Integrating Decision Making and Mental Health Interventions Research: Research Directions

The importance of incorporating patient and provider decision-making processes is in the forefront of the National Institute of Mental Health (NIMH) agenda for improving mental health interventions and services. Key concepts in patient decision making are highlighted within a simplified model of patient decision making that links patient-level/"micro" variables to services-level/"macro" variables via the decision-making process that is a target for interventions. The prospective agenda for incorporating decision-making concepts in mental health research includes (a) improved measures for characterizing decision-making processes that are matched to study populations, complexity, and types of decision making; (b) testing decision aids in effectiveness research for diverse populations and clinical settings; and (c) improving the understanding and incorporation of preference concepts in enhanced intervention designs.     

Bone Mineral Density Determinations by Dual-Energy x-ray Absorptiometry in the Management of Patients with Marfan Syndrome—Some Factors Which Affect the Measurement

Reduced bone mineral density (BMD) was sporadically reported in patients with Marfan syndrome. This may or may not place the Marfan patient at increased risk for bone fracture. In comparing the BMDs of our patients with those reported in the literature, it seemed that agreement between values, and hence the degree of osteoporosis or osteopenia reported, was dependent on the instrumentation used. The objective of this study was to statistically assess this impression. Bone mineral density measurements from our previously published study of 30 adults with Marfan syndrome performed on a Lunar DPXL machine were compared with studies published between 1993–2000 measured using either Lunar or Hologic bone densitometry instruments. The differences of our measurements compared with those made on other Lunar machines were not statistically significant, but did differ significantly with published results from Hologic machines (P < 0.001). Before progress can be made in the assessment of BMD and fracture risk in Marfan patients and in the evidence-based orthopedic management of these patients, standardization of instrumental bone density determinations will be required along with considerations of height, obesity, age, and sex.     

Physical Therapy and Complementary and Alternative Medicine: An Educational Tool for Enhancing Integration

In an outpatient rehabilitation setting, both patients’ use and therapists’ knowledge of complementary and alternative medicine (CAM) varies widely. Based on this observation and a recognition of CAM as an emerging practice area for rehabilitation professionals, it was felt that a thorough and consistent approach to the education and orientation of physical therapists to the world of CAM and integrative care was needed. This special interest paper will describe one center’s approach, development, and use of a unique and comprehensive training manual designed to provide both a structured and standardized approach for educating physical therapists about CAM and related therapeutic modalities. This innovative teaching tool allows for multiple methods of content delivery within a multidisciplinary format and can be used for those who practice currently or desire to practice in an integrative care environment.     

Effectiveness of needle and syringe programmes for preventing HIV transmission

Objective: To examine the effectiveness of needle and syringe programmes (NSPs) in preventing HIV transmission among injecting drug users (IDUs).Methods: An ecological study design was used to determine change in HIV prevalence among injecting drug users between cities with and without NSPs. Several data sources, such as electronic journal databases, surveillance reports, websites, and index review of relevant journals, were used to identify studies of HIV seroprevalence among IDUs, and presence of NSPs. The rate of change in HIV prevalence was estimated by regression analysis.Results: There were 778 years of data from 99 cities globally included in the analysis. HIV prevalence decreased by 18.6% per annum in cities that introduce NSPs, and increased by 8.1% in cities that had never introduced NSPs (mean difference −24.7% [95% CI: −43.8, 0.5%], P=0.06). The mean difference was –33% when comparison was weighted to one over the variance of the regression estimator (29% decrease in cities with NSPs and 5% increase in cities without NSPs, P<0.001). When analysis was restricted to cities with first HIV seroprevalence less than 10%, the average annual change in seroprevalence was 18% lower in cities with NSPs (P=0.03).Conclusions: Despite the inherent limitations within an ecological study design, the study provides additional evidence that NSPs reduce transmission of HIV infection. The rapid spread of HIV among IDU populations and increasing rates of injecting in many countries calls for scaling up of NSPs as well as other harm reduction strategies.     

Grandmothers, Fathers, and Depressive Symptoms Are Associated with Food Insecurity among Low-Income First-Time African-American Mothers in North Carolina

African Americans experience household food insecurity, ie, the limited availability of nutritionally adequate and safe food, or ability to acquire acceptable foods in socially acceptable ways, at three times the rate of non-Hispanic whites. Thirty percent of all African-American children live in food-insecure households. The purpose of this study was to identify characteristics associated with household food insecurity among a high-risk postpartum population. Two-hundred six low-income, African-American mother−infant dyads were recruited through the Special Supplemental Nutrition Program for Women, Infants, and Children clinics. The six-item US Department of Agriculture food security scale was used to classify households as food secure, marginally food secure, or food insecure. Multinomial logistic regression was used to estimate the association between selected maternal/household characteristics and household food-security status. Fifty-three percent of households were food secure, 34% were marginally food secure, and 13% were food insecure. Maternal education less than college (relative risk ratio [RRR]=0.46; 95% confidence interval [CI]: 0.22 to 0.98) was inversely associated with marginal food security. Depressive symptoms (RRR=1.09; 95% CI: 1.02 to 1.16) and having the baby's father in the household (RRR=3.46; 95% CI: 1.22 to 9.82) were associated with household food insecurity, while having a grandmother in the household (RRR=0.15; 95% CI: 0.03 to 0.80) was inversely associated with experiencing household food insecurity. Findings from this study suggest that young, low-income, African-American families with only one child are particularly susceptible to experiencing household food insecurity. Intergenerational support and transfer of knowledge can be a key protective attribute among low-income African-American households.     

Improvement of Atrophic Acne Scars with a 1,320 nm Nd:YAG Laser: Retrospective Study

Background. Facial acne scarring has been treated with multiple methods with varying degrees of improvement. Although the 1,320 nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser has been widely used to improve photoaging, studies analyzing its effects on atrophic acne scarring are limited.
Objective. To evaluate the efficacy of a dynamic cryogen-cooled 1,320 nm Nd:YAG laser for the treatment of atrophic facial acne scars in a larger cohort of patients with long-term follow-up.
Methods. Twenty-nine patients (skin phototypes I–IV) with facial acne scarring received a mean of 5.5 (range 2–17) treatments with a 1,320 nm Nd:YAG laser. Objective physician assessment scores of improvement were determined by side-by-side comparison of preoperative and postoperative photographs at a range of 1 to 27 months (mean 10.4 months) postoperatively. Subjective patient self-assessment scores of improvement were also obtained.
Results. Acne scarring was significantly improved by both physician and patient assessment scores. Mean improvement was 2.8 (  p < .05  ) on a 0- to 4-point scale by physician assessment and 5.4 (  p < .05  ) on a 0- to 10-point scale by patient assessment. No significant complications were observed.
Conclusions. Nonablative laser skin resurfacing with a 1,320 nm Nd:YAG laser can effectively improve the appearance of facial acne scars with minimal adverse sequelae.