Counsellors in primary care: benefits and lessons learned.

OBJECTIVE: To describe a program that integrates mental health counsellors within primary care settings, to present data on the program's impact, and to discuss lessons learned that may apply in other communities. METHODS: This paper describes a Canadian program that brings counsellors and psychiatrists into the offices of 87 family physicians in 36 practices in a community of 460,000 in Southern Ontario. It describes the goals and organization of the program and the activities of counsellors when working in primary care. In addition, it summarizes data from the program's evaluation, including demographic data and the individual problems seen and services delivered (all from the program's database) as well as data on patient outcomes using the General Health Questionnaire (GHQ), the Centre for Epidemiological Studies Depression (CESD) Rating Scale, and consumer-satisfaction questionnaires. RESULTS: Each counsellor sees an average of 161 new cases yearly. The major problems are depression, anxiety, and family problems. In fact, over 70% of individuals who are seen show significant improvements in outcomes. The program has led to a significant increase in access to mental health services, a reduction in the use of traditional mental health services, high levels of satisfaction with counsellors and family physicians, and significant improvements in symptoms and functioning of individuals seen. CONCLUSION: This program has effectively integrated counsellors within primary care settings, increasing the capacity of primary care to handle mental health problems, strengthening links between providers from different sectors, and making mental health care more accessible.     

Evaluation of global clustering patterns and strain variation over an extended ORF26 gene locus from Kaposi's sarcoma herpesvirus.

BACKGROUND: Small 233-bp or 330-bp DNA fragments of the ORF26 gene of human Kaposi's sarcoma herpesvirus (KSHV) have been used extensively to identify KSHV by PCR in clinical samples; to associate KSHV with novel diseases and to correlate KSHV strain differences with pathogenicity. OBJECTIVES: We evaluated the nature, extent and source of nucleotide sequence variability among a large and diverse set of known KSHV-positive DNA samples. STUDY DESIGN: Direct DNA PCR sequencing was carried out on 136 distinct Kaposi's sarcoma and primary effusion lymphoma-related samples from different geographic locations. RESULTS: The presence of 26 diagnostic nucleotide polymorphisms across an expanded 965-bp PCR locus define eight distinct ORF26E genotypes, three being of Eurasian origin, one from the Pacific Rim, and five from Sub-Saharan Africa. Previous ambiguities between some genotype patterns in the 330-bp locus data are fully resolved. CONCLUSIONS: This analysis provides an expanded database for understanding and evaluating ORF26 polymorphisms. In particular, the eight genotype clusters correlated with specific ethnic and geographic origins of the patients. Furthermore, the very low level of additional sporadic nucleotide variation found permits detection of spurious sequence errors or contamination present in some published data.     

Magnetic field coil measurements of the accuracy of extreme gaze ocular fixation.

PURPOSE: (1) To assess the adequacy of the magnetic field coil method (MFCM) for measures of extreme gaze ocular fixation; and (2) to measure the accuracy of ocular fixation for a short duration at gaze angles of 10 to 40 degrees. METHODS: Seven subjects participated. Two experiments were performed on the same day. In both experiments, the head and eye were rotated in opposite directions. In the first experiment, search coil slippage was assessed using photographs of a scleral search coil worn on one eye. These photographs were taken with a slitlamp biomicroscope equipped with a digital photography system as subjects rotated the eyes through nasal angles up to 40 degrees. In the second experiment, measures of ocular position were made using the MFCM as the eye was rotated through nasal angles up to 40 degrees to fixate a light-emitting diode target under two conditions. In one condition, subjects simply aimed the eye at the target. In the other, subjects placed a foveal afterimage on the target as the target was viewed through a pinhole. RESULTS: Temporal search coil slippage >10 arc min was noted for three subjects. For one subject, this slippage occurred at gaze angles > or =20 degrees, whereas for the other subjects, the slippage appeared at gaze angles of > or =30 degrees. Ocular fixation had to be assessed from the differences in fixation position between the two conditions in the second experiment because of search coil slippage and because the relationship between the anterior and posterior portions of the eyes changed for some individuals as the gaze angle changed. Fixation was usually accurate (within 10 arc min). There were occasional instances where fixation errors >15 arc min occurred, but we believe that all but one of these cases were attributable to poor localization of the afterimage. CONCLUSION.: Scleral search coils can slip on some individuals in extreme gaze. Search coils may also be inadequate to indicate the direction of the fovea in extreme gaze for some individuals because the relationship between the anterior and posterior portions can change with gaze angle. Once artifacts associated with the MFCM and localization of the afterimage are accounted for, ocular fixation is almost always within 10 arc min of the fixation target at gaze angles of 10 to 40 degrees.     

Late referral for end-stage renal disease: a region-wide survey in the south west of England.

BACKGROUND: The proportion of patients referred for renal replacement therapy (RRT) at a late stage of disease appears to be similar to that first described nearly 20 years ago. This study investigated the current scale of the problem in a large region in England, identifying the prior health care, patient characteristics, referral pattern, and outcomes of those accepted onto RRT. METHODS: Three hundred and sixty-one (88%) out of 411 patients accepted for RRT in six renal units in the South and West Region of the UK between 1 June 1996 and 31 May 1997 were studied retrospectively. We examined the history of chronic renal failure, referral path to nephrologist, management of chronic renal failure (CRF) and patient outcomes. Patients were categorized as 'late' if they were referred to the renal unit either within 4 months or within 1 month of requiring RRT. RESULTS: One hundred and twenty-four (35%) patients were referred within 4 months of RRT, and 84 (23%) within 1 month. The main differences between patients referred later and other patients was seen for those referred within 1 month. These patients were older and had more co-morbidity, significantly worse laboratory parameters at the start of RRT, were less likely to have received standard treatments for CRF, had less permanent dialysis access in place at the start of RRT (18% vs 47%, P=0.001), and had a significantly longer hospital stay (18 vs 10 days, P=0.001). Seventy-four (19%) patients died in the first 6 months: 27 (32%) in the 1-month group, 46 (16%) in all others (P=0.002). We found no evidence that patients referred late had defaulted from nephrology follow-up or had an excess of rapidly progressive disease. Though data were incomplete, there was evidence of prior CRF of over 1 year in all late referral groups. CONCLUSION: Nearly a quarter of patients are referred for specialist nephrology treatment at a very late stage, within 1 month of RRT. They are less likely to receive interventions that could alter the progression of CRF or reduce its associated co-morbidity, have a worse clinical state at the start of RRT, longer hospitalization and poorer survival. These differences were much less marked for those referred within 1-4 months of starting RRT, although this is an insufficient time to prepare for RRT. Further research is needed to determine the missed opportunities for more proactive diagnosis and management of CRF.     

A comparison of mammographic parenchymal patterns in premenopausal Japanese and British women

Normal premenopausal Japanese women have significantly more favourable mammographic parenchymal patterns (Wolfe Grades) than comparable British women. This finding is unaffected when the women are stratified by age, Quetelet's Index, age at menarche, age at first birth, and parity.