Care Management for Serious Mental Illness: A Systematic Review and Meta-Analysis.

OBJECTIVE: Persons with serious mental illness face adverse psychiatric and medical outcomes, and their care is associated with a large burden of health care costs. Care management, in which assessment, care planning, and care coordination are provided, is a common model of support, yet the evidence supporting its use among psychiatric populations is mixed. A systematic review and a meta-analysis were undertaken to determine the impact of care management on clinical outcomes, acute care utilization, cost, and satisfaction among adults with serious mental illness. METHODS: A multidatabase literature search was performed. Articles were included if they compared standard outpatient care plus care management with standard outpatient care alone for adults with serious mental illness and reported on one or more predefined outcomes. Randomized controlled trials (RCTs) and other study designs were permitted for inclusion in the systematic review. The meta-analysis included only RCTs. RESULTS: For the systematic review, 34 articles representing 28 unique studies were included. Fifteen of these articles, representing 12 unique studies, were included in the meta-analysis, which indicated that care management was associated with small, statistically significant improvements in psychiatric symptoms, overall quality of life (QOL), and mental QOL (Hedges' g range 0.13-0.26). In addition, care management was associated with a small, statistically significant reduction in inpatient psychiatric hospital days (Hedges' g=0.16, p=0.02). CONCLUSIONS: Care management is associated with fewer psychiatric symptoms and greater QOL for persons with serious mental illness. Further work is needed to determine which components of the intervention are associated with effectiveness.

Government political structure and violent death rates: A longitudinal analysis of forty-three countries, 1960-2008.

OBJECTIVES: Currently, little is known regarding the effect of regime type on mortality on a global level. The purpose of this study is to examine the effect of regime type on the rates of violent deaths (homicide, suicide, and combined rates). METHODS: Three measures of democracy were used to quantify regime type, the independent variable. Homicide and suicide rates were obtained from the World Health Organization. Multivariate conditional fixed-effects models were run to examine associations between regime characteristics and logged rates of homicide, suicide, and violent deaths. Models were adjusted for unemployment and economic inequality. RESULTS: Nations that scored higher on democracy indices, especially emerging democracies, experienced increased mortality due to violence. Homicide and suicide were divergent, showing a different time course and decreasing statistical power as a combined variable. Unemployment and inequality were associated with higher violence-related mortality. CONCLUSIONS: Homicide and suicide appear to be more prevalent in democracies. Future analyses should examine which aspects of democracies lead to higher rates of violent death and should seek to use independently collected mortality data.

Quality Versus Quantity: The Potential Impact of Public Reporting of Hospital Safety for Complex Cancer Surgery.

OBJECTIVE: To estimate the potential mortality reduction if patients chose the safest hospitals for complex cancer surgery. BACKGROUND: Mortality after complex oncologic surgery is highly variable across hospitals, and directing patients away from unsafe hospitals could potentially improve survivorship. Hospital quality measures are becoming increasingly accessible at a time when patients are more engaged in choosing providers. It is currently unclear what information to share with patients to maximally capitalize on patient-centered realignment. METHODS: The National Cancer Database was queried for adults undergoing 5 complex cancer surgeries (pulmonary lobectomy, pneumonectomy, esophagectomy, gastrectomy, and colectomy) for a primary cancer between 2008 and 2012. Risk-standardized mortality rate (RSMR) methodology, currently used by Medicare-based hospital rating systems, was used to classify hospitals as "safest" and "least safe" by procedure. Patients were modeled moving from "least safe" to "safest" hospitals and the potential number of lives saved through patient realignment determined. As surgical volume has historically been used to distinguish safe hospitals, comparisons were made to models moving patients from low-volume to high-volume hospitals. RESULTS: A total of 292,040 patients were analyzed. In an optimally modeled scenario, realignment using RSMR would result in a greater number of lives saved (3592 vs 2161, P < 0.01) and require only 15 patients to change hospitals to save a life, compared to 78 patients using volume models (P < 0.01). CONCLUSIONS: Public reporting of hospital safety, specifically based on RSMR instead of volume, has the potential to lead to meaningful reductions in surgical mortality after complex cancer surgery, even in the setting of a modest patient realignment.

Spontaneous regionalization of esophageal cancer surgery: an analysis of the National Cancer Database.

BACKGROUND: Esophagectomy patients are up to three times more likely to die after surgery when cared for at low-volume hospitals (LVHs). Increased awareness by patients and clinicians of the hazards of esophagectomy at LVHs, may inspire a "spontaneous regionalization" away from LVHs, yet the extent to which this has taken place is unclear. METHODS: Retrospective analysis of patients undergoing esophagectomy for esophageal cancer in the National Cancer Database (NCDB) across two eras: 2004-2006 (Era 1) and 2010-2012 (Era 2). Primary outcomes included the proportion of patients at high-volume hospitals (HVHs) (≥13/year per Leapfrog Group), adjusted, and unadjusted 90-day mortality. RESULTS: The NCDB captured 5,968 esophagectomy patients in Era 1 and 5,580 in Era 2, a 6.5% decrease (P<0.001). Fewer hospitals performed esophagectomies in Era 2 (756 vs. 663, P=0.014), yet the proportion of patients treated at LVHs declined slightly between eras (73% vs. 70%, P<0.001). Patients with high-risk attributes (e.g., advanced age, multiple comorbidities, etc.) were disproportionately treated at LVHs in both eras (77% Era 1, P<0.001, 73% Era 2, P=0.017). However, the 90-day mortality rate for patients with high-risk attributes decreased considerably between Eras at LVHs (19.3% to 12.3%, P<0.001). CONCLUSIONS: Spontaneous regionalization of esophageal cancer surgery has not occurred on a large scale, yet for high-risk patients, the hazards of being cared for at LVHs have dissipated. Further study is needed to optimize alignment of esophagectomy patients and hospitals.

Live bio-imaging with fully bio-compatible organic fluorophores.

We synthesized a new organic fluorescent dye named resveratrone glucoside from the photoreaction of naturally-occurring phytoalexin compound resveratrol glucoside (resveratrol-3-ß-mono-d-glucoside), which is abundant in various plants such as berries, herbs, nuts and grapes. Just like its predecessor molecule resveratrone that was previously discovered by our group, resveratrone glucoside possesses excellent optical properties including a high fluorescence quantum yield, a large Stokes' shift, and a large two-photon absorption cross section. In addition to these highly desirable properties, both fluorescent molecules can also be used as ideal bio-compatible organic fluorophores since they have remarkably low cytotoxicity, which we verified through our cell morphological study, trypan blue exclusion assay, Western blot analysis and fluorescence imaging of various live biological specimens. In particular, we note that resveratrone glucoside is much more soluble in aqueous solution because of its glycosidic side chain and therefore highly suitable for in vivo imaging. We demonstrated that resveratrone and resveratrone glucoside can be used in one- and two-photon fluorescence microscopic imaging of E. coli, yeast (S. cerevisiae), and mammalian cell lines including HeLa and MCF10A cells as well as to the live imaging and real-time tracking of the zebrafish embryo development. Both organic fluorophores can be readily obtained from a simple photoreaction of commercially available, inexpensive samples.