Factors Associated With Residual Breast Cancer After Re-excision for Close or Positive Margins

BACKGROUND

Successful breast conservation surgery (BCS) requires complete tumor excision. Margin status of the initial specimen determines the need for additional surgery. We explored factors associated with residual cancer (RC) upon follow-up surgery in patients with close, positive, or undetermined margins following BCS.

METHODS

A retrospective analysis of 276 patients with initial close, positive, or undetermined margins who underwent re-excision (RE) or mastectomy was conducted. All initial excisions were intended as definitive procedures. Chi-square analysis was used to identify factors that may predict RC.

RESULTS

Of 276 patients, 87 had close, 168 had positive, and 21 had undetermined margins on initial excision. Of this group, 63% (175/276) had RC upon RE or mastectomy. Of positive-margin patients, 68% had RC, compared with 53% of close-margin and 67% of undetermined-margin patients (P = .006). Tumors >/=2 cm were more often associated with RC than smaller tumors (70.8% vs. 56.5%; P = .07). This association was strongest in positive-margin patients (P = .04). High tumor grade was associated with RC in all groups. RC linearly increased with the number of involved margins (P = .02). Specimen inking with multiple colors was associated with decreased risk of RC (P = .004).

CONCLUSIONS

Over half of patients with involved or undetermined margins had RC upon RE or mastectomy. Positive and undetermined margins were more often associated with RC than close margins. Larger tumor size was associated with RC in patients with positive. Increasing tumor grade suggests a greater chance of detecting RC in all groups. Multiple involved margins led to a greater risk of RC.

Influence of carbohydrate ingestion on immune changes after 2 h of intensive resistance training

Thirty strength-trained subjects were randomized to carbohydrate (CHO) or placebo (Pla) groups and lifted weights for 2 h (10 exercises, 4 sets each, 10 repetitions, with 2- to 3-min rest intervals). Subjects received 10 ml·kg-1·h-1 CHO (6%) or Pla beverages during the weight training bout. Blood, saliva, and vastus lateralis muscle biopsy samples were collected before and after exercise. Blood cell counts were determined, and plasma was analyzed for IL-6, IL-10, IL-1 receptor antagonist (IL-1ra), IL-8, and cortisol. Muscle was analyzed for glycogen content and relative gene expression of 13 cytokines (IL-1α, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p35, IL-12p40, IL-15, IFN-γ, TNF-α) by use of real-time quantitative RT-PCR. Significant but modest increases were measured for plasma IL-6, IL-10, IL-1ra, and IL-8, but the pattern of increase did not differ between CHO and Pla groups. The rate of decrease in muscle glycogen content did not differ between CHO and Pla ( P = 0.463). Muscle cytokine mRNA was detected preexercise for IL-1β, IL-6, IL-15, IL-8, and TNF-α, and of these, IL-1β, IL-6, IL-8, and TNF-α were significantly increased after the 2-h weight training bout. The increase in mRNA (fold difference from preexercise) did not differ between CHO and Pla groups. In summary, CHO vs. Pla ingestion did not alter modest increases measured for plasma IL-6, IL-10, IL-1ra, and IL-8, and muscle gene expression for IL-1β, IL-6, IL-8, and TNF-α in strength-trained subjects lifting weights intensively for 2 h.

Presence of anti-Neoparamoeba sp. antibodies in Tasmanian cultured Atlantic salmon, Salmo salar L

Previous studies have indicated that when Atlantic salmon, Salmo salar L., are exposed to Neoparamoeba sp. the fish produce anti-Neoparamoeba sp. antibodies. It appears unlikely that these antibodies elicit any specific protection against amoebic gill disease (AGD) as fish with demonstrable activities have been affected by AGD. Experiments were conducted on Atlantic salmon cultured throughout Tasmania to assess the natural production of antibodies towards Neoparamoeba sp. Fish were sampled from areas where AGD was prevalent and from areas where there had been no reported cases. An enzyme-linked immunosorbent assay (ELISA) was used to measure anti-Neoparamoeba sp. antibody activities in serum. All fish from sea water had antibody activities greater than the negative control fish, including fish from areas with no reported cases of AGD. Time trial samples indicated that time after transfer to sea water did not appear to be a significant (P > 0.05) factor in antibody activity, however location was (P < 0.05). There was no agreement (corrected kappa value, 0.16) between the ELISA result and the isolation of Neoparamoeba sp. from the gills of the same fish. The results suggest that Atlantic salmon in seawater culture in Tasmania produce anti-Neoparamoeba sp. antibodies regardless of infection history, suggesting the presence of Neoparamoeba sp. in the environment.

Antigen recognition by rainbow trout (Oncorhynchus mykiss) of whole cell proteins expressed by Lactococcus garvieae when obtained directly from fish and under iron limited culture conditions

Infection by Lactococcus garvieae has become a widely recognised problem associated with intensively cultured fish. Long-term control of fish infections may be possible by vaccination providing a suitable and efficacious epitope is expressed during production of cells used for vaccine preparation. The identification of novel vaccine candidates must, therefore, consider how the host species recognises and responds to bacterial cell components. L. garvieae was cultured in iron deficient, limited and haem iron enriched media and the whole cell proteins expressed under these conditions were compared with those expressed in bacteria extracted with Percoll gradients directly from spleen tissue of infected rainbow trout (Oncorhynchus mykiss). SDS-PAGE of the cell proteins showed the existence of several different electropherotypes according to the iron status of the culture media. Only minor differences in cell protein profile were detected in bacteria obtained directly from fish spleens, but when the electropherograms were analysed by Western blots using L. garvieae hyperimmune fish sera, several proteins could be identified that were expressed only when L. garvieae was growing in vivo. Siderophore could be detected in culture supernatant of iron deficient, limited and haem iron enriched media but not in media with higher nutrient concentrations. The siderophore could not be identified as a type of catechol or hydroxymate. Rainbow trout recognise proteins in the range of approximately 50-80 kDa for bacterial cells obtained without subculture from infected fish and culture conditions can influence protein profiles for this pathogen.

Temporal and spatial distribution of paramoebae in the water column--a pilot study

Amoebic gill disease is the main disease affecting the salmonid industry in Tasmania, but no information on the distribution of the causative pathogen, Neoparamoeba pemaquidensis, in the aquatic environment is available. This pilot study aimed to determine temporal and spatial distributions of paramoebae species in the water column, using an immuno-dot blot technique. Water samples were collected from inside fish cages at various depths (0.5, 5.5 and 11.0 m) in both summer and winter, as well as various distances (0, 0.5, 240, 280, 750 and 1100 m) away from the sea cage and farming site. Paramoebae densities were estimated using the most probable number technique (MPN). Temperature, salinity, dissolved oxygen, turbidity, nitrite and nitrates, and bacterial counts were measured for each water sample. Data were analysed using a residual maximum likelihood test and significant associations between paramoebae densities and environmental factors were analysed. Results showed that densities were significantly higher in summer (P = 0.017), at 5.5 m depth (P = 0.029), and reduced to the lowest density at 1100 m away from the cage sites (P = 0.008). Bacterial counts, turbidity and temperature were found to be significantly associated with paramoebae densities.

Development of sensitive, high-throughput one-tube RT-PCR-enzyme hybridisation assay to detect selected bacterial fish pathogens

Bacterial monitoring and surveillance is critical for the early detection of pathogens to avoid the spread of disease. To facilitate this, an efficient, high-performance and high-throughput method to detect the presence of femotgram amounts of ribosomal RNA from 4 bacterial fish pathogens: Aeromonas salmonicida; Tenacibaculum maritimum (formerly Flexibacter maritimus); Lactococcus garvieae; and Yersinia ruckeri was developed. The system uses NucleoLink strips for liquid- and solid-phase PCR in 1 tube, to perform RT-PCR-enzyme hybridisation assays (RT-PCR-EHA) detecting 4 fg or less of rRNA from pure cultures and between 1 and 9 CFU per 200 microl sample volume from selective-enrichment culture media. The liquid-phase amplicons were visualised by gel electrophoresis and the solid-phase amplicons detected using internal probes and visualised using colorimetric detection and p-nitrophenylphosphate.

Optimisation of one-tube PCR-ELISA to detect femtogram amounts of genomic DNA

A simple, high-throughput, low-cost polymerase chain reaction-enzyme linked immunosorbent assay (PCR-ELISA) protocol that detects the presence of 4 fg of DNA from four bacterial fish pathogens Yersinia ruckeri, Tenacibaculum maritimum (formerly Flexibacter maritimus), Lactococcus garvieae and Aeromonas salmonicida was developed. DNA amplification was undertaken in a biphasic system with free and bound PCR that are achieved in the one NucleoLink tube. Solid-phase amplicons were detected using biotin labelled hybridization probes and visualised colourimetrically with streptavidin-alkaline phosphatase and p-nitrophenylphosphate as substrate. PCR and hybridization took less than 8 h to perform with maximum signal output for femtogram amounts of template DNA achieved within 24 h. Implementation and optimization of the protocol is discussed.

Canines as sentinel species for assessing chronic exposures to air pollutants: part 2. Cardiac pathology

The principal objective of this study is to evaluate by light and electron microscopy (LM, EM) the heart tissues in stray southwest and northeast metropolitan Mexico City (SWMMC, NEMMC) dogs and compare their findings to those from 3 less polluted cities (Cuernavaca, Tlaxcala, and Tuxpam). Clinically healthy mongrel dogs, including 109 from highly polluted SWMMC and NEMMC, and 43 dogs from less polluted cities were studied. Dogs residing in cities with lower levels of pollutants showed little or no cardiac abnormalities. Mexico City and Cuernavaca dogs exhibited LM myocardial alterations including apoptotic myocytes, endothelial and immune effector cells, degranulated mast cells associated with scattered foci of mononuclear cells in left and right ventricles and interventricular septum, and clusters of adipocytes interspersed with mononuclear cells. Vascular changes included scattered polymorphonuclear leukocytes (PMN) margination and microthrombi in capillaries, and small venous and arteriolar blood vessels. Small veins exhibited smooth muscle cell hyperplasia, and arteriolar blood vessels showed deposition of particulate matter (PM) in the media and adventitia. Unmyelinated nerve fibers showed endoneural and epineural degranulated mast cells. EM examination of myocardial mast cells showed distended and abundant rough endoplasmic reticulum with few secretory granules. Myocardial capillaries exhibited fibrin deposition and their endothelial cells displayed increased luminal and abluminal pinocytic activity and the formation of anemone-like protrusions of the endothelium into the lumen. A close association between myocardial findings, lung epithelial and endothelial pathology, and chronic inflammatory lung changes was noted. The myocardial changes described in dogs exposed to ambient air pollutants may form the basis for developing hypothesis-driven mechanistic studies that might explain the epidemiological data of increased cardiovascular morbidity and mortality in people exposed to air pollutants.

Canines as sentinel species for assessing chronic exposures to air pollutants: part 1. Respiratory pathology

A complex mixture of air pollutants is present in the ambient air in urban areas. People, animals, and vegetation are chronically and sequentially exposed to outdoor pollutants. The objective of this first of 2 studies is to evaluate by light and electron microscopy the lungs of Mexico City dogs and compare the results to those of 3 less polluted cities in MEXICO: One hundred fifty-two clinically healthy stray mongrel dogs (91 males/61 females), including 43 dogs from 3 less polluted cities, and 109 from southwest and northeast metropolitian Mexico City (SWMMC, NEMMC) were studied. Lungs of dogs living in Mexico City and Cuernavaca exhibited patchy chronic mononuclear cell infiltrates along with macrophages loaded with particulate matter (PM) surrounding the bronchiolar walls and extending into adjacent vascular structures; bronchiolar epithelial and smooth muscle hyperplasia, peribronchiolar fibrosis, microthrombi, and capillary and venule polymorphonuclear leukocytes (PMN) margination. Ultrafine PM was seen in alveolar type I and II cells, endothelial cells, interstitial macrophages (Mtheta), and intravascular Mtheta-like cells. Bronchoalveolar lavage showed significant numbers of alveolar macrophages undergoing proliferation. Exposure to complex mixtures of pollutants-predominantly particulate matter and ozone-is causing lung structural changes induced by the sustained inflammatory process and resulting in airway and vascular remodeling and altered repair. Cytokines released from both, circulating inflammatory and resident lung cells in response to endothelial and epithelial injury may be playing a role in the pathology described here. Deep concern exists for the potential of an increasing rise in lung diseases in child populations exposed to Mexico City's environment.

Rapid, high-throughput extraction of bacterial genomic DNA from selective-enrichment culture media

AIMS

To create a fast, sensitive and inexpensive high-throughput method for the extraction of bacterial genomic DNA from selective-enrichment culture media.

METHODS AND RESULTS

Lysis of bacteria was achieved using guanidinium isothiocyanate, and DNA was extracted using 96-well glass microfibre filtration plates. Extraction-PCR detected the presence of 1 cfu Yersinia ruckeri and 16 cfu Lactococcus garvieae 200 microl(-1) sample of selective-enrichment medium.

CONCLUSION

An efficient method for high-throughput extraction of bacterial genomic DNA from selective-enrichment culture media was achieved.

SIGNIFICANCE AND IMPACT OF THE STUDY

This method enables detection of covert bacterial infections in fish. The simultaneous extraction of large numbers of samples allows for its use in bacterial monitoring programmes and quarantine.

Expression of oestrogen and progesterone receptors by mast cells alone, but not lymphocytes, macrophages or other immune cells in human upper airways

BACKGROUND

Nasal polyposis often coexists with asthma in airway inflammatory conditions characterised by the infiltration of a range of immune cells. A potentially important role for ovarian hormones has been implicated in airway inflammation but the cellular target for such action is not known.

METHODS

Expression of oestrogen receptors (ER) and progesterone receptors (PR) was examined using immunohistochemistry in formalin fixed nasal polyp tissues from 47 subjects. The cells positive for ER or PR were confirmed by spatial location, dual immunolabelling, and histochemical staining.

RESULTS

Consistent with the known features of nasal polyps, CD4+ (T helper/inducer), CD8+ (cytotoxic/suppressor), CD68+ (macrophages), mast cells, eosinophils and neutrophils were all clearly detected by their relevant monoclonal antibodies or appropriate histochemical staining, but only mast cells tested positive for ER/PR labelling with their polyclonal and monoclonal antibodies. The frequencies for expression were 61.7% for ER positive and 59.6% for PR positive cells. The expression of ER/PR was independent of patient sex and age but was highly correlated with the numbers of mast cells (r = 0.973, p<0.001 for ER; r = 0.955, p<0.001 for PR). Fewer than 5% of mast cells were found to be negative for ER/PR expression.

CONCLUSIONS

Mast cells alone, but not lymphocytes, macrophages, or other immune cells, express ER/PR in human upper airways. Numerous ER/PR positive mast cells exist in nasal polyps, indicating that this may be a major route for the involvement of sex hormones in airway inflammation when exposed to the higher and varying concentration of oestrogen and progesterone characteristic of females.

Miniaturized tests for computer-assisted identification of motile Aeromonas species with an improved probability matrix

AIMS

To develop miniaturized tests for the phenotypic identification of motile Aeromonas species using an improved probability matrix.

METHODS AND RESULTS

Conventional tests were miniaturized for use in 96-well plates, and their performance assessed using 60 aeromonads comprising type and reference strains as well as clinical, fish and water isolates. A revised probability matrix for Aeromonas hybridization groups 1-14, including A. allosaccharophila, A. bestiarum, A. encheleia and A. popoffii, was developed. Using 26 tests, all the reference strains were correctly identified with the revised probability matrix, and 80% of the isolates were correctly identified at a Willcox probability level of 95%.

CONCLUSION

The compact test format, coupled with a robust identification matrix, provides a convenient basis for identifying motile aeromonads.

SIGNIFICANCE AND IMPACT OF THE STUDY

The identification system for identifying aeromonads will be of use to medical and veterinary laboratories undertaking disease diagnosis.

The effect of ice warning signs on ice-accident frequencies and severities

Signing of non-permanent road surface conditions, such as ice, is difficult because hazard formation, location, and duration are unpredictable. Subsequently, many state transportation departments have begun to question the sensibility of expending material and personnel resources to maintain ice warning signs when little proof exists of their effectiveness in improving highway safety. This research statistically studies the effectiveness of ice warning signs in reducing accident frequency and accident severity in Washington State. Our findings show that the presence of ice warning signs was not a significant factor in reducing ice-accident frequency or ice-accident severity. However, we were able to identify significant spatial, temporal, traffic, roadway and accident characteristics that influenced ice-accident frequency and severity. The identification of these characteristics will allow for better placement of ice warning signs and improvements in roadway and roadside design that can reduce the frequency and severity of ice-related accidents.

Case management: an update

BACKGROUND

Case management in its various forms represents a major innovation in mental health care. Its efficacy remains controversial.

AIMS

To update after a decade a previous review article (Holloway, 1991).

METHODS

Descriptive literature and controlled trials of case management and its derivative Assertive Community Treatment (ACT) was accessed through four comprehensive and systematic reviews of the literature, repeated Medline and Embase searches and personal contacts.

RESULTS AND CONCLUSIONS

The concept of case management has continued to evolve over the past decade. No controlled trial has been published exploring the model of the case manager as a service broker without responsibility for the provision of care. Basic case management principles have frequently been incorporated within routine clinical practice. Published controlled trials of ACT, which were almost exclusively carried out in North America, have shown markedly positive results. However caution is required in extrapolating these findings to routine clinical practice within different systems of health and social care. Case management is not in itself an effective treatment for severe mental illness.

Luminous vibriosis in rock lobster Jasus verreauxi (Decapoda: Palinuridae) phyllosoma larvae associated with infection by Vibrio harveyi

Studies were conducted to determine the cause of outbreaks of luminous vibriosis in phyllosoma larvae of the packhorse rock lobster Jasus verreauxi reared in an experimental culture facility. On 2 separate occasions mortalities of up to 75% over a period of 4 wk were observed in 4th to 5th and 8th to 10th instar phyllosomas at water temperatures of 20 and 23 degrees C, respectively. Affected larvae became opaque, exhibited small red spots throughout the body and pereiopods, and were faintly luminous when viewed in the dark. Histopathology showed that the gut and hepatopancreas tubules of moribund phyllosomas contained massive bacterial plaques. The hepatopancreas tubules of moribund larvae were atrophic and some contained necrotic cells sloughed into the lumen. Dense, pure cultures of a bacterium identified as Vibrio harveyi were isolated from moribund larvae. The disease syndrome was reproduced by in vivo challenge and V. harveyi was successfully reisolated from diseased larvae after apparently healthy larvae were exposed by immersion to baths of more than 10(4) V. harveyi ml(-1) at 24 degrees C. Injured larvae were more susceptible to infection than were healthy larvae. Survival of larvae experimentally and naturally exposed to V. harveyi was improved when antibiotics were administered via bath exposures.

Induction, characterisation and pathogenicity in rainbow trout Oncorhynchus mykiss (Walbaum) of Lactococcus garvieae L-forms

Difficulties with induction and cultivation of L-forms, particularly those derived from Gram positive parent cells, have constrained to some degree the ability to evaluate the pathogenicity of these morphotypes. Induction of L-forms of Lactococcus garvieae was undertaken using either charcoal or inactivated horse serum media supplemented with ampicillin, benzylpenicillin or erythromycin, the drug of choice for treatment of infections in rainbow trout, Oncorhynchus mykiss, (Walbaum), and NaCl as an osmotic stabiliser. Lysozyme treated cells could be cultured in a cell wall deficient state using media consisting of charcoal, NaCl and either ampicillin or benzylpenicillin. The influence of some amino acids for induction of L-forms was assessed by disc diffusion and combined interaction. Analysis of variance of colony counts indicated that the amino acids glycine, DL-methionine, L-threonine and L-serine (P<0.03), and the presence of charcoal were beneficial and that inactivated horse serum was detrimental to L-form development. Electron microscopy revealed that the cell wall of L-forms was missing and this cell had a greatly expanded volume compared to parent cells. Electrophoresis of whole cell proteins showed some variation of electropherotype between parent and L-form cells. L-forms expressed greater quantities of proteins with molecular mass of 36 and 66 kDa and parent cells contained greater quantities of proteins of molecular mass 29, 43 and 60 kDa. Additional proteins of molecular mass 32, 44 and 53 kDa were present in L-form extracts, and in parent cells of 34, 38, 40, 42, 85 and 123 kDa which may represent cell wall associated proteins or alterations in expression due to different growth rates. Intraperitoneal challenge of rainbow trout with L-forms failed to produce overt infection even in immune-suppressed fish, but L-forms were shown by indirect fluorescent antibody test to remain inkidney tissue. Fish were susceptible to infection when challenged with parent cells of L. garvieae.

Subjective quality of life, psychopathology, satisfaction with care and insight: an exploratory study

We have investigated the determinants of global subjective quality of life (GSQOL) using data from a controlled trial of intensive case management for the severely mentally ill. In a multiple regression analysis depression, age, objective quality of life and domain-specific quality of life together explained 59% of the variance in GSQOL. GSQOL was not significantly correlated with measures of positive psychotic symptomatology, insight or attitudes to treatment but was correlated with satisfaction with care (r = .21, p = .011). Change in GSQOL over 18 months was correlated with change in domain-specific quality of life (r = -.45, p = .002) and depression (r = -.43, p = .01): multiple regression analysis confirmed that both variables had an independent effect on change in GSQOL.

Psychological training improves mental health and job-finding among unemployed people

The negative psychological effects of unemployment are well documented: lowered self-esteem and confidence, social isolation, anxiety, depression, reduced life satisfaction, hopelessness about the future. Further, it has been established that these effects often prevent re-employment. The need for interventions to help unemployed people to minimise such psychological effects is clearly warranted, yet little psychological assistance is usually given. This paper describes a psychological intervention based on cognitive behavioural therapy (CBT), the principles of which have been successfully applied through individual psychotherapy to several psychiatric disorders. We adapted these principles to create a group-training programme for a non-psychiatric group--long term (>12 months) unemployed. The results demonstrated that significantly more of the CBT group than the control group improved on measures of mental health, as well as on success in job-finding: four months after the completion of training 34% of the CBT group c.f. 12% of the control group had found full-time work. Taking part-time and temporary work into account, these figures increased to 49% (CBT group) and 28% (control group), indicating the value of psychological interventions in reducing the negative psychological effects of unemployment, and helping the unemployed find jobs.

Effect of ozone on susceptibility to respiratory viral infection and virus-induced cytokine secretion

Airway epithelium is the primary target tissue for respiratory viruses as well as an important target of ozone (O(3)) toxicity. A change in the severity of viral airway infection may result from changes in epithelial cell susceptibility to infection, metabolic interference with viral replication, or altered production of immune regulatory molecules by the infected cells as a result of exposure to O(3). In this study we have investigated whether O(3) exposure alters the susceptibility of human airway epithelial cells to respiratory syncytial virus (RSV) infection, the production of infectious virus, and/or release of virus-induced cytokines IL-6 and IL-8. The epithelial cell line BEAS-2B grown on collagen-impregnated filters was exposed to O(3) (0.5 ppm for 60 min) or filtered air immediately before or 24 h after infection with RSV. Cells exposed to O(3) before RSV infection released 44% less virus over 4 days of infection while O(3) exposure post RSV infection had no effect on virus production. O(3) exposure preceding RSV infection showed short term additive effects of these treatments on epithelial cell IL-6 and IL-8 production, a decrease in cytokines at 48 h, but did not affect long term cytokine production by RSV-infected cells. Furthermore, O(3) exposure did not affect long term cytokine production by cells with an established RSV infection at the time of exposure. These data suggest that O(3) does not adversely affect viral airway infection, at least not on the level of the host cell for viral replication.

Clinical supervision: insider reports of a private world

An exploratory study, funded by the Department of Health, London and the Scottish Home and Health Department, Edinburgh, was conducted over an 18-month period to provide an informed view on possible assessment tools that could be used to assess the impact of clinical supervision (CS) in nursing and to report on the CS activities in 23 selected sites in England and Scotland. The study not only examined the utility of several standardized research instruments, to be reported separately, but also explored the experience of a small sub-sample of nurses (n = 34) engaged in CS, as supervisors and supervisees. Interviews were undertaken to help better understand some of the issues involved around the domains of structure, process and outcome. Respondents reported an enthusiasm for the opportunity to talk meaningfully to a trusted colleague about their personal circumstances at work. Such opportunities were particularly welcomed by nurses who wished to reflect upon their own practice with patients, especially when dealing with their clinical conditions which were upsetting, or otherwise challenging, and sometimes harrowing. Substantive and methodological areas of interest for future research are suggested.

Occupational stress and community mental health nursing: what CPNs really said

The Claybury Nursing Stress Study assessed the levels of occupational stress experienced by both ward-based and community nurses. This paper presents the results obtained from a qualitative analysis of statements made by community psychiatric nurses during a questionnaire based interview. Key areas identified by CPNs as relevant to stress and coping are reported and suggestions for further, qualitative research in this area are made.

Intensive case management for the severely mentally ill. Controlled trial

BACKGROUND

The aim was to compare the efficacy of intensive clinical case management (ICM) with standard community care in the management of 'hard to treat' patients with a severe mental illness.

METHOD

A randomised controlled trial was carried out in East Lambeth, a deprived area of inner London. Seventy people with psychosis designated as 'hard to treat' by referring teams were included; 35 were randomised to ICM (case load eight patients per worker), and 35 to standard care, which offered follow-up by a community psychiatric nursing service (30 patients per worker). Outcome measures were admissions and hospital bed utilisation; contact with services; symptomatology; social behaviour; social functioning; quality of life; patients' satisfaction with care at 9 and 18 months.

RESULTS

There were no differences in patients' symptoms, social behaviour or social functioning. Quality of life was significantly improved in patients receiving ICM at 9 months. Satisfaction with care was significantly greater among case-managed patients. All ICM patients remained in contact with services throughout the study, while six control patients were refusing all contact with services at 18 months.

CONCLUSIONS

ICM failed to improve the clinical outcome of 'hard to treat' patients. The service was successful in maintaining contact with patients, was greatly appreciated and had a positive effect on their perceived quality of life.