Case management: a critical review of the outcome literature

Case management has been an integral part of psychiatric practice in the United States for over a decade and has generated a large body of literature. The application of case management principles to the care of people suffering from psychiatric disorders is becoming increasingly popular in the United Kingdom and Europe and literature is now beginning to be published. However, no definitive statements about the efficacy of case management have been made due to a range of conceptual and methodological problems. The present paper is a critical review of the case management outcome literature. Reported outcomes are reviewed in the context of study design and service characteristics. The authors conclude that case management practice can have at least some impact on patients' use of services (including marked decrease in in-patient bed days); satisfaction with services; engagement with services; and social networks and relationships when it is delivered as a direct, clinical service with high staff: patient ratios. A set of recommendations are suggested for the future practice and presentation of research into case management.

Quantifying age and model uncertainties in palaeoclimate data and dynamical climate models with a joint inferential analysis

The study of palaeoclimates relies on information sampled in natural archives such as deep sea cores. Scientific investigations often use such information in multi-stage analyses, typically with an age model being fitted to a core to convert depths into ages at stage one. These age estimates are then used as inputs to develop, calibrate or select climate models in a second stage of analysis. Here, we show that such multi-stage approaches can lead to misleading conclusions, and develop a joint inferential approach for climate reconstruction, model calibration and age estimation. As an illustration, we investigate the glacial-interglacial cycle, fitting both an age model and dynamical climate model to two benthic sediment cores spanning the past 780 kyr. To show the danger of a multi-stage analysis, we sample ages from the posterior distribution, then perform model selection conditional on the sampled age estimates, mimicking standard practice. Doing so repeatedly for different samples leads to model selection conclusions that are substantially different from each other, and from the joint inferential analysis. We conclude that multi-stage analyses are insufficient when dealing with uncertainty, and that to draw sound conclusions the full joint inferential analysis should be performed.

The Use of Sodium Diphenyl Hydantoinate

Attention was drawn to the important work of Putnam and Merritt by an annotation in the Lancet last year. The results of their studies were published in two papers entitled “A New Series of Anti-convulsant Drugs Tested by Experiments on Animals” and “Sodium Diphenyl Hydantoinate in the Treatment of Convulsive Disorders”.

Isolation of Tasmanian Rickettsia-like organism (RLO) from farmed salmonids: identification of multiple serotypes and confirmation of pathogenicity

Atlantic salmon Salmo salar L. farmed in south-east Tasmania, Australia, are susceptible to infection by the Tasmanian Rickettsia-like organism (TRLO), a Gram-negative bacterium. Here, we report the first isolation of TRLO from south-east Tasmania in pure culture and show that the bacterium is culturable on both specialised enriched agar and in cell culture using the CHSE-214 cell line. In vitro cultured TRLO was used to reproducibly elicit disease in Atlantic salmon parr held in fresh water. In inoculated fish, TRLO was observed intracytoplasmically in peripheral blood leucocytes, suggesting that these cells are responsible for haematogenous dispersal of the bacterium within the host. Fish with experimentally induced disease presented with gross and histopathological changes similar to TRLO-infected fish at commercial marine farms. TRLO was also isolated in culture from farmed Atlantic salmon in the Tamar River and Macquarie Harbour production areas in Tasmania, both of which have no history of TRLO-associated disease. These TRLO isolates appear to be serologically distinct from each other as well as from isolates obtained from south-east Tasmania, linking each serotype to a specific geographical location within Tasmania. Despite the lack of clinical evidence of TRLO-linked disease in fish grown in the Tamar River and Macquarie Harbour, experimental infection trials demonstrably showed the pathogenic potential of these TRLO serovars. Together, these data provide evidence that TRLO is a fastidious, facultative intracellular bacterium and confirm TRLO as a pathogen of Atlantic salmon, causing a disease designated Tasmanian salmonid rickettsiosis.

Development and application of molecular methods (PCR) for detection of Tasmanian Atlantic salmon reovirus

Molecular (PCR) diagnostic tests for the detection and identification of aquareovirus in general, and Tasmanian Atlantic salmon reovirus (TSRV) specifically, were developed, and their diagnostic sensitivity and specificity were determined and compared with virus isolation in cell culture. Intralaboratory and interlaboratory comparison of PCR (conventional hemi-nested RT-PCR & RT-qPCR) and virus isolation in cell culture using finfish cell lines, CHSE-214 and EPC, was carried out for the detection and identification of TSRV using field samples of farmed Atlantic salmon Salmo salar, L. from various aquaculture sites around Tasmania. The interlaboratory comparison of diagnostic methods was carried out between two laboratories, AAHL-CSIRO and DPIPWE-Tasmania. A total of 144 fish from nine sites (12-33 fish per site) were sampled from two regions of Tasmania (Tamar River estuary in the north and Huon River estuary in the south-east) during late spring to early summer of 2009, and the data were analysed using different statistical approaches. The prevalence of TSRV ranged from 6% to 22% in both regions. All the diagnostic methods (data from both laboratories) had high specificity, while the estimated sensitivity varied between tests with RT-qPCR being the most sensitive (95.2%) method followed by virus isolation and then conventional hemi-nested RT-PCR.

Spinal Injuries in Canadian Ice Hockey: Documentation of Injuries Sustained from 1943-1999

Objectives:

Study objectives were: (a) to examine the causes and incidence of major spinal cord injuries sustained by ice hockey players; and (b) to add recently reported Canadian cases to the Canadian Ice Hockey Spinal Injury Registry to determine the effectiveness of prevention efforts.

Methods:

The study was a review of questionnaires returned retrospectively by physicians and other sources reporting ice hockey related spinal injuries in Canada. Physicians reported on the mechanism of injury, vertebral level of injury, presence of neurologic deficit, type of event, and type of fracture.

Results:

Between 1943 and 1999, 271 major spinal injuries were reported in Canadian ice hockey players, of which 49.0% occurred to players 16-20 years of age. Ontario has had a disproportionately large number of injuries compared to some provinces, especially Quebec. Of the spinal cord injuries, 65.8% resulted from colliding with the boards, and 36.6% were due to players being pushed or checked from behind. The recent survey shows that there has been a decline in the number of major spinal cord injuries in Canadian ice hockey, especially those causing paralysis due to checking or pushing from behind.

Conclusion:

Impact of the head with the boards after being checked or pushed from behind was the most common mechanism of spinal cord injury. Injury prevention programs are becoming effective in reducing the overall number of injuries, especially those due to checking from behind. Greater awareness of the occurrence and mechanisms of injury through educational programs and rules changes by organized hockey have reduced the annual incidence of catastrophic spinal injuries in Canadian ice hockey.

The impact of a diagnosis of personality disorder on service usage in an adult Community Mental Health Team

PURPOSE

Patients with a diagnosis of personality disorder (PD) have multiple and diverse needs. It has been noted that individuals with personality disorder are high users of health care resources, especially psychiatric services, ambulance services and emergency departments. In addition PD has been shown to be a significant predictor of disability and mental health consultations independent of Axis I disorders and physical conditions. This study aimed to compare the patterns of service usage, clinical ratings of symptoms and functioning, as well as demographic and clinically relevant historical variables between a group of patients with PD and a random sample of all other patients registered with a South London Community Mental Health Team.

METHODS

A case–control design was used to examine service usage patterns over a one-year period for 73 cases and 96 controls. Diagnoses were established by clinician discussion. Clinical outcomes were measured with Health of the Nation Outcome Scales and Global Assessment of Functioning, while service use was recorded using ten variables obtained from case note review.

RESULTS

People with a diagnosis of PD were more often white and had a history of abuse, particularly childhood emotional abuse. They were higher users of some aspects of the service as compared to controls, and had significantly higher severity of symptoms and poorer functioning on clinician-rated measures.

CONCLUSION

This study confirms previous findings that people with PD have more severe symptomatology and greater degrees of functional impairment when compared to those without. Community clinicians should routinely screen attenders to predict likely difficulties that might arise and to make provision for these difficulties in the treatment and management of clients.

Culturable microbiota of ranched southern bluefin tuna (Thunnus maccoyii Castelnau)

AIMS

The Australian tuna industry is based on the ranching of wild southern bluefin tuna (SBT, Thunnus maccoyii). Within this industry, only opportunistic pathogens have been reported infecting external wounds of fish. This study aimed to identify different culturable bacteria present in three cohorts of SBT and to determine normal bacteria and potential pathogens in isolates from harvest fish and moribund/dead fish. Post-mortem changes in the microbiota were also studied.

METHODS AND RESULTS

Moribund/dead showed a greater proportion of members from the family Vibrionaceae than harvested fish; the latter presented mainly non-Vibrio species. In harvested fish spleens, Vibrio splendidus I complex was the most commonly identified group among Vibrio isolates, while most groups from the family Vibrionaceae were isolated from gills. For moribund/dead, Vibrio chagasii and Photobacterium damselae subsp. damselae were common in gill, spleen and kidney samples. Non-Vibrio isolates from gills were characterized using 16S rRNA sequencing as Flavobacteriaceae and classes Gammaproteobacteria and Alphaproteobacteria, mainly from the genera Winogradskyella and Tenacibaculum. Post-mortem changes showed dynamic shifts in bacterial dominance in gills, with Vibrionaceae and non-Vibrio spp. found in similar proportions initially and types related to Pseudoalteromonas ruthenica prevailing after 27 h. Spleen samples showed little bacterial growth until 5 h post-mortem, while various Vibrio-associated species were isolated 27 h post-mortem.

CONCLUSIONS

Bacterial isolates found include a range of potentially pathogenic bacteria that should be monitored though most of them have yet to be associated with disease in tuna.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study forms a foundation for future research into the bacterial population dynamics under different culture conditions of SBT. An understanding of the bacterial compositions in SBT is necessary to evaluate the effects of some bacterial species on their health.

Laboratory evaluation of sample collection methods (organs vs swabs) for Tasmanian salmon reovirus detection in farmed Atlantic salmon, Salmo salar L

The use of swabs relative to organs as a sample collection method for the detection of Tasmanian salmon reovirus (TSRV) in farmed Tasmanian Atlantic salmon, Salmo salar L., was evaluated by RT-qPCR. Evaluation of individual and pooled sample collection (organs vs swabs) was carried out to determine the sensitivity of the collection methods and the effect of pooling of samples for the detection of TSRV. Detection of TSRV in individual samples was as sensitive when organs were sampled compared to swabs, and in pooled samples, organs demonstrated a sensitivity of one 10-fold dilution higher than sampling of pooled swabs. Storage of swabs at 4 °C for t = 24 h demonstrated results similar to those at t = 0. Advantages of using swabs as a preferred sample collection method for the detection of TSRV compared to organ samples are evident from these experimental trials.

The GoodNEWS (Genes, Nutrition, Exercise, Wellness, and Spiritual Growth) Trial: a community-based participatory research (CBPR) trial with African-American church congregations for reducing cardiovascular disease risk factors--recruitment, measurement, and randomization

INTRODUCTION

Although cardiovascular diseases (CVD) are the leading cause of death among Americans, significant disparities persist in CVD prevalence, morbidity, and mortality based on race and ethnicity. However, few studies have examined risk factor reduction among the poor and ethnic minorities.

METHODS

Community-based participatory research (CBPR) study using a cluster randomized design--African-American church congregations are the units of randomization and individuals within the congregations are the units of analysis. Outcome variables include dietary change (Diet History Questionnaire), level of physical activity (7-Day Physical Activity Recall), lipoprotein levels, blood pressure, fasting glucose, and hemoglobin A1c.

RESULTS

Eighteen (18) church congregations were randomized to either a health maintenance intervention or a control condition. Complete data were obtained on 392 African-American individuals, 18 to 70 years of age, predominantly employed women with more than a high school diploma. Treatment and intervention groups were similar at baseline on saturated fat intake, metabolic equivalent of tasks (METS) per day, and other risk factors for CVD.

CONCLUSIONS

The GoodNEWS trial successfully recruited and evaluated CVD-related risk among African-American participants using a CBPR approach. Several logistical challenges resulted in extending the recruitment, preliminary training, and measurement periods. The challenges were overcome with the assistance of a local community consultant and a professional event planner. Our experience supports the need for incorporating non-traditional community-based staff into the design and operational plan of CBPR trials.

Physical characterisation of Tenacibaculum maritimum for vaccine development

AIMS

Tenacibaculum maritimum is a well known fish pathogen worldwide, affecting many fish species including Atlantic salmon in Tasmania, Australia. The aim of this study was to characterise and understand the similarities and differences between the isolates in order to select isolates for later pathogenicity and vaccination trials.

METHODS AND RESULTS

Several physical characterisation tests were carried out: whole cell protein profiles, lipopolysaccharide profiles (LPS), extracellular product profiles (ECP), indirect immunofluorescent antibody test (IFAT) and hydrophobicity. The Tasmanian strains of T. maritimum appear relatively homogeneous physically, but antigenically different. All isolates were hydrophobic and produce a variety of ECP profiles. There were two isolates that stand out in all assays (89/4747 and 01/0356-7) and showed great variation from the other isolates. All isolates have been confirmed as T. maritimum.

CONCLUSIONS

Based on the tests carried out three isolates were chosen for in vivo trials: 89/4747, 89/4762, 00/3280.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first study to characterise T. maritimum isolates from Tasmanian waters. The opportunity to develop vaccines for the Tasmanian salmonid aquaculture industry is enhanced by a greater understanding of the physical characteristics of pathogens.

Assessing Analytical Variability of Measurement of Vitamin A in Corn-Soy Blend

Two multilaboratory investigations were conducted by SUSTAIN to assess variability in the measurement of vitamin A, the marker used to verify levels of vitamin premix addition to enriched/fortified food aid products, including the widely distributed corn-soy blend (CSB). CSB specifications identify AACC Approved Method 86-06 or equivalent methods for vitamin A analysis, however there is no requirement to demonstrate equivalency. CSB samples with known and blinded levels of vitamin A and a reference standard were analyzed by 16 laboratories using their respective methods. Calculated coefficients of variation across all laboratories and methods for unknown samples and reference standard were 35 and 7.1, respectively, suggesting the largest source of variation is the vitamin extraction procedure. Laboratories generally overestimated low levels and underestimated high levels of vitamin A within the range of 6000 and 16 000 IU/lb. Only two laboratories demonstrated excellent internal precision (300 IU vitamin A/lb) and reported values within 95 confidence interval for all blinded samples. Results of this study have implications both for quality control in food aid products (due to the use of vitamin A as a marker) and for regulatory oversight of vitamin A content in commercial food products.

Assessing analytical variability of measurement of vitamin A in corn-soy blend

Two multilaboratory investigations were conducted by SUSTAIN to assess variability in the measurement of vitamin A, the marker used to verify levels of vitamin premix addition to enriched/fortified food aid products, including the widely distributed corn-soy blend (CSB). CSB specifications identify AACC Approved Method 86-06 or equivalent methods for vitamin A analysis, however there is no requirement to demonstrate equivalency. CSB samples with known and blinded levels of vitamin A and a reference standard were analyzed by 16 laboratories using their respective methods. Calculated coefficients of variation across all laboratories and methods for unknown samples and reference standard were 35 and 7.1%, respectively, suggesting the largest source of variation is the vitamin extraction procedure. Laboratories generally overestimated low levels and underestimated high levels of vitamin A within the range of 6000 and 16 000 IU/lb. Only two laboratories demonstrated excellent internal precision (+/- 300 IU vitamin A/lb) and reported values within 95% confidence interval for all blinded samples. Results of this study have implications both for quality control in food aid products (due to the use of vitamin A as a marker) and for regulatory oversight of vitamin A content in commercial food products.

An outbreak of tuberculosis affecting cattle and people on an Irish dairy farm, following the consumption of raw milk

Bovine tuberculosis is an ongoing problem in Ireland, and herd incidence has remained at approximately 5% for some years. Spillover of infection from cattle to people remains an ever-present possibility, given the ongoing pool of infection in the Irish cattle population. This paper describes an outbreak of tuberculosis affecting cattle and people on a dairy farm in southeastern Ireland following the consumption of milk from a seven-year-old cow with tuberculous mastitis. Twenty-five of 28 calves born during autumn 2004 and spring 2005 were subsequently identified as TB reactors, and five of six family members were positive on the Mantoux test. During 2005, milk from this cow had mainly been used to feed calves, and was added only occasionally to the bulk tank. Therefore, the calves each received infected milk on an almost continuous basis between birth and weaning. The family collected milk from the bulk milk tank, and consumed it without pasteurisation. This case highlights the risks associated with the consumption of raw milk. In this family, TB has had a very significant impact on the health of two young children. These risks are well recognised, and relevant information for farmers is available. It is of concern, therefore, that raw milk consumption remains prevalent on Irish farms. New strategies are needed, in partnership with industry, to address this important issue. Keywords: bovine tuberculosis, Ireland, mastitis, milk, Mycobacterium bovis, pasteurisation, TB, zoonosis

The evaluation of human papillomavirus genotyping in cervical liquid-based cytology specimens; using the Roche Linear Array HPV genotyping assay

OBJECTIVE

To ascertain the usefulness of the Roche Linear Array human papillomavirus (HPV) genotyping assay for assessing HPV genotypes in liquid-based cytology (LBC) samples and to evaluate this methodology within a cytopathology laboratory. These tests are of importance as persistent infection with high-risk HPV genotypes is considered a causal factor in the development of cervical cancer.

METHODS

A total of 175 cervical LBC samples were tested using the Roche Linear Array HPV genotyping test. The suitability of the assay use in routine cytopathology laboratory was considered. HPV genotypes were matched to the cervical cytology results, which included negative, borderline nuclear abnormalities, mild, moderate and severe dyskaryosis.

RESULTS

The assay could be applied to screening samples with the combined result available at the reporting stage. There were no test failures. All samples used after cytological analysis had sufficient DNA for testing. The results were reproducible and easily read and there was concordance of results between biomedical scientists. The results of the assay showed co-infection with multiple HPV genotypes was common in both high-grade and low-grade cytology samples. The percentage of HPV+ samples in the normal cytology samples (although in this grouping the number of samples was low) was 37%. In the cytology samples reported as severe dyskaryosis the HPV genotypes most commonly found were HPV16 and HPV51.

CONCLUSION

The assay was able to detect multiple HPV infection with a wide range of genotypes in LBC samples sent for routine cytological analysis. It would be suitable for use in a cytopathology laboratory. The results of the assay show that the genotype profile has some variation from other geographical regions, and more work is needed to determine population prevalence, to ascertain the impact of the HPV vaccine, to evaluate test for cure and HPV triage management.

Surgical treatment of malignant carcinoid tumours of the appendix

Since their first description in 1882, malignant neoplasms of the appendix still remain rare. Malignant carcinoid tumours are the most common accounting for 85% of all appendiceal neoplasms. Preoperative diagnosis is invariably difficult, and precise treatment protocols for these neoplasms remain unclear. We reviewed our experience and searched published evidence to produce management guidelines. A retrospective review of all malignant carcinoid tumours diagnosed in our hospital between April 1994 and December 2003 was performed. Patient demographics, operative details, histological types and clinical outcomes were retrieved from case notes supplemented by a questionnaire to the patient's General Practitioner. A literature search was then performed. Nine patients were identified with classical carcinoid tumours (CCT); (M = 3 and F = 6, mean age: 43, range 14-81) and two patients with goblet-cell morphology (F = 2, age 46 and 76). Mean follow-up was 63 months (range 1-125 months). Nine patients were alive at the end of follow-up. Appendicectomy was performed for acute appendicitis. Other appendiceal pathologies were identified following hemicolectomy and oophorectomy. CCT are the most common tumours and have the better prognosis. From our experience and subsequent review of the literature, we recommend right hemicolectomy as the treatment of choice for malignant carcinoid tumours. However, small CCTs less than 2 cm in diameter at the tip of the appendix, with a low proliferative index, without angiolymphatic or mesoappendiceal extension can be treated by appendicectomy. Following oncological assessment, further adjuvant therapy should be considered for patients with advanced disease.

Changes to the phenotypic profile of Vibrio harveyi when infected with the Vibrio harveyi myovirus-like (VHML) bacteriophage

AIMS

To determine if infection of Vibrio harveyi with the V. harveyi myovirus-like (VHML) bacteriophage causes a change to the phenotypic profile of this species.

METHODS AND RESULTS

Using 46 biochemical and metabolic tests, phenotypic profiles for noninfected V. harveyi and VHML infected V. harveyi were developed. Comparison of the infected and bacteriophage-infected strains of V. harveyi 645, 20 and 45 were found to have different test results for d-gluconate utilization, gamma-glutamyl transpeptidase and sulfatase activity, respectively. Using probabilistic identification, VHML infected and noninfected strains were identified as V. harveyi and had similar Willcox probability scores though the modal likelihood scores were reduced for VHML infected strains. One VHML infected strain, 642b, was misidentified as V. campbellii by phenotyping but not by PCR. It would appear that the phenotype of V. harveyi strains infected with VHML, are sufficiently altered that they occur at the margins of the known range of strain variation for V. harveyi.

CONCLUSION

Infection of V. harveyi with VHML causes the phenotypic profile of the bacterium to change. This change reduces the modal likelihood score resulting in a poorer level of assurance for an identification of V. harveyi, especially in the natural host, strain 642. The bacteriophage VHML integrates into different sites in different strains of V. harveyi.

SIGNIFICANCE AND IMPACT OF THE STUDY

The identification of V. harveyi as the causative agent of mortality in aquatic organisms is predominantly achieved through phenotyping. Since bacteriophages alter virulence in V. harveyi, understanding the effect they have on phenotype is important.

Standardization of a broth microdilution susceptibility testing method to determine minimum inhibitory concentrations of aquatic bacteria

A multiple laboratory study was conducted in accordance with the standards established by the Clinical and Laboratory Standards Institute (CLSI), formerly the National Committee for Clinical Laboratory Standards (NCCLS), for the development of quality control (QC) ranges using dilution antimicrobial susceptibility testing methods for bacterial isolates from aquatic animal species. QC ranges were established for Escherichia coli ATCC 25922 and Aeromonas salmonicida subsp. salmonicida ATCC 33658 when testing at 22, 28 and 35 degrees C (E. coli only) for 10 different antimicrobial agents (ampicillin, enrofloxacin, erythromycin, florfenicol, flumequine, gentamicin, ormetoprim/sulfadimethoxine, oxolinic acid, oxytetracycline and trimethoprim/sulfamethoxazole). Minimum inhibitory concentration (MIC) QC ranges were determined using dry- and frozen-form 96-well plates and cation-adjusted Mueller-Hinton broth. These QC ranges were accepted by the CLSI/NCCLS Subcommittee on Veterinary Antimicrobial Susceptibility Testing in January 2004. This broth microdilution testing method represents the first standardized method for determining MICs of bacterial isolates whose preferred growth temperatures are below 35 degrees C. Methods and QC ranges defined in this study will enable aquatic animal disease researchers to reliably compare quantitative susceptibility testing data between laboratories, and will be used to ensure both precision and inter-laboratory harmonization.

Residues of spinosad in the tissues of sheep after aerosol treatment of blowfly myiasis

OBJECTIVE

To measure the residues of spinosad and chlorhexidine in the tissues of sheep after treatment of blowfly strike.

PROCEDURE

Fourteen sheep with natural myiasis and 12 with artificial infestations of Lucilia cuprina larvae had the wool removed over their infestations and were treated with an aerosol wound dressing containing spinosad and chlorhexidine. Sheep were killed up to 14 days after treatment and residues of the chemicals measured in tissues.

RESULTS

Chlorhexidine was not detected in any tissue. Residues of spinosad were highest in fat, lowest in muscle and intermediate in liver and kidney. The highest residue detected was 0.2 mg/kg spinosad in perirenal fat 7 days after generous treatment of a sheep with a large fly strike. Residues of spinosad in fat peaked 3 to 7 days after treatment and 1 to 3 days after treatment in liver and kidney.

CONCLUSION

These studies present a realistic worst-case in struck sheep and at the highest dose studied, equivalent to 5.8 mg spinosad per kg body weight, the maximum residue detected of 0.2 mg/kg in peri-renal fat was 20% of the Australian maximum residue limit. Muscle, liver and kidney residues of spinosad were also below the Australian maximum residue limits at all times.