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PubMed1995

International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: III. Clinical features affecting experts' therapeutic recommendations in anxiety disorders.

Our objective was to assemble expert clinical experience and judgment in the treatment of anxiety and related disorders in a systematic, quantitative manner. This article reports on some clinical features apart from diagnosis that may affect choice of strategy in the pharmacotherapy of anxiety disorders. A panel of internationally recognized experts in treating anxiety and depression was constituted by multistage peer nomination. Ninety percent (66 of 73) completed an extensive questionnaire. This report focuses on the expert panel's responses to questions on therapeutic options, based on multi-part case vignettes of several anxiety disorders presenting clinical variations within the same diagnosis. In the presence of higher levels of functional impairment, the experts more often recommended formal psychosocial procedures for adjustment disorder; medication for agoraphobia, social phobia, obsessive-compulsive disorder, and adjustment disorder; and polypharmacy for agoraphobia. Their therapeutic recommendations were not materially affected by chronicity in the case of panic disorder. Under the condition of heavy use of alcohol in the case of generalized anxiety disorder, the experts avoided benzodiazepines in favor of various other medications. In the presence of a serious cardiac conduction defect in the case of obsessive-compulsive disorder, they less often recommended medication. Those who did recommend medication changed their preference from tricyclic antidepressants (clomipramine) to selective serotonin reuptake inhibitors. Under the condition of a more severe precipitating event in the case of adjustment disorder, the experts were more likely to recommend both formal psychosocial intervention and medication.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

QA, RM and UM functions require coordinated information management.

The public demand for access to health care data in general has created a flurry of activity at the health care provider level. Specifically, data on quality plays a pivotal role in this competitive, litigious and cost-conscious environment. Currently, data (manual or computerized) on clinical and organizational performance is sparse, although health care institutions have traditionally had QA and related utilization review, risk management and peer review activities in place to fulfill requirements for licensing and accreditation. Where data exists in isolated pockets, little coordination or integration has occurred, thereby diminishing the potential value of the data as part of a comprehensive information system. Today, institutions are responding to the demands for QA, RM, UR data in many ways. Much progress has been made in establishing comprehensive QA programs utilizing centralized, coordinated data from multiple sources to demonstrate both clinical and organizational performance. These comprehensive programs have clearly defined the need for computerization with the ability to re-use existing information. Applying this technology, however, requires assessment and planning. Allowing department-oriented, microcomputer-based application prevents sharing of resources and in many cases results in redundant and perhaps uncoordinated data capture. Decentralizing of the decision-making process leaves the ultimate selection of computerized QA and related applications to the individual user, whose focus is generally centered on his/her own priority. These systems are frequently incompatible with other existing systems. This approach will not support the institution's need to provide timely, accurate, complete information about the quality of service rendered nor information critical for internal management and planning.(ABSTRACT TRUNCATED AT 250 WORDS)

Centralized Hospital Services↗
PubMed1992

Effective boards: how executive directors define and develop them.

There is growing recognition in the nonprofit field that the executive director has a key role in determining whether the board of directors will function effectively. To aid executives in this vital role, two recent studies defined a "good board" from the point of view of two samples of executive directors of community agencies, then sought factors related to board performance as measured by this definition. In interviews, executives whose boards scored higher than their peers on this performance measurement related how they work with their boards in such areas as recruitment of new members, financial management, fundraising, and leadership development.

Administrative Personnel↗
PubMed2005

Consciousness eclipsed: Jacques Loeb, Ivan P. Pavlov, and the rise of reductionistic biology after 1900.

The life sciences in the 20th century were guided to a large extent by a reductionist program seeking to explain biological phenomena in terms of physics and chemistry. Two scientists who figured prominently in the establishment and dissemination of this program were Jacques Loeb in biology and Ivan P. Pavlov in psychological behaviorism. While neither succeeded in accounting for higher mental functions in physical-chemical terms, both adopted positions that reduced the problem of consciousness to the level of reflexes and associations. The intellectual origins of this view and the impediment to the study of consciousness as an object of inquiry in its own right that it may have imposed on peers, students, and those who followed is explored.

Behaviorism↗
PubMed2004

Semaphorin 5A is a bifunctional axon guidance cue regulated by heparan and chondroitin sulfate proteoglycans.

The response of neuronal growth cones to axon guidance cues depends on the developmental context in which these cues are encountered. We show here that the transmembrane protein semaphorin 5A (Sema5A) is a bifunctional guidance cue exerting both attractive and inhibitory effects on developing axons of the fasciculus retroflexus, a diencephalon fiber tract associated with limbic function. The thrombospondin repeats of Sema5A physically interact with the glycosaminoglycan portion of both chondroitin sulfate proteoglycans (CSPGs) and heparan sulfate proteoglycans (HSPGs). CSPGs function as precisely localized extrinsic cues that convert Sema5A from an attractive to an inhibitory guidance cue. Therefore, glycosaminoglycan bound guidance cues provide a molecular mechanism for CSPG-mediated inhibition of axonal extension. Further, axonal HSPGs are required for Sema5A-mediated attraction, suggesting that HSPGs are components of functional Sema5A receptors. Thus, neuronal responses to Sema5A are proteoglycan dependent and interpreted according to the biological context in which this membrane bound guidance cue is presented.

Animals↗
PubMed2001

Perceived vulnerability to alcohol-related harm in young adults: independent effects of risky alcohol use and drinking motives.

Perceived vulnerability to negative outcomes can motivate heavy drinkers to adopt health-protective behavior, but little is known about determinants of perceived vulnerability to alcohol-related harm. University students (N = 286) were assessed to determine epidemiological risk status on a standardized problem drinking measure, typical reasons for drinking and cutting down, and perceived risk of experiencing alcohol-related harm. Results showed a positive relationship between problem drinking status and perceived risk of experiencing harm. However, at-risk drinkers believed that they were less likely to personally experience harm than comparable peers (p < .001), whereas not-at-risk drinkers showed no self-other differences in perceived vulnerability. Drinking motives significantly improved the prediction of perceived vulnerability when epidemiological risk status was controlled. Perceived vulnerability to alcohol-related harm is affected by problem drinking status and (independently) by the psychological functions that drinking serves.

Adult↗
PubMed2001

Report of the American Foundation for Urologic Disease (AFUD) Thought Leader Panel for evaluation and treatment of priapism.

PURPOSE: Patients with priapism often develop permanent erectile dysfunction and personal sexual distress. This report is intended to help educate the public by reviewing the varied definitions and classifications of priapism and limited literature reports of pathophysiology, diagnosis and treatment outcomes of priapism. The AUA priapism guidelines committee is responsible for creating consensus as to appropriate individual patient management of priapism by physicians. MATERIALS AND METHODS: A multidisciplinary panel, consisting of 19 thought leaders in priapism, was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease to address pertinent issues concerning the role of the urologist, primary care providers and other health care professionals in the education of the public regarding management of men with priapism. The panel utilized a modified Delphi method and built upon the peer review literature on priapism. RESULTS: The Thought Leader Panel recommended adoption of the definition of priapism as a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. Priapism is stressed to be an important medical condition that requires evaluation and may require emergency management. The classification system is categorized into ischemic and non-ischemic priapism. Essential elements of the ischemic classification are the inclusion of: (i) clinical characteristics of pain and rigidity; (ii) diagnostic characteristics of absence of cavernosal arterial blood flow; (iii) pathophysiological characteristics of a closed compartment syndrome; (iv) a time limit of 4 h prior to emergent medical care; and (v) a description of the potential consequences of delayed treatment. Essential elements of the non-ischemic classification are the inclusion of: (i) clinical characteristics of absence of pain and presence of partial rigidity; (ii) diagnostic and pathophysiological characteristics of unregulated cavernosal arterial inflow; and (iii) the need for evaluation but emphasizing the lack of a medical emergency. The panel recommended adoption of a rational management algorithm for the assessment and treatment of priapism where the cornerstone of initial assessment includes a careful clinical history, a focused physical examination and selected laboratory and/or radiologic tests. The panel recommended that specific criteria and clinical profiles requiring specialist referral should be identified. The panel further recommended that patient (and partner) needs and education concerning priapism should be addressed prior to therapeutic intervention, however only in the case of chronic management or post acute presentation evaluation should this delay intervention. Treatment goals to be discussed include management of the priapism with concomitant prevention of permanent and irreversible erectile dysfunction and associated psychosocial consequences. The panel recommended that when specific therapies for priapism are required, a step-care treatment approach based upon reversibility and invasiveness should be followed. CONCLUSIONS: The Thought Leader Panel calls for research to expand our understanding of the prevalence and diagnosis of priapism and education to create awareness among the public of the potential urgency of this condition. Critical areas to be addressed include the multiple pathophysiologies of priapism as well as multi-institutional trials to objectively assess safety and efficacy in the various treatment modalities.

Humans↗
PubMed2003

Processing by proprotein convertases is required for glypican-3 modulation of cell survival, Wnt signaling, and gastrulation movements.

Glypican (GPC)-3 inhibits cell proliferation and regulates cell survival during development. This action is demonstrated by GPC3 loss-of-function mutations in humans and mice. Here, we show that the GPC3 core protein is processed by a furinlike convertase. This processing is essential for GPC3 modulating Wnt signaling and cell survival in vitro and for supporting embryonic cell movements in zebrafish. The processed GPC3 core protein is necessary and sufficient for the cell-specific induction of apoptosis, but in vitro effects on canonical and noncanonical Wnt signaling additionally require substitution of the core protein with heparan sulfate. Wnt 5A physically associates only with processed GPC3, and only a form of GPC3 that can be processed by a convertase is able to rescue epiboly and convergence/extension movements in GPC3 morphant embryos. Our data imply that the Simpson-Golabi-Behmel syndrome may in part result from a loss of GPC3 controls on Wnt signaling, and suggest that this function requires the cooperation of both the protein and the heparan sulfate moieties of the proteoglycan.

Animals↗
PubMedDate not supplied

Demographic scope and economic magnitude of contemporary organ replacement therapies.

This analysis draws upon a variety of sources to provide a tally of the number of patients receiving organ replacement therapies and the costs associated with the provision of such therapies. Constituent data were available from treatment-specific patient registries, peer reviewed reports in scientific literature, business publications, and industry sources. The magnitude and economic scope of the contemporary organ replacement enterprise were found to be much larger than is generally recognized. In the year 2000, the lives of over 20 million patients will be sustained, supported, or significantly improved by functional organ replacement. The impacted population grows at over 10% per year. Worldwide, first year and follow-up costs of organ prosthesis exceeds $300 billion US dollars per year and represents between 7 and 8% of total worldwide health care spending. Remarkably, in the United States, the costs of therapies enabled by organ replacement technology exceed 1% of the Gross Domestic Product. These findings constitute an incontestable tribute to the scientific significance and medical impact of the still nascent field of substitutive medicine. At the same time, the enormous magnitude of resources dedicated to organ replacement raises several issues related to overall cost effectiveness of current modalities and raises challenges and opportunities for future technical developments.

Arthroplasty, Replacement↗
PubMed1993

Competence in children at risk for psychopathology predicted from confirmatory and disconfirmatory family communication.

The relationship between confirmation/disconfirmation in parental and family communication and offspring social competence was examined in 59 families in which at least one of the parents had been hospitalized for a functional psychiatric disorder. Communication samples were obtained using the Consensus Rorschach procedure both with parental couples and with parent-child family units. The communication was analyzed using the Confirmation-Disconfirmation Coding System (CONDIS). The competence at school of 7-and 10-year-old boys was rated by both peers and teachers. Competence at home was rated by the parents. The results indicated that the more competent the high-risk children were, both at school and at home, the more their family communicated in confirmatory ways and the less they communicated in disconfirmatory ways. Furthermore, although the parental couple CONDIS score and the family CONDIS score were modestly correlated, each contributed separately to the prediction of offspring competence. These communication data were not significantly related to parental psychopathology, neither severity of parental impairment nor the diagnosis of the patient-parent.

Adult↗
PubMed2006

Alzheimer's disease: psychopathology, medical management and dental implications.

BACKGROUND: The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental treatment of patients with Alzheimer's disease (AD). STUDIES REVIEWED: The authors conducted MEDLINE searches for 2000 through 2005 using the terms "Alzheimer's disease," "geriatric," "epidemiology," "pathophysiology," "treatment" and "dentistry." Reports selected for further review included those published in English in peer-reviewed journals. The authors gave preference to articles reporting randomized, controlled trials. RESULTS: AD is a progressive and fatal neurodegenerative disorder characterized by cognitive dysfunctions, particularly in learning and memory, and the emergence of behavioral abnormalities. Deficiencies in the cells responsible for storage and processing of information underlie the cognitive, functional and behavioral changes seen in patients with the disorder. CLINICAL IMPLICATIONS: As the elderly population grows, increasing numbers of Americans with AD will require dental treatment. The prevalence of dental disease likely will be extensive, because of diminished salivary flow and patients' inability to perform appropriate oral hygiene techniques. Preventive dental education for the caregiver and use of saliva substitutes and anticaries agents by the patient are indicated.

Age of Onset↗
PubMed1984

[Sample of high school students with a demonstration of intervening factors in school achievement and failure].

This research investigates the relationship and link between intellectual cathexis, school achievement and personality functioning in a representative sample of secondary school students aged 12 to 15 years. The level of structure of the personality plays a most significant role. Good school achievement does not necessarily depend on an optimal psychological equilibrium. In fact, the most determining factor seems to be the part played by the defense mechanisms--particularly those which aim at controlling libidinal drives--developed and elaborated during the period of latency. A certain intellectual potential, however, is a necessary but not sufficient condition for school achievement - indeed, an end of school certificate i.e. the Swiss "certificat de maturité" could be obtained by students of average intelligence. The capacity of maintaining an active intellectual investment seems to be an equally determining factor. This quality of functioning contains an oedipal component - particularly the ability of taking one's stand and of competing - as well as a pre-oedipal one - the narcissistic integrity, allowing one to preserve one's self-esteem facing difficulties. Contrary to our hypothesis, the quality of subject-environment interaction with family, peers, teachers, plays a relatively minor role. A more important aspect concerns the effects and results of relations established during childhood such as the interiorization of parental expectations, the quality of the superego, the degree of internal autonomy allowing compromise with external demands, etc. Underlying conflicts can intervene at several levels. One of these levels could result in the subject's incapacity to utilize his own resources and these imply consequences ranging from difficulties in basic school achievement to non-acquisition of cognitive mecanisms and under-development of symbolization. Psychological testing is a means of identifying the underlying difficulties and determining their nature. Remediating methods include psycho-pedagogical or psychotherapeutic intervention or, in some cases, both.

Achievement↗
PubMed1983

Peranal sleeve anastomosis for low rectal cancer.

Over a 3-yr period, 13 patients underwent surgery for a rectal tumor located between 5 and 7 cm from the anal verge. We modified Parks' procedure for a peranal sleeve anastomosis in order to avoid tension and retraction. Until now, the preferred operation for tumors at this location was abdominoperineal excision as devised by Miles. In the light of present-day knowledge, some of the lesions situated at a slightly lower level in the midrectum can be treated with a less mutilating surgical approach which is associated with continence and satisfactory sphincter function. There was no postoperative mortality. During a 5-yr follow-up period, 2 of the 13 patients died; there was no recurrence of local tumors.

Abscess↗
PubMed2004

One-year follow-up of a multiple-family-group intervention for Chinese families of patients with schizophrenia.

OBJECTIVES: This study tested the effectiveness of a mutual support multiple-family-group intervention for schizophrenia in terms of improvements in patients' psychosocial functioning, use of mental health services, and rehospitalization compared with a psychoeducation intervention and standard care. METHODS: A controlled trial was conducted in a sample of 96 Chinese families who were caring for a relative with schizophrenia in Hong Kong. The families were randomly assigned to one of three groups: mutual support (N=32), psychoeducation (N=33), and standard care (N=31). The interventions were delivered at two psychiatric outpatient clinics over a six-month period. The mutual support and psychoeducation interventions consisted of 12 group sessions every two weeks, each lasting about two hours. The mutual support group was a peer-led group designed to provide information, emotional support, and coping skills for caregiving in stages. The psychoeducation group was a professional-led group designed to educate families about the biological basis of schizophrenia and treatment and to improve illness management and coping skills. The standard care group and the other two groups received routine psychiatric outpatient care during the intervention. Data analyses of multiple outcomes over one-year follow-up were conducted on an intention-to-treat basis. RESULTS: Multivariate analyses of variance showed that the mutual support intervention was associated with consistently greater improvements in patients' functioning and rehospitalization and stable use of mental health services over the follow-up period compared with the other two interventions. CONCLUSIONS: The study provides evidence that mutual support groups can be an effective family intervention for Chinese persons with mental illness in terms of improving patients' functioning and hospitalization without increasing their use of mental health services.

Adult↗
PubMed1999

The joint actions of adolescents in peer conversations about career.

Ten career conversations between adolescent peers were video-taped to examine the joint actions of adolescents that emerge in actual conversations about career. Based on an action-theoretical approach, joint action refers to the intentional behavior of a group of people attempting to realize a common goal or engage in a common process. The actual conversations and the adolescents' recall of their thoughts and feelings during the conversations were used to identify the joint actions that occurred in the conversations and the meaning that the conversations had for the adolescents. Goals of the actions included educational planning, career selection, and personal future. The functions the adolescents undertook in the conversations to reach these goals were identified as exploring, formulating, validating, and challenging. Based on these results, it was proposed that self-refinement was the project that energized and guided the joint actions and lent meaning to the conversations.

Adolescent↗
PubMed1997

Heart failure treatment with angiotensin-converting enzyme inhibitors in hospitalized Medicare patients in 10 large states. The Large State Peer Review Organization Consortium.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors have been proved to reduce mortality, rates of hospitalization, and disease progression in patients with heart failure. Investigators have suggested that ACE inhibitors are underused in heart failure. METHODS: We examined the use of ACE inhibitors and the documentation of cardiac ejection fractions (EFs) in Medicare patients admitted to acute care hospitals with a principal diagnosis of heart failure. A random sample of at least 600 medical records in each of 10 populous states was retrospectively abstracted by peer review organizations. A total of 6749 records were reviewed of patients aged 65 years and older who were discharged in 1993 and 1994. The review tool was adapted from the Heart Failure Guidelines disseminated by the Agency for Health Care Policy and Research. An ideal candidate cohort was created of patients most likely to benefit from ACE inhibitors on the basis of their EF values (< 40%), renal function, absence of hyperkalemia, and absence of other contraindications. RESULTS: Fifty-five percent (95% confidence interval, 54%-56%) of patients received ACE inhibitors at discharge. In the ideal candidate group, 73% (95% confidence interval, 71%-75%) of patients received ACE inhibitors at discharge. The oldest group was least likely to have ACE inhibitors prescribed at discharge. The EF was documented in 59% (95% confidence interval, 58%-60%) of records. CONCLUSIONS: Medicare chart review suggests under-use of ACE inhibitors in up to one quarter of patients who have no clear contraindications. A substantial number of patients without documented EF are also likely to benefit from the use of ACE inhibitors.

Age Factors↗
PubMed1982

A multidimensional assessment of parent-identified behavior problem toddlers.

Sixty-eight 2- and 3-year-olds (46 parent-referred, 22 controls) participating in an identification, assessment, and follow-up study of hyperactivity and related behavior problems were evaluated on parent-report, observational, and cognitive measures. Referred youngsters were described by both parents as more active, inattentive, difficult to discipline, and aggressive with peers than were controls. Mothers of referred children also reported a more difficult infancy period. Laboratory assessments confirmed parental reports of current problems. Referred children shifted activities more during free play, were more active and inattentive during structured tasks, and made more impulsive responses on a delay task than did controls. Discriminant function analysis indicated that parental ratings of activity paired with laboratory measures of sustained attention and impulsivity correctly classified 88% of the sample. These data suggest that the core symptoms of hyperactivity can be identified in very young children, although their prognostic significance remains to be determined.

Attention↗