Consumer satisfaction with services in a regional psychiatric hospital: a collaborative research project in Kentucky.

Consumer satisfaction with mental health services is a dimension of outcome. This report is on a university and state mental health department research project that involved development of the Kentucky Consumer Satisfaction Instrument (KY-CSI) and a retrospective, cross-sectional study designed to measure consumer satisfaction with services at a regional psychiatric hospital. Triangulation of methods guided the survey of participants (N = 189) near discharge from the hospital during a 6-month period. Research associates, who were former consumers of mental health services, collected data during face-to-face interviews. Most participants were unemployed White men. Factor analysis indicated the 19-item instrument was unidimensional; Cronbach's alpha was 0.90. Multiple regression indicated predictors of satisfaction were levels of education and diagnosis. As education increased, satisfaction decreased; participants with a diagnosis of bipolar disorder tended to be more satisfied than those with other diagnoses. Analysis of qualitative data combined with standardized summary of KY-CSI items indicated participants were most satisfied with opportunities to talk with other patients and least satisfied about lack of involvement of people with whom they lived in discharge planning. Study findings guided recommendations for quality of care and additional studies at other hospital sites.

The neurobiology of schizophrenia.

The hypothesis that altered dopamine function is a major factor in the etiology of schizophrenia has persisted for some time, and changes in other neurochemical systems are strongly implicated as well. These findings are supported by the recent development of new, effective antipsychotic agents, such as clozapine and risperidone, whose actions are attributed to their combined serotonin and dopamine antagonism. In addition to their clinical efficacy, these agents are associated with substantially fewer extrapyramidal adverse effects. Continued research to identify the neurochemical alterations of psychotic diseases will undoubtedly have a favorable impact on the development of improved therapeutic regimens.

Clozapine therapy and clinical outcomes in Kentucky psychiatric hospitals.

We reviewed the protocol for determining patient eligibility to receive clozapine in Kentucky state psychiatric facilities. Results of a retrospective review of the clinical outcomes of the initial 42 patients who received clozapine under this protocol are reported. Patients receiving clozapine were severely ill patients with a mean duration of illness and mean length of current hospitalization of 11 years and 2 years, respectively. Symptomatic response was dramatic with a reduction in total Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression (CGI) ratings of 48.4% and 36.3%, respectively. The time patients spent in restraints decreased significantly following clozapine initiation. Clozapine was well tolerated, with sedation being the most common adverse effect reported. One patient experienced a seizure and another developed leukopenia. Following 12 weeks of clozapine treatment, the patient discharge rate was 42.9%.

Clinical sequelae of overt non-compliance with psychotropic agents.

A group of 487 patients admitted to Eastern State Hospital in Lexington, Kentucky, during a 3-month period were prospectively followed to determine the incidence of psychotropic medication refusal, unique characteristics of refusers, factors leading to refusal, and clinical outcome of those who refused. Patients who refused any dose(s) of psychotropic medications were identified within 24 hours of refusal. For patients who refused for 24 hours or more, the psychiatrist was asked to complete a 4-item questionnaire. Our data indicate that medication refusal leads to poorer clinical outcomes, as measured by length of hospitalization and incidence and duration of restraint episodes.

Carisoprodol (Soma): a new and cautious perspective on an old agent.

Carisoprodol (Soma, others) is a commonly prescribed, noncontrolled, skeletal muscle relaxant whose active metabolite is meprobamate. Patients for whom carisoprodol is prescribed are at risk for meprobamate dependence; several such cases have been reported. Toxicity and withdrawal associated with the use of meprobamate is high and has led to abandonment of this agent in clinical practice. Because carisoprodol possesses the same risks it should be avoided when possible, and it should be given schedule IV controlled substance status.

Epidural analgesia.

The process of nociception, the anatomy of the epidural space, and the placement of the epidural catheter are reviewed, and the pharmacology and pharmacokinetics, analgesic efficacy, and potential adverse effects of epidurally administered narcotics and local anesthetics are discussed, as well as patient monitoring standards and solution preparation guidelines for these agents. The epidural space is located between the dura mater (the outer-most membrane surrounding the spinal cord) and the vertebral canal. The site of catheter placement is determined by the dermatomes corresponding to the site of desired analgesia. The primary factors that differentiate epidural narcotics are related to their pharmacokinetic profiles. Morphine, which is hydrophilic, has a slower onset of action and a longer duration of analgesia than lipophilic compounds such as fentanyl; morphine also results in less segmentalization (the degree to which analgesia is limited to discrete dermatomal segments corresponding to the level of the epidural narcotic injection) than is seen with lipophilic compounds. Studies have shown that epidural narcotics provide superior pain relief compared with systemic narcotics. Common adverse effects associated with therapeutic doses of intraspinal narcotics include itching, nausea and vomiting, urinary retention, and sedation; respiratory depression is uncommon after epidural administration of narcotics. The most bothersome adverse effect encountered with analgesic doses of local anesthetics is paresthesia. Solutions for epidural administration must be sterile and preservative free. Epidural administration of narcotics and local anesthetics seems to provide better pain relief than conventional methods but may be associated with more bothersome adverse effects.

Patient-controlled analgesia: a review of effectiveness of therapy and an evaluation of currently available devices.

Patient-controlled analgesia (PCA) is a major advance in the management of pain in postoperative and cancer patients. The success of PCA has resulted in a proliferation of marketed devices to administer small bolus doses of parenteral pain-control drugs at fixed intervals controlled by the patient with the push of a button. Because patients demonstrate marked individual variation in pain medication requirements, PCA devices should be able to accommodate rapidly changing requirements for drugs with a minimum amount of effort on behalf of health care personnel. Crude electronic devices were developed in the late 1960s and the early 1970s and usually consisted of a syringe pump connected to some sort of timing device. Most modern PCA devices marketed in the past five years are much more sophisticated devices that are microprocessor based and some newer devices even generate hard copy for a permanent record of drug administration. Although many such devices are available (including a totally disposable PCA device), few have undergone extensive clinical evaluation. A review of the literature shows many devices are available for use without a single publication to document the safety and utility of the device in the routine patient care situation. Use of the PCA method of pain control will grow, and all hospital-based health care personnel should become familiar with their use and limitations.

Effects of Nematicides and Herbicides Alone or Combined on Meloidogyne incognita Egg Hatch and Development.

The effects of nematicides carbofuran (C) and fenamiphos (F) and herbicides metribuzin (M) and trifluralin (T), alone and in combination, on hatching, penetration, development, and reproduction of Meloidogyne incognita race 3 were determined under laboratory conditions. To study hatching, entire egg masses were exposed to nematicides (6 mug/ml), herbicides (0.5 mug/ml), and their combinations over a period of 16 days; the hatched juveniles were extracted and counted every 48 hours. Second-stage juveniles that hatched from day 6 to day 8 were used as inoculum to determine the effects of the chemicals on penetration, development, and reproduction of M. incognita on tomato 4, 16, and 32 days after inoculation. F, F + T, and F + M inhibited hatching; whereas, C, T, M, C + T, and C + M did not affect hatching, penetration, development of females, or reproduction. Since so few juveniles hatched from the fenamiphos treatments, we were not able to use them for the postinfection development study. There was no apparent reduction in the effect of the nematicides by the herbicides.

Pathogenicity of Pythium aphanidermatum to Chrysanthemum in Combined Inoculations with Belonolaimus longicaudatus or Meloidogyne incognita.

Rooted cuttings of 'Iceberg' chrysanthemum in steamed soil were inoculated with the nematodes Belonolaimus longicaudatus, and Meloidogyne incognita, alone and combined with Pythium aphanidermatum, a fungus pathogen of chrysanthemum. B. longicaudatus alone severely restricted the root system; with P. aphanidermatum also present, plant weight and height were further reduced and onset of symptoms was earlier. M. incognita + fungus interaction was similar but less intense. The fungus suppressed egg production of M. incognita but not the reproduction of B. Iongicaudatus. However, all three pathogens combined significantly suppressed reproduction of both nematodes and caused greatest inhibition of plant growth.

Effect of Meloidogyne incognita, M. hapla, and M. javanica on the Severity of Fusarium Wilt of Chrysanthemum.

Rooted cuttings of Chrysanthemum morifolium 'Yellow Delaware' (Fusarium-susceptible) and 'White Iceberg' (Fusarium-resistant) were greenhouse-grown in: (i) non-infested soil; (ii) soil infested with Fusarium oxysporum alone; (iii) soil infested with Meloidogyne incognita, M. javanica or M. hapla; and (iv) each nematode separately plus the fungus. All nematode species infected roots of both cultivars and caused characteristic root-knot symptoms but did not appreciably affect growth meassured by plant weight. Nematodes did not break Fusarium wilt resistance of 'White Iceberg'; however, wilt symptoms appeared earlier and were more severe among 'Yellow Delaware' plants inoculated with Meloidogyne javanica and F. oxysporum than with similar combinations of the fungus and M. incognita or M. hapla or with the fungus alone.