Neurocognitive impairment in a large sample of homeless adults with mental illness.

OBJECTIVE: This study examines neurocognitive functioning in a large, well-characterized sample of homeless adults with mental illness and assesses demographic and clinical factors associated with neurocognitive performance. METHOD: A total of 1500 homeless adults with mental illness enrolled in the At Home Chez Soi study completed neuropsychological measures assessing speed of information processing, memory, and executive functioning. Sociodemographic and clinical data were also collected. Linear regression analyses were conducted to examine factors associated with neurocognitive performance. RESULTS: Approximately half of our sample met criteria for psychosis, major depressive disorder, and alcohol or substance use disorder, and nearly half had experienced severe traumatic brain injury. Overall, 72% of participants demonstrated cognitive impairment, including deficits in processing speed (48%), verbal learning (71%) and recall (67%), and executive functioning (38%). The overall statistical model explained 19.8% of the variance in the neurocognitive summary score, with reduced neurocognitive performance associated with older age, lower education, first language other than English or French, Black or Other ethnicity, and the presence of psychosis. CONCLUSION: Homeless adults with mental illness experience impairment in multiple neuropsychological domains. Much of the variance in our sample's cognitive performance remains unexplained, highlighting the need for further research in the mechanisms underlying cognitive impairment in this population.

Economic impact of an enhanced recovery pathway for oesophagectomy.

BACKGROUND: Data are lacking to support the cost-effectiveness of enhanced recovery pathways (ERP) for oesophagectomy. The aim of this study was to investigate the impact of an ERP on medical costs for oesophagectomy. METHODS: This study investigated all patients undergoing elective oesophagectomy between June 2009 and December 2011 at a single high-volume university hospital. From June 2010, all patients were enrolled in an ERP. Clinical outcomes were recorded for up to 30 days. Deviation-based cost modelling was used to compare costs between the traditional care and ERP groups. RESULTS: A total of 106 patients were included (47 traditional care, 59 ERP). There were no differences in patient, pathological and operative characteristics between the groups. Median length of hospital stay (LOS) was lower in the ERP group (8 (interquartile range 7-18) days versus 10 (9-18) days with traditional care; P = 0·019). There was no difference in 30-day complication rates (59 per cent with ERP versus 62 per cent with traditional care; P = 0·803), and the 30-day or in-hospital mortality rate was low (3·8 per cent, 4 of 106). Costs in the on-course and minor-deviation groups were significantly lower after implementation of the ERP. The pathway-dependent cost saving per patient was €1055 and the overall cost saving per patient was €2013. One-way sensitivity analysis demonstrated that the ERP was cost-neutral or more costly only at extreme values of ward, operating and intensive care costs. CONCLUSION: A multidisciplinary ERP for oesophagectomy was associated with cost savings, with no increase in morbidity or mortality.

Publicly Available Metrics Underestimate AJNR Twitter Impact and Follower Engagement.

Social media use by professional organizations has increased as a platform to disseminate information, affording an alternative avenue to engage membership and the public. The American Journal of Neuroradiology (AJNR) posts cases and articles, hosts Tweet chats, advertises podcasts, and more on its Twitter account (@TheAJNR). The objective of this study was to determine whether user engagement is underestimated on the basis of publicly available metrics and to assess the engagement rate. This study demonstrated that engagement extends beyond visible metrics, suggesting an AJNR "silent" following beyond what is readily apparent. Median engagement rates from the @TheAJNR account from 2017 to 2019 appear stable since last reported in 2016 and are comparable with those reported in other professional medical journals.

Extended genotypic evaluation and comparison of twenty-two cases of lethal EEHV1 hemorrhagic disease in wild and captive Asian elephants in India.

Thirteen new lethal cases of acute hemorrhagic disease (HD) with typical histopathogical features were identified in young Asian elephants (Elephas maximus indicus) in India between 2013 and 2017. Eight occurred amongst free-ranging wild herds, with three more in camp-raised orphans and two in captive-born calves. All were confirmed to have high levels of Elephant Endotheliotropic Herpesvirus type 1A (EEHV1A) DNA detected within gross pathological lesions from necropsy tissue by multi-locus PCR DNA sequencing. The strains involved were all significantly different from one another and from nine previously described cases from Southern India (which included one example of EEHV1B). Overall, eight selected dispersed PCR loci totaling up to 6.1-kb in size were analyzed for most of the 22 cases, with extensive subtype clustering data being obtained at four hypervariable gene loci. In addition to the previously identified U48(gH-TK) and U51(vGPCR1) gene loci, these included two newly identified E5(vGPCR5) and E54(vOX2-1) loci mapping far outside of the classic EEHV1A versus EEHV1B subtype chimeric domains and towards the novel end segments of the genome that had not been evaluated previously. The high levels of genetic divergence and mosaic scrambling observed between adjacent loci match closely to the overall range of divergence found within 45 analyzed North American and European cases, but include some common relatively unique polymorphic features and preferred subtypes that appear to distinguish most but not all Indian strains from both those in Thailand and those outside range countries. Furthermore, more than half of the Indian cases studied here involved calves living within wild herds, whereas nearly all other cases identified in Asia so far represent rescued camp orphans or captive-born calves.

Fibroblast growth factor receptor-mediated rescue of x-ephrin B1-induced cell dissociation in Xenopus embryos.

The Eph family of receptor tyrosine kinases and their membrane-bound ligands, the ephrins, have been implicated in regulating cell adhesion and migration during development by mediating cell-to-cell signaling events. Genetic evidence suggests that ephrins may transduce signals and become tyrosine phosphorylated during embryogenesis. However, the induction and functional significance of ephrin phosphorylation is not yet clear. Here, we report that when we used ectopically expressed proteins, we found that an activated fibroblast growth factor (FGF) receptor associated with and induced the phosphorylation of ephrin B1 on tyrosine. Moreover, this phosphorylation reduced the ability of overexpressed ephrin B1 to reduce cell adhesion. In addition, we identified a region in the cytoplasmic tail of ephrin B1 that is critical for interaction with the FGF receptor; we also report FGF-induced phosphorylation of ephrins in a neural tissue. This is the first demonstration of communication between the FGF receptor family and the Eph ligand family and implicates cross talk between these two cell surface molecules in regulating cell adhesion.

Maximizing the Tweet Engagement Rate in Academia: Analysis of the AJNR Twitter Feed.

The use of social media by medical professionals and organizations is increasing, with Twitter receiving the most attention. User engagement is an important goal of social media activity, and engagement metrics represent a viable gauge of value in social media. No thorough analysis of tweet characteristics that increase academic user engagement has yet been published. In this study, the authors analyzed the American Journal of Neuroradiology Twitter feed to determine the tweet characteristics that were associated with higher engagement rates.

Ethical decision-making in the care of the dying and its applications to clinical practice.

In caring for dying patients, physicians and health team members face a number of decisions about how best to proceed with treatment. Many of these decisions carry implications for the life of the patient, either directly or indirectly. Recent discussions about the morality and wisdom of euthanasia provide an excellent stimulus to reexamine the ethical nature of these decisions. This paper reviews five ethical principles, and describes a process of decision-making that can result in two broad paths of action in relation to life-prolonging treatment. Case examples are presented for illustration. Appropriate ethical practice can be differentiated from acting with the primary intent to take life (euthanasia).

Hospital palliative care services: three models in three countries.

There is an increasing trend toward providing palliative care services within general hospitals. The history and work of three hospital palliative care teams is reviewed, one in New York, one in London, and one in Ontario, Canada. The evolution, leadership, structure, functioning, and financing of the teams is discussed. Indicators of success and survival, principally financial support, leadership, and acceptability within hospitals, are considered. It is recommended that the service traditionally limited to oncology patients be extended to other patient groups. It is also recommended that, taking into account cultural and institutional differences, standardized mechanisms be adopted so that services can be systematically audited and changes implemented. Research and education will become increasingly important if services within hospitals are to survive.

The Patient Care Travelling Record in palliative care: effectiveness and efficiency.

The Patient Care Travelling Record (PCTR) is a passport-like health-care summary that, in previous research by the authors, has been found to be a feasible and acceptable tool to convey important clinical information about the palliative care patient. This randomized controlled trial was conducted to determine the effectiveness and efficiency of this Record in improving patient mood, decreasing uncertainty, improving satisfaction with health care, reducing use of health-care services, and maximizing pain control. Eligible patients were randomized to receive or not receive the PCTR (completed by nurse or physician and reviewed jointly with the patient). As baseline entry into the study and then at 1 and 2 months, patients completed measures on level of certainty, mood states, satisfaction with care, levels of pain, and health-care services utilization. During the 2-year study period, only 20% (N = 61) of the patients enrolled in a palliative care program in Southern Ontario were eligible for the trial. Of these patients, 18 died, 15 declined to participate, and 7 were emotionally unable to complete the questionnaires. Thus 21 patients completed the trial. With the exception of those age 65 years and over, the patients using the Record reported decreased levels of uncertainty on follow-up. There was no additional use of health-care services, no differences in mood states, pain relief, or satisfaction with health care. It is significant that 80% of palliative patients were not eligible because their physical and psychological status rendered them insufficiently stable to participate in a research study. Because of their vulnerable status, these patients may be ideal for the utilization of the Record in clinical care. Although research in this palliative care population is challenging due to difficulties with recruitment and high dropout rates due to death, the PCTR, which was previously shown to be acceptable and feasible, has now been shown to be effective in reducing patient uncertainty, specifically for adults under 65 years. Indications for future research are described.

Medicaid-funded home care for the frail elderly and disabled: evaluating the cost savings and outcomes of a service delivery reform.

OBJECTIVES: In response to rising demand and increased costs for home care services for frail elderly and disabled Medicaid clients, New York City implemented cluster care, a shared-aide model of home care. Our objective: to evaluate the effects of cluster care on home care hours and costs, client functioning, depressive symptoms, and satisfaction. DATA SOURCES: Client interviews, conducted prior to implementation and again 16 months later; Medicaid claims records; home attendant payroll files; and vendor agency records. STUDY DESIGN: The study employed a pretest/posttest design, comparing 229 clients at the first seven demonstration sites to 175 clients at four comparison sites before and after cluster care implementation. Regression methods were used to analyze pre and post-intervention data. PRINCIPAL FINDINGS: Cluster care reduced costs by about 10 percent. Most savings occurred among the more vulnerable clients (those with five or more ADL/IADL limitations). Clients at cluster care sites who started out with fewer than five limitations appeared to decline somewhat more slowly than similarly impaired clients at comparison sites, while those with more than five ADL/IADLs tended to decline more rapidly. This difference was small-less than one limitation per year. Cluster care is associated with a significant decline in satisfaction but appears unrelated to depressive symptoms. CONCLUSIONS: Cluster care appears benign for home care clients with fewer limitations. For the more vulnerable, we recommend experimentation with low-cost interventions that might augment service and improve outcomes without reverting to traditional one-on-one care.

Practice expenses in the MFS (Medicare fee schedule): the service-class approach.

The practice expense component of the Medicare fee schedule (MFS), which is currently based on historical charges and rewards physician procedures at the expense of cognitive services, is due to be changed by January 1, 1998. The Physician Payment Review Commission (PPRC) and others have proposed microcosting direct costs and allocating all indirect costs on a common basis, such as physician time or work plus direct costs. Without altering the treatment of direct costs, the service-class approach disaggregates indirect costs into six practice function costs. The practice function costs are then allocated to classes of services using cost-accounting and statistical methods. This approach would make the practice expense component more resource-based than other proposed alternatives.

Improving access to family support organizations: a member survey of the AMI-Quebec Alliance for the Mentally Ill.

Family support organizations such as the Quebec Alliance for the Mentally Ill (AMI-Quebec) provide services for mentally ill individuals and their families. Despite possible benefits, there is often a lengthy period between identification of mental illness and involvement of family members with family support organizations. A survey of AMI-Quebec members was undertaken to assess this delay. Of the 186 respondents, 47 percent experienced a delay of more than two years. Only 10 percent were referred to the organization by psychiatrists. The majority would have liked to have become involved with AMI-Quebec earlier. Some approved of more proactive methods of recruitment by AMI-Quebec, such as a telephone call after an initial hospitalization.

Use of mental health services by formerly homeless adults residing in group and independent housing.

OBJECTIVE: The study examined patterns of mental health service use among 112 formerly homeless mentally ill adults to determine whether clients in a staffed group living situation would need fewer types of services or lesser amounts of some services than those living independently in single apartments. METHODS: Clients in the Boston McKinney demonstration project were randomly assigned to two housing types: individual apartments or a group living situation designed to teach residents to manage the house and their own affairs with minimal staff presence. The types and amounts of services these clients used during an 18-month period were documented and compared. RESULTS: Service use by all clients was heavy, especially use of inpatient psychiatric services. It did not differ by housing type. The large majority of clients in both housing types were able to remain housed and avoid homelessness. Clients who did not stay in assigned housing for the duration of the study had higher levels of inpatient service use, including detoxification and substance abuse treatment. CONCLUSIONS: When homeless mentally ill adults are provided permanent housing and accessible mental health treatment and specialized social services, they are likely to avoid unstable housing patterns, which are associated with higher use of inpatient services.

Utilization of physician services at the end of life: differences between the United States and Canada.

This study draws on physician claims for the elderly from the U.S. Medicare program and the Canadian provinces of Quebec and British Columbia to compare physician service use by people with fewer than six months to live relative to those who liver longer. Physician service quantities are expressed in relative value units (RVUs), and aggregated into clinical type-of-service categories. Relative to survivors, those in the United States approaching death receive about the same amount of evaluation and management services as those in Quebec and British Columbia, though less in absolute value; they also receive about the same amount of procedures as those nearing death in British Columbia, but half as much in proportion as people nearing death in Quebec. Further analyses of appropriateness of care to the dying appear no less necessary in Canada than in the United States.

Auditing the hospital care of dying patients.

It is essential that hospitals (both acute and chronic care) develop a means of determining the status of care to the dying patients and their families within the institution. This paper provides a description of the components of comprehensive care for the dying patient, based on the discipline of palliative/hospice care, and their incorporation into a specific audit tool designed for assessing the hospital care of such patients. An audit conducted in an acute care hospital is provided to illustrate the potential applications of the tool and the nature of the questions it can raise in forming a basis for staff education, resource planning, and directions for further inquiry.

Palliative care in medical education at McMaster University.

As professionals working within palliative care struggle to find their niche in the academic, administrative and service continuum of patient care, we have a growing desire to share what has been learned with students and colleagues. The opportunities for student physicians to learn the principles and practices of caring for the dying are few. The described curriculum content is dependent on the McMaster philosophy of medical education and the developmental level of the student physician. Areas included are: philosophy of palliative care, communication skills, symptom assessment and control, approach to ethical issues, decision making and interdisciplinary team function. The authors describe the university's current approach in its specific contribution to undergraduate and postgraduate medical education, the continuum throughout those years and an examination of recommendations for the future.

A patient care travelling record for palliative care: a feasibility study.

The provision of palliative care can be a complex process. Patients are treated in a variety of settings, by multiple persons, thus risking loss of continuity of care. These patients take numerous medications and require many complex treatment decisions in the course of their illness, making the ready availability of current and accurate information a vital component of effective care. The use of a patient care travelling health record, while requiring time and commitment from all parties to be effective, has been shown to be both feasible and helpful to patients, families, and health professionals. Considerable education and commitment is necessary to ensure compliance by all involved parties.

The nature and correlates of paid and unpaid work among service users of London Community Mental Health Teams.

Aims. Little is known about how the rates and characteristics of mental health service users in unpaid work, training and study compare with those in paid employment. Methods. From staff report and patient records, 1353 mental health service users of seven Community Mental Health Teams in two London boroughs were categorized as in paid work, unpaid vocational activity or no vocational activity. Types of work were described using Standard Occupational Classifications. The characteristics of each group were reported and associations with vocational status were explored. Results. Of the sample, 5.5% were in paid work and 12.7% were in unpaid vocational activity, (including 5.3% in voluntary work and 8.1% in study or training). People in paid work were engaged in a broader range of occupations than those in voluntary work and most in paid work (58.5%) worked part-time. Younger age and high educational attainment characterized both groups. Having sustained previous employment was most strongly associated with being in paid work. Conclusions. Rates of vocational activity were very low. Results did not suggest a clear clinical distinction between those in paid and unpaid activity. The motivations for and functions of unpaid work need further research.