Exclusions and limitations in children's behavioral health care coverage

OBJECTIVE: The objective of this study was to identify benefit limits, diagnostic exclusions, and service exclusions of private behavioral health care plans that can influence the delivery of care to children. METHODS: A total of 128 commercial, employment-based behavioral health plans were examined for types of benefit limits, service exclusions, and diagnostic exclusions applicable to children. RESULTS: Almost half of the plans had restrictions on the number of outpatient visits, with limits ranging from 12 to 60 clinic visits a year. More than half of the plans had limitations on the number of inpatient days, ranging from 20 to 60 days a year. Diagnoses excluded from coverage included autism, mental retardation, problems related to child abuse, and impulse control disorders, such as kleptomania and pyromania. Half of the services excluded could be categorized as either social and human services or complementary medicine rather than as mental health care. CONCLUSIONS: Plans commonly had service and diagnostic exclusions that could disrupt children's health care. The results of the study emphasize a need to address the types of treatment covered by mental health insurance.     

Should the guidelines for monitoring serum cholesterol levels in the elderly be re-evaluated?

Elevated circulating cholesterol can have profound effects on the health of an individual. Such excess cholesterol can promote coronary artery disease, production and accumulation of β-amyloid in the brain, and possibly Alzheimer’s disease (AD). In a clinical trial evaluating the benefit of a cholesterol-lowering drug in the treatment of AD, mean cholesterol levels at baseline among individuals participating in the trial were found to be relatively high. Based on this observation we suggest that cholesterol levels should be actively monitored in the elderly, as many individuals with AD are over 65 years of age and therefore excluded by currently accepted guidelines.     

Feasibility of a men’s health promotion programme in Irish primary care

Background  

To assess the feasibility of offering health promotion and preventive medicine initiatives in primary care.     

Hypertolerance to morphine in G(z alpha)-deficient mice

Our laboratory has generated a mouse deficient in the alpha (alpha) subunit of the G protein, G(z), (G(z alpha)) gene and we have examined the involvement of G(z alpha) in spinal and supraspinal analgesia and tolerance mechanisms. Spinal analgesia was tested by the response times to heat or cold tail flick times in a water bath at 50 degrees C or -5 degrees C and supraspinal analgesia was tested by the times for paw licking and jumping from a plate at 52 degrees C or 0.5 degrees C. Tolerance to morphine was induced in wild type and G(z alpha)-deficient mice over a 5 day period and the behavioral tests were performed daily. The tail flick reaction times to both hot and cold stimuli did not differ between the wild type and G(z alpha)-deficient mice. Analysis of the reaction times from the hot and cold plate tests showed the G(z alpha)-deficient mice developed tolerance to morphine to a greater degree and at a faster rate than wild type mice. Opioid binding assays were performed on synaptic membranes prepared from naive and morphine tolerant wild type and G(z alpha)-deficient brains. No changes in the affinity of morphine for its receptor or in the density of mu and delta opioid receptors were found between the two groups of mice in the naive or morphine tolerant state. This indicates that the absence of G(z alpha) does not affect opioid receptor affinity or receptor up or down regulation. Our results suggest that the presence of G(z alpha) delays the development of morphine tolerance and represents a possible therapeutic target for improving the clinical use of morphine.     

Whole body protein metabolism in children with cancer

Whole body protein synthesis and catabolism were measured using the [ring-2H5]phenylalanine and [1-13C]leucine primed constant infusion technique in 32 paediatric patients with cancer at different stages of treatment. Rates of synthesis (S) and catabolism (C) derived from the [ring-2H5]phenylalanine and [1-13C]leucine models were 4.7 (SD 1.3) (S) and 6.0 (1.5) (C) g/d/kg, and 5.5 (0.8) (S) and 6.8 (1.2) (C) g/d/kg, respectively. These results show that these two tracer techniques give similar results in this study population. Comparison of these values with results previously reported for groups of control children using the [ring-2H5]phenylalanine model (S = 3.69 and 3.93; C = 4.09 and 4.28 g/d/kg) and the [1-13C]leucine model (S = 4.32; C = 4.85 g/d/kg) show that rates of synthesis and catabolism were higher in cancer patients than in controls. Thus whole body protein turnover is increased in children under treatment for cancer. Other indices of metabolism such as plasma amino acids and intermediary metabolites were also measured and showed that, although subjects were in isotopic steady state, there were significant metabolic changes during the course of the primed constant infusions used to measure protein turnover.     

The Physician Belief Scale and psychosocial problems in children: a report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network

Clinicians' management of children with psychosocial problems may vary with their attitudes and beliefs. However, we lack sound instruments to assess these factors. This study examined the psychometric properties of the Physician Belief Scale (PBS). A modified version of the PBS was sent to clinicians who participated in two primary care research networks. Using factor analysis, we reduced the PBS to 14 items and 2 subscales. Cronbach's alpha values were high. Female clinicians, those using DSM-IV, and those having completed training earlier rated themselves as more psychosocially oriented. Identification and treatment of psychosocial problems were significantly related to scores on the Belief and Feeling subscale. The PBS provided only a modest amount of information regarding primary care practices. It is not clear if these limitations are attributable to the instrument or the many other barriers to effective psychosocial care.     

Health-related quality of life of patients with overactive bladder receiving immediate-release tolterodine

Overactive bladder (OAB) imposes a burden on many aspects of a patient's life. The health-related quality of life (HRQOL) of OAB patients has been shown to be lower than healthy or control patients. A goal of successful treatment is to improve the HRQOL of OAB patients. With newer OAB treatments becoming available, HRQOL is an important outcome to measure. Thus, the objective of this study was to compare the HRQOL of patients being treated with tolterodine immediate-release (IR) versus placebo for OAB. The King's Health Questionnaire (KHQ) and the Medical Outcomes Study Short Form 36 (SF-36) were administered at baseline and end of treatment (12 weeks) in a randomized, parallel groups, placebo-controlled, double-blind, multinational study designed to compare the clinical efficacy and safety of tolterodine to placebo in the treatment of OAB. At end of treatment KHQ domains selected a priori as primary HRQOL endpoints (incontinence impact and role limitations) significantly improved (PА.0001) with tolterodine IR. Domains selected a priori as secondary HRQOL or symptom endpoints (physical limitations, emotions, sleep and energy, severity (coping) measures, and symptom severity) were also significantly improved (PА.0074) following treatment with tolterodine IR. The tolterodine IR group had less severity of individual symptoms and significantly better patient rating of bladder control than the placebo group at end of treatment. As expected, the SF-36 did not detect treatment differences. In conclusion, many aspects of HRQOL, as measured by the KHQ, significantly improved with tolterodine IR treatment. These HRQOL improvements were consistent with clinical efficacy results. The findings demonstrate that tolterodine IR patients experience overall improvement in their condition that resulted in important impacts on their HRQOL.