Experience with clozapine in a community mental health care setting

BACKGROUND: Clozapine has been heralded as the first major breakthrough in antipsychotic drug therapy for treatment-resistant schizophrenia in 40 years. This study reports on the experience with clozapine in an outpatient, community mental health care setting. METHODS: All clinic patients receiving clozapine during the 4-year period 1992 to 1996 were retrospectively studied. Measures of improvement were changes in the Clinical Global Improvement (CGI) Scale and reduction in the number of hospital days after clozapine therapy. RESULTS: Testing with the CGI scale showed moderate or marked improvement in 63% of patients. Hospital days dropped from 7,919 to 1,833 for comparable time periods. Clozapine therapy had to be discontinued in only 21% of patients, and no serious side-effects occurred. CONCLUSION: Clozapine is an effective medication for treatment-resistant schizophrenia and can be safely used in chronic mental illness. Although the drug is expensive, the cost is offset by a remarkable reduction in hospital days.     

The compatibility of the retail setting with a patient-based practice model: reports from community pharmacists

The patient counselling and prospective drug utilization review mandates of the Omnibus Budget Reconciliation Act of 1990 raise the question of how compatible the retail pharmacy setting in the United States is with a patient-based model of pharmacy practice. In order to investigate this question, a self-administered questionnaire was distributed by pharmacy students to a convenience sample of pharmacists with at least one year's experience in the community setting. The questionnaire asks respondents to recall two incidents: one that caused them to gain or retain a patient or that was for some reason a source of professional satisfaction, and one that may have caused the loss of a patient or that they would handle differently if faced with the situation or problem again. The respondents practice in pharmacies in and around a large midwestern city. Data analysis showed that respondents tend to identify patient-based activities when recalling appropriate behaviours and traditional or customer-based activities when recalling inappropriate behaviours or mistakes. Patient-based activities can sometimes result in the loss of business, but they can also result in patronage gains, especially when performed in conjunction with good customer service. In summary, these pharmacists do implement a patient-based model in some situations. The patient-based and customer-based models can be complementary in that the patient can benefit from the services of an expert health professional while simultaneously being treated with the respect and 'customer knows best' attitudes indicative of the retail setting.     

Community-family network therapy in a rural setting

A model of family intervention with extended family members and significant community agency people is presented in an attempt to deal with the total social network surrounding a seriously dysfunctional family. They describe how this approach adapts itself well to a rural setting and seems to encompass most if not all of the significant helping systems in the family social sphere. The roles of the various team members are carefully outlined and the process of the therapeutic meeting is described. The authors believe that this approach has a facilitative effect to increase the functionality of already existing natural social systems on which the families are already quite dependent, but which prior to the network sessions were largely nonfunctional. The effect of all of this is to reduce drastically the amount of wasted time, energy, and effort that occurs when all the significant persons and agencies in the psychosocial sphere of a family are not working together in a coordinated manner.     

Fine needle aspiration cytology in a rural setting

OBJECTIVE: To compare, contrast and analyze the value and limitations of fine needle aspiration (FNA) cytology and core biopsy (CB) in a rural setting. STUDY DESIGN: Retrospective analysis of 100 FNA cytology and 100 CB results of mass lesions from 193 patients matched for age, sex and body organs, and referred for FNA or CB in rural New South Wales, Australia, between September 1990 and May 1996. RESULTS: FNA cytology and CB results from 193 patients were analyzed, based on anatomic location and cytologic criteria. Sites included lung, retroperitoneum, liver, breast, kidney, pancreas and ovary. The FNA group contained 6 inadequate, 14 benign, 3 atypical, 6 suspicious and 71 malignant cases, whereas the CB group had 1 inadequate, 24 benign and 75 malignant conditions. The inadequate samples in both groups were due to technical difficulty in obtaining representative material. The indeterminate (atypical and suspicious) group, which was the main pitfall of FNA, contained 4 low grade carcinomas, 3 low grade non-Hodgkin's lymphomas and 2 fibrocystic breast changes. The benign FNA group comprised 8 cysts, 5 inflammatory/reactive conditions and 1 benign tumor/hamartoma, whereas the benign CB group contained 11 cysts, 9 inflammatory/reactive conditions and 4 benign tumors. CONCLUSION: FNA was comparable to CB at most anatomic sites. CB occasionally offered additional information. This slight advantage was due to the availability of tissue from the first and often the only pass for assessment of architecture and performance of ancillary tests, which obviated the need for further sampling. On-site assessment of the core imprints at the time of the procedure by the highly skilled and experienced interventional cytopathologist was responsible for limiting the number of attempts to one core in most of the instances, therefore minimizing complications. Pathologists are encouraged to become more familiar with the criteria of aspiration cytology, which has proven its validity in the new cost-conscious environment. Despite the recent surge in the popularity of core biopsy, FNA cytology, when practiced in a multidisciplinary setting, with involvement of pathologists, radiologists and clinicians, is an extremely accurate test with very high sensitivity, which approaches that of surgical pathology, and specificity very similar to that of frozen section. FNA has a positive predictive value for a malignant diagnosis of almost 100%. FNA is a well-tolerated, relatively noninvasive test with a very low risk of complications.     

An assessment of care provided by a public sector STD clinic in Cape Town

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.     

Interviews as catalysts in a community setting.

Examined the effects of interviews about community experience on subsequent attitudes and behavior of adult residents in 2 new condominium communities. Volunteer (23 households) and randomly selected experimental (17 households) groups of respondents were interviewed in their homes. Questionnaires about community experience were administered shortly after the interviews (at 1 condominium) and 6 mo later (at both), and observers rated the activism of community leaders during the interim. Interviewed respondents gave less socially desirable and more extreme responses to the first questionnaire, reported more involvement in the community, and were rated more active in community affairs than uninterviewed controls (103 households). The dynamics of interviews as catalytic events are considered, and the implications of these findings for future use of interviews are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quality of life assessment by community pharmacists: an exploratory study

MtDNA sequencing was used to investigate the genetic population structure of Litoria pearsoniana, a wet forest-restricted hylid frog, endemic to southeast Queensland and northeast New South Wales, Australia. L. pearsoniana is regarded as endangered under Queensland legislation. Significant genetic divergence among populations of frogs from different rainforest isolates was identified, but the lack of reciprocal monophyly among adjacent isolates suggests this is the result of a relatively recent disruption to gene flow. A paired catchment study within a single rainforest isolate, the Conondale Range, revealed no substantial genetic structuring, indicating the occurrence of terrestrial dispersal among nearby streams either in the recent past or currently. Two major reciprocally monophyletic clades of mtDNA alleles were identified. These corresponded to two geographical regions separated by the Brisbane River valley; one consisting of the Conondale and D'Aguilar Ranges, and the other of the southern isolates in the Main, Border and Gibraltar Ranges. Sequence divergence between the two regions was more consistent with a late Miocene or Pliocene rather than late Pleistocene separation, and is similar to that found among phylogeographic divisions of rainforest reptiles and amphibians in north Queensland rainforests. The molecular evidence for long-term separation of these two regions is corroborated by the pattern of species turnover in the distributions of species of rainforest-restricted amphibians and reptiles. Bioclimatic modelling suggests that appropriate conditions for L. pearsoniana would have been restricted to isolated refugees in each phylogeographic division under cooler and drier climates, such as predicted for the last glacial maximum. Currently isolated montane areas may have been connected transiently during the past 2000 years. Identification of long-term zoogeographic divisions among southeast Queensland rainforest herpetofauna has important implications for conservation and management. Conservation management of L. pearsoniana should be applied at the scale of major rainforest isolates and the conservation status of the species should be assessed independently north and south of the historical division.     

Preventability of infant mortality in a rural community

Preventability of infant mortality in a rural southern county was examined with a Delphi technique using case summaries of infant deaths during a selected four-year period. The first two rounds were aimed at developing a consensus of panelists' opinions about problems leading to the high infant mortality rate in the study area. From these opinions, an Infant Mortality Preventability Decision Tree and a Problem List was developed. Panelists used these in Rounds III and IV to evaluate the case summaries. There were significant differences in the preventability ratings between physicians and nurses, indicating the importance of assessing individuals' philosophies of preventability when working with an interdisciplinary team of health care providers.     

Member ratings of health care provided by 48 physician groups

BACKGROUND: Satisfaction with health plan performance has been assessed frequently, but assessment of physician group performance is rare. OBJECTIVE: To present ratings of the care provided by physician groups to enrollees in a variety of capitated health maintenance organization plans. METHODS: A random sample was drawn of adult enrollees receiving managed health care from 48 physician groups in a group practice association. Each individual in the sample was mailed a 12-page questionnaire and 7093 were returned (59% response rate). The mean age of those returning the questionnaire was 51 years; 65% were women. RESULTS: Reliability estimates for 6 multi-item satisfaction scales were excellent, and noteworthy differences in ratings among groups were observed. In particular, ratings of overall quality ranged from a low of 28 to a high of 68 (mean, 50; SD, 10). Average scores for physician groups were strongly correlated across all scales, but no single group scored consistently highest or lowest on the different scales. Negative ratings of care were significantly related to the following: intention to switch to another physician group, difficulty in getting appointments, lengthy waiting periods in the reception area and examination room, the inability to get consistent care from one physician for routine visits, and not being informed by the office staff when there was a delay in seeing the primary care provider. CONCLUSIONS: Monitoring of health care quality at the physician group level is possible, and could be used for benchmarking, internal quality improvement, and for providing information to the public about how these physician groups will meet its needs.     

A rural vision of a healthy community

The planimetric Z-plasty proposed by Roggendorf provides elongation by excision of a pair of triangular pieces of tissue. The application of planimetric Z-plasties has been modified by making the vertical angle flexible, and making them continuous in the same or in opposite directions. Continuous planimetric Z-plasties in the same direction elongate an oblique contracture in the longitudinal direction. Continuous planimetric Z-plasties in an alternative direction elongate a disproportioned scar contracture in the longitudinal direction. Both techniques partially reduce unsightly scarring. Furthermore, they can be used in combination with V-Y-plasties. These modifications permit rational planing of the treatment of complicated scars with contracture.     

Preschool children of battered women identified in a community setting

This study describes and compares health, developmental, and behavioral manifestations of witnessing domestic violence in a health department population of preschool children (n = 15) of women detected to be battered (Conflict Tactics Scale [CTS], Straus, 1979). Comparisons included a community sample of the preschool children of nonbattered women (n = 62) to study the effect of mothers being battered, and a shelter sample of the preschool children of battered women (n = 53) to study the effect of "sheltering" on children's characteristics. Instrumentation included behavioral subscales, physical assessment, Denver II Developmental Screening, hemoglobin and lead levels, immunization, and nonmotor vehicle accident histories. Results showed more similarities between children of community (nonsheltered), battered and nonbattered women, but showed more differences between the children of community (nonsheltered) battered women and the children of sheltered, battered women. Battering intensity of the women was more severe in the shelter sample according to the CTS (p < .001), and more abnormal findings in their children were detected than in the community sample. When children of community (nonsheltered), battered women (n = 15) and children of sheltered, battered women (n = 53) were included in discriminant analysis of demographic characteristics, health status, and psychosocial variables, 87% of each group was classified correctly.     

Identifying patients with depression in the primary care setting: a more efficient method

OBJECTIVE: To determine if there is a core subset of depressive symptoms that could be used to efficiently diagnose depression after administering the 2-item PRIME-MD a screening questionnaire for depression. METHODS: One thousand patients selected randomly and by convenience from 4 primary care clinics were assessed by PRIME-MD and completed a questionnaire measuring the following validation variables: functional status and well-being, disability days, somatic symptoms, depression severity, suicidal thoughts, health care utilization, and the physician-patient relationship. RESULTS: Four symptoms (sleep disturbance, anhedonia, low self-esteem, and decreased appetite) accounted for virtually all the depression symptom-related variance in functional status and well-being, with 8.3% of patients having 2 of these symptoms and 8.2% having 3 or 4 of these symptoms. There was excellent agreement between diagnosis based on core symptoms and major depression (K= 0.77; overall accuracy rate, 94%). There were significant differences (P<.001) among patients with negative depression screen, 0 to 1, 2, and 3 to 4 core symptoms with scores on each of the validation variables getting progressively worse in these 4 groups. A cutoff point of 2 core symptoms identified all but 3 patients with major depression and an additional 5% of the entire sample without major depression who were significantly (P<.05) worse than patients without depression on each of the validation variables. CONCLUSION: A strategy that includes the use of a 2-item depression screener followed by the evaluation of 4 core depressive symptoms is an efficient and effective way of identifying and classifying primary care patients with depression in need of clinical attention.     

Health care needs in a nontraditional university setting

This paper describes early planning stages of a nurse-managed clinic to offer primary health care services in a nontraditional university setting. A community needs assessment was conducted with quantitative and qualitative findings reported. This unique setting triggered a number of considerations in planning for services. Recommendations for health services and resources for the university community are discussed.