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Purpose: To determine the effect of simulated radioscapholunate fusion with distal scaphoid excision (RSLF+DSE), 4-corner fusion with scaphoidectomy (4-CF), and proximal row carpectomy (PRC) on the wrist's range of motion (ROM), contact pressure, and contact force in a cadaveric model., Methods: Ten freshly frozen cadaveric wrists were tested under 4 sequential conditions: native wrist, RSLF+DSE, 4-CF, and PRC. The simulated fusions were performed using two 1.6-mm Kirschner wires. The ROM in the flexion-extension and radioulnar deviation planes was evaluated. Contact area, contact pressure, and contact force were measured at the scaphocapitolunate joint for the RSLF+DSE simulation and radiocarpal joint for the 4-CF and PRC simulations. Mechanical testing was performed using a 35-N uniaxial load and pressure-sensitive film., Results: The RSLF+DSE and 4-CF groups had a decreased wrist arc ROM compared with the native wrist. The PRC group had a greater wrist arc ROM compared with the RSLF+DSE and 4-CF groups, but compared to the native wrist, it demonstrated a mildly decreased wrist arc ROM. The carpal pressure and contact force were significantly increased in the RSLF+DSE, 4-CF, and PRC groups compared with those in the native wrist. The RSLF+DSE group had the smallest increase in the carpal pressure and contact force, whereas the PRC group had the greatest increase., Conclusions: Our study validates previous findings that PRC is motion-conserving but has the greatest contact force, whereas RSLF-DSE and 4-CF may cause a decrease in the ROM but have lower contact forces., Clinical Relevance: Understanding the underlying native wrist biomechanics and alterations following different surgical treatments may assist hand surgeons in their clinical decision making for the treatment of stage II scapholunate advanced collapse., (Copyright © 2021 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to determine whether aging imparts a clinically significant effect on the (1) mechanism of graft failure and (2) structural, material, and viscoelastic properties of patellar tendon allografts by evaluating these properties in younger donors (≤30 years of age) and older donors (>50 years of age)., Methods: A total of 34 younger (≤30 years of age) and 34 older (>50 years of age) nonirradiated, whole bone-tendon-bone allografts were prepared for testing by isolating the central third of the patellar tendon using a double-bladed 10-mm width scalpel under a 10-N load to ensure uniformity of harvest. Bone blocks were potted in polymethylmethacrylate within custom molds. Tendon length and cross-sectional area were measured using an area micrometer. A mechanical loading system was used to precondition the grafts for 100 cycles with a load between 50 N and 250 N (1 Hz). A creep load (500 N) was then applied at a rate of 100 mm/min (10 minutes). Grafts were allowed to recover at 1 N (10 minutes), followed by pull-to-failure at a rate of 100% strain per second. Mechanisms of failure (midsubstance vs avulsion) were noted and the structural, material, and viscoelastic properties calculated and compared between groups., Results: There were 33 (97%) midsubstance tears in the younger group and 28 (82%) in the older group (P = .034). Younger grafts showed greater ultimate load to failure (1,782 N [1,533, 2,032] vs 1,319 N [1,103, 1,533]) (P = .006) and ultimate tensile stress (37.4 MPa [32.4, 42.4] vs 27.5 MPa [22.9, 32.0]) (P = .006). There were no significant differences in displacement (P = .595), stiffness (P = .950), strain (P = .783), elastic modulus (P = .114), creep displacement (P = .881), and creep strain (P = .614)., Conclusions: This in vitro study suggests that aging weakens the bone-tendon junction and decreases the ultimate tensile strength of patellar tendon allografts. However, aging did not affect the displacement, strain, stiffness, elastic modulus, creep displacement, or creep strain of patellar tendon allografts., Clinical Relevance: Surgeons should be aware that patellar tendon allografts from donors >50 years of age have a lower ultimate tensile stress than donors ≤30 years of age., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: Selecting treatment for scapholunate (SL) instability is notoriously difficult. Many methods of reconstruction have been described, but no procedure demonstrates clear superiority. New methods proposed use internal bracing (IB) with suture anchors and flat braided suture (FBS), alone or as an augmentation with tendon autograft for SL ligament injuries. Our goal was to use computed tomography (CT) to analyze alignment of the SL joint after 3 different modes of fixation of SL instability: after reconstruction with IB incorporating either tendon autograft or the dorsal intercarpal ligament (DICL), or DICL capsulodesis without FBS., Methods: Ten fresh-frozen, matched-pair, forearm-to-hand specimens were used. Serial sectioning of the SL stabilizing ligaments was performed and the SL interval was measured with CT. We reconstructed the SL ligament with DICL capsulodesis alone (DICL) or with IB augmented with either tendon autograft (IB plus T) or DICL (DICL plus IB). The SL interval was measured with CT. Specimens underwent 500 weighted cycles on a jig and were reimaged. Differences in SL interval after repair and cycling were compared., Results: Dorsal intercarpal ligament capsulodesis augmented with IB best maintained the SL interval before and after cycling. Dorsal intercarpal ligament capsulodesis alone was inferior to DICL plus IB and IB plus T both before and after cycling., Conclusions: Dorsal intercarpal ligament capsulodesis augmented with IB appears to maintain better SL joint reduction than IB with tendon autograft., Clinical Relevance: This work serves as a necessary step for further study of the biomechanical strength and clinical application of FBS technology in the reconstruction of SL instability. Flat braided suture augmentation of DICL capsulodesis may provide another option to consider for reconstruction of SL instability., (Copyright © 2021 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Spiders spin high performance fibers with diverse biological functions and mechanical properties. Molecular and biochemical studies of spider prey wrapping silks have revealed the presence of the aciniform silk fibroin AcSp1-like. In our studies we demonstrate the presence of a second distinct polypeptide present within prey wrapping silk. Combining matrix-assisted laser desorption ionization tandem time-of-flight mass spectrometry and reverse genetics, we have isolated a novel gene called MiSp1-like and demonstrate that its protein product is a constituent of prey wrap silks from the black widow spider, Latrodectus hesperus. BLAST searches of the NCBInr protein database using the amino acid sequence of MiSp1-like revealed similarity to the conserved C-terminal domain of silk family members. In particular, MiSp1-like showed the highest degree of sequence similarity to the nonrepetitive C-termini of published orb-weaver minor ampullate fibroin molecules. Analysis of the internal amino acid sequence of the black widow MiSp1-like revealed polyalanine stretches interrupted by glycine residues and glycine-alanine couplets within MiSp1-like as well as repeats of the heptameric sequence AGGYGQG. Real-time quantitative PCR analysis demonstrates that the MiSp1-like gene displays a minor ampullate gland-restricted pattern of expression. Furthermore, amino acid composition analysis, coupled with scanning electron microscopy of raw wrapping silk, supports the assertion that minor ampullate silks are important constituents of black widow spider prey wrap silk. Collectively, our findings provide direct molecular evidence for the involvement of minor ampullate fibroins in swathing silks and suggest composite materials play an important role in the wrap attack process for cob-weavers.

Racial and Ethnic Approaches to Community Health (REACH 2010) is a U.S. Centers for Disease Control and Prevention demonstration program that responds to the U.S. Department of Health and Human Services' goal to eliminate racial and ethnic disparities in health status by the year 2010. As part of REACH 2010, community projects were funded to develop, implement, and evaluate community action plans to improve health care and outcomes for racial and ethnic populations. This article describes the program and details the progress of the REACH 2010: Charleston and Georgetown Diabetes Coalition in reducing disparities in care. Approaches employed by the Coalition included community development, empowerment, and education related to diabetes; health systems change associated with access, care, and education; and coalition advocacy. Racial disparities were identified for 12,000 African Americans with diabetes in this urban/rural South Carolina community. After 24 months, significant differences that initially ranged from 11% to 28% in African Americans (when compared with whites/others) were not observed on 270 chart audits for A1C, lipid and kidney testing, eye examinations, and blood pressure control. Future efforts will focus on maintaining progress, eliminating other disparities, and identifying the contributions of each intervention in eliminating racial disparities.

Aims: This study examines the outcomes at 1, 3 and 6 months after a very brief outpatient detoxification with buprenorphine in 18-25-year-old heroin users., Design: Prospective follow-up study., Setting: Outpatient drug treatment clinic, providing brief detoxification in downtown Baltimore, Maryland, USA., Participants: One hundred and twenty-three subjects between 18 and 25 years old; 56% male; 95% Caucasian; seeking detoxification; living in Baltimore City and five surrounding counties., Intervention: Detoxification with buprenorphine over 3 days. Follow-up at 1, 3 and 6 months., Measurements: Drug use history, the Addiction Severity Index at baseline and follow-up, urine drug screens, evaluation of the detoxification experience., Findings: By self-report, 37% of the total sample were not currently using heroin at 1 month, 32% at 3 months and 29% at 6 months, and 6.7%, 10.1% and 11.8% had an opioid negative urine test at 1, 3 and 6 months, respectively. There was a significant reduction from the baseline in mean Addiction Severity Index drug use composite score, as well as the mean number of days of heroin and cocaine use during past 30 days, that was sustained over the three follow-up points. Engagement in aftercare was generally poor., Conclusions: The findings show a reduced frequency and intensity of drug use, suggesting a possible role for brief outpatient detoxification in reducing the severity of dependence for some younger heroin users who may not yet be ready to engage in long-term abstinence-oriented or opioid substitution treatments.

Background: Unemployment remains a major consequence of schizophrenia and other severe mental illnesses. This study assesses the effectiveness of the Individual Placement and Support model of supportive employment relative to usual psychosocial rehabilitation services for improving employment among inner-city patients with these disorders., Methods: Two hundred nineteen outpatients with severe mental illnesses, 75% with chronic psychoses, from an inner-city catchment area were randomly assigned to either the Individual Placement and Support program or a comparison psychosocial rehabilitation program. Participants completed a battery of assessments at study enrollment and every 6 months for 2 years. Employment data, including details about each job, were collected weekly., Results: Individual Placement and Support program participants were more likely than the comparison patients to work (42% vs 11%; P<.001; odds ratio, 5.58) and to be employed competitively (27% vs 7%; P<.001; odds ratio, 5.58). Employment effects were associated with significant differences in cumulative hours worked (t(211) = -5.0, P =.00000003) and wages earned (t = -5.5, P =.00000003). Among those who achieved employment, however, there were no group differences in time to first job or in number or length of jobs held. Also, both groups experienced difficulties with job retention., Conclusions: As hypothesized, the Individual Placement and Support program was more effective than the psychosocial rehabilitation program in helping patients achieve employment goals. Achieving job retention remains a challenge with both interventions.

Objective: The aim of this study was to determine whether it is possible at the time of staff training to predict whether a mental health center will succeed in implementing family psychoeducation services., Methods: Fifteen mental health agencies in Maine and 51 in Illinois in which clinicians and administrators were trained in multifamily psychoeducation were studied. Participants were surveyed immediately after their initial training sessions and nine months later. Participants' demographic characteristics, agency characteristics, and principal components derived from the survey data were analyzed to identify factors associated with implementation of family psychoeducation services., Results: The regression model successfully predicted which sites would succeed. Success was more likely at sites where the treatment model was viewed more positively at the outset, where real and perceived resource limitations were addressed, where inducements to implementation were seen as less important, and where attention was paid to the difference between new and existing treatment methods. Nearly all the Maine sites (14, or 93 percent) implemented multifamily psychoeducation services, whereas only five of the Illinois sites (10 percent) implemented this form of treatment. The Maine trainees were less skeptical about family psychoeducation and more interested in receiving supervision and consultation. In Maine there was wide-ranging and local consensus before and during implementation, and more federal funding was available than in Illinois., Conclusions: Surveys of clinicians allowed prediction of which sites would successfully implement family psychoeducation services. Consensus building and funding appeared to be critical to successful outcomes.

This study identified demographic, clinical, and vocational rehabilitation-related correlates of long-term unemployment among 219 adults with severe mental illness. Fifty-one percent of the sample had been unemployed five or more years before enrollment. Older age, a diagnosis of psychosis, severity of negative symptoms, and more previous hospitalizations were all significantly related to long-term unemployment. Gender, race, education, substance disorder diagnosis, severity of negative symptoms, and vocational training experience were not. The findings underscore the relevance of clinical and neurocognitive impairments to long-term unemployment and point to the need to critically reevaluate the effectiveness of traditional vocational rehabilitation services.

This study evaluated the relationships between self-ratings of physical role functioning and general health, two components of the MOS SF-36, and a variety of demographic, quality of life, clinical, functional, and attitudinal variables in a cohort of adults living with severe and persistent mental illness (SPMI). We hypothesized that poorer self-perceptions of physical functioning and general health would be significantly related to more severe symptoms and poorer functioning and quality of life. Study subjects were 218 adults with SPMI enrolled in a randomized controlled trial comparing two vocational interventions for persons who were unemployed. Hierarchical regression analysis was used to determine whether psychiatric symptoms, poorer self-perceptions of role limitations due to physical health problems and overall general health independently contributed to more severe symptoms and poorer functioning and quality of life. Psychiatric symptoms were inversely related to size of social network and satisfaction with safety. Increased role limitations were associated with reduced medication compliance, general life satisfaction, and satisfaction with health, daily activities, and safety. Reduced general health was significantly associated with reduced work motivation, self-esteem, current inability to work, self-report of functioning, and almost all subjective life satisfaction domains. Within this group of people with severe mental illness, psychiatric symptoms were minimally associated with outcomes. Physical role limitations contributed more, and an integrated global measure of overall health perception was most important. If we are to help persons with severe mental illness maximize their quality of life and functioning, our clinical interventions should employ an approach that appreciates and recognizes the importance of the patients' experience of a holistic and integrated experience of health.

Objective: Clients with severe and persistent mental illnesses often require a representative payee to help manage benefit funds. This study compared the perceptions of clients and clinical case managers about the benefits of and problems with the representative payee relationship., Methods: Fifty-four clients receiving assertive community treatment completed an interview that assessed satisfaction with their experience of having a representative payee and the resulting impact on their substance use, budgeting, and housing. The clients' clinical case managers completed a similar questionnaire. Analyses examined associations between providers' and clients' responses and clients' gender, race, diagnosis, previous experience with a representative payee, and duration of the current representative payeeship., Results: Clients and case managers recognized benefits of the representative payeeship in the areas of housing, substance use, and budgeting. Although little evidence was found that the payeeship pervasively interfered with the therapeutic relationship, 44 percent of case managers reported incidents in which clients verbally abused them over management of their funds. Clients' satisfaction with the representative payeeship was initially low but grew over time. Longer duration of the current payeeship and clients' previous experience with representative payeeship were associated with greater satisfaction and fewer problems. Case managers overestimated clients' initial satisfaction and underestimated their current satisfaction., Conclusions: Findings suggest that both mental health professionals and clients value the representative payee process as helpful in improving outcomes, although the benefits of the arrangement may be more evident with time and experience.

Objective: The authors assessed the nature and stability of remission of substance use disorder among persons with severe mental illness at index hospitalization and at 1-year follow-up., Method: Consecutively admitted inpatients with severe mental illness completed the Structured Clinical Interview for DSM-III-R, Quality of Life Interview, and Addiction Severity Index at admission and 1 year later. Of the 268 patients, 70 were classified as past substance abusers in remission at baseline. Baseline characteristics and 1-year outcomes of this group were compared with those of the 109 current substance abusers and the 89 patients who were not substance abusers., Results: The past abusers were significantly more likely to be women, and they consistently differed significantly from the current abusers in variables involving frequency of drug and alcohol use at baseline. During the follow-up period, the patients with current abuse at baseline were significantly more likely to have recurrences of substance use disorders and to use substance abuse services, and they had significantly more months of alcohol use and alcohol use to excess during follow-up than did the past abusers., Conclusions: Baseline and follow-up assessments suggested that a substantial proportion of severely mentally ill patients with past substance use disorders are in stable remission.

Objective: Service utilization and outcomes of dually diagnosed patients with independent mental disorders and those with substance-induced mental disorders were compared., Method: Diagnosis, service use, and severity of substance use problems at baseline and 1 year later were assessed in consecutively admitted inpatients with independent mental disorders plus substance use disorders (N = 71), substance-induced mental disorders plus substance use disorders (N = 38), and independent mental disorders only (N = 59)., Results: At follow-up, patients with substance-induced mental disorders at baseline were more likely to have been rehospitalized than the other groups, were more likely to have used outpatient substance abuse services, were less likely to have an independent mental disorder, and had the most severe alcohol- and drug-related impairment., Conclusions: Treatment programs for both types of dual diagnosis patients must address mental health concerns.

Objective: The authors sought to determine how substance abuse affects family relationships of persons with severe mental illness., Method: Patient reports of family relationships were compared between 101 psychiatric inpatients with a concurrent substance use disorder and 78 subjects with severe mental illness only., Results: Patients with comorbid substance abuse reported significantly lower family satisfaction and a greater desire for family treatment. Objective indicators of frequency of family contact did not differ., Conclusions: Substance abuse is associated with low levels of satisfaction with family relationships among persons with severe mental illness. Family interventions would meet the stated needs of persons with mental illness and a comorbid substance use disorder and might help to engage them in treatment.

The impact on services and outcomes of the local mental health authorities (LMHAs) developed under the RWJF Program on Chronic Mental Illness (CMI) was evaluated in Baltimore, Cincinnati, Columbus, and Toledo. Two cohorts of clients with CMI discharged from an episode of acute 24-hour care were recruited in each city: the first cohorts were drawn shortly after the demonstration began and the second, two years later. The LMHAs in the three Ohio cities increased case management for the second cohorts at two months, but not at 12 months, after hospital discharge. The second cohorts in Baltimore and Cincinnati experienced lower turnover among case managers during the year after discharge, but there was no significant improvement in client outcomes. Creation of LMHAs may be a necessary, but not sufficient, step toward improving outcomes and should be followed by improvement in the quantity and quality of services.