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OBJECTIVE: To compare the efficacy and safety of a 25-microgram vaginal tablet of misoprostol (APL202) with dinoprostone (3-mg vaginal tablet) in cervical ripening and labour induction. DESIGN: A randomised, open-label, noninferiority, comparative study in two maternal populations. SETTING: Eighteen NHS study centres across the UK. POPULATION: Nulliparous or multiparous women with a singleton pregnancy eligible for induction of labour. METHODS: Women were randomised to receive either misoprostol, initially 25 micrograms (50 micrograms in nulliparous women with Bishop score < or =4) followed by 25 micrograms after 4 and 8 hours, or dinoprostone, initially 3 mg followed by 3 mg after 6 hours. Clinical noninferiority of misoprostol was defined as an absolute difference between treatments of no more than 10% for the primary outcome. MAIN OUTCOME MEASURES: The number of vaginal deliveries achieved within 24 hours of labour induction. Maternal and fetal safety outcomes. RESULTS: A total of 626 women were randomised to misoprostol (n = 318) or dinoprostone (n = 308) treatment. The rate of vaginal deliveries achieved within 24 hours of induction did not significantly differ between the misoprostol and dinoprostone (43 versus 47%; 3.74% difference, 95% CI -3.58 to 11.05, respectively) treatment groups. The treatments were generally comparable for other secondary efficacy measures. Maternal and fetal adverse events were similarly distributed across the misoprostol and dinoprostone groups. CONCLUSIONS: Low-dose misoprostol is efficacious in cervical ripening and labour induction and demonstrates a similar fetal and maternal safety profile to dinoprostone.

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OBJECTIVE: Telephone triage programs are becoming very common at children's hospitals across the nation. One of the proposed benefits of these programs is the more efficient use of health care resources by triaging patients to the appropriate level of health care. The purpose of this study is to examine the appropriateness of referrals to a pediatric emergency department (ED) by the Pediatric Health Information Line (PHIL), a hospital-based telephone triage program, versus all other sources of referrals. METHODS: A blinded Delphi rating system was used to review the physician's sheets of 133 consecutive ED referrals by PHIL for medical appropriateness. A total of 260 randomly selected control patients seen in the ED during the same period were similarly reviewed. If 2 of 3 pediatric emergency medicine physicians agreed that an ED visit was appropriate, then it was considered appropriate. A comparison of the 2 groups' ED appropriateness was made using a contingency table chi(2) test. An odds ratio with confidence limits was also calculated. Demographic data were collected for both groups including age, race, gender, and insurance status. RESULTS: The PHIL group had an appropriateness rate of 80.2%, compared with 60.5% for the control group (chi(2) = 14.6369; odds ratio = 2.65; 95% confidence interval [1.5759,4.5008]). CONCLUSIONS: This demonstrated that for the period studied, PHIL referrals to the ED had a 33% higher rate of appropriateness than controls. This evidence supports telephone triage as an efficient gatekeeper for health care resources.

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We tested the hypothesis that two pedicle screws placed in convergence offer more resistance to axial pullout than do two pedicle screws placed in parallel. Eight fresh cadaveric lumbar spines, L2-L5, were harvested. Individual vertebra were then paired for testing. Into each L2 and L3 vertebra, a pair of pedicle screws were inserted. The screws were placed parallel (i.e., at 0 degrees convergence) in L2 and at 30 degrees convergence in L3, in the first pair. In the second pair of L2 and L3, this order was reversed. Alternating the convergence angle was carried out on each successive pair of L2 and L3. A section of standard longitudinal rod was attached to each pedicle screw by using top-loading three-point shear clamp fixation with tangential lock screws. Transverse connectors were attached superiorly and inferiorly to the longitudinal rods. As in L2 and L3, each L4 and L5 received a pair of screws placed at either 0 or 30 degrees convergence, with the angle of convergence alternated on each successive pair. Each pair of screws in each vertebra was tested in axial pullout at 1 mm/s. Fourteen pairs of vertebra were tested and two findings emerged: paired pedicle screws at 30 degrees of convergence offered more resistance to axial pullout (28.6% on average) and sustained higher loads at the clinical threshold of loosening (101% on average) than paired pedicle screws placed in parallel. Thus there seems to be an advantage to screws placed in 30 degrees of convergence as compared with screws in parallel.

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OBJECTIVE: The purpose of the study was to gather baseline data on physician caseloads, particularly psychiatric caseloads, at public mental hospitals. METHOD: A 26-item survey was sent to medical directors of public mental hospitals in the United States and its territories. Questions focused on hospital demographics, programs, and medical staffing. Survey data were analyzed and descriptive statistics were determined. RESULTS: Of 295 surveys mailed, 195 (66%) usable surveys were returned. The hospitals had a mean bed capacity of 347 (SD=301, range=10-1,926), a mean current patient population of 321 (SD=277, range=7-1,815), and 950 mean annual admissions (SD=891, range=3-5,100). Acute care was the most common treatment program (81%), followed by long-term care (71%). A wide range of psychiatric caseloads by type of program existed, with approximately equal mean and median amounts. CONCLUSIONS: The caseloads reported were, overall, reasonable and expected by the type of treatment program. The range of caseloads, however, included extremely high outliers that raise concerns about the quality of care delivered.

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Mental health treatment teams are living systems at the group level and comprise key productive subsystems of organizations providing mental health care. Effective treatment teams, like effective organizations, are anticipatory systems that contain subsystems that model and predict future system and environmental conditions and enable responses that increase system viability. A systems analysis of treatment teams highlights their potential instability due to their tendencies to regress toward dysfunctional partial systems and their active maintenance in nonequilibrium steady states with their organizational and external environments. Team subsystems are analyzed from the viewpoints of system processes and also with regard to individuals and their roles. Boundary processes are central to effective team functioning, assure constancy of team membership, and regulate the team's interfaces with its parent agency and with the external environment. Various causes and forms of disturbed information processing within hierarchical organizations are examined, and their effects at the treatment team level are discussed. The conclusion of the discussion focuses on team leadership and how leadership expands upon the concept of the decider subsystem to include role and personal factors to the team's leaders, and functions that are anticipatory and integrative in nature. Effective leaders must set appropriate thresholds for feedback regulation processes, and balance several pairs of seemingly opposing forces, including homeostasis and development, role differentiation and role overlap, and personal accountability and empowerment of others.

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State-university collaboration programs often create ethical dilemmas for participants because of their conflicting values, goals, and expectations. Treatment and administrative staff in state agencies often seek to create an atmosphere of managed stability rather than fostering patients' autonomy. Academic participants in collaboration programs often feel impelled to change the system, even though the goal of collaboration requires them to find common ground with state agency staff. Academic participants must decide whether collaboration programs will contribute to needed reforms without overly compromising professional and academic standards. If they cannot endorse the values and quality of care provided in state systems, they must consider whether their participation should be conditioned on an agreement to work toward change. However, even in situations that are improving, clinicians must not let temporary compromises become permanent.

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Although treatment teams have been examined often in the mental health literature, this literature seldom addresses the crucial property of "teamness"--the key set of intangible phenomena that allow a team to function synergistically as more than the sum of its parts, and with a sense of team identity. In this paper, the concept of the work group is used to develop a framework for understanding the factors contributing to effective team functioning and identity, an their implications for the tasks of team leadership and sociotherapy: "the art of maintaining a social system in which the treatment of an individual patient can best occur" (Edelson 1970). Leadership activities that promote team cohesiveness and boundary maintenance are discussed, and suggestions are provided for ways in which the subjective experiences and emotional reactions of the leader and team members can be used to promote improved task performance and clinical care.

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The development of an active collaboration between the department of behavioral medicine and psychiatry of the University of Virginia School of Medicine and Western State Hospital is described. The collaboration includes clinical research and opportunities for training residents and medical students. University faculty provide clinical and administrative leadership at all levels of the hospital's organization. The hospital's clinical functioning has improved through direct involvement of university faculty in patient care, and its recruitment of physicians and psychologists has increased due to expansion of academic opportunities and program improvements. The authors use examples from the collaboration experience to illustrate key issues, such as strong leadership, sufficient resources, and an understanding of systems factors, that are necessary to overcome resistance to change.

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Fourteen patients receiving multiple antipsychotic drugs in a state mental hospital long-term unit comprised the study sample. They completed a 1-year clinical trial to reduce such drugs to a single antipsychotic agent. Six of the 14 patients were successfully converted to a single antipsychotic drug without clinical deterioration. Eight patients showed marked psychiatric decompensation when converted to single antipsychotic therapy. Factors that may have contributed to this difference are discussed.

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The 15 patients with the highest numbers of assaultive incidents over a one year period in a state mental hospital were identified and information collected regarding a variety of clinical and demographic characteristics. The results showed a group of patients who are relatively young, manifest severe symptomatology that is generally unresponsive to treatment, and have now been hospitalized continuously for greater than four years. The patients experienced the onset of symptoms as teenagers in most cases, showed poor psychosocial adjustment beyond childhood, and had positive family histories for mental illness or alcohol abuse. Patients with psychotic disorders predominated and tended to have positive symptoms rated as severe to very severe on the Global Rating Scale for Psychosis. Patients with nonpsychotic or personality disorders always showed a high frequency of self-injurious behavior in addition to their aggressive behavior toward others. A number of patients had a history of head trauma with EEG abnormalities. This information provides a starting point for subsequent studies examining potential distinctions between this subpopulation of patients and others, the motivation and circumstances of such incidents, and the interaction between the behaviors and their effects on those around them.

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Clinical and demographic data were collected on 203 state mental hospital patients whose length of stay was greater than one year. They comprised 45% of the average adult census and 37% were less than 35 years old. Males were younger and females more educated and likely to have been married at one time. The majority have diagnoses of schizophrenia or organic mental disorders; a few have personality disorders. Patients were treated with drugs but risk/benefit parameters remain to be defined. Thirty-two percent of patients have had a violent episode during the past six months. The prevalence of neurological abnormalities supports the need for specialized neurological and neuropsychological consultation and medical consultation. Most patients require the level of care provided by a hospital, while 15% are ready for discharge but have no housing available. Intermediate care facilities could provide alternatives for some patients otherwise unable to leave the hospital. The implications raised by these findings are discussed.

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