Search

This study was done to ascertain the knowledge and practice of medical officers on spirometry and management of COPD in a medical department of a state hospital. A total of 81 questionnaires with nine items were distributed to medical officers in the medical department (MD) and in other departments (controls). Eight incomplete questionnaires were rejected. In all 15 (21%) respondents were analysed from MD and 58 (79%) from the control group. The respondents from MD were aware that spirometry was important in COPD (100% versus 69%, P < 0.01) but in practice both groups were as likely to use peak expiratory flow rate. Respondents from MD were more likely to treat mild COPD (73% versus 12%, P < 0.001) according to Malaysian Thoracic Society COPD guidelines and also more likely to perform steroid trial (93% versus 37%, P < 0.001). Only 9 (60%) from MD and 33(57%) would refer patients for home oxygen assessment. This preliminary survey suggests that there was lack of translation of knowledge into practice particularly in terms of use of spirometry in COPD as well as lack of awareness for home oxygen assessment. A bigger survey involving all doctors in the state to answer issues raised in this preliminary survey is being conducted.

We report results of a study on suicides 1976-1998 of inpatient of the state Mental Hospital Bayreuth. Suicides were matched to a control group of psychiatric inpatients shortly admitted to the hospital after the suicide inpatient.

Background: Multiple studies have shown that individuals with severe mental illness are at increased risk for acquiring infection from human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Moreover, patients with chronic HCV infection are at risk for fulminant hepatitis from acquired infection with hepatitis A virus (HAV) or HBV, but there are limited data on the prevalence of HIV, HAV, and HBV in chronically hospitalized U.S. psychiatric patients without mental retardation who are HCV-seropositive. To address this issue, a comprehensive screening program was commenced at Oregon State Hospital (Salem, Ore.) beginning in 1999., Method: The computerized records of all non-geriatric adult inpatients at Oregon State Hospital on April 23, 2001, were reviewed to assess physician compliance with screening and the prevalence of infection with HIV, HAV, HBV, and HCV., Results: Among the 535 patient records reviewed, 94.8% of patients were screened for HCV, of whom 20.3% were seropositive. Among HCV-seropositive patients, only 1.9% were not screened for HAV and HBV, but 23.3% were not tested for HIV. In the HCV-seropositive group, 35.9% were HAV-positive, 49.5% HBV-positive, and 2.6% HIV-positive., Conclusion: Chronic psychiatric inpatients have high HCV prevalence rates. Hepatitis C-seropositive individuals may be at risk for complications unless vaccinated for HAV and HBV.

Objective: This study compared the effectiveness of using a review team and the usual self-reporting method in detecting different types of medication errors in a state psychiatric hospital., Methods: Medication errors were defined by using widely accepted criteria. Rates of prescription, transcription, administration, and dispensing errors were determined, and the risk of harm from each error was rated as high, moderate, or low. A review team was assigned to retrospectively review 31 patient records for prescription, transcription, and administration errors for a total of 1,448 patient-days. Dispensing errors, which can only be determined concurrently, were reported for an equivalent number of patient-days. The error rate was compared with the rate that was determined by the usual method of self-reports from all nursing and medical staff., Results: In the 31 charts retrospectively reviewed and the dispensing events concurrently reviewed, the team detected a total of 2,194 medication errors, whereas a total of nine errors were self-reported for the same patient group. Administration errors accounted for more than half of the total (66 percent), followed by transcription errors (23 percent), prescription errors (11 percent), and dispensing errors (less than 1 percent). Nineteen percent of errors were rated as having a low risk of harm, 23 percent as having a moderate risk, and 58 percent as having a high risk., Conclusions: Use of a review team should be considered as a method for detecting and reporting medication errors.

Unlabelled: The ingestion of caustic substances represents a serious problem, often with devastating consequences on the esophagus and the stomach., Objectives: 1) Determine the main caustic substance ingested and the lesions on the esophageal-gastric mucose. 2) Find out the clinical-epidemiological characteristics of these patients in our hospital., Results: 45 inpatients at the Hipólito Unanue National Hospital were evaluated between 1996 and 2001, 29 female patients (64.4%) and 16 male patients (35.6%) with an average age of 28 years in a range between 15 and 60 years. The caustic substances ingested were: bleach, 30 patients (66.7%), muriatic acid (hydrochloric acid) 13 patients (28.9%), nitric acid and caustic soda, one patient each (2.2%). Among the women: 24 patients ingested bleach (82.7%) 4 patients, muriatic acid (13.7%) and one patient, caustic soda (3.4%). Among the men: 9 patients took muriatic acid (56.3%) 6 patients, bleach (37.5%) 1 patient, nitric acid (6.25%); 29 patients ingested the caustic substances in pure form (64.4%) and 16 patients diluted with other substances: water, soft or alcoholic drinks, oatmeal (35.5%). The time passed between the ingestion and medical attention was of 104 minutes, with a range of 15 to 360 minutes. The average of total ingested solution was 73 ml., ranging between 10 ml and 170 ml. The reason for the ingestion was a conflict with their spouse, 24 patients (53.4%) family conflict, 13 patients (28.9%) accident, 4 patients (8.9%) psychiatric problems, 3 patients (6.7%) and a monetary factor, 1 patient (2.2%). The signs and symptoms when admitted into the hospital were: abdominal pain, 31 patients (68.9%) nausea, 22 patients (48.9%) vomit, 21 patients (46.7%) mouth cavity pain, 19 patients (42.2%) dysphagia, 14 patients (31.1%) sialorrhea, 14 patients (31.1%) odynophagia, 13 patients (15.6%) sensory disorder, 7 patients (15.6%) dysphonia, 3 patients (6.7%) and cephalea, 1 patient (2.2%). Oral compromise was: normal in 11 patients (24.4%) congestion in 23 patients (51.1%) and erosions in 11 patients (24.1%). Endoscopic lesions found were: grade 0 in 6 patients (13.3%) grade 1 in 21 patients (46.7%) Grade 2A in 7 patients (15.6%) Grade 3B in 2 patients (4.4%)., Conclusions: Adolescents and young adults are the age groups which most suffer of this pathology. Bleach is the most ingested caustic substance (66.7%). Women have a higher risk of ingesting a caustic substance (64.4%). Caustic substances are mostly ingested pure (64.4%). Conjugal conflicts are the main reason for caustic ingestion. Clinical symptoms vary, with abdominal pain being the main discomfort among these patients. Oropharyngeal congestion is the most frequent finding. Esophageal-gastric mucose edema and hyperemia (Zargar 1) are the endoscopic lesions mostly found.

This paper examines three sets of hypothetical variables-demographic, diagnostic, and service-that may explain recidivism and/or lost-to-follow-up in people recently discharged from inpatient care. Using chart reviews, these variables were collected on 110 people who were discharged from a state hospital during a 24-month period who met criteria for recidivism, 51 individuals who were lost to follow-up, and 106 peers selected randomly as a comparison group. Results of between-group and survival analyses showed that recidivism was associated with a lack of 24-hour follow-up after discharge, a relatively high number of prior hospitalizations, gender (female), and diagnosis (borderline personality disorder [BPD]). Lost-to-follow-up was associated with not receiving services 24 hours after discharge, gender (male), and relatively low prior hospitalizations. Research failed to show that either outcome was associated with rural versus urban/suburban catchments. This kind of information is useful for developing discharge plans that will help to keep people out of the hospital and keep them from being lost to follow-up.

Differences between public mental health delivery systems do not permit generalizing most research findings from one service system to another. Under certain circumstances, generalizing psychopharmacological research findings may be feasible when patients served at these health care systems share a similar illness severity profile. This study compared the illness severity of schizophrenia patients served at the Veterans Healthcare Administration (VA) with that for Non-VA Medicaid patients served at state facilities. Findings demonstrate remarkable clinical comparability and suggest the potential for generalizing psychopharmacological research findings from one health care delivery system to the other, after adjustments for relevant background characteristics.

Purpose: To systematically characterize antipsychotic medication coprescribing ('polypharmacy') in a large state hospital system., Methods: All antipsychotic prescriptions written for all adult in-patients (N = 8212) in New York state-run civil facilities for the year 1999 were identified using the Integrated Research Database (IRDB) created by the Information Systems Division of the Nathan Kline Institute for Psychiatric Research. Antipsychotics were considered to be intentionally coprescribed only when both were prescribed for an overlapping period of 28 days., Results: Coprescribing of typical, atypical, and depot antipsychotics comprised 31% of antipsychotic prescribing episodes. Medications were usually coprescribed with medications from outside their own antipsychotic class. Patient factors, such as age, diagnosis, and history of prior hospitalization, affected coprescribing rates (p < 0.001 for all indicated variables). Atypical antipsychotic medications were less likely to be given with another antipsychotic than were oral or depot typical medications., Conclusions: Coprescribing of antipsychotic drugs is a common practice in the New York State hospital system. The analysis of large clinical databases can yield valuable information about the kinds of complex pharmacotherapy regimens actually utilized in the treatment of the most severely ill patients.

Background: The recent amalgamation of data by users of the Perinatal Problem Identification Programme (PPIP) throughout South Africa has culminated in the publication of the Saving Babies report., Objectives: To determine the absolute rate of death from intrapartum-related birth asphyxia, and the contribution of intrapartum-related asphyxia to total perinatal mortality in South African hospitals, and to identify the primary obstetric causes and avoidable factors for these deaths., Methods: The amalgamated PPIP data for the year 2000 were obtained from 27 state hospitals (6 metropolitan, 12 town and 9 rural) in South Africa. In PPIP-based audit, all perinatal deaths are assigned primary obstetric causes and avoidable factors, and these elements were obtained for all deaths resulting from intrapartum-related birth asphyxia., Results: There were 123,508 births in the hospitals surveyed, with 4,142 perinatal deaths among infants > or = 1,000 g, giving a perinatal mortality rate of 33.5/1,000 births. The perinatal mortality rate from intrapartum-related birth asphyxia was 4.8/1,000 births. The most frequent avoidable factors were delay by mothers in seeking attention during labour (36.6%), signs of fetal distress interpreted incorrectly (24.9%), inadequate fetal monitoring (18.0%) and no response to poor progress in labour (7.0%). The perinatal mortality rates for metropolitan, town, and rural areas were 30.0, 39.4 and 30.9/1,000 births respectively. The contribution of intrapartum-related birth asphyxia to perinatal mortality in these areas was 10.8%, 16.7% and 26.4% respectively., Conclusion: The high rates of perinatal death from intrapartum-related birth asphyxia in South Africa are typical of those in underdeveloped countries, with the most serious deficiencies in rural areas. Most of these deaths are avoidable and the reduction of these rates presents an important challenge to providers of perinatal care in this country. Areas worthy of research and action include provision of mothers' waiting facilities in rural regions, improvements in fetal monitoring, partogram-based labour management, and the establishment of midwifery staffing norms for South African labour units.

Background: This retrospective study attempted to replicate the observation that African Americans are more prone to receive excessive doses of antipsychotics, even after variables that have not been well explored in previous studies (smoking and antipsychotic potency) are controlled for., Method: The populations of 2 neighboring U.S. state hospitals, which were screened for patients who smoked, were included. The total sample comprised 316 patients from the first hospital (surveyed in 1990) and 447 patients from the second hospital (surveyed in 1992) who were taking antipsychotics and were either African American or white. An excessive antipsychotic dose (greater than 1000 mg of chlorpromazine equivalents per day) was the dependent variable in logistic regressions in all patients and in those patients with or without (DSM-III-R) schizophrenia., Results: In the total sample from both hospitals, excessive dosing was associated with schizophrenia, age under 56 years, long hospitalization duration, high-potency antipsychotics, second hospital, and depot antipsychotics. The odds of being prescribed excessive doses of typical antipsychotics were 1.8 times higher for African American than for white schizophrenic patients. African American race in schizophrenic patients appeared to be associated with the prescription of high-potency antipsychotics and with excessive dosing of this type of antipsychotic. Excessive dosing did not appear to be associated with race in nonschizophrenic patients nor in schizophrenic patients taking low-potency antipsychotics., Conclusion: Pharmacogenetic differences are not likely to explain this racial difference in prescription of excessive dosing of high-potency antipsychotics, which suggests that clinician attitudes may be a possible explanation. In future studies, pharmacogenetic tests and control for confounding factors, such as smoking, will help to establish whether racial differences in dosing are influenced by different metabolic capacities or physician biases.

Objective: To describe the current drug use practices at the institution, and gather baseline data, which can serve as a basis for designing an appropriate intervention to improve the drug use profile., Method: A retrospective audit of in- and out-patient prescriptions, generated during the period January-March 1999. Indicators of drug use pattern include: average number of drugs prescribed per encounter (ANDPE), average number of antibiotics prescribed per encounter (ANAPE), % encounter with antibiotics (PEA), percent of antibiotic prescriptions based on microbial sensitivity test results (MCST). Additionally, a "knowledge, attitude and practice" (KAP) survey of prescribers and dispensers was performed. Indicators of prescribing and dispensing quality include: sources of drug/prescribing information, availability and use of the hospital formulary, knowledge of the prescribing process and the adequacy of the drug supply management system., Results: A total of 9984 outpatient prescriptions and 127 in-patient case notes were audited. The total number of prescribers and dispensers surveyed were 88 and 13 respectively. The ANDPE was found to be 3.16 for out-patients and 9.7 for in-patients, ANAPE was 1.1 and 2.4 for out-patients and inpatients respectively. The PEA was 50.3% for out-patients and 96.7% for in-patients. Only 4.2% of in-patient antibiotic prescriptions were based on MCST and percent encounter with switches in antimicrobial therapy was 52.1% while the average number of switches per encounter was 1.35. In 18.5% of the in-patient encounters there was evidence of drug incompatibilities. The KAP survey revealed that prescribers and dispensers in the hospital rely on different sources for their drug information needs (MIMS vs Martindale Extrapharmacoepia). None of the prescribers surveyed was able to correctly enumerate all the 4 steps involved in the prescribing process, about 25% got at least 2 steps correctly, and only 9.1% of the dispensers surveyed could accurately define a hospital formulary. The drug supply management system was found to be inadequate., Conclusion: The survey revealed that appreciable gaps in knowledge with respect to rational drug use, still exists among these cadre of healthcare professionals. The foregoing suggests an urgent need for review of current policies and systems in the hospital with the view of enhancing the drug use practices of the health providers. Specifically it is recommended that there should be an intervention program involving concerted continuing education (to influence the KAP of the various cadre of healthcare providers) and the establishment of a hospital formulary/standard treatment guidelines.

The purpose of the present study is to compare the demographic and clinical characteristics of African Americans with and without an immediate history of homelessness upon entry into a state psychiatric hospital. Four variables made statistically significant contributions to the logit model predicting homelessness with the other variables controlled. They were never being married, lifetime comorbid substance abuse, severe paranoia, and high self-esteem. The four significant predictors from the logit model were used to assign patients to different risk groups. There was a significant dose-response relationship between the percentage of cases of homelessness and the number of these risk indicators.

Objective: This report is an analysis of gender related differences in clinical characteristics and hospital based health resource utilization among older adults with schizophrenia and schizoaffective disorder in an acute care, state hospital over a one-year period., Methods: This retrospective record review is an analysis of age of illness onset, psychiatric and medical comorbidity, hospital utilization, and psychotropic medication use., Results: There were a total of 66 individuals with either schizophrenia or schizoaffective disorder. Mean age of this group was 55.2 +/- 4.62 years. Women were significantly over-represented among individuals with late onset schizophrenia and schizoaffective disorder. Men with schizophrenia had more comorbid substance abuse compared to women with schizophrenia (p < 0.05). Women and men did not differ significantly in hospital length of stay, amount or type of antipsychotic medication prescribed, or in utilization of seclusion/restraint in hospital. Both genders had substantial utilization of antipsychotic medication. Use of conventional antipsychotic medication monotherapy was always associated with use of anti-extrapyramidal symptom (anti-EPS) medication, while use of atypical antipsychotic medication monotherapy was more rarely associated with use of anti-EPS medication., Conclusions: In later life, women and men may have some areas of differing health care needs. Women in particular may benefit from psychoeducational approaches that address the experience of psychiatric illness of relatively recent onset (for example, symptom identification and acceptance of illness). Men may benefit from particular emphasis on treatment of comorbid substance abuse disorders., (Copyright 2002 John Wiley & Sons, Ltd.)

Concomitant medications are frequently used in the treatment of resistant psychiatric conditions to augment the primary psychotropic agent or to ameliorate side effects. The present study evaluated the prescription of concomitant psychiatric medications for psychiatric inpatients that were prescribed either olanzapine at its first commercial availability or another first-line antipsychotic agent. Sixty-nine newly admitted patients (mainly with schizophrenia) who were prescribed either olanzapine (n = 35) or another first-line antipsychotic agent (n = 34) were assessed (for the prescription of other concomitant psychotropic drugs) before (2-4 weeks prior to study) and following 8 weeks of treatment (unless discharged sooner). The results indicate that significantly fewer olanzapine-treated subjects were prescribed anticholinergic agents as compared to those prescribed other first-line antipsychotic agents, and a similar trend was noted in the prescription of mood stabilizers as well. Olanzapine-treated subjects used less as needed (PRN) antipsychotic medication compared to pre-olanzapine treatment period. Olanzapine-treated subjects used more anxiolytic agents compared to the control group in the early stages of treatment, probably due to the greater baseline severity of illness. These data suggest that olanzapine use is associated with less use of anticholinergic and mood-stabilizing agents as compared to older antipsychotic agents. These results also suggest that there is less need for PRN antipsychotic medication following olanzapine treatment. More severely ill subjects may require more anxiolytics during olanzapine initiation. The need for less anticholinergic and mood-stabilizing agent use with olanzapine could lead to greater adherence to long-term treatment and perhaps decreased cost (i.e. use of blood and organ system monitoring with mood stabilizers). At the end of treatment, olanzapine-treated subjects had statistically significantly lesser concomitant medicine usage compared to control subjects.

Physical control (mechanical restraint and locked seclusion) of psychiatric patients has received increasing scrutiny, and better understanding of the timing of physical control would allow for more informed choices about its implementation. This study examined temporal regularities in the use of physical control at a general psychiatric hospital over a period of 8.6 years. As hypothesized, physical control was not randomly distributed through time but instead showed positive autocorrelation; yearly, weekly, and daily cycles; and higher frequency at patients' smoking, meal, and medication times. These results are discussed in the context of physical control research, theory, and policy., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Objective: This study examined whether information obtained early in the hospitalization process can be used to assess a patient's need for extended care., Methods: A sample of 2,430 inpatients who were admitted to a state psychiatric facility during a one-year index period (January through December 1997) were randomly assigned to a primary sample or a replication sample. Data were collected on demographic characteristics and history of previous hospitalization. The Brief Psychiatric Rating Scale-Anchored Version (BPRS-A) was administered to patients within 48 hours of admission, and four new subscales derived from ratings of newly admitted patients were calculated. Univariate and multivariate analyses were conducted to identify factors associated with whether a patient was discharged to the community or transported to another hospital for extended care., Results: A discriminant analysis of the data correctly identified 70 percent of the patients who were referred for continued hospitalization and 80 percent of the patients who were discharged to the community. The main correlates of the need for extended inpatient services were, in descending order, scores on the BPRS-A resistance subscale, the number of previous referrals for extended hospitalizations, and scores on the BPRS-A positive symptoms and psychological discomfort scales., Conclusions: BPRS-A subscale scores should be considered to be at least as good as more traditional measures in predicting length of hospitalization.

Caregivers and long-term care staff seek appropriate placements for dementia sufferers, but there is little empirical research to guide such decision-making. However, recent national trends in mental health care have emphasized the placement of persons with serious mental illness in privatized, community-based residences. This body of empirical research has indicated that persons with psychosis, substance use disorder, assaultive behavior, and medication noncompliance have shorter tenure in these residential settings. These findings are also important for other, more traditional health care settings, as the patients discharged from community residences may require assistance on occasion from such other settings. This study continues the inquiry into the characteristics of patients with serious mental illness, who have shorter tenure in community residences. Dangerous behaviors, treatment-resistant psychosis, medical illnesses, and social-interpersonal skill deficiencies were common causes for discharge in this study. Since there remains a paucity of published empirical studies on the issue for patients with Alzheimer's disease and other dementias, we present the implications of, and guidelines for, addressing these issues in dementia sufferers in long-term care settings.

This paper examines changes in use of state mental hospitals in Washington State from July 1, 1990, to July 1, 1997. It focuses on the phenomenon of ongoing use of state mental hospital by patients over a period of years. Two panels of state mental hospital users were identified: one preceded and one followed implementation of state mental hospital downsizing policies. Though the number of adults per year using the state mental hospital decreased following policy implementation, there was a significant increase in the overall rate of ongoing use. A logistic regression for ongoing use with multiple individual and regional predictor variables is described.

Objective: The purpose is to explore differences in confirmed, unconfirmed, and false allegations of abuse made by consumers with mental retardation in regards to type of abuse and perpetrator., Method: Interviews were conducted with 1,220 people with mental retardation who were part of a class action lawsuit in North Carolina. A content analysis of abuse allegations was performed. Frequencies of responses and subgroup differences are reported for type of abuse allegation and perpetrator., Results: Unconfirmed claims are the most frequent. Females made more allegations of abuse than males in general, and more allegations of rape. There are no significant differences among the subgroups (confirmed, unconfirmed, and false allegations) by type of abuse allegation. There are significant differences among the subgroups in regard to the alleged perpetrator. Other consumers with mental retardation are most frequently accused of confirmed assaults. Staff members are most frequently accused in false allegations., Conclusion: Ability of the alleged victim to report information and timing of the investigation are important factors in substantiating abuse. Awareness of consumer-to-consumer violence and prevalence of false accusations against staff necessitates increased safeguards for both consumers and staff.

In the past, the term "chronic" referred to people who had serious mental illness and who typically received long-term care in a state mental hospital. Although this term recently has fallen out of favor, we resurrect the term here, not to revive a demeaning euphemism, but rather to redefine it as the result of a poor person-environment fit between the complex and challenging needs of those with serious psychiatric disorders and a community-based service system that often is ill-equipped to treat them. Previous research indicates that recurrent acute hospitalizations and an inability to establish or maintain tenure in the community may be due to a disconnection from community-based services and supports, social isolation, and demoralization. One promising approach to addressing these issues is that of peer support. To illustrate the potential utility of peer support in improving person-environment fit and decreasing the chronicity of the subsample of people who continue to have difficulty in establishing viable footholds in the community, we describe a peer support-based program, the Welcome Basket, developed, staffed, and managed entirely by mental health consumers. Preliminary analyses that evaluate Welcome Basket's effectiveness are included, and we discuss the implications of these data for future research and program development in this area.

This study explored factors associated with psychiatric morbidity in typhoid fever in a Nigerian general hospital. Information such as sociodemographic characteristics, symptom manifestations, results of investigations, neuropsychiatric symptoms, outcome and disposal were obtained from the case files of patients admitted for typhoid fever over a period of six years. The patients with psychiatric morbidity conspicuous enough to be documented by the attending physicians-mostly internists-were compared with those with no documented psychiatric morbidity on sociodemographic and clinical indices. Of the 136 cases, 26 (19.1%) had psychiatric morbidity. This included delirium (73.1%), generalized anxiety disorder (3.8%), depressive episode (3.8%), schizophrenia like disorder (3.8%) and monosymptomatic neuropychiatric manifestations such as apathy, hallucinations and irrelevant talking (15.5%). The clinical and sociodemographic indices that were significantly associated with psychiatric morbidity were diarrhea, blood biochemical imbalance and age (P<.05). Adolescents and young adults were more predisposed to developing psychiatric complications. Some factors potentially associated with psychiatric morbidity in typhoid fever have been identified. There is the need to prospectively assess the burden from psychiatric morbidity and identify interventions that may reduce it.

This study compared the discharge rates and drug costs of 789 patients with schizophrenia or schizoaffective disorder who began pharmacotherapy with olanzapine or risperidone between July 1997 and June 1998. Discharge rates 30 days after the start of treatment were 45 percent for the patients treated with risperidone and 32 percent for those treated with olanzapine (p=.001). Daily drug costs during the same period were $6.42 for risperidone and $12.29 for olanzapine (p<.001). For risperidone, lower dosages were associated with higher hospital discharge rates, whereas no significant association was observed for olanzapine. These data suggest that among inpatients with schizophrenia or schizoaffective disorder, use of risperidone results in a higher discharge rate and a lower drug cost than use of olanzapine.

This retrospective case note review describes the demographic, forensic and psychiatric backgrounds of 14 in-patient suicides in a maximum secure hospital. The majority were schizophrenic with chronic treatment-resistant illnesses, who had committed proportionally more violent offences, had a history of serious self-injury but no recognized clear depressive episodes. This profile is markedly different from that reported in general psychiatric in-patients, out-patients and suicides in prison, but is similar to that described in a maximum secure hospital in the United States and in long-stay patients in Canada. Many of the patients had continued to experience significantly subjective distress over many years. The clinical relevance of this series is discussed in the context of the assessment of suicidal intent in psychotic patients. We speculate that the decrease in in-patient suicides in the State Hospital may be due to a less restrictive ward milieu, increased staff/patient ratios, or the introduction of Clozapine.

This study examined whether inpatient bed reductions at a Department of Veterans Affairs (VA) medical center increased VA patients' use of state mental health agency services. Veterans residing in two Connecticut cities who used VA psychiatric services during fiscal years 1993 through 1998 (n = 2,943) were identified from computerized files. Then their records were merged with state files. Coinciding with the time of VA bed closures, the proportion of VA patients who used any state services increased from 2.6%, 2.8%, and 2.7% from 1993 through 1995 to 3.6%, 3.5%, and 3.6% from 1996 through 1998 (p < .03). These changes reflect increased likelihood of state outpatient service use, but not inpatient services. No statistically significant changes occurred in the cost of state services used by VA patients. Bed closure impact may be reflected in increased cross-system service use, which may be a useful indicator of unmet needs resulting from system changes.

Background: Dissemination in patients with cutaneous leishmaniasis has previously been recorded in human infection with Leishmania major and L. tropica. In this study, the potential for dissemination in different ethnic groups in Saudi Arabia was compared., Methods: The data were recorded from a group of 73 patients with suspected cutaneous leishmaniasis (43 Saudi and 30 non-Saudi) attending the Dermatology Clinics at King Fahd Hospital of the University and Al-Khobar Government Hospital at Al-Khobar, Eastern Region of Saudi Arabia. The patients were of various age groups (all male) between 1 and 55 years. The diagnosis of cutaneous leishmaniasis was confirmed clinically and by smear and skin biopsy. The following data were recorded for each patient: type, number, and anatomic sites of disseminative lesions and the frequency of co-occurrence of more than one type of lesion., Results: Three types of disseminative lesions due to zoonotic cutaneous leishmaniasis were recorded in 16 patients (21.92%): subcutaneous nodules, satellite papules, and subcutaneous induration. The percentage of disseminative lesions in non-Saudi patients (36.66%) was higher than in Saudi patients (11. 63%). This was also true for the number of lesions: a mean of 12.27+/- 10 and 6.4+/-3, respectively. The coexistence of more than one type of disseminative lesion was higher in non-Saudi patients (63. 63%) than in Saudi patients (20.0%), as well as the occurrence of lesions on more than one body site: 36.4% in non-Saudi patients and 20.0% in Saudi patients., Conclusions: The potential for dissemination due to cutaneous leishmaniasis was significantly higher in the nonindigenous population than in the indigenous population in Saudi Arabia. Disseminative lesions must be clinically differentiated from other skin diseases and appropriately treated by avoiding the use of intralesional drugs or physical therapy.

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

Objective: This study examined incarceration rates of users of Department of Veterans Affairs (VA) mental health services in 16 northeastern New York State counties between 1994 and 1997-a time of extensive bed closures in the VA system-to determine whether incarceration rates changed during this period., Methods: Data were obtained for male patients who used inpatient and outpatient VA mental health services between 1994 and 1997 and for men incarcerated in local jails during this period. For comparison, services use and incarceration data were obtained for all men who received inpatient behavioral health care at community general hospitals and state mental hospitals between 1994 and 1996 in the same counties. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between clinical and incarceration populations without relying on person-specific identifiers., Results: Of all male users of VA mental health services between 1994 and 1997, a total of 15.7 percent-39.6 percent of those age 18 to 39 years and 9.1 percent of those age 40 years and older-were incarcerated at some time during that period. Dual diagnosis patients had the highest rate of incarceration (25 percent), followed by patients with substance abuse problems only (21 percent) and those with mental health problems only (11 percent). The rate of incarceration among male patients hospitalized in VA facilities was lower than among men in general hospitals or state hospitals (11.6 percent, 23 percent, and 21.7 percent, respectively), but was not significantly different. No significant increase occurred in the annual rate of incarceration among VA patients from 1994 to 1997 (3.7 percent to 4 percent), despite extensive VA bed closures during these years., Conclusions: Substantial proportions of mental health system users were incarcerated during the study period, especially younger men and those with both substance use and mental health disorders. Rates of incarceration were similar across health care systems. The closure of a substantial number of VA mental health inpatient beds did not seem to affect the rate of incarceration among VA service users.

Objective: Despite growing numbers of elderly persons with serious mental illness such as schizophrenia, little research has been conducted on the manifestation of serious mental illness in later life, and our understanding of the mental health care needs of this population is limited. This study examined length of stay and medication use among women age 50 and older admitted to an acute care state psychiatric facility., Methods: A computerized record search for all women discharged from a large urban state psychiatric facility over a one-year period was undertaken. Demographic and resource utilization data, including total length of stay and pharmacy utilization, were obtained from the hospital database., Results: The database search produced the records of 564 women, with a mean age of 37.5 years. Women constituted 60 percent of patients over age 50. The mean length of stay was 16.1 days for the entire group; for women under age 50 (N=492), mean length of stay was 15 days, and for women age 50 and older (N=72), it was 23.1 days (p=. 01). Among those age 50 and older, 58.3 percent had a diagnosis of schizophrenia or schizoaffective disorder, compared with only 38 percent of those under age 50., Conclusions: Our data suggest that women constitute the majority of patients over age 50 in a state psychiatric facility and that they have longer stays than younger women.

Objective: To determine the presentation, aetiological pattern, management and outcome of intestinal obstruction at the Central Provincial General Hospital, Nyeri, Kenya., Design: A descriptive retrospective study., Setting: Surgical Department, Central Provincial General Hospital, Nyeri, Kenya., Subjects: All patients who were admitted and operated on for intestinal obstruction in the surgical department of the above hospital between January 1992 and May 1999., Results: A total of 139 patients were studied. There were 102 males and 37 females giving a male:female ratio of 2.8:1. The age range was two days to 85 years with the majority (43.2%) of the patients being in the age group 0-10 years. Vomiting and abdominal pain were the commonest symptoms while abdominal distension and abdominal tenderness were the leading signs. Abount seventy of the patients had any form of investigation with plain abdominal x-ray being the leading investigation. Sigmoid volvulus, external herniae, adhesions and bands and ileo-colic intussusception were the commonest causes of bowel obstruction. About a third (32.4%) of the patients were found to have gangrenous gut. Sixty three complications were recorded in 47 patients, with the leading complication being death (17.3%) followed by wound infection (14.4%)., Conclusion: Five leading causes of intestinal obstruction in Nyeri, Kenya, are: sigmoid volvulus, external herniae, adhesions and bands, ileocolic intussusception and small bowel volvulus.

Objective: To report and discuss differences between schizophrenic patients in the community and those in maximum security care., Method: Comparison of 193 community schizophrenic patients with 169 in high security care. Data included case notes, interviews and cognitive tests., Results: Compared to high security patients, community patients tended to be female and married. They had higher school achievement, higher premorbid IQ and better occupational levels, were less likely to have a family history of alcohol abuse, to have had police contact and to have attempted suicide. They had more frequent shorter psychiatric admissions and fewer current and lifetime schizophrenic symptoms. Logistic regression models discriminated the groups with considerable accuracy., Conclusion: Patients needing high security care may be recognizable when schizophrenia is first diagnosed. Progression to the State Hospital seems to result from schizophrenia together with other factors such as deprivation rather than from a worse schizophrenic process per se.

Background: The use of electroconvulsive therapy (ECT) in the state hospital setting currently represents a very small percentage of the total overall use of this modality in the treatment of the mentally ill., Method: Using records kept by a state hospital, we retrospectively identified all patients who had received ECT between the years 1986 and 1995. A review of the records at the state hospital from where patients were referred and the university hospital where ECT was administered was undertaken. Demographic and clinical characteristics, reasons for referral, symptom profile, ECT parameters, clinical outcomes, and restraint/ seclusion data were assessed., Results: Over 10 years, 21 patients were treated with ECT, representing 0.4% of all admissions to the state hospital. Of these subjects, 17 records could be retrieved. The majority were women (N = 12; 71%) and were diagnosed with a mood disorder. Ten subjects (59%) were over the age of 60 years, 4 of whom were 70 years or older. Most patients had a state hospital length of stay of 1 year or less. The mean number of ECT treatments was 12.2. There were no medical complications that led to premature termination of ECT. Eleven patients (65%) were discharged either directly from the university hospital or within 10 days of readmission to the state hospital. Six of 7 patients who had restraint and seclusion episodes prior to ECT were found to have no further episodes afterwards. The seventh experienced a dramatic decrease in number and total hours of episodes., Conclusion: For a substantial minority of patients in this state hospital setting, ECT appears to have been an effective and safe form of treatment, and its use should be considered early rather than late in the course of hospitalization.

Aim of the Study: To analyse the state and the structure of the neonatal lethality in the largest perinatal center of Bulgaria 'Maichin dom' during the last five years, and to compare them with the national data on neonatal mortality., Material and Methods: A retrospective study on the evolution of neonatal lethality in the recent 5 years and on its structure during the last 2 years was fulfilled using the data of the Department of Neonatology of the University hospital 'Maichin dom' concerning the infants' lethality. The results were compared to the national data on infants' mortality (in 28 days of life) and presented graphically., Results: The level of neonatal lethality in the University hospital increased invariably until 1997, when it reached the highest peak (12.7@1000), after that it decreased to 10.3@1000 in 1998. This tendency is predominantly due to the early neonatal mortality, which raised from 6.7@1000 in 1994 to 8.5@1000 in 1998, and remained at the same level in the last two years. The leading causes of neonatal lethality in the perinatal center are the congenital malformations--40.6@1000, which is higher than in the country. The congenital anomalies of central nervous system account to 75@1000 of all lethal malformations. The perinatal asphyxia is the second cause of death--34.7@1000, which is considerably less than in the country--41.3@1000. The neonatal respiratory distress syndrome is the third main cause of death in the neonatal period--9.4@1000 in the hospital; 10.9@1000--in the country. The neonatal lethality is mainly due to the premature infants--82.5@1000 in 1997 and 90.6@1000 in 1998. The relative portion of the term infants considerably decreased in these two years--from 17.5@1000 to 9.4@1000. These numbers are 100 times less than the data of the whole country., Conclusions: The evolution of the neonatal lethality in the University hospital 'Maichin dom' has a similar tendency of the neonatal mortality in Bulgaria, the increase being mostly due to the early neonatal mortality. The leading causes of death are the congenital malformations and predominantly the central nervous system defects. The perinatal asphyxia is the second most frequent lethal cause with a relative portion which is less than that in the country. The lethality of the premature infants in the hospital is 6 times less than that in the country and the neonatal lethality of term infants is practically discriminated.

Patients' rights issues are currently being discussed in health care at both the private and public levels in Turkey. In this study, 317 patients were interviewed upon hospital discharge and asked what they knew about their "rights" as patients. According to the collected data, 63% of the patients were not aware that they had any rights in receiving health care services at all. Since this is the first study of its type in Turkey, further research in this area is needed. In closing, it is recommended that hospitals in Turkey adapt routine policies similar to those in the United States for informing customers about their rights for safe, effective and efficient health care provision.

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

Objective: We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany., Method: We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992., Results: The LKH patients were significantly older (74.8 +/- 8.7 y versus 70.3 +/- 8.3 y), more often living alone and/or without children. 31.9% of them were living in a nursing home compared to 6.5% of the PUK patients. Psychic disorders had not shown up before old age in 55.7% of all cases. 50.4% of the patients were in a psychiatric hospital for the first time. The majority of the patients (65.6%) had not been investigated by a psychiatrist before admission., Conclusions: More socially handicapped patients were treated in the LKH. For most cases, the hospital treatment had been the first psychiatric treatment at all.

Objective: We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany., Method: We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992., Results: Most patients of the LKH suffered from organic brain diseases/dementia (63.4%; PUK: 29.1%). In the PUK, depression was the most frequent diagnosis (57.6%; LKH: 21.1%). A part of about 25% of the patients showed neurological deficits. Specialised diagnostics were performed mostly in the PUK. Both institutions treated the wide majority of patients with CNS drugs. Antidementia drugs were given significantly more often in the LKH. About one third of the patients were released into changed living environments., Conclusions: Patients with further progressed dementias were treated mainly in the LKH. This has consequences for diagnostics, treatment duration and side effect rate.

Prior to managed care, extensive research documented the characteristics of assaultive inpatients in traditional state mental hospital settings as primarily older, male, psychotic patients with histories of violence toward others and of substance abuse. Recent early studies in rural and urban hospital settings have suggested that the characteristics of assaultive patients may be changing to include younger, more frequently female, patients with personality disorders and histories of personal victimization. This two-points-in-time study sought to assess the nature of assaultive patients in a suburban traditional state mental hospital after the implementation of managed care initiatives, and compared to the nature of the assaultive patients before and after the downsizing of this state mental health facility. Before census reduction, the assaultive patients were of the traditional type. After census reduction, the assaultive patients reflected more recent trends. The implications of the findings are discussed, and strategies for fostering facility safety in light of the newer violent patient are outlined.

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

Background: Several studies have shown a growth in the number of visits to accident and emergency (A&E) hospital departments with a high proportion of inappropriate utilization. Methods to identify improper use based on implicit criteria limit the comparisons between hospitals. The aim of this study is to know the proportion of inappropriate attendance's in an A&E department and their associated factors, using a method with objective criteria., Methods: An instrument based on diagnosis-independent explicit criteria was used to identify inappropriate visits in a random sample of 1845 14-year-old greater patients attended to A&E medical services, and the factors associated with improper demand were analysed., Results: The proportion of inappropriate attendance's was of the 26,8% (495/1. 845). The unadjusted analysis show that the smaller age, absence of comorbidity, spontaneous visit and some diagnostic groups (diseases of the skin, muscle-skeletal, mental, and bad defined symptoms) were associated to a greater proportion of improper use. Upon adjusting the variables through logistics regression, the age, associated pathology, the spontaneous attendance's and diagnostic groups, maintained the association with improper use, but other variables as woman gender, and night hours were also associated to inappropriate utilization., Conclusions: At least the fourth part of the attendance's in the A&E medical services do not require urgent attention. Inappropriate utilization is associated to characteristic of the patient and the attended process.

Background: In spite of some inherent limitations, naturalistic data can provide information on populations that have greater heterogeneity than can controlled clinical trials and on functional outcomes that may be especially important in clinical practice. In the present retrospective naturalistic study, we evaluated key clinical outcomes among the first wave of risperidone-treated patients at a state psychiatric hospital., Method: Outcome data were extracted from the charts of 142 patients 2 years after initiation of treatment with risperidone. Their diagnoses included DSM-III-R schizophrenia (57%), schizoaffective disorder (22%), dementia and other organic conditions (7%), bipolar disorder (5%), and other psychiatric disorders (9%)., Results: During the 2-year period, 92 of 142 patients were discharged from the hospital: 61 (43%) were discharged on risperidone treatment and 31 (22%) were discharged on treatment with other drugs. At the time of the study, 50 of 142 patients were still in the hospital: of these, 18 (13%) were still receiving risperidone. The modal maximum daily dose of risperidone was 4.1 mg in patients discharged on risperidone treatment and 7.5 mg in patients still in the hospital. All groups were granted more ward privileges after starting risperidone, the most being granted to patients discharged from the hospital on risperidone treatment (p<.05 versus patients discharged on treatment with other drugs) and those still receiving risperidone in the hospital. Significantly fewer patients discharged on risperidone treatment than on treatment with other drugs were readmitted to the hospital within 2 years after discharge (p<.01)., Conclusion: Improved privilege levels and a reduced readmission rate indicate that risperidone was an effective antipsychotic agent among a heterogeneous patient population in a state hospital. These factors may be especially important to justify use of this agent in the current fiscal climate.

Objective: This study examined the mental health service utilization and costs of 321 discharged state hospital patients during a 3-year follow-up period compared with costs if the patients had remained in the hospital., Method: The study subjects were long-stay patients discharged from Philadelphia State Hospital after 1988. A longitudinal integrated database on all mental health and medical services reimbursed by Medicaid and Medicare as well as state- and county-funded services was used to construct service utilization and unit cost measures., Results: During the 3-year period after discharge, 20%-30% of the patients required rehospitalization an average of 76-91 days per year. The percentage of rehospitalized patients decreased over time, but the number of hospital days increased. All of the discharged patients received case management services, and a majority also received outpatient mental health care (66%-70%) and residential services (75%) throughout the follow-up period. The total treatment cost per person was approximately $60,000 a year after controlling for inflation, with costs rising slightly over the 3-year period. The estimated cost of state hospitalization, with the use of 1992 estimates, would have been $130,000 per year if the patients had remained institutionalized., Conclusions: This analysis suggests that most former long-stay patients are able to live in residential settings while receiving community outpatient treatment and intensive case management services at a reduced cost. There is no indication of cost shifting from the psychiatric to the health care sector; however, some cost shifting from the state mental health agency to the Medicaid program has occurred, since most psychiatric hospital care now takes place in community hospitals.

Objective: The purpose of this study was to examine rehospitalization rates of people receiving risperidone or clozapine who had been discharged from state psychiatric hospitals in Maryland., Method: Rehospitalization status was monitored for all patients discharged from state psychiatric facilities on a regimen of either risperidone or clozapine between March 14, 1994, and Dec. 31, 1995. Patients were followed up with respect to readmission until Dec. 31, 1996. Time to readmission was measured by the product-limit (Kaplan-Meier) formula. Risk factors associated with rehospitalization were examined., Results: One hundred sixty patients were discharged on risperidone, 75 having the diagnosis of schizophrenia. The patients with schizophrenia were more likely to be readmitted than the 85 patients with other mental disorders. Recidivism rates for schizophrenic patients discharged on risperidone versus those discharged on clozapine were not significantly different over the 24-month study period. However, no patient who received clozapine and remained discharged for more than 10 months (N = 49) was readmitted, while the readmission rate for risperidone-treated patients appeared to be steady up to 24 months. At 24 months 87% of the clozapine-treated patients and 66% of the risperidone-treated patients remained in the community. No clinical or demographic variables were found to predict rehospitalization., Conclusions: This study demonstrates that the rehospitalization rates of patients taking the second-generation antipsychotics risperidone and clozapine are lower than those in previously published reports of conventional antipsychotic treatment.

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