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HIV-AIDS medical care systems that do not have full integration of mental health, alcohol, and substance use services--including the key components of prophylaxis, medication adherence, and outpatient symptom management--risk less-than-optimal outcomes. This chapter provides a model for integrated treatment.
Cocaine abuse by methadone-maintained patients threatens to undermine the success of methadone programs by sustaining a drug-abusing lifestyle as well as contributing to the spread of HIV. The search for a pharmacotherapeutic agent for the treatment of cocaine has met with limited success. The most promising results emerge when specific agents, such as desipramine, are matched appropriately to specific patient characteristics, such as depression or antisocial personality disorder. For some patients, abstinence from cocaine may also require the addition of intensive psychosocial treatments that target the considerable problems faced by inner-city opioid-addicted individuals. This article discusses ways in which future research could be directed toward investigating the interaction between psychosocial services and pharmacologic treatments, while at the same time developing and testing hypotheses concerning appropriate patient-treatment matching variables.
In an effort to improve the psychological health of the athlete who has sustained an injury, the Performance Enhancement Group program for injured athletes was created. This paper will offer a model for the Performance Enhancement Group program as a way to: 1) support the athlete, both mentally and physically; 2) deal with the demands of rehabilitation; and 3) facilitate the adjustments the athlete has to make while being out of the competitive arena. The program consists of responsibilities for professionals in sport psychology (ie, assessment/orientation, support, education, individual counseling, and evaluation) and athletic training (ie, organization/administration, recruitment and screening, support, application of techniques, and program compliance). The paper will emphasize that the success of the program is dependent on collaboration between professionals at all levels.
Quality assurance (QA) and risk management (RM) programs are intended to improve patient care, meet accreditation standards, and ensure compliance with liability insurance policies. The purpose of this project was to obtain and disseminate information on whether dental schools integrate QA and RM and what mechanisms have been most effective in measuring accomplishments in these programs. All sixty-five U.S. and Canadian dental schools were sent a twenty-nine-item survey, and forty-six (71 percent) schools responded. The main findings are as follows: 66 percent had a written QA program combined with a QA committee; 95 percent received administrative support; there was wide variation in the makeup of the QA committee; many institutions reported significant changes resulting from the QA program; and over half of the respondents merged QA and RM in some fashion. To develop or maintain an effective QA/RM program, the authors propose the following: obtain active support from the dean; develop goals and mission/vision statements; include trained personnel on the committee; establish wide levels of involvement in the QA program; develop QA measurements to ensure compliance with institutionally developed standards of patient care; and establish continuous cycles of improvement.
Previous mass campaigns against the endemic treponematoses have taught investigators several lessons that, along with current constraints and altered circumstances, must be considered in the formulation of a contemporary strategy for the control or eradication of yaws, endemic syphilis, or pinta. A time-limited, vertical approach is necessary in highly endemic areas initially to reduce the level of transmission. Elsewhere, control activities should be integrated into other primary health care interventions, especially health education, water and sanitation programs, maternal and child health care, and provision of essential drugs. Control of the endemic treponematoses is an ideal means of strengthening primary health care in endemic areas.
BACKGROUND: The period preceding death is often characterized by increased utilization of medical resources. There is an ongoing debate on the reasons for and the appropriateness of increased utilization at the end of life. OBJECTIVES: To study end-of-life practices in the PACE program and to assess the contribution of individual characteristics versus program site to the variation in use of services. RESEARCH DESIGN: Retrospective analyses of utilization and health status data for the last 3 years before death. Multivariate regression techniques were used to estimate models predicting utilization of services and the percent of variation explained by individual characteristics and program sites in relation to time from death. SUBJECTS: The study comprised 2160 persons enrolled in 10 PACE sites who died before 2000. MEASURES: Monthly utilization by service type (eg, hospital, nursing home, primary care physicians), socioeconomic, and health status data. RESULTS: Utilization of health services increases as early as 7 months before death, with the largest increase in the last month. The increase is dominated by hospital use. During the last month before death variation across program sites explains twice as much of the variation in service utilization as does variation in individual characteristics. CONCLUSIONS: The variation in end-of-life practices across PACE program sites, which are not attributed to differences in individual characteristics, raises two important questions: what are the causes for these variations; and are these variations desirable? Further research is required to answer both questions.
This article explores the parallel structures and service delivery systems of the Older Americans' Act and the Ryan White CARE Act, argues that social workers should have a working knowledge of both pieces of public policy, and suggests integration or coordination of aging and HIV services. Two vignettes illuminate the issues and implications for HIV and aging network social workers. The authors argue that HIV social workers should know more about services for older people and that gerontological social workers should know more about HIV services so that HIV-infected and HIV-affected older people do not remain unserved, unseen, and unheard.
There is a need for less expensive alternative therapies, especially in the treatment of chronic illnesses. This presentation addresses the issues inherent in the use of natural products in a drug-discovery or development program and reviews a model program developed by the U.S. National Institutes of Health (NIH) and administered by the Fogarty International Center at the NIH. Eighty percent (80%) of the world's population relies on medicinal plants for their primary health care. The World Health Organization has been promoting traditional medicine as a source of less expensive, comprehensive medical care, especially in developing countries. Natural products have also been successful in drug development. Over 50% of the best-selling pharmaceuticals in use today are derived from natural products. In a natural-product drug development program, it is the diversity of the natural products that is especially interesting. Thanks to technologic advances, now is a good time to be looking for new drugs in the natural-product arena. But there are major hurdles to overcome in a natural-products development program, namely, time-to-lead, supply, and ownership. Time-to-lead is complex because most natural products are mixtures or crude extracts. It can be very difficult to isolate the active principles and elucidate their structures. The difficulty of obtaining sufficient supply is often given as a reason for not becoming involved in natural-product drug development or discovery. This presentation details some ways these seeming hurdles can be overcome. The concept of ownership has changed dramatically in recent years. Until recently, genetic resources were considered to belong to no one and to therefore be the heritage of everyone. The United Nations Convention on Biodiversity and the meetings in Rio de Janeiro in 1992, redefined biodiversity ownership. Genetic biodiversity has a potential value and belongs to the country of origin. The International Conservation of Biodiversity Groups (ICBGs) was founded in 1992 to address such issues. This presentation discusses the importance of integrating efforts in conservation, economic development, and drug development into one program. The presentation details a collaboration that includes an ICBG based at the Walter Reed Army Institute of Research and its four partner organizations and discusses the associated programs the collaboration has underway.
In July 1988 St. Mary Medical Center (SMMC), Long Beach, CA, established Older Adult Services (OAS) to help the elderly of the community. At the time, SMMC was already providing a number of services for the elderly, but OAS enables it to provide a continuum of care. In addition, the medical staff committee developing the geriatric program recommended establishing a geriatric assessment team headed by a fellowship-trained geriatrician, having that geriatrician serve as medical director of the inpatient skilled nursing facility (SNF), having the geriatric team develop treatment protocols in various aspects of care, and extending OAS within the community. The categories of service within the continuum are extended care, acute care, ambulatory care, home care, outreach, wellness, and housing. SMMC does not directly provide all services; rather, through integrating mechanisms, it uses community-based services or services provided by other institutions to meet some patient needs. A key element to integrating the continuum is the involvement of OAS in the SNF. The SNF medical director can bring the expertise of the geriatric assessment team to a wide sphere of the medical community. This sphere of influence quickly spreads to the hospital's entire medical community. Through direct participation in utilization review and quality assurance in the SNF, the OAS director can influence the quality of care.
Managed care organizations (MCOs) are being recruited to support school health services delivered in school clinics. Schools without clinics already provide numerous health services and could provide more if they had support from managed care organizations. This article describes the first two years of a San Diego-based collaborative consisting of MCOs, school districts, and other health care agencies. By establishing trust, developing overriding principles, and creating an interagency communication infrastructure, this collaborative has encouraged shared management of many student health issues. Because the agreements apply to all schools, programs can reduce high rates of absenteeism district-wide and avoid unnecessary doctor appointments for common health problems. These collaborative agreements are designed to be financially self-sustaining. However, data collection, the logistics of obtaining parental consent, and getting health professionals to communicate with each other in new ways remain to be significant challenges.
The Steer-a-Year course is designed to provide classroom and hands-on experience, industry-student interaction, and student group problem-solving opportunities. It is a cooperative agreement between the Department of Animal Sciences and the Oregon Cattlemen's and Cattlewomen's Associations. Steers are donated to the program by beef producers, fed a high concentrate ration to a target BW and condition, and marketed as either carcass or retail beef. After feed and management expenses are deducted, the Department of Animal Sciences retains one-half of the profit to be used for beef facilities improvements, and the other half is distributed to the donor's choice of either the Oregon Cattlemen's or Cattlewomen's Association. Approximately 30 steers have been donated to the program annually each of the past eight years. The donor receives updates regarding steer performance during the feeding period and carcass data following harvest of the animal. Students and instructors feed and manage the steers. The instructor uses classroom time to provide information to enable students to make informed management decisions. Officers are elected from within the class each term. Student officers are responsible for ensuring that cattle are managed and fed appropriately, and they lead the class in writing and sending producer updates. An evolving facet of the program is processing and marketing. Steers are sold locally through the Clark Meat Science Center. Students are encouraged to participate in a separate course in which they process the steers into retail product. In this manner, students can be involved in procurement, management, processing, and marketing. The course is challenging for the instructor since it requires management of lecture material, cattle health and feeding, producer and employee rapport, and student participation to ensure annual success of the program in terms of student learning and public relations. The course is very well received by students, most of whom have labeled it as a great learning experience.
BACKGROUND: Gene expression microarrays are a prominent experimental tool in functional genomics which has opened the opportunity for gaining global, systems-level understanding of transcriptional networks. Experiments that apply this technology typically generate overwhelming volumes of data, unprecedented in biological research. Therefore the task of mining meaningful biological knowledge out of the raw data is a major challenge in bioinformatics. Of special need are integrative packages that provide biologist users with advanced but yet easy to use, set of algorithms, together covering the whole range of steps in microarray data analysis. RESULTS: Here we present the EXPANDER 2.0 (EXPression ANalyzer and DisplayER) software package. EXPANDER 2.0 is an integrative package for the analysis of gene expression data, designed as a 'one-stop shop' tool that implements various data analysis algorithms ranging from the initial steps of normalization and filtering, through clustering and biclustering, to high-level functional enrichment analysis that points to biological processes that are active in the examined conditions, and to promoter cis-regulatory elements analysis that elucidates transcription factors that control the observed transcriptional response. EXPANDER is available with pre-compiled functional Gene Ontology (GO) and promoter sequence-derived data files for yeast, worm, fly, rat, mouse and human, supporting high-level analysis applied to data obtained from these six organisms. CONCLUSION: EXPANDER integrated capabilities and its built-in support of multiple organisms make it a very powerful tool for analysis of microarray data. The package is freely available for academic users at http://www.cs.tau.ac.il/~rshamir/expander.
INTRODUCTION: At the present time there is considerable controversy over the course to follow in attention to patients with psychogeriatric disorders. Rapid diagnosis and maintaining the patients in their homes are the basic objectives of the policy of sharing responsibility among those involved. DEVELOPMENT: We review the bibliography and suggest a form of attention based on experience acquired in the dementia evaluation unit of the Programme Vida als Anys of the Generalitat de Catalunya. The model described is based on making the diagnosis in the patient's home, giving support to the family and integrating the patient into a follow-up unit, with a person responsible for evaluating and resolving the needs of both patient and family as they arise. In order to carry out this programme, the attention must be given by multidiscliplinary units with the necessary resources.
BACKGROUND: Clinicians and scientists have important and complementary roles to play in improving the management of pediatric infectious diseases. The clinician's role is to provide optimal care for the individual patient, whereas the scientist is closely involved in teaching and research. OBJECTIVES: To review the current challenges in the management of childhood infections and the contributions of different groups to meeting these challenges. DISCUSSION: The pattern of infectious diseases in children is constantly changing, emphasizing the importance of microbiologic research in meeting these challenges. In the clinical setting the research results must be applied and integrated in routine practice. The development and successful clinical use of new diagnostic techniques, new antibiotics and new vaccines provide good examples of the teamwork between scientists and clinicians, which is essential for progress in the field of common childhood infectious diseases. The most urgent challenges in this area that now face physicians are the increasing prevalence of antibiotic-resistant bacteria, especially the spread of penicillin-resistant Streptococcus pneumoniae, and the growing numbers of immunocompromised children. Devising and implementing strategies to meet these demands will require a continuing commitment from pediatricians and microbiologists.
A 3-year study of the efficacy of the complex prophylaxis system of stomatological diseases in children showed that the severity of dental caries, according to the CFE index, diminished by 65.6 per cent in the children included in the clinical trial and by 23.5 per cent in the children undergoing mass examination. In order to increase the efficacy of prophylactic measures, the stomatological component will be included in the integrated prophylaxis programme of non-infectious chronic diseases, which will be carried out in the Latvian SSR under the auspices of the WHO.
The Cleveland Clinic is a large multispecialty group practice. The need for a palliative care program was identified and the program started in 1987. A key concept has been that the existing structure of hospice care as defined by Medicare is insufficient to address the needs of patients with incurable disease. The field of palliative medicine implies physician expertise in several key areas: (1) communication; (2) decision-making; (3) management of complications; (4) symptom control; (5) care of the dying; and (6) psychosocial care. The development of the program (the first in the United States) since 1987 has put in place the following major services, listed consecutively: (1) hospital consultation service; (2) outpatient clinics; (3) acute care inpatient service; (4) hospice and home care service; (5) acute-care palliative medicine inpatient unit; and (6) hospice inpatient facility. Program development has meant that a new program has been introduced approximately every 18 months since the start of the program. This has considerable implications for staffing, the management of change, and competition for scarce resources within a contracting health care budget. The staffing of the program has focused on developing specialized attending physicians using a multidisciplinary approach dedicated to enhancing the role of nursing in the field. The major budgeted areas are (1) the acute-care palliative medicine unit, and (2) the hospice and home care service. Specific commitment has been made to research and education because of the desire to develop an intellectual basis for the practice of palliative medicine. This requires structured activities in both areas with a systematic approach to research and education. The complexity of developing a service should not be underestimated. There has been consistent support for the program by senior leadership within the Cleveland Clinic Foundation, including the cancer center. The major lessons learned during program development have been: (1) to focus on quality of patient care; (2) to commit to academic endeavor in research and education; (3) to secure institutional commitment to program development; (4) to establish a positive, proactive, businesslike approach; (5) to defend budget and personnel, albeit within a difficult time in health care; and (6) to commit to success, i.e., never promise anything on which you do not deliver. The future development of post-acute-care services serving predominantly the chronically ill elderly population suggest an expanded administrative and conceptual role for the future development of palliative medicine to help serve the needs of the aging population in the United States.
The general lines of radiocardiographic practice in the framework of rehabilitation of cardiac patients based on 15 years experience are summed up. The basic technical elements of the scheme were: integration of the radiocyclographic method and of nuclear procedures with the traditional diagnostic investigations, with microcatheterization, co-ordination of the loading principle in the form of exercise tolerance tests with the radiocardiographic and radiocyclographic routine, adaptation of digital data collection and storing for off-line computer analysis, extension of the data collecting system of the radioisotope laboratory to the adjoining intensive care unit. In a group of middle-aged patients with earlier transmural infarction being on a rehabilitation training program the responses to loading were similar to those of a control group formed by normal aged males. In the patients having had artificial valve implantation or mitral commissurotomy, a favourable progress in terms of the New York Heart Association (NYHA) rating was demonstrable, the most informative parameter of assessment having been the distribution of effective circulating blood volume in the central circulation. Moreover, an increase in stroke volume at rest as well as in response to loading was demonstrable within 1--2 months after operation and also 3 1/2 years later. The diagnostic value of the 133Xe-technique for the measurement of ventilation and perfusion of the upper and lower regions of the lung was confined to patients with mitral stenosis or mitral valvular disease.
The frequency and severity of dental caries and periodontal diseases among the population of the Latvian SSR, as well as the risk factors which contribute to the development of these morbid processes were studied. It was found that dental caries are present in 98 per cent of pupils aged 12 years, the CFE index (Caries Filling Extraction Index) representing 6.7. Among adolescent aged 15 years, a healthy periodontium and a good hygienic state of the oral cavity were found only in 2 per cent. Taking into account the high frequency of these diseases, the primary prophylaxis programme of dental caries and periodontopathies was included as a component in the integrated WHO programme of prevention and control of noninfectious chronic diseases in the Latvian SSR.