Outpatient Treatment Strategies Research Articles

Readmission and Dropout in Outpatient Centers: An Analysis of Real-World Data in Patients with Dual-Diagnosis

AbstractSubstance use disorder treatment faces challenges such as dropout, relapse, and readmission. This study aims to identify factors associated with readmission and those influencing dropout among dual diagnosis (DD) patients (those with both a substance use disorder and another psychiatric disorder) attending outpatient addiction centers. Retrospective cohort study using the electronic health records of 8383 outpatients diagnosed with DD. Bivariate analysis and regression analysis were applied to control for the variables. Age, incarceration for 30 days prior to admission, and specific patterns of consumption increased the likelihood of readmission. Specifically, individuals who reported no substance use in the 30 days before admission or those diagnosed with an opioid or cocaine use disorder were particularly susceptible to readmission. Of the dual diagnoses, patients with personality disorders were more likely to be readmitted. In relation to dropout, opioid dependence and frequency of use were associated with a higher probability of dropout. Patients with poorer adherence to treatment and previous readmissions were also more likely to drop out. Enhancing treatment adherence and reducing dropout and readmission rates poses a challenge in managing patients with DD. Leveraging electronic health records offers enhanced ecological validity concerning the outpatient treatment requirements for such patients. Therapeutic adherence, alongside specific sociodemographic variables and consumption patterns, emerges as pivotal factors in this context. Identifying and understanding these variables facilitates the customization of outpatient treatment strategies to better meet the needs of patients with comorbidities.

Novel Outpatient Treatment Strategy for Cranial Infections – A Single-Center Experience

Novel Outpatient Treatment Strategy for Cranial Infections – A Single-Center Experience

Economic Implications of Endometriosis: A Review.

Endometriosis is a chronic inflammatory disease that can have serious physical and emotional consequences for patients in terms of pain, quality of life, and infertility. Despite affecting about 10% of women, the pathophysiology and economic impact of the disease are not fully understood. This study aimed to review and summarize research articles quantifying the direct and indirect costs of endometriosis in the context of current national and international treatment guidelines. A search including the terms 'endometriosis' AND 'costs' OR 'cost of illness' OR 'cost analysis' OR 'economic burden' was performed, focusing on studies published between January 2000 and May 2022. Total costs, costs of primary and secondary care, productivity losses, and indirect costs were reported. The medical costs of endometriosis were principally registered in secondary care settings, where surgery was the main cost driver. There was considerable variability of populations and study settings, with the overall direct medical cost range of endometriosis from US$1459 to US$20,239 (2022) per patient per year. An increasing trend has been reported in secondary care costs over time; however, not enough data were available at this time to evaluate inpatient and outpatient costs versus treatment strategies. Similarly, further research is required to evaluate the costs and potential savings associated with new therapies. Numerous studies have evaluated the indirect costs of endometriosis in recent years, finding costs between US$4572 and US$14,079 (2022). Currently, limited data are available on the economic burden of the disease at the patient level.

The CHIVA strategy applied to large-diameter saphenous veins.

CHIVA (Cure Conservatrice et Hemodynamique de l'Insufficience Veineuse en Ambulatoire) is a conservative outpatient treatment strategy for chronic venous disease (CVD) that preserves the superficial venous system. A modified two-stage strategy is used in patients with a great saphenous vein (GSV) diameter ≥9 mm with the goal to decrease the risk of symptomatic superficial vein thrombosis (SVT), as the risk of complications is higher when first and second stage is performed simultaneously. We conducted a retrospective observational study of 111 patients with CVD and a GVS diameter ≥9 mm treated with two possible stages of the CHIVA strategy, between January 2010 and December 2019. The goal of the first stage was to interrupt the main reflux escape point (incompetent saphenofemoral junction), thereby lowering the venous pressure and achieving a sufficient reduction in GSV diameter to enable, if necessary, a second stage that consists of disconnection of secondary reflux exit point (incompetent saphenous tributaries), with a lower risk of symptomatic SVT when patients do not show significant clinical improvement. Reductions in GSV diameter, postoperative complications and clinical improvement were analyzed. There were 60 men (54.1%) and 51 women (45.9%) with a mean age of 57±11.9 years. All patients undergone first surgical stage, and this interruption of the saphenofemoral junction was the single procedure in 77.5% of cases (86 patients). Mean follow-up time was 19.8 months. The second stage was performed in 25 patients (22.5%). Mean preoperative GSV diameter was 10.2±1.1 mm and this decreased to 7.1±1.5 mm after the first surgery (mean reduction, 3±1.5 mm, P<0.001). Six patients (5.4%) experienced recurrence due to recanalization of the reflux point and 16 patients (14.4%) developed SVT, which was symptomatic in 12 cases (10.8%). Interruption of the main reflux escape point as a single procedure in patients with a GSV diameter ≥9 mm led to a significant reduction in diameter and sufficient clinical improvement in almost 80% of cases.

The University of Kansas Health System Outpatient Clinical Concussion Comprehensive Protocol: An Interdisciplinary Approach.

Objective:The concussion team at The University of Kansas Health System outpatient rehabilitation spine center is comprised of experienced multi-disciplinary experts including physical therapists and a speech language pathologist. The team set forth with a purpose of creating and organizing an internal physical therapy clinical recommendation protocol for initial evaluations and subsequent treatments for the concussed patient. The aim of this paper is to share these recommendation protocols with other therapy teams and provide a foundational layout for treating the patient with post-concussion symptoms in an outpatient physical therapy clinical setting.Study design:Clinical recommendation protocol provides guidance for patients ages 10+ from initial evaluation through discharge with emphasis on evidence-based research in the areas of: oculomotor, cervical, vestibular, post-concussion migraine influence, mood disorders(such as anxiety and depression), exertion, and cognitive communicative dysfunction.Results:Finding a written, comprehensive clinical resource protocol for post-concussion outpatient evaluation(s) and treatment strategies can be difficult. This document serves as a resource for other outpatient concussion rehabilitation clinics, providing rationale, and objective measurement tools, for assessing and treating concussion patients. To the authors’ knowledge, no other research has produced a practical, efficient evaluation tool to be utilized at bed side, condensing evidence-based research into an easy-to-use form.Conclusion:The University of Kansas Health System outpatient concussion rehabilitation center developed clinical recommendation protocols for concussion care. The intent was to standardize assessment and treatment for concussion patients and to share these objective measurement tools and procedures, focused on a team approach of concussion providers, as a clinical outline for both the novice and seasoned clinician specializing in the field of concussion work in an outpatient rehabilitation setting.

Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis.

Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.

Challenges posed by COVID-19 and neurosurgical nursing strategies in developing countries.

Background: Neurosurgical patients with stroke, trauma, and brain tumors can be among the victims of the COVID-19 pandemic in developing countries, which need to be managed efficiently.Methods: This is an overview of neurosurgical nurses’ challenges and strategies in the current COVID-19 pandemic environment in developing countries.Results: Here, we reviewed the unique challenges of providing neurosurgical nursing services during the COVID-19 pandemic in developing countries. We address specific issues such as transferring neurosurgical patients, allocating medical supplies, prioritizing neurosurgical services, COVID-19 testing protocols, and patient triage (emergent vs. urgent vs. delayed surgery). Teleconsultation, telenursing services for outpatient treatment, follow-up and virtual teaching strategies associated with neurosurgical nursing are discussed.Conclusion: Neurosurgical nursing during the COVID-19 pandemic in developing countries requires transparent planning, implementation, and careful consideration of various telemedicine strategies.

Implementation of the WHO guideline on treatment of young infants with signs of possible serious bacterial infection when hospital referral is not feasible in rural Zaria, Nigeria: Challenges and solutions.

Bacterial infection is one of the leading causes of mortality in young infants globally. The standard practice to manage young infants with any sign of possible serious bacterial infection (PSBI) is in a hospital setting with parenteral antibiotics, which may not be feasible for majority of cases in most low resource settings. The World Health Organization developed a guideline on management of PSBI in young infants when referral is not feasible in 2016. We conducted implementation research in selected communities in Zaria Local Government Areas of Kaduna State with an estimated population of 50,000 with the aim of understanding how to implement the WHO PSBI treatment guideline to achieve high coverage with low case fatality and treatment failure rates. Implementation was within the programmatic settings using existing health structure. We conducted policy dialogue with decision makers to adapt the recommendations to their social, cultural and programmatic context in Nigeria, held orientation meetings with program managers, built capacity of the health workers and supported the implementation within the health system. We supported a non-government organization to conduct community sensitization to promote care seeking and adherence to treatment advice. The research team collected data systematically on all young infants identified to have PSBI, the treatment they received and the clinical outcome. Between April 2016 and March 2017, we identified 347 young infants up to 2 months of age with signs of PSBI who received treatment either as an outpatient or in a hospital among 2,154 births in the study population. The coverage of PSBI treatment in the study area was 95.5% assuming that 10% of all births have an episode of PSBI in the first two months of life. Most (89%) sick young infants with PSBI were identified by the community-oriented resource persons and sent to the Primary Health Care Centres (PHCs). Most families (97%) refused referral and were treated at a primary health care centre on outpatient basis. There were 12 deaths (3.5%) and 17 non-death treatment failures (4.9%) in 343 infants in whom an outcome could be ascertained. While non-death treatment failure rate was highest in 0-6-day infants with fast breathing (14.4%), case fatality was highest in those with signs of critical illness (20%). We have demonstrated that outpatient treatment strategy for young infants with PSBI when referral is not feasible is implementable within the programmatic settings, achieving very high population coverage and relatively low treatment failure and case fatality rates. Implementation at scale will require government's commitment to strengthen the health system with trained, motivated health care providers and necessary commodities.

The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880 by Wendy Gonaver

Reviewed by: The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880 by Wendy Gonaver Dea H. Boster (bio) The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880. By Wendy Gonaver. (Chapel Hill: University of North Carolina Press, 2019. Pp. 268. Cloth, $90.00; paper, $32.95.) Founded in Williamsburg in 1773 and renamed in 1841, the Eastern Lunatic Asylum of Virginia was the first public mental health facility in America. Physician John M. Galt II, who served as its superintendent from 1841 until his death by laudanum overdose in 1862, had a unique, albeit racialized vision for the institution and the populations it would serve. The asylum was progressive in the United States for its utilization of environmental-moral therapy, nonrestraint, and outpatient treatment strategies, all of which were novel approaches to psychiatric intervention in the early nineteenth century. Galt also courted controversy for his admission of black patients (both free and enslaved) and use of enslaved staff and caregivers, making it the only institution in the United States “to openly contend with the contradiction of deploying nonviolent curative means within a context of systemic social violence” (6). In that respect, the phrase “the peculiar institution” in the book’s title has a double meaning, referring both to slavery and to the asylum itself. Delving deeply into the asylum’s archive (housed until recently in a hospital storage closet), the author traces the complex genealogy of this fascinating institution through physician notes, patient records, family and staff correspondence, and a variety of other primary documents to identify how it changed from a racially integrated site of treatment for the mentally ill to a segregated institution for the “defective” within a forty-year period. The monograph is organized around different themes: psychiatry and treatment regimes in the context of racism and slavery, the roles and strategic negotiations of enslaved attendants and patients, the slippery relationships between madness and religious enthusiasm, issues of gender and the psychological trauma of domestic violence, and the impact of [End Page 261] the Civil War and Reconstruction on the asylum (as well as broader ideas about mental illness and eugenic defectiveness). Each chapter is rich with poignant details that illuminate the complexities of this institution and the humanity of those who lived with it, breathing life (and agency) into individuals whose stories would otherwise remain unknown. When Galt assumed his role as superintendent at the institution, many of his policies were on the fringe of medical practice and seemed discordant with his personal views on slavery and racial difference. As a result of Galt’s untimely death and Union occupation of the region during the Civil War, the asylum became increasingly obsolete and disorganized. During Reconstruction, the Central Lunatic Asylum was established as a separate institution for African American patients and featured more punitive incarceration (including restraint and eugenic sterilization) for those increasingly seen as “permanently defective” (196). In many ways, Gonaver’s riveting and thorough analysis of the Eastern Lunatic Asylum defies easy explanation. Although the book’s subject matter is limited to one institution and a discrete time period, the author makes a strong case for situating that place and time at a number of crucial intersections in American medicine, society, and culture. On the surface, the book reinforces historical links between ideas about race and disability, particularly mental illness, which is an increasingly prevalent perspective in recent scholarship. However, Gonaver’s analysis simultaneously combats prevalent biases in Western medical history more broadly, most notably the focus on European and northern American (also white) institutions and physicians in declension narratives of asylum medicine. The author also demonstrates how nineteenth-century constructions of insanity were linked with a staggering variety of other factors, including slavery as both a social category and a labor system; gender, race, and social class in the American South; religiosity and antislavery activism during the Second Great Awakening; sexuality and propriety in the Victorian era; medical eclecticism and professional identities; the social and political upheaval of the Civil War; and Reconstruction policies and the rise of Jim Crow in the late nineteenth century. Yet, at the same time, the book never loses its close connection to the...

Costs of outpatient and inpatient MRSA screening and treatment strategies for patients at elective hospital admission - a decision tree analysis

BackgroundNosocomial infections are among the most common complications in hospitals. A major part is caused by multidrug-resistant organisms (MDRO). MRSA is still the most prominent and frequent MDRO. The early detection of carriers of multidrug-resistant bacteria is an effective measure to reduce nosocomial infections caused by MDRO. For patients who are planning to go to the hospital, an outpatient screening for MDRO and pre-hospital decolonization is recommended. However, the effectiveness of such pre-admission MDRO management in preparation for a planned hospital stay has not yet been sufficiently scientifically examined from an economic perspective.MethodsA decision tree will be used to develop scenarios for MDRO screening and treatment in the context of the outpatient and inpatient sectors using MRSA-positive patients as an example. Subsequently, the expected costs for the respective strategy are presented.ResultsThe decision tree analysis shows that the expected costs of outpatient MRSA management are €8.24 and that of inpatient MRSA management are €672.51.ConclusionThe forward displacement of the MRSA screening to the ambulatory sector and any subsequent outpatient decolonization for patients with a planned hospitalization is the most cost-effective strategy and should become a standard benefit. Excluding opportunity costs, the expected costs of inpatient MRSA management are €54.94.

Treatment-Refractory Obsessive-Compulsive Disorder in Adults: A Cost-Effectiveness Analysis of Treatment Strategies.

This study sought to assess the cost-effectiveness of 7 treatment strategies for treatment-refractory obsessive-compulsive disorder (OCD) in adults. A model was developed to evaluate treatment alternatives for adults (18-64 years old) that consisted of 2 parts: a decision analytic model and a Markov model. The decision analytic model stratified 7 outpatient treatment strategies, and the Markov model accumulated benefits and costs across the life expectancy of a simulated cohort of individuals. The model was parameterized with probabilistic and deterministic parameters from the literature and an outcomes database to perform a Monte Carlo simulation of a hypothetical cohort of 100,000 adults with OCD to estimate net health benefits (NHBs), costs, and incremental cost-effectiveness ratio (ICER) for each treatment strategy. OCD was considered treatment refractory in adults with an OCD diagnosis who failed first-line therapies. Encounters took place from 2012 to 2015, and the analyses were performed from November 2016 to February 2017. Partial hospitalization with step-down to intensive outpatient treatment was the most cost-effective of the 7 strategies, with an estimated ICER of $7,983 and mean (SD) NHB of 10.96 (0.53) quality-adjusted life-years (QALYs) remaining. This result was 2.2 QALYs greater than that of the trial-based antidepressant and cognitive-behavioral therapy (ADM + CBT) strategy. Three additional ADM + CBT strategies were estimated not to be statistically significantly different from each other. These 4 ADM + CBT strategies outperformed both pharmacotherapy-only strategies. Treatment strategies that include higher-intensity CBT, with effectiveness outcomes that approached efficacy estimates, were superior to real-world CBT strategies. However, given the limited availability of high-quality CBT, especially through use of commercial insurance networks, specialized treatment programs offer greater effectiveness than real-world therapies in achieving wellness for this severe patient population.

An introduction to the 'Psycho-Physiological-Stress-Test' (PPST)-A standardized instrument for evaluating stress reactions.

Using a standardized instrument to evaluate patients’ stress reactions has become more important in daily clinical routines. Different signs or symptoms of stress are often unilaterally explored: the physiological, psychological or social aspects of stress disorders are each viewed on a single dimension. However, all dimensions afflict patients who have persistent health problems due to chronic stress. Therefore, it is important to use a multidimensional approach to acquire data. The ‘Psycho-Physiological-Stress-Test’ (PPST) was established to achieve a comprehensive understanding of stress and was further developed at the Charité—Universitätsmedizin Berlin in collaboration with the Psychological Department of Freie Universität Berlin. The PPST includes a series of varying stress phases, embedded in two periods of rest. Physiological and psychological parameters are simultaneously measured throughout the test session. Specifically, the PPST activates the sympathetic stress axis, which is measured by heart rate, blood pressure, respiration depth and rate, electro dermal activation and muscle tension (frontalis, masseter, trapezius). Psychological data are simultaneously collected, and include performance, motivation, emotion and behavior. After conducting this diagnostic test, it is possible to identify individual stress patterns that can be discussed with the individual patient to develop and recommend (outpatient) treatment strategies. This paper introduces the PPST as a standardized way to evaluate stress reactions by presenting the results from a sample of psychosomatic inpatients (n = 139) who were treated in Charité—Universitätsmedizin Berlin, Germany. We observed that the varying testing conditions provoked adjusted changes in the different physiological parameters and psychological levels.

Adoption, Acceptability, and Effectiveness of a Mobile Health App for Personalized Prostate Cancer Survivorship Care: Protocol for a Realist Case Study of the Ned App.

BackgroundBy 2030, prostate cancer will be the most commonly diagnosed cancer in North America. To mitigate this impending challenge, comprehensive support mechanisms for disease- and treatment-specific changes in health and well-being must be proactively designed and thoughtfully implemented for streamlined survivorship care. mHealth apps have been lauded as a promising complement to current outpatient treatment and monitoring strategies, but have not yet been widely used to support prostate cancer survivorship needs. A realist evaluation is needed to examine the impact of such apps on the prostate cancer survivorship experience.ObjectiveWe seek to gain an understanding of how an mHealth app for prostate cancer survivorship care called Ned (No Evident Disease) is adopted and accepted by patients, caregivers, and clinicians. We also aim to determine the effect of Ned on health-related quality of life, satisfaction with cancer care, unmet needs, self-efficacy, and prostate cancer-related levels of anxiety.MethodsThe Ned case study is a 12-month mixed-methods embedded single-case study with a nested within-group pre-post comparison of health outcomes. We will give 400 patients, 200 caregivers, and 10 clinicians access to Ned. Participants will be asked to complete study assessments at baseline, 2 months, 6 months, and 12 months. We will conduct 30 semistructured qualitative interviews with patients (n=20) and their caregivers (n=10) poststudy to gain insight into their experience with the app.ResultsWe recruited our first survivor in October 2017 and anticipate completing this study by May 2019.ConclusionsThis will, to our knowledge, be the first realist case study to evaluate an app for prostate cancer survivorship care. Prostate cancer survivors are set to increase in number and longevity, heightening the need for integrated survivorship solutions to provide them with optimal and durable outcomes. The knowledge gained from this study will comprehensively inform how and why Ned works, for whom, and in what circumstances. Understanding the impact of digital health interventions such as Ned on how survivors care for themselves is critical to realizing patient-centered care.

Abstract 034: Remote Patient Monitoring for Postpartum Hypertension: A Pilot Study

Background: Postpartum hypertension is a leading indication for hospital readmission and maternal mortality. Objective: To conduct a pilot intervention to establish the feasibility of telehealth monitoring/treatment after hospital discharge for women with or at risk of developing severe postpartum hypertension (SBP &gt; 150 or DBP &gt; 105 mmHg). Methods: This prospective intervention at a Midwestern academic group practice included adult women with a hypertension-related diagnosis in the antenatal and/or postpartum period. Prior to discharge, patients received a tablet computer and blue tooth equipment (scale, blood pressure, oxygen saturation and heart rate monitor) to transmit home vital signs daily to a nurse. Patients had a nurse telehealth visit 48 hours and 7 days post-discharge. A nurse-driven outpatient treatment algorithm was developed and utilized for initiation and/or cessation of antihypertensive medications. Study follow-up was 6 weeks postpartum, followed by transfer to routine clinical care. Results: Among the 121 women with a hypertension-related disorder of pregnancy; 32 of the intended 55 have been enrolled to date (26%). [HJ2] Among the study patients, 6/32 (19%) were discharged on antihypertensive medication, of which 4/6 (67%) required an increase in the dose after discharge. After discharge, 10/32 (31%) required antihypertensive initiation after discharge due to development of severe hypertension. Overall, postpartum blood pressures became severe on day 4.9 (mean SBP was 158mmHg and DBP was 96mmHg). Among enrolled participants, there were two emergency room visits, however no hospital readmissions; 3/32 (9%) discontinued the study prior to study completion due to social situations. Conclusions: The preliminary results of our pilot intervention demonstrate feasibility and patient acceptability with telehealth monitoring for postpartum hypertension-related disorders. Furthermore, we demonstrated important temporal trends in the natural history of postpartum hypertension from discharge through 6 weeks postpartum which will guide larger clinical trials. Telehealth monitoring is a promising outpatient treatment strategy for postpartum hypertension to reduce readmissions and decrease maternal morbidity.

Predictors of early relapse among adolescent crack users

ABSTRACTRelapse is associated with a poor prognosis among drug users. Crack cocaine users are more prone to severe dependence because of the intensity of use. Additionally, initiating drug use during adolescence worsens users' prognosis due to the increased rates of impulsivity and other risk behaviors. This study aimed to identify the predictors of early relapse among adolescent crack users discharged from inpatient treatment. A cohort study was conducted with 89 psychiatric inpatients aged 12–17 years from two different hospitals in southern Brazil who met the criteria for crack abuse or dependence. Demographic data, substance use disorders, psychiatric comorbidities, and crack consumption profile were assessed during hospitalization using the Teen Addiction Severity Index, Schedule for Affective Disorders and Schizophrenia for School Age Children—Present and Lifetime, and Crack Consumption Profile. Participants were re-assessed at 1 and 3 months after hospital discharge to determine their crack cocaine use based on self-report, family/caregiver information, and urine tests, whenever possible. There were extremely high rates of relapse (valid percent) in the first and third months, 65.9 and 86.4%, respectively. Statistically significant associations were observed between relapse in the first month and length of cocaine/crack cocaine use, and length of hospital stay. Data at 3 months were not analyzed because of the small number of patients who did not relapse. The high rates and significant associations found in this study suggest that intensive outpatient treatment strategies targeting this population should be developed and implemented to prevent early relapse after detoxification. One of the possible approaches, based on recent studies, might explore motivation as a strategy to reduce the rate of early relapse.

Consensus treatment of medication overuse headache in Latin America and Europe

Medication overuse headache (MOH) is preventable and treatable. However, MOH is a major contributor to headache-related disability, affecting up to 70% of patients in headache specialty practices (1). The man- agement of MOH is complicated as patients often have difficulty stopping the overused medication and relapse rates following successful detoxification are high, con- sistent with the concept of MOH as a bio-behavioral disorder, with a shared neurobiology to addiction (2). Analgesics appear to carry varying risks for MOH among susceptible patients, with the strongest associ- ations reported for opioid- and butalbital-containing analgesics (3,4). Non-steroidal anti-inflammatory drugs (NSAIDs) carry the lowest risk, and may even be protective in the development of chronic daily head- days 1-7)), allowance for symptomatic treatment using a different medication than that previously overused (starting on day 8), and regular clinic follow-up over a 6-month period. The majority of patients were treated as outpatients (77.7%), but three centers used inpatient detoxification. For these three centers, the patients' dis- tance from the hospital and personal preferences were used to determine inpatient versus outpatient treat- ment. The subjects were mostly female, and afflicted with migraine, although 39 subjects (10.3%) had pure tension-type headache. Subjects were excluded if they had previously failed a prior detoxification protocol, were overusing 'pure' opioids, benzodiazepines or bar- biturates, were currently treated with a preventative medication, and if they had significant psychiatric comorbidity. During the 6-month observation period, a larger proportion of subjects undergoing outpatient detoxification dropped out of the study (33.9%) com- pared with those undergoing inpatient detoxification (12.5%). Based on an intention-to-treat analysis, nearly two-thirds of patients were no longer overusing medications at the end of the study protocol and nearly half had reverted to an episodic headache pattern. Further, less than 10% relapsed during months 2 through 6 (i.e. stopped overusing during month 1, but then restarted overusing between months 2 and 6). Among patients who completed the detoxification treatment, inpatient and outpatient treatment strategies had similar efficacy. The most important conclusion from this study is that MOH is a treatable condition across international borders and healthcare settings, with most patients benefiting from a combination of advice, detoxification,

Acute behavioral interventions and outpatient treatment strategies with suicidal adolescents.

Despite the prevalence of suicidal thoughts and behaviors among adolescents, there is limited knowledge of effective interventions to use with this population. This paper reviews the findings of studies on behavioral interventions for adolescents who are at acute suicide risk, as well as outpatient treatment and risk management strategies with suicidal adolescents. The importance of addressing comorbid behaviors and enhancing protective factors are discussed. Cultural considerations in working with suicidal adolescents and strategies for conducting culturally competent treatment are explored.

Validation of the modified Vesikari score in children with gastroenteritis in 5 US emergency departments.

The burden of acute gastroenteritis (AGE) in US children is substantial. Research into outpatient treatment strategies has been hampered by the lack of easily used and validated gastroenteritis severity scales relevant to the populations studied. We sought to evaluate, in a US cohort, the reliability, construct validity, and generalizability of a gastroenteritis severity scale previously derived in a Canadian population, the modified Vesikari score (MVS). We conducted a prospective, cohort, clinical observational study of children 3 to 48 months of age with acute gastroenteritis presenting to 5 US emergency departments. A baseline MVS score was determined in the emergency department, and telephone follow-up 14 days after presentation was used to assign the follow-up MVS. We determined reliability using inter-item correlations; construct validity via principal component factor analysis; cross-sectional construct validity via correlations with the presence of dehydration, hospitalization, and day care and parental work absenteeism; and generalizability via score distribution among sites. Two hundred eighteen of 274 patients (80%) were successfully contacted for follow-up. Cronbach α was 0.63, indicating expectedly low internal reliability because of the multidimensional properties of the MVS. Factor analysis supported the appropriateness of retaining all variables in the score. Disease severity correlated with dehydration (P < 0.001), hospitalization (P < 0.001), and subsequent day care (P = 0.01) and work (P < 0.001) absenteeism. The MVS was normally distributed, and scores did not differ among sites. The MVS effectively measures global severity of disease and performs similarly in varying populations within the US health care system. Its characteristics support its use in multisite outpatient clinical trials.

Reasons for hospitalizations in adults with diabetes in Kuwait

BackgroundA large proportion of hospitalizations for diabetes are preventable. We carried out this study to determine the prevalence and reasons for hospitalization in adults with diabetes in Kuwait. Materials and methodsA cross-sectional study was conducted of all hospital admissions in the Department of Medicine at Al-Sabah Hospital in Kuwait during a 2-month period. Admissions were classified into three groups: (i) medical history of diabetes; (ii) unrecognized diabetes or new hyperglycemia (i.e., an admission for fasting blood glucose ⩾7mmol/l or random blood glucose ⩾11.1mmol/l); and (iii) no diabetes. ResultsDiabetes was the principal or secondary diagnosis in 40.6% of hospitalizations. Unrecognized diabetes or new hyperglycemia was found in 12.9% of the patients. Patients with diabetes or new hyperglycemia were significantly older and had longer hospital stay compared to non-diabetic patients. The three most common reasons for hospitalizations in patients with diabetes were diseases of the cardiovascular system (53.6%), diseases of the respiratory system (22.8%), and diabetes as a principal diagnosis (6.3%). The five most frequent specific causes for hospitalizations in patients with medical history of diabetes as a secondary diagnosis were acute coronary syndrome (27.2%), pneumonia (14.3%), heart failure (11.2%), cerebrovascular accident (10.3%), and chronic obstructive airway disease (3.6%). ConclusionDiabetes imposes a great burden on secondary health care in Kuwait. Effective primary care and hospital outpatient preventive and treatment strategies, including education, multifactorial intervention for cardiovascular risk factors, and influenza and pneumococcal immunizations for patients with diabetes may reduce these hospitalizations among diabetic patients.

Successful outpatient management of pelvic actinomycosis by ceftriaxone: a report of three cases

Pelvic actinomycosis is a chronic granulomatous suppurative disease caused by actinomyces israeli. Intravenous penicillin is the preferred antimicrobial but it requires hospitalization up to one month. An outpatient treatment strategy would be cost effective and a good choice for patients. Here we present three cases in which intramuscular ceftriaxone was successfully used in the outpatient settings following surgery and IV penicillin treatment in the hospital.