Housing outcomes and predictors of success: the role of hospitalization in street outreach.

ACCESSIBLE SUMMARY: What is known on the subject? Outreach services are often successful in engaging and housing street homeless individuals. People experiencing homelessness have greatly increased rates of mental illness and substance abuse. What this paper adds to existing knowledge? Given the relative lack of research involving street homeless individuals, this retrospective chart review examined factors associated with successful housing by a multidisciplinary street outreach team, including the use of hospitalization as an intervention within a housing first framework. The majority of clients were successfully housed by the end of outreach team involvement. An admission to hospital was strongly associated with successful housing for those with a psychotic disorder. What are the implications for practice? Multidisciplinary outreach teams, specifically those with psychiatric and nursing support, successfully work with and house people experiencing street homelessness and psychosis. Mental health nurses embedded in the community are an essential link between inpatient and outpatient care for highly vulnerable street homeless individuals. Introduction Housing-first strategies have helped establish housing as a human right. However, endemic homelessness persists. Multidisciplinary outreach teams that include nursing, social and psychiatric services allow for integrative strategies to engage and support clients on their housing trajectory. The following retrospective review focused on the identification of demographic, clinical, and service characteristics that predicted the obtainment of housing, and explored the role of psychiatric hospitalization as an intervention, not an outcome measure, in contrast to previous studies. These have rarely focused on street homelessness. METHOD: A retrospective chart review of 85 homeless, primarily rough-sleeping, clients was conducted to determine housing outcomes and the factors associated with obtaining housing through care provided by a psychiatric street outreach team in Toronto, Canada. Demographics, homelessness duration, diagnosis, hospitalization and housing status were tracked during team involvement. RESULTS: Overall, 46% (36/79) were housed during the study term. Securing housing at the end of treatment/data collection was significantly enhanced by hospitalization (OR = 9.04, 95% CI [2.43, 33.59]). It was significantly diminished by psychosis (OR = 0.22, 95% CI [0.05, 0.95]) and prior homelessness >36 months (OR = 0.10, 95% CI [0.02, 0.50]). Twenty-three of 31 (74%) hospitalized clients with psychosis were subsequently housed, compared to 4 of 30 (13%) not hospitalized (Fisher's exact, P < .001). DISCUSSION: Multidisciplinary street outreach teams successfully house long-standing homeless clients (>12 months without a permanent address) with serious mental illness and/or substance abuse. Hospitalization can be utilized as a complimentary intervention, particularly for those with psychosis, in the continuum of housing first initiatives, and can contribute to securing housing for those with persistent psychotic disorders. Implications for nursing practice Community mental health nurses are uniquely positioned to translate care between hospital and community settings, ensuring timely assessment, intervention and treatment of clients who are historically difficult to engage.

Hydrogen peroxide- and peroxynitrite-induced mitochondrial DNA damage and dysfunction in vascular endothelial and smooth muscle cells.

The mechanisms by which reactive species (RS) participate in the development of atherosclerosis remain incompletely understood. The present study was designed to test the hypothesis that RS produced in the vascular environment cause mitochondrial damage and dysfunction in vitro and, thus, may contribute to the initiating events of atherogenesis. DNA damage was assessed in vascular cells exposed to superoxide, hydrogen peroxide, nitric oxide, and peroxynitrite. In both vascular endothelial and smooth muscle cells, the mitochondrial DNA (mtDNA) was preferentially damaged relative to the transcriptionally inactive nuclear beta-globin gene. Similarly, a dose-dependent decrease in mtDNA-encoded mRNA transcripts was associated with RS treatment. Mitochondrial protein synthesis was also inhibited in a dose-dependent manner by ONOO(-), resulting in decreased cellular ATP levels and mitochondrial redox function. Overall, endothelial cells were more sensitive to RS-mediated damage than were smooth muscle cells. Together, these data link RS-mediated mtDNA damage, altered gene expression, and mitochondrial dysfunction in cell culture and reveal how RS may mediate vascular cell dysfunction in the setting of atherogenesis.

A conceptual framework for achieving high-quality care in nursing homes.

Nursing home care accounts for 12% of healthcare expenditures in the United States, yet serious concerns remain about the quality of care provided in these settings. This article describes a comprehensive systems model that views organizational environments as consisting of four interacting dimensions: organizing arrangements, social factors, technology, and physical setting. This model is then used as a conceptual framework (vis-à-vis an extensive literature review) to identify factors that contribute to poor-quality care in nursing homes and to highlight previous research efforts. The literature review also provides a useful framework to guide nursing home administrators and healthcare quality professionals in their implementation of quality improvement processes and serves to help direct future research in this very important arena.

The impact of type of employment on women's use of prenatal-care services and family planning in urban Cebu, the Philippines.

This study re-evaluates the relationship of urban women's employment to their health-service and contraceptive use, drawing on data from the Cebu Longitudinal Health and Nutrition Survey. Multivariate analyses reveal significant differences across types of work for the likelihood of both obtaining timely prenatal care and practicing contraception at one year postpartum. Wage workers in white-collar jobs are significantly more likely than those not employed for pay to have obtained prenatal care and are substantially more likely to have adopted a contraceptive method in the year following childbirth. Women who are self-employed also are significantly more likely than those not employed for pay to be using contraceptives. Blue-collar wage work and piecework employment have no relationship to either dependent variable. These findings suggest that work-related autonomy encourages women to exercise control in other areas of their lives.

PIP: This article examined the relationship between women's employment and use of prenatal care services and family planning in Cebu, the Philippines. Data were obtained from the Cebu Longitudinal Health and Nutrition Baseline and Follow-up Survey among a 12-month birth cohort of 2695 Filipino infants and their mothers, residing in a sample of 33 urban and rural barangays in 1983 and 1984. The largest percentage of women who had early prenatal care were white collar workers (WCWs) and professionals (57%), followed by blue collar, service, and self-employed workers (22%), and non-wage workers (23%). The smallest percentage of women obtaining prenatal care were pieceworkers (15%). Modern contraceptive use at 1 year postpartum was greatest among WCWs (34%), followed by self-employed workers (32%) and non-wage workers (26%). The lowest proportion were pieceworkers among modern method users, and blue collar workers and service workers among traditional method users. Logistic models indicate that WCWs were 2.5 times more likely than non-wage workers to obtain care within the first 5 months of pregnancy. Among women who received free care, WCWs still had the best prenatal care patterns. The likelihood of prenatal care was the same for blue collar workers, self-employed workers, and pieceworkers. Women aged 25-34 years were more likely than older women to obtain early prenatal care. Husband's education, a resident grandmother, and household assets contributed to a higher likelihood of seeking early prenatal care. The degree of autonomy on the job was more closely related to contraceptive and health service use.

The king is dead; long live the king: narrative therapy and practicing what we preach.

Narrative therapy has been associated with the assumptions of postmodernism and social constructionism; both of which support the notion that there are no truths, just points of view. Thus, narrative therapists have sought to privilege the voices of their clients in the process of delivering them from the oppressive weight of dominant, cultural grand narratives. Have they been as willing and adept at respecting the voices of other professionals, and their colleagues within the narrative camp? This question is discussed in relation to the underlying assumptions that inform narrative practice. It is concluded that narrative has perhaps unwittingly fallen prey to the human tendency to reify metaphors and make gurus of leaders.

Geographic concentration of violence between intimate partners.

OBJECTIVES: To explore geographic patterns of violence between intimate partners in a metropolitan area with one of the highest injury mortality rates in the nation-Duval County, Florida, which includes the city of Jacksonville. METHODS: Using police reports of all serious violent incidents in Duval County in 1992 excluding robberies, the authors analyzed patterns in the location of the incidents. Only cases for which the relationship between the offender and victim was recorded were used. RESULTS: Thematic maps reveal that census tracts with rates above the 75th percentile of assaultive violence between intimates are clustered in certain parts of the city. Concentrated poverty tracts had median rates of violence between intimate nine times higher than other tracts. CONCLUSIONS: The finding that violence between intimate partners is concentrated in central city poverty neighborhoods opens up avenues for prevention.

Treatment of HeLa cells with bacterial water extracts inhibits Shigella flexneri invasion.

Pathogenesis mediated by Shigella flexneri requires invasion of the gastrointestinal epithelium. It has been previously shown that HeLa cells challenged with S. flexneri show alterations in their phosphotyrosine-containing protein profile. In this report, we demonstrated that bacterial water extracts (WE) abrogated the invasion of HeLa cells by S. flexneri in a dose-dependent manner. A proteinaceous component of S. flexneri was shown to be responsible for this inhibitory activity. Proteins encoded on the 140-MDa plasmid were not responsible for the observed inhibition. WE from other Gram-negative bacteria also inhibited Shigella invasion of HeLa cells pretreated with WE showed changes in the profile and the intensity of phosphotyrosine-containing protein bands. These data were consistent with a surface protein component in WE which initiated aberrant host cell signaling at the membrane which may account for the inhibition of bacterial entry.

Alcohol use among pedestrians and the odds of surviving an injury: evidence from Florida law enforcement data.

Alcohol consumption by pedestrians is widely recognized as a factor influencing the risk of being hit by a motor vehicle, but its effect on the likelihood of dying, given that a collision has occurred, is more uncertain. Studies of drivers find that alcohol increases the risk. Unlike previous studies based on clinical data, the present study is population-based and takes into account indicators of crash severity. Using Florida law enforcement data, logistic regression models yielded a four to fivefold increase in the odds ratios associated with alcohol use, depending on the model. Findings from a model investigating the magnitude of the potential bias due to differential investigative behavior indicated bias may account for some but not all of the increase in the odds of dying. Recommendations include improving law enforcement procedures for identifying alcohol impairment and increasing public awareness of the risk involved in mixing heavy drinking and walking.

Inequities in health care and survival after injury among pedestrians: explaining the urban/rural differential.

This study investigated whether rural/urban differences in injury mortality and morbidity are primarily due to medical care maldistribution or to other factors such as sociodemographic or environmental characteristics that are highly correlated with location. To separate incidence from case-fatality rates, the study analyzed the determinants of survival rather than cause-specific mortality rates. Using information from Florida traffic crash reports for 1988 through 1990, the study focused on Florida pedestrians hit by motor vehicles. It explores the effect of individual-level demographic characteristics, crash-level indicators of impact severity, and county-level measures of socioeconomic and medical care resources, on the odds a pedestrian survived an injury. Logistic regression analyses reveal the importance of both road environment and percent of the county that is rural. However, these analyses are not able to isolate the influence of medical care from the level of urbanization. Although the percent rural was statistically significant, indicators of the mechanical energy involved in producing the injury, posted speed, and a dark road environment were substantively more important determinants of survival.

Shigella flexneri-HeLa cell interactions: a putative role for host cell protein kinases.

Epithelial cell invasion has been shown to be a prerequisite for Shigella flexneri virulence. Recently, we have documented the induction of transcription factor DNA binding activities as a result of S. flexneri challenge of HeLa cells. In this report, we show that HeLa cells challenged with S. flexneri display differences in phosphotyrosine-containing proteins. These changes are detected as early as 5 min post-challenge. Challenge with a noninvasive ipaB mutant strain resulted in the induction of a similar, but less intense, profile of phosphotyrosine-containing host cell proteins. Phosphotyrosine-containing proteins could be detected in S. flexneri, but were unique from those detected following HeLa cell challenge. S. flexneri invasion of HeLa cell monolayers was reduced by treatment with protein kinase inhibitors. These data suggest a role for protein kinases in the initial response of host cells to S. flexneri.

"Empowering" women.

PIP: Healthcare providers and policymakers have been confused by suggestions that empowering women will help them to practice family planning. Two experts on women's health stress that empowerment is a process rather than a single event and should be considered as such when exploring the relationship between women's empowerment and women's use of family planning. Empowerment is a series of steps by which individuals gain access to critical economic and educational resources such as information, assets, cash, and skills. These resources are then used to bring about environmental change and influence other persons and institutions with competing or conflicting interests. Empowerment should be viewed as a process in which all voices are encouraged to be heard for the ultimate goal of securing mutually beneficial solutions. Spouses, partners, and mothers-in-law often make decisions for women on contraceptive choice and use. Women also may not have the money needed to pay for desired and needed family planning and health services. The relationship between empowerment and women's use of family planning is therefore complex and problematic. Comprehensive reproductive health programs, however, help empower women as a result of their ability to transform power relations within the family, community, and society, and challenge female subordination. The authors note that researchers in exploring the relationship between family planning, reproductive health, and empowerment may want to consider the political, economic, and household dimensions of women's lives. It is also noted that results from at least one study suggest that work alone may not be a vehicle for women's empowerment.^ieng

Immunization of mice with Yersinia enterocolitica leads to the induction of antithyrotropin receptor antibodies.

It is well established that autoimmune Graves' disease, which is characterized by hyperthyroidism, is mediated by autoantibodies to the thyrotropin receptor (TSHr). Although what initially triggers this autoantibody response is not known, a number of studies have suggested that Yersinia enterocolitica, an enterobacteria, could initiate the immune response against the TSHr. In this study, we produced antibodies against purified extracellular domain of human TSHr (ETSHr) and showed that anti-ETSHr antibodies reacted with envelope preparations from Y. enterocolitica. This reactivity was specifically blocked by preincubating sera with purified ETSHr. Moreover, antibodies reactive with ETSHr were induced by immunizing mice with Y. enterocolitica but not with Shigella flexneri SA100, Salmonella typhimurium TML, and Listeria monocytogenes. Anti-Y. enterocolitica antisera specifically reacted with the ETSHr protein and the reactivity could be blocked both by ETSHr and Y. enterocolitica envelope proteins. Our studies provide the first direct evidence that immunization with Y. enterocolitica can lead to the production of antibodies capable of reacting with TSHr and might provide the initial stimulus necessary for breakdown of self-tolerance to TSHr, eventually leading to the development of autoimmunity to TSHr.

Women's work and infant care in the Philippines.

Using data from a survey of 3000 Filipino infants and mothers, we analyze the implications of having more than one preschooler on several work outcomes, as well as the effect of availability of substitute care givers. The work outcomes of interest are those thought to be least compatible with infant care: work outside the home, wage work remunerated on a time basis, and long working hours. Our findings suggest that having multiple preschoolers only makes a difference for mothers whose household income is below the median: it increases their likelihood of working outside the home. Grandmothers and paid helpers consistently increase the likelihood of the various work outcomes and increase hours worked. Our findings suggest that urban residence, an indicator of work opportunity structure, increases the likelihood of wage-time work and is associated with longer working hours.

Combat and social support as variables in perceived symptomatology of combat-related posttraumatic stress disorder.

This study used an analog approach to the perceptions of tour of duty, combat and noncombat, and levels of social support, high and low. Their influence was assessed in the symptomatology of Posttraumatic Stress Disorder. 80 subjects were randomly assigned to read one of four vignettes depicting levels of combat and social support as main effects. Results were congruent with recent research indicating significant main effects for combat and social support in the symptomatology of Posttraumatic Stress Disorder.

Patient assessment and treatment planning in child and adolescent partial hospital programs.

Thirty-six patient records were examined during site visits to 18 child and adolescent (PH) programs. The documentation of patient assessment and treatment planning was examined. The history of present illness, past psychiatric history, and medical history were at least adequate in about 60-70% of evaluations. Treatment plans were generally complete, but at least one-half of mandated treatment plan reviews lacked revisions. Psychiatric justification of admission and diagnosis was poor in 41% and 44% of charts, respectively, and there was no documentation of ongoing psychiatrist-patient contact in 44% of charts. Possible explanations for these findings include inadequate funding of PH programs, lack of psychiatric time, and uniform approaches to treatment.