New directions in substance abuse services: programmatic innovations in the Veterans Administration

The purpose of this paper to describe the Department of Veterans Affairs' (VA) recent expansion and enhancement of its substance abuse treatment services. Several treatment innovations are considered from both clinical and administrative perspectives. These services include extended care programs for multiply impaired patients, programs for substance abuse patients with comorbid psychiatry conditions and services designed to improve continuity of care and community re-entry. Emergent themes include a broadening of services to meet the needs of a changing substance abuse population and an emphasis on providing more cost-efficient treatment.

High-sensitivity detection of CH radicals in flames by use of a diode-laser-based near-ultraviolet light source

CH radical distributions in ethylene-air and methane-air diffusion flames are mapped by wavelength-modulation absorption spectroscopy (WMS). Tunable, wavelength-modulated 426-nm light is generated by frequency doubling of a modulated 852-nm distributed Bragg reflector diode laser. Absorbances of 5 x 10(-5) are measured with second-harmonic (2f) WMS with a signal-to-noise ratio of 3:1 in a 3-Hz measurement bandwidth. The feasibility of simultaneous line-of-sight absorption and spatially resolved laser-induced-fluorescence detection with a single excitation beam is also demonstrated. This near-UV source is suitable for microgravity drop-tower experiments and other applications in which compact, rugged, energy-efficient instrumentation is required.

Strategies to improve diabetes care delivery

Although the primary care office is an important location for integrating new advances in the treatment of diabetes, the current delivery of preventive primary care for patients with diabetes falls short of clinical recommendations. Barriers within the existing health care system, practice structure, and physician and patient support services are among the most commonly cited obstacles to initiating better preventive care. As public health groups demand greater accountability from the medical system, regulatory efforts focus more scrutiny on systems, clinic practices, and even individual physician practices. Although improving care delivery effectively and efficiently is difficult, strategies to exist that can increase the likelihood of improving patient outcomes. Successful diabetes initiatives are often characterized by the consensual adoption of an evidence-based treatment plan. Effective physician-oriented interventions include the use of reminder systems, local opinion leaders, and academic detailing. In addition, several national diabetes initiatives are likely to influence primary care practice. New measures of accountability will be widely used to determine the quality of primary diabetes care delivery.

Measuring substance abuse program treatment orientations: the Drug and Alcohol Program Treatment Inventory

Assessment of therapeutic orientation is a significant problem in substance abuse program evaluation. This study reports the initial results of a new approach to measuring treatment orientation through a self-report survey that focuses on distinctive features of substance abuse treatment orientations. The Drug and Alcohol Program Treatment Inventory (DAPTI) assesses treatment goals and activities specific to eight orientations: AA/12 Step, Therapeutic Community, Cognitive-Behavioral, Insight/Psychodynamic, Rehabilitation, Dual Diagnosis, Medical and Marital/Family Systems. We present findings from a nationwide assessment of 327 Veterans Administration (VA) Substance Abuse treatment programs that demonstrate promising subscale internal consistency, discriminant validity, and concurrent validity. In addition, the DAPTI distinguishes between programs with independently verified orientations and between inpatient, extended care, outpatient, and methadone maintenance programs. The DAPTI may be helpful in systematically assessing differences in treatment orientations between different types of programs, such as inpatient, community residential, and outpatient care.

Comparison of home glucose monitoring with the oral glucose tolerance test to detect gestational glucose intolerance

BACKGROUND

Recent evidence suggests that infant morbidity is increased among women who have abnormal prenatal glucose screening tests but who do not have gestational diabetes mellitus (GDM). These women fall into a diagnostic gray zone and historically have not been treated.

METHODS

Forty-eight pregnant women with abnormal oral glucose challenge test results performed self-monitored blood glucose (SMBG) testing seven times per day for 1 week before undergoing a diagnostic 100-g oral glucose tolerance test (OGTT). At delivery, perinatal complications and birthweights were recorded. Results of SMBG tests for women with normal OGTTs were correlated with infant birthweights.

RESULTS

Thirteen infants (37%) were found to be large for gestational age (LGA). Significant correlation was found between increasing birthweight and increasing average fasting SMBG values (P < .001), increasing percentage of SMBG values above 120 mg/dL (6.7 mmol/L) (P < .01), and increasing average SMBG values (P < .016).

CONCLUSIONS

Maternal home glucose values at 28 weeks correlate with the risk of LGA infant births among women in the diagnostic gray zone. Women with average fasting SMBG values > 95 mg/dL (5.3 mmol/L) are at increased risk for giving birth to LGA infants and may be more likely to exhibit complications usually associated with GDM.

Determinants of readmission following inpatient substance abuse treatment: a national study of VA programs

This study examines program determinants of one aspect of VA inpatient substance abuse treatment program performance. Performance was measured by the ratio of a program's readmission rate to the expected rate for programs with similar patients. Six-month readmission rates in 101 VA treatment programs were analyzed. Preliminary analyses indicated that patient differences across programs accounted for 36% of the variance in readmission rates. Program differences accounted for 47% of the variance in case-mix-adjusted readmission rate. Among program factors selected through a literature review, better than expected readmission performance was associated with having fewer early discharges, a longer intended treatment duration, more patient participation in aftercare, more family or friend assessment interviews, and treating more patients on a compulsory basis. Performance was not related to stress management training, patient attendance at more self-help meetings during treatment, staff characteristics, or average staff costs per patient day. The findings indicate that treatment retention, duration, and increased aftercare may be targeted to reduce high readmission rates. Last, there were only small differences in the model over 30, 60, 90, and 365 day follow-up intervals, suggesting substantial stability of the findings.

Diabetes care by primary care physicians in Minnesota and Wisconsin

BACKGROUND

The purpose of this study was to identify the characteristics of diabetes care delivered by primary care physicians.

METHODS

Twenty-seven primary care physicians recruited through the Minnesota Academy of Family Physicians Research Network and the Wisconsin Research Network recorded a sample of 240 visits for care of patients with diabetes mellitus. Information was collected concerning physician and patient demographics, practice characteristics, and patterns of delivery of diabetes care including referral and clinical outcomes.

RESULTS

Seventeen percent of the patients in this study had type I diabetes mellitus; 81% had type II. Fourteen percent of the patients with type I diabetes and 20% of patients with type II were within their target glucose range. Average hemoglobin-A1c was 10.0% +/- 3.4% and 8.9% +/- 2.3% for patients with type I and type II diabetes, respectively (normal, 4.0% to 6.1%). Two distinct patterns of referral existed for patients with newly diagnosed type I diabetes: 44% of physicians rarely referred these patients, whereas 20% almost always referred. Although distance to specialists increased as community size decreased, frequency of referral was not related to practice location. Ninety-five percent of physicians in this study were directly involved in the diabetes education of their patients, and 56% had no certified diabetes educator available.

CONCLUSIONS

Over the course of this study, patients frequently persisted with treatment regimens that failed to stabilize blood glucose values. With recent evidence that improved glucose control may delay or prevent diabetes complications, it is increasingly important for the primary care physician to optimize available resources to improve glucose control in patients with diabetes in an effort to improve long-term clinical outcomes.

Picosecond infrared study of the photodynamics of carbonmonoxy-cytochrome c oxidase

Time-resolved infrared (TRIR) techniques have been employed to study the reactions of carbon monoxide with the cytochrome alpha 3-Cu(B) site of cytochrome c oxidase (CcO). The ligation dynamics immediately following photodissociation have been investigated using picosecond TRIR spectroscopy and linear dichroism. The rate of photoinitiated transfer of CO from cytochrome alpha 3 to CuB was measured directly by monitoring the development of the transient CuBCO absorption. In less than 1 ps, a stationary CuBCO spectrum develops, which together with the CO infrared linear dichroism is constant until the CO dissociates from CuB on a microsecond time scale. These observations indicate that the CO is transferred between metals and reaches its equilibrium conformation in less than 1 ps. This unprecedented ligand transfer rate has profound implications with regard to the structure and dynamics of the cytochrome alpha 3-CuB site, the functional architecture of the protein, and coordination dynamics in general.

The psychosocial effects of support group intervention on AICD recipients and their significant others

The automatic implantable cardioverter defibrillator (AICD) is one treatment method employed for patients with actual or potential malignant ventricular tachyarrhythmias. Support group intervention has been shown to be of value in promoting adaptation and coping skills. This exploratory pilot study compared the psychosocial effects of support group intervention on 11 AICD recipients who regularly attended support group, ten spouses, or significant others who also attended and five AICD recipients who were unable to attend. The Spielberger State Anxiety Inventory, The Anxiety Visual Analogue Study (VAS), the Medical Outcome Study (MOS) Short Form General Health Survey, and anecdotal reports were used. Results showed that quantitative data were not significantly changed by support group interventions. Qualitative data demonstrated improved ability to cope and increased satisfaction with life in group participants, however, it was difficult to ascertain whether this was a result of passage of time.

Symptom monitoring in schizophrenia: potential for enhancing self-care

In this study a symptom self-regulation model was used as a framework to examine the characteristics and stability of indicators of illness identified by individuals with schizophrenia. Subjects were interviewed to determine if they could identify indicators of illness and describe characteristics of their primary indicator. Primary indicators of illness from 51 subjects were categorized as anxiety-based, depressive, or psychotic. Subjects who identified psychotic indicators were more confident that their indicator occurred when they were getting ill than subjects with anxiety-based or depressive indicators, and subjects who identified psychotic and depressive indicators reported that their indicators were more troublesome than those identifying anxiety-based indicators. Anxiety-based indicators were reported by subjects to occur more frequently than indicators from the other two categories. Findings from a follow-up interview of 28 subjects 1 year later showed that approximately half reported either the same primary indicator of illness or identified an indicator in the same category (anxiety-based, depressive, or psychotic) as they had 1 year previously. The implications of the findings for enhancing self-care through monitoring symptoms are discussed.

Interleukin 2 receptor expression in patients with head and neck squamous carcinoma. Effects of thymosin alpha 1 in vitro

Altered cellular immunity in patients with advanced head and neck cancer includes impairments in lymphokine production, blastogenesis, in vitro cytotoxicity, and T-cell levels. Recent evidence for the potential importance of in lymphokine interleukin 2 (IL-2) in patients with cancer prompted a study of the kinetics of IL-2 receptor expression on lymphocytes from patients with untreated advanced head and neck cancer and normal subjects and an evaluation of the in vitro effects of the T-cell immune-reconstituting peptide, thymosin alpha 1. Concanavalin A-stimulated IL-2 receptor expression was maximal after 72 hours and was higher in normal subjects than in patients. This was due to lower levels of helper/inducer (CD4) cells expressing IL-2 receptors in the patients compared with the normal subjects. Thymosin alpha 1 further decreased levels of IL-2 receptor-positive (both CD4 and CD8) cells at 48 and at 72 hours. At 96 hours, levels of IL-2 receptor-positive cells and proportions of cells in G2 and M phases of the cell cycle were similar among both groups of subjects. Simultaneous cell kinetic studies indicated that thymosin alpha 1 down regulation of IL-2 receptors was not due to an effect on proliferation and that differences in IL-2 receptor expression at 72 hours among normal subjects and the patients with cancer were more likely related to differences in cell proliferation kinetics.

Alterations in T-lymphocyte subpopulations in patients with head and neck cancer. Correlations with prognosis

Impaired cell-mediated immunity has been consistently demonstrated in patients with advanced head and neck squamous cancer (HNSC); however, the results of prior studies of correlations of cellular immune parameters with treatment outcome have been inconsistent, and routine assessment of immune parameters has been of limited clinical use. To determine the prognostic importance of alterations in the proportions of various T-lymphocyte subpopulations in the peripheral blood of patients with HNSC, levels of T3, T4, T6, T8, T9, T10, T11, and Leu 7 cells were quantitated by flow cytometry in 80 previously untreated patients and prospectively correlated with tumor characteristics and clinical course (median length of follow-up, 27 months). The mean helper/suppressor cell ratio (T4/T8) increased progressively with increasing tumor stage and was significantly elevated among patients with cancer as a group and in patients with advanced (stage III or IV) disease compared with 40 normal subjects. Decreased disease-free survival was significantly associated with elevated T4/T8 ratios and low percent T8 and T11 cell levels. The prognostic significance of percent T8 (cytotoxic/suppressor) cell levels persisted even after adjusting for known prognostic factors of tumor stage, T class, N class, and tumor site. These correlations provide new insight into immune alterations in HNSC that may prove useful in identifying patients with early clinical disease who have a poor prognosis.

Use of symptoms by schizophrenics to monitor and regulate their illness

Interviews with 62 outpatients with chronic schizophrenia and schizoaffective disorder indicated that many patients monitor symptoms that they associate with changes in their illness and alter their behavior based on their symptoms. Ninety-eight percent of the subjects identified symptoms, two-thirds of which were nonpsychotic, that indicated to them they were getting worse. Eighty-two percent of those who identified symptoms of decompensation responded by altering their behavior, either by self-treatment (such as self-medicating, engaging in a diversionary activity, or attempting to ignore the symptoms), by seeking mental health assistance, or both. The authors compare their findings with those of other studies and discuss the study's implications for research on and care of schizophrenic patients.

Lymphocyte subpopulations infiltrating squamous carcinomas of the head and neck: correlations with extent of tumor and prognosis

Because little is known about the mechanisms involved in local tumor-host immune reactions in squamous carcinoma of the head and neck, a study was undertaken to better characterize the types of immune cells present at the local tumor site and determine their relationship to tumor extent, systemic cellular immune parameters, and clinical outcome. In 40 untreated patients, lymphocyte subsets (LS) at the tumor-host interface were quantitated immunohistologically from serial sections of frozen tumor specimens and correlated with concurrently measured peripheral LS levels and in vitro lymphocyte reactivity to phytohemagglutinin (PHA). The majority of infiltrating lymphocytes were T cells with rare B or Leu 7 cells. Proportions of T4 and T8 were similar in peritumor stroma; however, T8 cells predominated tumor parenchyma. Stromal and parenchymal infiltration by LS were not related to peripheral blood LS levels, lymphocyte reactivity, or tumor site. However, parenchymal T11 and T4 cell infiltration was less in advanced primary tumors (T3, T4) than in early tumors (T1, T2) (P = 0.01, P = 0.067, respectively), as was peripheral lymphocyte reactivity to PHA (P = 0.013). Short-term disease-free interval and actuarial survival differed significantly--according to parenchymal T11 and T4 cell infiltration--and were not related to T8, Leu 7, and B-cell infiltration. The findings extend prior studies of lymphocytic infiltration in head and neck cancer and demonstrate the potential importance of differences in tumor stromal and parenchymal infiltration. Together with recent evidence that T4 cells are critical for lymphokine production and for the proliferation of cytotoxic effector cells, the current results suggest that T4 cells play a critical role in the local immune response in squamous carcinoma of the head and neck.

Beta endorphin enhances in vitro lymphokine production in patients with squamous carcinoma of the head and neck

Recent studies of the effects of endorphins and other neuropeptides on immune mechanisms suggest that immune reactive cells have specific opioid-like and nonopioid endorphin receptors, and indicate that neuropeptides may participate in regulating in vivo immune functions. Earlier demonstrations of impaired cellular immunity and impaired lymphokine production in patients with cancer of the head and neck prompted an investigation of the in vitro effects of beta-endorphin on the production of leukocyte migration inhibitory factor (LIF) in 29 patients with head and neck cancer and in 45 normal subjects. LIF production in response to phytohemagglutinin was significantly less in the cancer patients compared to normal subjects (p less than .001). beta-endorphin significantly enhanced LIF production in the cancer patients (p = .01) to levels that did not differ significantly from normal levels. A correlation of levels of lymphocyte subpopulations in the cancer patients suggested that enhancement of lymphokine production by beta-endorphin was related to levels of T8 (suppressor/cytotoxic) cells. The results confirm earlier demonstrations of impaired lymphokine production in patients with head and neck cancer and indicate that beta-endorphin can modulate in vitro lymphokine responses in such patients. These findings suggest that neuroendocrine peptides may play an important role in regulating immune function. Further study of the role of neuropeptides in the immune response should provide additional insight into the characterization of cellular immune dysfunction associated with head and neck cancer and should lead to the development of innovative immunotherapeutic treatment strategies.

Definite vs adjuvant radiotherapy. Comparative effects on lymphocyte subpopulations in patients with head and neck squamous carcinoma

The recent association of alterations in T-lymphocyte subpopulations and impaired cellular immunity prompted an investigation of the effects of radiotherapy (RT) on serial levels of lymphocyte subsets in 30 patients with head and neck squamous carcinoma. Percentage and absolute levels of T3, T4, T6, T8, T10, T11, and Leu 7 cells were measured before, during, and after RT at monthly intervals for six months and compared with levels in 40 normal subjects. Sixteen patients received curative and 14 postoperative adjuvant RT. Before treatment, mean subset levels were similar among the patient and normal groups except for elevated Leu 7 (natural killer) cells in patients with stage I and II disease. There were profound decreases in absolute levels of each subpopulation during and after RT. The percentage of T4 (helper/inducer) cells decreased, whereas that of T8 (cytotoxic/suppressor) and Leu 7 cells tended to increase. Compared with normal values, the mean T4/T8 ratio decreased significantly by six months after RT, when absolute levels of the subsets had rebounded to pretreatment levels in the definitive RT group but remained profoundly decreased in the adjuvant group. The differing recovery patterns suggest that factors other than RT may contribute to persistent immunosuppression following RT.

In vitro immune modulation by thymosin alpha 1 in patients with head and neck squamous cell carcinoma

To determine if patients with head and neck squamous cell carcinoma represent an appropriate population for immune reconstitution with thymosin alpha 1, leukocyte migration inhibition (LMI) in response to phytohemagglutinin was measured in 24 previously untreated patients with head and neck cancer, and the in vitro effects of thymosin alpha 1 on migration inhibition were assessed. Compared to normal subjects, LMI was impaired in the head and neck cancer patients. Thymosin alpha 1, in vitro, was associated with improvement in LMI in the cancer patients. Improvements in migration response with thymosin alpha 1 appeared to be independent of levels of various T-lymphocyte subpopulations. However, patients with a normal LMI response had lower suppressor/cytotoxic cell levels than normal subjects or patients with impaired LMI. The findings confirm prior reports of the effects of thymic hormones on lymphokine production in vitro and provide rationale for further clinical studies of thymosin alpha 1 in patients with head and neck squamous cell carcinoma.