"[I] don't wanna just be like a cog in the machine": Narratives of autism and skilled employment.

LAY ABSTRACT: Autistic people are less likely to be employed than the general population. Autistic people with skilled training (e.g. training for jobs in acting, plumbing, science, or social work) might be even less likely to get a good job in their field. Little is known about the experiences of autistic people in skilled employment or what employment success means to them. We interviewed 45 autistic people with skilled training in a wide range of fields, 11 job supervisors, and 8 topic experts. We asked them about their experiences, what they felt helped them to be successful at work, and what employment success means to them. Participants talked about the high stakes of disclosure, taking unconventional pathways to careers, disconnects with service and support systems, mental health challenges from trauma and burnout, the autistic advantages in the workplace, and complex dimensions of discrimination. Participants said success meant opportunities for growth, good work/life balance, financial independence, sense of community, and feeling valued, accepted, and like their work had meaning. Things that helped them be successful included flexible, accepting workplaces, supportive and respectful supervisors, and direct communication. What we learned suggests that an individualized, wholistic approach to autism employment intervention that considers both employers and employees and employee mental health could be useful. We also recommend more research into disclosure and destigmatizing disability at work.

"All these people saved her life, but she needs me too": Understanding and responding to parental mental health in the NICU.

OBJECTIVE: To explore the mental health needs of parents of infants in a neonatal intensive care unit (NICU), as well as barriers and solutions to meeting these needs. DESIGN: Qualitative interviews conducted with parents and staff (n = 15) from a level IV NICU in the Northwestern United States. Thematic analysis completed using an inductive approach, at a semantic level. RESULTS: (1) Information and mental health needs change over time, (2) Staff-parent relationships buffer trauma and distress, (3) Lack of continuity of care impacts response to mental health concerns, (4) NICU has a critical role in addressing parental mental health. CONCLUSION: Mental health support should be embedded and tailored to the NICU trajectory, with special attention to the discharge transition, parents living in rural areas, and non-English-speaking parents. Research should address structural factors that may impact mental health such as integration of wholistic services, language barriers, and staff capacity.

Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis.

CONTEXT: Concern regarding the adverse effects of estrogen and other hormones for treating menopausal symptoms has led to demand for other options; however, the efficacy and adverse effects of nonhormonal therapies are unclear. OBJECTIVE: To assess the efficacy and adverse effects of nonhormonal therapies for menopausal hot flashes by reviewing published randomized controlled trials. DATA SOURCES: MEDLINE (1966-October 2005), PsycINFO (1974-October 2005), and the Cochrane Controlled Clinical Trials Register Database (1966-October 2005) were searched for relevant trials that provided data on treatment of menopausal hot flashes using 1 or more nonhormonal therapies. STUDY SELECTION: All English-language, published, randomized, double-blind, placebo-controlled trials of oral nonhormonal therapies for treating hot flashes in menopausal women measuring and reporting hot flash frequency or severity outcomes. DATA EXTRACTION: Trials were identified, subjected to inclusion and exclusion criteria, and reviewed. Data on participants, interventions, and outcomes were extracted and trials were rated for quality based on established criteria. A meta-analysis was conducted for therapies with sufficient trials reporting hot flash frequency outcomes. DATA SYNTHESIS: From 4249 abstracts, 43 trials met inclusion criteria, including 10 trials of antidepressants, 10 trials of clonidine, 6 trials of other prescribed medications, and 17 trials of isoflavone extracts. The number of daily hot flashes decreased compared with placebo in meta-analyses of 7 comparisons of selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) (mean difference, -1.13; 95% confidence interval [CI], -1.70 to -0.57), 4 trials of clonidine (-0.95; 95% CI, -1.44 to -0.47), and 2 trials of gabapentin (-2.05; 95% CI, -2.80 to -1.30). Frequency was not reduced in meta-analysis of trials of red clover isoflavone extracts and results were mixed for soy isoflavone extracts. Evidence of the efficacy of other therapies is limited due to the small number of trials and their deficiencies. Trials do not compare different therapies head-to-head and relative efficacy cannot be determined. CONCLUSION: The SSRIs or SNRIs, clonidine, and gabapentin trials provide evidence for efficacy; however, effects are less than for estrogen, few trials have been published and most have methodological deficiencies, generalizability is limited, and adverse effects and cost may restrict use for many women. These therapies may be most useful for highly symptomatic women who cannot take estrogen but are not optimal choices for most women.

The evaluation of rectal bleeding in adults. A cost-effectiveness analysis comparing four diagnostic strategies.

BACKGROUND: Though primary care patients commonly present with rectal bleeding, the optimal evaluation strategy remains unknown. OBJECTIVE: To compare the cost-effectiveness of four diagnostic strategies in the evaluation of rectal bleeding. DESIGN: Cost-effectiveness analysis using a Markov decision model. DATA SOURCES: Systematic review of the literature, Medicare reimbursement data, Surveillance, Epidemiology, and End Results (SEER) Cancer Registry. TARGET POPULATION: Patients over age 40 with otherwise asymptomatic rectal bleeding. TIME HORIZON: The patient's lifetime. PERSPECTIVE: Modified societal perspective. INTERVENTIONS: Watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema (FS+ACBE), and colonoscopy. OUTCOME MEASURES: Incremental cost-effectiveness ratio. RESULTS OF BASE-CASE ANALYSIS: The incremental cost-effectiveness ratio for colonoscopy compared with flexible sigmoidoscopy was 5,480 dollars per quality-adjusted year of life saved (QALY). Watchful waiting and FS+ACBE were more expensive and less effective than colonoscopy. RESULTS OF SENSITIVITY ANALYSES: The cost of colonoscopy was reduced to 1,686 dollars per QALY when age at entry was changed to 45. Watchful waiting became the least expensive strategy when community procedure charges replaced Medicare costs, when age at entry was maximized to 80, or when the prevalence of polyps was lowered to 7%, but the remaining strategies provided greater life expectancy at relatively low cost. The strategy of FS+ACBE remained more expensive and less effective in all analyses. In the remaining sensitivity analyses, the incremental cost-effectiveness of colonoscopy compared with flexible sigmoidoscopy never rose above 34,000 dollars. CONCLUSIONS: Colonoscopy is a cost-effective method to evaluate otherwise asymptomatic rectal bleeding, with a low cost per QALY compared to other strategies.