Squamous cell carcinoma involving the temporal bone: lateral temporal bone resection as primary intervention.

OBJECTIVE: To provide an up-to-date review of treatment and outcomes of patients with squamous cell carcinoma (SCCA) involving the temporal bone. DESIGN: Retrospective cohort study of all patients treated at our institution for SCCA of the temporal bone between 1995 and 2007 with follow-up until 2011. Factors evaluated were demographics, presenting findings, follow-up time, previous treatment, workup, stage, surgical intervention, adjuvant therapy, histopathologic findings, recurrence, and survival. SETTING: Tertiary care academic medical center. PATIENTS: Thirty patients with SCCA of the temporal bone, originating from the external auditory canal and adjacent sites. INTERVENTION: Surgical resection ± adjuvant therapy. Lateral temporal bone resection was the primary and most aggressive procedure performed. MAIN OUTCOME MEASURES: Disease-free survival. RESULTS: The overall disease free survival for this series when considering both external auditory canal and adjacent site SCCAs was 70%. When evaluated by tumor stage, disease-free survival was as follows: T1 tumors = 100%, T2 tumors = 100%, T3 tumors = 67%, and T4 tumors = 56%. Aggressive tumors of this series originating at periauricular sites behaved in a similar manner to primary canal tumors. Need for surgical resection of CN VII was associated with diminished survival on multivariate analysis. CONCLUSION: Lateral temporal bone resection provides comparable disease free survival rates to more radical surgical therapy. Such resection is appropriate for many SCCAs of the external auditory canal and adjacent sites, as these tumors are similar in disease progression and prognosis. CN VII involvement portends a poor outcome.

Does adherence to medications for type 2 diabetes differ between individuals with vs without schizophrenia?

Individuals with schizophrenia are at increased risk for poor health outcomes and mortality. This may be due to inadequate self-management of co-occurring conditions, such as type 2 diabetes. We compared adherence to oral hypoglycemic medications for diabetes patients with vs without comorbid schizophrenia. Using Veterans Affairs (VA) health system administrative data, we identified all patients with both schizophrenia and type 2 diabetes and with at least one oral hypoglycemic prescription fill in fiscal year 2002 (N = 11 454) and a comparison group of patients with diabetes who were not diagnosed with schizophrenia (N = 10 560). Nonadherence was operationalized as having a medication possession ratio indicating receipt of less than 80% of needed hypoglycemic medications. Poor adherence was less prevalent among diabetes patients with (43%) than without schizophrenia (52%, P < .001). In multivariable analyses, having schizophrenia was associated with a 25% lower likelihood of poor adherence compared with not having schizophrenia (adjusted odds ratio: 0.75, 95% confidence interval: 0.70-0.80). Poorer adherence was associated with black race, homelessness, depression, substance use disorder, and medical comorbidity. Having more outpatient visits, a higher proportion of prescriptions delivered by mail, lower prescription copayments, and more complex medication regimens were each associated with increased adherence. Among veterans with diabetes receiving ongoing VA care, overall hypoglycemic medication adherence was low, but individuals with comorbid schizophrenia were more likely to be adherent to these medications. Future studies should investigate whether factors such as comanagement of a chronic psychiatric illness or regular contact with mental health providers bestow benefits for diabetes self-management in persons with schizophrenia.

An evaluation of a Medicaid expansion for cancer care: The Breast and Cervical Cancer Prevention and Treatment Act of 2000.

The National Breast and Cervical Cancer Early Detection Program is a multifaceted, federal program that provides breast and cervical cancer screening and diagnostic services to low-income women, but does not cover the costs of treatment. This study used a fixed-effects, longitudinal time-series research design (from 1995 to 2005) to evaluate the impact of a Medicaid expansion aimed at covering treatment for program clients, enacted via the Breast and Cervical Cancer Prevention and Treatment Act of 2000. In summary, the Treatment Act of 2000 had some positive impacts, including a 12.8% decrease in the average number of days to definitive cervical diagnosis for White women. Nonetheless, the Treatment Act also had some negative impacts on the timing of diagnosis and treatment services, including a significant increase in the average time between a diagnosis of cervical dysplasia or cancer and the initiation of treatment for Black and Hispanic women (7-15 days across age groups). The Treatment Act was also associated with a 9% decrease in the probability that Black women would initiate treatment within 60 days of a cervical diagnosis (-.094; 95% confidence interval [CI] -.178 to -.01). As such, although the Treatment Act had no impact on the proportion of clients who initiated breast cancer treatment within 60 days, it reduced the probability that Black women initiated cervical treatment within an accepted benchmark for timely care.

Who cares for involuntary clients?

The objectives of this study were to compare characteristics of outpatient substance abuse treatment (OSAT) units that serve high proportions of involuntary clients (ICs) with those that serve a low percentage of such clients. The authors analyze unit-level 1995-2005 data from the National Drug Abuse Treatment System Survey (NDATSS). Approximately 1/6 of OSAT units draw the dominant majority of their clients from involuntary referrals. OSAT units that treat a high proportion of ICs are less likely to be accredited by professional organizations, have fewer treatment staff with advanced degrees, and have shorter average treatment duration than do OSAT units that serve few ICs. OSAT units that serve ICs are more likely to offer legal and domestic violence services but are less likely to offer mental health services or aftercare. OSAT units that serve ICs are less likely to be hospital-affiliated than are other units. Clients at such facilities are more likely to be convicted of driving while intoxicated (DWI), are younger, are less likely to have received prior treatment, are more likely to remain abstinent after treatment, but are more likely to be remanded back to courts. The authors conclude that ICs are an important market niche in OSAT care. DWI is by far the most common offense reported in units that specialize in ICs. Aside from legal and domestic violence services, units with a high proportion of ICs appear to offer somewhat less intensive and professionalized services than do other facilities; however, clients at these units are more likely to be abstinent at the end of treatment and but more likely to be remanded back to the courts.

Reinstitutionalization following psychiatric discharge among VA patients with serious mental illness: a national longitudinal study.

Patterns of reinstitutionalization following psychiatric hospitalization for individuals with serious mental illnesses (SMI) vary by medical and psychiatric health care settings. This report presents rates of reinstitutionalization across care settings for 35,527 patients following psychiatric discharge in the Department of Veterans Affairs (VA) health system, a national health care system. Over a 7-year follow-up period, 30,417 patients (86%) were reinstitutionalized. Among these patients, 73% were initially reinstitutionalized to inpatient psychiatric settings. Homelessness, medical morbidity, and substance use were associated with increased risks for reinstitutionalization. Despite the VA's increased emphasis on outpatient services delivery, the vast majority of patients experienced reinstitutionalization in the follow-up period. Study findings may inform efforts to refine psychiatric and medical assessment for service delivery for this vulnerable population.

Duration of nonmethadone outpatient treatment: results from a national survey.

OBJECTIVES: This study examined organizational trends from 1990 to 2000 and unit characteristics associated with the duration of nonmethadone outpatient addiction treatment. METHODS: Program directors and clinical supervisors from a nationally representative panel of nonmethadone outpatient units in the United States were surveyed in 1990, 1995, and 2000. Treatment duration was measured from clinical supervisors' reports of the average length of stay. Negative binominal regression models controlled for multivariate effects. RESULTS: Treatment duration modestly declined between 1990 and 2000 while addiction severity increased. Affiliation with a mental health center, older program age, JCAHO accreditation-ostensibly a marker for structural quality-and serving more clients with prior authorization requirements- a measure of managed care stringency-were associated with shorter treatment durations. CONCLUSIONS: These findings suggest that treatment duration did not increase between 1990 and 2000 despite clients' worsening addiction severity and growing evidence that longer duration of formal treatment improves treatment outcome. In addition, programs with JCAHO accreditation and stronger managed care oversight appeared to seek efficiencies through reductions in treatment duration.

Decrease in the prevalence of environmental tobacco smoke exposure in the home during the 1990s in families with children.

OBJECTIVES: This study explored correlates with and changes in the prevalence of environmental tobacco smoke (ETS) exposure of children in the home. METHODS: We used multiple logistic regression to explore ETS exposures as reported in the 1992 and 2000 National Health Interview Survey. RESULTS: ETS exposure in homes with children declined from 35.6% to 25.1% (P <.001) between 1992 and 2000, whereas smoking prevalence declined 26.5% to 23.3%. Home ETS exposures were more prevalent among non-Hispanic Whites than among African Americans (adjusted odds ratio [AOR] = 0.702; 95% confidence interval [CI] = 0.614, 0.802), Asian Americans (AOR = 0.534; 95% CI = 0.378, 0.754), and Hispanics (AOR = 0.388; 95% CI = 0.294, 0.389). Exposures declined across all groups, with greater gains in higher education and income groups. CONCLUSIONS: Home ETS exposure declined sharply between 1992 and 2000, more than would be predicted by the decline in adult smoking prevalence.