Narratives in a users' and carers' group: meanings and impact.

BACKGROUND: Carers who wished to share their experiences with a national working group (the Consumer Group) prepared narratives as a way of identifying areas for discussion. METHODS: The narratives were submitted to one author and subjected to thematic qualitative analysis. The themes were fed back to the Group for discussion. RESULTS: Five main themes were identified: difficulties in obtaining a diagnosis; acting as an advocate; stresses of caring; practical problems with social care; and emotions experienced by carers. CONCLUSIONS: The narratives provided a means of sharing carers' experiences and creating initiatives for further action by the Group. They have an impact on the people who hear or read them but may also be therapeutic for those who produce them. Narratives can also be a powerful tool in teaching and training, and in identifying areas for service and professional improvement.

Evaluation of United States Department of Agriculture-sponsored consumer materials addressing food security.

PURPOSE: Food insecurity in the United States is a major public health issue. The main objective of this study was to evaluate the availability and quality of printed materials addressing food security targeted to special populations by the United States Department of Agriculture (USDA). DESIGN: Nutrition education resources addressing food security available from USDA websites were selected for analysis. SETTING: Not applicable. PARTICIPANTS: The review team consisted of project staff (n = 6), two of who were fluent in Spanish. METHOD: Selection criteria were established to identify the food-security materials, and a group of reviewers assessed the quality of each publication both quantitatively and qualitatively. A consensus meeting among the reviewers was held to make final determinations of the quality of the materials. The quantitative data analysis consisted of basic descriptive statistics. RESULTS: Among the 27 materials initially identified, 20 were either irrelevant or of low relevance to food security. Moreover, very few of them were intended for minority populations. The quality of most of the materials ranged from "average" to "good." Some of the major weaknesses include readability level, lack of cultural relevance, and inadequate coverage of food insecurity. CONCLUSION: Very few materials on food insecurity are of high quality. In the development of such materials, emphasis should be given to the readability level, content, and cultural relevance.

Autologous peripheral blood progenitor cells are a potential source of parvovirus B19 infection.

BACKGROUND: Parvovirus B19 is a cause of delayed red blood cell (RBC) engraftment after marrow transplantation (BMT). The diagnosis of parvovirus infection requires serologic and DNA testing in the context of clinical disease and characteristic marrow morphologic findings; however, the source of infection is often difficult to determine. STUDY DESIGN AND METHODS: Investigation of a case of delayed RBC engraftment and pure RBC aplasia (PRCA) occurring 3 months after autologous peripheral blood progenitor cell (PBPC) transplantation in a patient with high-risk diffuse large B-cell lymphoma. DNA testing of serum and of a sample of cryopreserved PBPCs was performed. RESULTS: Marrow morphology showed a maturational arrest of erythroid cells with giant proerythroblasts. Polymerase chain reaction and nucleic acid hybridization confirmed the presence of parvovirus DNA in the serum and in a sample of sequestered PBPCs saved at the time of PBPC harvest. PRCA resolved after the administration of intravenous immune globulin. CONCLUSION: Autologous PBPCs are a potential source of parvovirus infection, which may cause significant disease after autologous BMT.

Psychotherapies and older adults.

OBJECTIVE: To confirm clinical experience which suggests that older people are offered psychotherapies significantly less often than younger ones. For those who are able to access psychotherapeutic help the outcome is comparable, sometimes better, than for younger patients. METHOD: Contemporary and older seminal literature was reviewed for psychodynamic, cognitive-behavioural, reminiscence and systemic family therapies treating older patients. RESULTS: The main findings supported the experience of staff in old age psychiatry that if the reluctance of referrers and sometimes of older patients themselves can be overcome this type of work is valuable and effective. CONCLUSIONS: Each patient is unique. Generalizations are not always appropriate, however, with advancing years some common themes emerge in therapeutic work. It may be necessary to make modifications to the therapeutic technique to accommodate the difficulties experienced by people in later life but also to use their strengths. Staff working in this field need to have the capacity to be aware of and to understand their own feelings and prejudices about the second half of life. For patients not offered formal therapy a psychotherapeutic approach will nevertheless enhance their psychiatric care. Although the body of research is growing, more work needs to be done in evaluating all of the psychotherapies offered to older people.

Cost-effectiveness of a transplantation strategy compared to melphalan and prednisone in younger patients with multiple myeloma.

High dose chemotherapy with autologous stem cell transplantation (ASCT) improves outcomes in patients 65 years of age or less with multiple myeloma. Survival and costs in a cohort of 16 patients who received melphalan and prednisone as part of a clinical trial were compared with those of 36 patients referred to our centre for consideration of ASCT. In the transplant group, survival and costs were extrapolated to match the period of observation in the melphalan and prednisone group. Patient-specific and average costs were calculated from the perspective of the Ontario Ministry of Health. Costs and survival were varied by 50% in the sensitivity analysis. Transplantation improved life expectancy by 19.3 months with a cost difference of 30,517 Canadian dollars. The incremental cost-effectiveness of transplantation compared with melphalan and prednisone was 25,710 Canadian dollars per life-year gained when additional pamidronate and follow-up costs were considered. Discounting costs and survival at 3 and 5% did not result in important differences. The sensitivity analysis resulted in best and worse case scenarios for transplantation compared with melphalan and prednisone of 13,049 dollars and 63,954 dollars per life-year gained respectively. In comparison with melphalan and prednisone, ASCT appears to be cost-effective in patients 65 years old or younger with myeloma.

The case against "the evidence": a different perspective on evidence-based medicine.

BACKGROUND: An evidenced-based approach to psychiatry is playing an increasingly prominent role in treatment decision-making for individual patients and for populations. Many doctors are now critical of the emphasis being placed on "the evidence" and concerned that clinical practice will become more constrained. AIMS: To demonstrate that evidence-based medicine is not new, sources of evidence are limited and psychosocial aspects of medicine are neglected in this process. METHOD: Some of the literature is reviewed. Ideas and arguments are synthesised into a critical commentary. RESULTS: These are considered under four headings: evidence-based medicine is not new; what evidence is acceptable; the doctor as therapist; and the emergence of a new utilitarian orthodoxy. CONCLUSIONS: It is agreed that a degree of professional consensus is necessary. However, too great an emphasis on evidence-based medicine oversimplifies the complex and interpersonal nature of clinical care.