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At least 199 records · Page 11Linked to original sources
PubMed1999

Street outreach for homeless persons with serious mental illness: is it effective?

OBJECTIVES: This study examined data on case management clients who are homeless and have a severe mental illness to determine how those contacted through street outreach differ in their socio-demographic characteristics, service needs, and outcomes from those clients contacted in shelters and other health and social service agencies. METHODS: As part of the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program, data were obtained from potential clients over the first 3 years of the program at the time of the first outreach contact (n = 11,857), at the time of enrollment in the case management program (n = 5,431), and 3 months after enrollment (n = 4,587). RESULTS: Clients contacted at outreach on the street, as opposed to being contacted in shelters and service agencies, were generally worse off. They were more likely to be male, to be older, to spend more nights literally homeless before the contact, to have psychotic disorders, and took longer to engage in case management. They expressed less interest in treatment and were less likely to enroll in the case management phase of the project. Subjects contacted on the street who did enroll were more impaired than their street counterparts who did not enroll. Three month outcome data showed that enrolled clients contacted through street outreach showed improvement that was equivalent to those enrolled clients contacted in shelters and other service agencies on nearly all outcome measures. CONCLUSION: Street outreach to homeless persons with serious mental illness is justified as these clients are more severely impaired, have more basic service needs, are less motivated to seek treatment, and take longer to engage than those contacted in other settings. Street outreach is further justified as it engages the most severely impaired among the street population. Street outreach also appears to be effective as the clients reached in this way showed improvement equal to that of other clients in most outcome domains when baseline differences were taken into account.

Adult↗
PubMedDate not supplied

Changes in exercise capacity and lipids after clinic versus home-based aerobic training in coronary artery bypass graft surgery patients.

PURPOSE: Despite the documented benefits of participating in rehabilitation programs, access to cardiac rehabilitation is limited for a large number of people with coronary artery disease (CAD). There is potential to increase participation in exercise training if home-based exercise were a viable option. METHODS: We conducted a retrospective database review of 1,042 patients who took part in exercise rehabilitation following coronary artery bypass graft surgery (CABGS) between 1992 and 1998. Of these, 713 patients took part in supervised exercise, and 329 were in an unsupervised, home-based group. All exercise protocols were based upon American College of Sports Medicine guidelines, and patients in both groups received exercise prescriptions that were similar in intensity, frequency, and duration. RESULTS: There were no differences between groups at baseline. Following 6 months of exercise training, there were substantial improvements in peak VO2, peak workload, and peak MET levels in both the supervised and unsupervised groups (P < 0.0001). Patients in the supervised group had significant improvements in both LDL and HDL-cholesterol, whereas the home-based group showed improvement in HDL-cholesterol only. When analyzed by sex, men performed better than women for all measures of exercise capacity; however, women in both groups showed approximate 20% improvements (P < 0.05) in exercise capacity as well as improvements in HDL-cholesterol. CONCLUSION: Stable post CABGS patients who receive a detailed exercise prescription to follow at home do as well as those in supervised rehabilitation.

Aged↗
PubMed2000

Efavirenz- and adefovir dipivoxil-based salvage therapy in highly treatment-experienced patients: clinical and genotypic predictors of virologic response.

OBJECTIVE: To determine the impact of prior nonnucleoside reverse transcriptase inhibitor (NNRTI) therapy, genotypic resistance, and other variables on response to efavirenz (EFV)- and adefovir dipivoxil (ADV)-based salvage therapy. DESIGN: Retrospective clinical cohort study. SETTING: One university and one community-based HIV clinic. STUDY SUBJECTS: All 33 patients who were coenrolled in both the EFV and ADV expanded access programs. INTERVENTIONS: Patients received EFV 600 mg/day and ADV 120 mg/day in addition to other antiretroviral agents. OUTCOME MEASURE: HIV viral load (<500 copies/ml) at 12 and 24 weeks. RESULTS: 10 of 33 (30%) patients at 12 weeks and 8 of 33 (24%) patients at 24 weeks had viral loads <500 copies/ml. Prior NNRTI use and a history of any NNRTI-associated mutations predicted failure. Patients with Y181C or G190A single mutations had an initial greater magnitude of viral load suppression than those with K103N, but this advantage was short lived. No one with any NNRTI mutations responded with a viral load <500 copies/ml at 12 or 24 weeks. CONCLUSIONS: EFV/ADV-based salvage yielded viral load suppression at 24 weeks in 42% (8 of 19) of patients who were highly NRTI and protease inhibitor experienced but NNRTI naive. NNRTI-experienced study subjects had a poor response regardless of the specific NNRTI resistance mutation they harbored.

Adenine↗
PubMedDate not supplied

Bosentan.

Bosentan is the first endothelin (ET) receptor antagonist approved by the Food and Drug Administration for the management of pulmonary arterial hypertension (PAH). In patients with World Health Organization Class III and IV PAH, bosentan has demonstrated improvement in dyspnea and exercise tolerance. ET also plays an important role in the pathophysiology of different vascular diseases. Therefore, bosentan also may have the potential to alter the outcome of many other diseases, such as heart failure, hypertension, ischemic heart disease, and renal disease, as well as cerebrovascular disorders. Because of the rarity and the poor prognosis of patients with PAH, as well as the requirement of close monitoring of bosentan (due to its potential of causing liver dysfunction and its teratogenic effects), bosentan is currently available only through a special access program and is distributed by certain selected pharmacies. Patients who are receiving bosentan should be taught to recognize early signs and symptoms of liver dysfunction and possible pregnancy. In addition, bosentan is not only a substrate but also an inducer of CYP3A4 and CYP2C9. Therefore, it is anticipated that numerous drug interactions may occur. Patients should be advised to consult their physicians or pharmacists should they need to consume other prescription or nonprescription medications.

Antihypertensive Agents↗
PubMed1993

Use of health care services in two rural communities in Tanzania.

This study was undertaken to investigate the pattern of utilization of medical and dental health care services in rural Tanzania. Two hundred adults, 91 men and 109 women aged 20 or over, were interviewed. Nearly all subjects reported using modern dental and medical health care services. Home remedy was the only indigenous method of treatment used for dental problems while for medical problems a traditional healer was the most commonly used indigenous alternative. The use of both indigenous and modern health care services was significantly lower for dental than for medical problems (P < 0.05). It seems that the pattern of utilization of health care services differs for medical and dental problems. This should be taken into account when planning comprehensive health care services for rural African societies.

Adult↗
PubMed1993

Hope for Haiti?

Haiti, one of the world's five poorest nations, gets international attention because of the number of refugees who leave by boat in search of a better future. The 80,000 inhabitants of Ile de la Gonave are neglected, even in Haiti--there is no government medical post, and facilities in the health posts run by missions are minimal. Typhoid and cholera epidemics threaten the island. Médecins Sans Frontières plans to send staff and supplies and train local health workers.

Haiti↗
PubMed2000

The case management relationship and outcomes of homeless persons with serious mental illness.

OBJECTIVE: The effect of the case management relationship on clinical outcomes was examined among homeless persons with serious mental illness. METHODS: The sample consisted of the first two cohorts that entered the Access to Community Care and Effective Services and Supports (ACCESS) program, a five-year demonstration program for mentally ill homeless persons funded by the Center for Mental Health Services in 1994. At baseline, three months, and 12 months, clients were characterized as not having a relationship with their case manager or as having a low or high therapeutic alliance with their case manager. Analyses were conducted to test the association between the case manager relationship at baseline, three months, and 12 months and clinical outcomes at 12 months. RESULTS: Multivariate analyses of covariance were conducted for 2,798 clients who had outcome data at 12 months. No significant associations were found between the relationship with the case manager at baseline and outcomes at 12 months. At three months, clients who had formed an alliance with their case manager had significantly fewer days of homelessness at 12 months. Clients who reported a high alliance with their case manager at 12 months had significantly fewer days of homelessness at 12 months than those with a low alliance, and those with a low alliance at 12 months had fewer days of homelessness than clients who reported no relationship with their case manager. Clients with a higher alliance at both three and 12 months reported greater general life satisfaction at 12 months. CONCLUSIONS: The study found that clients' relationship with their case manager was significantly associated with homelessness and modestly associated with general life satisfaction.

Adult↗
PubMed1997

Impact of representative payees on substance use by homeless persons with serious mental illness.

OBJECTIVE: Assignment of representative payees, third parties responsible for managing clients' funds, has been proposed to counter potential use of public support payments for abused substances by people with severe mental illness and substance use disorders. This study examines substance use outcomes in a sample of homeless persons with serious mental illness and substance use disorders, some of whom were assigned representative payees. METHODS: The subjects were participating in the Access to Community Care and Effective Services and Supports (ACCESS) program, a federally funded demonstration program on integrating service systems. Clients were assessed at baseline and three months after case management services were initiated. Factorial repeated-measures analysis of covariance was used to examine substance use among four client subgroups, two of which had payees and two of which did not. RESULTS: Clients in this sample (N = 1,348) showed significant improvement on all measures of substance use over the first three months in the program. Those with payees showed no greater improvement in substance abuse than those without payees, although they did have fewer days of homelessness. CONCLUSIONS: This study failed to find evidence that merely adding external money management services to existing services improves substance abuse outcomes among clients who had dual diagnoses and were homeless. Besides assigning a payee, structured behavioral interventions may be needed to produce additional clinical benefits.

Adult↗
PubMed1996

Pediatric enteral access center: a multidisciplinary approach.

The need for enteral access and gastrostomy placement in children has increased dramatically over the past several years. In the following article, we present a case report of a typical patient undergoing evaluation for enteral nutrition and enteral access. Following the case report, we describe our newly formed Pediatric Enteral Access Program including patient selection, the method of gastrostomy placement, risks and benefits, cost analysis, and follow-up of this ever-increasing population of children.

Child Nutrition Disorders↗
PubMed1992

Didanosine.

OBJECTIVE: To review the chemistry, intracellular metabolism, pharmacokinetics, and clinical experience with didanosine (2',3'-dideoxyinosine [ddI]). DATA SOURCES: English-language articles and conference proceedings (indexing terms were didanosine, 2',3'-dideoxyinosine, and ddI). STUDY SELECTION: Available Phase I studies and abstracts determined to have clinical significance were included. DATA EXTRACTION: Clinical experience with ddI is limited to uncontrolled Phase I studies and a large "expanded-access" program. The primary outcome parameters used to evaluate ddI were the HIV surrogate markers: CD4+ lymphocytes and p24 antigen. Thus, the clinical data reviewed here must be evaluated critically and be considered preliminary until the results of studies comparing ddI with zidovudine (ZDV) and combination studies are available. DATA SYNTHESIS: Didanosine has been approved for the treatment of HIV infection in patients who are unable to tolerate ZDV because of adverse effects (e.g., anemia and neutropenia) or who experience clinical or immunologic deterioration while receiving ZDV. Compared with ZDV, ddI has a long intracellular half-life and negligible bone-marrow toxicity. It also has in vitro activity against ZDV-resistant strains of HIV. Phase I studies indicate that ddI has a beneficial effect on the CD4+ cell counts and HIV p24 antigen concentrations. As a result of the acid-labile nature of ddI, oral formulations are buffered or must be mixed with antacid to neutralize gastric pH. Bioavailability then averages 20-40 percent, depending on the dose and formulation given. The plasma half-life, total body clearance, and volume of distribution of ddI are one to two hours, 0.7-1 L/kg/h, and 0.8-1 L/kg, respectively. Painful peripheral neuropathy and pancreatitis (dose-limiting toxicities of ddI) occurred in 34 and 9 percent of patients in Phase I studies, respectively. CONCLUSIONS: Didanosine has demonstrated preliminary efficacy in the treatment of late-stage HIV infection; however, its effect on patient survival, its efficacy relative to ZDV, and its utility in combination with other agents are still under evaluation.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Zalcitabine.

OBJECTIVE: To review the chemistry, intracellular metabolism, pharmacokinetics, and clinical trials of zalcitabine (2'3'-dideoxycytidine, ddC). DATA SOURCES: English-language articles and conference procedings. The indexing terms used were zalcitabine, 2'3'-dideoxycytidine, and ddC. STUDY SELECTION: In addition to the manufacturer's package insert, available Phase I and Phase I/II studies were reviewed. DATA EXTRACTION: Clinical experience with ddC has been limited to uncontrolled studies and an expanded-access program. Efficacy was evaluated solely on surrogate markers of HIV disease: CD4+ lymphocyte counts and p24 antigen determinations. Clinical endpoints, such as disease progression and survival rates, must be provided to the Food and Drug Administration (FDA) for continued approval. DATA SYNTHESIS: The FDA has approved use of ddC in combination with zidovudine (ZDV) as therapy of HIV infection for patients with CD4+ lymphocyte counts < or = 300 cells/mm3 who have experienced significant clinical or immunologic deterioration. Although ddC has the same mechanism of action as other nucleoside analogs, it is more potent on a molar basis. The drug is stable in gastric pH and has good bioavailability (approximately 70-90 percent), but is rapidly cleared from plasma (half life approximately 1-3 h). Intracellular concentrations of ddC triphosphate, the active form, are probably related to plasma concentrations, yet may persist in cells longer than the parent drug persists in plasma. When used as primary therapy in patients with CD4+ < or = 300 cells/mm3, ddC/ZDV increased CD4+ lymphocyte counts and reduced plasma p24 antigen concentrations. In comparison to ZDV monotherapy data taken from other studies, ddC/ZDV appeared to demonstrate a more pronounced and sustained increase in CD4+ cell counts; however, this observation cannot be confirmed until the results of ZDV-controlled comparisons are available. Overall, 17-31 percent of the patients receiving the currently recommended initial dosage of ddC experience peripheral neuropathy. CONCLUSIONS: In combination with ZDV, ddC appears to augment the CD4+ cell response of ZDV monotherapy in the treatment of HIV infection for ZDV-naive patients, although controlled studies and rigorous statistical analyses are lacking at present. The efficacy of ddC/ZDV in patients who received prior treatment with ZDV monotherapy is unclear at the present.

Adolescent↗
PubMed1993

High perinatal and neonatal mortality in rural India.

A prospective study conducted in rural India on pregnant women showed poor utilization of primary health services and very poor maternal care receptivity especially in terms of antenatal care. A very high perinatal mortality rate of 81.3/1000 live births and a neonatal mortality rate of 63.7/1000 live births was observed in the present study. Out of 204 live births, 72.05% of newborn developed complications within 6 weeks of the delivery. Most of the complications were of a minor nature and could be attributed to poor environmental conditions, lack of personal hygiene and ignorance. The study highlights the need for training of grass root level workers for the improvement of perinatal and neonatal care in rural India.

Female↗
PubMedDate not supplied

Salvage treatment with lopinavir/ritonavir (Kaletra) in HIV-infected patients failing all current antiretroviral drug families.

BACKGROUND: Lopinavir/ritonavir (Kaletra) is the latest available protease inhibitor (PI). It has shown greater potency than the former PIs in phase II/III trials, either in naive or in PI-experienced patients being naive for nonnucleoside reverse transcriptase inhibitors (NNRTIs). METHOD: We analyzed the first 138 patients recruited during the expanded access program in an HIV/AIDS reference center. Only patients who had significant past exposure to all three different antiretroviral drug families and who were failing their current regimens were chosen. RESULTS: A total of 93 and 76 patients completed, respectively, 3 and 6 months of follow-up. Mean plasma HIV RNA log(10) copies/mL before beginning Kaletra was 4.04 +/- 1.1 and mean CD4 count was 285 +/- 197 cells/mL. Overall, 76.3% and 63.2% of patients showed a significant virologic response (defined as >1 log reduction in plasma HIV RNA and/or a reduction to less than 500 HIV RNA copies/mL) at 3 and 6 months, respectively. The mean CD4 increase was +77.3 cells/mL at 6 months. Thirteen individuals did not complete 6 months on therapy: there were 2 deaths (1 was non-AIDS related), 2 patients were lost to follow-up, 7 patients withdrew due to potential drug adverse events, and 2 patients withdrew due to complications of intercurrent illnesses. Triglyceride levels significantly increased 3 months after initiation of Kaletra (+70 mg/dL; p =.04) while cholesterol levels remained stable (+7.7 mg/dL; p =.7). Sequence analysis at baseline showed a median number of PI mutations of 4 (0 to 12). Overall, 45% of patients harbored >/=5 PI mutations. Attainment of plasma HIV RNA <500 copies/mL occurred in 88% of patients with </=5 PI mutations but only in 48% of those harboring >5 PI mutations (p <.001). Baseline mutations at codons 71 and 82 were associated with a lower response to Kaletra. CONCLUSION: Kaletra is relatively well tolerated and provides potent antiviral activity in heavily pretreated patients. Significant virological responses are seen in more than three quarters of patients at 3 months. Genotyping at the time of initiation of salvage therapy with Kaletra might help to predict which individuals will experience a greater benefit.

Adult↗