Effectiveness of the DROP training for military behavioral health providers targeting therapeutic alliance and premature dropout.

AbstractPremature discontinuation from behavioral health treatment is a major problem reducing effectiveness of care in military populations. A training was developed and delivered to 622 behavioral health providers across 15 sites within the Army behavioral healthcare system. The training taught two techniques to foster treatment engagement: (1) Progress Informed Treatment, consisting of reviewing symptom assessments and outcome measures, and (2) assessment and discussion of the treatment alliance via a paper survey given near the end of each session. Eighty-five percent of providers indicated the training was useful and 89% of providers incorporated a technique into their practice. Dropout before the fourth session was significantly reduced in the six months following training, from 72.5% to 67.1% in Service Members (SM; X2(1, N=9127) = 39.58, p < .001). In both the pre and post-training periods, providers working at the Master's level, SM aged 17 or 46 or older, and clients receiving a mood, PTSD, anxiety, adjustment, substance or childhood/adolescent psychiatric diagnosis experienced significantly less dropout, while SM aged 18-21 had significantly more dropout. This training is a feasible and available option to increase treatment engagement and improve treatment outcomes for service members.

Antithrombotic therapy prescribed for patients with non-rheumatic atrial fibrillation.

Patients with non-rheumatic atrial fibrillation have a fivefold increased risk of stroke. Warfarin reduces this risk by approximately two thirds, but evidence for benefit from aspirin is less compelling. We assessed whether our current practice reflects the message of the trials. In a retrospective case record study we reviewed notes of 131 patients with atrial fibrillation (AF), mean age 79 (range 53-95) years, admitted to a medical unit (72) or geriatric assessment unit (59). Thirty-two patients had paroxysmal AF. Of 115 patients with nonrheumatic AF, 36 (31%) had one or more recorded contraindication to anti-coagulation. Although 79 patients (69%) had no recorded contraindication to warfarin, only 2 took warfarin and 15 aspirin prior to admission. Ten patients commenced warfarin and 8 aspirin before discharge. Thirty-nine patients (53%) without contraindication, were discharged without antithrombotic therapy. Despite evidence to support anticoagulating patients with non-rheumatic AF, this rarely occurs.

Use of plasma ferritin concentration to diagnose iron deficiency in elderly patients.

AIMS: To determine a concentration of ferritin below which the possibility of iron deficiency should be considered in elderly patients. METHODS: Consecutive new referrals to a geriatric unit (n = 472) were studied prospectively. Full blood count, ferritin, serum vitamin B12 and red cell folate were measured for all patients. A blood film was assessed independently by three haematologists for features of iron deficiency. For those with ferritin of 12-45 ng/ml, bone marrow aspirates were performed and examined for the presence of stainable iron. When possible, a trial of oral iron was given to those with ferritin of < or = 45 ng/ml and response was determined by re-measurement of full blood count and ferritin after a minimum of three weeks of treatment. RESULTS: Bone marrow examination was performed in 32 patients with ferritin of 12-45 ng/ml, of whom 27 (84%) had absent stainable iron, suggesting that most elderly patients with ferritin in this range have iron deficiency. Compared with those with ferritin of 100-299 ng/ml, in whom iron stores were presumed to be normal, patients with ferritin of 12-45 ng/ml had a significantly lower mean haemoglobin and mean red blood cell volume. Furthermore, patients with ferritin up to 75 ng/ml had a significantly higher mean red cell distribution width, and were more likely to have an iron deficient blood film. CONCLUSION: Iron deficient erythropoiesis can occur in elderly patients with ferritin up to 75 ng/ml. This is much higher than the lower limit of the "normal" range usually quoted for younger subjects; this difference should be taken into account when ferritin concentrations are interpreted in elderly patients.

Use of the erythrogram in the diagnosis of iron deficiency in elderly patients.

In elderly patients the diagnosis of iron deficiency from full blood count indices is often difficult. We assessed an automated technique (numerical data of the erythrogram; Technicon H*1) by which the proportions of microcytic (< 60 fl) and/or hypochromic (< 28 g.dl-1) red blood cells are determined. Of 472 elderly patients investigated, 100 (21%) were found to have iron deficiency (plasma ferritin < or = 45 ng.ml-1). Less than two-thirds of patients with iron-deficient erythropoiesis (anaemia or microcytosis) had increased proportions of hypochromic and/or microcytic red blood cells. Furthermore, the erythrogram was not sensitive in detecting latent or early iron deficiency. The erythrogram also lacked specificity for iron deficiency anaemia as many patients with mild normocytic anaemia associated with chronic inflammatory disease had increased proportions of hypochromic and/or microcytic red blood cells. Although patients with iron deficiency had increased proportions of hypochromic normocytic (p < 0.01) and normochromic microcytic red blood cells (p < 0.05) compared to those with chronic inflammatory disease and normal or raised iron stores (ferritin > or = 100 ng.ml-1, n = 32), there was a large overlap between these two groups, and the grossly elevated erythrogram results in patients with iron deficiency were almost always associated with a mean cell volume (MCV) < 80 fl, whereas none of the patients with chronic inflammatory disease and normal or raised iron stores had an MCV < 80 fl. Thus the erythrogram does not appear to be of value in the routine assessment of iron status in elderly patients.

How do local doctors react to a hospice?

Postal questionnaires were sent to general practitioner principals and hospital consultants in Ayrshire a year before and again 13 months after the opening of the Ayrshire Hospice. Seventy-three per cent of 342 doctors replied to the first survey and 62% replied to the second survey. There was initially a fairly strongly felt need for a hospice, with median Visual Analogue Score (VAS) of 16 ('definite need' = 0 and 'definitely no need' = 100). After the opening of the hospice doctors were much more enthusiastic (median VAS 5; p less than 0.0001). Doctors feeling no need for a hospice (VAS greater than 75) became fewer (9.6% before opening, 2% after). Doctors who would refer patients to a hospice, at first 82%, numbered 92% after opening. Seventy-one per cent of general practitioners and 60% of consultants had referred patients to the hospice within a year of opening. After opening, specialist advice with home care was considered the most useful aspect, in-patient beds useful, and day hospice least useful. Seventy-three per cent of referring doctors found the hospice a great help. In both surveys general practitioners and consultants felt the hospice should be run by a mixture of voluntary and NHS finance. Doctors appeared willing to learn about palliative care from hospice doctors, particularly after hospice opening. Doctors were initially rather dissatisfied with palliative care in existing hospitals, but became less so (particularly about pain control) after hospice opening. Surprisingly, in both surveys the attitudes of general practitioners and consultants were virtually identical.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of pre-admission screening of elderly patients accepted for major joint replacement.

Valuable orthopaedic operating time is frequently lost because patients are found to be medically unfit for surgery on admission. One hundred and forty seven consecutive patients aged 60 years or older, who had been accepted for major joint replacement and who lived within 15 miles of the Western Infirmary, Glasgow were screened at a preadmission clinic. The screening protocol had been agreed by orthopaedic and anaesthetic staff involved in major joint replacement surgery. Some 42 patients had medical illnesses which would have resulted in surgery being postponed and a further five had their surgery cancelled. Six patients passed fit for surgery at the pre-admission screening clinic were unfit for surgery on admission. Two patients in this group had their surgery cancelled. Using the guidelines suggested, pre-admission screening could be carried out by the patient's general practitioner (GP) or by a member of the medical staff when the patient attends the orthopaedic out-patient clinic. By following a simple protocol the amount of valuable operating time lost through unrecognised or poorly controlled medical illness could be greatly reduced. Pre-admission screening should result in more efficient use of scarce hospital resources and improved patient care.

Adenocarcinoma of the esophagus and/or gastric cardia.

One hundred twenty-nine adenocarcinomas involving the esophagus and/or gastric cardia differed significantly from 212 cancers of the rest of the stomach as follows: male-female ratio, 6:1 versus 2:1, birth outside Canada, US or UK, 12% versus 34%; parent or sibling with gastric cancer, 5% versus 13%; previous duodenal ulcer, 23% versus 9%; chronic reflux symptoms, 25% versus 3%; hiatal hernia, 51% versus 11%. Of the 129 esophagocardia cancers, 24 involved the esophagus alone, 48 the cardia and esophagus, 33 the cardia alone or cardia and fundus, and 24 the upper stomach and lower esophagus extensively. Thirty-four were associated with Barrett's esophagus. The 72 patients with involvement of both the upper stomach and lower esophagus (48 cardia and esophagus, 24 extensive) were identical with the esophagocardia group as a whole. The 24 patients with esophageal cancer and the 34 with Barrett's epithelium were the same clinically as the whole esophagocardia group except more had chronic reflux and hiatal hernia. The 33 patients with cancer confined to the cardia or cardia and fundus resembled the whole esophagocardia group but did not have Barrett's esophagus. Adenocarcinoma of the esophagocardia region is probably a different disease from cancer of the rest of the stomach.

The efficacy of barium enema in the elderly.

Ninety-seven consecutive patients more than 70 years old (Group O) undergoing barium enema were studied to assess the usefulness of this investigation in their management. The patient's ability to co-operate was studied. Diagnostic yield was noted and compared to 70 consecutive patients less than 60 years old (Group Y). There was no correlation between mental test score, hearing or visual impairment and the patient's ability to co-operate. A significantly greater number of positive examinations was found in Group O (P less than 0.05). Following a positive examination, 55% of patients in Group O had a change in management. Surgical management was pursued in 14 patients, 11 of whom had a tumour.

Prospective study of drug reporting by general practitioners for an elderly population referred to a geriatric service.

A prospective study was carried out in which the drug history of patients which was provided by general practitioners was compared with the drugs found by geriatricians in patients' homes in 700 referrals to geriatricians. Drug compliance was not assessed. The drug history appeared to be accurate in one third of referrals. Underreporting of medication was common and increased as the number of prescribed drugs increased. Roughly one fifth of patients had at least one potential drug interaction. Keeping careful prescription records, regular review, and accurate reporting of medication should reduce drug associated morbidity in elderly patients.

The role of drugs in falls in the elderly.

Drugs can contribute to falls in the elderly. Older people have more diseases, take more medications, and more frequently have drug side effects. Current studies show that the link between drugs and falls is best illustrated by the barbiturates, and well founded with phenothiazines and tricyclic antidepressants. The more types of drugs a patient receives, the greater the likelihood of a fall. Combining drugs with various diseases adds to the risk. New research should concentrate on naming individual drugs in larger surveys of falling. Much more sophisticated statistical procedures and testing would allow analysis of the specific dangers of drug and drug/disease combinations.

Oxygen as a driving gas for nebulisers: safe or dangerous?

Changes in blood gas tensions occurring when 100% oxygen or air was used as the driving gas for nebulised salbutamol were studied in 23 patients with severe airways obstruction. The patients fell into three groups: nine had chronic bronchitis and emphysema with carbon dioxide retention, seven had emphysema and chronic bronchitis without carbon dioxide retention, and seven had severe asthma (no carbon dioxide retention). When oxygen was used as the driving gas patients who retained carbon dioxide showed a mean rise of 1.03 kPa (7.7 mm Hg) in their pressure of carbon dioxide (Pco2) after 15 minutes (p less than 0.001) but the Pco2 returned to baseline values within 20 minutes of stopping the nebuliser. The other two groups showed no rise in Pco2 with oxygen. When air was used as the driving gas none of the groups became significantly more hypoxic. Although it is safe to use oxygen as the driving gas for nebulisers in patients with obstructive airways disease with normal Pco2, caution should be exercised in those who already have carbon dioxide retention.

Coronary care in the elderly.

Over a five-year period (1974-78), 2947 patients were admitted to the Coronary Care Unit, Victoria Infirmary, Glasgow, and it was confirmed that 1474 of these patients had had a myocardial infarction. Over 70% were of state pensionable age, that is women over the age of 60 years and men over 65 years. No difference was found in the incidence of successful resuscitation from primary ventricular fibrillation following acute myocardial infarction between the under-60-year-old and over-70-year-old age groups. Further, this study did not show any rise in mortality, with age, following acute myocardial infarction.

Lung involvement in Hodgkin's disease.

Lung involvement occurred in 43% of 284 patients with Hodgkin's disease in Nottingham during 1960-75. It was commoner than pleural, hilar or mediastinal node involvement, although over three-quarters of patients with any other thoracic manifestation subsequently developed pulmonary involvement. The patients with pulmonary involvement contained significantly fewer with the histological feature of lymphocyte predominance. The commonest radiographic type, peribronchial infiltration, tended to occur early in the course of the disease while less common types, homogeneous or pneumonic infiltrates and nodules, occurred later. Modern chemotherapy was very effective in the treatment of pulmonary Hodgkin's disease. Since two-thirds of the patients who developed lung involvement already had stage IIIB or IV disease, the early use of chemotherapy should reduce the incidence of this common complication.