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.     

Cavernous Haemangiomas of the Spinal Cord. A Review of 117 Cases

 The data of 48 studies (published between 1903 and 1996), presenting information of all together 107 patients (108 lesions) regarding pre-treatment clinical and radiological factors, treatment strategies, and the outcome, plus our own experience of nine patients were retrospectively re-analyzed. The prognostic influence of pre-treatment factors was estimated with the chi-square statistics. Clinical evaluation before/after treatment was performed using the Frankel scale. The average bleeding rate was obtained from the ratio of percentage of first bleeding events in the population to the mean age of the population.  There were 47 males and 69 females (aged from twelve to 88 years). Thirty nine percent of the lesions were found in the cervical, 54% in the thoracic (30% upper, 24% lower) and 7% in the lumbar cord. The peak age of presentation was in the fourth decade, the median duration of symptoms was 32 months. Clinical symptoms before treatment were progressive in all cases. Three patterns of clinical presentation could be identified: a) episodes of stepwise clinical deterioration (30%), b) slow progression of neurological decline (41%), c) acute onset with rapid or gradual decline over weeks or months (26%). 58% of the lesions showed clinical or radiological signs of haemorrhage. In 66% of surgical patients (91 efficiently documented cases), clinical improvement was achieved, 28% remained unchanged and 6% deteriorated. Whereas age, sex and lesion location had no influence on the results, duration of symptoms (<three years) correlated significantly to a better outcome (p<0.02).  Surgical management in symptomatic patients is recommended. Once clinical signs caused by the malformation have appeared, the patients tend to experience progressive neurological deterioration.     

Quality-of-Life Outcome After Laparoscopic Adjustable Gastric Banding for Morbid Obesity

Background: The definition of success and failure of a bariatric procedure should include weight loss as well as improvement of comorbidity and quality-of-life (QoL) assessment. QoL measures changes in physical, functional, mental, and social health in order to evaluate benefits of new programs and interventions. Material and Methods: From April 1995 until March 1999, 287 patients underwent laparoscopic adjustable silicone gastric banding (LASGB) at Northwest Hospital Frankfurt a.M. (Germany). In this study, 100 of 287 patients (preoperative mean BMI 48.3 kg/m²; mean age 35.2 years) with a follow-up >18 month were evaluated. All patients underwent anonymous questionnaire (26 questions with a maximum score of 60) about different aspects of QoL outcome after LSAGB. Results: In this study, 4 of 100 patients refused to give an answer to the QoL questions. Therefore 96 patients were evaluated. The QoL auto-evaluation of the patients shows that QoL generally improved after surgery in 92%. Using the scoring system, 44% of patients have excellent, 52% good, and only 4% bad results. The 4 patients who refused had to be classified as failure. General acceptance of LSAGB is wide, but gastrointestinal side effects are recognizable in more than 78% of operated patients. Successful weight loss is followed by an improvement of comorbidities. Conclusions: Safe, effective bariatric procedures increase the quality of life in morbidly obese patients markedly. Bariatric surgeons are committed to support and help their patients until they reach a new quality of life after obesity surgery.     

Neuropsychological outcome after traumatic temporal lobe damage

Summary The most frequent sequelae after severe brain injury include changes in personality traits, disturbances of emotional behaviour and impairment of cognitive functions. In particular, emotional changes and/or verbal and non verbal dysfunctions were found in patients with bilateral or unilateral temporal lobe lesions. The aim of our study is to correlate the localization of the brain damage after severe brain injury, in particular of the temporal lobe, with the cognitive impairment and the emotional and behavioural changes resulting from these lesions.The patients with right temporal lobe lesions showed significantly better scores in verbal intelligence and verbal memory in comparison with patients with left temporal lobe lesions and those with other focal brain lesions or diffuse brain damage. In contradistinction, study of the personality and the emotional changes (MMPI and FAF) failed to demonstrate pathological scores in the 3 groups with different CT lesions, without any significant difference being found between the groups with temporal lesions and those with other focal brain lesions or diffuse brain damage.The severity of the brain injury and the prolongation of the disturbance of consciousness could, in our patients, account for prevalence of congnitive impairment on personality and emotional changes.     

体外受精胚胎移植后妊娠结局分析

目的　探讨通过体外受精 -胚胎移植妊娠妇女的妊娠结局。方法　对自 2 0 0 0年 9月～ 2 0 0 2年1 1月在我院实施IVF -ET的 75例患者 ,80个妊娠周期的临床资料进行回顾性分析。结果　 80个周期中 ,宫内妊娠率 96 2 5 % (77/ 80 ) ,其中自然流产率 2 3 75 % (1 9/ 80 ) ;妊娠 <1 6周流产率 1 6 2 5 % (1 3/ 80 ) ;妊娠 >1 6周流产率 7 5 0 % (6 / 80 ) ,其中 5周期均发生双胎妊娠 ;分娩率 72 5 0 % (5 8/ 80 ) ,早产率 1 5 0 0 % (1 2 / 80 ) ,宫外孕发生率 3 75 % (3/ 80 )。新生儿死亡率 3 6 1 % (3/ 83) ,均死于三胎妊娠早产。结论　减少IVF -ET后多胎妊娠率 ,加强多胎妊娠的整个孕期监护 ,以利于减少多胎妊娠 >1 6周流产率及早产率 ,是降低IVF -ET后妊娠胎儿丢失的有效方法     

Extreme hyperbilirubinaemia in Zimbabwean neonates: neurodevelopmental outcome at 4 months

As part of a prospective study of severely jaundiced Zimbabwean infants, the relationship between maximum total serum bilirubin (TSB) concentration in the neonatal period and neurodevelopmental outcome at the corrected age of 4 months was studied. Fifty infants with a TSB of >400 μmol/l (23.4 mg/dl) were enrolled and screened with a neonatal neurological examination (NNE). The cause of jaundice was low birth weight in 22 (44%), ABO incomptability in 8 (16%), sepsis in 8 (16%) and congenital syphilis (6%) in 3 infants. In 9 infants a cause could not be determined. At 4 months, 2 infants had died and 3 were lost to follow up, leaving 45 infants for the infant motor screen (IMS) at 4 months of age. Mean TSB in the neonatal period was 485 μmol/l (28.2 mg/dl), and 7 infants received an exchange transfusion. Mean TSB of the infants with an exchange transfusion was 637 μmol/l (37.2 mg/dl) (range 429–865 μmol/l (25–50.3 mg/dl)) and of the infants without transfusion 459 μmol/l (26.8 mg/dl) (range 400–740 μmol/l (23.4–43 mg/dl)) (P < 0.0001). The TSB was not associated with birth weight, gestational age, gender or head circumference of the baby. On the IMS, 6 of 45 (13.3%) infants scored abnormal, 6 (13.3%) suspect and 33 (73%) scored normal. Three of the six (50%) remaining infants who received an exchange transfusion scored abnormal on the IMS while only 3 of the 39 (8%) infants without exchange transfusion were abnormal. Conclusion More than 25% of infants with a TSB of >400 μmol/l (23.4 mg/dl) scored abnormal or suspect at 4 months of age and half of these infants already showed irreversible neurological symptoms. All infants who scored abnormal or suspect on the IMS with bilirubin levels between 400 and 500 μmol/l (23.4 and 29.2 mg/dl) had haemolytic disease or were premature. Received: 4 October 1996 / Accepted: 5 February 1997     

Evaluation of neurodevelopmental outcome in highrisk infants in Australia

An understanding of the neurodevelopmental outcome of long-term survivors of neonatal intensive care is essential for the informed management of preterm or high risk infants. This annotation looks at the current status of neonatal follow-up services in Australasia and highlights problems in the collection and interpretation of data. It suggests that we should work towards achieving a consensus on standard definitions and test regimes and on national data collection.     

糖尿病合并妊娠伴视网膜病变孕妇的临床观察

目的：研究糖尿病合并妊娠伴视网膜病变孕妇的妊娠结局及孕期视网膜病变。方法：回顾性分析１９８１～１９９５年间４９例糖尿病孕妇妊娠情况。伴视网膜病变的１６例分为第Ⅰ组；无视网膜病变的３３例分为第Ⅱ组。第Ⅰ组糖尿病病程平均为８．９２±４．３５年；第Ⅱ组为３．１１±１．７４年。结果：第Ⅰ组孕妇并发症及围产儿发病率较高，但两组比较，差异无显著性（Ｐ＞０．０５）。３１．１％孕妇视网膜病变在孕期加重，但仍属单纯型（背景期）。结论：糖尿病合并妊娠伴眼底病变时，仍可以继续妊娠，但孕期应密切观察眼底变化和严格控制血糖。     

Outcome of fetuses with heart disease diagnosed in utero

OBJECTIVE—To review the outcomes of 193 fetuses with cardiac abnormalities detected by echocardiography.METHODS—A total of 422 fetuses between 16 and 41 gestational weeks, referred to paediatric cardiologists for detailed echocardiography, were included in this study.RESULTS—Structural heart defects were found in 55 (28%), isolated arrhythmia in 105 (54%), and other non-structural abnormalities (dilated cardiomyopathy, hypertrophic cardiomyopathy, aneurysm of the foramen ovale, isolated pericardial effusion or echogenic foci) in 33 (17%) of 193 fetuses. Total mortality was 26%. The prognosis was poor in fetuses with structural heart defects; 37 of 55 cases (67%) died in utero or postnatally. Chromosomal abnormality was associated with structural heart defect in 38% of fetuses, of whom 38% died. Among fetuses with isolated arrhythmia survival was 95%. Poor outcome was associated with complete heart block (n=14) in 2 (14%) fetuses with hydrops and heart rate of less than 55 per minute, and with supraventricular tachycardia (n=21) in three (14%) neonates delivered prematurely at a mean gestational age of 33 weeks. Furthermore, nine of 12 fetuses (75%) with structural heart defects and arrhythmia died. Among fetuses with non-structural cardiac abnormalities, survival was 73%. Poor outcome was evident in fetuses with dilated cardiomyopathy in eight of 13 (62%) and with hypertrophic cardiomyopathy in one of eight (13%) of cases.CONCLUSIONS—Factors associated with a poor prognosis were: structural heart defect associated with chromosomal abnormality or arrhythmia, congestive heart failure associated with supraventricular tachycardia or complete heart block, especially if delivery occurs preterm; and fetal hydrops with congestive heart failure and atrioventricular valve regurgitation.