A survival strategy for an academic psychiatry department in a managed care environment.

The changing economics of medical practice have had a profound effect on the educational, research, and service missions of academic departments of psychiatry across the country. The authors describe the development of a managed behavioral health care organization in their parent academic health system as a survival strategy for allowing their department to function in a managed care environment. They present a series of lessons learned in this effort to adapt to a highly volatile managed behavioral health care market: know how you fit into your market as well as your institution, form cooperative alliances within and outside of your institution, provide incentives to manage risk, focus on core competencies, innovate in your areas of strength, and collect data.     

Testing the fetal origins hypothesis in twins: the Birmingham twin study

Aims/hypothesis. To test whether the link between birthsize and raised blood pressure or glucose tolerance is due to genetic or intrauterine factors, we studied whether differences in birthweight between pairs of monozygous and dizygous twins are associated with adult differences in blood pressure and glucose tolerance.¶Methods. A sample of 58 monozygous and 140 dizygous twins were identified from a register of births in Birmingham, United Kingdom, between 1950 and 1954. The twins had their blood pressure measured and underwent an oral glucose tolerance test.¶Results. There were no statistically significant associations between birthweight, length or ponderal index, and either blood pressure or glucose tolerance in the twins. Although there were substantial within-pair differences in birthweight between monozygous and dizygous twin pairs, these differences did not correlate with the adult outcomes. Monozygous correlations, however, for both blood pressure and glucose tolerance were statistically significantly higher than dizygous correlations and a quantitative genetic model suggested statistically significant heritability for these traits. In contrast correlations of birthsize were similar in monozygous and dizygous pairs suggesting only a small genetic component in determining fetal size.¶Conclusion/interpretation. Our results show that birthsize in twins does not predict adult blood pressure or glucose tolerance. We also suggest that shared genetic determinants for fetal growth and adult outcomes are not likely to be prevalent or powerful. [Diabetologia (2001) 44: 33–39]     

Quality of dying and death with cancer in Israel

Background

The quality of dying and death refers to the evaluation of the final days of life and the moment of death with respect to how it is prepared for, faced and experienced by those with a terminal illness. It includes experience in multiple domains: physical, psychological, social, spiritual or existential, the nature of health care, life closure and death preparation, and the circumstances of death.

Aim

To explore the quality of dying and death in cancer patients in Israel and its relationship to place of death and socio-demographic characteristics of the primary caregivers and the deceased.

Design

Retrospective assessment of the quality of dying and death, based on caregiver responses to the Quality of Dying and Death (QODD) questionnaire (overall score ranges from 0 to 100; higher scores reflect better dying and death experiences) 8 to 10 months after the death.

Participants

Ninety-five caregivers of Jewish cancer patients, most of whom were female spouses or children of the deceased.

Results

Mean QODD score was 57.2 (standard deviation [SD]?=?15), which is in the low-moderate range. Place of death, gender and age of the caregiver, and age of the deceased, were associated with QODD score.

Conclusions

This retrospective study in Israel demonstrated that the overall quality of dying and death was regarded as poor by almost half of the caregivers. These findings may reflect the relative lack of specialized palliative care and advance care planning in Israel at the time of this study, which took place between 2006 and 2009. Further research and enhancement of palliative care resources may be needed in Israel and several encouraging recent developments (e.g. staff training and legislation) suggest that such changes are now underway.     

Hyperproinsulinemia is associated with increased beta cell demand after hemipancreatectomy in humans.

The cause of disproportionate hyperproinsulinemia in patients with type II diabetes is controversial. To examine whether increased beta cell demand might contribute, we measured proinsulin and insulin concentrations in clinically healthy humans who had undergone hemipancreatectomy for the purpose of organ donation, a procedure previously demonstrated to increase beta cell demand and diminish insulin secretory reserve capacity. Subjects were studied at least 1 yr after hemipancreatectomy. Seven donors were followed prospectively and serves as their own controls. Nine additional donors were matched with normal controls (cross-sectional group). Fasting serum concentrations of intact proinsulin and conversion intermediates (total) were measured by a two-step radioimmunoassay; independent determinations of intact proinsulin and 32,33 split proinsulin were performed using an immunoradiometric assay. Serum total proinsulin values were significantly greater in hemipancreatectomized groups than controls (prospective group: predonation = 6.24 +/- 1.14 pM, postdonation = 34.63 +/- 17.47 pM, P < 0.005; cross-sectional group: controls = 5.78 +/- 1.12 pM, donors = 15.22 +/- 5.20 pM, P < 0.025). The ratio of total proinsulin to immunoreactive insulin was directly correlated with fasting plasma glucose and showed a significant inverse relationship to secretory reserve capacity. Both absolute and relative hyperproinsulinemia is found in hemipancreatectomized donors. These data demonstrate that partial pancreatectomy with its associated increase in beta cell demand raises measures of proinsulin in humans.     

Insulin sensitivity and secretion in normal children related to size at birth,postnatal growth,and plasma insulin-like growth factor-I levels

Aims/hypothesis Type 2 diabetes risk is associated with low birth weight, rapid weight gain during childhood, and shorter stature and lower circulating IGF-I levels in adults. The largest variations in growth rates occur during the first postnatal years. We hypothesised that early postnatal variations in height and weight gain and IGF-I levels may be associated with risk markers for adult disease.Methods We measured the fasting insulin sensitivity (Homeostasis model) and insulin secretion post-oral glucose (insulinogenic index 0–30 min) in 851 normal 8-year-old children from a prospective birth cohort. We examined associations between size at birth, postnatal weight gain and circulating IGF-I levels with insulin sensitivity and secretion at 8 years of age.Results Fasting insulin sensitivity at 8 years was closely related to current BMI (r=–0.33, p<0.0005). Lower insulin sensitivity and higher BMI and waist circumference were all predicted by greater weight gain between birth to 3 years of age (all p<0.0005); lower birth weight was associated with reduced insulin sensitivity only in the highest current BMI tertile (r=0.17, p=0.006). In contrast, lower insulin secretion was related to smaller size at birth (p=0.01), independent of postnatal weight gain and insulin sensitivity. Lower insulin secretion was also independently related to shorter stature at 8 years of age relative to parental height (p=0.047) and with lower plasma IGF-I levels at 5 years of age (n=252, p=0.004).Conclusions/interpretation Associations between lower birth weight and insulin resistance may be dependent on rapid weight gain during the early postnatal years. However, irrespective of postnatal weight gain, smaller size at birth, lower IGF-I levels and lower childhood height predicted reduced compensatory insulin secretion.Abbreviations ALSPAC Avon Longitudinal Study of Pregnancy and Childhood     

Blastomycosis in a young African man presenting with a pleural effusion

Blastomyces dermatitidis is a dimorphic fungus endemic to northwestern Ontario, Manitoba and some parts of the United States. The fungus is also endemic to parts of Africa. Pulmonary and extrapulmonary findings of a 24-year-old African man who presented with weight loss, dry cough and chronic pneumonia not resolving with antibiotic treatment are presented. The unusual occurrence of pulmonary blastomycosis associated with skin lesions and a moderate pleural effusion is reported.     

A Quasi-Experimental Analysis of Elementary School Absences and Fine Particulate Air Pollution

Fine particulate air pollution (PM_2.5) has been associated with many adverse health outcomes including school absences. Specifically, a previous study in the Utah Valley area, conducted during a time with relatively high air pollution exposure, found significant positive correlations between school absences and air pollution.We examined the hypothesis that ambient PM_2.5 exposures are associated with elementary school absences using a quasi-natural experiment to help control for observed and unobserved structural factors that influence school absences. The Alpine, Provo, and Salt Lake City school districts are located in valleys subject to daily mean PM_2.5 concentrations almost twice as high as those in the Park City School District. We used seminonparametric generalized additive Poisson regression models to evaluate associations between absences and daily PM_2.5 levels in the 3 districts that were exposed to the most pollution while using Park City absences as a quasi-control. The study covered 3 school years (2011/12-2013/14).School absences were most strongly associated with observed structural factors such as seasonal trends across school years, day-of-week effects, holiday effects, weather, etc. However, after controlling for these structural factors directly and using a control district, a 10 μg/m³ increase in PM_2.5 was associated with an approximately 1.7% increase in daily elementary school absences.Exposure to ambient air pollution can contribute to elementary school absences, although this effect is difficult to disentangle from various other factors.