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This chapter examines critical issues in women’s behavioral health from an interdisciplinary public health perspective. The content discusses some of the major concerns in improving women’s health outcomes, including a discussion of current challenges in prevention and treatment of HIV, postpartum depression, and trauma-informed care, which are significant public health concerns. The chapter concludes with an Implications for Behavioral Health section, discussing the relevance of each issue to the overall field of women’s behavioral health and health-care policy.

The goal was to examine risk factors and expenditures for early rehospitalization (within 30 days of discharge) for non-behavioral health conditions among Medicaid-enrolled Floridians over 8 years. There were 1,689,797 hospitalization episodes with 19% (N = 314,742) resulting in early rehospitalization. Total gross charges for early rehospitalization were over 13 billion dollars. In Cox proportional hazards regression adjusted for demographic and health covariates, drug use disorder was associated with 50% increased risk of early rehospitalization. Having major depressive disorder increased risk by 17%; psychotic disorder, bipolar disorder, and alcohol use disorder increased risk of early rehospitalization slightly by 10, 6, and 6% respectively. The effect of dementia on risk was minimal at 2%. Risk of early rehospitalization decreased by 3.5% per year over the 8 years of the study. Attention to mental health problems, especially drug use disorder, may help further reduce rates of early readmission for non-behavioral health conditions.

Hospitalizations for physical health problems can cause great mental health challenges. We examined risk factors and expenditures for early readmission for inpatient psychiatric treatment following a hospitalization for a non-psychiatric condition.We used eight years of Florida Medicaid enrollment and claims data for (FY 2003-2011) as well as data obtained from the Florida Center for Health Information and Policy Analysis, Inpatient Hospital Database, to identify episodes of hospitalization for all Medicaid-enrolled older adults. There were a total of 781,660 index hospitalizations for non-behavioral health-related hospitalizations, 2690 (0.3%) of which resulted in a behavioral health-related rehospitalization within 30 days after discharge. We estimated the relative risk of early rehospitalization using Cox proportional hazards regression.Participants (n = 276,254) were 76.8 ± 8.3 years old; 68.4% female and 43.5% White. As expected, we found that having a preexisting behavioral health disorder (including severe mental illness, substance use disorder, or dementia) greatly increased the risk of readmission. We also found that male gender increased the risk of early readmission. Older age, being Black and having one or more comorbid medical conditions as identified by the Charlson Index were associated with substantially reduced risk.Identifying hospitalized patients with psychiatric conditions, as well as those who are relatively young within this age group, male, White rather than Black or of other race, alcohol abusers, and those without comorbid conditions, and providing them with care to address their behavioral needs may help in efforts to reduce early rehospitalizations for psychiatric conditions.

OBJECTIVE The study examined risk factors for readmission to acute care among Florida Medicaid enrollees with schizophrenia treated with antipsychotics. METHODS Medicaid and service use data for 2004 to 2008 were used to identify adults with schizophrenia discharged from hospitals and crisis units who were taking antipsychotics. Data were extracted on demographic characteristics, service use before admission, psychopharmacologic treatment after discharge, and readmission to acute behavioral health care. Cox proportional hazards regression estimated readmission risk in the 30 days after discharge and in the period after 30 days for participants not readmitted in the first 30 days. RESULTS The mean±SD age of the 3,563 participants was 43.4±11.1; 61% were male, and 38% were white. Participants had 6,633 inpatient episodes; duration of hospitalization was 10.6±7.0 days. Readmission occurred for 84% of episodes, 23% within 30 days. Variables associated with an increased readmission risk in the first 30 days were shorter hospitalization (hazard ratio [HR]=1.18, 95% confidence interval [CI]=1.10-1.27, plt;.001), shorter time on medication before discharge (HR=1.19, CI=1.06-1.35, p=.003), greater prehospitalization use of acute care (HR=2.64, CI=2.29-3.05, plt;.001), serious general medical comorbidity (HR=1.21, CI=1.06-1.38, p=.005), and prior substance abuse treatment (HR=1.58, CI=1.37-1.83, plt;.001). After 30 days, hospitalization duration and time on medication were not significant risk factors. CONCLUSIONS Short hospital stays for persons with schizophrenia may be associated with risk of early readmission, possibly because the person is insufficiently stabilized. More chronic risk factors include prior acute care, general medical comorbidity, and substance abuse.

YchF is one of two universally conserved GTPases with unknown cellular function. As a first step toward elucidating YchF’s cellular role, we performed a detailed biochemical characterization of the protein from Escherichia coli. Our data from fluorescence titrations not only confirmed the surprising finding that YchFE.coli binds adenine nucleotides more efficiently than guanine nucleotides, but also provides the first evidence suggesting that YchF assumes two distinct conformational states (ATP- and ADP-bound) consistent with the functional cycle of a typical GTPase. Based on an in vivo pull-down experiment using a His-tagged variant of YchF from E. coli (YchFE.coli), we were able to isolate a megadalton complex containing the 70S ribosome. Based on this finding, we report the successful reconstitution of a YchF•70S complex in vitro, revealing an affinity (KD) of the YchFE.coli•ADPNP complex for 70S ribosomes of 3 μM. The in vitro reconstitution data also suggests that the identity of the nucleotide-bound state of YchF (ADP or ATP) modulates its affinity for 70S ribosomes. A detailed Michaelis-Menten analysis of YchF’s catalytic activity in the presence and the absence of the 70S ribosome and its subunits revealed for the first time that the 70S ribosome is able to stimulate YchF’s ATPase activity (~10-fold), confirming the ribosome as part of the functional cycle of YchF. Our findings taken together with previously reported data for the human homolog of YchF (hOLA1) indicate a high level of evolutionary conservation in the enzymatic properties of YchF and suggest that the ribosome is the main functional partner of YchF not only in bacteria.

Objectives:The ability of nursing homes to manage the mental health needs of their residents is crucial to providing high quality care. An important element is preventing exacerbations of psychiatric conditions that trigger discharge from the nursing home (NH) because of an emergency commitment (EC) for an involuntary psychiatric examination. The objective of this study was to examine the relationship between resident and facility characteristics and the risk of EC for involuntary psychiatric examination among Medicaid-enrolled NH residents in Florida. Design: This retrospective cohort study employed 2.5years (31 December 2002 through 30 June 2005) of Medicaid enrollment and fee-for-service, pharmacy, and involuntary commitment data to examine resident characteristics. NH characteristics were obtained from the Online Survey Certification and Reporting database. Setting: Medicaid-certified NHs in Florida (N=584). Participants: Medicaid-enrolled NH residents (N=32,604). Results:Younger age, male gender, having dementia, having a serious mental illness (SMI), and residing in a for-profit facility were all independently associated with the greater risk of EC. Although most residents with EC were prescribed psychotropic medication, less than half received non-pharmacological behavioral health outpatient services before or after their involuntary psychiatric examination. Conclusion: Our findings highlight the salience of resident and facility characteristics to prevalence rates of EC for involuntary psychiatric examinations among NH residents and underscore a need for increased education, communication, and future research on the predictive factors as well as the consequences of these adverse events. Copyright # 2011 John Wiley & Sons, Ltd.

We examined patterns and correlates of arrest/re-arrests among offenders with a serious mental illness over a 4-year period. County criminal justice records and health and social service datasets were used to identify and describe inmates jailed in Pinellas County, Florida, between 7/03 and 6/04. A total of 3,769 participants (10.1% of arrestees) had a serious mental illness. Participants averaged 4.6 arrests (SD 3.9, median 4) and 150.6 days in jail (SD 175.0, median 90).Working from the trajectories of offending theory and literature we used latent class growth analysis to identify three classes of offenders with consistent numbers of arrests over a 4-year period and nearly parallel arrest trajectories; a sporadic arrest class (n 469) with minimal arrests, a low arrest chronic class (n 3,090, about one arrest/year); and a high arrest chronic class (n 210, about four arrests/year). Analysis of arrests by age group within each of the classes suggested that for the low and high arrest chronic classes arrest rates persist throughout adult life. In multinomial logistic regression, homelessness, a co-occurring substance abuse diagnosis, fewer mental health outpatient service contacts and more mental health emergency room/inpatient contacts were associated with being in a class with more arrests. Arrests among offenders with a serious mental illness appear to be unusually high, to be firmly established in late adolescence and to persist over time. Successful strategies to reduce the arrest rates of this population must address the needs of these offenders early in their criminal careers.

Despite the increasing number of men and women with serious mental illness (SMI) incarcerated in America's jails, little research exists on the role gender may play in arrest among persons with SMI. This study examined correlates of arrests among offenders with SMI, specifically the role of gender. County criminal justice records, as well as county and statewide social service archival databases, were used to identify jail inmates with SMI in a large urban county in Florida. Of the 3,769 inmates identified, 41% were female. This study identified three distinct classes of male and female offenders within which persons had similar trajectories of arrests over the 4-year study period representing those with minimal, low, and high arrest rates. Findings suggest some important differences between women and men in risk factors for re-arrests. Attention to these factors may improve the ability to prevent future recidivism among men and women with SMI.

Objective: This study identified characteristics and experiences of arrestees and jail inmates with a serious mental illness that were associated with misdemeanor and felony arrests and additional days in jail. Methods: County and statewide criminal justice records and health and social service archival data sets were used to identify inmates with serious mental illness who were in the Pinellas County, Florida, jail between July 1, 2003, and June 30, 2004, and their health and social service contacts from July 1, 2002, to June 10, 2006. Criminal justice and mental health services were recorded longitudinally across 16 quarters, or 90day periods. Generalized estimating equations for count data were used to describe the associations between individual characteristics and experiences and the risks of misdemeanor and felony arrests and additional days in jail. Results: A total of 3,769 jail inmates (10.1% of all jail inmates) were diagnosed as having a serious mental illness. Participants experienced a mean±SD of .90±.60 arrest for every three quarters and 10.9±23.6 days in jail per quarter that they resided in the county. Being male, being homeless, not having outpatient mental health treatment, and having an involuntary psychiatric evaluation in the previous quarter were independently associated with significantly increased odds of misdemeanor arrests and additional days in jail. On the other hand, being black, being younger than 21 years, having a nonpsychotic diagnosis, and a co-occurring substance use disorder diagnosis were all independently associated with significantly increased odds of felony arrests, and with the exception of having a nonpsychotic diagnosis, they were also significantly associated with additional days in jail. Conclusions: Findings suggest that there are subgroups of individuals with a serious mental illness in the criminal justice system that may require different policy and programmatic responses. (Psychiatric Services 61:451–457, 2010)

The yKu protein of Saccharomyces cerevisiae is important for genome stability by repressing recombination involving telomeric sequences. The mechanism of this repression is not known, but silent heterochromatin such as HML, HMR, and telomeres are compartmentalized at the nuclear periphery and yKu is proposed to interact with these regions and to play a role in telomeric silencing and tethering. We have utilized ChIP on chip, quantitative PCR, and quantitative recombination assays to analyze yKu binding and its effect on genome stability in wild-type and mutant backgrounds. Our data suggest that, although yKu binds to the TG1-3 repeats and other parts of the genome when needed, such as during nonhomologous end-joining, it specifically binds to core X sequences in addition to the mating-type loci, HML and HMR. Association with core X occurred in the absence of Sir proteins, and enhanced binding was observed at silenced ends compared to nonsilenced ends. In contrast, binding to HML and HMR was totally dependent on Sir2–4p and partially dependent on Sir1p with a stronger association at HML in both MATa and MATα strains. Using yku80 separation-of-function mutants, we show a direct correlation between core X binding and recombination rate. We believe our findings support our hypothesis that yKu and core X play a pivotal role in maintaining genome stability through nuclear architecture by mediating a defensive fold-back structure at yeast chromosome ends.

Parallel β -helices are among the simplest repetitive structural elements in proteins. The folding behavior of β -helix proteins has been studied intensively, also to gain insight on the formation of amyloid fibrils, which share the parallel β -helix as a central structural motif. An important system for investigating β -helix folding is the tailspike protein from the Salmonella bacteriophage P22. The central domain of this protein is a right-handed parallel β -helix with 13 windings. Extensive mutational analyses of the P22 tailspike protein have revealed two main phenotypes: temperature-sensitive-folding (tsf) mutations that reduce the folding efficiency at elevated temperatures, and global suppressor (su) mutations that increase the tailspike folding efficiency. A central question is whether these phenotypes can be understood from changes in the protein stability induced by the mutations. Experimental determination of the protein stability is complicated by the nearly irreversible trimerization of the folded tailspike protein. Here, we present calculations of stability changes with the program FoldX, focusing on a recently published extensive data set of 145 singe-residue alanine mutants. We find that the calculated stability changes are correlated with the experimentally measured in vivo folding efficiencies. In addition, we determine the free-energy landscape of the P22 tailspike protein in a nucleation–propagation model to explore the folding mechanism of this protein, and obtain a processive folding route on which the protein nucleates in the N-terminal region of the helix.

Objective To examine resident and facility characteristics associated with psychiatric hospitalizations (PH) for Medicaid enrolled nursing home (NH) residents. Methods Participants were all Medicaid enrolled NH residents (n = 32,604) from all Medicaid certified nursing homes in Florida (n = 584) with complete data. We used individual demographic and diagnostic characteristics, as well as facility characteristics, to explore risk of psychiatric hospitalization in this dataset. Results Using generalized estimating equations, we found that younger age, male gender, poor physical health, serious mental illness, dementia, and drug use disorder were associated with risk of psychiatric hospitalization. Most notably, residents under 65 were more than three times more likely to undergo psychiatric hospitalization and dementia was associated with a three-fold increase in the risk of psychiatric hospitalization. Predictors of PH differed somewhat for younger and older residents. Among facility characteristics, greater facility size, low proportion of those paying via Medicare and high proportion of residents with serious mental illness were associated with increased risk of psychiatric hospitalization, whereas, low proportion of residents paying via Medicaid, high proportion of residents paying via Medicare, and low proportion of resident with serious mental illness were associated with reduced risk. Conclusions Both resident and facility characteristics impact risk for psychiatric hospitalization. Attention to identified predictors may reduce risk and improve outcomes for nursing home residents. Copyright © 2008 John Wiley & Sons, Ltd.

Permanency planning has been the accepted practice of the American child welfare system for the past quarter-century. Permanency planning for foster care is the process of taking prompt, decisive action to maintain children in their own homes, or to permanently place them with other families. This study examined the significant predictors of successful permanency planning and length of stay in foster care for children served by the child welfare system in Florida. A retrospective study was made of children who had been placed into and exited foster care in Florida between July 1, 1998, and December 1, 1999. Each child ( n = 7807) was studied for 12 months from the day of entry into foster care. The relative importance of factors contributing to the outcome of permanency planning was determined using logistic regression. Results showed that across the state, the child's geographic district of residence was the single most important predictor of outcome. Geography accounted for a 7-fold difference among districts in the rate of successful permanency planning. Other factors that helped determine the outcome of permanency planning were race, presence of a mental disorder, developmental disabilities and placement in therapeutic foster care.

While some studies show a significant advantage in adherence rates with use of atypical versus typical antipsychotic medication, others show no advantage or mixed results (Jones et al. (2006). Archives of General Psychiatry, 63, 1079-1087; Rosenheck, (2006). Archives of General Psychiatry, 63, 1074-1076). This study examined treatment outcomes and costs associated with adherence rates by antipsychotic medication class for adult Medicaid beneficiaries in Florida diagnosed with schizophrenia. Outcomes examined include arrests, involuntary commitments, and physical and behavioral healthcare costs. Study findings demonstrate that medication adherence for persons with schizophrenia may be as important to treatment costs and benefits as the class of medication used.

Traumatic brain injury (TBI) is a major public health concern. Such injuries often result in dramatic changes in the individual's life-course due to the associated complex co-morbidities. Limited research exists on the use and expenditures incurred for behavioural healthcare services post-TBI. This study examined predictors of behavioural service use, incarceration and associated expenditures for individuals with TBI.Emergency Medical Services and Medicaid Claims data were used to identify individuals diagnosed with a TBI in Pinellas County, Florida, in FY 2005. Ten statewide and local administrative data sets from 2005-2008 were employed to determine subject's demographic characteristics, criminal justice encounters, behavioural health services use and associated expenditures. Average annual expenditures and use of mental health, substance abuse and criminal justice services over a 3-year period were determined.A total of 1005 individuals diagnosed with TBI were identified and, of these, 910 survived the 3-year period. Study participants were grouped into high and low behavioural health expenditure groups. Those in the high expenditure group were more likely to be male, white and to have received behavioural health services.This study provides new information about predictors of behavioural health service use and Medicaid expenditures for Floridians with TBI.

Anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL) has a good prognosis compared to ALK-negative ALCL, possibly as a result of the immune recognition of the ALK proteins. The aim of our study was to investigate the presence of both a B and cytotoxic T cell (CTL) response to ALK in ALK-positive ALCL. We confirmed the presence of an antibody response to ALK in all 9 ALK-positive ALCL patients investigated. An ELISpot assay was used to detect a gamma-interferon (IFN) T cell response after short term culture of mononuclear blood cells with 2 ALK-derived HLA-A*0201 restricted peptides: ALKa and ALKb. A significant gamma-IFN response was identified in all 7 HLA-A*0201-positive ALK-positive ALCL patients but not in ALK-negative ALCL patients (n = 2) or normal subjects (n = 6). CTL lines (>95% CD8-positive) raised from 2 ALK-positive ALCL patients lysed ALK-positive ALCL derived cell lines in a MHC-Class I restricted manner. This is the first report of both a B cell and CTL response to ALK in patients with ALK-positive ALCL. This response persisted during long-term remission. The use of modified vaccinia virus Ankara (MVA) to express ALK is also described. Our findings are of potential prognostic value and open up therapeutic options for those ALK-positive patients who do not respond to conventional treatment.

This analysis examined data from mothers at 2 of the 9 sites participating in Substance Abuse and Mental Health Services Administration's (SAMHSA's) national Women Co-occurring Disorders and Violence Study (WCDVS). According to previous literature, it was hypothesized that women in the WCDVS would be at high risk of perpetrating child abuse. This research examined mothers' potential for physical child abuse and assessed the association between child abuse potential, current mental health symptoms, alcohol and drug use severity, and trauma. Results revealed that participants had significant potential for child abuse. Hierarchical regression analyses revealed that current mental health symptoms were the strongest predictor of mothers' scores on the Child Abuse Potential (CAP) Inventory. This study highlights the important relationships between commonly used instruments across the mental health, substance, and child welfare fields and the potential dual use of these instruments. Implications for policy and practice are discussed.

Using data from a common cross-site protocol administered at study enrollment, in this article we examine key characteristics of 2,729 participants in the Women, Co-Occurring Disorders and Violence Study (WCDVS), including demographics, physical health, mental health, substance abuse, trauma experiences, parenting status, and past history of service use. These data are important because they represent the first federal initiative that addresses the significant lack of appropriate services for women with co-occurring substance use and mental health disorders who have experienced trauma. Study findings reveal a very vulnerable population with extensive histories of abuse and substantial physical and mental health service needs. Data suggest a pressing need for increased availability of physical and mental health services capable of serving the complex needs of women with co-occurring disorders and histories of interpersonal violence (physical and/or sexual abuse). Equally important are funding strategies to support needed services. © 2005 Wiley Periodicals, Inc. J Comm Psychol 33: 429–443, 2005.

Protein-protein interactions govern a wide range of cellular processes. Molecular recognition responsible for homodimerization and heterodimerization in the rel/NF-κB family of eukaryotic transcription factors relies on a small cluster of hydrophobic residues. We have carried out a structural analysis of six NF-κB p50 dimer interface mutants; one of them revealed a remarkable alteration. One or possibly both its mutations cause a switch into an intertwined dimer, in which the molecular partners exchange nearly half of their fold. In spite of the extensive swapping of secondary structure elements, the topology within each counterpart is preserved, with a very similar overall structure and minimal changes at the interface. Thus intertwining rescues structure and function from a destabilizing mutation. Since the mutants originate from a directed evolution experiment and are functional, the data provide an evolutionary snapshot of how a protein structure can respond to mutations while maintaining a functional molecular architecture.

This study assessed short-term effects of the removal of injectable risperidone long-acting therapy from the Florida Medicaid preferred drug list (PDL) in April 2006.A difference-in-difference approach was used to contrast changes (60 days pre and post) in health care utilization and costs of Medicaid recipients who were receiving risperidone long-acting therapy when the policy was changed (N=247) and of a matched sample who received risperidone long-acting therapy in April 2005 (non-PDL, N=247).The policy change was associated with increased acute care events. Whereas acute care events declined for the non-PDL group, involuntary commitments and total acute care events increased for the PDL group, as did expenditures for crisis-related events. Medicaid pharmacy costs fell for both groups, but total expenditures did not decline significantly for the PDL group.The PDL restriction was associated with increased acute care events and did not reduce short-term Medicaid program expenditures.

The desirability of inducing cytotoxic T cell responses to defined epitopes in humans has led to the development of a variety of recombinant delivery systems. Recombinant protein particles derived from a yeast retrotransposon (Ty) and the modified Ankara vaccinia (MVA) virus can deliver large epitope strings or even whole proteins. Both have previously been administered safely in humans. Immunization with recombinant Ty and MVA containing a single Plasmodium berghei class I-binding epitope provided 95% sterile protection against malaria in mice. The sequence of immunization, Ty followed by MVA, was critical to elicit high levels of IFN-gamma-producing cells and protection. The reciprocal sequence (MVA/TY) or homologous boosting was not protective. Both constructs (Ty and MVA) contain the H-2Kd-restricted pb9 CTL epitope from the circumsporozoite protein of P. berghei among a string of 8-15 human P. falciparum-derived CTL epitopes restricted through 7 common HLA alleles as well as widely recognized CD4 T cell epitopes. Thus, the novel recombinant Ty/MVA prime/boost combination with these constructs provides a safe alternative for evaluation for human vaccination against P. falciparum malaria.

A vaccine against human immunodeficiency virus (HIV) is still awaited. Although the correlates of protection remain elusive, it is likely that CD8+ T cells play an important role in the control of this infection. To firmly establish the importance of these cells in protective immunity, a means of efficient elicitation of CD8+ T cell responses in the absence of antibody is needed and, when available, might represent a crucial step towards a protective vaccine. Here, a novel vaccine candidate was constructed as a multi-cytotoxic T lymphocyte (CTL) epitope gene delivered and expressed using modified vaccinia virus Ankara (MVA). The immunogen consists of 20 human, one murine and three rhesus macaque epitopes. The non-human epitopes were included so that the vaccine can be tested for immunogenicity and optimal vaccination doses, routes and regimes in experimental animals. Mice were immunized intravenously (i.v.) or intramuscularly (i.m.) using a single dose of 10(6) p.f.u. of the recombinant MVA and the induction of CTL was assessed. It was demonstrated that both administration routes induced specific CTL responses and that the i.v. route was moderately more immunogenic than the i.m. route. The frequencies of ex vivo splenocytes producing interferon-y upon MHC class I-restricted peptide stimulation were determined using an ELISPOT assay. Also, the correct processing and presentation of some HLA-restricted epitopes in human cells was confirmed.

Genome projects invariably are missing the subtelomeric regions due to cloning, sequencing and informatic problems. The repetitive nature of these sequences and the shared homology between different subtelomeres in most organisms preclude assembly of the regions leaving them incomplete. This is clearly an issue when a great deal of interesting biology, as seen in the previous chapters, involves the subtelomeres. In some cases, organism-specific or individual strain-specific approaches have been used to obtain material for sequencing and analysis as well as assembly. However, a more general approach applicable to most organisms has been elusive. Various cloning techniques have been tried and developed with mixed success. The most promising general approach involves individual telomere regions cloned as yeast artificial chromosomes (YACs), isolating them from all the other subtelomeres that have overlapping homology. This is time-consuming, and there is still a bottleneck in sequencing these. New sequencing technologies may solve many of the technical problems, yet there are still informatic problems with assembly because of the repetitive nature of the regions. Although progress has been made, the solution to efficient completion of subtelomeric regions will likely take combined approaches, such as deep sequencing in pedigrees to look for genetic linkage (associations) with known segregating sites near the ends of chromosomes. An efficient and cost-effective approach is needed before individual genome projects can move into population genomics involving the subtelomeres which is crucial for studies of diversity in parasites as well as in quantitative genetic studies in many organisms.

Objective: This study was an investigation ofjudgments regarding quality of life of mdividuals with severe mental disorders from two different perspectives: patient self-report versus provider. Method: Judgments on several dimensions of quality of life were collected from a convenience sample of 37 schizophrenic patients and their primary clinicians by using the well-known Quality of Life Index of Spitzer et al. and the more recently developed Quality of Life Index-Mental Health. Both indexes capture judgments on a number of dimensions. Patterns of concordance for the patient-provider pairs were tested by using Cohen’s kappa and Pearson correlation coefficients. Results: The results suggest that patients ‘ and providers’ judgments are more likely to coincide on clinical aspects, such as symptoms and function, than on social aspects. Specifically, there was moderate agreement on symptoms and function, less agreement on physical health, and little to no agreement on social relations and occupational aspects of quality of life. Conclusions: Such differences support the notion that treatment strategies and mental health services should address a wide range of needs reflecting different aspects of quality oflife perceived as important by different patients. (Am J Psychiatry 1996; 153:497-502)

Objectives: We hypothesized that variability in voluntary movement paths of assisted living facility (ALF) residents would be greater in the week preceding a fall compared with residents who did not fall. Design: Prospective, observational study using telesurveillance technology. Setting: Two ALFs. Participants: The sample consisted of 69 older ALF residents (53 female) aged 76.9 (SD � 11.9 years). Measurement: Daytime movement in ALF common use areas was automatically tracked using a commercially available ultra-wideband radio real-time location sensor network with a spatial resolution of approximately 20 cm. Movement path variability (tortuosity) was gauged using fractal dimension (fractal D). A logistic regression was performed predicting movement related falls from fractal D, presence of a fall in the prior year, psychoactive medication use, and movement path length. Fallers and non-fallers were also compared on activities of daily living requiring supervision or assistance, performance on standardized static and dynamic balance, and stride velocity assessments gathered at the start of a 1-year fall observation period. Fall risk due to cognitive deficit was assessed by the Mini Mental Status Examination (MMSE), and by clinical dementia diagnoses from participant’s activities of daily living health record. Results: Logistic regression analysisrevealed odds offallingincreased2.548 (P ¼.021) forevery0.1 increase in fractal D, and having a fall in the prior year increased odds of falling by 7.36 (P ¼.006). There was a trend forlongermovement paths toreduce the odds of falling (OR .976P ¼.08) but it was notsignificant. Number of psychoactive medications did not contribute significantly to fall prediction in the model. Fallers had more variable stride-to-stride velocities and required more activities of daily living assistance. Conclusions: High fractal D levels can be detected using commercially available telesurveillance technologies and offers a new tool for health services administrators seeking to reduce falls at their facilities.

Although evidence-based practice guidelines have been developed to achieve greater consistency and quality in mental health care, insufficient research exists on implementing these guidelines among different racial/ethnic groups and the impact of guideline adherence on treatment outcomes. This study compared mental health care received by community dwelling Latino and non-Latino White Medicaid enrollees in Florida with a diagnosis of major depressive disorder (MDD) and examined predictors of adherence to American Psychiatric Association (APA) guidelines for the treatment of MDD. Latinos were more likely than Whites to receive guideline adherent treatment (OR = 1.21, P < .0001). Enrollees receiving combination drug therapy were most likely to receive treatment consistent with APA guidelines (OR = 4.25, P < .0001). Despite research demonstrating the efficacy of evidence–based practices, many study participants did not receive guideline adherent treatment. Policies and practices targeted at increasing adherence to approved guidelines and improving treatment outcomes are recommended.

One of the major virulence factors of the malaria causing parasite is the Plasmodium falciparum encoded erythrocyte membrane protein 1 (PfEMP1). It is translocated to It the membrane of infected erythrocytes and expressed from approximately 60 var genes in a mutually exclusive manner. Switching of var genes allows the parasite to alter functional and antigenic properties of infected erythrocytes, to escape the immune defense and to establish chronic infections. We have developed an efficient method for isolating VAR genes from telomeric and other genome locations by adapting transformation-associated recombination (TAR) cloning, which can then be analyzed and sequenced. For this purpose, three plasmids each containing a homologous sequence representing the upstream regions of the group A, B, and C var genes and a sequence homologous to the conserved acidic terminal segment (ATS) of var genes were generated. Co-transfection with P. falciparum strain ITG2F6 genomic DNA in yeast cells yielded 200 TAR clones. The relative frequencies of clones from each group were not biased. Clones were screened by PCR, as well as Southern blotting, which revealed clones missed by PCR due to sequence mismatches with the primers. Selected clones were transformed into E. coli and further analyzed by RFLP and end sequencing. Physical analysis of 36 clones revealed 27 distinct types potentially representing 50% of the var gene repertoire. Three clones were selected for sequencing and assembled into single var gene containing contigs. This study demonstrates that it is possible to rapidly obtain the repertoire of var genes from P. falciparum within a single set of cloning experiments. This technique can be applied to individual isolates which will provide a detailed picture of the diversity of var genes in the field. This is a powerful tool to overcome the obstacles with cloning and assembly of multi-gene families by simultaneously cloning each member.

Objectives: Nursing home (NH) hospitalizations place an enormous economic burden on an already overtaxed American healthcare system. Hospitalizations for “ambulatory care-sensitive” (ACS) conditions are considered preventable, as these are physical health conditions that can potentially be treated safely in a NH. The authors examined risk factors, including mental disorders and dementia, for hospitalization of Medicaid-enrolled NH residents with ACS conditions during fiscal year 2003–2006. Methods: The authors merged Medicaid claims and enrollment data and Online Survey Certification and Reporting information for 72,251 Medicaid-enrolled NH residents in 647 NHs in Florida. The authors identified at least one ACS hospitalization in 8,382 residents for a total of 10,091 hospital admissions (18.5% of all hospitalizations). The authors used Cox proportional hazard regression to assess time to the first ACS hospitalization. Results: In a fully adjusted model, younger age, non-white race, dementia, and serious mental disorder were associated with greater risk of ACS hospitalization. In addition, residents with a diagnosed mental disorder and no dementia incurred relatively high expenditures for ACS hospitalizations. Among facility characteristics, participants from for-profit facilities, facilities that were not a member of a chain, had more Medicaid recipients, and fewer than 120 beds had greater risk of ACS hospitalizations. Conclusions: Attention to the identified predictors of hospitalization for ACS conditions, which are potentially preventable, could reduce the risk and cost of these hospitalizations among Medicaid-enrolled NH residents. The need to reduce unnecessary hospitalization will become only more urgent as the population ages and healthcare expenses continue to escalate.

Objectives: Hospitalizations for long term care residents, including those from assisted living facilities (ALFs), are very costly, often traumatic, and increase risk for iatrogenic disorders for those involved. Currently, hospital expenditures account for approximately one-third of total national health care spending. Hospitalizations for ambulatory careesensitive (ACS) conditions are considered potentially avoidable, as these are physical health conditions that can often be treated safely at a lower level of care or occur as a result of lack of timely, adequate treatment at a lower level of care. The goal was to examine risk factors for hospitalization for an ACS condition of Medicaid-enrolled younger and older ALF residents during 2003e2008. Design: This is a retrospective cohort study that used 5 years of Medicaid enrollment and fee-for-service claims data. Participants: The study sample included 16,208 Medicaid-enrolled ALF residents in Florida, 7991 (49%) of whom were 65 years of age or older. Results: In total, study participants had 22,114 hospitalizations, 3759 (17%) of which were for an ACS condition. Sixteen percent of all ALF residents (n ¼ 2587), about 12% of the younger residents and 20% of the older residents, had at least one ACS hospitalization. ACS hospitalizations constitute 13% of all hospitalizations for the younger residents and 22% of all hospitalizations for the older residents. Using Cox proportional hazard regression, we found that for both age groups, increased age, being Hispanic or of other race/ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. For older residents, having a dementia diagnosis and being African American reduced the risk of ACS hospitalization, whereas for younger residents having a major psychotic disorder reduced the risk of ACS hospitalization. Conclusion: The results highlight the need for increased education, communication, and future research on these predictive factors. The increased frequency of hospitalization for ACS conditions among ALF residents with minority status and older age may well indicate that their more complex health care needs are not being adequately addressed. The role of serious mental illness and dementia in risk for ACS hospitalization also deserves further attention.

Objective To examine (1) arrest outcomes for adults with schizophrenia and bipolar disorder who were treated with first-generation antipsychotics (FGAs) or second-generation atypical antipsychotics (SGAs) and (2) the interaction between medication class and outpatient services in a Florida Medicaid program. Method In a secondary data analysis, Florida Medicaid data covering the period from July 1, 2002, to March 31, 2008, were used to identify persons diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder and to examine antipsychotic medication episodes lasting at least 60 days. There were 93,999 medication episodes in the population examined (N = 36,519). Medication episodes were coded as (1) SGA-aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, risperidone, risperidone long-acting therapy, or ziprasidone; or (2) FGA-any other antipsychotic medication. Outpatient services were defined as the proportion of 30-day periods of each medication episode with at least 1 behavioral health visit. Survival analyses were used to analyze the data, and they were adjusted for the baseline propensity for receiving an SGA. Results Second-generation antipsychotic episodes were not associated with reduced arrests compared to FGA episodes; however, the interaction between outpatient services and SGA episodes was significant (hazard ratio [HR] = 0.68; 95% CI, 0.50-0.93; P = .02) such that an SGA episode with an outpatient visit during at least 80% of every 30-day period of the episode was associated with reduced arrests compared to SGA episodes with fewer outpatient services. There was no significant effect for concurrent FGA episodes and outpatient treatment (HR = 0.81; 95% CI, 0.60-1.10; P = .18). Substance use, poor refill compliance, and prior arrest increased risk of subsequent arrest. Conclusions The interaction between outpatient visits and treatment with SGAs was significantly associated with reduced arrests. These findings indicate the importance of concurrent antipsychotic medications and outpatient services to affect arrest outcomes for adults with schizophrenia and bipolar disorder.

The primary objective of this chapter is to provide information on economic, psychiatric, and cultural factors that influence service access by racial/ethnic minority women. A secondary objective is to discuss the policy implications of existing research for mental health services that are provided to this population. These objectives draw from the extent and nature of the problems faced by minority women. According to the recent estimates, of the nearly 153 million women living in the USA, more than 31 million (20%) are members of racial/ethnic minorities (U.S. Census Bureau 2007). Their health, therefore, both physical and mental, assumes significance in terms of health services provision and overall social policy.

Mental disorders are significant contributors to the global burden of disease. Worldwide, it is estimated that approximately 450 million people suffer from a mental disorder (World Health Organization 2001). In developing countries, mental disorders are second only to cardiovascular diseases in contributing to lost years of life (World Health Organization 2003). Although mental disorders have a potential impact upon all individuals, it is important to recognize gender differences in the rates, experience, and course of mental disorders. For example, a recent Substance Abuse and Mental Health Services Administration (SAMHSA) report states that

Overview & Epidemiology of Mental Disorders in Women.- Public Health and Women's Mental Health.- Epidemiology of Mental Disorders in Girls and Female Adolescents.- Mental Conditions in Adult Women: Epidemiology and Impact.- Epidemiology of Mental Disorders in Older Women.- Physical Illness and Medical Needs of Women with Mental Disorders.- Selected Disorders.- Depression and Postpartum Disorders.- Eating Disorders.- Menopause.- Substance Abuse.- HIV/AIDS and Mental Disorders.- Services Delivery & Emerging Research.- Services in an Era of Managed Care.- Evidence-Based Medicine.- Mental Health Issues of Incarcerated Women.- Services in the Workplace.- Organizational Stress and Trauma-Informed Services.- Services in Rural Areas.- Social and Community Contexts.- Racial and Ethnic Disparities.- Parenting and Recovery for Mothers with Mental Disorders.- Navigating the Worlds of Information.

Most Medicaid Drug Use Review (DUR) Programs disseminate prescribing practice guidelines by providing written reviews to physicians about specific prescribing practices that do not follow established criteria and inviting their comment. This study reviewed physicians' written responses to explore relationships between DUR communications and the degree to which these communications affect awareness of prescribing issues, increase knowledge, change erroneous beliefs, and generate intentions to apply the information appropriately. The form, content, and effective tone for all responses received in 1990 regarding five different drug therapy issues (N = 240) was recorded. Response rates, comprehension, counterarguments, and prescribing intentions varied by drug therapy issue. Attention to the communication process could improve the dissemination of prescribing practice guidelines by DUR Programs.

This study examines the work of the nurse's aide through a combination of participant observation and in-depth interviews with 30 nurse's aides. Data were analyzed using the grounded theory method of constant comparative dimensional analysis. Findings suggest that strategies developed by individual nurse's aides to organize their work are important determinants of both the quality of care and worker turnover. Quality of care may be better explained by Litwak's theory about the difficult juxtaposition between primary and formal groups than by the nurse's aides' lack of knowledge.

Endothelin-like immunoreactivity was detected in human (15.6 +/- 2.7 pg/ml) and bovine (11.1 +/- 0.98 pg/ml) aqueous humour of the eye. These concentrations are 2-3 times higher than the corresponding plasma levels. Cultured human nonpigmented ciliary epithelial cells released endothelin-like immunoreactivity with a maximum of 2.1 +/- 0.32 pg/(cm2* 48 h). The release was stimulated by fetal calf serum, thrombin, carbachol and phorbol ester and blocked by cycloheximide. Immunocytochemistry showed cytoplasmic staining of cultured human nonpigmented ciliary epithelial cells for endothelin-1. Endothelin-1 was shown to induce contractions in isolated human ciliary muscle by isometric force measurements. Endothelin in the aqueous humour may play a role in the regulation of intraocular pressure.

Demographic, diagnostic, and service expenditure characteristics of Florida Medicaid enrollees who died by suicide were investigated. Among persons receiving Medicaid and Supplemental Security Income (SSI), findings indicate the most powerful predictors of suicide were involuntary psychiatric examination, mental health hospitalization, and high mental health service use. Among Medicaid enrollees not receiving SSI, strongest suicide predictors were mental health hospitalization, high expenditures for physical health medications, and involuntary psychiatric examination. Findings suggest reducing involuntary psychiatric examinations and mental health hospitalizations while improving physical health may reduce suicide in the Medicaid population. Comprehensive hospital discharge planning, adherence monitoring with follow-up care, training mental health providers in assessing suicide lethality, and providing adequate assessment time are all crucial to achieve these objectives.

We have investigated the stability of three tailspike proteins (TSPs) from bacteriophages Sf6, P22, and HK620. Tailspikes are rod-like homotrimers with comparable beta-solenoid folds and similarly high kinetic stability in spite of different amino acid sequences. As tailspikes bind polysaccharides to recognize the bacterial host cell, their stability is required for maintenance of bacteriophage infectivity under harsh extracellular conditions. They resist denaturation by SDS at ambient temperature and their unfolding is slow even in 6 m guanidinium hydrochloride (GdmHCl). This makes them interesting candidates for very stable carbohydrate binding protein materials.

This study examined how the mental health needs of nursing home (NH) residents with serious mental illness (SMI) are addressed. Data were collected from three sources: interviews with 84 SMI stakeholders; surveys of 206 NH staff members; and focus groups at two psychiatry specialty NHs. Four common themes emerged: placement of older adults with SMI was a significant problem for discharge planners and NH admission coordinators; NH staff reported being uneasy with SMI residents and were concerned over aggressive behavior; staff in NHs with psychiatry specialty units appeared more comfortable serving SMI residents; and SMI training was a consistent recommendation of all SMI stakeholders and NH staff. Implications for training are discussed.

Subtelomeric regions are often under-represented in genome sequences of eukaryotes. One of the best known examples of the use of telomere proximity for adaptive purposes are the bloodstream expression sites (BESs) of the African trypanosome Trypanosoma brucei. To enhance our understanding of BES structure and function in host adaptation and immune evasion, the BES repertoire from the Lister 427 strain of T. brucei were independently tagged and sequenced. BESs are polymorphic in size and structure but reveal a surprisingly conserved architecture in the context of extensive recombination. Very small BESs do exist and many functioning BESs do not contain the full complement of expression site associated genes (ESAGs). The consequences of duplicated or missing ESAGs, including ESAG9, a newly named ESAG12, and additional variant surface glycoprotein genes (VSGs) were evaluated by functional assays after BESs were tagged with a drug-resistance gene. Phylogenetic analysis of constituent ESAG families suggests that BESs are sequence mosaics and that extensive recombination has shaped the evolution of the BES repertoire. This work opens important perspectives in understanding the molecular mechanisms of antigenic variation, a widely used strategy for immune evasion in pathogens, and telomere biology.

Background African trypanosomes (including Trypanosoma brucei) are unicellular parasites which multiply in the mammalian bloodstream. T. brucei has about twenty telomeric bloodstream form Variant Surface Glycoprotein (VSG) expression sites (BESs), of which one is expressed at a time in a mutually exclusive fashion. BESs are polycistronic transcription units, containing a variety of families of expression site associated genes (ESAG s) in addition to the telomeric VSG. These polymorphic ESAG families are thought to play a role in parasite-host adaptation, and it has been proposed that ESAG diversity might be related to host range. Analysis of the genetic diversity of these telomeric gene families has been confounded by the underrepresentation of telomeric sequences in standard libraries. We have previously developed a method to selectively isolate sets of trypanosome BES containing telomeres using Transformation associated recombination (TAR) cloning in yeast. Results Here we describe the isolation of repertoires of BES containing telomeres from three trypanosome subspecies: Trypanosoma brucei gambiense DAL 972 (causative agent of West-African trypanosomiasis), T. b. brucei EATRO 2340 (a nonhuman infective strain) and T. equiperdum STIB 818 (which causes a sexually transmitted disease in equines). We have sequenced and analysed the genetic diversity at four BES loci (BES promoter region, ESAG6, ESAG5 and ESAG2) from these three trypanosome BES repertoires. Conclusion With the exception of ESAG2, the BES sequence repertoires derived from T. b. gambiense are both less diverse than and nearly reciprocally monophyletic relative to those from T. b. brucei and T. equiperdum. Furthermore, although we find evidence for adaptive evolution in all three ESAG repertoires in T. b. brucei and T. equiperdum, only ESAG2 appears to be under diversifying selection in T. b. gambiense. This low level of variation in the T. b. gambiense BES sequence repertoires is consistent both with the relatively narrow host range of this subspecies and its apparent long-term clonality. However, our data does not show a clear correlation between size of trypanosome host range and either number of BESs or extent of ESAG genetic diversity.

This article compares behavioral health service use and cost for foster care versus nonfoster care children; children before, during, and after foster care placement; and successfully reunified versus nonsuccessfully reunified foster care children. Behavioral health service costs for children in foster care were higher than for children not in foster care. Children in foster care used more services during their foster care placement than before placement and after discharge. Nonsuccessfully reunified children received a significantly larger quantity of services than those successfully reunified.

Trypanosoma brucei switches between variant surface glycoproteins (VSGs) allowing immune escape. The active VSG is in one of many telomeric bloodstream form VSG expression sites (BESs), also containing expression site-associated genes (ESAGs) involved in host adaptation. The role of BES sequence diversity in parasite virulence can best be understood through analysis of the full repertoire of BESs from a given T. brucei strain. However, few BESs have been cloned, as telomeres are highly underrepresented in standard libraries. We devised a strategy for isolating the repertoire of T. brucei 427 BES-containing telomeres in Saccaromyces cerevisiae by using transformation-associated recombination (TAR). We isolated 182 T. brucei 427 BES TAR clones, 167 of which could be subdivided into minimally 17 BES groups. This set gives us the first view of the breadth and diversity of BESs from one T. brucei strain. Most BESs ranged between 40 and 70 kb (average, 57 ± 17 kb) and contained most identified ESAGs. Phylogenetic comparison of the cohort of BES promoter and ESAG6 sequences did not show similar trees, indicating rapid evolution most likely mediated by sequence exchange between BESs. This cloning strategy could be used for any T. brucei strain, facilitating research on the biodiversity of telomeric gene families and host-pathogen interactions.

Purpose:To identify the process by which parents of premature infants seek information, the kinds of information they seek, and the resources they use to meet their educational and support needs.Design/Sample:Descriptive study using 19 parent interviews and 64 questionnaires.Main Outcome Variable:The process parents use to obtain information and support.Results:Parents of premature infants make a transition from being passive recipients of information to actively seeking it. They spend 10–20 hours a week gathering information during the first month of the baby’s hospitalization. They desire more information than is provided, particularly in the areas of infant health, infant care, and coping. Family is the primary source of support prior to birth and after discharge, but during the infant’s convalescence, nurses are the main source of support and help for parents in understanding and adapting to their baby. Many parents would use a computer-based resource for information if it were available to them.