What is Family Preservation and Why Does it Matter?

This paper describes competing ideas about family preservation, defined both as a defined program of social services and a philosophical approach to helping troubled families. A straightforward definition has become almost impossible because the phrase has taken on so many different meanings, provoking controversy about its "real" meaning and value. Indeed, "family preservation" has become the proverbial elephant whose splendors and horrors are described with great certainty by those impressed by only one of its aspects. While skirmishes between "child savers" and "family preservers" have been part of the child welfare field since its beginning at the turn of the last century, recent debates over family preservation have been especially heated, generating more confusion and animosity than might be expected from the ranks of the small and usually mild-mannered social work profession. The debate is so heated that the director of one of the nation's largest child welfare agencies said recently that he is afraid to "even use the two words on the same page." <1> While the debate about the value of family preservation is unresolved, experimentation with different approaches to service delivery over the last two decades has helped to lay the groundwork for a resurgence of interest in family and community-centered reforms. Better understanding of the family preservation "debates" may be helpful if these reforms are to be successful over the long term. The paper discusses the competing ideas, values, and perceptions that have led observers to their different understandings of family preservation. It briefly chronicles the history of child welfare and examines key theories that have helped lay the groundwork for the resurgence of interest in family-centered services. It concludes with observations about how the competing values at stake in family preservation may affect the next generation of reforms.

Diagnosis of sexually transmitted infections in developing nations using syndromic management: Is it working?

Sexually transmitted infections (STIs) are a major public health problem, and controlling their spread is a priority. According to the World Health Organization (WHO), there are 340 million new cases of treatable STIs among 15–49 year olds that occur yearly around the world (1). Infection with STIs can lead to several complications such as pelvic inflammatory disorder (PID), cervical cancer, infertility, ectopic pregnancy, and even death (1). Additionally, STIs and associated complications are among the top disease types for which healthcare is sought in developing nations (1), and according to the UNAIDS report, there is a strong connection between STIs and the sexual spread of HIV infection (2). In fact, it is estimated that the presence of an untreated STI can increase the likelihood of contracting and spreading HIV by a factor up to 10 (2). In addition, developing countries are poorer in resources and lack inexpensive and precise diagnostic laboratory tests for STIs, thereby exacerbating the problem. Thus, the WHO recommends syndromic management of STIs for delivering care where lab testing is scarce or unattainable (1). This approach utilizes the use of an easy to use algorithm to help healthcare workers recognize symptoms/signs so as to provide treatment for the likely cause of the syndrome. Furthermore, according to the WHO, syndromic management offers instant and legitimate treatment compared to clinical diagnosis, and that it is also more cost-effective for some syndromes over the use of laboratory testing (1). In addition, even though it has been shown that the vaginal discharge syndrome has low specificity for gonorrhea and Chlamydia and can lead to over treatment (1), this is the recommended way to manage STIs in developing nations. Thus, the purpose of this paper is to specifically address the following questions: is syndromic management working to lower the STI burden in developing nations? How effective is it, and should it still be recommended? To answer these questions, a systematic literature review was conducted to evaluate the current effectiveness of syndromic management in developing nations. This review examined published articles over the past 5 years that compared syndromic management to laboratory testing and had published sensitivity, specificity, and positive predicative value data. Focusing mainly on vaginal discharge, urethral discharge, and genital ulcer algorithms, it was seen that though syndromic management is more effective in diagnosing and treating urethral and genial ulcer syndromes in men, there still remains an urgent need to revise the WHO recommendations for managing STIs in developing nations. Current studies have continued to show decreased specificity, sensitivity and positive predicative values for the vaginal discharge syndrome, and high rates of asymptomatic infections and healthcare workers neglecting to follow guidelines limit the usefulness of syndromic management. Furthermore, though advocate d as cost-effective by the WHO, there is a cost incurred from treating uninfected people. Instead of improving this system, it is recommended that better and less expensive point of care and the development of rapid test diagnosis kits be the focus and method of diagnosis and treatment in developing nations for STI management. ^

The diagnostic value of a 12-lead electrocardiogram in patients with cardiac tamponade due to a malignant pericardial effusion

Background. Cardiac tamponade can occur when a large amount of fluid, gas, singly or in combination, accumulating within the pericardium, compresses the heart causing circulatory compromise. Although previous investigators have found the 12-lead ECG to have a poor predictive value in diagnosing cardiac tamponade, very few studies have evaluated it as a follow up tool for ruling in or ruling out tamponade in patients with previously diagnosed malignant pericardial effusions. ^ Methods. 127 patients with malignant pericardial effusions at the MD Anderson Cancer Center were included in this retrospective study. While 83 of these patients had a cardiac tamponade diagnosed by echocardiographic criteria (Gold standard), 44 did not. We computed the sensitivity (Se), specificity (Sp), positive (PPV) and negative predictive values (NPV) for individual and combinations of ECG abnormalities. Individual ECG abnormalities were also entered singly into a univariate logistic regression model to predict tamponade. ^ Results. For patients with effusions of all sizes, electrical alternans had a Se, Sp, PPV and NPV of 22.61%, 97.61%, 95% and 39.25% respectively. These parameters for low voltage complexes were 55.95%, 74.44%, 81.03%, 46.37% respectively. The presence of all three ECG abnormalities had a Se = 8.33%, Sp = 100%, PPV = 100% and NPV = 35.83% while the presence of at least one of the three ECG abnormalities had a Se = 89.28%, Sp = 46.51%, PPV = 76.53%, NPV = 68.96%. For patients with effusions of all sizes electrical alternans had an OR of 12.28 (1.58–95.17, p = 0.016), while the presence of at least one ECG abnormality had an OR of 7.25 (2.9–18.1, p = 0.000) in predicting tamponade. ^ Conclusions. Although individual ECG abnormalities had low sensitivities, specificities, NPVs and PPVs with the exception of electrical alternans, the presence of at least one of the three ECG abnormalities had a high sensitivity in diagnosing cardiac tamponade. This could point to its potential use as a screening test with a correspondingly high NPV to rule out a diagnosis of tamponade in patients with malignant pericardial effusions. This could save expensive echocardiographic assessments in patients with previously diagnosed pericardial effusions. ^

Supplemental Nutrition Assistance Program: A policy analysis of restricting foods with minimal nutritional value

In 2011, expenditures for the Supplemental Nutrition Assistance Program (SNAP) reached an all-time high of $72 billion. The goal of SNAP is " to alleviate hunger and malnutrition…by increasing food purchasing power for all eligible households who apply for participation." It has been well established that proper nutrition is essential to good health, making SNAP an important program to public health consumers. Thus, this analysis examined whether SNAP is meeting its stated goal and whether the goal would be reduced if the purchase of foods of minimal nutritional value (FMNV) were restricted. ^ A review of existing literature found that SNAP has been shown to alleviate hunger, but the studies on the nutritional impact of the program were not sufficient to assert whether change is needed. When considering whether limiting FMNV would reduce or improve the effectiveness of SNAP at alleviating hunger and malnutrition, there is very little information on which to base a policy change, particular one that singles out a low income group to restrict purchases. ^ Several states have attempted to restrict the purchase of FMNV but, to date, no such change has been implemented or tested. Conducting pilot studies on the restriction of FMNV, along with better data collection on SNAP purchases, would guide policy changes to the program. Although there are many potential public health benefits to restricting FMNV purchase using SNAP dollars, research is needed to quantify the cost impact of these benefits.^

Measuring value in cancer-related health care: A case study in head and neck cancer

In the current climate of escalating health care costs, defining value and accurately measuring it are two critical issues affecting not only the future of cancer care in particular but also the future of health care in general. Specifically, measuring and improving value in cancer-related health care are critical for continued advancements in research, management, and overall delivery of care. However, in oncology, most of this research has focused on value as it relates to insurance industry and payment reform, with little attention paid to value as the output of clinical interventions that encompass integrated clinical teams focusing on the entire cycle of care and measuring objective outcomes that are most relevant to patients. ^ In this study, patient-centered value was defined as health outcomes achieved per dollar spent, and calculated using objective functional outcomes and total care costs. The analytic sample comprised patients diagnosed with three common head and neck cancers—cancer of the larynx, oral cavity, and oropharynx—who were treated in an integrated tertiary care center over an approximately 10-year period. The results of this study provide initial empirical data that can be used to assess and ultimately to help improve the quality and value of head and neck cancer care, and more importantly they can be used by patients and clinicians to make better-informed decisions about care, particularly what therapeutic services and outcomes matter the most to patients.^