A study of thiotepa, etoposide and fractionated total body irradiation as a preparative regimen prior to bone marrow transplantation for poor prognosis patients with neuroblastoma.

We report the toxicity and efficacy of a new conditioning regimen for bone marrow transplantation (BMT) in children with poor prognosis neuroblastoma (NBL). Twenty-seven patients with poor prognosis NBL were treated with teniposide (360 mg/m2) or etoposide (500 mg/m2), thiotepa (600-900 mg/m2), and 1200 cGy fractionated total body irradiation (fTBI) followed by autologous marrow rescue (n = 19) or allogeneic BMT from HLA-identical siblings (n = 8). The two patients who received teniposide, 600 mg/m2 thiotepa and fTBI had minimal toxicity but relapsed 4 and 12 months post-auto BMT. The next two patients received 750 mg/m2 thiotepa, 500 mg/m2 etoposide and TBI. They tolerated the conditioning regimen well and are alive and in remission 77 and 75 months post-BMT. At the next thiotepa dose level (900 mg/m2), the first two allograft recipients both experienced fatal regimen-related toxicity. All subsequent allograft recipients received 750 mg/m2 thiotepa and autograft recipients received 900 mg/m2 thiotepa. As of 1 April 1995, eight of the 19 patients who received autologous marrow are surviving disease-free 21 to 77 months post-BMT. Nine autograft recipients relapsed at 2 to 37 months following transplantation. One patient died of hepatic veno-occlusive disease 2 months after auto BMT, and one of pneumonia 6 months post-transplantation. Three allograft recipients have relapsed at 6, 10 and 39 months post-transplant and three are alive and in remission 75, 53 and 27 months post-BMT. Overall, 11/27 patients (41%) are alive and in remission 21-77 months (median 47 months) following BMT. A conditioning regimen consisting of 500 mg/m2 etoposide, thiotepa (750 mg/m2 for allograft recipients and 900 mg/m2 for autograft recipients) and 1200 cGy fTBI has acceptable toxicity and is at least as effective as melphalan-containing regimens in the treatment of high-risk NBL.

Preparing adequate medical staff committee minutes: tips for handling a difficult task.

Preparation of medical staff committee minutes can be a difficult and frustrating challenge for medical staff leaders and those who advise them. Inadequate or inaccurate minutes can lead to loss of a defense against liability and poor performance on accreditation surveys and governmental inspections. This article discusses the purposes of minutes and offers various tips for achieving these purposes through careful preparation and review.

Survey of Florida's public agency psychiatrists.

The results are reported of a statewide survey of 309 physicians practicing at least part-time in public mental health agencies in Florida. Sixty-one percent (189) completed and returned the self-administered mail questionnaire. More than two-thirds received their medical degree outside the United States. Nearly one-half practiced primarily in community mental health centers. More than two-fifths reported total annual income between $75,000 and $100,000. Nearly one-fourth noted community service as an important factor in attracting them to their practice location. One-fifth reported a variety of regulations as important obstacles in their practice. Survey results are compared to other statewide and national psychiatric studies.

Moving from quality assurance to continuous quality improvement.

Though numerous proponents of the change from quality assurance (QA) to continuous quality improvement (CQI) have emphasized the drawbacks of the former and the advantages of the latter, there has been relatively little systematic consideration and comparison of the costs and benefits of each. A proper comparison is probably not possible, because the data seem to be lacking. Instead, much of the discourse has been based upon anecdotes, analogies from other industries, and unsupported assertions. This article grows out of a concern that, in making the switch from QA to CQI, we will discard or inadvertently lose much of value in QA and may not achieve many of the things that proponents expect CQI will accomplish. QA has served the health care field well. Its achievements ought to be preserved and built upon, not discarded.

Quality assurance to continuous quality improvement: challenges for the medical staff.

Hospital medical staffs will have to make a major transition over the next few years from quality assurance to continuous quality improvement. As this article discusses, many elements of the change are new to health care, as yet untested, and should be approached carefully.

Utilization review: theory, practice, and issues.

Utilization review is now carried out by most hospitals and many health care agencies, government-sponsored local agencies, third-party payers, and private companies, yet few practical explanations of the process are available. In this guide, the author differentiates between internal and external review and their likely outcomes, outlines the development of a utilization review system, and describes the stages and levels of review. Psychiatric utilization review is especially difficult to carry out; thus it rarely goes beyond evaluating need for hospitalization and length of stay. Utilization review in general still must deal with issues related to confidentiality, the clinical responsibility of the reviewer, and whether certification for admission can reward poor or inappropriate care.

Guidelines for the practice of utilization review: essential but lacking.

Utilization review (UR) has developed to the point where it soon will be, if it is not already, a separate profession. Yet it lacks practice guidelines and principles to guide practitioners. In the absence of such, practitioners may inappropriately use those of their original professions or other guidelines not in conformity with the objectives of UR. Practice guidelines for UR should arise out of professional consensus following extensive discussions. As a step in that direction, a number of proposed guidelines are presented.

A national study of state-supported psychiatric research institutes.

States have funded psychiatric research through a variety of mechanisms, including psychiatric research institutes. The authors identified and surveyed 33 such institutes to obtain information on their organizational characteristics. Twenty-nine institutes responded; more than half were organizationally located within a university setting, and a similar number were involved in research, education, and direct services. Clinical research was the most prevalent type of research conducted, and annual state revenue appropriations were the major source of funding. Because budgetary problems have threatened their future funding in some states, the authors believe the institutes should increase efforts to demonstrate their relevance to state mental health needs.

Quality assurance in mental health care.

Quality assurance activities, in place at all institutions accredited by the Joint Commission on Accreditation of Healthcare Organizations and many other agencies, are sure to play an increasing role in the mental health care field. This paper familiarizes mental health professionals with the terminology and activities of quality assurance and how they relate to other health care monitoring programs, such as utilization review, peer review, risk management, and credentialing and privileging. The historical development of quality assurance and special problems encountered in trying to quantify the quality of psychiatric care are also discussed.

APA's model commitment law and the need for better mental health services.

The author commends the American Psychiatric Association's model law on civil commitment model law on civil commitment as a practical document that is symbolic of psychiatry's concern about the quality of public mental health services. However, he believes that even the most progressive mental health laws have done little to ensure better or more responsive delivery of psychiatric services. Their effectiveness has been hampered by states' failure to provide funds for adequate services, lax interpretation and application of their provisions, and increasingly bureaucratic procedures resulting in impersonal treatment of patients. The author would strengthen the model law's section on patient advocacy, giving greater autonomy to advocates, and would extend legal authority for commitment to psychologists meeting specific qualifications.

Noninstitutional treatment for sex offenders in Florida.

The authors describe the availability and characteristics of noninstitutional treatment for sex offenders found in a survey of 63 community mental health providers in Florida. The results cover offense categories, referral sources, numbers in treatment, annual case load, and program characteristics. More sex offenders were being treated in the community than in state-operated residential programs, and 21% of the patients currently receiving community treatment were self-referred. The authors recommend that researchers and policy makers direct more attention to community treatment of sex offenders, its efficacy, and training for those delivering the treatment.