Modified therapeutic community for mentally ill chemical "abusers": background; influences; program description; preliminary findings

This paper briefly surveys the literature that addresses the problem of co-occurring mental and "substance abuse disorders." It discusses several convergent influences on the development of modified therapeutic community (TC) approaches. The paper describes in some detail the modified TC program for mentally ill chemical "abusers" (MICAs). The paper also summarizes research data that establish positive retention rates and significant in-treatment change to support the effectiveness of the modified TC and to underscore the limited effect of treatment-as-usual approaches. Treatment approaches must be comprehensive, multidimensional, of relatively long duration, and must systematically address the interrelated problems of mental illness and substance use.

Coronary angioplasty for elderly patients with "high risk" unstable angina: short-term outcomes and long-term survival

OBJECTIVES

We sought to compare the short- and long-term mortality rates in patients > or = 70 years old with unstable angina undergoing percutaneous transluminal coronary angioplasty (PTCA) with predicted coronary artery bypass graft surgery (CABG) short-term and U.S. census long-term mortality rates.

BACKGROUND

Coronary angioplasty is an alternative revascularization strategy for patients with medically refractory rest angina and a high risk of adverse outcomes with CABG. Patients > or = 70 years old are a specific high risk subset.

METHODS

A total of 131 consecutive patients aged > or = 70 years with unstable angina underwent PTCA; 82 (62%) of 131 had been refused CABG. Mortality over time was obtained from the Veterans Affairs Beneficiary Index Records Locator Subsystem. Predicted 30-day CABG-associated mortality was obtained from the Veterans Affairs Cardiac Risk Assessment Model. Mortality over time was expressed with Kaplan-Meier curves.

RESULTS

The observed 30-day angioplasty survival rate was 87% compared with the predicted surgical 30-day survival rate of 85.5%. In those patients who survived 6 months after angioplasty (84%), their subsequent 1-, 2-, 3-, 4- and 5-year survival rates were comparable to age-matched subjects in the U.S. census. Mortality in certain subsets known to be at very high risk for CABG-for example, patients who had a previous CABG-was not high in this cohort of elderly subjects. The extremely high risk subsets identified in this PTCA cohort (shock, heart failure, pressors required, balloon pump required) were relatively infrequent subsets.

CONCLUSIONS

For selected elderly patients with unstable angina deemed to be at "high risk" or even "prohibitive risk" for CABG, PTCA is an alternative revascularization strategy. The long-term mortality of successfully treated elderly patients is comparable to age-matched subjects. A prospective, multicenter, randomized trial of CABG versus PTCA, which includes patients > or = 70 years old, is being conducted (Veterans Affairs Cooperative Study 385: AWESOME).

Effect of outdoor airborne particulate matter on daily death counts

To investigate the possible relationship between airborne particulate matter and mortality, we developed regression models of daily mortality counts using meteorological covariates and measures of outdoor PM10. Our analyses included data from Cook County, Illinois, and Salt Lake County, Utah. We found no evidence that particulate matter < or = 10 microns (PM10) contributes to excess mortality in Salt Lake County, Utah. In Cook County, Illinois, we found evidence of a positive PM10 effect in spring and autumn, but not in winter and summer. We conclude that the reported effects of particulates on mortality are unconfirmed.

Effectiveness of percutaneous transluminal coronary angioplasty for patients with medically refractory rest angina pectoris and high risk of adverse outcomes with coronary artery bypass grafting

This study was undertaken to test the hypothesis that percutaneous transluminal coronary angioplasty (PTCA) is a reasonable alternative to coronary artery bypass grafting (CABG) for some high-risk patients with medically refractory rest angina. Over a 5-year period, 1 operator at a tertiary Veterans Affairs Medical Center performed angioplasty on 624 patients, of whom 441 had unstable angina. Of these 441 patients, 288 had rest angina and 225 had medically refractory rest angina. Medically refractory unstable angina was defined as reversible myocardial ischemia occurring at rest in an intensive care unit setting with low flow oxygen despite the following medications: (1) oral aspirin, intravenous heparin, or both; (2) some combination of beta blocker, calcium blocker, and/or nitrate so that resting heart rate is < 70 beats/min or resting blood pressure < 140 mm Hg, or both. There were 207 patients with medically refractory rest angina who had > or = 1 of the following characteristics predictive of a more than twofold increased risk of operative death at CABG: age > 70 years, prior CABG, recent myocardial infarct, need for intravenous nitroglycerin, need for intraaortic balloon pump, and left ventricular ejection fraction < 0.35. Of these 207 patients, 11 died (5%) during index hospitalization, 196 (95%) were discharged, and 186 (90%) went home angina free. There were 2 emergency CABGs and 9 acute myocardial infarctions. At follow-up (3 to 60 months, average 24), there were 27 late deaths (for a total of 38 [18%]), 8 (4%) late CABGs, and 44 (21%) late PTCAs (with 17 [8%] late myocardial infarctions). The 2-year mortality of 18% for this cohort is comparable to a 21% 2-year mortality observed in a group of 1,073 "high-risk" patients who underwent CABG in the Veterans Affairs Medical Center from 1987 to 1988. These data support the hypothesis that PTCA provides an alternative to CABG in some high-risk patients with medically refractory rest angina.

Evaluation of rotavirus infection and diarrhea in Iowa commercial pigs based on an epidemiologic study of a population represented by diagnostic laboratory cases

Group A, B, and C rotaviruses were identified in 9% (96/1,048) of pig fecal specimens submitted to the Iowa State University Veterinary Diagnostic Laboratory during 1987 and 1988. Six of the rotaviruses were group B, 5 were group C, and the remaining 89% were group A. Of the rotavirus cases with more than 1 serotype, 5 were multiple group A serotypes, 1 involved a group A and B serotype, and 1 included 2 group C serotypes. A retrospective epidemiologic evaluation of pig diarrhea in herds of origin was done using data obtained from the accession records of the rotavirus and 88 matched nonrotavirus pig diarrhea control cases. Herds from which rotavirus cases were derived experienced lower morbidity, mortality, and case fatality rates than matched control herds. The incidence of diarrhea decreased rapidly among all pigs from birth to 3 weeks of age. The peak incidence for piglet diarrhea occurred in February, and a moderate rise occurred in August-September. Definitive evidence for transmissible gastroenteritis virus was found in 12% of nonrotavirus cases but none of the rotavirus cases in which it was sought. Other pathogenic microorganisms were identified less frequently and inconsistently.

Percutaneous transluminal angioplasty of saphenous vein grafts for medically refractory unstable angina

OBJECTIVES

We attempted to answer the question, Is balloon angioplasty a reasonable alternative to repeat coronary artery bypass graft surgery in patients with previous coronary bypass graft surgery, medically refractory unstable angina and vein graft lesions?

BACKGROUND

Patients with medically refractory unstable angina need revascularization. Patients with previous coronary artery bypass graft surgery and medically refractory angina are at "high risk" for adverse outcomes with repeat coronary bypass graft surgery. Conversely, patients with angioplasty of old vein grafts are also at "high risk" for adverse outcomes.

METHODS

Balloon angioplasty of 89 lesions in saphenous vein grafts was performed in 75 consecutive patients with medically refractory unstable angina. Of these 75 patients, 24 (32%) had myocardial infarct within 30 days, 23 (31%) had left ventricular ejection fraction < 0.35, and 50 (67%) had major comorbidity. Patients underwent standard balloon angioplasty with aggressive use of intravenous and intracoronary heparin, urokinase, nitroglycerin, oral aspirin, calcium channel blocking agents and coumadin.

RESULTS

Angiographic success (reduction of stenosis < or = 50% without major complication) was seen in 84 of 89 lesions. Clinical success (angiographic success plus hospital discharge without major complication) was seen in 70 of 75 patients. During index hospitalization, two patients (3%) died, two (3%) had nonfatal infarcts, and one (1%) had emergency reoperation (coronary bypass graft surgery). In late follow up (3 to 66 months), 14 (20%) patients were lost to follow-up, 17 (23%) had repeat percutaneous transluminal coronary angioplasty, 2 (3%) had late bypass graft reoperation, 18 (25%) had late death, and 1 (< 1%) had a heart transplant. Of the 41 patients alive after one or more angioplasties, 25 have little or no angina, and 16 have occasional or more angina. We compared long-term survival rate in these 75 patients with a cohort of patients with high risk, unstable angina from the Veterans Affairs Surgical Registry (2,570 patients). The 30-day survival rate was better in patients with coronary angioplasty (97% vs. 92%, p < 0.05), but by 6 months there was no difference, and by 5 years a trend toward a higher survival rate with coronary artery bypass graft surgery was seen.

CONCLUSIONS

Balloon angioplasty of saphenous vein grafts with aggressive adjunctive pharmacotherapy is a reasonable alternative to repeat coronary bypass graft surgery in patients with medically refractory unstable angina, previous coronary bypass graft surgery and saphenous vein narrowing.

Negative emotion as predictor of relapse in persons with schizophrenia living in board and care homes

Negative emotion exhibited by the board and care providers toward residents, resident behavior, medication dosage, medication noncompliance, and gender were used to predict resident relapse over a 6-month period. Relapse was defined as movement to a higher, more intensive level of care. Eighty-four residents with a diagnosis of chronic schizophrenia disorder, living in board and care homes in the Fresno, California, area participated in the study. Board and care providers were interviewed using Kreisman's Patient Rejection Scale and Gurel's Behavior Rating Scale. Neither patient rejection nor resident behavior was predictive of relapse; however, medication noncompliance did predict relapse with the male residents and lower medication dose predicted relapse with the female residents. Rejection of the patient by the board and care operator was found to correlate .73 and .64 with negative behavior of the male and female residents respectively. Implications of these results for expressed emotion research were discussed.

Effect of muramyl dipeptide on immunogenicity of Corynebacterium pseudotuberculosis whole-cell vaccines in mice and lambs

Colostrum-deprived lambs and CF1 mice were vaccinated with water-in-oil emulsion vaccines containing nonviable whole cells (WC) of Corynebacterium pseudotuberculosis with and without muramyl dipeptide (MDP). Efficacy of vaccines was determined from the survival of mice and lesions in lambs after IV injection of 10(4) colony-forming units of C pseudotuberculosis. In mice, protection was related to the concentration of WC in the vaccine. At 50, 100, or 150 micrograms of WC, protection was good (78.8%). At 10 or 25 micrograms of WC, protection was considerably less (54.7%). At high WC concentrations, protection could only be moderately increased to 82.3% with high (50 and 100 micrograms) concentrations of MDP or increased to 90% protection with low (5 and 10 micrograms) concentrations of MDP. At low WC concentrations, protection significantly decreased to 32% (P less than 0.025) with high concentrations of MDP, but significantly increased to 72.5% (P less than 0.025) with low concentrations of MDP. Therefore, the amount of protection with lower concentrations of WC and MDP was comparable with the amount of protection with higher concentrations of WC without MDP. In lambs, high prechallenge antibody titers (geometric mean titers from 5.1 to 5.4 by day 35) were observed after vaccination with WC. Protection and vaccination site abscesses in lambs were related to the concentration of WC and MDP. Pulmonary or vaccination site abscesses were not observed in 4 of 4 lambs vaccinated with 1 mg of WC + 50 micrograms of MDP.

Serum complement activity and serum enzymes in rats after a subcutaneous injection of toxin prepared from Pasteurella multocida type D

Toxin produced by Pasteurella multocida type D was investigated for its effect on serum complement and serum biochemistry in rats. Rats were given a sublethal single subcutaneous injection of D toxin equivalent to 0.2 microgram/kg of body weight. Serum obtained 1, 3, 5 and 7 days post-treatment was tested for complement activity, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Serum complement titers were significantly elevated (P less than 0.05) at all times after injection of toxin compared to rats injected with diluent and tested at the same intervals. Bilirubin was decreased but both control and D toxin-treated rats had low concentrations of bilirubin in their sera. The other biochemical constituents measured had no consistent pattern that would indicate liver damage in the rats.

The effectiveness of flurazepam as night sedation prior to the removal of third molars

Anxiety prior to dental treatment is a well-recognized problem. Although oral sedation has been recommended the night before appointments to reduce this anxiety, there are no well-controlled studies to support this claim. The present double-blind cross-over study investigated the effect of 30 mg of flurazepam taken the night before the removal of impacted third molars. Preoperative anxiety, visuomotor performance and sleep patterns were investigated in 20 adult patients with similarly impacted third molars. While preoperative flurazepam led to a statistically significant improvement in sleep patterns, there was no reduction in pre-operative anxiety on the morning of surgery. In addition, the flurazepam-treated group demonstrated significantly impaired visuo-motor performance 60 min after intravenous sedation compared to this group where intravenous sedation was used only preceded by placebo. Patients had a significant preference for flurazepam over placebo as a night-time sedative.

Immunogenetic studies of multiple sclerosis patients in Caithness County, Scotland

The present report indicates that there is an increased frequency of HLA-B7 in multiple sclerosis patients compared to unrelated controls and unaffected siblings. HLA-A3 was not significantly increased. The increased frequency of certain HLA antigens was not reflected in increased titres of serum measles antibodies in this group. In contrast to our previous studies, there were only minimal differences in the cellular response to measles antigen in multiple sclerosis patients as compared to siblings and unrelated controls.

Microvillous surface area in secondary disaccharidase deficiency

Electron microscopy was used to measure microvillous surface area in seven small intestinal biopsies showing secondary disaccharidase deficiency and in five biopsies having normal disaccharidase levels. There were significant reductions in microvillous surface area in the enzyme deficient group, although the microvilli were not severely damaged. Histological abnormality was not always present with disaccharidase deficiency. There was no significant difference in intraepithelial lymphocyte counts between the two groups.

A collaborative day treatment program for chronic patients in adult homes

Three agencies providing services for the Nassau County (N.Y.) Department of Mental Health initiated a pilot program to provide comprehensive day treatment services to chronic psychiatric patients living in adult homes in Long Beach, New York. After screening, the clients are assigned to the regular day program of one of the centers. Two buses transport the clients to and from the centers, and a paraprofessional is assigned to each bus to encourage group discussion and interaction. The sponsoring agencies found that the original expectations for rehabilitating the clients were unrealistic. However, while clinical symptomatology was not altered, many of the clients manifested improved social behavior as the result of training in social and daily-living skills, and rates of rehospitalization were substantially reduced.

Neonatal hyperammonaemia with complete absence of liver carbamyl phosphate synthetase activity

Two newborn infants, male (A) and female (B), with lethal hyperammonaemia are described in the same family. In both, symptoms started on the second day of life. Lethargy and hypotonia were the most prominent initial findings and were followed by convulsions and coma. In both, blood ammonia levels rose to 570 mumol/u (795 microgram/100 ml) a few hours before death, which occurred on the third and fourth day of life respectively. Assay of liver urea cycle enzymes in baby B showed a complete absence of mitochondrial carbamyl phosphate synthetase activity.