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BACKGROUND: Health agencies across the world have echoed the recommendation of the U.S. Institute of Medicine (iom) that survivorship care plans (scps) should be provided to patients upon completion of treatment. To date, reviews of scps have been limited to the United States. The present review offers an expanded scope and describes how scps are being designed, delivered, and evaluated in various countries. METHODS: We collected scps from Canada, the United States, Europe, the United Kingdom, Australia, and New Zealand. We selected for analysis the scps for which we could obtain the actual scp, information about the delivery approach, and evaluation data. We conducted a content analysis and compared the scps with the iom guidelines. RESULTS: Of 47 scps initially identified, 16 were analyzed. The scps incorporated several of the iom's guidelines, but many did not include psychosocial services, identification of a key point of contact, genetic testing, and financial concerns. The model of delivery instituted by the U.K. National Cancer Survivorship Initiative stands out because of its unique approach that initiates care planning at diagnosis and stratifies patients into a follow-up program based on self-management capacities. SUMMARY: There is considerable variation in the approach to delivery and the extent to which scps follow the original recommendations from the iom. We discuss the implications of this review for future care-planning programs and prospective research. A holistic approach to care that goes beyond the iom recommendations and that incorporates care planning from the point of diagnosis to beyond completion of treatment might improve people's experience of cancer care.

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BACKGROUND: Healthy lifestyle behaviours may improve outcomes for people with colorectal cancer (crc), but the intention to take action and to change those behaviours may vary with time and resource availability. We aimed to estimate the prevalence of current lifestyle behaviours in people with and without crc in our community, and to identify their desire to change and their resource preferences. METHODS: A mixed-methods survey was completed by people diagnosed with crc who were pre-treatment (n = 54), undergoing treatment (n = 62), or done with treatment for less than 6 months (n = 67) or for more than 6 months (n = 178), and by people without cancer (n = 83). RESULTS: Current lifestyle behaviours were similar in all groups, with the exception of vigorous physical activity levels, which were significantly lower in the pre-treatment and ongoing treatment respondents than in cancer-free respondents. Significantly more crc respondents than respondents without cancer had made lifestyle changes. Among the crc respondents, dietary change was the change most frequently made (39.3%), and increased physical activity was the change most frequently desired (39.1%). Respondents wanted to use complementary and alternative medicine (cam), reading materials, self-efficacy, and group activities to make future changes. CONCLUSIONS: Resources for lifestyle change should be made available for people diagnosed with crc, and should be tailored to address physical activity, cam, and diet. Lifestyle programs offered throughout the cancer trajectory and beyond treatment completion might be well received by people with crc.

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In 1993, the Access to Community Care and Effective Services and Supports (ACCESS) federal demonstration program was initiated. Using a quasi-experimental design, the 5-year demonstration program sought to assess the impact of integrated systems of care on outcomes for homeless persons with mental illness. The authors report on which integration strategies were chosen and how their implementation is quantified. Data collected primarily through annual site visits revealed that only two strategies were used by all nine systems. The systems integration strategies employed remained relatively stable over the 5 years. Successful implementation appears to be related to the strategies selected.

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Nearly everyone writing on homelessness over the past 15 years has called for comprehensive integrated systems of care to address the multiple and complex needs of people who become homeless, especially those with mental illness. What is often overlooked is that calls for systems integration are far from new. Although the names have changed over the years, the underlying concepts have not. The purposes of this paper are fourfold: (1) to clarify the distinction between services integration and systems integration; (2) to map the evolution of federal programs to demonstrate that most of these really have been focused on services integration rather than systems integration; (3) to assess the extent that data from these programs supports the idea of systems integration; and (4) to show how the current ACCESS demonstration for persons who are homeless and mentally ill is likely to provide answers that prior programs have not. Without these new data, systems integration, as one solution to the problems of homelessness, remains a theory without empirical evidence; albeit a theory with persuasive conceptual underpinnings.

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OBJECTIVES: A major proposal for appropriately treating persons with mental illnesses who have been arrested is to divert them from jail to community-based mental health programs. However, there are few available definitions, guidelines, and principles for developing effective diversion programs. The goal of this research was to determine the number and kinds of jail diversion programs that exist, how they are set up, and which types of programs are effective. METHODS: On the basis of information gathered during a national mail survey (n = 1263) and follow-up telephone survey of 115 responding jails, 18 sites were selected for on-site interviews based on perceived effectiveness and presence of a formal diversion program. RESULTS: Data are presented from a national sample of jail diversion programs (n = 18). Key factors for developing diversion programs and descriptors of effective programs are presented. CONCLUSIONS: It is clear that controlled, longitudinal studies of these programs' effectiveness, using client-based and organizational outcome measures, are badly needed.

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OBJECTIVES: The authors sought information on the number, structure, and effectiveness of programs aimed at diverting mentally ill inmates from the criminal justice system into the mental health treatment system. METHODS: A working definition of a jail diversion program was developed. Mail surveys were distributed to 1,263 U.S. jails with a capacity of 50 or more detainees to ascertain the presence or absence of diversion programs. Telephone interviews with samples of respondents and nonrespondents to the mail survey yielded additional information about the programs' operation, funding, staffing, and directors' perceptions of their effectiveness. RESULTS: Information obtained from the mail and telephone surveys indicated that only 52 U.S. jails with a capacity of 50 or more detainees had formal mental health diversion programs that fit the definition developed by the authors. Programs in larger jails served fewer violent felons than did those in smaller jails. Three-fourths of the programs were located in mental health agencies. Two-thirds of program directors considered the programs to be moderately or very effective. CONCLUSIONS: Only a small number of U.S. jails have diversion programs for mentally ill detainees, and objective data on their effectiveness are lacking. Systematic evaluations are needed to determine what types of programs work best for which types of detainees.

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Over the past decade, researchers have documented the range of needs and devised new methods for increasing our understanding of the homeless severely mentally ill population. Clinicians have developed an appreciation of the difficulty and complexity of effectively treating this population, and policymakers have become increasingly aware of the barriers to developing services and housing. In this article, the progress-to-date in research, the evolution of new service approaches, and the development of federal, state, and local policies to meet the needs of homeless mentally ill individuals are assessed. The many challenges that remain are also considered.

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Spontaneous (effort) subclavian vein thrombosis in young persons has historically produced long-term disability from arm swelling and exercise limitation because of failure of the occluded vein to recanalize. Several investigators have speculated that the use of thrombolytic therapy to produce clot dissolution followed by resection of the first rib to prevent recurrence might be ideal management of this condition. Our recent experience with treatment of two such patients formed the basis for this report. Two young men were seen within 24 hours of onset of acute arm swelling, found by venography to be caused by acute thrombosis of the subclavian vein at the level of the first rib. They were treated with systemic thrombolytic therapy with intravenous streptokinase. Both had prompt resolution of all signs and symptoms, confirmed by repeat venography to be accompanied by recanalization of the occluded veins. Both were then anticoagulated with heparin followed by warfarin and underwent elective first rib resection, after which anticoagulation was discontinued. Both patients have remained asymptomatic. Persistent venous patency has been confirmed by repeat venography. Thrombolytic therapy to recanalized spontaneous (effort) subclavian vein thrombosis followed by first rib resection appears to be an advance in the treatment of this condition and may avoid the long-term disability with which it has historically been associated.

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A young male patient with traumatic lung cyst, a rare lesion of blunt chest trauma, is presented. Compression of an elastic thorax with narrowing or closure of the airway produces a bursting or shearing force that creates an intrapulmonary cavity. The cyst may be filled with blood and is often associated with pulmonary contusion. The diagnosis is one of exclusion, based on an awareness that lung cyst can develop after trauma. Chest computerized tomography, as in the case described, may be useful to further delineate the lesion. Patients with traumatic lung cyst should be watched for respiratory distress, but the clinical course is usually uncomplicated, and the lesion completely resolves in 2 to 4 months. There are two indications for surgical treatment: infection in the cavity that is unresponsive to a trial of appropriate antibiotic therapy, and a cavity that does not progressively become smaller. In the patient presented, lobectomy was done 9 days postinjury and the cyst removed, and his subsequent recovery was without problems.

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