The impact of criminal justice institutions on substance abuse treatment.

This article explores drug treatment from a community provider perspective. Specifically, it examines the impact of criminal justice institutions on substance abuse treatment: the gray zone where jurisprudence meets the therapeutic.

Effect of mibefradil, a T-type calcium channel blocker, on morbidity and mortality in moderate to severe congestive heart failure: the MACH-1 study. Mortality Assessment in Congestive Heart Failure Trial.

BACKGROUND: Calcium antagonists have proved disappointing in long-term congestive heart failure (CHF) studies. Mibefradil, a new calcium antagonist that selectively blocks T-type calcium channels, has been shown to be an effective antihypertensive, antianginal, and anti-ischemic agent, and because of its different mechanism of action, it may be beneficial as adjunct therapy in CHF patients. METHODS AND RESULTS: This multicenter, randomized, double-blind study compared mibefradil with placebo as adjunct to usual therapy in 2590 CHF patients (NYHA class II to IV; left ventricular fraction <35%). The initial 50-mg daily dose of mibefradil was uptitrated to 100 mg after 1 month and continued up to 3 years. Patients were monitored at 1 week; 1, 2, and 3 months; and every 3 months thereafter. All-cause mortality, cardiovascular mortality, and cardiovascular morbidity/mortality were analyzed by use of the log-rank test (alpha=0.05). Substudies included exercise tolerance, plasma hormone and cytokines, echocardiography, and quality of life. Total mortality was similar between mibefradil- and placebo-treated patients (P=0.151). The 14% increased risk of mortality with mibefradil in the first 3 months was not statistically significant (P=0.093). Treatment groups had similar cardiovascular mortality (P=0.246), cardiovascular morbidity/mortality (P=0.783), and reasons for death or hospitalization. Patients comedicated with mibefradil and antiarrhythmics (class I or III), including amiodarone, had a significantly increased risk of death. Substudies demonstrated no significant differences between treatments. CONCLUSIONS: When used as adjunct therapy, mibefradil did not affect the usual outcome of CHF. The potential interaction with antiarrhythmic drugs, especially amiodarone, and drugs associated with torsade de pointes may have contributed to poor outcomes early in the study.

Perceptions of pediatric emergency medicine fellows and program directors about research education.

UNLABELLED: Pediatric emergency medicine (PEM) fellows who entered training after January 1995 are required to complete three years of fellowship training. Additionally, they are required to receive instruction in related basic sciences and to demonstrate research competence. OBJECTIVES: To determine: 1) whether PEM fellows and program directors perceive their programs as providing adequate training in research principles, 2) the manner in which these principles are taught, and 3) the commitment of fellows and program directors to research and research training. METHODS: Pediatric emergency medicine fellows who participated in the Fourth Annual PEM Fellows Conference (Miami, Florida, March 1997) were surveyed. The survey was then extended via mail to all PEM fellows and program directors in the United States and Canada. RESULTS: A total of 159 of the 220 fellows (72%) in the United States and Canada returned completed questionnaires. Fifty-three of 70 PEM fellows (76%) who attended the conference completed questionnaires, and 106 of 167 fellows (63%) who did not attend the conference responded by mail. Fifty-three of the 63 program directors (84%) returned completed questionnaires. Of 159 responding fellows, 86 (54%), and of 53 responding program directors, 29 (58%) reported that their programs lacked adequate training in one or more of the surveyed research areas. Thirteen program directors (25%) reported no formal research training in their curricula. Programs that included formal research training were perceived to have higher overall quality than programs that failed to offer such formal training. Sixty-six of 158 responding fellows (42%) anticipated an ongoing commitment to research in their careers. One hundred fourteen of 153 responding fellows (75%) indicated that, if given the option, they would have pursued a two-year "clinical track" PEM board certification that did not include a research requirement. CONCLUSIONS: More than half of surveyed PEM fellows and program directors perceived important deficiencies in research education within their training programs. Further research is necessary in order to evaluate the validity of these perceptions.

The Walden House Young Adult HIV project: meeting the needs of multidiagnosed youth.

Walden House, Inc.'s Young Adult Human Immunodeficiency Virus (HIV) (YAH) project is supported by the Special Projects of National Significance Program of the Health Resources and Services Administration (SPNS-HRSA). This project has served 512 high-risk young people (ages 13-25 years), 101 of them living with HIV/acquired immunodeficiency syndrome (AIDS). The YAH project offers treatment services and a coordinated support system to adolescents and young adults who are in need of HIV/AIDS services as well as behavioral health care; all clients suffer from multiple diagnoses. This system includes medical and psychological assessment, referral and coordination; therapy and counseling services; transportation; peer education and counseling; legal information and referral; and case management for long-term options. YAH provides HIV testing access, pretest and posttest counseling, HIV and sexually transmitted disease education, HIV-positive speakers as role models, and community-based outreach. YAH also serves as a resource within Walden House to spur enhancement of service provision for HIV care as well as programming for young people. The emphasis is on providing a comprehensive continuum of services, with the case manager and peer staff coordinating services to try to meet the diverse needs of each client. The complexity and intensity of the target population's needs challenge the traditional models of care. This project provided almost 4 h daily of cost-effective rehabilitation programming to each client, increased participants' self-reported measures of well-being, and increased staff's ability to deal with HIV issues.

The Clinical Oncology Career Development Award of the American Cancer Society. A 5-year evaluation.

BACKGROUND: In 1985, the American Cancer Society (ACS) replaced their Junior Faculty Clinical Oncology Program with the 3-year Clinical Oncology Career Development Award (COCDA). It was proposed that the longer duration and larger stipend of the COCDA would have a greater impact in encouraging promising young clinical oncologists to enter and remain in academic oncology. The COCDA was evaluated at this time to determine whether these goals had been achieved. METHODS: A questionnaire was sent to 104 of the total of 121 people who received awards in 1985, 1986, and 1987. RESULTS: A review of the 85 completed questionnaires showed that the COCDA had a significant impact on the recipients. Most have remained in academic settings and have flourished, as evidenced by their publication record and success in obtaining extramural funds, despite their clinical orientation. CONCLUSIONS: The COCDA has achieved its initial goals and will remain an important part of the professional education efforts of the ACS.

A socioeconomic analysis of digital replantations resulting from home use of power tools.

Forty-seven digits in 21 patients who sustained partial or complete amputations from the home use of power tools were replanted or revascularized during a 1-year period. This represented 69% of the microvascular surgery performed for hand injuries during that year. The cost of repairing an average of 2.4 digits was $7000 (surgeon's fee) plus $697 per hour (operating room fee), as per fiscal year 1987. Postoperative hospitalization averaged 15 days at a cost of $15,679. Hand rehabilitation averaged 8 months at a cost of $3348. Fifty-four percent of the patients had no insurance. Fourteen of 21 patients (67%) required at least one additional procedure. Two patients had to make a career change after the injury. The majority of patients with digital replantations were dissatisfied with the emotional costs and the number of subsequent operations. Lack of patient and family awareness of the length of the rehabilitative period was particularly evident.

Immunotopographic assessment of lymphoid and plasma cell malignancies in the bone marrow.

To determine the utility of tissue section immunochemistry in the evaluation of bone marrow involved by lymphoid and plasma cell malignancies, snap-frozen, undecalcified bone marrow core and aspirate samples from 23 patients with these disorders were studied with a battery of monoclonal antibodies. With techniques that preserve architecture, difficult diagnostic cases characterized by core but not aspirate involvement, or the reverse, were resolved. By means of an extensive battery of monoclonal antibodies applied to serial sections, complex tumor cell phenotypes were established in all 23 cases. In addition to the identification of straightforward monoclonal surface immunoglobulin expression in small cleaved cell lymphomas (four cases), the battery approach added immunologic certainty in malignancies with unusual or difficult phenotypes: peripheral T-cell lymphomas with idiosyncratic antigen expression, and chronic lymphocytic leukemias and small cell lymphomas with faint surface immunoglobulin expression (four cases). For the chronic lymphocytic leukemias and the small cell lymphomas, the combined IgD+, B2+, B1+, Ia+, Leu-1+ phenotype taken as a whole had greater utility than any isolated marker. The acute lymphocytic leukemias and the myelomas studied demonstrate the wide range of B-cell antigens that must be detected to account for the variety of B-cell neoplasms encountered. Additionally, the previously undescribed phenotypic subset of CALLA+ myelomas, which is of prognostic relevance, was identified. Marrow frozen section immunotyping is a major asset in the evaluation of patients with lymphoma, leukemia, and myeloma when special care is accorded to tissue handling and to treatment of endogenous peroxidase/pseudoperoxidase and interstitial immunoglobulin.

Computerized assessment of human neurotoxicity: sensitivity to nitrous oxide exposure.

We recently developed a flexible, portable, computer-based neurobehavioral evaluation system (NES) to standardize data collection in epidemiologic field studies of individuals at risk for neurobehavioral toxicity. The current study was performed to examine the system's sensitivity to subtle neurobehavioral impairment induced pharmacologically in normal subjects. Twelve men 18 to 36 years old were tested with the NES three times, in an initial training session followed by separate drug and control sessions in randomized order. During drug sessions subjects received a combination of 20% nitrous oxide and 80% oxygen through a nasal mask. In control sessions subjects received 100% oxygen. Nine NES tests evaluating psychomotor performance, visuospatial ability, memory, and mood were administered in approximately 40 minutes. Nitrous oxide exposure impaired performance on three tests: continuous performance, symbol-digit substitution, and finger tapping. Another test, pattern memory, showed a trend toward impairment, while the remainder were not affected by the drug. These data are consistent with previous reports that the threshold effect of nitrous oxide is a decrement in psychomotor speed. The findings indicate that our NES is sensitive to short-term impairment in central nervous system function of the type induced by a number of neuroactive agents. In view of its efficiency in data acquisition and analysis, computerized neurobehavioral testing appears to be a very promising method for evaluation of effects of a wide range of pharmacologic agents.

Determining health insurance coverage of technology: problems and options.

By deciding which medical procedures are eligible for reimbursement, health insurance programs possess the potential to affect significantly technology use and health care spending. Traditionally, insurers have adopted a passive stance and made relatively few negative coverage determinations. However, resistance to rapidly rising costs has created a powerful inducement for third-party payors to become more prudent purchasers of health care services. Consequently, both Medicare and Blue Cross--Blue Shield are considering the implementation of changes that may ultimately result in more restrictive coverage decisions. This article examines the coverage process of Medicare and Blue Cross--Blue Shield and the policy changes that both programs are considering. In addition, it discusses the strengths and drawbacks of four coverage policy options: restricting insurance coverage of unproven procedures, introducing cost-effectiveness criteria, educating physicians and educating consumers.

MEDLINE demand profiles: an analysis of requests for clinical and research information.

When a medical library serves both research scientists and practicing physicians, it may be predicted from the results of previous studies that computerized bibliographic search services will show more research and less clinical activity. The present paper reports the results of a statistical analysis of professional use of the National Library of Medicine's bibliographic retrieval system. MEDLINE (Medical Literature Analysis and Retrieval System on-Line), at a large medical school library. Results indicate that (1) demand for MEDLINE service is primarily research oriented; (2) frequency of use bears a relationship to rank and departmental affiliation; (3) broad and comprehensive searches are requested more frequently than searches for specific information; (4) usage shows an interesting curvilinear relationship with age and status of the user; and (5) grant funds and support correlate with the number of searches requested. Implication of these findings are that since clinicians' use of MEDLINE was found to be minimal, information services should be reevaluated in order to assist in meeting their information needs more effectively.