Participant satisfaction with group and individual components of Adolescent Impact: a secondary prevention intervention for HIV-positive youth.

Adolescent Impact, a developmentally targeted behavioral intervention aimed at decreasing risk behaviors and promoting health care adherence, was delivered to 83 HIV-infected youth, aged 13-21 years, receiving care in five urban HIV centers. Participants completed a patient satisfaction survey following the 12 part intervention consisting of seven groups and five individual sessions. A feedback questionnaire was also completed during each group session to gain more insight on participant experiences. Several indicators suggested high levels of satisfaction. First, overall attendance was relatively high. Second, participants rated their subjective experience and group content favorably. No differences in satisfaction ratings emerged between perinatally infected adolescents and those who acquired HIV through risk behaviors. However, differences emerged regarding perceived intervention utility and content-specific preferences. Findings suggest that Adolescent Impact participants were satisfied with the intervention and that a heterogeneous group of HIV-infected youth could be advantageously integrated into the same secondary prevention program.

The incidence and risk factors associated with postoperative delirium in geriatric patients undergoing surgery for suspected gynecologic malignancies.

BACKGROUND: The incidence of postoperative delirium (PD) in the elderly ranges between 3-60% but has never been examined in gynecologic oncology. Our goal was to identify pre, intra, and postoperative risk factors associated with the development of PD. METHODS: English speaking women of 60 years and above undergoing major surgery for suspected gynecologic malignancies were invited to participate. Enrolled patients were administered a pre and postoperative Mini-Mental State Exam (MMSE), and the postoperative Confusion Assessment Method was used to diagnosis PD. Pre, intra, and postoperative clinicopathology parameters were collected. Statistics included the Pearson chi-squared tests and multivariate logistic regression. RESULTS: Eighteen of a total of 103 patients (17.5%) developed PD. Univariate analysis revealed significant associations (p<0.05) between the development of delirium and age, albumin level, Charlson comorbidity index, performance status, dementia, level of education, number of pre and postoperative medications, prolonged oxygen or Foley catheter usage (>2 d), increased narcotic use (above standard regimens), postoperative transfusion, bed restriction and change in MMSE scores (pre vs. post). Using multivariate logistic regression analysis, older patients (p=0.0002), on multiple medications (p=0.008), given additional narcotic doses (p<0.0001) were at highest risk for the development of delirium. Intraoperative parameters were not correlated with outcome. CONCLUSIONS: PD is a common complication in older women undergoing major gynecologic surgery. Increased narcotics, age, and preoperative medications were strongly associated with this adverse event. Prevention needs to focus on i) identifying patients at higher risk for PD based on preoperative parameters, and ii) eliminating known postoperative risk factors.

Reduced red blood cell destruction by antibody fragments.

Antibodies to blood group antigens can cause immune RBC destruction directly (extravascular destruction) or indirectly through subsequent complement activation (intravascular hemolysis). The Fc portion of the IgG antibody is responsible for the effector functions of immune RBC destruction. We hypothesized that sensitization of RBCs with blood group antigen-specific IgG antibodies lacking their Fc portion would escape from the recipient's immune system, allowing for a longer survival period of the RBCs in the circulation. Direct injection of mouse RBC-specific Ter-119 monoclonal antibody into mice resulted in a more severe anemia compared with that in mice injected with the Ter-119 F(ab')2 fragment. We found that mouse RBCs coated in vitro with the Ter-119 F(ab')2 fragment, when transfused into mice, survived longer in circulation compared with RBCs coated with whole Ter-119 IgG molecule. The data support the conclusion that antibodies can be rendered less pathogenic through removal of their Fc portion.

Ryan White CARE Act Title IV: building networks to improve healthcare delivery to the HIV infected.

There has been little evaluation of the implementation of HIV consortia that were created under Title IV of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. In 1993, Mor and colleagues reported that the effectiveness of networks established by the Robert Wood Johnson Foundation had been compromised by the inability of the participating agencies to work together, given their competing goals and varied institutional cultures. In a study published in 1995, Roy and colleagues identified the following as determinants of successful project implementation: federal and local government support, management-level support and technical assistance, and linkages between participating agencies. This article describes the role that network infrastructure can play in developing interagency collaboration, and the importance of network infrastructure in coordinating the delivery of care at the service-delivery level. The authors describe the efforts of the Lower New York Consortium for Families with HIV (hereafter, "the Consortium") to develop integrative mechanisms at both the network level and the program level. As the number of infected women grows, so does the need to improve the delivery of services and to reduce barriers to the receipt of care. In itself, the support of individual agencies that provide case-management services may not be enough to improve service delivery and reduce barriers; the experiences of networks such as the Consortium may help inform the development of guidelines for creating and enhancing the coordination of services to assure improvements in care. Systematic studies are needed to evaluate different models of collaboration and of coordinating care to determine whether the effort to develop consortia is justified by improved access to care and improved health.

DNA analysis in microfabricated formats.

The use of microfabricated DNA analysis tools utilizing microfluidics will provide the next generation of inexpensive DNA diagnostics. It will also provide methodologies to measure gene expression in a massively parallel manner, eventually providing the methodologies to measure most or all the human genes of significance on a single chip. These technologies, including PCR analysis, electrophoresis and gene chips are described using examples from the archival literature.

Measuring HIV/AIDS case management.

Studies of HIV/AIDS case management have been limited by their almost exclusive focus on adults and by the limitations of available methodologies. This study assesses the use of a time study methodology to measure the case management activities of 20 case managers in two urban hospital pediatric and adult HIV/ AIDS clinics and in 3 community organizations. Case management activity was sampled using a beeper case managers carried, which signaled randomly 8 times a day over 5 consecutive days. When the signal "beeped", case managers checked on a form the appropriate descriptor of their involvement in case management tasks and with different clients. The results suggest that the Time Study methodology is a useful and valid way of measuring case management.

Measuring case management for families with HIV.

Case management has been recognized as a major way for coordinating the multiple services needs for people with HIV/AIDS. Such coordination is required because of the progressively debilitating nature of this chronic disease and the fragmented health care and social services delivery system. One of the major problems with the study of case management is the difficulty in actually measuring it. Another major limitation has been the focus almost exclusively on adult models of HIV/AIDS case management. This study was undertaken to assess the efficacy of a time study methodology to measure differences in case management activities when case managers work with families and when they work with individuals. Ten case managers from two urban hospital pediatric and adult HIV/AIDS clinics and 10 case managers from 3 community organizations participated. Case management activity was sampled using a beeper carried by case managers which signaled randomly 8 times a day over 5 consecutive days. When the signal "beeped", case managers checked off on a 1-page form the appropriate descriptor of their involvement concerning task initiation, interaction, location, type, function as well as information about client needs, HIV status, and family history. The results suggest that the Time Study methodology is a useful and valid way of measuring case management and of identifying differences in case mix, client need and background, and case management techniques when case managers work with families and with individuals.

Towards inexpensive DNA diagnostics.

Methodologies to obtain DNA sequence information efficiently and accurately will provide the basis for a broad spectrum of economical products and applications to a variety of industrial sectors, in addition to healthcare. Such technologies will build upon the evolving molecular biology and instrumentation base that is serving a specific research market. This will require the efficient integration of technical advances in microchemistry, micromachining, separation technologies, detection systems, microelectronics and information technology, and will involve the expertise of engineers, physicists, chemists, mathematicians, computer scientists and molecular biologists. The biotechnology, microelectronics, software, instrumentation, pharmaceutical and fine chemical industries will be vital to this development.

Emergency room visit time: changes over a 16-year period.

A one-week time and motion study was conducted at a large urban hospital replicating a study performed in 1969 in the same hospital, allowing a longitudinal study of emergency room utilization to be reported. Despite a 36% increase in the number of emergency room patients over the 16-year period, the findings from both studies replicate many of the patterns previously reported. Over time, both length of stay and wait times to see physicians have increased, although the values are still well within the ranges found in the literature. As competition increases, hospitals and their emergency room managers will have to determine what constitutes acceptable visit and waiting times in order to compete effectively for emergency room "clientele." Studies such as this one serve as a foundation for hospitals to implement policy changes that will improve health care delivery, and, in fact, this institution has already implemented changes based on this study.

Survey method for post-marketing drug surveillance: a demonstration.

Distinguishing characteristics of a community survey method for post-marketing drug monitoring are described, as are results of a pilot study of the method. Representative samples of outpatients treated with tricyclic antidepressants or benzodiazepine anxiolytics were identified in a clinic or pharmacy and interviewed at baseline and specified intervals thereafter in the home or by telephone. Data were collected by lay interviewers trained to use a detailed interview schedule designed with input from experts in pharmacology, relevant clinical disciplines, and survey research. The critical validity question was the degree to which predicted outcomes for the two well-studied drug classes matched observed outcomes. The analytic design involved two contrast groups, three measurement periods, and six key symptom measures. The latter were specific to the disorder (anxiety and depression), to the medications, or to neither the disorders nor the medication (neutral symptoms). Predictions took account of degree and direction of change, as well as differences in profile levels over time. Results conformed precisely to expectations. As one component of a comprehensive system, the method provides an opportunity to examine efficacy as well as safety under conditions that are typically absent or excluded in clinical trials. Data on patterns of prescribing by physicians and use by patients are valuable by-products that are immediately relevant for professional education and product liability. Advantages and limitations of the method are discussed.

Analyzing patient satisfaction: a multianalytic approach.

A telephone survey of 9% of first quarter discharges at The New York Hospital was undertaken to identify the dimensions of a patient satisfaction questionnaire and the determinants of patient satisfaction. The questionnaire included measures of overall satisfaction with hospital services, satisfaction with ten aspects of service, and patient expectations. Relatively high inter-item correlations indicate that the questionnaire can be shortened and the same overall dimensions measured. A longer questionnaire would still be necessary to ascertain the relative values of measures within any one dimension. The best determinants of overall satisfaction with hospital care appear to be patient expectations and satisfaction with nursing care. Patient satisfaction with nursing care, however, seems to hinge on satisfaction with services not under a nurse's control.

The stresses of psychotherapeutic work: a replication and extension.

The present study represents a replication and extension of a recent investigation of the patterns of stresses in psychotherapeutic work. A sample of 227 licensed psychologists who were practicing in Northern California were administered two Likert-type rating scales, which were expanded versions of questionnaires originally developed by Farber and Heifitz (1981). Factor analysis of the data revealed that the stressful aspects of therapeutic work include maintaining the therapeutic relationship, scheduling difficulties, professional doubt, work overinvolvement, and feeling personally depleted. In addition, stressful patient behaviors were found to cluster into five distinct categories: Expressions of negative affect, resistances, psychopathological symptoms, suicidal threats, and passive-aggressive behaviors. Demonstration of the empirical generalizability of the factor structure and of the relative importance of stressful therapeutic events argues for the usefulness of the extended versions of The Therapeutic Stresses and Stressful Patient Behaviors rating scales.

Relation of family factor to treatment outcome for bulimic patients.

The psychotherapy of 25 normal weight bulimic adolescent and late adolescent women (age 15-32 years, mean = 21 years), was reviewed to evaluate developmental and diagnostic precursors and the outcome of psychoanalytically oriented long-term therapy (mean = 33 sessions). Psychotherapy outcome was scored in these categories: bingeing and purging; food obsession; school/work satisfaction; equilibration with family of origin, and achievement of heterosexual closeness. On factor analysis, all factors loaded highly and a global outcome score was derived which was used as the dependent variable in a step-wise regression analysis with 18 family factors as independent variables. To identify family patterns that predicted degree of improvement, a multiple regression analysis was performed. Results indicated that family variables associated with maternal warmth explained an appreciable proportion of the variance in outcome. Such a finding is consistent with the formulation that patients with benign archaic maternal representations were better able than their counterparts with less benign maternal images to form a positive transference and better working alliance with the (female) therapist.

Organizational size and perceptions in a residential treatment program.

Centralization of a residential mental health treatment program from three small houses to one large facility provided a naturally occurring opportunity to study the effect of organizational size on the perceptions held by clients and staff. Quantitative data were repeatedly collected on their perceptions of themselves, the organization as a whole, and subgroups within the organization during their involvement in both the small and large social contexts. Results of repeated measures analyses of variance provided considerable support for the theoretically derived hypotheses of heightened anxiety, self-impoverishment, more negative views of the psychosocial environment, and greater psychological distance in the large organizational context.

Biofeedback, self-control and tension headache.

This research tested the belief that muscle contractions are a primary source of tension headache. EMG level was found to be associated with both headache-specific and more global symptoms following biofeedback training. However, the level of pretreatment relationship between EMG level and headache symptoms was weak, and the amount of reduction in EMG activity over the course of biofeedback did not explain improvement. In addition, although the voluntary control over muscle spasming evidence by lowered EMG readings appeared to enhance patients' post-treatment level of self-control, this cognitive process variable also could not account for outcome variance. The results offer limited support for the muscle-origins conception of tension headache and suggest the need for further research to clarify the contribution of physiological, cognitive and social factors to pain reduction.

The mid-life male sex-change applicant: a multiclinic survey.

Directors of coordinators of a cross-section of North American Gender Identity Clinics provided descriptive information on 1,637 sex-change applicants and psychosocial, psychosexual, and psychiatric data on 21 middle-aged male candidates. To determine the age relatedness of the findings, the mid-life male candidates were then compared on selected characteristics with a random sample of younger biological males seeking sexual reassignment at the Vanderbilt Gender Identity Clinic. The results are consistent with previous findings highlighting the factors at mid-life that intensify the male transsexual's desire for sexual transformation. Viewing the aging gender dysphoria patient's surgical request from a developmental perspective promotes appreciation of his predicament and informed consideration of his treatment options.

Borderline personality disorder and the MMPI.

Fourteen patients diagnosed as borderline on the basis of the Diagnostic Interview for Borderlines obtained a mean group profile of 8-2-7 similar in configuration, but more elevated than that obtained by a group of 7 diagnostically heterogeneous controls. The borderline patients manifested significantly greater hypochondriasis, depression and hysteria, slightly more schizotypal features, a more deviant self-presentation, and lesser defensiveness. However, considerable heterogeneity in symptomatology was found within the borderline subsample. Further, clinical scales comprised of a higher proportion of relatively subtle and presumably less structured items did not discriminate borderline from control patients more effectively than did those scales made up of a lower proportion of such items. The results offer partial support for the construct validity of the borderline syndrome and for the usefulness of the MMPI in differentiating it from other psychiatric disorders.

A stalemate on test-tube baby research.

KIE: Although the now-defunct Ethics Advisory Board of the Department of Health, Education, and Welfare concluded in 1979 that research on in vitro fertilization with embryo transfer was ethically acceptable, federal approval and funding have not been forthcoming. Arguments over the moral status of the embryo, the danger of abnormal fetuses, and the possibility of undesirable applications of research are the major reasons for the delay. While privately funded research has continued, the benefits of wide-scale, federally-funded research have been delayed, and the costs to infertile couples are great. Suggestions for breaking the stalemate are made, though quick action is considered unlikely.^ieng