Multi-level assessment protocol (MAP) for adoption in multi-site clinical trials.

The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) is intended to test promising drug abuse treatment models in multi-site clinical trials, and to support adoption of new interventions into clinical practice. Using qualitative research methods we asked: How might the technology of multi-site clinical trials be modified to better support adoption of tested interventions? A total of 42 participants, representing 8 organizational levels ranging from clinic staff to clinical trial leaders, were interviewed about their role in the clinical trial, its interactions with clinics, and intervention adoption. Among eight clinics participating in the clinical trial, we found adoption of the tested intervention in one clinic only. In analysis of interview data we identified four conceptual themes which are likely to affect adoption and may be informative in future multi-site clinical trials. We offer the conclusion that planning for adoption in the early stages of protocol development will better serve the aim of integrating new interventions into practice.

Drug court effectiveness: a review of California evaluation reports, 1995-1999.

Over the past two decades, drug courts have emerged as a viable alternative for addressing drug cases within the criminal justice system. In California, the Drug Court Partnership Program (DCPP) was created in 1998 and has supported and funded the development of drug courts throughout the State. This article reports on a review of California drug court evaluations through January 2000 conducted as part of an evaluation of the California DCPP. A total of 23 evaluations were collected. Seventeen were reviewed in detail, and six were excluded because they were internal reports rather than evaluations. A standardized review process was initiated which led to a scored rating of the evaluation reports. Results of this review support previous findings that drug court participants may experience reduced rearrest rates by 11% to 14% compared to nonparticipants. The largest reduction in rearrest rates appears among graduates. The graduation rates were between 19% and 54%. Costs and savings associated with drug courts were discussed but no conclusions were possible based on the findings from these evaluations. The evaluation of the effectiveness of drug courts presents unique challenges. This review concludes with a discussion of evaluation methods (e.g. standardizing rate calculations, term definitions) that would strengthen drug court research.

Clients entering drug abuse day treatment: 18-month outcomes.

Clients who entered and remained in day treatment for at least 2 weeks (N = 66) were interviewed at 6, 12, and 18 months after baseline. Follow-up rates for each time point ranged from 58% to 68%, and 30 clients (45%) were interviewed at every time point. Those who were consistently followed (N = 30) did not differ from those who were not consistently followed (N = 36) on demographics or on outcome variables measured at baseline. Comparison of mean outcome scores across time using MANOVA indicated significant changes from baseline to 6 months in the areas of alcohol, drug, legal, and social problem severity, and these changes were maintained up to 18 months postadmission. Outcomes reflecting psychiatric symptoms and employment also changed over time, but exhibited different patterns of change. Results are confounded by treatment received, since many respondents also participated in residential treatment during follow-up. Day treatment can serve clients having a range of substance abuse problems, and can act as a bridge to traditional residential treatment. Randomized clinical trials, where clients receive only one or the other type of treatment, are needed to assess the effectiveness of day treatment alone.

Auditory threshold shift following meatal pressure change in ossicular disorders.

Auditory threshold shifts for air conduction following meatal pressure changes were examined in 30 normal ears and in 27 ears with ossicular abnormalities. Negative and positive changes in meatal pressure caused threshold elevation at frequencies lower than 1,000 Hz in all normal ears. In the ears with ossicular fixations, air pressures were less effective in attenuating hearing as compared with normal ears. Clearly different results were obtained in the patients with incudostapedial disconnection without stapes fixation. Thresholds were elevated by positive pressure, although marked threshold gains were measured by negative pressure at low frequency tones. Differences in threshold levels between the air pressures of +200 and -200 mm H2O were 26 to 40 dB at 250 Hz. This marked reverse effect in direction of the threshold shifts cannot be explained only by relative compliance changes in the tympanic membrane. Possible mechanisms underlying this phenomenon are discussed.

[Ventilation and passages in the middle ear. A study by HRCT in patients with attic cholesteatoma].

Operative records of 75 patients with acquired attic cholesteatoma were evaluated and compared with preoperative HRCT findings. The cholesteatoma extensions were classified into five groups as follows; Group 1 (cholesteatoma limited to the attic, 9 cases), Group 2 (cholesteatoma occupying both the attic and the aditus, 5 cases), Group 3 (cholesteatoma extending down to the posterior tympanum, also occupying an area as in Group 2, 6 cases), Group 4 (cholesteatoma occupying the attic, the aditus and the mastoid antrum, 14 cases), and Group 5 (cholesteatoma extending down to the posterior tympanum, also occupying an area as in Group 4, 41 cases). Ventilatory conditions, or the existence of soft tissue density, were evaluated by HRCT at such locations as the supratubal recess, mesotympanum, anterior and posterior parts of the tympanic isthmus, epitympanum, and mastoid antrum. Results are as follows. In Group 1, all these locations were aerated with the exception of a few cases. In Group 2, complete opacification was observed in almost all of the antrums. Soft tissue masses involved the anterior and/or posterior parts of the tympanic isthmus in both Groups 3 and 5. In Group 3, the posterior part of tympanic isthmus was less aerated than the anterior part of tympanic isthmus. In Group 5, all locations were filled with soft tissue density except the supratubal recess and the mesotympanum, where some degree of aeration was observed. These results indicate that blockage of the ventilatory passages is not essential for formation of an attic cholesteatoma. Soft tissue density in HRCT is not the cause, but rather, the result of extension of a cholesteatoma.

[A case of hypopharyngeal stenosis caused by late radiation injuries--reconstruction of the hypopharynx with myomucosal tongue flap].

The authors reported a 47-year-old man with hypopharyngeal stenosis caused by late radiation injuries. At the age of ten he underwent irradiation (3000rads) to the neck because of the cervical lymphadenopathy. He had keroid skin change at the age of 19, hypothyroidism since 26, right cervical and brachial plexus neuropathy since 33, and paralysis and papilloma of right vocal cord at 34. And at the age of 41 he underwent tracheostomy owing to laryngeal stenosis. In November 1984 (at age 43) he felt abnormal sensation on the throat but had no dysphagia nor misdiglutition. On November 1987 he had difficulties of swallowing, and could not take anything but fluid. At that time he was diagnosed as hypopharyngeal stenosis. With steroids and antibiotics his difficulties of swallowing were reduced. He experienced the same difficulties on April 1988. Since December 1988 his dysphagia got worse and was not recovered with medication. On May 17 1989, laryngopharyngectomy was performed. At the level of cricoid cartilage hypopharynx was resected. As for the posterior wall, pharynx and cervical esophagus were fixed to prevertebral fascia and anastomosed with end-to-end. And antero-lateral defects were reconstructed with myomucosal tongue flap. Postoperatively he could eat orally. On the basis of the experience of this case and the review of the literature the authors conclude that myomucosal tongue flap is one of alternatives for hypopharyngeal reconstruction.