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BACKGROUND: There is growing evidence that homeless individuals have longer inpatient lengths of stay with significantly higher medical costs than domiciled individuals. We compared adjusted mean lengths of stay among domiciled patients and homeless patients discharged to a hospital hotel (hoptel). Because the hoptel allowed homeless patients to be discharged when medically indicated, we hypothesized no significant differences in lengths of stay between the 2 groups after adjustment for severity of illness. METHODS: Demographic, diagnosis, and length of stay data were obtained for all patients discharged from all inpatient wards at a large, urban Veterans Affairs Medical Center during the first 32 months of hoptel operation (1996 through 1998). Adjusted mean lengths of stay for domiciled patients and homeless patients discharged to the hoptel were compared. ANCOVA was used to adjust for demographic characteristics (age, income, race/ethnicity), diagnosis-related group (DRG), principal diagnosis, and substance abuse comorbidity. Three types of hospitalizations were analyzed on the basis of major DRG categories: general medical, psychiatric, and all hospitalizations. RESULTS: No significant differences were found in adjusted mean lengths of stay between domiciled patients and homeless patients discharged to the hoptel. Homeless hoptel patients stayed an average 0.7, 0.3, and 0.4 days longer than domiciled patients for all, general medical, and psychiatric hospitalizations (P = 0.504, 0.627, and 0.839), respectively. CONCLUSIONS: These data suggest that hoptels may help equalize inpatient lengths of stay among domiciled and homeless patients discharged to a hoptel. Public health care systems seeking innovative ways of reducing inpatient lengths of stay among homeless patients ought to consider establishing hoptels.
OBJECTIVE: We have studied the outcome after a stroke on being discharged from a department of physical medicine and rehabilitation in patients with hemiplegia, and the factors influencing the choice of the orientation. MATERIAL AND METHOD: This prospective study was based on 93 patients. The mode of discharged was patient's domicile, institution, the number of death was also noted. The potentially influential factors studied were age, the side with hemiplegia, the aetiology of the hemiplegia, co-morbidity, the delay in starting rehabilitation, the neurological damage evaluated by the Orgogozo score, the initial functional damage evaluated by Functional Independence Measure (FIM) and by the functional score carried out within the framework PMSI(1) (computerised programme of medical care), the existence of aphasia, the existence of a depressive syndrome, presence of hemineglect, presence of superficial or profound sensory disorders, incontinence at the start of rehabilitation and at one month after the stroke, the existence of cognitive or psychiatric disorders. The tests used were the non-parametric test of Mann and Whitney, the chi(2) test and the correlation test. The threshold of significance used was 0.05. RESULTS: Based on 93 patients (47 women and 46 men, average age 64.8) 81 have gone back to their previous domicile, 11 were oriented toward an institution. One patient died. The predictive factors or those linked to an absence of return to the previous domicile were the age, social situation, the delay in starting rehabilitation, presence of aphasia, the initial and final functional damage, the impossibility to walk, the presence of a depressive syndrome, urinary incontinence. CONCLUSION: The authors stress the importance of familial environment and of functional independence in establishing a prognosis for return to the domicile.
The present study compared pregnant drug-dependent women reporting homelessness (n=117) or being domiciled (n=118) at treatment enrollment on initial psychosocial functioning and subsequent drug treatment outcome. Homeless pregnant women presented with greater drug use and medical problems, less social service income, and more family/social difficulties than domiciled women. Homeless women had greater rates of psychiatric problems including suicidality and higher rates of physical, emotional and sexual abuse than their domiciled counterparts. Treatment retention was poorer for homeless than domiciled pregnant women. Results suggest that treatment should address the housing needs of pregnant drug abusers as well as their related social and psychiatric problems.
Evaluating the representativeness of homeless samples is important for generalizing research findings on the homeless and designing interventions targeting their health needs. The present study contrasts homeless and domiciled free-clinic users (216 homeless [132 men, 84 women], 212 domiciled [102 men, 110 women]) and 531 community homeless persons (388 men, 143 women) on latent variables representing substance use, mental and physical health, appearance, life satisfaction, and health services utilization (HSU). Homeless clinic patients equalled the community sample in substance abuse and psychological problems but exceeded the sample in HSU and cleanliness. Homeless clinic users reported more substance abuse, poorer health, greater mental illness and mental HSU, less cleanliness, and lower life satisfaction than domiciled patients. Relationships among the variables are reported, and implications concerning health needs among the homeless are discussed.
Further studies pm yjr rofr,op;phu pg ,i;yo;r dv;rtpdod (MS) IN Finland were carried out in three different types of geographical unit: in counties, combined clerical districts, and single clerical district. For longitudinal studies, the prevalence of MS by present domicile was compared to that by place of birth, and also to the number of MS cases in relation to the number of births. The analysis was based on 1,866 living MS patients. The highest prevalence by present domicile was recorded in the southwestern county of Turku and Pori (52.3 cases per 100,000 inhabitants). It was 39.6 for the whole country. Two separate clusters were found at the level of combined and single clerical districts: one in the western county of Vaasa, and another in the southwestern county of Turku and Pori. The highest prevalences by present comicile were found in two clerical districts of Vaasa (83.5 and 79.7). They also had very high prevalences by place of birth. They lie close to each other, but are not immediate neighbours. Another high-risk focus was revealed in an area of the neighbouring districts of Turku and Pori. In fact, the two highest prevalences by place of birth were found in this region (123.1 and 95.0). The focus extended from the coastal area to the more central region of the county, and further to the western districts of the otherwise medium-risk county of Hme. Thus, two separate foci were found in Finland: one in the western and another in the southwestern part of the country. The clustering became even more pronounced when the prevalences by place of birth were analysed. Considering that the Finnish population still largely originates from genetic isolates of varying degrees, gene enrichment explains the clustering at least partly.
A serological survey with latex agglutination test to detect anti-Toxoplasma gondii antibodies was conducted on 800 serum samples collected from domiciled cats at animal hospitals in various areas of Japan. The overall prevalence was 6.0% (48/800). Among 48 positive individuals, there was no specific distribution of strength of antibody titers; the titers were 1:64 in 8 cats, 1:128 in 12, 1:256 in 8, 1:512 in 10, 1:1,024 in 8 and 1:2,048 in 2. The maximum prevalence was 15.4% in 13 cats at 17-23 yrs old group, whereas all were negative in 58 cats aged 12-16 yrs. The age groups in the order of higher prevalence were 8, 4, 10, 5, 3, and 7 yrs, showing no aging effect to the prevalence. In terms of rearing conditions of those cats, they were classified into 4 groups, i.e., indoor, free, outdoor, and others. The prevalence in the outdoor group (11.1%) was significantly higher (p < 0.05) than that in the free group (4.8%). Epidemiological aspects observed in the domiciled cats were different from those reported in the stray cats.
In most countries, Chagas disease transmission control remains based on domestic insecticide application. We thus evaluated the efficacy of intra-domicile cyfluthrin spraying for the control of Triatoma dimidiata, the only Chagas disease vector in the Yucatán peninsula, Mexico, and monitored potential re-infestation every 15 days for up to 9 months. We found that there was a re-infestation of houses by adult bugs starting 4 months after insecticide application, possibly from sylvatic/peridomicile areas. This points out the need to take into account the potential dispersal of sylvatic/peridomestic adult bugs into the domiciles as well as continuity action for an effective vector control.
Although homelessness in patients with combined addictive and psychiatric illness is a common problem, little has been reported about the epidemiology of homelessness in this patient population. The authors, in a study of 100 dually diagnosed patients admitted to a large metropolitan psychiatric hospital, found that a large portion of patients (N = 46) were homeless at the time of admission. Alcohol and crack/cocaine were the most frequently used drugs. Interestingly, there were no significant differences on most parameters between those who were homeless and those who were not. The authors observed that among the disadvantaged, inner-city dually diagnosed, many move in and out of the homeless state, seriously compromising their chances for recovery. Self-help treatment programs were more commonly used by homeless than domiciled patients. The homeless population may therefore be amenable to treatment in 12-step groups, as are domiciled patients.
BACKGROUND: Our previous publications on the epidemiology of blastomycosis suggested that the etiologic organism, Blastomyces dermatitidis, may be acquired at home, however this view was challenged in an editorial. METHODS: 1) Field study of 2 properties that preliminarily suggested disease acquisition in the home. Owner interviews, site visits and environmental cultures using our in-vitro technique were used. 2) An address registry of human and dog blastomycosis cases was constructed from extensions of our previously published case series. 3) Literature review. RESULTS: 1) Blastomycosis occurred in a dog (December, 1998) and then a cat confined to its home (September, 1999), from a household in urban Manitowoc County, WI; and additionally in a house-confined cat (July, 1998) at a home in Milwaukee, WI. Interviews implicated the basement and the attic or basement, respectively, as the most likely source of infection at these homes. Environmental cultures were negative for Blastomyces. Of the 229 domiciles in the registry, a minimum of 27 (12%) were associated with more than one blastomycosis case, 10 sites with more than two and 7 with more than three. In 4 domiciles, repeat cases occurred in different families. Most cases were separated by 1 year or more (range: 3 weeks to 7 years). Recent case series reveal a minority of outdoor activities and occupations among humans with blastomycosis. The organism has been isolated from an inhabited yard and from a house being razed. CONCLUSIONS: There appears to be growing evidence that blastomycosis may be acquired at home, and that B. dermatitidis may be relatively persistent on certain properties.
The arguments in favour of caring for psychiatric patients in locations which are close to their domicile, are by no means new. Practically all of these arguments had already been brought forward by Griesinger, and we can also read them up in the minutes of the meetings of the Federal Germany Parliamentary Committee for Youth, Family and Health Problems. A frequent argument against the decentralisation of psychiatric care by setting up psychiatric departments in general hospitals is that this would eventually lead to a kind of two-class psychiatry. In simplified language, this would imply that those patients who are acutely diseased, are admitted to a general hospital, whereas the chronically diseased persons remain in the large-scale psychiatric Land hospital. However, this is not necessarily so, if such psychiatric departments of regional competence are compulsorily allocated to a certain area, which means they are compelled to admit patients residing in their area, while being prohibited from transferring these patients to another, far-away hospital. The departments in Rheydt and Hanover, for example, show that relevant experience collected outside Germany applies likewise to the Federal Republic. In fact, the reports published by these two hospitals show that psychiatry conducted close to the domicile of the patients improves outpatient follow-up of patients with chronic disturbances, whereas the number of compulsory admissions is dramatically reduced. On the other hand, the rate of admission is increased, and the period of hospitalisation reduced. In the long run, this results in a pattern of psychiatric care in which long-term outpatient therapy predominates. We can sum up by saving that community-centered and population oriented working is by no means a panacea for all problems of psychiatric care which have remained unsolved to data. However, experience has shown that the method is feasible and, on the whole a promising one. It is precisely the return of psychiatry to the communal level which opens up non-professional resources which would otherwise remain untapped. It must be borne in mind, however, that the physician's own psychiatric practice is exposed to the public eye to greater extent than before. This offers a real chance. The psychiatrist can take advantage of this chance only if he develops a kind of sixth sense for social processes and requirements within the community, for the best way to influence them, and to make use of them for translating one's own goals into reality. Of course, this will always involve the risk of overstepping one's own area of jurisdiction, but this need not be dramatised.
UNLABELLED: The prevalence of obesity in children has increased dramatically during the past decades, and requires efficient care. OBJECTIVES: To determine changes in anthropometric parameters and basal metabolic rate (BMR) in obese adolescents during and after 2 types of weight-reduction programs. SUBJECTS AND METHODS: Twenty-six adolescents (group I, Z-score of BMI = 4.72) followed a 9-month-weight reduction program including a moderate energy restriction and regular physical activities in a specialized institution. In addition, 39 adolescents (group E, Z-score of BMI = 2.83) followed at home a 9-month-weight reduction program including medical and dietetic advices. Body composition (by impedancemetry) and BMR (by indirect calorimetry) were assessed before the beginning (M0), 4 months after (M4) and at the end (M9) of the programs, then 4 months (M13) and 16 month (M25) after the end of the weight-reduction programs. RESULTS: Twenty-two adolescents in group I and 20 adolescents in group E completed the study. At M0, age, body weight (BW), fat-free mass (FFM) and BMR of subjects of group I were higher (1.0 year, 36 %, 30 % and 23 %, respectively, P < 0.001), than those of group E. Pubertal stage and percentage of fat mass (FM) were not significantly different between the 2 groups. At M9, adolescents of group I showed significant reductions in BW and FM (-19 and -37 %, respectively, P < 0.001), but not significant differences in FFM. In addition, BMR decreased significantly between M0 and M4, both in absolute value (-6.7%, P < 0.001) and after adjustment for FFM (-5.8%, P < 0.001), and the difference was maintained until M9. Between M9 and M13, BW and Z-score of BMI were maintained in 12 adolescents, but increased (+9.7% and 14.8%, respectively, P < 0.001) in 10 adolescents. However, BMR did not change significantly in all adolescents. Between M13 and M25, BW, FM, FFM and BMR increased significantly (+13%, +34%, +6% et +5%, respectively, P < 0.001). During the 25 month period, adolescents of group E showed significant increases in BW, FFM and BMR (+8%, +14% and +10%, respectively, P < 0.001), and maintained their Z-score and FM. CONCLUSION: The reduction in BMR during the weight-reduction program at the institution could contribute to body weight regain in the post-obese adolescents if they do not maintain the lifestyle habits taught during the weight-reduction period. In other respects, Z-score was stabilized in 51% of domiciled obese adolescents.
The aim of this study was to examine risk factors for and causes of mortality in patients with obstructive sleep apnoea syndrome (OSAS) treated by nasal continuous positive airway pressure (CPAP). Univariate and multivariate analyses of the data on patients registered in the Association Nationale pour le Traitement A Domicile de l'Insuffisance Respiratoire chronique (ANTADIR) Observatory between January 1, 1985 and December 31, 1993 and followed to January 1, 1996. Survival ratios were compared to those of the French population. A case control study compared patients who died with patients of the same age and sex, in the same Regional Association, who were equipped with CPAP at the same time. Five-thousand-six-hundred-and-sixty-nine patients had CPAP treatment. Two-hundred-and-seventy-six had died. One-hundred-and-twenty-four deaths were examined and compared to 123 control subjects. Overall mortality was the same as the general French population. Independent risk factors for death were age, oxygen tension in arterial blood (Pa,O2) and forced expiratory volume in one second (FEV1) (per cent predicted). In the case-control study independent risk factors for death in the past history were cardiac arrhythmia with an odds ratio (OR) of 2.8 (95% confidence interval (CI) 1.1-7.2), respiratory disorders (OR 2.8; CI 1.6-4.9) ischaemic events (OR 2.2; CI 1.2-4.2), neurological and psychiatric disorders (OR 2.4; CI 1.1-5.4). A significant excess of cardiovascular deaths and an excess of deaths from accidents and poisonings was found. In conclusion, patients die on therapy predominantly from cardiovascular causes but many have a past history of cardiovascular conditions. Compliance with treatment may be important for survival. Continuous positive airway pressure is an effective therapy for obstructive sleep apnoea syndrome but older patients with reduced spirometry and hypoxaemia may need more attention paid to these aspects of their condition.
Data were collected on indicators of mental health status and substance abuse among 214 homeless and 250 domiciled but impoverished patients who sought care in a community medical clinic in a California beach community. Although both groups had a high prevalence of problems, homeless patients were significantly more likely to have been hospitalized for alcohol or mental problems, to have been arrested because of drinking, and to have experienced delirium tremens. Homeless persons were also more likely to have made a suicide attempt, to have experienced recent psychotic symptoms, and to be dissatisfied with life. The findings suggest that primary medical care settings serving the poor and homeless may present an excellent opportunity for delivering mental health services and that psychiatrists should expand their involvement in such settings.
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Concentration of three heavy metals (mercury (Hg), lead, (Pb), and cadmium, (Cd)) and one metalloid (arsenic [As]), were determined by atomic absorption spectrophotometry in five tissues (muscles, liver, kidneys, gills, and gonads) of five fish species (carp-Cyprinus carpio, tench-Tinca tinca, sval-Leuciscus svallizi, gray mullet-Mugil cephalus, and eel-Anguilla anguilla) taken out from the end fIow (last 20 km) of the river Neretva, south Croatia, in the wider region of town Metković, during the summer of the year 2003. Only Cd concentration in all fish types was higher than the maximal allowed concentration (MAC) in Croatia, but its concentration in muscles reaches this value only in four samples. However, in carp, tench, and mullet, Cd concentrations higher than MAC in some other countries were found. Hg concentration is much lower than MAC in the most countries. Pb is found in higher quantities only in carp, some values reaching MAC in Germany, and many values being higher than MAC in Denmark (with exception of gonads). As concentrations are much lower than MAC in all countries, but it seems that mullet tends to accumulate this metalloid, especially in the muscles. Therefore, in several samples, muscle As concentration in mullet reached half of the MAC value in the most countries. Of the analyzed fish types, eel, containing the smallest quantities of heavy metals, is recommended for human diet, while carp, consumed most frequently by local inhabitants and numerous tourists, shares with mullet the last place on the recommendation list. Also, it is suggested that meals prepared with analyzed fish sorts should not contain some inner organs (kidneys and liver), as well as gills (alternatively, the whole head). Our final conclusion is that fish types eating predominantly meat contain less heavy metal in their tissues, and therefore are more suitable for human diet.
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