Expression of matrix metalloproteinases during ascorbate-induced differentiation of osteoblastic MC3T3-E1 cells.

The mouse calvarial osteoblast MC3T3-E1 cells released 92 kDa and 68 kDa of gelatinase activities into the conditioned media (CMs) from undifferentiated cells. When differentiation was induced by cultivating cells with ascorbate-2-phosphate (AscP), 68-kDa activity increased significantly in parallel with production of 60-kDa activity. These enzymes required Ca2+ and Zn2+ ions for their proteolytic activities. The 68-kDa activity was immunologically identified as latent matrix metalloproteinase 2 (MMP-2). The 92-kDa activity was deduced to be latent MMP-9 based on its molecular mass. The 60-kDa activity band was found to possess both gelatin and beta-casein hydrolyzing activities, indicating that this activity band might comprise the active form of MMP-2 and latent MMP-13. MC3T3-E1 cells were found to express MMP-2, MMP-13, and membrane type (MT)1-MMP genes by Northern blotting. MMP-2 was expressed constitutively. MMP-13 was up-regulated during the growth with AscP. MT1-MMP expression also was modulated by AscP; at the early stage of differentiation, its messenger RNA (mRNA) level increased and then decreased gradually to the control level. These changes in the profiles of MMPs observed here could be attributed to the maturation of collagenous extracellular matrix (ECM) induced by AscP.

Service utilization and cost of community care for discharged state hospital patients: a 3-year follow-up study.

OBJECTIVE: This study examined the mental health service utilization and costs of 321 discharged state hospital patients during a 3-year follow-up period compared with costs if the patients had remained in the hospital. METHOD: The study subjects were long-stay patients discharged from Philadelphia State Hospital after 1988. A longitudinal integrated database on all mental health and medical services reimbursed by Medicaid and Medicare as well as state- and county-funded services was used to construct service utilization and unit cost measures. RESULTS: During the 3-year period after discharge, 20%-30% of the patients required rehospitalization an average of 76-91 days per year. The percentage of rehospitalized patients decreased over time, but the number of hospital days increased. All of the discharged patients received case management services, and a majority also received outpatient mental health care (66%-70%) and residential services (75%) throughout the follow-up period. The total treatment cost per person was approximately $60,000 a year after controlling for inflation, with costs rising slightly over the 3-year period. The estimated cost of state hospitalization, with the use of 1992 estimates, would have been $130,000 per year if the patients had remained institutionalized. CONCLUSIONS: This analysis suggests that most former long-stay patients are able to live in residential settings while receiving community outpatient treatment and intensive case management services at a reduced cost. There is no indication of cost shifting from the psychiatric to the health care sector; however, some cost shifting from the state mental health agency to the Medicaid program has occurred, since most psychiatric hospital care now takes place in community hospitals.

Cost comparison of state hospital and community-based care for seriously mentally ill adults.

OBJECTIVE: In 1989, Philadelphia began a bold experiment involving the total shutdown of a 500-bed state hospital. This study examines the service utilization and cost of treating individuals with serious mental illness in a community-based care system in which the state hospital was replaced with 60 extended acute care beds in general hospitals and 583 residential beds. METHOD: A pre-post study design was used to determine the utilization and cost differences before and after the state hospital closed for individuals with a diagnosis of schizophrenia who required extended psychiatric hospitalization following an acute care crisis episode in a general hospital. The number and cost of days spent in general and in extended hospital and residential treatment were compared on an episode and an annual basis. RESULTS: The results of this analysis showed that after the state hospital closed, the direct treatment cost of an episode of care increased from $68,446 to $78,929, and the average annual cost of care per patient increased from $48,631 to $66,794 because of an increase in acute care hospitalization. CONCLUSIONS: This study suggests that an "admission" cohort of seriously mentally ill patients requires an optimal mix of acute care, extended care, and residential beds, as well as ambulatory services, in order for cost-efficient care to be delivered during a crisis period. Determining the appropriate allocation and supply of beds in different settings is essential if community mental health systems are to manage the care of individuals with serious mental illness outside of institutional settings.

Homelessness among persons with serious mental illness in an enhanced community-based mental health system.

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.

[...and after the clinic? Reflections on domestic-familial rehabilitation and management of the spinal cord injured patient]. / ...und nach der Klinik? Uberlegungen zur häuslich-familiären Rehabilitation und zur pflegerischen Versorgung des Querschnittgelähmten.

Both from a personal and professional perspective, considerations are presented concerning the domiciliary-familial rehabilitation of persons with spinal cord injury. The field of tension present within the living community affected by the disability (parents/children, partners, children/parents) is examined, the various specific strains, physical, mental, social-societal, are outlined. The problems entailed as regards autonomy/dependence, intimateness/distantness, lover, mother/father, and avoiding/facing conflict, are analyzed, and possible solutions suggested.

[Interdisciplinary education in geriatrics]. / Interdisziplinäre Fortbildung in der Geriatrie.

A four-week basic course in geriatric medicine was developed, that is interdisciplinary and with many practical aspects. The participants have rated the interdisciplinary concept very positively, at the end of the course and 13 months after the course. Interdisciplinary learning is possible, makes sense and promotes the necessary geriatric teamwork; specific professional training can, however, not be substituted.

Service components of case management which reduce inpatient care use for persons with serious mental illness.

This is a study of two types of case management: case management (CM) which provided the service coordination functions, and Intensive Case Management (ICM) which consisted of both the coordination function and the provision of direct support to the client. Using secondary data on public clients, characteristics of mental health service use were analyzed for 80 ICM and 84 CM clients. The ICM clients had significantly fewer episodes per patient and less inpatient days per year than the CM clients. These findings suggest that direct support services make a significant difference in reducing annual hospital care.

[Urinary incontinence in the elderly. 1: Forms of urinary incontinence--basic diagnosis--additional diagnosis]. / Harninkontinenz im Alter. Teil 1: Formen der Harninkontinenz-Basisdiagnostik-Zusatzdiagnostik.

Every geriatric patient should routinely be questioned about possible urinary incontinence. The basic diagnostic work-up comprises the clinical history, wherever indicated a geriatric assessment, a nursing care history, a physical examination and a micturition protocol. Furthermore, determination of postvoid residual urine, laboratory investigations and a urine-analysis should be done in all patients. Ultrasonography of the urinary tract is a simple non-invasive procedure that can exclude the presence of large tumors, stones in the bladder and urinary retention. Only selected patients require a greater diagnostic effort prior to treatment, for example, urologic and/or gynecologic investigations or a urodynamic evaluation.

[Urinary incontinence in the elderly, 2: Therapy--from toilet and pelvic floor training to drug therapy and incontinence aids]. / Harninkontinenz im Alter, Teil 2: Therapie-vom Toiletten-und Beckenbodentraining bis zur medikamentösen Therapie und Hilfsmittelversorgung.

The therapeutic strategy rests on a simple basic diagnostic investigation. As a rule, the greatest importance attaches to toilet training and individual counseling. In this context, the work of a specialist nurse capable of providing both the patient and his/her relatives with competent instruction is of considerable importance. A greater diagnostic effort is needed only for selected prior to the initiation of therapy. Even in the elderly patient urinary incontinence is curable or can at least be improved; it is not an inevitability of old age.