[New tools for preventing and evaluating risk practices for hepatitis C transmission among injection drug users: some reflections on injection rooms and the measurement of risk-taking behaviors]

Injection rooms should be able to contribute to the prevention of the risks of transmission of hepatitis C (HCV) among intravenous drug users (IDUs). However, these services have yet to be set up and tested in France. This article presents a literature review of injection rooms and explores possible ways of evaluating the effects of this type of service on risks for HCV. Given the difficulties of estimating the service's impact on the incidence of HCV, evaluations could target injection-related risk taking behaviors. The second part of the article addresses the issue of risk taking practices and presents a new research tool able to explore out-of-the-ordinary situations involving risk-taking. Tested on a population of IDUs in Marseille, this tool detects forms of risk-taking and contexts in which injection is performed, which are always missed by the usual measures of risk practices. It could therefore be added to these measures and be useful for evaluating injection rooms.

Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial

OBJECTIVES

This study tested a psychiatric rehabilitation approach for organizing and delivering services to street-dwelling persons with severe mental illness.

METHODS

Street-dwelling persons with severe mental illness were randomly assigned to the experimental program (called Choices) or to standard treatment in New York City. We assessed study participants at baseline and at 6-month intervals over 24 months, using measures of service use, quality of life, health, mental health, and social psychological status. The average deviation from baseline summary statistic was employed to assess change.

RESULTS

Compared with persons in standard treatment (n = 77), members of the experimental group (n = 91) were more likely to attend a day program (53% vs 27%), had less difficulty in meeting their basic needs, spent less time on the streets (55% vs 28% reduction), and spent more time in community housing (21% vs 9% increase). They showed greater improvement in life satisfaction and experienced a greater reduction in psychiatric symptoms.

CONCLUSIONS

With an appropriate service model, it is possible to engage disaffiliated populations, expand their use of human services, and improve their housing conditions, quality of life, and mental health status.

Social and emotional problems in children with neurofibromatosis type 1: evidence and proposed interventions

OBJECTIVE

To describe social and emotional problems in children and adolescents with neurofibromatosis type 1 (NF1) and propose interventions. Our hypothesis is that children with NF1 will have significantly more social and emotional problems, compared with their unaffected siblings and children in the general population.

STUDY DESIGN

Forty-three children with NF1 and 22 unaffected siblings (ages 5 to 18 years) were assessed with a standardized test completed by parents and teachers (the Child Behavior Checklist).

RESULTS

As with other aspects of NF1, there was variable expressivity. However, when rated by parents, children with NF1 had significantly more problems in comparison with test norms or unaffected siblings on 7 of 8 scales: Social Problems, Attention Problems, Anxiety/Depression, Withdrawal, Thought Problems, Somatic Complaints, and Aggressive Behavior. Children with NF1 also scored lower than unaffected siblings on measures assessing sports and other activities. Teachers reported fewer differences.

CONCLUSIONS

We propose interventions in the form of information for parents; early screening and treatment for speech, motor, and cognitive problems; and an increased level of intervention to prevent and treat psychologic problems, including systematic screening with standardized tests.

Thoracic tumors in children with neurofibromatosis-1

Thoracic tumors have been infrequently reported as a complication of neurofibromatosis-1 (NF1). To determine the prevalence and clinical features of thoracic tumors seen in children with NF1, we reviewed medical records and imaging studies for a group of 260 pediatric patients with NF1 followed in a multidisciplinary NF Center. Extrapleural thoracic tumors were seen in nine patients with NF1, corresponding to a prevalence of 3.5% in this hospital-based series of patients. Pathological studies of the tumors demonstrated plexiform neurofibroma in four cases and neurofibrosarcoma in one case. The remaining four cases were suspected to be plexiform neurofibroma based on clinical features but have not been confirmed histologically. Three patients presented with symptoms of chest pain, syncope, or wheezing; six patients were asymptomatic at the time of diagnosis of the tumors. Physical findings frequently found in patients with thoracic tumors were scoliosis (especially focal scoliosis) and visible plexiform neurofibromas of the neck. We conclude that NF1 patients presenting with any of these signs and symptoms should be screened for thoracic tumors with chest X-ray and magnetic resonance imaging as needed. It is unknown whether screening asymptomatic NF1 patients with chest X-rays on a regular basis will result in an improved outcome.

Ullrich-Turner syndrome and neurofibromatosis-1

There is a well-known association between neurofibromatosis-1 (NF1) and Noonan syndrome-like manifestations, including short stature, short broad neck, and hypertelorism. These anomalies are thought to be due to variable expression of the NF1 gene. We report on two girls with NF1 who were found to have the Ullrich-Turner syndrome. Case 1, a 12-year-old white girl, was followed in a Neurofibromatosis Clinic because of multiple café-au-lait spots and a family history of NF1 in her mother and sister. On examination, she had short stature, hypertelorism, and short neck with low posterior hairline. Karyotype was 86% 46,XY/14% 45,X. Case 2, the first child of a woman with NF1, presented at birth with lymphedema of hands and feet and a short broad neck. Karyotype was 45,X. At age 23 months she was short, had epicanthic folds, hypertelorism, narrow palate, right simian crease, 19 café-au-lait spots, and axillary freckling. We conclude that chromosome studies should be performed in girls with NF1 who have short stature and Noonan- or Ullrich-Turner-like findings. Dilemmas raised by the dual diagnoses of NF1 and Ullrich-Turner syndrome include potential risks of growth hormone therapy and estrogen replacement therapy.

The paradoxes of reform: reevaluating Italy's mental health law of 1978

Recent data on Italy's mental health law of 1978 delineate a more complex picture of deinstitutionalization than that suggested by the first wave of enthusiastic writings on the law's implementation. In violation of the law's original intent, many Italian regions depend heavily on newly established hospital-based units, while development of community services has been uneven. Factors affecting implementation include both ambiguous and unenforceable provisions in the law and unwillingness at the national and local levels to fund necessary community alternatives. Recent proposals to "reform the reform" may move Italian psychiatry even further away from the legacy of successful deinstitutionalization in cities such as Trieste and Arezzo.

Breaking the circuit of social control: lessons in public psychiatry from Italy and Franco Basaglia

Much public discourse in the United States and in Canada acknowledges the dismal failure of the policy to 'deinstitutionalize' mental patients and to return them to some semblance of community living. The American Psychiatric Association has recently called for a reassessment of institutional alternatives--a call for a return to the asylum--in response to the needs of the new population of so-called homeless mentally ill. Here we contrast the failures of North American deinstitutionalization with the relative successes achieved in those regions of Italy where deinstitutionalization was grounded in a grassroots alternative psychiatry movement and professional and political coalition, Psichiatria Democratica. Democratic psychiatry challenged both the medical and the legal justifications for the segregative control of the 'mentally ill': madness as disease, and the constant over-prediction of the dangerousness of the mental patient. In addition, the movement challenged traditional cultural stereotypes about the meanings of madness, and was successful in gaining broad-based community support from political parties, labor unions, student groups, and artist collectives that were enlisted in the task of reintegrating the ex-mental patient. The Italian experiment, although flawed and riddled with its own inconsistencies and contradictions, offers evidence that deinstitutionalization can work without recreating in the community setting the same exclusionary logic that was the foundation of the asylum system.