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The self-exclusion program: legal and clinical considerations.

In recent years, attention focused on compulsive gambling(1), and its causes and cures, has increased at a notable rate. Among the measures taken to help the compulsive gambler is the voluntary(2) self-exclusion program which is either in place or being considered in various states.(3) Although the programs differ from jurisdiction to jurisdiction, the basic premise is that the gambler requests that he be banned from the gaming establishment and/or removed from its mailing list. This article examines this new concept primarily from a legal perspective. The self-exclusion program represents a state-created legal entity constructed upon a clinical foundation. It prominently includes several clinical references to mental health principles. Of necessity, there appear some analogies to the field of substance abuse; these have provided at least a starting point for more particularized study and research in the fledgling field of compulsive gambling treatment.

Disruptive, Impulse Control, and Conduct Disorders↗

Multi-level determinants of retention in a home-visiting child abuse prevention program.

OBJECTIVE: This exploratory study investigated how attributes from multiple domains influence retention in a voluntary home-visiting child abuse prevention program. METHOD: A sample of 1093 "at-risk" families participated in a home-visiting child abuse prevention program. A total of 71 Family Support Workers (FSWs) provided home visitation services in 12 different communities. Hierarchical general linear modeling (HGLM) was used to examine the community, home visitor, and maternal attributes that predicted retention in the program beyond 1 year. RESULTS: Multi-level analyses (HGLM) revealed significant community, home visitor, and maternal level effects. Families were less likely to remain in a home-visiting child abuse prevention program for at least 1 year if they lived in an area with high community violence. Families were more likely to remain when the home visitor received more hours of direct supervision. Older mothers were more likely to remain for at least 1 year than were younger mothers. Hispanic mothers were more likely to remain than were White non-Hispanic mothers. CONCLUSIONS: These findings demonstrate the utility of looking across multiple levels of influence when examining retention in home-visiting child abuse prevention programs. To increase retention rates home visitors will need to be adaptable to fit the needs of families in violent communities. Supervisors can influence retention rates by providing more hours of direct supervision. Other strategies that may contribute to program retention include meeting the scheduling needs of younger mothers and involving the families of younger mothers more effectively.

Adult↗

Dopamine D2 receptor gene expression in rat lines selected for differences in voluntary alcohol consumption.

A selective breeding program has led to the establishment of the alcohol-preferring AA (Alko, Alcohol) and alcohol-avoiding ANA (Alko, Nonalcohol) rat lines. To reveal putative baseline differences in dopamine receptor gene expression and dopamine receptor binding profile in the AA and ANA rat lines, we assessed striatal D2 mRNA levels in these two rat lines. Autoradiographical studies on dopamine D1 and D2 receptors in the striatum and nucleus accumbens were also performed with [3H]SCH 23390 and [125I]iodosulpiride/[3H]spiperone, respectively. The baseline differences in D1 or D2 receptor binding and D2 receptor gene expression between AA and ANA rat lines are marginal, and are not likely to play a role in the genetic background of the differential alcohol drinking behavior of these rat lines.

Alcohol Drinking↗

[Patients with end-stage chronic renal insufficiency on programmed withdrawal from dialysis].

UNLABELLED: The voluntary discontinuation of dialysis by patients is a common mode of death in dialysis programmes. Unfortunately the Spanish experience has not been related in the nephrological literature. Initiation of, and withdrawal from, dialysis pose ethical questions for medicine in the 21st century. The dialysis population is aging and they have multiple medical problems. The choice may be between prolongation of quantity or quality of life. We evaluated a protocol for initiation of dialysis in patients with end stage renal failure and their subsequent withdrawal. We determined the factors predicting withdrawal of dialysis and revised the protocol to take account of these. We carried out an opinion poll of doctors and nurses about the effectiveness of the protocol. We studied prospectively the reasons for death of patients in the last seven years. RESULTS: Thirty patients were withdrawn from dialysis out of 116 who died during treatment by hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) in the last seven years. Vascular nephropathy is the principal disease predicting withdrawal from dialysis; the main precipitating cause is mental incapacity. The availability of a protocol for withdrawal of dialysis is well received by doctors and nurses and it engenders moral and legal calm when facing difficult decisions. Twenty-six per cent of deaths on regular dialysis are the result of withdrawal of treatment.

Adult↗

Electrophysiologic properties and nature of ventrolateral thalamic nucleus neurons reactive to converging inputs of paleo- and neocerebellar origin.

Acute experiments were carried out in chloralose-anesthetized, curarized, and artificially ventilated cats to investigate the consistency and functional characteristics of converging cerebellar nuclear (fastigial, interpositus, dentate nuclei) inputs to single neurons of the ventrolateral thalamic nucleus, and the nature (thalamocortical relay or interneuronal) of its convergent neuronal population responsive to stimulation of the cerebellar nuclei. From unitary analysis of both extra- and juxtacellular recordings, we conclude that convergence of paleo- and neocerebellar impulses on thalamic ventrolateral neurons occurs widely, and that both excitatory (mono- and polysynaptic) and inhibitory (di- and polysynaptic) effects are induced on the same neurons by cerebellar nuclei stimulation; these effects concern about 40% of the thalamic ventrolateral neuronal population tested using the extracellular recording technique and about 75% of the ventrolateral nucleus neurons tested using the juxtacellular recording; activation of neocerebellar nuclear outputs generates mainly excitatory and excitatory-inhibitory response patterns, whereas activation of the paleocerebellar nuclear outputs evokes predominantly inhibitory and excitatory-inhibitory response patterns; the convergent paleo- neocerebellar neurons are found commonly in the more anterior ventrolateral nucleus stereotaxic planes; and from the results obtained by stimulation of the somatomotor cortical areas, a large proportion of the ventrolateral nucleus convergent units consists of thalamocortical relay cells. The results have implications for a possible integration between posture and voluntary movements at the level of the thalamic relay nucleus of the cerebellar-cortical pathway, and an interaction between central feedback and peripheral feedback in the programming, execution, and correction of voluntary movements.

Animals↗

Occupational health service for farmers in Sweden.

Farming is an occupation in which risks and many health hazards have been identified. Unlike other Swedish industrial sectors, agriculture has not had an occupational health service until recently. At the initiative of local farmers' groups, a trial program was started in 1977, and occupational health care for farmers and farm workers has gradually developed since then. Today, 35,000 farmers are affiliated on a voluntary basis. The occupational health program offers biennial health checkups, along with informational activities and farm visits during the interim. Nurses, physicians, and physiotherapists deal with work-related symptoms and diseases, and safety engineers conduct farm visits. The large number of environmental hazards existing in agriculture constitutes a spur to further development of the occupational health service and to research. Results so far are promising, and occupational health care in agriculture should be encouraged.

Agriculture↗

Medicare program; Medicare prescription drug discount card. Interim final rule with comment period.

Section 101, subpart 4 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, codified in section 1860D-31 of the Social Security Act, provides for a voluntary prescription drug discount card program for Medicare beneficiaries entitled to benefits, or enrolled, under Part A or enrolled under Part B, excluding beneficiaries entitled to medical assistance for outpatient prescription drugs under Medicaid, including section 1115 waiver demonstrations. Eligible beneficiaries may access negotiated prices on prescription drugs by enrolling in drug discount card programs offered by Medicare-endorsed sponsors. Eligible beneficiaries may enroll in the Medicare drug discount card program beginning no later than 6 months after the date of enactment of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and ending December 31, 2005. After December 31, 2005, beneficiaries enrolled in the program may continue to use their drug discount card during a short transition period beginning January 1, 2006 and ending upon the effective date of a beneficiary's outpatient drug coverage under Medicare Part D, but no later than the last day of the initial open enrollment period under Part D. Beneficiaries with incomes no more than 135 percent of the poverty line applicable to their family size who do not have outpatient prescription drug coverage under certain programs--Medicaid, certain health insurance coverage or group health insurance (such as retiree coverage), TRICARE, and Federal employees Health Benefits Program (FEHBP)--also are eligible for transitional assistance, or payment of $600 in 2004 and up to $600 in 2005 of the cost of covered discount card drugs obtained under the program. In most cases, any transitional assistance remaining available to a beneficiary on December 31, 2004 may be rolled over to 2005 and applied toward the cost of covered discount card drugs obtained under the program during 2005. Similarly, in most cases, any transitional assistance remaining available to a beneficiary on December 31, 2005 may be applied toward the cost of covered discount card drugs obtained under the program during the transition period. The Centers for Medicare & Medicaid Services will solicit applications from entities seeking to offer beneficiaries negotiated prices on covered discount card drugs. Those meeting the requirements described in the authorizing statute and this rule, including administration of transitional assistance, will be permitted to offer a Medicare-endorsed drug discount card program to eligible beneficiaries. Endorsed sponsors may charge beneficiaries enrolling in their endorsed programs an annual enrollment fee for 2004 and 2005 of no more than $30; CMS will pay this fee on behalf of enrollees entitled to transitional assistance. To ensure that eligible Medicare beneficiaries take full advantage of the Medicare drug discount card program and make informed choices, CMS will educate beneficiaries about the existence and features of the program and the availability of transitional assistance for certain low-income beneficiaries; and publicize information that will allow Medicare beneficiaries to compare the various Medicare-endorsed drug discount card programs.

Centers for Medicare and Medicaid Services, U.S.↗

Reduction of muscular hypertonus by long-term muscle stretch.

In 10 patients with spastic paraparesis, the effect of long-term stretch on hip adductor muscle tone was studied. Stretch was accomplished by using a mechanical leg-abductor device giving individually adjusted adductor muscle stretch in single or repeated 30 min periods. The effect on muscle tone was estimated from surface EMG activity and by range of voluntary and passive hip abduction. The passive movements were obtained by an individually adjusted constant pulling force. After a single session of stretch, range of voluntary hip abduction increased 3 to 16 degrees (average 85%). Range of passive movement increased 1 to 9 degrees (average 23%). After repeated stretch periods in a home program (4 patients), range of voluntary hip abduction increased 5 to 22 degrees (average 255%). Range of passive movements increased 6 to 12 degrees (average 48%). In all patients studied the co-activation of the antagonists in voluntary hip abduction was reduced after a stretch session.

Adult↗

[Evaluation of health education programs].

Health education may be defined as a process that seeks to achieve voluntary changes in behavior conducive to health. Systematic program planning, based on an extensive investigation of the needs of a specific population is essential if health education is to attain validity in the eyes of the public, health professionals and policy makers who assess its value. In addition, unless educational programs have clearly defined and measurable objectives, health education will continue to be an area that uses the measurement of activities, rather than the measurement of changes in behavior and health status, as its ultimate goal. The PRECEDE model, presented here, offers a quantifiable means of conducting an educational diagnosis in health, behavioral and cognitive, attitudinal and organizational terms before the development of an educational program. The process allows the practitioner to define objectives, which form the basis for subsequent analyses of the effectiveness of the program.

Attitude to Health↗

An epidemic like any other? Rights and responsibilities in HIV prevention.

Throughout the 1980s and into the 1990s, HIV prevention has been closely associated with the protection of individual human rights. Traditional public health measures such as compulsory testing and isolation have largely been rejected as ineffective in public health terms and inappropriate in the context of human rights protection. HIV prevention has been based instead chiefly on elective measures --information, education, counselling, and voluntary testing. In the past five years there have been important clinical, epidemiological, and social developments in the AIDS epidemic. These changes, combined with a growing recognition of possible weaknesses inherent in a strictly voluntarist approach to HIV prevention, may herald a new approach to AIDS control which places more weight on social responsibility in the context of HIV prevention.

Acquired Immunodeficiency Syndrome↗

The acute non-hospital: a California model.

Crisis residential programs were established by the California legislature in 1978 to provide an alternative to hospitalization for treatment of voluntary acute psychiatric patients. The five crisis residential programs in San Diego County, California, provide high-quality mental health care that is community-based and considerably less expensive than traditional in-hospital programs. Currently, the majority of public-sector, voluntary adult patients in San Diego County receives acute psychiatric inpatient services in these programs. This paper provides a description of the facilities, staff composition, patients, treatment model, and costs.

California↗

Eugenics and genetic testing.

Pressures to lower health-care costs remain an important stimulus to eugenic approaches. Prenatal diagnosis followed by abortion of affected fetuses has replaced sterilization as the major eugenic technique. Voluntary acceptance has replaced coercion, but subtle pressures undermine personal autonomy. The failure of the old eugenics to accurately predict who will have affected offspring virtually disappears when prenatal diagnosis is used to predict Mendelian disorders. However, when prenatal diagnosis is used to detect inherited susceptibilities to adult-onset, common, complex disorders, considerable uncertainty is inherent in the prediction. Intolerance and the resurgence of genetic determinism are current pressures for a eugenic approach. The increasing use of carrier screening (to identify those at risk of having affected offspring) and of prenatal diagnosis could itself generate intolerance for those who refuse the procedures. Genetic determinism deflects society from social action that would reduce the burden of disease far more than even the maximum use of eugenics.

Abortion, Eugenic↗

Development of a program for identification of patients with familial hypercholesterolemia in British Columbia: a model for prevention of coronary disease.

We have developed a targeted approach to identification of high-risk patients in British Columbia, Canada, as an initial strategy for the prevention of coronary disease. Patients with the diagnosis of familial hypercholesterolemia have been identified through the Lipid Clinic. First degree relatives of these persons and subsequently identified individuals will be screened for the presence of hypercholesterolemia. Using this approach, the likelihood of identifying persons at high risk is high, close to 50%. The program will also allow collection of data on factors affecting the expression of hyperlipidemia and atherosclerosis and their response to therapy. In an effort to establish the infrastructure that would be necessary for identification and management of such patients throughout the province, a Lipid Clinic Outreach Program has been developed. The objective is to provide each community in the province with expertise to manage hyperlipidemia without traveling to a major urban area. With this infrastructure in place, this will serve patients who have premature atherosclerosis due to other causes and will also form the framework for dissemination of heart health policies and programs by different levels of government, voluntary and professional organizations, as well as the private sector. From a targeted family centered pilot program, a broad approach to the prevention of coronary artery disease in this community will be possible.

Ambulatory Care↗

Electronic reporting to improve patient safety.

BACKGROUND: Limited data are available on the experiences of voluntary event reporting systems to improve patient safety. OBJECTIVE: Development and implementation of educational initiatives to facilitate the use of an electronic reporting system (ERS) in an academic medical center to measure the impact on knowledge of the ERS on reporting behavior and safety attitudes and to evaluate the accuracy of the information being reported. METHODS: A voluntary internal confidential electronic system for reporting safety events was implemented which involved patients and visitors. A multifaceted educational program was developed to promote safety awareness and use of the ERS system. The safety event detail reported for the calendar year 2002 was tracked and trended and central event analyses were performed for five high event clinical areas. A survey was administered to assess safety knowledge and attitudes of patient care personnel. RESULTS: 2843 safety events were entered into the ERS during 2002 with an increase during the course of the year (p = 0.055, linear trend) for all events. Nurses entered 73% of the events and physicians only 2%. 453 events (16%) were unsafe conditions or near misses and 623 (22%) were associated with patient harm. System factors were considered by the reporter as contributing to the event in only a few cases (5%). Central event analysis revealed that 39% of events had coding errors either in event classification, level of impact, or location; significant underreporting was also present. Although survey response rates were low (10.3%), responders showed a high degree of knowledge on general questions of patient safety and an increase in knowledge on use of the ERS (p = 0.0015, linear trend). CONCLUSIONS: Knowledge on the use of the reporting system and the frequency of reported events increased over the first year of the study. More work is needed to involve physicians in reporting, to improve the accuracy of submitted information, and to better prioritize, organize, and streamline event analysis.

Computer Literacy↗