg/m ( 2 ) per week given i.v. for 4 weeks followed by a 2-week rest period. Patients with recurrent tumors received therapy until disease progression or unacceptable toxicity. Patients with newly diagnosed tumors initially received 3 cycles of treatment to assess tumor response and then were allowed radiotherapy at physician's choice; patients who demonstrated a response to CPT-11 prior to radiotherapy were allowed to continue the drug after radiation until disease progression or unacceptable toxicity. A 25% to 50% dose reduction was made for grade III-IV toxicity. Responses were assessed after every course by gadolinium-enhanced MRI of the brain and spine. Twenty-two patients received a median of 2 courses of CPT-11 (range, 1-16). Responses were seen in 4 of 9 patients with GBM or anaplastic astrocytoma (44%; 95% confidence interval, 11%-82%) (complete response in 2 patients with recurrent GBM lasting 9 months and 48+ months; partial response in one patient with a newly diagnosed midbrain GBM lasting 18 months prior to radiotherapy; and partial response lasting 11 months in 1 patient with recurrent anaplastic astrocytoma), 1 of 5 patients with recurrent ependymoma (partial response initially followed by stable disease lasting 11 months), and none of 5 patients with recurrent diffuse pontine glioma. Two of 3 patients with medulloblastoma/primitive neuroectodermal tumor had stable disease for 9 and 13 months. Toxicity was mainly myelosuppression, with 12 of 22 patients (50%) suffering grade II-IV neutropenia. Seven patients required dose reduction secondary to neutropenia. CPT-11, given in this schedule, appears to be active in children with malignant glioma, medulloblastoma, and ependymoma with acceptable toxicity. Ongoing studies will demonstrate if activity of CPT-11 can be enhanced when combined with alkylating agents, including carmustine and temozolomide.