Predicting successful completion of an aftercare program following treatment for alcoholism: The role of dispositional optimism.

In this study we investigated several variables as potential predictors of success in completing a transition program after treatment for alcoholism. Subjects were 54 men who had completed a 30-day treatment program and who were subsequently admitted to a 90-day inpatient aftercare program. The outcome measure was successful completion of this latter program. Predictor variables were dispositional optimism, hassles, uplifts, and several demographic variables. Optimism was positively associated with successful outcome. The simple association between uplifts and outcome also approached significance, but in the opposite to expected direction. Discriminant analyses used both of these variables, as well as age and education level, as predictors of successful outcome. There was no evidence of a role for hassles. Discussion centers on the importance of dispositional optimism as a predictor of successful adaptation in a variety of behavioral domains. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients with low back pain not returning to work. A 12-month follow-up study

STUDY DESIGN: A prospective study of patients treated with a light mobilization program for long-term low back pain. OBJECTIVES: To examine whether medical, psychological, or social factors predict failure to return to work within 12 months in the Scandinavian system of compulsory workers' compensation and social insurance, after a light mobilization program administered 8-12 weeks after initial sick leave. SUMMARY OF BACKGROUND DATA: The relative power of predicting factors varies in previous work, and there are no previous data on prognostic factors for light mobilization programs. METHOD: Patients (n = 260) on sick leave for 8-12 weeks for low back pain were examined with a battery of psychological and medical tests, before entering a light mobilization program. The treatment was given regardless of radiographic or clinical findings. The patients were encouraged to be active participants in the management and prevention of their back pain. Their sick leave status then was checked through registers 12 months after they had entered the treatment program. RESULTS: For those not returning to work within 12 months (23%), only combined models had acceptable predictive power (77%; discriminant analyses). Dominant variables were low Internal Health Locus of Control Score, restricted lateral mobility, and reduced work ability. The predictive value of each set of variables, taken alone, was significant only for medical variables (67% correct prediction). CONCLUSIONS: The final discriminant function may have potential as a brief screening instrument for the number of patients with low back pain who do not benefit from the light mobilization program.     

Cost-effectiveness of inpatient substance abuse treatment

OBJECTIVE: To identify the characteristics of cost-effective inpatient substance abuse treatment programs. DATA SOURCES/STUDY SETTING: A survey of program directors and cost and discharge data for study of 38,863 patients treated in 98 Veterans Affairs treatment programs. STUDY DESIGN: We used random-effects regression to find the effect of program and patient characteristics on cost and readmission rates. A treatment was defined as successful if the patient was not readmitted for psychiatric or substance abuse care within six months. PRINCIPAL FINDINGS: Treatment was more expensive when the program was smaller, or had a longer intended length of stay (LOS) or a higher ratio of staff to patients. Readmission was less likely when the program was smaller or had longer intended LOS; the staff to patient ratio had no significant effect. The average treatment cost $3,754 with a 75.0% chance of being effective, a cost-effectiveness ratio of $5,007 per treatment success. A 28-day treatment program was $860 more costly and 3.3% more effective than a 21-day program, an incremental cost-effectiveness of $26,450 per treatment success. Patient characteristics did not affect readmission rates in the same way they affected costs. Patients with a history of prior treatment were more likely to be readmitted but their subsequent stays were less costly. CONCLUSIONS: A 21-day limit on intended LOS would increase the cost-effectiveness of treatment programs. Consolidation of small programs would reduce cost, but would also reduce access to treatment. Reduction of the staff to patient ratio would increase the cost-effectiveness of the most intensively staffed programs.     

Day hospital/crisis respite care versus inpatient care, Part II: Service utilization and costs

OBJECTIVE: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. METHOD: The patients (N = 197) were randomly assigned to one of the two programs and followed for 10 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient, day hospital, and outpatient services provided by the CMHC. RESULTS: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was +7,100, or roughly 20% of the total direct costs. There were no significant differences between programs in service utilization or costs during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staff and capital costs but significantly different operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). CONCLUSIONS: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital's relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care.     

Completion and subject loss within an intensive hepatitis vaccination intervention among homeless adults: The role of risk factors, demographics, and psychosocial variables.

Objective: Unprotected sexual behavior, needle sharing, and a prison history are major correlates of hepatitis B Virus (HBV). These risk factors are common among homeless people who also have elevated rates of HBV. We examine whether these behaviors were associated with completion or loss to follow-up of the most intensive and successful condition of a 3-arm HBV vaccination intervention. Significant results would imply that those most in need are the least compliant. Contributions of baseline demographics, physical health, psychosocial variables, and health beliefs were also assessed. Design: Three-hundred thirty- one adults from Los Angeles' Skid Row were assigned to nurse-case-managed sessions with hepatitis education, incentives, and tracking. Successive predictive structural equation models assessed the amount of variance accounted for by the risk variables, demographics, and the health-related variables. Main Outcome Measures: (1) Completion of 3 injections by 6 months; and (2) loss to a 6-month follow-up questionnaire. Results: The 3 risk factors explained 2% of the variance in completion and 1% of the variance in loss. Adding the other variables increased the variance explained to 14% for completion and 13% for loss. African American ethnicity, positive coping, social support, poorer health, no prison history, and greater efficacy significantly predicted completion. White ethnicity, less social support, better health, and less intention to complete predicted participant loss. Conclusion: The program was not strongly rejected differentially as a function of preexisting hepatitis B risk behaviors. Programs designed for homeless people should include malleable psychosocial and health belief model variables. These aspects of the lives of homeless people provide leverage points for future interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Can it be predicted which patients with chronic low back pain should be offered tertiary rehabilitation in a functional restoration program? A search for demographic, socioeconomic, and physical predictors

STUDY DESIGN: A prospective clinical trial was conducted that involved six groups of patients with chronic low back pain selected from a large cohort (N = 816). OBJECTIVES: To correlate pretreatment baseline variables with outcome parameters after treatment in a functional restoration program or in control programs, to identify possible factors predictive of the need for functional restoration. SUMMARY OF BACKGROUND DATA: Since the functional restoration program was first described, research has focused on identifying patients who will or will not benefit from such a program. The value of previous studies is limited, however, because predictive factors from a control group were not "subtracted." METHODS: Eight hundred sixteen patients with chronic low back disability were included. All had a structured medical examination, including various physical tests before participation in either a functional restoration program (n = 621) or shorter "control" outpatient programs (n = 144). A smaller group of the cohort (n = 51) had no treatment and served as a pure control group. Six groups were selected from the cohort: Three underwent an identical functional restoration program and three underwent different outpatient control programs. Several baseline demographic, physical, and socioeconomic variables were correlated to 1-year outcome parameters. RESULTS: Age, days of sick leave, connection to the work force, and back pain intensity, were significantly correlated to success 1 year after entry into the study in all groups, no matter what kind of treatment was administered. Back muscle endurance, sports activity, activity of daily living scores, and vibrations were of importance in some outcome parameters for success after functional restoration. Smoking was positively correlated to disability pension. Days of sick leave and, in functional restoration, ability to work were the only factors that were correlative with statistics for people who withdrew. CONCLUSIONS: Different factors can be identified as predictive of outcome in a functional restoration program, but most of these factors were also shown to predict success for shorter control outpatient programs or of no treatment.     

Outcome of multimodal day treatment for children with severe behavior problems: a five-year follow-up

OBJECTIVE: To evaluate the long-term outcome of a multimodal day treatment program for children with severe behavior problems and to identify factors that may predict a positive outcome. METHOD: Thirty-three children who completed a day treatment program were assessed using a prospective, single-cohort design tested at intake, discharge, and 5-year follow-up. The child's functioning was assessed using the Revised Child Behavior Profile (RCBP), Hare Self-Esteem Scale, Depression Self-Rating Scale, Hopelessness Scale for Children, Index of Peer Relations, and a 5-point ordinal scale for scholastic reintegration. RESULTS: Repeated-measures analyses of variance showed that improvement was maintained on all measures between intake and 5-year follow-up. A stepwise multiple regression showed that 92% of the adjusted variance in the behavioral functioning of the children at 5-year follow-up, as assessed by the RCBP, was explained by parental cooperation, initial RCBP total and externalizing scores, and history of problem pregnancy. CONCLUSIONS: Children who were admitted to a day treatment setting appear to function well globally, even 5 years after discharge. Parental cooperation was the most important variable in predicting positive outcome.     

GRE predictive validity in a Master's program in clinical psychology.

Presents predictive validity data for GRE scores collected in the Master's program in clinical psychology at Acadia University. The program typically admits 4 or 5 students per year, and the current sample consists of 37 students (29 females, 8 males) who have completed their 2-yr residency requirement in the program over the past 10 years. Upon application, 12 of the admitted students did not provided GRE scores, and of the other 25, 4 did not write the Advanced test in psychology. Cumulative undergraduate 4-point GPAs and 4 GRE scores were used as predictors, and these means are lower than would be found in PhD graduate programs in larger schools or PhD-level programs. Outcome variables were whether students were accepted into a PhD program; external awards; graduating on time; and thesis publication. A series of t-tests were conducted to examine which predictors discriminated between outcome variables. Results show that GRE scores were highly predictive of a range of outcome variables in the Acadia Master's program where there is a higher degree of variability in predictors. The importance of how GRE scores are used in combination with other predictors is noted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Some characteristics of effective psychiatric treatment programs.

Describes a VA cooperative study seeking to identify the ward milieu characteristics of effective psychiatric programs. It is the largest study undertaken so far in terms of number of programs (79), patients (21,667), characteristics examined (191), and adequacy of outcome measures used to estimate program effectiveness. It was performed as a multivariable, correlational natural history study. Differences in characteristics of patients treated in each program were controlled statistically, and a cross-validation design and multiple outcome measures were used to make spurious findings less likely. Program variables were divided into treatment and setting characteristics, or those characteristics that the staff did and did not have control over. Since the most promising treatment characteristics are to be used in a blind follow-up to this study, this article deals mainly with the setting variables. The major finding reported here is that patients admitted to and treated on wards in which a mixture of acute and chronic patients were being treated had better outcomes than patients treated on wards with a more narrowly defined patient population. (30 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Latent variable assessment of outcomes in a nurse-managed intervention to increase latent tuberculosis treatment completion in homeless adults.

To assess predictors of latent tuberculosis infection (LTBI) completion by using structural equation modeling (SEM) among homeless adults, a group at great risk for LTBI and active tuberculosis (TB). LTBI therapy is effective in stemming the progression to active TB, yet treatment adherence among homeless persons is difficult to attain. Design: By using SEM, the authors assessed predictors of LTBI completion among a sample of 494 homeless adults in Los Angeles, CA, who received either a nurse case-managed program (NCM) or a usual care program. Main Outcome Measures: Latent variables were created with the baseline variables of site type, age, intervention status, dissatisfaction with health care, depression, TB risk assessment, alcohol use, heroin or cocaine use, and TB knowledge. Outcome variables included many of the same baseline variables as well as treatment completion. Results: LTBI treatment completion (100% adherence) was significantly and positively associated with participation in NCM, older age, and less heroin or cocaine use. NCM also predicted greater TB knowledge, greater ease of treatment, and more satisfaction with treatment (NCM completion rate = 64%, control rate = 42%). Conclusion: The culturally competent NCM program, combined with active tracking and incentives, was successful in a difficult-to-treat and highly transient population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Solicitation of elderly depressives for treatment outcome research: A comparison of referral sources.

Investigated differences among 725 elderly Ss (aged 60–80 yrs) solicited by traditional, semitraditional, or nontraditional methods for a clinical trial of psychotherapy for unipolar depression. 307 Ss from the initial sample completed the Beck Depression Inventory and the Hamilton Rating Scale for Depression and were interviewed using the Schedule for Affective Disorders and Schizophrenia; of these, 112 Ss were invited to participate, 67 of whom completed 16 wks of psychological assessment. Traditional referrals were defined as those coming from typical channels used by agencies and therapists, with no direct appeal to clients; semitraditional referrals included those coming from channels used to inform community members of available mental health services; and nontraditional referrals included direct media-related appeals aimed at potential clients. Demographics, treatment history, pretreatment status, treatment completion, and outcome were examined across referral source categories. Among the 112 Ss meeting inclusion criteria and the 67 Ss completing treatment, no significant differences were observed across referral source. It is suggested that the use of the media for recruitment may be beneficial in providing educational information to elderly individuals who are often reluctant to seek psychological services. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomised comparison of ciprofloxacin suspension and pivmecillinam for childhood shigellosis

BACKGROUND: Infections caused by multiply resistant Shigella species are a major cause of childhood morbidity and mortality in Third World countries. The fluoroquinolone agent ciprofloxacin is active in vitro against these strains of bacteria, but has not been routinely used to treat acute childhood infections because of concern that quinolones may cause arthropathy in children. We undertook a randomised double-blind study to test the effects of ciprofloxacin treatment in children with shigella dysentery. METHODS: We compared the efficacy and toxic effects of ciprofloxacin suspension (10 mg/kg every 12 h for 5 days, maximum individual dose 500 mg) with those of pivmecillinam tablets (15-20 mg/kg every 8 h for 5 days, maximum individual dose 300 mg). We enrolled 143 children aged 2-15 years with dysentery of 72 h or less duration. Patients stayed in hospital for 6 days, and were followed up 7, 30, and 180 days after hospital discharge. Joint symptoms and function were assessed daily for 6 days. Clinical success was defined as the absence of frank dysentery on day 3, and on day 5 no bloody-mucoid stools, one or no watery stool, six or fewer total stools, and no fever. If no shigella were isolated from faecal samples on day 3 or thereafter, treatment was judged bacteriologically successful. FINDINGS: 13 patients were excluded since they did not meet eligibility criteria; 10 withdrew before day 5. Thus 120 patients (60 in each group) completed the study. Treatment was clinically successful in 48 (80%) of 60 patients who received ciprofloxacin and in 39 (65%) of 60 patients who received pivmecillinam (p=0.10). Treatment was bacteriologically successful in all of the patients receiving ciprofloxacin, and in 54 (90%) of the patients receiving pivmecillinam (p=0.03). Joint pain after treatment began in 13 (18%) of 71 patients who received ciprofloxacin and 16 (22%) of 72 patients who received pivmecillinam (p>0.2), and no patient had signs of arthritis. INTERPRETATION: In our trial, ciprofloxacin suspension and pivmecillinam had the same clinical efficacy. Ciprofloxacin had greater bacteriological efficacy and was not associated with the development of arthropathy. We conclude that ciprofloxacin is an effective and safe drug for use in multiply resistant childhood shigellosis.     

Bailout and corrective use of Gianturco-Roubin flex stents after percutaneous transluminal coronary angioplasty: operator reports and angiographic core laboratory verification from the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention Registry

OBJECTIVES: We sought to determine the in-hospital clinical outcome and angiographic results of patients prospectively entered into the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention (NHLBI/NACI) Registry who received Gianturco-Roubin stents as an unplanned new device. BACKGROUND: Between August 1990 and March 1994, nine centers implanted Gianturco-Roubin flex stents as an unplanned new device in the initial treatment of 350 patients (389 lesions) who were prospectively enrolled in the NHLBI/NACI Registry. METHODS: Patients undergoing implantation of the Gianturco-Roubin flex stent were prospectively entered into the Gianturco-Roubin stent portion of the NHLBI/NACI Registry. Only subjects receiving the Gianturco-Roubin stent as a new device in an unplanned fashion are included. RESULTS: The mean age of the patient group was 61.8 years, and the majority of the patients were men. A history of percutaneous transluminal coronary angioplasty (PTCA) was present in 35.4% of the group, and 16.9% had previous coronary artery bypass graft surgery. Unstable angina was present in 67.7%. Double- or triple-vessel coronary artery disease was present in 55.4%, and the average ejection fraction was 58%. The presence of thrombus was noted in 7.3%, and 7.2% had moderate to severe tortuosity of the lesion. The angiographic success rate was 92%. Individual clinical sites reported that 66.3% of the stents were placed after suboptimal PTCA, 20.3% for abrupt closure and 13.4% for some other technical PTCA failure. Major in-hospital events occurred in 9.7% of patients, including death in 1.7%, Q wave myocardial infarction in 3.1% and emergency bypass surgery in 6%. Abrupt closure of a stented segment occurred in 3.1% of patients at a mean of 3.9 days. Cerebrovascular accident occurred in 0.3%, and transfusion was required in 10.6%. Vascular events with surgical repair occurred in 8.6% of patients. CONCLUSIONS: Despite these complications, the use of this device for the treatment of a failed or suboptimal PTCA result remains promising given the adverse outcome of abrupt closure with conventional (nonstent) treatment.     

Incidence of implantable defibrillator discharges after coronary revascularization in survivors of ischemic sudden cardiac death

Coronary revascularization has been suggested as sole therapy for secondary prevention of sudden cardiac arrest associated with ischemia. The use of implantable defibrillators (ICD) in combination with coronary revascularization for this patient population is unclear. Among 412 consecutive patients receiving an ICD, 23 (6%) were identified as sudden cardiac arrest survivors who were noninducible with programmed stimulation and had unstable angina or ischemia on a functional study; they underwent successful coronary revascularization. During a follow-up of 34 +/- 18 months, 10 (43%) of the 23 patients received ICD shocks (8 +/- 8 per patient, range 1 to 22 shocks), and nine of the 10 patients had syncope/presyncope associated with at least one ICD discharge. Patients with ICD discharges were compared with those without ICD discharges, and no clinical characteristics were statistically different between the two groups. In conclusion, revascularization alone may be inadequate therapy for survivors of sudden cardiac arrest associated with ischemia who are noninducible with programmed stimulation, and clinical variables cannot predict which patients are likely to have recurrent malignant ventricular arrhythmias.     

Employment-seeking experiences of resident physicians completing training during 1996

CONTEXT: Studies analyzing the physician workforce have concluded that the United States is verging on a physician oversupply, yet we lack persuasive evidence that this is resulting in physician underemployment and/or unemployment. OBJECTIVE: To determine the degree to which graduating residents have difficulty finding or are unable to find employment in their primary career choices. DESIGN: Two 1-page surveys sent separately to residents and to program directors to collect information on the employment status of residents who were completing a graduate medical education program at the end of the 1995-1996 academic year. SETTING: A total of 25 067 resident physicians scheduled in the spring of 1996 to complete a residency program accredited by the Accreditation Council on Graduate Medical Education, and 4569 program directors in 31 specialties and subspecialties. MAIN OUTCOME MEASURE: Both the graduates' employment status and the degree of difficulty they experienced securing a practice position, as reported by resident physicians and program directors. RESULTS: After 6 months of data collection, 12135 (48.4%) of 25 067 resident physicians responded to the survey. Of the respondents, 11 200 had completed their training, and 7628 (68.1%) were attempting to enter the workforce, 28.4% were seeking additional training, and 3.5% were fulfilling their military obligations. Of the 7628 resident physicians who sought employment, 67.3% obtained clinical practice positions in their specialties, 15.5% took academic positions, 5.0% found clinical positions in other specialties, 5.1% had other plans, and 7.1% did not yet have positions but were actively looking. In addition, 22.4% of resident physicians who found clinical positions reported significant difficulty finding them. The subgroup reporting greater difficulty finding clinical positions included international medical graduates (more than 40%),those completing programs in the Pacific or East North Central region, and those in several specialties. The 1996 graduating residents reported significantly higher rates of difficulty finding suitable employment than program directors reported for their graduates (22.4% vs 6.0%); however, the percentage of graduates reported by both groups as entering the workforce was the same (68.1%). Program directors reported an unemployment rate of only 1.2%, for their 1996 graduates, which was less than the rate reported by the resident physicians (7.1%). CONCLUSIONS: Resident physicians' direct reports of their employment-seeking experiences differ from what program directors report. Program directors accurately determined the number of residents pursuing further training; however, they did not have complete information about the employment difficulties experienced by their graduates. Based on graduates' reports, we conclude that employment difficulties are greatest among international medical graduates and vary by specialty and geographic region.     

Factors associated with sexual behavior problems in young sexually abused children

OBJECTIVE: To identify variables associated with the presence of sexual behavior problems in young sexually abused children. METHOD: Data were gathered from the clinical records of 100 sexually abused boys and girls ages 3-7 years enrolled in two treatment programs. Information was coded systematically on approximately 350 areas related to the child and family's history and functioning, the sexual abuse experience, and treatment outcome. The children were grouped and compared according to their presenting sexual behavior into three categories: (1) developmentally "expected"; (2) "sexualized/self-focused"; and (3) problematic "interpersonal" sexual behavior. RESULTS: Bivariate and multivariate analyses highlighted five variables which were predictive of sexual behavior problems among sexually abused children. Sexual arousal of the child during his/her sexual abuse, the perpetrator's use of sadism, and a history of physical and emotional abuse differentiated between those children with and without "interpersonal" sexual behavior problems. Who the child blamed for his/her sexual abuse further contributed to the distinction between children whose sexual behavior was exclusively "self-focused" (sexualized) versus "interpersonal." CONCLUSIONS: The five major predictor variables, as well as other variables identified in this study, have potential utility in assessing child risk for negative outcomes and determining referral priorities for sexual abuse treatment. Given that sexual arousal and who the child blames for the abuse are prominent variables associated with sexual problems and self-blame, clinicians will need to ensure that sexually abused children and their caregivers are given specific opportunities to deal with these areas in the supportive context of treatment. Children with sexual behavior problems differ not only in the type and level of sexual behavior they exhibit but in most other areas as well, suggesting a need for differential assessment and individualized treatment approaches.     

Preoperative prediction of postoperative deep vein thrombosis

A range of clinical data was obtained from 124 patients about to undergo operation and several coagulation tests were performed. No patient received prophylaxis for deep vein thrombosis, and isotopic scanning after operation showed that 20 patients had developed thrombosis. a simiple prognostic index for predicting which patients would develop postoperative deep vein thrombosis was constructed using the clinical and coagulation data obtained before operation. The five variables with the best predictive power-euglobulin lysis time, age, presence of varicose veins, fibrin related antigen, and percentage overweight-produced an equation that identfied 95% of those who developed deep vein thrombosis and misallocated only 28% of those who did not develop thrombosis. In view of the complications that low-dose heparin and dextran can cause, giving prophylaxis to under a third of the patients who will not develop deep vein thrombosis is clearly better than giving it to all.     

The role of trauma and dissociation in cognitive-behavioral psychotherapy outcome and maintenance for panic disorder with agoraphobia

The relationship between traumatic experiences and dissociation with pretreatment psychopathology and rates of recovery, relapse and maintenance for patients receiving cognitive-behavioral treatments for panic disorder with agoraphobia (PDA) were investigated. One-hundred and forty-seven subjects who met DSM-III criteria for agoraphobia with panic attacks and who completed participation in one of two previously conducted treatment outcome studies were mailed packets containing measures to assess history of trauma, victimization and dissociation. Eighty-nine of these were returned and completed sufficiently to be included in the present study. It was hypothesized that a variety of trauma-related variables (e.g. history of traumatic experience, type of trauma, age at which the trauma first occurred, perceived responsibility, social supports available, self-perceived severity, level of violence, and whether or not the traumatic event was followed by self-injurious or suicidal thoughts and/or behaviors) and dissociative symptomatology would be predictive of (1) greater psychopathology at pretreatment, (2) poorer treatment response and (3) higher relapse rates and poorer maintenance over a 1 year longitudinal follow-up. These hypotheses were supported by the findings and the theoretical, empirical and clinical implications are discussed.     

Mutations in the iduronate-2-sulfatase gene in five Norwegians with Hunter syndrome

OBJECTIVES: Adolescents with human immunodeficiency virus (HIV) infection are at increased risk for tuberculosis (TB), underscoring the importance of early identification of TB infection. The goals of this study were to assess the factors associated with the completion of evaluations for TB in a cohort of HIV-positive adolescents and young adults and to describe the prevalence of Mycobacterium tuberculosis infection and adherence to antituberculous treatment regimens. METHODS: A retrospective chart review was done for all HIV-positive adolescents and young adults, ages 13 to 21 years (n = 49), seen in a comprehensive care program from January 1991 through December 1992. Data collected included CD4 cell count, HIV clinical status, living situation, substance use history, and the completion of an annual evaluation for TB infection. The evaluation consisted of a tuberculin skin test (Mantoux test), using an intraepidermal injection of 0.1 mL of 5 tuberculin units of purified protein derivative (PPD) and a simultaneous Merieux multitest anergy panel. Chi-square analysis was used to assess the association between the completion of the evaluation for TB and both living status and substance use. RESULTS: Thirty-one (63%) of 49 patients completed evaluations for TB. Of the 31 completed evaluations, 18 were assessed by clinic staff on site, and 13 were assessed by other medical or trained nonmedical observers through community networking efforts. Neither homelessness nor illicit substance use were factors in the completion of the evaluation. Six (19%) of the 31 patients had positive PPD skin test results. Three had medical histories and chest radiographs suggesting active TB, and all were hospitalized for at least 2 weeks. Two had positive cultures for M tuberculosis, although the third also responded clinically to antituberculous therapy. All three were otherwise asymptomatic for HIV infection, with only moderately depressed CD4 cell counts. All three were homeless and used crack cocaine. After the initial treatment as inpatients, none completed treatment within the prescribed time period. CONCLUSIONS: The completions of the evaluations for TB were greatly facilitated by community networking, but innovative strategies to enhance both screening and treatment programs, such as training youth service providers in the community to read PPD skin tests, expansion of directly observed therapy services, and youth-centered programs for housing and substance use, need further development. The high prevalence of TB in the cohort underscores the need for providers to increase efforts to identify cases of TB infection among adolescents and young adults and to incorporate HIV risk assessment, counseling, and testing into their practices routinely.