Dissemination in cutaneous leishmaniasis due to Leishmania major in different ethnic groups in Saudi Arabia

BACKGROUND

Dissemination in patients with cutaneous leishmaniasis has previously been recorded in human infection with Leishmania major and L. tropica. In this study, the potential for dissemination in different ethnic groups in Saudi Arabia was compared.

METHODS

The data were recorded from a group of 73 patients with suspected cutaneous leishmaniasis (43 Saudi and 30 non-Saudi) attending the Dermatology Clinics at King Fahd Hospital of the University and Al-Khobar Government Hospital at Al-Khobar, Eastern Region of Saudi Arabia. The patients were of various age groups (all male) between 1 and 55 years. The diagnosis of cutaneous leishmaniasis was confirmed clinically and by smear and skin biopsy. The following data were recorded for each patient: type, number, and anatomic sites of disseminative lesions and the frequency of co-occurrence of more than one type of lesion.

RESULTS

Three types of disseminative lesions due to zoonotic cutaneous leishmaniasis were recorded in 16 patients (21.92%): subcutaneous nodules, satellite papules, and subcutaneous induration. The percentage of disseminative lesions in non-Saudi patients (36.66%) was higher than in Saudi patients (11. 63%). This was also true for the number of lesions: a mean of 12.27+/- 10 and 6.4+/-3, respectively. The coexistence of more than one type of disseminative lesion was higher in non-Saudi patients (63. 63%) than in Saudi patients (20.0%), as well as the occurrence of lesions on more than one body site: 36.4% in non-Saudi patients and 20.0% in Saudi patients.

CONCLUSIONS

The potential for dissemination due to cutaneous leishmaniasis was significantly higher in the nonindigenous population than in the indigenous population in Saudi Arabia. Disseminative lesions must be clinically differentiated from other skin diseases and appropriately treated by avoiding the use of intralesional drugs or physical therapy.

Utilization of local jails and general hospitals by state psychiatric center patients

The idea that the deinstitutionalization of state psychiatric centers has resulted in increased utilization of general hospitals and correctional facilities by people with severe and persistent mental illness is widely held. This hypothesis of trans-institutionalization was tested by examining hospitalization and incarceration rates of people who had been or would be institutionalized in state psychiatric centers in 16 upstate New York counties. The results do not support the hypothesis of trans-institutionalization. Assumptions underlying the hypothesis are examined, potential explanations for the observed patterns are discussed, and areas for further research are suggested.

Admissions, length of stay, and medication use among women in an acute care state psychiatric facility

OBJECTIVE

Despite growing numbers of elderly persons with serious mental illness such as schizophrenia, little research has been conducted on the manifestation of serious mental illness in later life, and our understanding of the mental health care needs of this population is limited. This study examined length of stay and medication use among women age 50 and older admitted to an acute care state psychiatric facility.

METHODS

A computerized record search for all women discharged from a large urban state psychiatric facility over a one-year period was undertaken. Demographic and resource utilization data, including total length of stay and pharmacy utilization, were obtained from the hospital database.

RESULTS

The database search produced the records of 564 women, with a mean age of 37.5 years. Women constituted 60 percent of patients over age 50. The mean length of stay was 16.1 days for the entire group; for women under age 50 (N=492), mean length of stay was 15 days, and for women age 50 and older (N=72), it was 23.1 days (p=. 01). Among those age 50 and older, 58.3 percent had a diagnosis of schizophrenia or schizoaffective disorder, compared with only 38 percent of those under age 50.

CONCLUSIONS

Our data suggest that women constitute the majority of patients over age 50 in a state psychiatric facility and that they have longer stays than younger women.

Bed closures and incarceration rates among users of Veterans Affairs mental health services

OBJECTIVE

This study examined incarceration rates of users of Department of Veterans Affairs (VA) mental health services in 16 northeastern New York State counties between 1994 and 1997-a time of extensive bed closures in the VA system-to determine whether incarceration rates changed during this period.

METHODS

Data were obtained for male patients who used inpatient and outpatient VA mental health services between 1994 and 1997 and for men incarcerated in local jails during this period. For comparison, services use and incarceration data were obtained for all men who received inpatient behavioral health care at community general hospitals and state mental hospitals between 1994 and 1996 in the same counties. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between clinical and incarceration populations without relying on person-specific identifiers.

RESULTS

Of all male users of VA mental health services between 1994 and 1997, a total of 15.7 percent-39.6 percent of those age 18 to 39 years and 9.1 percent of those age 40 years and older-were incarcerated at some time during that period. Dual diagnosis patients had the highest rate of incarceration (25 percent), followed by patients with substance abuse problems only (21 percent) and those with mental health problems only (11 percent). The rate of incarceration among male patients hospitalized in VA facilities was lower than among men in general hospitals or state hospitals (11.6 percent, 23 percent, and 21.7 percent, respectively), but was not significantly different. No significant increase occurred in the annual rate of incarceration among VA patients from 1994 to 1997 (3.7 percent to 4 percent), despite extensive VA bed closures during these years.

CONCLUSIONS

Substantial proportions of mental health system users were incarcerated during the study period, especially younger men and those with both substance use and mental health disorders. Rates of incarceration were similar across health care systems. The closure of a substantial number of VA mental health inpatient beds did not seem to affect the rate of incarceration among VA service users.

Intestinal obstruction at a provincial hospital in Kenya

OBJECTIVE

To determine the presentation, aetiological pattern, management and outcome of intestinal obstruction at the Central Provincial General Hospital, Nyeri, Kenya.

DESIGN

A descriptive retrospective study.

SETTING

Surgical Department, Central Provincial General Hospital, Nyeri, Kenya.

SUBJECTS

All patients who were admitted and operated on for intestinal obstruction in the surgical department of the above hospital between January 1992 and May 1999.

RESULTS

A total of 139 patients were studied. There were 102 males and 37 females giving a male:female ratio of 2.8:1. The age range was two days to 85 years with the majority (43.2%) of the patients being in the age group 0-10 years. Vomiting and abdominal pain were the commonest symptoms while abdominal distension and abdominal tenderness were the leading signs. Abount seventy of the patients had any form of investigation with plain abdominal x-ray being the leading investigation. Sigmoid volvulus, external herniae, adhesions and bands and ileo-colic intussusception were the commonest causes of bowel obstruction. About a third (32.4%) of the patients were found to have gangrenous gut. Sixty three complications were recorded in 47 patients, with the leading complication being death (17.3%) followed by wound infection (14.4%).

CONCLUSION

Five leading causes of intestinal obstruction in Nyeri, Kenya, are: sigmoid volvulus, external herniae, adhesions and bands, ileocolic intussusception and small bowel volvulus.

Differences between patients with schizophrenia within and without a high security psychiatric hospital

OBJECTIVE

To report and discuss differences between schizophrenic patients in the community and those in maximum security care.

METHOD

Comparison of 193 community schizophrenic patients with 169 in high security care. Data included case notes, interviews and cognitive tests.

RESULTS

Compared to high security patients, community patients tended to be female and married. They had higher school achievement, higher premorbid IQ and better occupational levels, were less likely to have a family history of alcohol abuse, to have had police contact and to have attempted suicide. They had more frequent shorter psychiatric admissions and fewer current and lifetime schizophrenic symptoms. Logistic regression models discriminated the groups with considerable accuracy.

CONCLUSION

Patients needing high security care may be recognizable when schizophrenia is first diagnosed. Progression to the State Hospital seems to result from schizophrenia together with other factors such as deprivation rather than from a worse schizophrenic process per se.

Use of electroconvulsive therapy in a state hospital: a 10-year review

BACKGROUND

The use of electroconvulsive therapy (ECT) in the state hospital setting currently represents a very small percentage of the total overall use of this modality in the treatment of the mentally ill.

METHOD

Using records kept by a state hospital, we retrospectively identified all patients who had received ECT between the years 1986 and 1995. A review of the records at the state hospital from where patients were referred and the university hospital where ECT was administered was undertaken. Demographic and clinical characteristics, reasons for referral, symptom profile, ECT parameters, clinical outcomes, and restraint/ seclusion data were assessed.

RESULTS

Over 10 years, 21 patients were treated with ECT, representing 0.4% of all admissions to the state hospital. Of these subjects, 17 records could be retrieved. The majority were women (N = 12; 71%) and were diagnosed with a mood disorder. Ten subjects (59%) were over the age of 60 years, 4 of whom were 70 years or older. Most patients had a state hospital length of stay of 1 year or less. The mean number of ECT treatments was 12.2. There were no medical complications that led to premature termination of ECT. Eleven patients (65%) were discharged either directly from the university hospital or within 10 days of readmission to the state hospital. Six of 7 patients who had restraint and seclusion episodes prior to ECT were found to have no further episodes afterwards. The seventh experienced a dramatic decrease in number and total hours of episodes.

CONCLUSION

For a substantial minority of patients in this state hospital setting, ECT appears to have been an effective and safe form of treatment, and its use should be considered early rather than late in the course of hospitalization.

The state of the state mental hospital at the turn of the century

There is a core of services whose specific content varies from place to place that still appears to belong to the state mental hospital.

[Gerontopsychiatric treatment in comparison between integrated management at a university and separated management at a district hospital. 1: Patient characteristics]

OBJECTIVE

We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany.

METHOD

We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992.

RESULTS

The LKH patients were significantly older (74.8 +/- 8.7 y versus 70.3 +/- 8.3 y), more often living alone and/or without children. 31.9% of them were living in a nursing home compared to 6.5% of the PUK patients. Psychic disorders had not shown up before old age in 55.7% of all cases. 50.4% of the patients were in a psychiatric hospital for the first time. The majority of the patients (65.6%) had not been investigated by a psychiatrist before admission.

CONCLUSIONS

More socially handicapped patients were treated in the LKH. For most cases, the hospital treatment had been the first psychiatric treatment at all.

[Gerontopsychiatric treatment in comparison between integrated management at a university and separated management at a district hospital. 2: Diagnoses and treatment]

OBJECTIVE

We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany.

METHOD

We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992.

RESULTS

Most patients of the LKH suffered from organic brain diseases/dementia (63.4%; PUK: 29.1%). In the PUK, depression was the most frequent diagnosis (57.6%; LKH: 21.1%). A part of about 25% of the patients showed neurological deficits. Specialised diagnostics were performed mostly in the PUK. Both institutions treated the wide majority of patients with CNS drugs. Antidementia drugs were given significantly more often in the LKH. About one third of the patients were released into changed living environments.

CONCLUSIONS

Patients with further progressed dementias were treated mainly in the LKH. This has consequences for diagnostics, treatment duration and side effect rate.

Using artificial neural networks and the Gutenberg-Richter power law to "rightsize" a behavioral health care system

The authors propose a new paradigm for designing and managing behavioral health care systems by using artificial neural networks to measure quality of care (Q), using length-of-stay (LOS) prediction and the variation in LOS prediction, and subsequently using the variation of Q to obtain a measure of uncertainty in treatment. The paper proposes that mental illness is fractal in nature (self-similar at all scales) and conforms to power laws like the Gutenberg-Richter (G-R) law, whereby there is a log-log relationship between frequency of episodes (i.e., admissions) and the severity of those episodes. The paper also hypothesizes that 28% is the average uncertainty (residual or excess entropy) in the treatment of mental illness. The authors use the G-R paradigm to calculate the severity of admission and, subsequently, the minimum number of beds for different behavioral health care facilities and propose the optimal partition of beds between community and state services, thereby "balancing" the delivery system. The data presented support the notion that mental illness manifests complexity and "self-organized criticality." The authors hypothesize that correcting deviations from the theoretical G-R curve for each level of care will allow optimum resource distribution, improve quality of care, and reduce costs.

[Accident and emergency department inappropriate utilization. An evaluation with explicit criteria]

BACKGROUND

Several studies have shown a growth in the number of visits to accident and emergency (A&E) hospital departments with a high proportion of inappropriate utilization. Methods to identify improper use based on implicit criteria limit the comparisons between hospitals. The aim of this study is to know the proportion of inappropriate attendance's in an A&E department and their associated factors, using a method with objective criteria.

METHODS

An instrument based on diagnosis-independent explicit criteria was used to identify inappropriate visits in a random sample of 1845 14-year-old greater patients attended to A&E medical services, and the factors associated with improper demand were analysed.

RESULTS

The proportion of inappropriate attendance's was of the 26,8% (495/1. 845). The unadjusted analysis show that the smaller age, absence of comorbidity, spontaneous visit and some diagnostic groups (diseases of the skin, muscle-skeletal, mental, and bad defined symptoms) were associated to a greater proportion of improper use. Upon adjusting the variables through logistics regression, the age, associated pathology, the spontaneous attendance's and diagnostic groups, maintained the association with improper use, but other variables as woman gender, and night hours were also associated to inappropriate utilization.

CONCLUSIONS

At least the fourth part of the attendance's in the A&E medical services do not require urgent attention. Inappropriate utilization is associated to characteristic of the patient and the attended process.

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.

Risperidone use at a state hospital: a clinical audit 2 years after the first wave of risperidone prescriptions

BACKGROUND

In spite of some inherent limitations, naturalistic data can provide information on populations that have greater heterogeneity than can controlled clinical trials and on functional outcomes that may be especially important in clinical practice. In the present retrospective naturalistic study, we evaluated key clinical outcomes among the first wave of risperidone-treated patients at a state psychiatric hospital.

METHOD

Outcome data were extracted from the charts of 142 patients 2 years after initiation of treatment with risperidone. Their diagnoses included DSM-III-R schizophrenia (57%), schizoaffective disorder (22%), dementia and other organic conditions (7%), bipolar disorder (5%), and other psychiatric disorders (9%).

RESULTS

During the 2-year period, 92 of 142 patients were discharged from the hospital: 61 (43%) were discharged on risperidone treatment and 31 (22%) were discharged on treatment with other drugs. At the time of the study, 50 of 142 patients were still in the hospital: of these, 18 (13%) were still receiving risperidone. The modal maximum daily dose of risperidone was 4.1 mg in patients discharged on risperidone treatment and 7.5 mg in patients still in the hospital. All groups were granted more ward privileges after starting risperidone, the most being granted to patients discharged from the hospital on risperidone treatment (p<.05 versus patients discharged on treatment with other drugs) and those still receiving risperidone in the hospital. Significantly fewer patients discharged on risperidone treatment than on treatment with other drugs were readmitted to the hospital within 2 years after discharge (p<.01).

CONCLUSION

Improved privilege levels and a reduced readmission rate indicate that risperidone was an effective antipsychotic agent among a heterogeneous patient population in a state hospital. These factors may be especially important to justify use of this agent in the current fiscal climate.

Rehospitalization rates of patients recently discharged on a regimen of risperidone or clozapine

OBJECTIVE

The purpose of this study was to examine rehospitalization rates of people receiving risperidone or clozapine who had been discharged from state psychiatric hospitals in Maryland.

METHOD

Rehospitalization status was monitored for all patients discharged from state psychiatric facilities on a regimen of either risperidone or clozapine between March 14, 1994, and Dec. 31, 1995. Patients were followed up with respect to readmission until Dec. 31, 1996. Time to readmission was measured by the product-limit (Kaplan-Meier) formula. Risk factors associated with rehospitalization were examined.

RESULTS

One hundred sixty patients were discharged on risperidone, 75 having the diagnosis of schizophrenia. The patients with schizophrenia were more likely to be readmitted than the 85 patients with other mental disorders. Recidivism rates for schizophrenic patients discharged on risperidone versus those discharged on clozapine were not significantly different over the 24-month study period. However, no patient who received clozapine and remained discharged for more than 10 months (N = 49) was readmitted, while the readmission rate for risperidone-treated patients appeared to be steady up to 24 months. At 24 months 87% of the clozapine-treated patients and 66% of the risperidone-treated patients remained in the community. No clinical or demographic variables were found to predict rehospitalization.

CONCLUSIONS

This study demonstrates that the rehospitalization rates of patients taking the second-generation antipsychotics risperidone and clozapine are lower than those in previously published reports of conventional antipsychotic treatment.

[Drug-dependent offenders committed for disciplinary action. Results of a cross-sectional survey]

In comparison to the middle of the 80th, the group of patients who are addicted to legal and illegal drugs and are treated in special forensic hospitals, has significantly changed. Polyvalent dependence is the predominant diagnosis. There has been an increase in violence of index delinquency. In the middle of the 80th, most of the patients were committed because of criminal offences against the BtMG (German law to sentence drug abusers). Today, robbery turns out to be the "classical" index delinquency. The problem of defining "false admission" to a forensic hospital has to be considered in a multidimensional way.

[The incidence and structure of congenital anomalies at the Maternity Home State University Hospital, Sofia in the period of 1992-1996]

This is a retrospective study on the dynamics of inborn malformations in University Hospital of Obstetrics and Gynaecology 'Maĭchin Dom', Sofia for a five-years-long period of time (1992-1996). The results show that the rate of inborn anomalies in the discussed period of time remains approximately the same, while there is an increase of the relative part of heavy and life-threatening malformations. They cause death of nearly half of term infants who die in the neonatal period. These facts lead to the conclusion that to decrease perinatal and neonatal mortality, early and exact prenatal diagnosis of inborn malformations is absolutely necessary.

The structure of economic incentives in the Robert Wood Johnson/HUD Program on Chronic Mental Illness 1988

This paper describes the financial arrangements put into place by cities participating in the Robert Wood Johnson Foundation's Program on Chronic Mental Illness. Descriptive information is given on the level of expenditure, the mix of revenues, and the terms under which local, federal, and Medicaid dollars are allocated to local programs. Data are presented on the use of state hospitals and the number of severely mentally ill individuals in treatment. These data are used to make observations on the initial stages of the demonstration.

The failure of the diversion process: the impact of transferring of patients to state hospitals

The diversion of people with severe mental illness into the private sector is examined. The purpose of the diversion system is to reduce the number of admissions to the state hospitals by diverting patients into the private hospitals, which may offer more diverse treatment to these patients. Insurance is highlighted as an important factor in diverting patients from state hospitals. When the diversion system fails and the patient is transferred from the private sector to the state hospitals, continuity of care is disrupted. The failure of the diversion is more costly not only to the patient but to the federal and state governments as well. Policy issues such as cost to the mental health system and continuity of care are discussed.

Uses of an empirically derived client typology based on level of functioning: twelve years of the CCAR

The Colorado Client Assessment Record (CCAR) is a problem checklist and level of functioning rating instrument used to describe admission to a public mental health system. A brief, non-technical summary of recent research and administrative applications involving this instrument is presented. A stable factor structure, generalizable to several diverse client populations, is reported. Scaling procedures for measuring these procedures and a client typology based on this scaling are described. The client typology is differentially related to the types of services received and the costs of treatment episodes. The typology is also used to understand differences in case mixes and lengths of stay at two state hospitals.

The relationship between supply and hospitalization rates for mental illness and substance use disorders

This study investigated the extent to which mental illness and substance use hospitalization rates were related to the supply of psychiatric treatment services. Supply variables, notably the per capita rate of psychiatrists, primary care physicians, and specialty units, were strongly related to mental illness and substance use hospitalization rates to acute care hospitals across 114 small geographic areas in Iowa. The supply of outpatient services was not related to hospitalization rates. The need to study the reliability of patient assessment processes, refine guidelines and admissions criteria, and understand the contributions of supply variables to hospitalization rates are indicated by these results. A conceptual model is offered within which the dynamic cycle from patient functioning to service delivery may be framed.

An analysis of financial incentives in the performance contract of Montana

In an effort to contain costs and provide appropriate services, a growing number of states are experimenting with the terms of their fiscal transfers to localities. This paper contains an analysis of the economic incentives present in one such effort, the performance contract of the state of Montana. This contract contains incentives which do not fully support the attainment of a number of possible social goals, but these incentives could be strengthened by some simple amendments to the existing structure.