Patient,Provider, and Treatment Factors Associated with Poor-Quality Care for Schizophrenia

Interventions are needed to improve the quality of care for schizophrenia. However, in designing these interventions it would be helpful to understand better which patients are at highest risk for poor-quality care and why care for this disorder is often of poor quality. We study the extent to which patient and treatment factors are associated with poor-quality care in 224 patients randomly sampled from two mental health clinics. Quality of medication management is evaluated using an established method based on national treatment recommendations. Multivariate regression is used to study the effect of patient and treatment factors on treatment quality, controlling for provider. Risk for poor-quality care was greater for patients who were more severely ill, older, and less compliant with treatment recommendations. There were trends toward poor management of symptoms in men and substance abusers, and poor management of side effects in Black patients. Provision of poor-quality care was associated with failure to document symptoms and side effects in the medical record. Interventions to improve care for schizophrenia should attend to the need for accurate clinical assessment and strategies for managing challenging clinical situations.     

Brain Death and Organ Donation in Germany: Analysis of Procurement in a Neurosurgical Unit and Review of Press Reports

Summary  Objective. A prospective study was undertaken to determine the number of potential organ donors in a neurosurgical intensive care unit and to record the actual number of organ donations. The reasons for refusal of organ donations were analysed with respect to the controversial public discussion of the brain death concept and the transplantation law in Germany.  Methods. From 1994 to 1997, the number of cases of brain death, and the number of cases in which relatives consented or refused to organ donation as well as the number of actual organ explantations was recorded. Over the same period, press reports of 5 German language newspapers were analysed with regard to the authors' position on brain death and transplantation law, their qualification, intention, and mode of presentation.  Results. Annually, about 70 deaths occurred on the department's intensive care unit of which almost 30% of the patients were determined to have suffered brain death without any obvious contraindications against organ donation. The refusal rate of relatives rose from 56% up to 78%, and the rate of organ donors thus decreased from 5% in 1994 to 4% presently in the department. About 100 reports were published each year in the analysed newspapers, of which about 90% voiced approval of organ transplantation. During the review period, the depiction became more objective (57% in 1994 to 82% in 1997) and the suspicious attitude toward the technique of brain death diagnosis declined. Whereas 50% of the articles rejected the brain death concept in 1994, this figure decreased to 39% in 1997 and conversely the concept of consent rose from 33% in 1994 to 56% in 1997.  Conclusion. In Germany, the relatives refusal rate in organ donation is continuously high, presumable due to a depressing 39% of press reports rejecting the brain death concept, and resulting in a very low number of organ donations. There is hope that the transplantation law which has finally passed German parliament in 1997, confirming the brain death concept as well as the legal principle of prior consent by the donor or consent by the relatives will eventually result in an increase of organ donation especially when supported by an educational campaign which is embodied in the transplantation law.     

Medical treatment of primary sclerosing cholangitis

Until 1970, primary sclerosing cholangitis (PSC) was considered to be a medical curiosity. With the development of endoscopic cholangiography, PSC is now recognized more frequently and is a common indication for liver transplantation. PSC is usually progressive, leading to cirrhosis, portal hypertension, and liver failure. The manifestations of disease may be clinically similar to those of other causes of bile duct obstruction and must be distinguished from gallstone disease, bile duct carcinoma, primary biliary cirrhosis, and secondary biliary cirrhosis due to bile duct stricture. Medical management of PSC must take into account the likelihood that destroyed bile ducts do not regenerate as hepatocytes do. Hence, PSC should be treated early in its course. The goal of therapy is to prevent further damage and destruction of bile ducts. In this article, we will present relevant data concerning the medical management of primary sclerosing cholangitis. Received for publication on March 8, 1999; accepted on April 5, 1999     

Recent status of primary sclerosing cholangitis in Japan

Patients with primary sclerosing cholangitis (PSC) in Japan have two peaks in age distribution, one in their twenties and the other in their fifties and sixties. PSC patients in Japan have different characteristics from those in other countries: there is a higher incidence of eosinophilia (27%) and positivity for anti-nuclear antibody (30%), less frequent complication with inflammatory bowel diseases (IBD; 21%), and more frequent complication with chronic pancreatitis (15%). In younger patients in Japan (those aged less than 40 years), the incidence of positivity for anti-nuclear antibody was lower (20% vs 38% P < 0.05), complication with IBD was more frequent (39% vs 9% P < 0.01), complication with chronic pancreatitis was less frequent (4% vs 22% P < 0.01), and damage to both the intra- and extrahepatic bile ducts was more frequent (89% vs 56% P < 0.01) than in older patients (those aged 40 years or more). These findings suggest that younger PSC patients in Japan have characteristics similar to those of patients in other countries, and that in Japan older PSC patients have a different pathogenesis from that of younger patients. Received for publication on Feb. 16, 1999; accepted on April 5, 1999     

c-Jun expression after axotomy of corneal trigeminal ganglion neurons is dependent on the site of injury

The proto-oncogene c-Jun has been implicated in the control of neuronal responses to injury and in axonal growth during regenerative processes. We have investigated the expression of c-Jun during normal terminal remodelling in trigeminal ganglion neurons innervating the cornea and after acute injury of epithelial nerve terminals or parent axons. Remodelling and rearrangement, or damage limited to corneal epithelium endings, was not a trigger for activation of c-Jun expression. However, injury of parent axons in the stroma or in the orbital ciliary nerves induced c-Jun expression in 50% of the population of corneal neurons, which included all of the large myelinated and 20% of the small neuropeptide-containing corneal neurons. This suggests that c-Jun expression in trigeminal ganglion neurons is not associated with normal remodelling or regeneration of peripheral nerve terminals, and that it takes place only when parent axons are injured. A substantial number of damaged neurons do not express c-Jun, indicating that in primary sensory neurons, injury and regeneration may not always be coupled to the expression of this proto-oncogene.     

Designing an intervention to prevent suicide: PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial)

Suicide is a major public health problem with greatest risk in the very old. This paper describes an approach to reducing the risk of suicide by intervening on depression in elderly primary care patients. Depression is an appropriate target for an intervention as it is highly prevalent in primary care, is a strong risk factor for suicide, and is more often than not inadequately treated. PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) is a National institute of Mental Health (NIMH)-funded collaborative study that is testing this approach to suicide risk prevention in 18 primary care practices in the United States. PROSPECT'S intervention of "guideline management" introduces a health specialist into the primary care setting to help physicians provide "on-time, on-target" treatment and long-term management of late-life depression following structured clinical guidelines. The effectiveness of the intervention in reducing suicidal risk and depression is evaluated by following a representative sample of older patients identified using a 2-stage design.     

Termination of extracorporeal membrane oxygenation for cardiac support

The determination of when to stop extracorporeal membrane oxygenation (ECMO) rests upon demonstration of the return of adequate cardiac function to support vital organs and permit subsequent recovery. In general, patients with myocardial stun will recover function within several days. Factors that limit recovery include elevated end diastolic pressures leading to marginal myocardial perfusion, ongoing organ damage, massive anasarca, or progressive deterioration in lung function. Following a trial of slow weaning of ECMO support to condition the heart to take over the entire system flow requirements, decannulation can be accomplished in a standard fashion. When weaning is not successful and additional time does not lead to adequate recovery of cardiac function, physicians and nurses must be prepare to realistically advise families regarding such options as cardiac transplantation or withdrawal of support. It is critically important to provide an open and nonjudgmental environment for families to make these difficult decisions. The greatest difficulties involve ethical and emotional decisions that need to be made in a timely fashion to prevent undo burden on the patient when further ECMO support is futile.     

Interactive technology applications for behavioral counseling: issues and opportunities for health care settings

CONTENT: This article discusses the rationale for, and the potential benefits and limitations of, computer-based interactive health communication (IHC) programs for health behavior counseling. We describe common barriers to health behavior counseling in medical settings and show how IHCs can address these issues. Following an overview of current and likely near-future IHCs, the potential impact of IHCs on the patient-provider relationship is considered. Results from evaluations of IHCs are summarized and important and unique issues in evaluating IHCs are discussed. We conclude with recommendations for clinical applications, including recommendations for consumers considering purchase or adoption of IHCs and recommendations for future research.     

Pilot study of a visitor volunteer programme for community elderly people receiving home health care

There is a need to evaluate community support programmes for elderly people. In this randomized control trial (RCT), we determined the effectiveness of 'friendly visitors' in a volunteer programme of a visiting nurses organization in Southern Ontario, Canada. The Volunteer Friendly Visitor Programme was developed to support elderly people receiving homemaking and nursing care in the community. Volunteers are screened, trained, interviewed and matched to homebound elderly clients for general interest, visit expectations and personality. Volunteers spend three to four hours on average per week with clients socializing in mutually agreed-upon ways. The nursing staff identified clients who were lonely for this additional support. These newly-referred clients were randomly allocated to receive a friendly visitor or not for six weeks. Those receiving the volunteer visitor improved in life satisfaction and two social support measures: worth and social integration. Thus, the addition of volunteer visitors to planned homemaking and nursing care made a difference for elderly in the community.