967 resultados para Hospitalized


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The aim of this study was to examine the association between determinants of access to healthcare and preventable hospitalizations, based on Davidson et al.'s framework for evaluating the effects of individual and community determinants on access to healthcare. The study population consisted of the low income, non-elderly, hospitalized adults residing in Harris County, Texas in 2004. The objectives of this study were to examine the proportion of the variance in preventable hospitalizations at the ZIP-code level, to analyze the association between the proximity to the nearest safety net clinic and preventable hospitalizations, to examine how the safety net capacity relates to preventable hospitalizations, to compare the relative strength of the associations of health insurance and the proximity to the nearest safety net clinic with preventable hospitalizations, and to estimate and compare the costs of preventable hospitalizations in Harris County with the average cost in the literature. The data were collected from Texas Health Care Information Collection (2004), Census 2000, and Project Safety Net (2004). A total of 61,841 eligible individuals were included in the final data analysis. A random-intercept multi-level model was constructed with two different levels of data: the individual level and the ZIP-code level. The results of this study suggest that ZIP-code characteristics explain about two percent of the variance in preventable hospitalizations and safety net capacity was marginally significantly associated with preventable hospitalizations (p= 0.062). Proximity to the nearest safety net clinic was not related to preventable hospitalizations; however, health insurance was significantly associated with a decreased risk of preventable hospitalization. The average direct cost was $6,466 per preventable hospitalization, which is significantly different from reports in the literature. ^

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The Center for Disease Control and Prevention (CDC) estimates that more than 2 million patients annually acquire an infection while hospitalized in U.S. hospitals for other health problems, and that 88,000 die as a direct or indirect result of these infections. Infection with Clostridium difficile is the most important common cause of health care associated infectious diarrhea in industrialized countries. The purpose of this study was to explore the cost of current treatment practice of beginning empiric metronidazole treatment for hospitalized patients with diarrhea prior to identification of an infectious agent. The records of 70 hospitalized patients were retrospectively analyzed to determine the pharmacologic treatment, laboratory testing, and radiographic studies ordered and the median cost for each of these was determined. All patients in the study were tested for C. difficile and concurrently started on empiric metronidazole. The median direct cost for metronidazole was $7.25 per patient (95% CI 5.00, 12.721). The median direct cost for laboratory charges was $468.00 (95% CI 339.26, 552.58) and for radiology the median direct cost was $970.00 (95% CI 738.00, 3406.91). Indirect costs, which are far greater than direct costs, were not studied. At St. Luke's, if every hospitalized patient with diarrhea was empirically treated with metronidazole at a median cost of $7.25, the annual direct cost is estimated to be over $9,000.00 plus uncalculated indirect costs. In the U.S., the estimated annual direct cost may be as much as $21,750,000.00, plus indirect costs. ^ An unexpected and significant finding of this study was the inconsistency in testing and treatment of patients with health care associated diarrhea. A best-practice model for C. difficile testing and treatment was not found in the literature review. In addition to the cost savings gained by not routinely beginning empiric treatment with metronidazole, significant savings and improvement in patient care may result from a more consistent approach to the diagnosis and treatment of all patients with health care associated diarrhea. A decision tree model for C. difficile testing and treatment is proposed, but further research is needed to evaluate the decision arms before a validated best practice model can be proposed. ^

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Background. According to the WHO 2007 country report, Haiti lags behind the Millennium Development Goal of reducing child mortality and maintains the highest under-5 mortality rate in the Western hemisphere. 3 Overall, few studies exist that seek to better grasp barriers in caring for a seriously ill child in a resource-limited setting and only a handful propose sustainable, effective interventions. ^ Objectives. The objectives of this study are to describe the prevalence of serious illnesses among children hospitalized at 2 children's hospitals in Port au Prince, to determine the barriers faced when caring for seriously ill children, and to report hospital outcomes of children admitted with serious illnesses. ^ Methods. Data were gathered from 2 major children's hospitals in Port au Prince, Haiti (Grace Children's Hospital [GCH] and Hopital d l'Universite d'Etat d'Haiti [HUEH]) using a triangulated approach of focus group discussions, physician questionnaires, and retrospective chart review. 23 pediatric physicians participated in focus group discussions and completed a self-administered questionnaire evaluating healthcare provider knowledge, self-efficacy, and perceived barriers relating to the care of seriously ill children in a resource-limited setting. A sample of 240 patient charts meeting eligibility criteria was abstracted for pertinent elements including sociodemographics, documentation, treatment strategies, and outcomes. Factors associated with mortality were analyzed using χ2 test and Fisher exact test [Minitab v.15]. ^ Results. The most common primary diagnoses at admission were gastroenteritis with moderate dehydration (35.5%), severe malnutrition (25.8%), and pneumonia (19.3%) for GCH, and severe malnutrition (32.6%), sepsis (24.7%), and severe respiratory distress (18%) for HUEH. Overall, 12.9% and 27% of seriously ill patients presented with shock to GCH and HUEH, respectively. ^ Shortage of necessary materials and equipment represented the most commonly reported limitation (18/23 respondents). According to chart data, 9.4% of children presenting with shock did not receive a fluid bolus, and only 8% of patients presenting with altered mental status or seizures received a glucose check. 65% of patients with meningitis did not receive a lumbar puncture due to lack of materials. ^ Hospital mortality rates did not differ by gender or by institution. Children who died were more likely to have a history of prematurity (OR 4.97 [95% CI 1.32-18.80]), an incomplete vaccination record (OR 4.05 [95% CI 1.68-9.74]), or a weight for age ≤3rd percentile (OR 6.1 [95% CI 2.49-14.93]. Case-fatality rates were significantly higher among those who presented with signs of shock compared with those who did not (23.1% vs. 10.7%, RR=2.16, p=0.03). Caregivers did not achieve shock reversal in 21% of patients and did not document shock reversal in 50% of patients. ^ Conclusions. Many challenges face those who seek to optimize care for seriously ill children in resource-limited settings. Specifically, in Haiti, qualitative and quantitative data suggest major issues with lack of supplies, pre-hospital factors, including malnutrition as a comorbidity, and early recognition and management of shock. A tailored intervention designed to address these issues is needed in order to prospectively evaluate improvements in child mortality in a high-risk population.^

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Background. The incidence of Clostridium difficile -associated diarrhea (CDAD) is increasing worldwide likely because of increased use of broad spectrum antibiotics and the introduction of a clonal hyper-virulent strain called the BI strain. Short-term complications of CDAD include recurrent disease, requirement for colectomy, and persistent disease. However, data on the long-term consequences of CDAD are scarce. Among other infectious diseases (Shigella, Salmonella, and Campylobacter), long-term consequences such as irritable bowel syndrome (IBS), chronic dyspepsia/diarrhea, and other GI effects have been noted. Since the mechanism of action of these agents is similar to C.difficile, we hypothesized that patients with CDAD have greater likelihood of developing IBS and other functional gastrointestinal disorders (FGIDs) in the long-term as compared to a general sample of recently hospitalized patients. ^ Objective. To evaluate the long-term gastrointestinal complications of CDAD, (IBS, functional diarrhea, functional abdominal bloating, functional constipation and functional abdominal pain syndrome). ^ Methods. The current study was a secondary analysis of a previously completed observational case-control outcome study. Adult CDAD patients at St. Luke's Episcopal Hospital, Houston (SLEH) were followed up and interviewed by telephone six months after the initial diagnosis thereafter evaluated for the development of IBS and other FGIDs. A total of 46 patients with CDAD infection were recruited at SLEH between May-November 2007. The comparators were patients hospitalized in SLEH within one month before or after the admission of the reference case, hospital length of stay within one week longer or shorter than reference case, and age within 10 years more or less than the reference case. Cases and comparators were compared using Fisher's exact test. A p<0.05 was considered significant. ^ Results. Thirty CDAD patients responded to the questionnaires and were compared to 40 comparators. No comparator developed a FGID, while 3 (10%) CDAD patients developed new onset IBS (p=0.07), 4 (13.3%) developed new onset Functional Diarrhea (p=0.03), and 3 (10%) developed new onset Functional Constipation (p=0.07). No patient developed Functional Abdominal Bloating and Functional Abdominal Pain Syndrome. ^ Conclusion. In this study, new onset functional diarrhea was significantly more common in patients CDAD within six months after initial infection compared to matched controls.^

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Objective. To evaluate the host risk factors associated with rifamycin-resistant Clostridium difficile (C. diff) infection in hospitalized patients compared to rifamycin-susceptible C.diff infection.^ Background. C. diff is the most common definable cause of nosocomial diarrhea affecting elderly hospitalized patients taking antibiotics for prolonged durations. The epidemiology of Clostridium difficile associated disease is now changing with the reports of a new hypervirulent strain causing hospital outbreaks. This new strain is associated with increased disease severity and mortality. The conventional therapy for C. diff includes metronidazole and vancomycin but high recurrence rates and treatment failures are now becoming a major concern. Rifamycin antibiotics are being developed as a new therapeutic option to treat C. diff infection after their efficacy was established in a few in vivo and in vitro studies. There are some recent studies that report an association between the hypervirulent strain and emerging rifamycin resistance. These findings assess the need for clinical studies to better understand the efficacy of rifamycin drugs against C. diff.^ Methods. This is a hospital-based, matched case-control study using de-identified data drawn from two prospective cohort studies involving C. diff patients at St Luke's Hospital. The C. diff isolates from these patients are screened for rifamycin resistance using agar dilution methods for minimum inhibitory concentrations (MIC) as part of Dr Zhi-Dong Jiang's study. Twenty-four rifamycin-rifamycin resistant C. diff cases were identified and matched with one rifamycin susceptible C. diff control on the basis of ± 10 years of age and hospitalization 30 days before or after the case. De-identified data for the 48 subjects was obtained from Dr Kevin Garey's clinical study at St Luke's Hospital enrolling C. diff patients. It was reviewed to gather information about host risk factors, outcome variables and relevant clinical characteristic.^ Results. Medical diagnosis at the time of admission (p = 0.0281) and history of chemotherapy (p = 0.022) were identified as a significant risk factor while hospital stay ranging from 1 week to 1 month and artificial feeding were identified as an important outcome variable (p = 0.072 and p = 0.081 respectively). Horn's Index assessing the severity of underlying illness and duration of antibiotics for cases and controls showed no significant difference.^ Conclusion. The study was a small project designed to identify host risk factors and understand the clinical implications of rifamycin-resistance. The study was underpowered and a larger sample size is needed to validate the results.^

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Background. The parents of a sick child likely experience situational anxiety due to their young child being unexpectedly hospitalized. The emotional upheaval may be great enough that their anxiety inhibits them in providing positive support to their hospitalized child. Because anxiety affects psychological distress as well as behavioral distress, identifying parental distress helps parents improving their coping mechanisms. ^ Purpose. The study compared situational anxiety levels between Taiwanese fathers and mothers and focused on differences between parental anxiety levels at the beginning of the child's unplanned hospitalization and at time of discharge. The study also identified factors related to the parents' distress and use of coping mechanisms. ^ Methods. A descriptive, comparative research design was used to determine the difference between the anxiety levels of 62 Taiwanese father-mother dyads during the situational crisis of their child's unexpected hospitalization. The Mandarin version (M) of Visual Analog Scale (VAS-M), State-Trait Anxiety Inventory (STAI-M), and the Index of Parent Participation/Hospitalized Child (IPP/HC-M) were used to differentiate maternal and paternal anxiety levels and identify factors related to the parents' distress. Questionnaires were completed by parents within 24-36 hours of the child's hospital admission and within 24 hours prior to discharge. A paired t-test, two sample t-test, and linear mixed regression model were used to test and support the study hypothesis. ^ Results. The findings reveal that the mothers' anxiety levels did not significantly differ from the fathers' anxiety level when their child had a sudden admission to the hospital. In particular, parental state anxiety levels did not decrease during the child's hospital stay and subsequent discharge. Moreover, anxiety levels did not differ between parents regardless of whether the child's disease was acute or chronic. The most effective factor related to parental situational anxiety was parental perception of the severity of the child's illness. ^ Conclusions. Parental anxiety was found to be significantly related to changes in their perception of the severity of their child's illness. However, the study was not able to illustrate how parental involvement in the child's hospital care was related to parental perception of the severity of their child's illness. Future studies, using a qualitative approach to gamer more information as to what variables influence parental anxiety during a situational crisis, may provide a richer database from which to modify key variables as well as the instruments used to improve the quality of the data obtained. ^

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More than a quarter of patients with HIV in the United States are diagnosed in hospital settings most often with advanced HIV related conditions.(1) There has been little research done on the causes of hospitalization when the patients are first diagnosed with HIV. The aim of this study was to determine if the patients are hospitalized due to an HIV related cause or due to some other co-morbidity. Reduced access to care could be one possible reason why patients are diagnosed late in the course of the disease. This study compared the access to care of patients diagnosed with HIV in hospital and outpatient setting. The data used for the study was a part of the ongoing study “Attitudes and Beliefs and Steps of HIV Care”. The participants in the study were newly diagnosed with HIV and recruited from both inpatient and outpatient settings. The primary and the secondary diagnoses from hospital discharge reports were extracted and a primary reason for hospitalization was ascertained. These were classified as HIV-related, other infectious causes, non–infectious causes, other systemic causes, and miscellaneous causes. Access to care was determined by a score based on responses to a set of questions derived from the HIV Cost and Services Utilization Study (HCSUS) on a 6 point scale. The mean score of the hospitalized patients and mean score of the patients diagnosed in an outpatient setting was compared. We used multiple linear regressions to compare mean differences in the two groups after adjusting for age, sex, race, household income educational level and health insurance at the time of diagnosis. There were 185 participants in the study, including 78 who were diagnosed in hospital settings and 107 who were diagnosed in outpatient settings. We found that HIV-related conditions were the leading cause of hospitalization, accounting for 60% of admissions, followed by non-infectious causes (20%) and then other infectious causes (17%). The inpatient diagnosed group did not have greater perceived access-to-care as compared to the outpatient group. Regression analysis demonstrated a statistically significant improvement in access-to-care with advancing education level (p=0.04) and with better health insurance (p=0.004). HIV-related causes account for many hospitalizations when patients are first diagnosed with HIV. Many of these HIV-related hospitalizations could have been prevented if patients were diagnosed early and linked to medical care. Programs to increase HIV awareness need to be an integral part of activities aimed at control of spread of HIV in the community. Routine testing for HIV infection to promote early HIV diagnosis can prevent significant morbidity and mortality.^

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Purpose of the study. The purpose was to determine if sleep deprivation in hospitalized older adults predicts the development of delirium, and if sleep is predicted by nighttime light and sound levels. ^ Method. This observational feasibility study enrolled 54 adults ≥70 years of age (mean age 79, range 70–94) who were negative for delirium. The sample was monitored for sleep via wrist actigraphy, and light and sound levels were monitored from 2200 to 0700 the first night of hospitalization. The Richards Campbell Sleep Questionnaire (RCSQ) was administered to measure subjective sleep satisfaction. Subjects were assessed for delirium daily using the Confusion Assessment Method. ^ Conclusions. Of 50 subjects completing the study, two (4%) developed delirium. Mean nighttime sleep was 225 minutes (± 137) with frequent awakenings (13 ± 6) Light levels were elevated episodically (mean intense light = 64 lux, lasting 1¾ hours); median sound levels [49.65 dB(A)] exceeded WHO recommendations [35 dB(A)]. Neither median sound (r = -.63, p = 67) nor mean light levels (r = -.104, p = .47) significantly correlated with sleep. Mean RCSQ was 50.7 ± 24 and showed a moderate correlation with nighttime sleep minutes (r = .577, p .000). Power analysis determined that 294 subjects will be required to determine if nighttime sleep minutes predict delirium, and 182 subjects will be required to determine if sound and light levels predict nighttime sleep minutes.^

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Background. Nosocomial infections are a source of concern for many hospitals in the United States and worldwide. These infections are associated with increased morbidity, mortality and hospital costs. Nosocomial infections occur in ICUs at a rate which is five times greater than those in general wards. Understanding the reasons for the higher rates can ultimately help reduce these infections. The literature has been weak in documenting a direct relationship between nosocomial infections and non-traditional risk factors, such as unit staffing or patient acuity.^ Objective. To examine the relationship, if any, between nosocomial infections and non-traditional risk factors. The potential non-traditional risk factors we studied were the patient acuity (which comprised of the mortality and illness rating of the patient), patient days for patients hospitalized in the ICU, and the patient to nurse ratio.^ Method. We conducted a secondary data analysis on patients hospitalized in the Medical Intensive Care Unit (MICU) of the Memorial Hermann- Texas Medical Center in Houston during the months of March 2008- May 2009. The average monthly values for the patient acuity (mortality and illness Diagnostic Related Group (DRG) scores), patient days for patients hospitalized in the ICU and average patient to nurse ratio were calculated during this time period. Active surveillance of Bloodstream Infections (BSIs), Urinary Tract Infections (UTIs) and Ventilator Associated Pneumonias (VAPs) was performed by Infection Control practitioners, who visited the MICU and performed a personal infection record for each patient. Spearman's rank correlation was performed to determine the relationship between these nosocomial infections and the non-traditional risk factors.^ Results. We found weak negative correlations between BSIs and two measures (illness and mortality DRG). We also found a weak negative correlation between UTI and unit staffing (patient to nurse ratio). The strongest positive correlation was found between illness DRG and mortality DRG, validating our methodology.^ Conclusion. From this analysis, we were able to infer that non-traditional risk factors do not appear to play a significant role in transmission of infection in the units we evaluated.^

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This study aims to address two research questions. First, ‘Can we identify factors that are determinants both of improved health outcomes and of reduced costs for hospitalized patients with one of six common diagnoses?’ Second, ‘Can we identify other factors that are determinants of improved health outcomes for such hospitalized patients but which are not associated with costs?’ The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database from 2003 to 2006 was employed in this study. The total study sample consisted of hospitals which had at least 30 patients each year for the given diagnosis: 954 hospitals for acute myocardial infarction (AMI), 1552 hospitals for congestive heart failure (CHF), 1120 hospitals for stroke (STR), 1283 hospitals for gastrointestinal hemorrhage (GIH), 979 hospitals for hip fracture (HIP), and 1716 hospitals for pneumonia (PNE). This study used simultaneous equations models to investigate the determinants of improvement in health outcomes and of cost reduction in hospital inpatient care for these six common diagnoses. In addition, the study used instrumental variables and two-stage least squares random effect model for unbalanced panel data estimation. The study concluded that a few factors were determinants of high quality and low cost. Specifically, high specialty was the determinant of high quality and low costs for CHF patients; small hospital size was the determinant of high quality and low costs for AMI patients. Furthermore, CHF patients who were treated in Midwest, South, and West region hospitals had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. Gastrointestinal hemorrhage and pneumonia patients who were treated in South region hospitals also had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. This study found that six non-cost factors were related to health outcomes for a few diagnoses: hospital volume, percentage emergency room admissions for a given diagnosis, hospital competition, specialty, bed size, and hospital region.^

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Purpose. The focus of maternal role development, historically, has been on the tasks and processes during pregnancy as they relate to postpartum role transition. The purpose of this study was to investigate how women hospitalized with high-risk pregnancy cognitively construct pregnancy and impending motherhood. ^ Design. The study employed a triangulation design using a convergence model with a dominant focused ethnographic approach. ^ Setting. The antepartum units of two tertiary care centers in a large metropolitan city in southeast Texas. ^ Sample. Data saturation was determined with thirteen (13) primigravid women who had been hospitalized more than 72 hours with preterm labor (PTL) or preterm premature rupture of membranes (PPROM) who subsequently delivered seventeen (17) infants which included 4 sets of twins. ^ Methods. Open-ended, semi-structured interviews and field work were used to explore the development of maternal role in this population. After collecting descriptive data, long individual interviews were conducted and the Prenatal Self Evaluation Questionnaire (PSEQ), an instrument to measure prenatal adaptation to pregnancy, was administered. The interview focused on exploring the woman's experiences of pregnancy and impending motherhood while hospitalized. Interview data and field notes were coded and analyzed using qualitative thematic analytic techniques. The PSEQ was scored and the findings of the qualitative data and PSEQ data were compared. ^ Findings. Thematic analysis of the qualitative data provided an understanding of the cognitive process that occurs as the pregnant woman builds a relationship with the fetus. Thematic analysis resulted in a conceptual model with two complementary components that occur throughout the pregnancy: Establishing a Relationship and Dynamic Equilibrium. Establishing a Relationship includes subthemes of: Courting, Building a Connection, and Engagement. Dynamic equilibrium is the balance between expectations and reality and exists regardless of pregnancy complications. The negotiation of this potential imbalance is triggered by uncertainty, loss of autonomy and control, and isolation and is exacerbated by the high-risk pregnancy and subsequent hospitalization. These triggers can serve as obstacles to maternal role development, but may be mediated by external support from friends and family or health care providers. Support from others may come in the form of anticipatory guidance, presence, or activities that promote self-agency. PSEQ scores were similar to previous reports, but due to the small sample, scores were used primarily for comparison to qualitative data. The qualitative findings were congruent with the PSEQ findings in all of the subscales except in the concern for the well-being of the baby. Interview reports included comments demonstrating significant concern for the well-being of the infant, yet the related subscale did not demonstrate such concern. ^ Conclusions. An understanding of the cognitive process involved in establishing a relationship with the developing fetus related to impending motherhood and the importance of dynamic equilibrium can allow healthcare providers and those who interact with pregnant women to support development of the maternal role and anticipate those barriers that may impede that process. Findings from this study identify those triggers and mediators that influence development of the maternal role and suggest potential intervening strategies for those involved in the care of childbearing families. ^

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A descriptive study of demographic and psychosocial factors believed to be associated with employment was carried out through face-to-face interviews with 417 chronically mentally-ill patients. Subjects had been hospitalized a minimum of two times for psychiatric treatment, had been discharged from at least one of these hospitalizations in the two years prior to the study, and were currently residing within a specific community mental health center catchment area in Texas. The study group ranged in age from 16 to 68 years and over one-half had chart diagnoses of schizophrenia.^ A structured interview was developed which addressed current employment status, length of current employment, job title of current or last job, and detailed work history for the prior five years. Four measures of social support were included in the interview. Each subject was asked to identify one recent work and one recent non-work situation which had been stressful or very demanding. A coping questionnaire was verbally administered to measure the ways in which subjects had coped with these specific stressful situations.^ Analysis of results revealed that 27 percent of the sample was gainfully employed at time of interview. Differences between the employed and unemployed groups were analyzed by t-test an chi square. The employed demonstrated significantly more weeks of employment in the prior five years than the unemployed. The current jobs of the employed required a significantly higher relationship to "things" or inanimate objects than the last jobs of the unemployed. Subjects diagnosed as schizophrenic were significantly less likely to be employed than subjects with other diagnoses.^ Employed subjects scored significantly higher on three of four measures of social support than unemployed subjects, including reported frequency of social group attendance and/or meetings with mental health professionals. Problem-focused coping was used significantly more by the employed than by the unemployed to deal with stressful situations in the work, but not the non-work, context. ^

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Coronary perfusion with thrombolytic therapy and selective reperfusion by percutaneous transluminal coronary angioplasty (PTCA) were examined in the Corpus Christi Heart Project, a population-based surveillance program for hospitalized acute myocardial infarction (MI) patients in a biethnic community of Mexican-Americans (MAs) and non-Hispanic whites (NHWs). Results were based on 250 (12.4%) patients who received thromobolytic therapy in a cohort of 2011 acute MI cases. Out of these 107 (42.8%) underwent PTCA with a mean follow-up of 25 months. There were 186 (74.4%) men and 64 (25.6%) women; 148 (59.2%) were NHWs, 86 (34.4%) were MAs. Thrombolysis and PTCA were performed less frequently in women than in men, and less frequently in MAs than in NHWs.^ According to the coronary reperfusion interventions used, patients were divided in two groups, those that received no-PTCA (57.2%) and the other that underwent PTCA (42.8%) after thrombolysis. The case-fatality rate was higher in no-PTCA patients than in the PTCA (7.7% versus 5.6%), as was mortality at one year (16.2% versus 10.5%). Reperfusion was successful in 48.0% in the entire cohort and (51.4% versus 45.6%) in the PTCA and no-PTCA groups. Mortality in the successful reperfusion patients was 5.0% compared to 22.3% in the unsuccessful reperfusion group (p = 0.00016, 95% CI: 1.98-11.6).^ Cardiac catheterization was performed in 86.4% thrombolytic patients. Severe stenosis ($>$75%) obstruction was present most commonly in the left descending artery (52.8%) and in the right coronary artery (52.8%). The occurrence of adverse in-hospital clinical events was higher in the no-PTCA as compared to the PTCA and catheterized patients with the exception of reperfusion arrythmias (p = 0.140; Fisher's exact test p = 0.129).^ Cox regression analysis was used to study the relationship between selected variables and mortality. Apart from successful reperfusion, age group (p = 0.028, 95% CI: 2.1-12.42), site of acute MI index (p = 0.050) and ejection-fraction (p = 0.052) were predictors of long-term survival. The ejection-fraction in the PTCA group was higher than (median 78% versus 53%) in the no-PTCA group. Assessed by logistic regression analysis history of high cholesterol ($>$200mg/dl) and diabetes mellites did have significant prognostic value (p = 0.0233; p = 0.0318) in long-term survival irrespective of treatment status.^ In conclusion, the results of this study support the idea that the use of PTCA as a selective intervention following thrombolysis improves survival of patients with acute MI. The use of PTCA in this setting appears to be safe. However, we can not exclude the possibility that some of these results may have occurred due to the exclusion from PTCA of high risk patients (selection bias). ^

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The purpose of this study was to determine the impact of traditional psychiatric services with case management services on the functioning of people with schizophrenia. Traditional services were defined as routine clinic services consisting of medication follow-along, psychotherapy, and support services. Case management consisted of activities involved in linking, planning, and monitoring services for the outpatient client who has schizophrenia. The target population was adult schizophrenics who had been receiving outpatient clinic services for a minimum of six months. Structured interviews were conducted using standardized scales (e.g., Quality of Life, Self-Efficacy, and Brief Symptom Inventory) with 78 outpatient client volunteers from two sites: Nova Scotia (Canada) and Texas (USA). The researcher tested for differences in psychiatric symptomatology, recidivism, and quality of life for persons with schizophrenia receiving traditional psychiatric services in Nova Scotia and traditional plus case management services in Texas. Data were collected from the structured interviews and medical records review forms. Types of services were blocked into low and high levels of Intensity (frequency x minutes) and compared to determine the relative contribution of each. Finally, the role of clients' self-efficacy was tested as an intervening variable. Although the findings did not support the hypotheses in the direction anticipated, there were some interesting and useful results. From the Nova Scotia site, clients who received low levels of services were hospitalized less compared to the Texas site. The more psychotic a patient was the higher their involvement in medication follow-along and the more monitoring they received. The more psychotherapy received, the lower the reported satisfaction with social relationships. Of particular interest is the role that self-efficacy played in improved client outcomes. Although self-efficacy scores were related to improved functioning, the mechanism for this still needs to be clarified through subsequent research. ^

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High levels of poverty and unemployment, and low levels of health insurance coverage may pose barriers to obtaining cardiac care by Mexican Americans. We undertook this study to investigate differences in the use of invasive myocardial revascularization procedures received within the 4-month period following hospitalization for a myocardial infarction (MI) between Mexican Americans and non-Hispanic whites in the Corpus Christi Heart Project (CCHP). The CCHP is a population-based surveillance program for hospitalized MI, percutaneous transluminal coronary angioplasty (PTCA), and aortocoronary bypass surgery (ACBS). Medical record data were available for 1706 patients identified over a three-year period. Mexican Americans had significantly lower rates of receiving a PTCA following MI than non-Hispanic Whites (RR: 0.56, 95% CI: 0.44-0.70). No meaningful ethnic difference was seen in the rates of ACBS use. History of PTCA use appeared to interact with ethnicity. Among patients without a history of PTCA use, Mexican Americans were less likely to receive a PTCA than non-Hispanic whites (RR: 0.59; 95% CI: 0.46-0.76). Among patients with a history of PTCA use, however, Mexican Americans were more likely to receive a PTCA than non-Hispanic whites (RR: 1.47; 95% CI: 0.75-2.87).^ Differences in the effectiveness of a first-time PTCA and first-time ACBS between Mexican Americans and non-Hispanic whites in the CCHP were also investigated. Mexican Americans were more likely to receive a 2nd PTCA (RR: 1.56, 95% CI: 1.11-2.17) and suffer a subsequent MI (RR: 1.42, 95% CI: 1.03-1.96) following a first-time PTCA than non-Hispanic whites. No meaningful ethnic differences were found in the rates of death and rates of ACBS following a first-time PTCA. Also, no significant ethnic differences were found in the rates of any of the events following a first-time ACBS. After adjusting for potential demographic, socioeconomic, clinical and angiographic confounders using Cox regression analysis, Mexican Americans were still more likely to receive a 2nd PTCA (HR: 1.38; 95% CI: 0.99-1.93) following a first-time PTCA than non-Hispanic whites. A significant difference in the rates of a subsequent MI following a first-time PTCA persisted (HR: 1.39, 95% CI: 1.01-1.93). (Abstract shortened by UMI.) ^