When should governments increase the supply of psychiatric beds?

Low numbers of hospital-based psychiatric beds create problems for people with severe mental illness (SMI), when they face extended emergency department (ED) waits, higher thresholds for admission to an acute bed, and short revolving-door stays with high rates of rehospitalisation. Limited access to inpatient treatment has been associated with higher suicide risk, premature mortality, homelessness, violent crime and incarceration. Ultimately, people with SMI can be transinstitutionalised to the criminal justice system. In the USA, for example, prisons have replaced mental hospitals as the largest institutions housing people with SMI. There is no international consensus on the safe minimum numbers of acute, forensic and rehabilitation beds needed to reduce these risks. As a consequence, Organisation for Economic Cooperation and Development (OECD) countries have wide variations in the mix of hospital beds with an average of 71 beds per 100 000 population. Policymakers face difficult choices with few studies to guide decisions on supplying beds. The UK Royal College of Psychiatrists offered a policy framework, which was adapted for Australia. The government of the State of South Australia increased the supplies of crisis, acute and forensic beds to meet a mandatory target to safely reduce mental health boarding in the EDs.

Carpal canal pressures after volar plating of distal radius fractures.

Elevated pressures within the carpal canal are known to occur after distal radius fractures. Controversy exists regarding prophylactic carpal tunnel release after open reduction with internal fixation of distal radius fractures. The purpose of this study was to determine the tissue pressures within the carpal canal after volar plating of distal radius fractures. This study was a prospective, observational, IRB approved research study. Ten consecutive patients undergoing volar plating of distal radius fractures were enrolled. After the distal radius fractures were reduced and fixed with volar plates, slit catheters were inserted into the carpal canals for continuous postoperative pressure monitoring for 24 hours. The maximum recorded pressure was 65 mmHg, which occurred in the only patient with fracture blisters. Peak pressures remained at 40 mmHg or less (range 16-40, mean 29) in all patients without fracture blisters. At the conclusion of data collection, all pressures were at 31 mmHg or less. No patient complained of median nerve dysfunction during the study period. Routine prophylactic carpal tunnel release is not recommended after volar plating of distal radius fractures based on these pressure recordings.

Evaluation of the Affirm Ambient Temperature Transport System for the detection and identification of Trichomonas vaginalis, Gardnerella vaginalis, and Candida species from vaginal fluid specimens.

The objective of this study was to measure the performance of the Affirm Ambient Temperature Transport System (ATTS) over time and to estimate the length of time the system can preserve a vaginal specimen containing the three common organisms causing vaginitis: Trichomonas vaginalis, Candida species, and Gardnerella vaginalis (one of the causative agents of bacterial vaginosis). Women with symptoms of vaginitis presenting to one of three clinical centers were evaluated over a 4- to 8-week period. Four simultaneously obtained swabs were collected and tested by the Affirm VPIII assay at time zero with and without a preservative reagent, at 24 h with reagent, and at either 48 or 72 h with reagent. For each of the three organisms, Trichomonas, Gardnerella, and Candida, positivity at each time point was evaluated and compared to that at reference time zero with and without the ATTS. A total of 940 specimens were obtained from the three clinical sites. Eight hundred three were positive for one or more of the three organisms. Gardnerella had the highest overall positive rate (62%), followed by Candida with 18% and Trichomonas at 9%. The percent sensitivity versus control for Trichomonas ranged from 100% at time zero with and without reagent to 91% by 72 h. Gardnerella and Candida sensitivity remained at 100% for each time period. The Affirm VPIII ATTS system performed within 10% of the control swab (no transport reagent) at all four time points (0, 24, 48, and 72 h) for Trichomonas, Gardnerella, and Candida.

Enhanced pneumocystis carinii activity of new primaquine analogues.

New analogues of the venerable antimalarial drug primaquine have been synthesized and bioassayed in vivo against Pneumocystis carinii, a life-threatening infection common among immunosuppressed patients. Two of these new compounds are significantly more active than primaquine itself, and provide new information for future drug design and development in this area.

Extensor tendon lacerations in a preterm neonate.

A fetus of 30-weeks' gestation sustained 2 extensor tendon lacerations as an intraoperative complication of an emergency Cesarean section. This report describes treatment of the tendon lacerations in the preterm neonate using 2 different repair techniques which both yielded an excellent clinical outcome.

A kinematic study of the cervical spine before and after segmental arthrodesis.

STUDY DESIGN: The acute kinematic consequence of segmental arthrodesis in the cervical spine on the remaining open motion segments was studied in a cadaveric model. OBJECTIVES: To evaluate the distribution of motion across unfused cervical motion segments after a segmental arthrodesis. The applied load was determined as a function of arthrodesis length and level by using a fixed range of motion for the cervical spine (C2-T1). SUMMARY OF BACKGROUND DATA: An increased incidence of degenerative disease may exist at the levels immediately adjacent to a cervical arthrodesis as a result of alteration in biomechanical behavior at these levels. METHODS: One-, two-, and three-level fusions were simulated in multilevel ligamentous human cervical spines. Specimens were tested nondestructively through a 30 degrees range of sagittal plane rotation. Motion was recorded using three-dimensional stereophotogrammetry. Sagittal plane rotation of each motion segment in the fusion models was compared with the corresponding rotation in the unfused specimen. RESULTS: In the C2-C4 fusion, the increase in motion at C5-C6 was statistically less (P < 0.05) than the increase at C7-T1. In the C2-C5 fusion, the increase in motion at C5-C6 was statistically less (P < 0.05) than the increases at C6-C7 and C7-T1. For each of the five other fusion types tested, no statistical differences existed between the increases in sagittal rotation at any of the open motion segments. The bending moment necessary to produce 30 degrees of sagittal rotation increased nonlinearly as the number of motion segments fused increased. CONCLUSIONS: Under what was considered a realistic loading paradigm, sagittal plane rotation was not increased disproportionately at the motion segments immediately adjacent to a segmental arthrodesis in the cervical spine. The nonlinear rise in applied bending moment to achieve constant displacement was characteristic of the behavior of the ligaments and intervertebral discs throughout the spine as they underwent increasing deformation.

Ceramic anterior spinal fusion. Biologic and biomechanical comparison in a canine model.

STUDY DESIGN: Three types of porous ceramic bone graft substitutes were used for anterior interbody fusion in the canine thoracic spine. OBJECTIVES: To compare the biomechanical stiffness and histologic appearance of fused spinal segments using ceramic graft substitutes versus autogenous bone graft. SUMMARY OF BACKGROUND DATA: The relative success or failure of ceramic grafts is influenced by many variables, including the composition of the ceramic, location in the spine, stability, and the animal model used. METHODS: Four experimental groups were evaluated: autogenous tricortical iliac crest (n = 6); hydroxyapatite ceramic (Interpore-200; n = 6); biphasic (60 : 40) hydroxyapatite/tricalcium phosphate ceramic (Zimmer; n = 4); and calcium carbonate ceramic (Inoteb; n = 4). All dogs were killed 8 weeks after surgery. After postmortem removal of anterior spinal instrumentation, the spinal segments underwent nondestructive biomechanical testing and light microscopic histologic evaluation. RESULTS: Biomechanical testing showed that spines from the autogenous tricortical iliac crest group were statistically significantly stiffer in flexion, extension, left and right bending, and torsion than all ceramic groups. No differences in stiffnesses were observed among the three ceramic groups. Histologically, the autogenous tricortical iliac crest graft performed best, with osseous union at 10 of 12 interfaces. Of the ceramic grafts, hydroxyapatite/tricalcium phosphate and calcium carbonate demonstrated more consistent junction healing than the hydroxyapatite group, where four of 12 interfaces resulted in a nonunion. In the ceramic groups, a variable amount of revascularization and new bone was observed within the grafts. CONCLUSIONS: Autogenous iliac crest bone graft provides superior healing in this anterior spine fusion model. Additional investigation is needed before ceramic grafts can be considered satisfactory alternatives to anterior autogenous bone grafts.

The effects of internal fixation on calcium carbonate. Ceramic anterior spinal fusion in dogs.

STUDY DESIGN: An anterior interbody fusion was performed in the canine thoracic spine. Either calcium carbonate or autologous iliac crest bone graft was used to fill a surgically created spinal defect between T7 and T8. Some of the spines were stabilized intraoperatively with anterior instrumentation. Four experimental arthrodesis groups were studied: iliac crest bone graft with or without instrumentation and ceramic with or without instrumentation. OBJECTIVE: To evaluate the effects of internal fixation on an anterior interbody fusion using calcium carbonate ceramic, and to compare this with autologous iliac crest bone grafting. SUMMARY OF BACKGROUND DATA: Bone grafting can be associated with significant morbidity, and an acceptable substitute material is sought. In vivo analysis of ceramic as a substitute has revealed fracture and failure of the implant. Creating a stable environment with internal fixation may improve the performance of ceramic as a bone graft substitute. METHODS: Fusions were evaluated in 20 adult beagles 8 weeks after surgery. Structural properties of the fusion segment were evaluated with biomechanical testing. Histologic analysis was performed to determine junction healing, new bone formation, and revascularization. RESULTS: Fusion segments with iliac crest bone graft and instrumentation were significantly stiffer than the other three groups in all tested modes of angular deformation. Greater junction healing was seen when instrumentation was used with iliac crest bone graft. Greater junction healing, new bone formation, and revascularization were observed when instrumentation was used with calcium carbonate ceramic. Most of the ceramic implants without fixation demonstrated near complete isolation with no revascularization. CONCLUSIONS: Internal fixation resulted in histologically and biomechanically superior healing of autologous iliac crest bone graft in this canine model of anterior interbody fusion. Although fixation did not statistically improve the biomechanical properties of ceramic fusion segments, it had a profound effect on the ability of the ceramic to be revascularized and remodeled. Porous ceramic bone graft substitutes appear to depend on a stable environment for incorporation.

Big fish in a small pond: advantages and disadvantages of a first-mover strategy.

The case of a free-standing psychiatric hospital moving into a small rural market as the sole provider of hospital-based psychiatric services is examined as an example of a first-mover strategy. The theoretical bases for a first mover advantage are considered together with an analysis of the situational factors necessary to the strategy's success. The case study illustrates some of the potential consequences of success, namely the attraction of a new competitor with a broader scope of services. The case also illustrates other lessons for market niche competitors in enhancing their likelihood of survival and success in their selected market.

Effects of levcromakalim and RP52891 on NANCe nerve-mediated changes in pulmonary dynamics evoked by vagal stimulation in the guinea-pig.

The effects of the potassium channel activators (KCA) levcromakalim and RP52891 on NANCe nerve-mediated changes in pulmonary dynamics were investigated in the anaesthetized guinea-pig, using a newly-developed respiratory dynamics computer. Levcromakalim (0.025-0.2 mg/kg i.v.) and RP52891 (0.05-0.5 mg/kg i.v.) caused dose-dependent inhibition of NANCe nerve-mediated increases in airways resistance (RAW) and decreases in dynamic compliance (Cdyn). These effects of the KCAs persisted for at least 1 h. Unlike NANCe nerve-mediated responses, equivalent challenges with exogenously-administered substance P (SP; 10-25 micrograms/kg i.v.) and neurokinin A (NKA; 0.5-2.0 micrograms/kg i.v.) tended to produce progressively increasing responses but this effect was not statistically significant. Levcromakalim (0.2 mg/kg i.v.) and RP52891 (0.5 mg/kg i.v.) did not significantly decrease responses to exogenously-administered SP, although NKA-induced bronchoconstriction was attenuated. Glibenclamide (25 mg/kg i.v.) partially reversed the NANCe-inhibitory effects of levcromakalim (0.1 mg/kg i.v.) and RP52891 (0.25 mg/kg i.v.) and fully reversed their hypotensive effects. We have shown that levcromakalim and RP52891 inhibit bronchoconstrictor responses to NANCe nerve stimulation. This involves the opening of a glibenclamide-sensitive K(+)-channel and may represent effects at a pre-junctional site on NANCe neurones to reduce transmitter release.

The management of upstream and downstream risk through selective contracting.

Common strategies employed by many organizations include designating certain suppliers as primary sources and targeting certain customers who are appealing competitively. Such selective strategies are appearing more frequently in the health care sector today. This paper examines the use of selective contracting by managed care programs to simultaneously increase control over costs (provider selection) and decrease risk (subscriber selection).

Is quality of health care a meaningful guide?

Health care consumers are beginning to learn that "what you don't know can hurt you." Though consumers consistently rank quality of care as an important attribute, "quality of care" does not appear to be particularly useful in decision making. The quality of health care is difficult to measure, communicate, and interpret. Yet if consumers are to make efficient choices including both value and cost in their decisions, quality information must be available to them. This paper outlines a scheme to conceptualize quality of care and suggests some ways to operationalize measures of quality that could provide empirically based indices of quality of care to facilitate health care consumer decision-making.