Biomedical subjects
Publications and source records attributed to R Feldman.
A 50-year-old man arrives in the emergency room with signs and symptoms occurring intermittently over a period of 48 h consistent with a myocardial infarction. He has several major risk factors for a recurrent event. A number of management strategies have already been attempted. Two opinions for further management are presented.
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 (AT1) receptor blockers are two separate classes of drugs. Although they are both effective antihypertensive agents, they exert their effects through different pharmacological mechanisms. Nonetheless, they have often proved indistinguishable in terms of the surrogate endpoints used in short term clinical studies. Considerable data are available on the long term benefits of ACE inhibition; however, studies looking at the long term effects of AT1 receptor blockade are not yet complete. If ACE inhibitors prove to be distinguishable from AT1 receptor blockers in terms of disease-related outcomes, the reason may be the selective effects of ACE inhibitors on insulin resistance and insulin-mediated vascular function.
OBJECTIVE: To assess the effects of payment methods on the costs of care in medical group practices. DATA SOURCES: Eighty-six clinics providing services for a Blue Cross managed care program during 1995. The clinics were analyzed to determine the relationship between payment methods and cost of care. Cost and patient data were obtained from Blue Cross records, and medical group practice clinic data were obtained by a survey of those organizations. STUDY DESIGN: The effects of clinic and physician payment methods on per member per year (PMPY) adjusted patient costs are evaluated using a two-stage regression model. Patient costs are adjusted for differences in payment schedules; patient age, gender, and ACG; clinic organizational variables are included as explanatory variables. DATA COLLECTION: Patient cost data were extracted from Blue Cross claims files, and patient and physician data from their enrollee and provider data banks. Medical group practice data were obtained by a mailed survey with telephone follow-up. PRINCIPAL FINDINGS: Capitation payment is correlated with lower patient care costs. When combined with fee-for-service with withhold provisions, this effect is smaller indicating that these two clinic payment methods are not interchangeable. Clinics with more physician compensation based on measures of resource use or based on some share of the net revenue of the clinic have lower patient care costs than those with more compensation related to productivity or based on salary. Salary compensation is strongly associated with higher costs. The use of physician profiles and clinical guidelines is associated with lower costs, but referral management systems have no such effect. The lower cost clinics are the smaller, multispecialty clinics. CONCLUSIONS: This study indicates that payment methods at both the medical group practice and physician levels influence the cost of care. However, the methods by which that influence is manifest is not clear. Although the organizational structure of clinics and their use of managed care programs appear to play a role, this influence is less than expected.
Atrophic gastritis is an autoimmune gastropathy in which there is destruction of gastric parietal cells. This results in intrinsic factor deficiency and disturbance in vitamin B12 absorption. Its clinical manifestationa are therefore the consequences of B12 deficiency and include anemia and neurological defect. In addition, lack of B12 results in metabolic changes, including disturbances of methionine metabolism and accumulation of homocysteine. In recent years, there has been increasing evidence suggesting that hyperhomocysteinemia is a risk factor for thrombo-embolic disease. We describe a 51-year-old man with atrophic gastritis, severe B12 deficiency and hyperhomocysteinemia. The initial clinical manifestation was pulmonary embolism, without either anemia or neurological signs. B12 deficiency should therefore be considered in patients being investigated for hypercoagulability.
There is a new and growing interest among community mental health providers and administrators in the area of correctional psychiatry. From a column in Psychiatric Times to committees and task forces in APA and the American Academy of Psychiatry and the Law, increased attention is being paid to the great need for the treatment of mentally ill offenders. In this article, we will introduce the reader to the magnitude of the correctional system and to the prevalence of mental illness in the correctional population. We will then describe several model programs designed to work with mentally disordered offenders, and outline a novel collaborative approach between a CMHC and a Probation Office designed to help mentally disordered offenders succeed in community treatment. Several barriers to treatment faced by this population will be identified, including double stigma, lack of family/social support, comorbidity, adjustment problems, and boundary issues. Case vignettes designed to illustrate key points will be included.
This study examined relations between mother-infant affect synchrony and the emergence of children's self-control. Mother-infant face-to-face play and infant difficult temperament were examined at 3 and 9 months. Maternal and infant affective states at play were coded in 0.25-s frames, and synchrony was computed with cross-correlation functions. Self-control, verbal IQ, and maternal warm discipline were assessed at 2 years. Maternal synchrony with infant affect at 3 months (infant-leads-mother-follows relation) and mutual synchrony at 9 months (cross-dependence between maternal and infant affect) were each related to self-control at 2 years when temperament, IQ, and maternal style were partialed. Infant temperament moderated the relations of synchrony and self-control, and closer associations were found between mutual synchrony and self-control for difficult infants. Shorter lags to maternal synchrony at 3 months were independently related to self-control. The mutual regulation of affect in infancy, as moderated by temperament, is proposed as an important contributor to the emergence of self-regulation.
OBJECTIVE: To determine whether children with borderline pathology have a specific pattern of psychological risk factors. METHOD: The subjects were 94 school-age children in day treatment, divided into borderline (n = 41) and nonborderline (n = 53) groups using the child version of the Retrospective Diagnostic Interview for Borderlines. All children were assessed using the Child Behavior Checklist, the Schedule for Affective Disorders and Schizophrenia for School-Age Children, and the Psychosocial Questionnaire. Parental pathology was assessed by a computerized version of the Structured Clinical Interview for DSM-III-R. RESULTS: Children with borderline pathology had higher rates of physical abuse, sexual abuse, severe neglect, as well as family breakdown and parental criminality. In multivariate analyses, the discriminating factors were sexual abuse and parental criminality. Borderline pathology was highly comorbid with conduct disorder, but most of these results remained significant in reanalyses comparing children with and without conduct disorder. CONCLUSIONS: Borderline pathology in children has a unique pattern of risk factors not accounted for by conduct disorder alone.
This study focuses on early parental preoccupations and behaviors (EPPB) surrounding the birth of a new family member. An interview instrument was developed to assess EPPB at eight months prepartum and two weeks and three months postpartum. Measures with adequate psychometric and conceptual properties were used to assess the overall level of parental preoccupations and associated actions as well as three content domains: caregiving (CARE), relationship building (RELATIONSHIP), and anxious intrusive thoughts associated with harm avoidant behaviors (AITHAB). The hypothesis that preoccupations and behaviors would peak for both parents close to the birth of the child was confirmed. Measures of EPPB were distinguished from symptoms of depression and generalized anxiety. Consistent with our a priori hypothesis the content and character of the AITHAB was found to resemble the symptoms of obsessive-compulsive disorder (OCD). The study findings suggest the potential adaptive significance of EPPB and the possible evolutionary origins of OCD.
Two methylenecyclopropane nucleoside analogues with a phenylphosphoralaninate moiety, QYL-685 and QYL-609, exert potent and specific activities against human immunodeficiency virus type 1 strain LAI (HIV-1(LAI)) and HIV-2 in vitro. In this study, we induced HIV-1 variants resistant to QYL-685 by exposing HIV-1(LAI) to increasing concentrations of QYL-685. After 16 passages, the virus (HIV-1(P16)) was less sensitive to QYL-685 (104-fold), QYL-609 (>41-fold), and (-)-beta-2',3'-dideoxy-3'-thiacytidine (3TC) (>1, 100-fold) than was HIV-1(LAI) and contained an M184I mutation. Two infectious clones, HIV-1(M184I) and HIV-1(M184V), were resistant to QYL-685, QYL-609, and 3TC, confirming that the M184I mutation was responsible for the observed resistance. Viral-fitness analyses (competitive HIV-1 replication assays) revealed that in the absence of drugs, M184I and M184V conferred a replication disadvantage on the virus compared to the replication efficiency of the wild-type infectious clone (HIV-1(wt)). However, in the presence of QYL-685 (4 microM), HIV-1(M184I) and HIV-1(M184V) showed greater fitness than HIV-1(wt). These data may provide structural and virological relevance with regard to the emergence of M184I and M184V substitutions in HIV-1.
OBJECTIVE: The paper describes initial results of collaboration between a mental health treatment program at a community mental health center in Baltimore and a probation officer of the U.S. federal prison system to serve the mental health needs of offenders on federal probation, parole, supervised release, or conditional release in the community. METHODS: A forensic psychiatrist in the treatment program and a licensed social worker in the probation office facilitate the close working relationship between the agencies. Treatment services provided or brokered by the community mental health center staff include psychiatric and medical treatment, intensive case management, addictions treatment, urine toxicology screening, psychosocial or residential rehabilitation services, intensive outpatient care, partial hospitalization, and inpatient treatment. RESULTS: Among the 16 offenders referred for treatment during the first 24 months of the collaborative program, 14 were male and 14 were African American. Three of the 16 violated the terms of their release due to noncompliance with stipulated mental health treatment; only one of the three had been successfully engaged in treatment. One patient died, two completed their terms of supervision, and ten remained in treatment at the time of the report. CONCLUSIONS: The major strength of this collaboration is the cooperation of the treatment and monitoring agencies with the overall goal of maintaining the offender in the community. Further research is needed to confirm the effectiveness of the clinical model in reducing recidivism and retaining clients.
Higher fruit and vegetable consumption is associated with a reduced risk of certain cancers and chronic diseases. The 5-a-Day for Better Health community studies are evaluating population-based strategies to achieving dietary behavior change using the stages-of-change model and associated theories. The authors present baseline comparisons of stages of change for fruit and vegetable consumption among adults and young adults in eight study sites representing diverse regions of the United States and diverse populations and settings. Three dominant stages, precontemplation, preparation, and maintenance, were found across sites. Women and those with college degrees were more likely to be in action/maintenance. Fruit and vegetable consumption, self-efficacy, and knowledge of the 5-a-Day recommendation were positively associated with more advanced stages of change in all study sites. The authors discuss the findings in relation to possible limitations of this and other dietary stages-of-change measures and suggest directions for future research.
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STUDY QUESTIONS: To determine factors that distinguish effective rural hospital consortia from ineffective ones in terms of their ability to improve members' financial performance. Two questions in particular were addressed: (1) Do large consortia have a greater collective impact on their members? (2) Does a consortium's economic environment determine the degree of collective impact on members? DATA SOURCES AND STUDY SETTING: Based on the hospital survey conducted during February 1992 by the Robert Wood Johnson Hospital-Based Rural Health Care project of rural hospital consortia. The survey data were augmented with data from Medicare Cost Reports (1985-1991), AHA Annual Surveys (1985-1991), and other secondary data. STUDY DESIGN: Dependent variables were total operating profit, cost per adjusted admission, and revenue per adjusted admission. Control variables included degree of group formalization, degree of inequality of resources among members (group asymmetry), affiliation with other consortium group(s), individual economic environment, common hospital characteristics (bed size, ownership type, system affiliation, case mix, etc.), year (1985-1991), and census region dummies. PRINCIPAL FINDINGS: All dependent variables have a curvilinear association with group size. The optimum group size is somewhere in the neighborhood of 45. This reveals the benefits of collective action (i.e., scale economies and/or synergy effects) and the issue of complexity as group size increases. Across analyses, no strong evidence exists of group economic environment impacts, and the environmental influences come mainly from the local economy rather than from the group economy. CONCLUSION: There may be some success stories of collaboration among hospitals in consortia, and consortium effects vary across different collaborations. RELEVANCE/IMPACT: When studying consortia, it makes sense to develop a typology of groups based on some performance indicators. The results of this study imply that government, rural communities, and consortium staff and steering committees should forge the consortium concept by expanding membership in order to gain greater financial benefits for individual hospitals.
Assessment of the caregiver-child relationship has become an intrinsic part of the preschool child psychiatric evaluation. Normal and abnormal development of relationship is influenced by a myriad of genetic, psychological, cultural, and environmental factors in both the caregiver and the young child. In the past, professionals from different fields, like pediatrics, neurology, development, and social welfare, would understand the child and his or her environment with their own tools. Since then, these parallel lines have converged into a more complementary and integrated view. The need to evaluate the caregiver, the child, the caregiver-child interaction, and the context of the relationship makes the evaluation a challenging multidisciplinary process, in which standardized assessment tools have to be integrated into a sound clinical conceptualization of the evaluated relationship.
OBJECTIVE: To determine whether children with borderline pathology have a specific pattern of neuropsychological risk factors. METHOD: The subjects were 94 school-age children in day treatment, divided into borderline (n = 41) and nonborderline (n = 53) groups according to results of the Child version of the Diagnostic Interview for Borderlines. All children were assessed with the Child Behavior Checklist, the Schedule for Affective Disorders and Schizophrenia for School-Age Children, and a neuropsychological battery. RESULTS: Children with borderline pathology had abnormal scores on the Wisconsin Card Sorting Test and on the Continuous Performance Test, both of which suggested problems with executive function. Although borderline pathology was highly comorbid with conduct disorder, most results were independent of this comorbidity. CONCLUSIONS: Borderline pathology in children has a unique pattern of neuropsychological risk factors that may reflect a diathesis for this syndrome.
This paper suggests that the Federal Employees Health Benefits Program (FEHBP) is perhaps a model for Medicare reform. First, we introduce the FEHBP and describe important features, such as the method for determining the government's premium contribution. Second, we examine the cost performance of the FEHBP program, and conclude that the FEHBP has out-performed private health insurance programs and Medicare in its ability to control costs. Third, we discuss the problem of adverse selection in the FEHBP. We conclude that the FEHBP has experienced some selection problems, but not enough to prevent it from offering a wide variety of choices without standardized benefits or direct risk adjustment. For a demonstration of competitive pricing in Medicare, the fourth section compares the FEHBP to two models of Medicare reform: "FEHBP for Medicare," proposed by Butler and Moffit; and the "Denver design."
Attachment has generally been examined from the infant's perspective. We focused on mothers' post-partum thoughts and behaviors. Guided by an ethological approach, maternal bonding was examined under conditions of proximity, separation, and potential loss. Ninety-one mothers were interviewed: mothers of full-term infants who maintained continuous proximity to the infant, mothers of healthy premature infants who were separated from the infant, and mothers of very low birthweight infants who experienced potential loss and prolonged separation. Mothers of term infants reported medium-to-high levels of preoccupations with thoughts of infant safety and well-being. Preoccupations increased with separation (Group 2) and significantly decreased with impending loss (Group 3). Attachment behaviors and representations were the highest among mothers of term infants and declined linearly with the duration of mother-infant separation. Maternal trait anxiety and depression were related respectively to higher levels of preoccupations and reduced attachment behaviors and representations, independent of the infant medical condition and mother-child separation. Discussion focused on the comparability of maternal and infant attachment in relation to the neurobiological system underlying bond formation.
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