0977 Risk Factors For Developing Sleep Disorders In Children

Introduction

Unidentified sleep disorders can affect emotional, cognitive and social development in children. Screening for sleep disorders within the pediatric population is not common practice during medical visits. The objective of this study is to identify specific questions related to behavioral and physiological factors having potential to screen and detect those at risk for sleep disorders in a general pediatric clinic.

Methods

A retrospective archive from electronic medical records was analyzed from 1,361 children patients, 0-18 years old, that visited a pediatric clinic from March-November of 2019. Children or their parents reported on the presence of eight objective behavioral and physiological factors on the Kids Sleep Screener Questionnaire (KSSQ), which were used as potential risk factors for sleep disorders. Propensity of daytime sleepiness was measured through the Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD). Scores higher than 11 were considered a positive indicator of potential sleep disorders because of excessive daytime sleepiness. Positive scores from the ESS-CHAD were used for comparison with the KSSQ factors using chi-square test of SAS software.

Results

Among the eight factors, snoring was the strongest risk factor and increased sleep duration was the weakest risk factor associated with a positive ESS-CHAD. Relationships among risk factors and the increased likelihood for developing sleep disorders were statistically significant (p<0.05-p<0.0001) and identified as following: snoring by 2.46 times, restless sleeper by 2.03 times, behavioral or learning difficulties by 1.43 times, nocturnal awakenings by 1.16 times, excessive sleepiness during the day by 1.10 times. Sleep onset latency and increased sleep duration were weak indicators due to a likeliness of less than one time (p<0.05) to be associated with a positive ESS-CHAD. Abnormal sleep behavior was not a statistically significant risk factor (p≥0.05) for potential sleep disorders in children.

Conclusion

There were associations between seven behavioral and physiological risk factors with overall sleep propensity in children. These results exhibit that the KSSQ is an important tool to identify potential sleep disorders in children and the need for follow up with a sleep specialist. The KSSQ is under validation for becoming a standard sleep screener in pediatrics.

Support

N/A

IDO, COX and iNOS have an important role in the proliferation of Neospora caninum in neuron/glia co-cultures

Central nervous system (CNS) is the main site for encystment of Neospora caninum in different animal species. In this tissue, glial cells (astrocytes and microglia) modulate responses to aggression in order to preserve homeostasis and neuronal function. Previous data showed that when primary cultures of glial cells are infected with N. caninum, they develop gliosis and the immune response is characterized by the release of TNF and IL-10, followed by the control of parasite proliferation. In order to elucidate this control, three enzymatic systems involved in parasite-versus-host interactions were observed on a model of neuron/glia co/cultures obtained from rat brains. Indoleamine 2,3-dioxygenase (IDO), induced nitric oxide synthase (iNOS) responsible for the catabolism of tryptophan and arginine, respectively, and cycloxigenase (COX) were studied comparing their modulation by respective inhibitors with the number of tachyzoites or the immune response measured by the release of IL-10 and TNF. Cells were treated with the inhibitors of iNOS (1.5 mM L-NAME), IDO (1 mM 1-methyl tryptophan), COX-1 (1 μM indomethacin) and COX-2 (1 μM nimesulide) before infection with tachyzoites of N. caninum (1:1 cell: parasite). After 72 h of infection, immunocytochemistry showed astrogliosis and a significant increase in the number and length of neurites, compared with uninfected co-cultures, while an increase of IL-10 and TNF was verified. N. caninum did not change iNOS activity, but the inhibition of the basal levels of this enzyme stimulated parasite proliferation. Additionally, a significant increase of about 40% was verified in the IDO activity, whose inhibition caused 1.2-fold increase in parasitic growth. For COX-2 activity, infection of cultures stimulated a significant increase in release of PGE₂ and its inhibition by nimesulide allowed the parasitic growth. These data indicate that iNOS, IDO and COX-2 control the proliferation of N. caninum in this in vitro model. On the other hand, the release of IL-10 by glia besides modulating the inflammation also allow the continuity of parasitism.

Do Distinct Biomes Influence the Cuticular Chemical Profile in Orchid Bees?

Cuticular chemical profiles of Euglossa cordata L. males were analyzed to test whether ecological predictors affect their composition and relative proportion. Males were collected in areas of Caatinga and Atlantic Forest from Brazil during two distinct seasonal periods. We found 48 compounds from the cuticular extracts of males, which consisted of hydrocarbons (71.39%), acetates (16.79%), esters (10.5%), alcohols and others (1.31%). We verified that when specimens were separated between biomes, they did not show a qualitative differentiation, but a small quantitative variation of compounds was found between some alkanes. We suggest that these results reflect stability of epicuticular compounds even under variable environmental conditions.

Nitrogen metabolism in lactating goats fed with diets containing different protein sources

This study aimed to evaluate urea excretion, nitrogen balance and microbial protein synthesis in lactating goats fed with diets containing different protein sources in the concentrate (soybean meal, cottonseed meal, aerial part of cassava hay and leucaena hay). Four Alpine goats whose mean body weight was 42.6±6.1 kg at the beginning of the experiment, a mean lactation period of 94.0±9.0 days and a production of 1.7±0.4 kg of milk were distributed in a 4×4 Latin square with four periods of 15 days. Diets were formulated to be isonitrogenous, containing 103.0 g/kg of CP, 400 g/kg of Tifton 85 hay and 600 g/kg of concentrate. Diet containing cottonseed meal provided (p<0.05) increased excretion of urea and urea nitrogen in the urine (g/d and mg/kg of BW) when compared with leucaena hay. The diets affected the concentrations of urea nitrogen in plasma (p<0.05) and excretion of urea nitrogen in milk, being that soybean meal and cottonseed meal showed (p<0.05) higher than the average aerial part of the cassava hay. The use of diets with cottonseed meal as protein source in the concentrate in feeding of lactating goats provides greater nitrogen excretion in urine and negative nitrogen balance, while the concentrate with leucaena hay as a source of protein, provides greater ruminal microbial protein synthesis.

Persistent infection with neurotropic herpes viruses and cognitive impairment

BACKGROUND

Herpes virus infections can cause cognitive impairment during and after acute encephalitis. Although chronic, latent/persistent infection is considered to be relatively benign, some studies have documented cognitive impairment in exposed persons that is untraceable to encephalitis. These studies were conducted among schizophrenia (SZ) patients or older community dwellers, among whom it is difficult to control for the effects of co-morbid illness and medications. To determine whether the associations can be generalized to other groups, we examined a large sample of younger control individuals, SZ patients and their non-psychotic relatives (n=1852). Method Using multivariate models, cognitive performance was evaluated in relation to exposures to herpes simplex virus type 1 (HSV-1), herpes simplex virus type 2 (HSV-2) and cytomegalovirus (CMV), controlling for familial and diagnostic status and sociodemographic variables, including occupation and educational status. Composite cognitive measures were derived from nine cognitive domains using principal components of heritability (PCH). Exposure was indexed by antibodies to viral antigens.

RESULTS

PCH1, the most heritable component of cognitive performance, declines with exposure to CMV or HSV-1 regardless of case/relative/control group status (p = 1.09 × 10-5 and 0.01 respectively), with stronger association with exposure to multiple herpes viruses (β = -0.25, p = 7.28 × 10-10). There were no significant interactions between exposure and group status.

CONCLUSIONS

Latent/persistent herpes virus infections can be associated with cognitive impairments regardless of other health status.

Effects of IFN-γ, TNF-α, IL-10 and TGF-β on Neospora caninum infection in rat glial cells

Neospora caninum causes abortion in cattle and neurological disorders in dogs. The immunological response to this parasite has been described as predominantly of the Th1 type. However, infected primary glial cell cultures release IL-10 and IL-6 but not IFN-γ. This suggests a rather protective response of the glia to avoid inflammatory damage of the nervous tissue. In this study, we investigated the effects of pro-inflammatory cytokines in primary mixed cultures of rat astrocytes and microglia infected with N. caninum. The cells were treated with either IFN-γ, TNF-α, anti-IL-10 or anti-TGF-β antibodies and were infected with parasite tachyzoites 24h later. Trypan Blue exclusion and MTT assays were performed to test cell viability. It was observed that cytokines, antibody treatment and in vitro infection did not reveal significant cell death in the various culture conditions. Treatment with 50, 150 and 300 IU/mL of either IFN-γ or TNF-α reduced tachyzoites numbers in cultures by 36.7%, 54.8% and 63.8% for IFN-γ and by 27.6%, 38.4% and 29.7% for TNF-α, respectively. In the absence of IL-10 and TGF-β, tachyzoite numbers were reduced by 52.8% and 41.5%, respectively. While IFN-γ (150 and 300 IU/mL) increased the nitrite levels in uninfected cells, parasite infection seemed to reduce the nitrite levels, and this reduction was more expressive in IFN-γ-infected cells, thereby suggesting an inhibitory effect on its production. However, TNF-α, IL-10 and TGF-β did not affect the nitrite levels. Basal PGE(2) levels also increased by 17% and 25%; 78% and 13% in uninfected and infected cells treated with IFN-γ or anti-TGF-β, respectively. Nevertheless, the antibody neutralization of IL-10 reduced PGE(2) release significantly. These results highlight the possibility of a combined effect between the IFN-γ and parasite evasion strategies and show that the IFN-γ, TNF-α, IL-10 and TGF-β cytokines participate in parasite proliferation control mechanisms.

Heritability of functioning in families with schizophrenia in relation to neurocognition

The role of daily functioning is an integral part of the schizophrenia (SZ) phenotype and deficits in this trait appear to be present in both affected persons and some unaffected relatives; hence we have examined its heritability in our cohort of African American schizophrenia families. There is now ample evidence that deficits in cognitive function can impact family members who are not themselves diagnosed with SZ; there is some, but less evidence that role function behaves likewise. We evaluate whether role function tends to "run in families" who were ascertained because they contain an African American proband diagnosed with SZ.

METHODS

We analyzed heritability for selected traits related to daily function, employment, living situation, marital status, and Global Assessment Scale (GAS) score; modeling age, gender, along with neurocognition and diagnosis as covariates in a family based African-American sample (N=2488 individuals including 979 probands).

RESULTS

Measures of role function were heritable in models including neurocognitive domains and factor analytically derived neurocognitive summary scores and demographics as covariates; the most heritable estimate was obtained from the current GAS scores (h2=0.72). Neurocognition was not a significant contributor to heritability of role function.

CONCLUSIONS

Commonly assessed demographic and clinical indicators of functioning are heritable with a global rating of functioning being the most heritable. Measures of neurocognition had little impact on heritability of functioning overall. The family covariance for functioning, reflected in its heritability, supports the concept that interventions at the family level, such as evidenced-based family psychoeducation may be beneficial in schizophrenia.

Expression of secretory leukocyte proteinase inhibitor in the submandibular glands of AIDS patients

OBJECTIVE

Secretory leukocyte proteinase inhibitor (SLPI) is an endogenous proteinase inhibitor present in mucosal secretions. It also displays antimicrobial activity including anti-human immunodeficiency virus activity. This protease inhibitor is also expressed in submandibular glands (SMG), but there are few data on its expression in AIDS patients with infectious conditions.

METHODS

We analyzed the expression of SLPI using immunohistochemistry in submandibular gland samples of 36 AIDS patients [10 with normal histology, 10 with chronic nonspecific sialadenitis, eight with mycobacteriosis, and eight with cytomegalovirus (CMV) infection] and 10 HIV-negative controls. The proteinase inhibitor was quantified using image analysis and expressed as % of positively stained area.

RESULTS

There was a higher expression of SLPI in AIDS patients with CMV infection (% of stained area, mean+/-SD: 37.37+/-14.45) when compared with all other groups (P=0.009). There were no significant differences between control subjects (22.70+/-9.42%) and AIDS patients without histologic alterations (18.10+/-7.58%), with chronic nonspecific sialadenitis (17.13+/-5.36%), or mycobacterial infection (21.09+/-4.66%).

CONCLUSION

Cytomegalovirus infection increases SLPI expression in the SMG of AIDS patients. Our results reveal new insights into the pathogenic association between HIV and CMV in AIDS patients.

Nucleus image properties and cell death in MCF-10F cells grown on slide substrates differing in nature and size

The immortalized human breast epithelial cell line MCF-10F is an important tool for studies on experimental tumorigenesis induced by drugs, transfected Ha-ras oncogene, and hormones. Considering that many relevant data have thus far been established only for MCF-10F cells cultivated on glass, and that there are data showing different cell death ratios for tumorigenic cells obtained from benzo[a]pyrene (BP)-transformed MCF-10F cells cultivated on plastic compared with glass, nuclear parameters estimated by image analysis and cell death ratios were compared for cells grown on plastic and glass substrates differing in chamber surface sizes and working culture medium volumes. It was concluded that for slides with a growth size equal to 9.4 cm2, plastic substrate was more advantageous than glass for growing MCF-10F cells because although the apoptotic ratios (AR) for the cells grown on plastic are low as it would be expected for nontransformed cells, they are bigger than those reported for the BP-transformed MCF-10F cells cultivated on the same substrate but closer to those of the BP-transformed MCF-10F cells receiving a normal chromosome 17. In addition, the plastic substrate did not induce variable nuclear image results as those found in the latter. The 0.5-cm2-sized chambers on plastic slides proved to be inadequate for cell nuclear image analysis and cell death studies on account of the variable geometric, densitometric, and textural results and ARs produced and the unpublished consideration of a very slow growth rate generated under this growth condition.

Study of dental enamel and synthetic hydroxyapatite irradiated by EPR at K-band

In this preliminary work the EPR spectra of a small dental enamel block and a synthetic B-type hydroxyapatite in powder form, both irradiated with gamma rays, were analyzed in K-band. The spectra of the dental enamel block allow the analysis of independent components with different angular orientations, while the study of the dosimetric properties of the synthetic hydroxyapatites showed good performance of this spectrometer. K-band spectra show better resolution when compared to X-band, while using significantly less sample material.

Study of the microencapsulation of camu-camu (Myrciaria dubia) juice

The camu-camu, like many other Amazonian fruits, shows an excellent potential for use due to its high vitamin C content, and the use of these natural resources could result in greater development of the Amazonian region. Few studies have been conducted with this fruit, and such studies are necessary in order to develop the required technology to allow for its utilization, thus avoiding or at least decreasing wastage of such a rich raw material. The principle objective of this study was to develop a process for the microencapsulation of camu-camu juice, optimizing the operational conditions. The processing conditions consisted of blanching at a temperature of 95 +/- 2 degrees C for 2 min, followed by cooling in an ice bath and juice extraction using a brush type depulper. The juice was dried with gum arabic or malt dextrin in a mini-spray dryer using an air entry temperature of between 100-160 degrees C and wall material concentration varying between 5-35%, in accordance with a factorial experimental design. Both the air entry temperature and the amount of wall material, plus the interaction between the two, gave significant positive effects at the level of 5% probability on the yield of juice powder. The optimum conditions for juice yield and vitamin C retention were established as 15% wall material and an air entry temperature of 150 degrees C.

Pathogenesis of hepatic septal fibrosis associated with Capillaria hepatica infection of rats

Septal fibrosis is a common form of hepatic fibrosis, but its etiology and pathogenesis are poorly understood. Rats infected with the helminth Capillaria hepatica constitute a good experimental model of such fibrosis. To investigate the pathogenetic contribution of the several parasitic factors involved, the following procedures were performed in rats: a) regarding the role of eggs, these were isolated and injected either into the peritoneal cavity or directly into the liver parenchyma; b) for worms alone, 15-day-old infection was treated with mebendazole, killing the parasites before oviposition started; c) for both eggs and worms, rats at the 30th day of infection were treated with either mebendazole or ivermectin. Eggs only originated focal fibrosis from cicatricial granulomas, but no septal fibrosis. Worms alone induced a mild degree of perifocal septal fibrosis. Systematized septal fibrosis of the liver, similar to that observed in the infected controls, occurred only in the rats treated with mebendazole or ivermectin, with dead worms and immature eggs in their livers. Thus, future search for fibrogenic factors associated with C. hepatica infection in rats should consider lesions with both eggs and worms.

Absenteeism and productivity among mental health employees

We examined archival data to test the hypothesis that absenteeism is inversely related to work productivity among mental health employees at a Veterans Affairs Medical Center outpatient clinic. Results provided partial support for this hypothesis in that there was an inverse correlation between one measure of productivity and the percentage of sick and family care leave taken on Mondays and Fridays (r=.54). No significant relationship between work productivity and total sick and/or family care leave was found, although there was a trend in that direction (r=.34). These data suggest that mental health clinicians who use high levels of sick and/or family care leave are not necessarily unproductive workers. However, high percentages of absenteeism on Mondays and Fridays may represent a red flag for identifying under-performing clinicians. Examination of absenteeism patterns may prove useful for administrators. Management policy strategies to reduce absenteeism are suggested.

Report of three cases of circulating heparin-like anticoagulants

Clinically significant endogenous circulating heparin-like anticoagulant activity has been associated with hematological malignancies, liver damage, and other pathological conditions. The source of high plasma concentrations of endogenous heparin-like anticoagulants is poorly understood. We report three cases of circulating heparin-like anticoagulants in three patients with hematological malignancies: CLL, multiple myeloma, and T-prolymphocytic leukemia. The severity of bleeding in our patients ranged from severe epistaxis and deep-site hematoma to bleeding of biopsy site and occasional ecchymosis.

Panic disorder in primary care: patients' attributions of illness causes and willingness to accept psychiatric treatment

OBJECTIVE

This study assessed the causes that primary care patients with panic disorder (PD) attribute to their panic symptoms, and their acceptance of various psychiatric treatment options.

METHODS

In a cross-sectional assessment of 306 patients treated at two primary care clinics, 42 met criteria for DSM-IV PD in the past year. The authors classified these 42 PD-positive patients to one of two groups: those receiving both primary and specialty mental health care (PC+MH; n = 19) and those receiving only primary care (PC-only; n = 23). Patients rated the probability of four possible causes of their panic symptoms, and level of acceptability of three psychiatric and two medical treatments for PD. To place primary care patients' ratings into a broader context, a third contrast group of PD-positive patients, recruited from clinical trials of investigational PD pharmacotherapies (n = 31), also rated causes and treatment acceptability.

RESULTS

Participants of the three treatment groups attributed psychiatric causes for their panic symptoms in approximately the same proportion (78 percent to 90 percent; p = ns). PC-only participants attributed medical causes for panic symptoms more frequently than PC+MH and PD Clinical Trials participants (48 percent vs. 5 percent and 32 percent; p = .01). Remarkably, the great majority of patients across all groups expressed willingness to see psychiatrists (84 percent to 94 percent) and psychotherapists (95 percent to 100 percent), and to take psychotropic medications (87 percent to 100 percent).

CONCLUSIONS

In this study most patients attributed a psychiatric cause for panic symptoms and communicated strong acceptance of psychiatric treatment. Thus, we recommend that primary care clinicians more assertively inform their patients of PD diagnoses and recommend psychiatric treatments with less fear about stigmatizing and alienating them.

Cockroach allergens and asthma

Asthma and allergy are the most common diseases associated with cockroach infestation of houses in the United States and other parts of the world. Sensitization and exposure to cockroach allergens is associated with increased asthma morbidity in the United States, especially among lower socioeconomic groups, including African American and Hispanic populations. Exposure to cockroach allergens in the first 3 months of life has been associated with repeated wheezing and asthma. The principal domestic cockroach species are Blattella germanica and Periplaneta americana. Both species produce several potent allergens, including Bla g 2 (inactive aspartic proteinase), Bla g 4 (calycin), Bla g 5 (glutathione-S-transferase), the group 1 cross-reactive allergens Bla g 1 and Per a 1, and tropomyosin. Structural homology between tropomyosins from cockroaches, mites, and shrimp may explain clinical cases of the oral allergy syndrome. The 3-dimensional structures of several cockroach allergens are known, and biologically active recombinant allergens have been produced in high-level expression vectors. The use of recombinant cockroach allergens should allow mechanisms of cockroach-induced asthma to be investigated and may lead to the development of new approaches to asthma treatment. Environmental allergen measurements of Bla g 1 and Bla g 2 have allowed exposure levels that cause allergic sensitization to be established. Abatement studies have shown that a sustained decrease in cockroach allergen levels is difficult but can be accomplished by professional application of insecticides, together with rigorous household cleaning. Cockroach asthma is an important public health problem that affects patients who are the least likely to be compliant with treatment with asthma medications or environmental control. Patient education, improvements in the housing stock, and improvements in environmental and immunologic treatment strategies are likely to be the most successful approaches to reduce the prevalence of cockroach-induced asthma.

Procedural and methodological issues in telepsychiatry research and program development

OBJECTIVE

The authors reviewed the literature related to telepsychiatry-applications of videoconferencing technology for mental health care-which offers hope for an affordable means of solving long-standing workforce problems, particularly in geographical areas where specialist providers are not readily available.

METHODS

To conduct a comprehensive review of the telepsychiatry literature, the authors searched the MEDLINE database (1970 to February 2000), using the keywords telepsychiatry, telemedicine, and videoconferencing. Studies were selected that included the use of videoconferencing technology for the provision of any form of mental health care services.

RESULTS AND CONCLUSIONS

Psychiatric interviews conducted by telepsychiatry appear to be generally reliable, and patients and clinicians generally report high levels of satisfaction with telepsychiatry. A significant limitation of the literature is the lack of empirical research on telepsychiatry, especially cost analyses and clinical outcome studies. The authors outline a research agenda addressing the procedural and methodological issues that should shape future research: study design, outcome measurement, consideration of patient characteristics, and program design.

Probing the specificity of cysteine proteinases at subsites remote from the active site: analysis of P4, P3, P2' and P3' variations in extended substrates

We have determined the kinetic parameters for the hydrolysis by papain, cathepsin B and cathepsin L of internally quenched fluorescent peptides derived from the lead peptides Abz-AAFRSAQ-EDDnp [in which Abz and EDDnp stand for o-aminobenzoic acid and N-(2,4-dinitrophenyl)ethylenediamine respectively], to map the specificity of S(4) and S(3) subsites, and Abz-AFRSAAQ-EDDnp, to identify the specificity of S(2)' and S(3)'. Abz and EDDnp were the fluorescent quencher pair. These two series of peptides were cleaved at the Arg-Ser bond and systematic modifications at P(4), P(3), P(2)' and P(3)' were made. The S(4) to S(2)' subsites had a significant influence on the hydrolytic efficiencies of the three enzymes. Only papain activity was observed to be dependent on S(3)', indicating that its binding site is larger than those of cathepsins B and L. Hydrophobic amino acids were accepted at S(4), S(3), S(2)' and S(3)' of the three enzymes. The best substrates for cathepsins L and B had Trp and Asn at P(2)' respectively; variations at this position were less accepted by these enzymes. The best substrates for papain were peptides containing Trp, Tyr or Asn at P(3)'. Basic residues at P(3) and P(4) were well accepted by cathepsin L and papain. We also explored the susceptibility of substrates Abz-AFRSXAQ-EDDnp, modified at P(2)' (X), to human cathepsin B mutants from which one or two occluding loop contacts had been removed. The modifications at His(111) (H111A) and His(110) (H110A) of cathepsin B led to an increase in k(cat) values of one or two orders of magnitude. The hydrolytic efficiencies of these cathepsin B mutants became closer to those of papain or cathepsin L.

[Reinfections and the development of schistosomal periportal fibrosis in the murine model]

Experimental pipestem fibrosis of the liver developed more frequently (69.2%) in mice submitted to repeated infections with Schistosoma mansoni, than with single infection (11.1%). The counting of eggs in the liver revealed no significant differences between the two experimental groups. Although the reason why multiple infections favor the development of pipestem fibrosis has not been elucidated, the data obtained represent an experimental support to clinico-epidemiological claims that repeated infections play a role in pathogenesis of hepatosplenic schistosomiasis

Using principles of ACT to integrate community care for people with mental retardation and mental illness

The authors describe the use of an Assertive Community Treatment (ACT) approach in a community living program for persons with both mental retardation and mental illness. The development of the program occurred in the context of a statewide project to serve more than 1,000 dually diagnosed persons who were members of a class action lawsuit against the State of North Carolina. The use of ACT principles marked a substantive departure from the residential supervision and brokered service model employed for the Class throughout the State. The authors describe the public policy context within which the program was developed, discuss the rationale for selecting the ACT model, describe its implementation, and summarize service utilization and outcome information. Changes by the funding agency in its expectations of program staffing and reimbursement methodology that were made after the program was approved led to its early demise. Although the program lasted less than 2 years, during its tenure most participants realized marked improvement in symptoms and community adjustment. Results may cautiously be interpreted as indicating that ACT may reduce the reliance on 24-hour residential and community supervision for many persons with both mental retardation and mental illness.

Home-based multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis: clinical outcomes

OBJECTIVE

The primary purpose of this study was to determine whether multisystemic therapy (MST), modified for use with youths presenting psychiatric emergencies, can serve as a clinically viable alternative to inpatient psychiatric hospitalization.

METHOD

One hundred sixteen children and adolescents approved for emergency psychiatric hospitalization were randomly assigned to home-based MST or inpatient hospitalization. Assessments examining symptomatology, antisocial behavior, self-esteem, family relations, peer relations, school attendance, and consumer satisfaction were conducted at 3 times: within 24 hours of recruitment into the project, shortly after the hospitalized youth was released from the hospital (1-2 weeks after recruitment), and at the completion of MST home-based services (average of 4 months postrecruitment).

RESULTS

MST was more effective than emergency hospitalization at decreasing youths' externalizing symptoms and improving their family functioning and school attendance. Hospitalization was more effective than MST at improving youths' self-esteem. Consumer satisfaction scores were higher in the MST condition.

CONCLUSIONS

The findings support the view that an intensive, well-specified, and empirically supported treatment model, with judicious access to placement, can effectively serve as a family- and community-based alternative to the emergency psychiatric hospitalization of children and adolescents.

Cockroach allergens and asthma in Brazil: identification of tropomyosin as a major allergen with potential cross-reactivity with mite and shrimp allergens

BACKGROUND

Cockroaches produce several proteins that induce IgE antibody responses. Although cockroaches are abundant in warm and humid areas, sensitization to cockroach allergens has not been investigated in Brazil.

OBJECTIVE

The aims of this study were to investigate the frequency of cockroach allergy among patients with asthma, rhinitis, or both in Brazil and to identify American cockroach allergens.

METHODS

Skin tests using cockroach extracts were performed on children and young adults with asthma, rhinitis, or both. A Periplaneta americana complementary (c)DNA library was screened by using IgE antibodies from Brazilian patients allergic to cockroaches. Reactivity of an mAb directed to Dermatophagoides pteronyssinus tropomyosin against cockroach tissue was examined by immunofluorescence.

RESULTS

Cockroach allergy was present in 55% and 79% of the patients, as determined by using skin prick tests alone or combined prick and intradermal tests, respectively. Five cDNA clones reacted with IgE antibody and contained the same sequence. A representative clone (1300 bp), pa 12, coded for a protein that reacted with 50% of the sera from patients allergic to cockroaches on plaque immunoassay and showed a high degree of homology to tropomyosins, particularly those from invertebrates. P americana tropomyosin showed 80%, 81%, and 82% sequence identity to tropomyosins from D pteronyssinus, D farinae, and shrimp, respectively, which have been previously defined as important allergens. An mAb directed against D pteronyssinus tropomyosin, which also recognizes shrimp tropomyosin, showed binding to cockroach striated muscle.

CONCLUSION

Our results support the recommendation that cockroach extracts should be routinely used for the evaluation of patients with asthma, rhinitis, or both in Brazil. The identification of P americana tropomyosin as an important allergen will make it possible to investigate cross-reactivity among cockroaches, mites, and food derived from invertebrates.

Alcohol dependence and hospitalization in schizophrenia

Treatment of schizophrenia is often complicated by substance abuse. We report here findings of a retrospective study evaluating readmission rates of patients meeting DSM IV criteria comorbid for schizophrenia and alcohol or drug dependence treated with depot haloperidol or fluphenazine over a 2-year period. During the study period, 14 of the 26 (54%) male veteran patients were admitted to the VAMC, Charleston; 46% of patients met criteria for alcohol, marijuana or cocaine dependence. Patients with alcohol dependence appeared to be at highest risk for hospital admission (p < 0.05). Moreover, patients with alcohol dependence had longer hospital stays (p < 0.05) than patients without alcohol dependence. Marijuana or cocaine dependence was slightly, but not statistically more common among admitted patients. Marijuana or cocaine dependence did not predict length of stay or number of admissions. Alcohol dependence may be an important factor in schizophrenic exacerbation, and may be an important target for treatment.

Assertive community treatment for people with severe mental illness: the effect on hospital use and costs

OBJECTIVE

To determine the effect of the Program for Assertive Community Treatment (PACT) model on psychiatric inpatient service use in a population of non-emergency psychiatric patients with severe chronic mental illness, and to test for variations in this effect with program staffing levels and patient characteristics such as race and age.

DATA SOURCES/STUDY SETTING

Data are taken from a randomized trial of PACT in Charleston, South Carolina for 144 patients recruited from August 1989 through July 1991.

STUDY DESIGN

Subjects were randomly assigned either to one of two PACT programs or to usual care at a local mental health center. Effects on hospital use were measured over an 18-month follow-up period via multiple regression analysis.

DATA COLLECTION METHODS

Data were obtained from Medicaid claims, chart reviews, subject, case manager, and family interviews; searches of the computerized patient and financial databases of the South Carolina Department of Mental Health and relevant hospitals; and searches of the hard copy and computerized financial databases of the two major local hospitals providing inpatient psychiatric care.

PRINCIPAL FINDINGS

PACT participants were about 40 percent less likely to be hospitalized during the follow-up period. The effect was stronger for older patients. Lower PACT client/staff ratios also reduced the risk of hospitalization. No evidence of differential race effects was found. Given some hospital use, PACT did not influence the number of days of use.

CONCLUSIONS

Controlling for other covariates, PACT significantly reduces hospitalizations but the size of this effect varies with patient and program characteristics. This study shows that previous results on PACT can be applied to non-emergency patients even when the control condition is an up-to-date CMHC office-based case management program.

The contribution of treatment outcome research to the reform of children's mental health services: multisystemic therapy as an example

Service system reforms of the past decade have yielded innovations in type, accessibility, and cost of services provided for some children and families with serious problems, but few of the treatments delivered have been empirically evaluated. Rigorous tests of well-conceived treatments are needed to provide a solid foundation for continued reform. Multisystemic therapy has demonstrated efficacy in treating serious clinical problems in adolescents and their multineed families and is an example of the successful blending of rigorous treatment outcome research and service system innovation.

Bridging the gap between inpatient and outpatient providers using organizational elements of assertive community treatment

Even among comprehensive local public mental health systems, there remain large gaps in continuity of care following discharge from inpatient settings. The authors describe a modification of the assertive community treatment (ACT) program model that links inpatients to ongoing community-based care, and provide preliminary evidence of its effectiveness as a component in a rationally organized comprehensive system of care. Given the recent trend toward managed Medicaid arrangements, there will be increased pressure to reduce clients' length of stay in ACT programs. State mental health authorities are cautioned to resist allowing managed care contractors to radically change the conditions under which ACT programs operate until there is greater evidence of the effectiveness of alternative approaches.

Investigating family-based alternatives to institution-based mental health services for youth: lessons learned from the pilot study of a randomized field trial

The development and validation of family-based alternatives to out-of-home placements for children is an important goal in the mental health services field. The rigorous evaluation of such alternatives, however, can be difficult to accomplish. The purpose of this article is to describe initial barriers experienced during the pilot study of a randomized trial, funded by the National Institute of Mental Health, conducted in a field setting, and the strategies that were used to overcome these barriers. The randomized trial is examining home-based multisystemic therapy as an alternative to the psychiatric hospitalization of youths presenting psychiatric emergencies. The pilot study illuminated the interface of treatment and services research issues, prompting significant changes in the project's clinical procedures, organization, and supervisory processes, as well as in the project's interface with existing community resources for serving youths with serious emotional disturbances.

Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders

This study evaluated the impact of an integrated (mental health/substance abuse) assertive community treatment program on homeless persons with serious mental and substance use disorders. High rates of retention in treatment, housing stability, and community tenure were attained, and all but the most severe substance users appeared to gain these benefits. While the intervention appears to be an effective means of retaining in services and monitoring such difficult-to-treat and costly populations, it did not yield high rates of abstinence and social benefits in severe users.

Research on field-based services: models for reform in the delivery of mental health care to populations with complex clinical problems

OBJECTIVE

Clinical services for psychiatrically impaired populations have only recently been studied with scientifically valid designs to explore innovations in structure, accessibility, and financing. Health systems reform in the United States has provided the impetus for better defining clinically effective and cost-sensitive models for mental health services. This article reviews assertive community treatment, used for adults with severe mental illnesses, and multisystemic therapy, used for adolescents with serious emotional disturbances, as examples of service system innovations that have been studied with controlled clinical trial designs and have demonstrated efficacy in treating difficult and costly clinical populations.

METHOD

The authors reviewed the published controlled clinical trials of assertive community treatment and multisystemic therapy, focusing on the clinical and administrative elements that distinguish them from traditional service systems.

RESULTS

A qualitative assessment of these two approaches suggests that they share common elements, with important implications for mental health policy. Specifically, the use of an ecological model of behavior applied to mental health patients is critical to both systems. In addition, therapeutic principles emphasizing pragmatic (outcome-oriented) treatment approaches, home-based interventions, and individualized goals are key elements of their success. Most important, both systems embody a therapeutic philosophy demanding therapist accountability, in which personnel are rewarded for clinical outcomes and therapeutic innovation rather than for following a prescribed plan.

CONCLUSIONS

As empirically tested approaches, assertive community treatment and multisystemic therapy provide a scientific foundation for continued reform and serve to illustrate critical elements in designing new community treatment initiatives for behavioral as well as medical conditions.

Assertive community treatment: an update of randomized trials

OBJECTIVE

Results of randomized clinical trials of assertive community treatment for seriously mentally ill patients published between 1990 and 1994 are reviewed to synthesize the state of knowledge about this research and to clarify continuing research directions.

METHODS

Randomized trials of interventions that used treatment principles and practices consistent with the Program for Assertive Community Treatment model or close adaptations whose results were published since 1990 were identified by literature searches using MEDLINE and PsychLit and by contact with investigators of ongoing trials.

RESULTS

Controlled clinical trials have been conducted with a wide range of severely mentally ill populations, including patients in Great Britain, patients with recent-onset schizophrenia, veterans, dually diagnosed clients, and homeless persons. Methodological improvements in some studies include increased attention to monitoring the experimental and comparison interventions, as well as larger sample sizes and longer duration of the clinical trials than in earlier efficacy trials. Strong positive effects of assertive community treatment on hospital days and on patient and family satisfaction were found. Gains in functional outcomes, such as employment, may require interventions specifically targeted to these outcomes.

CONCLUSIONS

Questions about the role of assertive community treatment as time-limited treatment, as an adjunct to other services and treatment, or as a comprehensive and continuous service system for adults with severe mental illness require further research. The growing research base should provide valuable information on costs, outcomes, and indications for assertive community treatment that can be evaluated by policy-makers.

Dissemination of assertive community treatment programs

OBJECTIVE

The study sought to estimate the number of programs in the U.S. for severely mentally ill adults that used the assertive community treatment model and to describe variations in characteristics of the intervention across programs.

METHODS

Assertive community treatment programs identified by state mental health authorities completed a 12-item survey. The survey included questions on caseload, composition of the treatment team, nature of services, and structure of service provision.

RESULTS

A total of 303 of 340 programs (89 percent) identified by states responded to the survey. More than 75 percent provided most of their services in the field, delivered medications, included medical staff on the assertive community treatment team, and had caseload ratios of less than 20 consumers for each provider.

CONCLUSIONS

Assertive community treatment programs have disseminated quite unevenly across 33 states, with the highest concentrations of programs in midwestern and eastern states.

Modifying the PACT model: preserving critical elements

Few agencies have the resources to replicate the Program for Assertive Community Treatment (PACT) model pioneered in Madison, Wisconsin, which calls for around-the-clock, comprehensive treatment and rehabilitation services for persons with serious mental illness. Most agencies modify the model program, and little is known about patient outcomes in such altered programs. This paper discusses issues in modifying the PACT model, especially for use in rural areas. The authors focus on six basic elements of the PACT model: multiservice teams, 24-hour service availability, small caseloads that do not vary in composition, ongoing and continuous services, assertive outreach, and in vivo rehabilitation. They describe how programs in South Carolina that are adaptations of the PACT model have retained these elements and achieved desired outcomes with smaller teams operating on modified schedules.

Dexamethasone for the treatment of depression: a randomized, placebo-controlled, double-blind trial

OBJECTIVE

The authors' goal was to assess dexamethasone for the treatment of depression.

METHOD

Thirty-seven outpatients (11 men and 26 women) meeting DSM-III-R criteria for major depressive disorder were randomly assigned to receive either placebo or 4 mg/day of oral dexamethasone for 4 days. Baseline Hamilton depression scale scores were compared with scores obtained 14 days after the first dose of study medication. Data were analyzed by using two-sample t tests, chi-square methods, and Fisher's exact test.

RESULTS

Seven (37%) of the 19 patients given dexamethasone but only one (6%) of the 18 patients given placebo responded positively. No adverse events or side effects were reported, and all patients who entered the study completed it.

CONCLUSIONS

A brief course of oral dexamethasone (4 days) was significantly more effective than placebo within 14 days for the treatment of depression in a randomized, double-blind study of depressed outpatients.

The response of an assertive community treatment program following a natural disaster

A newly forming model treatment program for seriously mentally ill adults was dramatically affected by a natural disaster in September 1989. Hurricane Hugo rendered the offices of the Assertive Community Treatment Program uninhabitable, its vehicles marginally driveable, and its resources virtually nonexistent. In the three months following the storm, however, not a single psychiatric rehospitalization took place. Although the authors cannot claim that the program model was solely responsible for this outcome, this paper illustrates the service system elements that contributed to the program's effectiveness in the wake of one of the nation's most severe natural disasters.

A community-based public-academic liaison program

OBJECTIVE

The authors discuss obstacles and incentives associated with successful community-based public-academic liaison activities and illustrate their conclusions by describing their public-academic liaison program, which received the American College of Psychiatrists' first annual Award for Creativity in Psychiatric Education.

METHOD

The first 8 years of a state/university collaboration are described in which the parties involved first developed a variety of innovative services designed to fill specific gaps in the public service delivery system and subsequently integrated academic research and training components.

RESULTS

The carefully planned and monitored process resulted in the exponential growth of interest in public sector work, the realization of the university's primary goals of developing high quality training and research sites, a substantial increase in the number of graduates accepting positions in the public sector, several projects funded by the National Institute of Mental Health, and two national awards.

CONCLUSIONS

These collaborations illustrate the highly complementary relationship of public-academic liaison activities and their potential capacity to improve access to services, substantially improve the quality of these services, generate extramural support for services research, and increase the number of well-trained professionals in the public sector.