Social support and outcome of alcoholism treatment: an exploratory analysis

Social support is becoming recognized as a positive influence on health and health maintenance. Forms of support which bolster the patient's sense of personal efficacy should enhance the alcoholic's ability to cope with a specific stressor (i.e., overcoming his or her addiction). Patients reporting higher levels of social support during alcoholism treatment, especially support that enhances his or her self-esteem, should therefore demonstrate improved outcome compared to patients with lower levels. Sixty-one consecutive admissions to an inpatient alcoholism treatment program at a rural midwestern medical center completed an assessment of six forms of social support (Guidance, Reliable Alliance, Reassurance of Worth, Opportunity for Nurturance, Attachment, and Social Integration) in terms of support obtained from family and friends and from the treatment environment. For each patient, additional information concerning age, marital status, financial support, and previous alcohol-related hospitalizations was also obtained. Outcome of treatment was measured by readmission for an alcohol-related diagnosis within 1 year of discharge. Survival analysis found that reassurance of worth from family and friends and number of previous hospitalizations were independent and significant predictors of time to readmission. Higher levels of reassurance of worth or esteem support significantly lengthened time to readmission, with the reverse relationship found for number of previous hospitalizations. These results suggest that specific sources (family and friends) and forms (reassurance of worth) of social support are important to the recovering alcoholic and that the effect of social support on treatment outcome is independent of the alcoholic's history of prior treatment failure. Interventions or program modifications should be designed specifically to bolster these facets of social support rather than addressing more general forms of support.

Activated CD-8 cells and HLA DR expression in alcoholics without overt liver disease

Lymphocytes from alcoholics without liver disease were immunophenotyped by flow cytometry immediately after admission for detoxication and again after 4 to 10 days of abstinence. We found a small but significant elevation of T lymphocytes at admission compared to controls and decreases in the numbers of B cells and natural killer cells in many patients. A significant elevation of activated T cells was confirmed. The ratio of activated T cells to activated non-T cells was also substantially increased, but declined slightly during early withdrawal. The increase in activated T cells was due mostly to increased numbers of activated CD8hi cells. These activation changes did not revert toward normal as quickly as the other changes and may represent an indication of immune damage at a preclinical stage. An additional finding of interest was a substantial decrease in the expression of HLA DR on CD4+ and non-T cells. The significance of this decrease is not known, but we speculate that it may result in a decline in the efficiency of antigen presentation.

Compliance with medical practice guidelines: the case of home oxygen

Standard and straight forward practice guidelines for administration of home oxygen therapy have been long established and widely accepted. Medical records for 418 patients prescribed home oxygen through hospital-based programs at seven Veterans Administration medical centers (VAMCs) were reviewed to determine compliance with practice guidelines at the time of initial and current prescriptions. Rates of appropriate prescription at some VAMCs were very high but were too low at other VAMCs, especially given the criteria's simplicity and clarity. Practice guidelines should be implemented in conjunction with regular review mechanisms or other controls in place to ensure compliance.

Patient factors predicting early alcohol-related readmissions for alcoholics: role of alcoholism severity and psychiatric co-morbidity

The current study was undertaken primarily to identify whether psychiatric co-morbidity was associated with the rate and time of alcohol-related inpatient readmissions for a group of 255 patients discharged from alcoholism treatment at a midwestern rural medical center. A structured interview obtained information regarding psychiatric disorders, including depression, antisocial personality disorders and polysubstance abuse, as well as alcohol history and sociodemographics. Ninety-eight subjects (38.4% of sample) were readmitted for alcoholism-related diagnoses within 15 months of discharge. Patients with a long history of heavy drinking, high daily alcohol consumption and history of previous alcoholism treatment were most likely to be readmitted with an alcoholism-related primary diagnosis. Once these variables were controlled for, other major psychiatric disorders, polysubstances abuse and sociodemographic variables did not appear to predict time to readmission. However, other potentially more sensitive outcome measures such as return to drinking were not evaluated in the present study.

Prolonged maternal fluid supplementation in breast-feeding

A randomized, crossover study design was used to evaluate the effect of prolonged maternal fluid supplementation on the milk supply of breast-feeding women. A total of 19 well-nourished women whose infants were solely breast-fed and thriving were enrolled when their infants were 90 to 120 days of age. Of this group, 15 women consumed at least a 25% increase in fluids above baseline for 7 days. Mean daily milk production was 767 +/- 178 mL for the baseline period and 744 +/- 138 mL for the increased fluid period. There was no significant change in milk production between baseline and increased fluid periods. No significant linear relationship between the percentage increase in fluid intake and percentage change in milk production was found.

Appropriateness of admissions and discharges among readmitted patients

This study examined the relationships between appropriateness of readmission within two weeks of discharge and appropriateness of previous admission and discharge, bed section, type of readmission, and patient demographic, medical condition, and hospital stay characteristics. Using the Department of Veterans Affairs (VA) Patient Treatment File and medical records, 445 readmissions to a highly affiliated midwestern VA Medical Center in fiscal year 1984 were examined. Appropriateness was determined by four trained medical record abstractors using InterQual admission and discharge standards. Type of readmission was based on a pilot-tested flowchart. Appropriateness of readmission was significantly associated with that of the previous admission and discharge, with the relationship varying by admission, discharge, and readmission bed sections. Reasons for inappropriate admissions, discharges, and readmissions also varied by bed section. For the majority of inappropriate readmissions, there was clear written evidence in the medical record during the previous hospital stay that the patient was directed to return for readmission. Inappropriate readmissions were more likely than appropriate readmissions to have a primary diagnosis of neoplasm or digestive disorder. These results indicate the importance of examining both the operational efficiencies during the previous admission and the clinical criteria for admitting, discharging, and readmitting patients in assessing the appropriateness of readmissions.

Longitudinal characteristics of hospital use before and after alcoholism treatment

The frequency of inpatient hospital care for three years before and three years after alcoholism treatment was evaluated for a group of 255 patients of predominantly lower socioeconomic status treated for alcoholism at a rural midwestern medical center in 1983. Subjects were interviewed while in treatment to obtain information regarding alcoholism history and demographics. Hospital care was ascertained from an electronic data file of discharges from 172 acute care hospitals throughout the United States and Puerto Rico. One-third of the sample was never hospitalized for an alcohol-related condition in the years prior to or after alcoholism treatment, and 23% of the sample experienced no hospitalizations at all other than the treatment episode when interviewed. The majority of hospital stays before and after treatment were attributed to alcohol abuse. The frequency and total hospital length of stay for alcohol-related admissions increased yearly before treatment, peaked in the year after treatment, and then declined, but not to earliest pretreatment levels. Subjects experienced significantly more hospitalizations and length of stay after alcoholism treatment than before when comparing both the two three-year periods and the immediate 12 months before and after treatment. More frequent hospital care was also significantly associated with higher levels of daily alcohol consumption and drinking duration but not with sociodemographic indicators.

Documentation and appropriateness of prescribing for Veterans Administration ambulatory-care patients

Information about active prescriptions in pharmacy medication profiles of outpatients at a Veterans Administration (VA) medical center was compared with corresponding information in the medical records to determine the completeness of prescription documentation. Appropriateness of prescribing was assessed by comparison with explicit criteria. Information about the active prescriptions included in 300 randomly selected patient medication profiles was collected from August to October 1984. The completeness of prescription information documentation was determined by comparing the data obtained from the patient's medication profile with the corresponding medical record entry. Medication profiles were screened for three types of potentially inappropriate prescribing: inappropriate daily dosage, inappropriate duplication of therapy, and interacting drug combinations. A total of 287 patient medication profiles and medical records were studied. Only 60 medical records (20.9%) had accurate documentation of all drug names, drug strengths, and directions for use when compared with the medication profiles. Evidence of potentially inappropriate prescribing was present in medication profiles of 43.4% of the patients. Medical record documentation was insufficient for a provider to detect 50.0% of the dosage deviations, 33.3% of the duplications of therapy, and 26.1% of the drug-drug interactions. The probability that evidence of potentially inappropriate prescribing would be present in a medication profile increased as the number of drugs per patient increased. However, there was no significant positive association between insufficient medical-record documentation and the presence of any of the three indicators of potentially inappropriate prescribing in the medication profile.(ABSTRACT TRUNCATED AT 250 WORDS)

Water intakes of lactating women

Women are commonly advised to increase their water intake during lactation, even though empirical data describing fluid intakes of successfully lactating women is lacking. Water intake from solid food and beverage was determined from 135 food records completed by 26 lactating women who had fully breast-fed their infants for 3 to 4 mo. Inter-subject variability in total water intake, food water, and beverage was significantly greater (one-way analysis of variance, p less than 0.01) than intra-subject variability. Total water consumption/subject (mean +/- SEM) was 2860 +/- 108 g/day, with 640 +/- 48 g/day from food and 2220 +/- 110 g/day from beverage. One-third of the subjects consumed less than the 1 g of water/kcal of energy need described in the current Recommended Dietary Allowances. Thus, it appears that while many successfully lactating women consume large quantities of water, many do not consume enough to satisfy theoretical recommendations. Results indicate that estimation of water intake must include water available in food as well as in beverage.

The long-term outcome of nonsuppurative otitis media with effusion

Seventy-four children were enrolled in a double-blind placebo-controlled study to define the outcome of nonsuppurative otitis media with effusion (OME) over a 12-week period. Participants were randomly assigned to one of three treatment groups: pseudoephedrine (4 mg/kg/day), chlorpheniramine (0.35 mg/kg/day), or placebo. The children were reexamined at 2, 4, 8, and 12 weeks after enrollment unless earlier dismissed from the study because OME resolved or acute suppurative otitis media developed. Of the 66 children completing the study protocol, 44 percent had resolved OME, 38 percent developed acute suppurative otitis media, 14 percent had unresolved OME, and 4 percent developed severe hearing loss or medication side effects by the end of 12 weeks. The greatest incidence of both suppurative otitis media and resolution of OME occurred by 2 weeks of follow-up. There was no significant difference in resolution of effusion between treatment groups. Children who were 18 months of age or older with unilateral effusion had the best likelihood of resolution.

Effect of supplemental fluids on human milk production

The effect of supplemental fluid intake on milk production was evaluated in a randomized, crossover design study of breast-feeding mothers. Twenty-six women whose infants were growing well with breast-feeding alone were enrolled in the study when their infants were 90 to 120 days of age. Twenty-one women consumed at least a 25% increase in fluids (mean 59%, range 26% to 140%). Mean daily milk production was 814 +/- 163 ml/day in the baseline period and 797 +/- 157 ml/day during increased fluid intake. There was no significant change in milk production between study periods and no significant relationship between percent increase in fluid intake and change in milk production nor between volume of fluid intake and volume of milk produced.

Investigation of a model for the initiation of breastfeeding in primigravida women

Primigravida women are faced with the decision about how they will feed their infants. Many will decide to breastfeed but the motivation for this choice is unclear. While certain beliefs and worries about breastfeeding appear to predict women who will choose to breastfeed, such concepts are influenced by a combination of other values, support resources and socioeconomic background. The main goal of this research was to demonstrate how multivariate analysis can be applied to the infant-feeding decision and how it can lend a theoretical interpretation to social issues such as the initiation of breastfeeding. One hundred completely breastfeeding and 57 bottle feeding primigravida women were enrolled in the study and completed a pretested Likert-type questionnaire. Three primary predictors for the initiation of breastfeeding were identified: positive maternal beliefs about breastfeeding; the absence of maternal worries about breastfeeding; and higher levels of maternal education. Secondary psychosocial predictors significantly associated with maternal breastfeeding beliefs included maternal beliefs in increased personal satisfaction from breastfeeding and maternal beliefs in preventive health measures. Secondary psychosocial predictors significantly related to maternal worries about breastfeeding before breastfeeding began. Over half of the strength of the direct psychosocial predictors for breastfeeding initiation could be attributed to their respective groups of indirect predictors. Thus, the main contribution of this research has been to shift the emphasis of past research away from differences between groups of bottle feeders and breastfeeders to focus more precisely on the decision-making process involved in the infant feeding choice.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing initiation of breast-feeding

We used the critical incidence method to study factors motivating 33 primigravidas and 39 multigravidas to initiate breast-feeding of their infants. Women chose breast-feeding because they believed that it would provide protection to the infant against infection, establish maternal-infant bonding, was convenient, provided better nutrition than cow's milk formula, was emotionally satisfying, and was the natural way to feed infants. The decision to breast-feed was made well in advance of pregnancy by primigravidas and shortly before pregnancy by multigravidas. Friends who had successfully nursed infants were as influential as immediate family members in influencing our study subjects in their decision to breast-feed. Prenatal counseling, though important, may not be the optimal period for motivating women to breast-feed.