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[Behavior therapy and communication theory as treatment for inpatients with anorexia nervosa (author's transl)].

A staged program for inpatient treatment of anorexia nervosa is presented. This program integrates behaviour-therapeutic and interactional models. Results show that five of seven patients completed the program successfully and maintained their stable condition after an average catamnestic period of 16 months. The necessity of integrating both models and the practical difficulties in a clinical setting are discussed.

Adolescent↗

A curriculum based on systems theory.

This paper describes an entry-level curriculum based on systems theory that was designed to promote integrated thinking and a shared image of practice among all of the members of an educational community that included students, faculty, and clinicians. Initiated in 1983, the program integrates occupational therapy theory, critical thinking, and knowledge about person-environmental transactions with traditional medical, biological, psychological, and sociological course work to create a unique educational experience. The curriculum model is based on a spiral learning process that encourages integrated thinking. Furthermore, all concepts are systematically tied to the occupation core, the central theme of the program. Fieldwork is used to reinforce ideas presented in the classroom and features discrete learning experiences where students demonstrate their integration of knowledge and skills. In an evaluation of the program, responses from 78 clinician, 51 alumni, and 132 student questionnaires; feedback from 132 fieldwork supervisors; and longitudinal data from 33 alumni confirmed that graduates are critical thinkers who appreciate the diverse needs of clients while demonstrating an appreciation for the curative effect of meaningful, goal-directed activities.

Curriculum↗

Trends in acute mental health care: comparing psychiatric and substance abuse treatment programs.

This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs' programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The author's suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (e.g., by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).

Acute Disease↗

Strategies for the physiome project.

The physiome is the quantitative description of the functioning organism in normal and pathophysiological states. The human physiome can be regarded as the virtual human. It is built upon the morphome, the quantitative description of anatomical structure, chemical and biochemical composition, and material properties of an intact organism, including its genome, proteome, cell, tissue, and organ structures up to those of the whole intact being. The Physiome Project is a multicentric integrated program to design, develop, implement, test and document, archive and disseminate quantitative information, and integrative models of the functional behavior of molecules, organelles, cells, tissues, organs, and intact organisms from bacteria to man. A fundamental and major feature of the project is the databasing of experimental observations for retrieval and evaluation. Technologies allowing many groups to work together are being rapidly developed. Internet II will facilitate this immensely. When problems are huge and complex, a particular working group can be expert in only a small part of the overall project. The strategies to be worked out must therefore include how to pull models composed of many submodules together even when the expertise in each is scattered amongst diverse institutions. The technologies of bioinformatics will contribute greatly to this effort. Developing and implementing code for large-scale systems has many problems. Most of the submodules are complex, requiring consideration of spatial and temporal events and processes. Submodules have to be linked to one another in a way that preserves mass balance and gives an accurate representation of variables in nonlinear complex biochemical networks with many signaling and controlling pathways. Microcompartmentalization vitiates the use of simplified model structures. The stiffness of the systems of equations is computationally costly. Faster computation is needed when using models as thinking tools and for iterative data analysis. Perhaps the most serious problem is the current lack of definitive information on kinetics and dynamics of systems, due in part to the almost total lack of databased observations, but also because, though we are nearly drowning in new information being published each day, either the information required for the modeling cannot be found or has never been obtained. "Simple" things like tissue composition, material properties, and mechanical behavior of cells and tissues are not generally available. The development of comprehensive models of biological systems is a key to pharmaceutics and drug design, for the models will become gradually better predictors of the results of interventions, both genomic and pharmaceutic. Good models will be useful in predicting the side effects and long term effects of drugs and toxins, and when the models are really good, to predict where genomic intervention will be effective and where the multiple redundancies in our biological systems will render a proposed intervention useless. The Physiome Project will provide the integrating scientific basis for the Genes to Health initiative, and make physiological genomics a reality applicable to whole organisms, from bacteria to man.

Computer Simulation↗

Enhancing outcomes in an indicated drug prevention program for high-risk youth.

This study examined the net effects of refining a high school-based indicated drug prevention program. The Personal Growth Class (PGC), tailored to meet the needs of high-risk youth, was designed to increase control of drug use, school performance, and emotional well-being. The program integrates social support and life-skills training. Process evaluation revealed the need for program enhancements to address underestimated levels of depression, anger, and suicidal behaviors prevalent among high-risk youth and to ensure that core content was being emphasized consistently. Youth participating in Late cohorts received the refined PGC with enhanced skills training. Study participants (N = 280) were youth, primarily ages fifteen to-seventeen, at high-risk for school failure or dropout. Indicators of emotional well-being (e.g., depression, stress, anger, self-esteem, personal control), drug involvement, and school performance were compared for Late versus Early cohorts. Regression analyses revealed the Late versus Early cohorts showed significantly greater decreases in hard drug use, depression, perceived stress, and anger, and greater increases in self-esteem. The results support arguments that effective indicated prevention programs should target specific high-risk youth employing strategies to counteract the multifaceted risk factors they experience and enhance needed protective factors.

Adolescent↗

Fine particles and oxidant pollution: developing an agenda for cooperative research.

This paper describes a background for the North American Research Strategy for Tropospheric Ozone (NARSTO) cooperative program integrating studies of O3 and PM2.5. It discusses several important aspects for rationalizing NARSTO's trinational investigative approach, including (1) an outlook on the state of knowledge about fine particles in the troposphere and their origins in Canada, Mexico, and the United States; (2) the need for enhancement and strengthening of key field measurements in relation to tropospheric chemistry and a health effects component; and (3) the use of a central theme for advancing air quality modeling using evolving techniques to integrate and guide key process-oriented field campaigns. The importance of organizing a scientific program to acquire "policy-relevant" information is stressed, noting cooperative research directions that address combined PM2.5 and O3 issues, illustrated through exploration of hypothetical pathways of PM2.5 response to choices of O3 and PM precursor emission reductions. The information needed for PM2.5 research is noted to intersect in many cases with those of O3, but diverge in other cases. Accounting for these distinctions is important for developing NARSTO's strategy over the next decade.

Air Pollution↗

An innovative strategy for conducting clinical research: the academic associate program.

Performance of high-quality clinical research usually requires procurement of substantial funding to support and sustain the research infrastructure. The authors have developed a program to support a research infrastructure that minimizes financial start-up costs and maximizes productivity of clinical-educator faculty with limited protected time. The program integrates clinical research with undergraduate education. The authors report the experience with the academic associate program at two academic institutions. They describe the program, provide measures of program success, and discuss potential methods for other institutions to initiate similar programs. Similar programs can be developed in a variety of outpatient and inpatient settings allowing the performance of high-quality clinical research in a time-efficient and cost-effective manner.

Academic Medical Centers↗

[The integration of teaching and care: a conceptual approach].

The author describes the origin of community medicine, its diffusion and the source of Teaching-Caring Integration Programs. Besides this, she points out the fundamental concepts that identify the Teaching-Caring Integration as an of teaching-service integration.

Brazil↗

The role of the EAP in the identification and treatment of substance abuse.

Employee Assistance Programs (EAPs) are cost-effective strategies for employers to contain the substantial direct and indirect costs of substance abuse in the workplace. EAPs offer prevention, early detection, assessment of referral, and after-care programs to help stem the enormous costs of substance abuse in the workplace. Most effective employer substance abuse programs integrate drug-testing and EAP services to ensure a well coordinated, cost-effective program.

Humans↗

[Program of community integration: search for new strategies and new life styles].

The Program of Community Integration of the Municipal Bureau of Health of the city of Ribeirão Preto aims at promoting health, directing its actions for the change of life styles. The purpose of this study is to look, in the light of the framework of Health Promotion and through declarations of users of the program, how it has been formed as an important strategy to increase the autonomy and emancipation of the population. The analysis reveals that the program has improved the autonomy and emancipation of the population, as an important instrument for life defence.

Brazil↗

[The prevention of acute disorders of cerebral circulation: the theory and the reality].

It would be valid to conduct prophylaxis of acute cerebrovascular disturbances (ACVD) in the context of state integral program of prophylaxis of the main noninfectious diseases. Its basic principles are: control of risk factors, integral approach and priority of populational strategy. The main medical directions of ACVD prophylaxis are: control of arterial hypertension and prevention of cardioembolic insult in patients with heart rhythm disorders. It is also possible to prevent repeated ACVD in patients with transitory ischemic attacks and minor insults. The best result is prognosed in combination of the state policy of providing the healthy mode of life of population and medical prophylaxis of ACVD in high risk groups.

Acute Disease↗

Predicting vocational functioning and outcome in schizophrenia outpatients attending a vocational rehabilitation program.

BACKGROUND: Vocational rehabilitation is a central issue in the rehabilitation of patients with chronic schizophrenia. However, even with the help of comprehensive integration programs, achieving this objective remains a very ambitious and difficult undertaking. Therefore, a profound and up-to-date knowledge of vocational functioning and outcome predictors in patients who have the goal to return into competitive employment is imperative. The objective of the present study was to test the predictors summarized in the recent review of Cook and Razzano, as well as to test those predictors specified in the nine hypotheses put forward by Anthony and Jansen in schizophrenia patients enrolled in a vocational rehabilitation program. METHODS: The predictive value of ten hypotheses centering on vocational functioning and outcome were consecutively tested in a sample of 53 schizophrenia patients. Those predictors identified as significant were then taken into a 'winner take all' regression in order to determine which of them were the best. RESULTS: The overall work performance observed in a workshop proved to be the best predictor of vocational functioning. Contrary to the pivotal claim in Anthony and Jansen's review, in our sample, negative symptoms indeed influenced vocational functioning, outcome and functional skills. Cognitive impairments, social competence and fatalistic control beliefs also had predictive value for vocational functioning and outcome. CONCLUSIONS: These results reflect the accumulated findings of the past decade as summarized by Cook and Razzano. Moreover, they serve to substantiate the necessity of promoting the concept of cognitive remediation and associated programs designed to transform fatalistic beliefs into feelings of hopefulness, thereby enhancing the readiness of schizophrenia patients to enroll in rehabilitation programs.

Adult↗

A model for educating humanistic physicians in the 21st century: the new medicine, patient, and society course at Tel Aviv University.

BACKGROUND: The impact of the social and behavioral sciences on medical education has often been limited due to a variety of organizational, curricular and professional barriers. The new "Medicine, Patient, and Society (MPS)" program in Tel Aviv attempts to rectify this educational shortcoming by exploring new ways to help students acquire the knowledge, attitudes and skills needed for becoming humanistic physicians and for helping patients (and themselves) adopt healthy behaviors. To work toward this goal, this program integrates the biomedical and psychosocial aspects of health care, providing developmentally appropriate learning experiences according to levels of training, together with a variety of educational methods, including learner-centered approaches. OBJECTIVES: To implement and evaluate the MPS pilot program. METHODS: The MPS program uses a "seamless" model of behavioral science education. This integrated curriculum interweaves several elements: behavioral science topics (presented through multiple approaches), clinical experiences, practical medical skills, and an independent project. During the program's first year there is a strong focus on "health" rather than "disease," with activities designed to encourage healthy behaviors, including smoking cessation, stress management, birth control, AIDS education, life cycle and preventive health services. Assessment of the pilot for first-year students included standardized questionnaires, student focus groups, participant observation of educational activities, and committee feedback. RESULTS: Students' quantitative evaluations indicated high levels of satisfaction with the MPS program, but their qualitative evaluations revealed some concerns. Participant observations and focus groups added unexpected insights. Student concerns included performance fears, difficulties with "learner-centered" education, and incompatibilities between more traditional first-year courses and the MPS program. Long-term follow-up will be needed to determine the impact of this emphasis on health during the first year. We assume it serves as a helpful foundation for students before they focus on disease and its sequelae in their later years.

Journal Article↗

Vertical integration strategies: revenue effects in hospital and Medicare markets.

The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post-hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue.

California↗

The effect of an integrated stress management program on the psychologic and physiologic stress reactions of peptic ulcer in Korea.

The purpose of this study was to identify the effects of an integrated stress management program on symptoms of stress and ulcer healing in a sample of Koreans at a major medical center in Seoul, Korea. The study employed an experimental design with two treatment groups. One treatment group (n=23) participated in an integrated stress management program that consisted of seven 1h sessions over a 4-week period. A second treatment group (n=24) was only given a tape on progressive muscle relaxation. Data were collected over a 4-month period on 47 subjects. Participants were randomly assigned to the two treatment groups. Symptoms of stress were measured by the symptoms of stress scale (Kogan, Self-regulation on Stress Reaction by Biofeedback, Korean Psychiatric Academic Society, Korea) translated into Korean. Stage of ulcer healing was evaluated by a physician using an endoscope. Physiologic stress reactions were measured by biofeedback equipment. The integrated stress management program treatment group reported significantly lower stress symptom scores than the progressive muscle relaxation-only group (t=3.66, P<0.001). The integrated stress management group also demonstrated a greater improvement in ulcer healing than the progressive muscle relaxation group (t=1.95, P<0.05). The integrated stress management program was more effective in decreasing self-reported stress symptoms and resulted in a more significant ulcer healing than the progressive muscle relaxation treatment.

Adolescent↗

Social work and primary health care: an integrative approach.

An interinstitutional, interagency Consortium has been formed in Houston to develop an innovative service model and provide interdisciplinary primary care/mental health training. The Houston Consortium Program integrates mental health professionals and trainees into the primary care framework of a neighborhood center serving a low-income, predominatly Mexican-American population. The introduction of mental health, psychosocial, and cross-cultural perspectives to complement the long-standing physiological concerns of health professionals fosters an holistic approach to patient care. The social workers' full participation as members of primary care teams builds upon their traditional training to provide them the experience and skills required to function effectively in the expanded coordinative capacity of health/mental health manager as defined by the President's Commission on Mental Health. It is anticipated that Consortium Program can serve as a heuristic model in the development of a nationwide pattern of comprehensive care.

Community Health Centers↗

International Health Fellowship: a proposed curriculum for emergency physicians.

There are a growing number of emergency physicians (EPs) working in health care abroad. There are, however, no formal training programs for EPs in international health. An International Health Fellowship has been developed to provide training for EPs in public health and international medicine. The fundamental competencies of a fellow completing the International Health Fellowship include assessment of medical need, program development, integration of programs into the existing health care framework, and evaluation of projects. This article outlines the philosophy of a training program in international health, provides an overview of the goals and objectives for such a program, and describes the development of an existing fellowship. The International Health Fellowship will develop leaders in the field of global health by combining clinical expertise, practical field experience, formal public health training, and research and education in international health. Physicians completing a fellowship will be prepared to work within foreign health systems to develop, integrate, and evaluate health care programs on an international scale.

Curriculum↗

A review of clinical characteristics and residential treatments for adolescent delinquents with mental health disorders: a promising residential program.

As treatment systems throughout the country have deinstitutionalized, under-use of community-based residential treatment systems has escalated. Reliance on juvenile justice systems for the care of the mentally ill adolescent has increased. There is considerable overlap between the mentally ill adolescent population within the community-based mental health systems and the offender population within the juvenile justice systems. With the inconsistent epidemiological prevalence and longitudinal treatment data, mental health treatment providers have also begun addressing this problem. This is currently being done by designing and implementing community-based residential mental health programs for delinquent adolescents of the juvenile justice system as well as nondelinquent adolescents within the mental health treatment systems. Providers have relied on both systems' literature in establishing theoretical treatment programs. The authors review critical treatment components currently used by both the treatment and juvenile justice systems. A promising integrative program is described.

Adolescent↗