[Design, implementation and evaluation of an educational approach for patients with PICC line and midline]

OBJECTIVES

Design the competency framework and an interview guide for patients with PICC line or midline. Develop a patient satisfaction evaluation questionnaire.

METHODS

A multidisciplinary team has developed a reference system for the skills of patients with PICC line or midline. The skills are classified in three categories: knowledge, know-how and attitudes. An interview guide was written in order to transmit the priority skills, determined beforehand, to the patient. A second multidisciplinary team designed a questionnaire to evaluate patient satisfaction.

RESULTS

The competency framework includes nine competencies: four, knowledge-based; three, know-how-based and two, attitude-based. Among these competencies, five were considered to be priorities. The interview guide is a tool that allows care professionals to transmit the priority skills to patients. The satisfaction questionnaire explores the information received by the patient, the passage through the interventional technical platform, the end of the management before the return home, and the overall satisfaction of the patients with the course of the device placement. Over a 6-month period, 276 patients responded with a high satisfaction rate.

CONCLUSIONS

The PICC line or midline patient's competency framework has made it possible to list all the skills that patients should acquire. The interview guide serves as a support for the care teams in the patient education process. This work could be used by other establishments to develop the educational process around these vascular access devices.

Consensus statement from 2nd International Conference on Controversies in Vitamin D

The 2nd International Conference on Controversies in Vitamin D was held in Monteriggioni (Siena), Italy, September 11-14, 2018. The aim of this meeting was to address ongoing controversies and timely topics in vitamin D research, to review available data related to these topics and controversies, to promote discussion to help resolve lingering issues and ultimately to suggest a research agenda to clarify areas of uncertainty. Several issues from the first conference, held in 2017, were revisited, such as assays used to determine serum 25-hydroxyvitamin D [25(OH)D] concentration, which remains a critical and controversial issue for defining vitamin D status. Definitions of vitamin D nutritional status (i.e. sufficiency, insufficiency and deficiency) were also revisited. New areas were reviewed, including vitamin D threshold values and how they should be defined in the context of specific diseases, sources of vitamin D and risk factors associated with vitamin D deficiency. Non-skeletal aspects related to vitamin D were also discussed, including the reproductive system, neurology, chronic kidney disease and falls. The therapeutic role of vitamin D and findings from recent clinical trials were also addressed. The topics were considered by 3 focus groups and divided into three main areas: 1) "Laboratory": assays and threshold values to define vitamin D status; 2) "Clinical": sources of vitamin D and risk factors and role of vitamin D in non-skeletal disease and 3) "Therapeutics": controversial issues on observational studies and recent randomized controlled trials. In this report, we present a summary of our findings.

Oncologist use and perception of large panel next-generation tumor sequencing

BACKGROUND

Genomic profiling is increasingly incorporated into oncology research and the clinical care of cancer patients. We sought to determine physician perception and use of enterprise-scale clinical sequencing at our center, including whether testing changed management and the reasoning behind this decision-making.

PATIENTS AND METHODS

All physicians who consented patients to MSK-IMPACT, a next-generation hybridization capture assay, in tumor types where molecular profiling is not routinely performed were asked to complete a questionnaire for each patient. Physician determination of genomic 'actionability' was compared to an expertly curated knowledgebase of somatic variants. Reported management decisions were compared to chart review.

RESULTS

Responses were received from 146 physicians pertaining to 1932 patients diagnosed with 1 of 49 cancer types. Physicians indicated that sequencing altered management in 21% (331/1593) of patients in need of a treatment change. Among those in whom treatment was not altered, physicians indicated the presence of an actionable alteration in 55% (805/1474), however, only 45% (362/805) of these cases had a genomic variant annotated as actionable by expert curators. Further evaluation of these patients revealed that 66% (291/443) had a variant in a gene associated with biologic but not clinical evidence of actionability or a variant of unknown significance in a gene with at least one known actionable alteration. Of the cases annotated as actionable by experts, physicians identified an actionable alteration in 81% (362/445). In total, 13% (245/1932) of patients were enrolled to a genomically matched trial.

CONCLUSION

Although physician and expert assessment differed, clinicians demonstrate substantial awareness of the genes associated with potential actionability and report using this knowledge to inform management in one in five patients.

CLINICAL TRIAL NUMBER

NCT01775072.

Phase 1 study of twice weekly pulse dose and daily low-dose erlotinib as initial treatment for patients with EGFR-mutant lung cancers

Background

Patients with EGFR-mutant lung cancers treated with EGFR tyrosine kinase inhibitors (TKIs) develop clinical resistance, most commonly with acquisition of EGFR T790M. Evolutionary modeling suggests that a schedule of twice weekly pulse and daily low-dose erlotinib may delay emergence of EGFR T790M. Pulse dose erlotinib has superior central nervous system (CNS) penetration and may result in superior CNS disease control.

Methods

We evaluated toxicity, pharmacokinetics, and efficacy of twice weekly pulse and daily low-dose erlotinib. We assessed six escalating pulse doses of erlotinib.

Results

We enrolled 34 patients; 11 patients (32%) had brain metastases at study entry. We observed 3 dose-limiting toxicities in dose escalation: transaminitis, mucositis, and rash. The MTD was erlotinib 1200 mg days 1-2 and 50 mg days 3-7 weekly. The most frequent toxicities (any grade) were rash, diarrhea, nausea, fatigue, and mucositis. 1 complete and 24 partial responses were observed (74%, 95% CI 60-84%). Median progression-free survival was 9.9 months (95% CI 5.8-15.4 months). No patient had progression of an untreated CNS metastasis or developed a new CNS lesion while on study (0%, 95% CI 0-13%). Of the 18 patients with biopsies at progression, EGFR T790M was identified in 78% (95% CI 54-91%).

Conclusion

This is the first clinical implementation of an anti-cancer TKI regimen combining pulse and daily low-dose administration. This evolutionary modeling-based dosing schedule was well-tolerated but did not improve progression-free survival or prevent emergence of EGFR T790M, likely due to insufficient peak serum concentrations of erlotinib. This dosing schedule prevented progression of untreated or any new central nervous system metastases in all patients.

The interpersonal theory of suicide and adolescent suicidal behavior

BACKGROUND

Joiner's interpersonal theory of suicide (IPTS) proposes that suicide results from the combination of a perception of burdening others, social alienation, and the capability for self-harm. The theory gained some empirical support, however the overall model has yet to be tested. This study aimed to test the main predictions of IPTS in a large community sample of Israeli adolescents.

METHOD

1196 Israeli Jewish and Arab high-school pupils participating in the SEYLE project completed a self-report questionnaire measuring perceived burdensomeness, thwarted belongingness, health risk behaviors, and non-suicidal self-injury (risk variables), and suicidal ideation and suicide attempts (outcome measures). The data were tested in cross-sectional regression models.

RESULTS

Consistent with IPTS, perceived burdensomeness was found to interact with thwarted belongingness, predicting suicidal ideation. Depression mediated most of the effect of thwarted belongingness and perceived burdensomeness on suicidal ideation. Acquired capability for self-harm, as measured by health risk behaviors and direct non-suicidal self-injurious behaviors, predicted suicide attempt. However, this mechanism operated independently from ideation rather than in interaction with it, at variance with IPTS-based predictions.

LIMITATIONS

The cross-sectional design precludes conclusions about causality and directionality. Proxy measures were used to test the interpersonal theory constructs.

CONCLUSION

The findings support some of the IPTS predictions but not all, and imply two separate pathways for suicidal behavior in adolescents: one related to internalizing psychopathology and the other to self-harm behaviors. This conceptualization has clinical implications for the differential identification of adolescents at risk for suicidal behavior and for the development of prevention strategies.

Report from a forum on US heart allocation policy

Since the latest revision in US heart allocation policy (2006), the landscape and volume of transplant waitlists have changed considerably. Advances in mechanical circulatory support (MCS) prolong survival, but Status 1A mortality remains high. Several patient subgroups may be disadvantaged by current listing criteria and geographical disparity remains in waitlist time. This forum on US heart allocation policy was organized to discuss these issues and highlight concepts for consideration in the policy development process. A 25-question survey on heart allocation policy was conducted. Among attendees/respondents were 84 participants with clinical/published experience in heart transplant representing 51 US transplant centers, and OPTN/UNOS and SRTR representatives. The survey results and forum discussions demonstrated very strong interest in change to a further-tiered system, accounting for disadvantaged subgroups and lowering use of exceptions. However, a heart allocation score is not yet viable due to the long-term viability of variables (used in the score) in an ever-developing field. There is strong interest in more refined prioritization of patients with MCS complications, highly sensitized patients and those with severe arrhythmias or restrictive physiology. There is also strong interest in distribution by geographic boundaries modified according to population. Differences of opinion exist between small and large centers.

PKPD modelling of the interrelationship between mean arterial BP, cardiac output and total peripheral resistance in conscious rats

BACKGROUND AND PURPOSE

The homeostatic control of arterial BP is well understood with changes in BP resulting from changes in cardiac output (CO) and/or total peripheral resistance (TPR). A mechanism-based and quantitative analysis of drug effects on this interrelationship could provide a basis for the prediction of drug effects on BP. Hence, we aimed to develop a mechanism-based pharmacokinetic-pharmacodynamic (PKPD) model in rats that could be used to characterize the effects of cardiovascular drugs with different mechanisms of action (MoA) on the interrelationship between BP, CO and TPR.

EXPERIMENTAL APPROACH

The cardiovascular effects of six drugs with diverse MoA, (amlodipine, fasudil, enalapril, propranolol, hydrochlorothiazide and prazosin) were characterized in spontaneously hypertensive rats. The rats were chronically instrumented with ascending aortic flow probes and/or aortic catheters/radiotransmitters for continuous recording of CO and/or BP. Data were analysed in conjunction with independent information on the time course of drug concentration using a mechanism-based PKPD modelling approach.

KEY RESULTS

By simultaneous analysis of the effects of six different compounds, the dynamics of the interrelationship between BP, CO and TPR were quantified. System-specific parameters could be distinguished from drug-specific parameters indicating that the model developed is drug-independent.

CONCLUSIONS AND IMPLICATIONS

A system-specific model characterizing the interrelationship between BP, CO and TPR was obtained, which can be used to quantify and predict the cardiovascular effects of a drug and to elucidate the MoA for novel compounds. Ultimately, the proposed PKPD model could be used to predict the effects of a particular drug on BP in humans based on preclinical data.

Innovations in drug-eluting stents

Coronary artery disease affects patients worldwide and is a major cause of morbidity and mortality. Historically, the treatment approach for patients with coronary syndromes has been surgical. In the 1970s, percutaneous balloon angioplasty was introduced, leading to creation of a new field of interventional cardiology, which allowed a non-surgical minimally invasive approach to treat patients with coronary artery disease. However, the major limitations of balloon angioplasty were acute vessel closure and later restenosis. The introduction of bare metal stents and then drug-eluting stents (DES) revolutionized the practice of interventional cardiology and allowed for safe treatment of increasingly complex coronary artery lesions. Although drug-eluting coronary stents improve patient outcomes, they still have limitations. These limitations may arise from delayed endothelialization, local vessel hypersensitivity and endothelial dysfunction secondary to the drug elution, the durable polymer coating, or the stent scaffold. This comprehensive review will discuss the evolution of intracoronary stents from their introduction to current utilization of DES as well as future research on bioabsorbable stents and polymers.

Experimental observations of soliton wave trains in electron beams

The first experimental observation of a Korteweg-de Vries-type soliton wave train in intense electron beams is reported. A narrow, large-amplitude perturbation on a long-pulse beam is observed to steepen and spawn a soliton wave train. The pulse width and amplitude of each peak remain unchanged over a long propagation distance, and the amplitude is inversely proportional to the square of the width. Two such pulses are seen to pass through each other, emerging from the collision unchanged. The experimental results are reproduced by particle-in-cell simulations.

Simian virus 40-, but not human papillomavirus-, transformation of prostatic epithelial cells results in loss of growth-inhibition by 1,25-dihydroxyvitamin D-3

In addition to its well known calcemic actions, 1,25-dihydroxyvitamin D-3 [1,25(OH)(2)D] exhibits differentiating and antiproliferative effects in several types of cancer cells. 1,25(OH)(2)D receptors (VDR) as well as 1,25(OH)(2)D-mediated growth-inhibition have been demonstrated in human prostate cancer cell lines. In order to further develop model systems for the study of 1,25(OH)(2)D action and to elucidate the mechanism of growth-inhibition, we studied several human prostate cell lines immortalized with either simian virus 40 (SV40) or human papillomavirus type 18 (HPV). The SV40-transformed cell lines P69SV40-T and P153SV40-T were not growth-inhibited by 1,25(OH)(2)D at concentrations as high as 100 nM, whereas the HPV-transformed cells PZ-HPV-7 and CA-HPV-10 were growth-inhibited. All cell lines expressed VDR, and VDR mRNA was demonstrated by Northern blot analysis. All cells exhibited induction of 24-hydroxylase mRNA, a 1,25(OH)(2)D responsive gene, after 1,25(OH)(2)D treatment. In an attempt to understand the apparent dissociation of 1,25(OH)(2)D actions in the SV40-transformed cells, we turned to the human prostate cancer cell line DU 145. These cells, like the SV40-transformed cells, are not growth-inhibited but demonstrate induction of 24-hydroxylase mRNA after 1,25(OH)(2)D treatment. DU 145 cells contain a mutated retinoblastoma gene (Rb) which contributes to their uncontrolled growth, analogous to the disruption of Rb by SV40 and HPV. We compared DU,145 cells to DU 145 cells transfected with normal Rb (DU 145/Rb). Similar to DU 145, DU 145/Rb cells were not growth-inhibited by 1,25(OH)(2)D, while 24-hydroxylase mRNA was induced. These results suggest that divergent pathways mediate the growth-inhibitory effect of 1,25(OH)(2)D and its induction of 24-hydroxylase. It also appears that the antiproliferative effect of 1,25(OH)(2)D is mediated by an Rb-independent mechanism.

Mixed methods study of management of health conditions in rural low-income families: implications for health care policy in the USA

INTRODUCTION

The purpose of this mixed methods study was to examine the health issues and health management strategies utilized by rural low-income women and their families to inform the design, implementation, and evaluation of health reform in rural areas of the USA. METHODS; Quantitative data was analyzed from 271 rural, low-income women and their families and qualitative data from a sub-sample of 44. Specifically explored were the: (1) types and perceived severity of health conditions rural, low-income individuals report; (2) perceived value and utilization of a usual source of care; and (3) strategies these individuals employ to manage their health.

RESULTS

Rural American families manage multiple healthcare needs with limited resources; 42.1% reported 1-4 chronic conditions in the family, 31.4% reported 5-8 conditions, and 17.7% reported 9 or more conditions. The majority of participants (79.0%) reported having a doctor or other healthcare professional that they usually see; 61.3% reported their partners had a usual provider, and 91.7% reported their children had a usual provider. Analysis of the qualitative data revealed two main themes regarding management of health conditions: (1) lack of engagement in managing overall health; and (2) ineffective utilization of health care.

CONCLUSIONS

Rural low-income individuals in the US may benefit from new policies that promote patient-centered, personalized care. However, any policy change must be carefully designed to consider the ways in which rural American families manage their health in order to improve individual health status and reduce rural health disparities.

Effect of nesiritide in patients with acute decompensated heart failure

BACKGROUND

Nesiritide is approved in the United States for early relief of dyspnea in patients with acute heart failure. Previous meta-analyses have raised questions regarding renal toxicity and the mortality associated with this agent.

METHODS

We randomly assigned 7141 patients who were hospitalized with acute heart failure to receive either nesiritide or placebo for 24 to 168 hours in addition to standard care. Coprimary end points were the change in dyspnea at 6 and 24 hours, as measured on a 7-point Likert scale, and the composite end point of rehospitalization for heart failure or death within 30 days.

RESULTS

Patients randomly assigned to nesiritide, as compared with those assigned to placebo, more frequently reported markedly or moderately improved dyspnea at 6 hours (44.5% vs. 42.1%, P=0.03) and 24 hours (68.2% vs. 66.1%, P=0.007), but the prespecified level for significance (P≤0.005 for both assessments or P≤0.0025 for either) was not met. The rate of rehospitalization for heart failure or death from any cause within 30 days was 9.4% in the nesiritide group versus 10.1% in the placebo group (absolute difference, -0.7 percentage points; 95% confidence interval [CI], -2.1 to 0.7; P=0.31). There were no significant differences in rates of death from any cause at 30 days (3.6% with nesiritide vs. 4.0% with placebo; absolute difference, -0.4 percentage points; 95% CI, -1.3 to 0.5) or rates of worsening renal function, defined by more than a 25% decrease in the estimated glomerular filtration rate (31.4% vs. 29.5%; odds ratio, 1.09; 95% CI, 0.98 to 1.21; P=0.11).

CONCLUSIONS

Nesiritide was not associated with an increase or a decrease in the rate of death and rehospitalization and had a small, nonsignificant effect on dyspnea when used in combination with other therapies. It was not associated with a worsening of renal function, but it was associated with an increase in rates of hypotension. On the basis of these results, nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure. (Funded by Scios; ClinicalTrials.gov number, NCT00475852.).

DDAVP responsiveness in children with mild or moderate haemophilia A correlates with age, endogenous FVIII:C level and with haemophilic genotype

In most individuals with moderate/mild haemophilia A, FVIII:C levels increase following DDAVP administration to a haemostatic range, thus avoiding the need for FVIII concentrates. We sought to determine the relationship between responsiveness to DDAVP in boys (<18 years old) with mild/moderate haemophilia and patient age, haemophilic severity and haemophilic genotype. Our cohort consisted of 13 boys with moderate and 61 boys with mild haemophilia who, between them, had 38 different mutations; 21 had unique mutations not shared by any other clinic patient, whereas 53 shared one of 17 mutations with some other clinic patient (included 26 boys with ≥ 1 haemophilic brother). Patient age and endogenous FVIII:C levels were strong predictors of response to DDAVP. Younger patients responded less well to DDAVP and 10 of the 11 patients, when retested at an older age, showed an improved response to DDAVP. Only 1 patient with moderate haemophilia responded to DDAVP, whereas 80% of patients with mild haemophilia responded (including all patients with an endogenous FVIII:C of >0.15 U mL(-1)). Almost all patients with the same mutation had the same response to DDAVP or only a minor discordance in response. Patient's age, disease severity and genotype all are predictors of response to DDAVP.

Search for inherited susceptibility to radiation-associated meningioma by genomewide SNP linkage disequilibrium mapping

Background:

Exposure to ionising radiation is a well-established risk factor for multiple types of tumours, including malignant brain tumours. In the 1950s, radiotherapy was used to treat Tinea Capitis (TC) in thousands of children, mostly of North-African and Middle Eastern origin, during the mass migration to Israel. The over-representation of radiation-associated meningioma (RAM) and other cancers in specific families provide support for inherited genetic susceptibility to radiation-induced cancer.

Methods:

To test this hypothesis, we genotyped 15 families segregating RAM using high-density single-nucleotide polymorphism (SNP) arrays. Using the family-based association test (FBAT) programme, we tested each polymorphism and haplotype for an association with RAM.

Results:

The strongest haplotype associations were attained at 18q21.1 (P=7.5 × 10⁻⁵), 18q21.31 (P=2.8 × 10⁻⁵) and 10q21.3 (P=1.6 × 10⁻⁴). Although associations were not formally statistically significant after adjustment for multiple testing, the 18q21.1 and 10q21.3 associations provide support for a variation in PIAS2, KATNAL2, TCEB3C, TCEB3CL and CTNNA3 genes as risk factors for RAM.

Conclusion:

These findings suggest that any underlying genetic susceptibility to RAM is likely to be mediated through the co-inheritance of multiple risk alleles rather than a single major gene locus determining radiosensitivity.

Morphology of Lignin-Polyurethane Blends

The morphology of blended polyurethane (PU) sealants was studied by scanning electron microscopy (SEM) and differential scanning calorimetry (DSC). The PU was modifided by mechanical mixing with various amounts of Lignin (L) to achieve a homogeneous blend. Specimens were subjected to control (C), accelerated weathering (AW), and natural weathering (NW) conditions. Results obtained from SEM analysis reveal an even distribution of L particles in the PU matrix. Furthermore, the SEM photomicrographs clearly emphasize the differing morphologies of the constituent phases. They also depict the differences in surface texture between control and aged specimens. The DSC analysis shows that the two phases are immiscible which is in agreement with observations by microscopy.

Recycling Lignin for Engineering Applications

Lignin, a complex natural polymer produced by all vascular terrestrial plants is second in abundance only to cellulose and is the matrix holding plant fibres together. Lignins are recovered mainly as byproducts from woodpulping processes with about 100 million tons produced annually worldwide.

Large volume uses for lignin byproduct other than for generation of energy (kraft process) are most likely to be in materials applications.

In the last decades many studies aimed to the recycling of different lignins (sulfite, kraft, organosolv, steam exploded, hydrolytic, etc.) in polymeric systems based on thermoplastics, thermosettings, elastomers, adhesives, sealants, etc.

Among all the technical lignins, sulfate lignins are chemically the most reactive and are therefore used to modify polymers. The oldest and the most familiar application of lignin as a component of polymeric materials involves the reinforcement of rubber. Multicomponent materials can be created by combination with other macromolecules like polyethylene, polypropylene, or poly(vinyl alcohol) to produce polyblends, block copolymers or interpenetrating polymer networks.

The present communication will try to present such examples of polymeric systems based on recycled lignin, and synthetic polymers such as: polyurethane, epoxy, acrylics, silicones.

Photoprotection by 1alpha,25-dihydroxyvitamin D and analogs: further studies on mechanisms and implications for UV-damage

Ultraviolet (UV) irradiation causes DNA damage in skin cells, immunosuppression and photocarcinogenesis. 1alpha,25-dihydroxyvitamin D3 (1,25D) reduces UV-induced DNA damage in the form of cyclobutane pyrimidine dimers (CPD) in human keratinocytes in culture and in mouse and human skin. UV-induced immunosuppression is also reduced in mice by 1,25D, in part due to the reduction in CPD and a reduction in interleukin (IL-6. The cis-locked analog, 1alpha,25-dihydroxylumisterol3 (JN), which has almost no transactivating activity, reduces UV-induced DNA damage, apoptosis and immunosuppression with similar potency to 1,25D, consistent with a non-genomic signalling mechanism. The mechanism of the reduction in DNA damage in the form of CPD is unclear. 1,25D doubles nuclear expression of p53 compared to UV alone, which suggests that 1,25D facilitates DNA repair. Yet expression of a key DNA repair gene, XPG is not affected by 1,25D. Chemical production of CPD has been described. Incubation of keratinocytes with a nitric oxide donor, SNP, induces CPD in the dark. We previously reported that 1,25D reduced UV-induced nitrite in keratinocytes, similar to aminoguanidine, an inhibitor of nitric oxide synthase. A reduction in reactive nitrogen species has been shown to facilitate DNA repair, but in view of these findings may also reduce CPD formation via a novel mechanism.

Systematic comparison of nonmelanoma skin cancer microarray datasets reveals lack of consensus genes

BACKGROUND

DNA microarray technology has revealed vast numbers of gene expression alterations associated with human malignancies. Assigning validity and biological significance to these changes, however, remains a considerable hurdle. Recently, microarray analysis has been applied to the study of nonmelanoma skin cancer.

OBJECTIVES

To compare experimental data rigorously in order to strengthen conclusions regarding the pathogenesis of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), and to evaluate systematically the experimental and statistical parameters that may impact the degree of consensus among differentially expressed genes (DEGs) between studies.

METHODS

We performed a systematic comparison of 10 studies that applied DNA microarray technology to study BCC/SCC.

RESULTS

A total of 1133 DEGs collectively reported across the studies were compared, and 64 DEG overlaps were found: 18 DEG overlaps in SCC vs. SCC study comparisons, 18 DEG overlaps in BCC vs. BCC study comparisons and 28 DEG overlaps in BCC vs. SCC study comparisons. We documented differences in several experimental methods that may account for the relative lack of consensus between studies, including sample type, tissue procurement/handling, microarray chip and statistical analysis. The two most dysregulated biological pathways across all studies involved genes with enzymatic and structural/adhesion functions.

CONCLUSIONS

DEGs that were found to overlap across two or more studies and biological pathways with the largest representation of DEGs across studies may be particularly relevant to disease pathogenesis and serve as targets for future therapy. In future work, more consistent experimental methods across laboratories may improve the validity of reported DEGs and strengthen conclusions drawn from microarray data.

Clinical case management of revolving door patients - a semi-randomized study

OBJECTIVE

To assess the effectiveness of psychiatric clinical case management.

METHOD

Subjects with at least three admissions in the previous 2 years were randomized into a clinical case management group (CMG; n = 122) and a standard care group (SCG; n = 95). Individuals who refused or were not located were included in a third, non-randomized no-treatment group (NTG; n = 153). Parameters assessed included utilization of in-patient services and psychosocial functioning.

RESULTS

We found no difference between the CMG and the SCG in psychosocial functioning as evaluated by interviewers, and no difference between the three groups in hospitalization. In subjects' self-ratings, the CMG showed slight improvement in psychosocial functioning.

CONCLUSION

Clinical case management did not prove itself superior to standard care in a revolving door population.