Evaluation of rayon swab surface sample collection method for Bacillus spores from nonporous surfaces.

AIM: To evaluate US Centers for Disease Control and Prevention recommended swab surface sample collection method for recovery efficiency and limit of detection for powdered Bacillus spores from nonporous surfaces. METHODS AND RESULTS: Stainless steel and painted wallboard surface coupons were seeded with dry aerosolized Bacillus atrophaeus spores and surface concentrations determined. The observed mean rayon swab recovery efficiency from stainless steel was 0.41 with a standard deviation (SD) of +/-0.17 and for painted wallboard was 0.41 with an SD of +/-0.23. Evaluation of a sonication extraction method for the rayon swabs produced a mean extraction efficiency of 0.76 with an SD of +/-0.12. Swab recovery quantitative limits of detection were estimated at 25 colony forming units (CFU) per sample area for both stainless steel and painted wallboard. CONCLUSIONS: The swab sample collection method may be appropriate for small area sampling (10 -25 cm2) with a high agent concentration, but has limited value for large surface areas with a low agent concentration. The results of this study provide information necessary for the interpretation of swab environmental sample collection data, that is, positive swab samples are indicative of high surface concentrations and may imply a potential for exposure, whereas negative swab samples do not assure that organisms are absent from the surfaces sampled and may not assure the absence of the potential for exposure. SIGNIFICANCE AND IMPACT OF THE STUDY: It is critical from a public health perspective that the information obtained is accurate and reproducible. The consequence of an inappropriate public health response founded on information gathered using an ineffective or unreliable sample collection method has the potential for undesired social and economic impact.

Identifying highly effective psychotherapists in a managed care environment.

OBJECTIVE: To investigate the variability and stability of psychotherapists' effectiveness and the implications of this differential effectiveness for quality improvement in a managed care environment. STUDY DESIGN: Subset archival outcome data for patients receiving behavioral health treatment were divided into 2 time periods to cross-validate the treating therapists' effectiveness. After categorizing the therapists as "highly effective" and "others" during the baseline period, the stability of their individual effectiveness was cross-validated in the remaining time period. METHODS: Outcomes for 10 812 patients (76.0% adults, 24.0% children and adolescents) treated by 281 therapists were included. Patients initiated treatment between January 1999 and June 2004. Mean residual change scores obtained by multiple regression were used to adjust for differences in case mix among therapists. Raw change scores as well as mean residualized change scores were compared between the 71 psychotherapists identified as highly effective (25%) and those identified as other (remaining 75%). RESULTS: During the cross-validation period, mean differences in residualized change score between highly effective therapists and others were statistically significant (difference = 2.8; P < .001), which corresponded to an average of 53.3% more change in raw change scores with the highly effective therapists. Results could not be explained by case mix differences in diagnosis, age, sex, intake scores, prior outpatient treatment history, length of treatment, or therapist training/experience. CONCLUSION: Behavioral health outcomes for a large system of care could be significantly improved by measuring clinical outcomes and referring patients to therapists with superior outcomes.

Using self-report to improve substance abuse risk assessment in behavioral health care.

BACKGROUND: Primary care and behavioral health clinicians frequently fail to detect substance-related problems among their patients, thereby leading to increased morbidity and mortality and health care costs. A managed behavioral health care organization(MBHO) conducted a quality improvement initiative in which clients seeking outpatient psychotherapy were screened by self-report for substance-related problems, and clinicians were provided with feedback in cases of discrepant findings. METHOD: Client self-report questionnaires, which included items inquiring regarding problems related to substance abuse, were administered at multiple points during treatment episodes. Clinicians were also asked to complete assessments, including indicating the presence of a substance abuse problem. RESULTS: Clinicians failed to identify substance abuse problems in > 80% of the cases where the patient endorsed items clearly related to substance abuse on the outcome questionnaire. In the quality improvement intervention, the MBHO sent letters alerting clinicians to the clients' self-reported substance abuse problems. The concordance between clinician assessment and client self-reported problems then increased significantly. DISCUSSION: Results of the study argue for the utility of using client self-report measures as part of a comprehensive effort to measure and improve the effectiveness of behavioral health care treatment services.

Permanganate oxidation of sorbed polycyclic aromatic hydrocarbons.

The polycyclic aromatic hydrocarbons (PAH) that contaminate soils at many industrial and government sites are resistant to natural biotic and abiotic degradation processes. The recalcitrant nature of these compounds may require aggressive chemical treatment to effectively remediate these sites. This study was conducted to assess the viability of permanganate oxidative treatment as a method to reduce PAH concentration in contaminated soils. Study results demonstrated a reduction in soil sorbed concentration for a mixture of six PAHs that included anthracene, benzo(a)pyrene, chrysene, fluoranthene, phenanthrene, and pyrene by potassium permanganate (KMnO4) oxidative treatment. The greatest reduction in soil concentration was observed for benzo(a)pyrene, pyrene, phenanthrene, and anthracene at 72.1, 64.2, 56.2, and 53.8%, respectively, in 30 min at a KMnO4 concentration of 160 mM. Minimal reductions in fluoranthene and chrysene concentration were observed at 13.4 and 7.8%, respectively, under the same conditions. A relative chemical reactivity order of benzo(a)pyrene>pyrene>phenanthrene>anthracene>fluoranthene>chrysene towards permanganate ion was observed. Aromatic sextet theory was applied to the degradation results to explain the highly variable and compound-specific chemical reactivity order.

Improving suicide risk assessment in a managed-care environment.

This article describes the quality improvement intervention of a managed behavioral healthcare company to improve the quality of suicide risk assessments by its panel of providers. At-risk cases are identified by the patient's self-reported high frequency of suicidal ideation on a standardized outcome measure. Clinicians also assess severity of suicidal ideation based on clinical interviews. The clinician's assessment is identified as probably erroneous if the patient report indicates a high frequency of suicidal ideation and the clinicians assessment of suicidal ideation is none. The article describes the methods used to encourage clinicians to utilize information from the patient self-report measure as part of the clinical assessment. Probable suicidal ideation assessment errors were subsequently reduced by 29% over a 1-year period of administration.

Understanding patterns of genetic diversity in the oak gallwasp Biorhiza pallida: demographic history or a Wolbachia selective sweep?

The endosymbiont Wolbachia can be responsible for selective sweeps on mitochondrial DNA variability within species. Similar signals can also result from demographic processes, although crucially the latter affect nuclear as well as mitochondrial loci. Here we present data on Wolbachia infection status and phylogeographic patterning for a widely distributed insect host, the oak gallwasp Biorhiza pallida (Hymenoptera: Cynipidae). Two hundred and eighteen females from eight European countries were screened for Wolbachia. All individuals from Hungary, Italy, France, U.K., Ireland, Switzerland, Sweden, and northern and southern Spain were infected with a single group A strain of Wolbachia, while populations in central Spain were not infected. A mitochondrial marker (cytochrome b) shows low variation and departure from neutrality in infected populations, but greater variation and no deviation from neutrality in Wolbachia-free populations. This pattern is compatible with a Wolbachia-induced selective sweep. However, we also find parallel differences between infected and uninfected populations for nuclear markers (sequence data for ITS1 and ITS2). All markers support the existence of a deep split between populations in Spain (some free of Wolbachia), and those in the rest of Europe (all infected). Allelic variation for five allozyme loci is also consistent with the Spain-rest of Europe split. Concordant patterns for nuclear and mitochondrial markers suggest that differences in the nature and extent of genetic diversity between these two regions are best explained by differing demographic histories (perhaps associated with range expansion from Pleistocene glacial refugia), rather than a Wolbachia-associated selective sweep.

Pushing the quality envelope: a new outcomes management system.

This article is based on the authors' experience in designing and implementing outcomes management systems for large managed care organizations. Topics addressed include design of instruments, use of cost-effective technology, development of computerized decision-support tools, and methods for case-mix adjustment. The case-mix-adjustment models are based on a data repository of several thousand treatment cases with multiple measurement points across the course of treatment. Data from controlled and field studies are described. These data suggest that the outcomes management methods outlined in this article can result in significantly improved clinical outcomes and a more rational allocation of behavioral health care resources.

Reporting outcomes for stage IV pressure ulcer healing: a proposal.

OBJECTIVES: To calculate the average daily healing rate for Stage IV pressure ulcers. To create and analyze wound healing curves. DESIGN: Retrospective analysis of healing rates of Stage IV pressure ulcers. SETTING: Veterans Affairs Transitional Care Unit at the VA North Texas Health Care System. PARTICIPANTS: Nine residents with pelvic Stage IV pressure ulcers that were fully healed. INTERVENTIONS: A sodium chloride-impregnated gauze or calcium alginate was the primary dressing, followed by a hydrocolloid or foam dressing. Eschar was removed by sharp, mechanical debridement, and fibrous necrotic tissue was removed with wet-to-dry dressings. MAIN OUTCOME MEASURES: Wounds were measured weekly using linear length and width in centimeters; measurements were multiplied to obtain wound area. The end of treatment was considered to be full epithelialization of the wound. RESULTS: Wound area reduction in square centimeters per day generally increased as initial wound area increased. However, the reduction in pressure ulcer area did not occur at a strict linear rate. The wound healing curves demonstrated the granulation, contraction, and epithelialization phases of wound healing. CONCLUSIONS: Calculation of an average daily healing rate is a useful method for determining pressure ulcer healing outcomes. Averaging together wound healing curves would enable health care providers to more accurately predict future healing times and quickly assess delays in healing. A standardized method for reporting healing rates would also help establish a baseline rate of pressure ulcer healing.

Extraterrestrial handedness: a reply.

Recent investigations of stable isotope ratios of amino acids from the Murchison meteorite have shown them to be of unambiguous extraterrestrial origin, and examinations of their enantiomeric compositions, where terrestrial contamination can be excluded, have found a consistent excess of L-enantiomers. One explanation for this observation has been the asymmetric photolysis of racemic extraterrestrial amino acids by circularly polarized light (CPL) in the synchrotron radiation from orbiting electrons around the pulsar remnants of supernovae. Mason (1997) has attempted to discredit this mechanism on the grounds that circular dichroism (CD) bands for optically active molecules alternate in sign and sum to zero over the entire spectrum, and hence enantioselective photochemical reactions cannot be induced by broad band CPL. We submit arguments disputing this conclusion and present reasons for expecting that broad band CPL synchrotron radiation would be quite capable of inducing asymmetric photolysis, particularly in aliphatic amino acids.

Hypopharyngeal cancer patient care evaluation.

A survey was conducted to identify demographics and standards of care for treatment of hypopharyngeal squamous cell carcinoma in the United States. Data were accrued from voluntary submission of cancer registry and medical chart information from 769 hospitals representing 2939 cases diagnosed from 1980 to 1985 and 1990 to 1992. Clinical findings, diagnostic procedures employed, treatment practices, and outcome are presented. Overall, 5-year disease-specific survival was 33.4%, which segregated to 63.1% (stage I), 57.5% (stage II), 41.8% (stage III), and 22% (stage IV). Survival was best for patients treated with surgery only (50.4%), similar with combined surgery and irradiation (48%), and worse with irradiation only (25.8%). This analysis provides a standard to which current treatment practice and future clinical trials may be compared.

Patterns of care for cancer of the larynx in the United States.

OBJECTIVE: To assess case-mix characteristics, treatment patterns, and outcomes for laryngeal cancer using the largest series of patients to date. DESIGN: Analyses performed on retrospectively collected survey data submitted by hospitals for diagnostic periods 1980 through 1985 and 1990 through 1992 (with a 9-year follow-up for the long-term group). SETTING: Broad spectrum of US hospitals (N = 769). PATIENTS: Consecutively accrued series of patients with laryngeal cancer (N = 16,936), with only squamous cell carcinomas (N = 16,213) analyzed. INTERVENTIONS: Surgery, radiation therapy, and chemotherapy. MAIN OUTCOME MEASURES: Descriptive analyses of case-mix, diagnostic, and treatment characteristics plus recurrence and 5-year, disease-specific survival outcomes. RESULTS: There was a slight increase across these years in stage IV disease and in radiation therapy (with or without surgery and/or chemotherapy). Overall diversity of management of this disease (by site and stage) was apparent. Five-year survival rates indicated a large difference between modified groupings of the T and N classifications, separating stages III and IV cases into localized disease (87.5% for T1-T2; 76.0% for T3-T4 cases) and regional metastasis (46.2%). CONCLUSIONS: Regardless of improvements in entering data in hospital records (most commendably, staging), more rigorous standards are needed. Also, the small increase in advanced-stage patients indicates that efforts toward early detection have not been successful. The rise in radiation therapy perhaps reflected an increased use of nonsurgical treatment for early-stage patients and organ-sparing radiochemotherapy protocols for advanced-stage patients. Regrouping stages III and IV cases into localized disease vs regional metastasis appears to predict survival better. Ongoing refinements of the American Joint Committee on Cancer staging scheme will hopefully improve this cancer's classification.

Hematopoietic augmentation by a beta-(1,4)-linked mannan.

CARN 750 (injectable acemannan) is a polydispersed beta-(1,4)-linked acetylated mannan isolated from the Aloe barbadensis plant. It has multiple therapeutic properties including activity in wound repair and as a biological agent for the treatment of neoplasia in animals as well as the ability to activate macrophages. We report herein that CARN 750 directly or indirectly has significant hematoaugmenting properties. We observed that the subcutaneous administration of CARN 750 significantly increases splenic and peripheral blood cellularity, as well as hematopoietic progenitors in the spleen and bone marrow as determined by the interleukin-3-responsive colony-forming unit culture assay and the high-proliferative-potential colony-forming-cell (HPP-CFC) assay (a measure of primitive hematopoietic precursors) in myelosuppressed (7 Gy) C57BL/6 mice. The greatest hematopoietic effect was observed following sublethal irradiation in mice receiving 1 mg CARN 750/ animal, with less activity observed at higher or lower doses. Further, CARN 750, following daily injection, has activity equal to or greater than the injection of an optimal dose of granulocyte-colony-stimulating factor (G-CSF) in myelosuppressed mice. In this comparison, significantly greater activity was observed in the splenic and peripheral blood cellularity, and in the frequency and absolute number of splenic HPP-CFC as compared to the mice receiving G-CSF at 3 micrograms/animal. CARN 750, when administered to myelosuppressed animals, decreased the frequency of lymphocytes with a concomitant significant increase in the frequency of polymorphonuclear leukocytes (PMN). However, owing to the increased cellularity, a significant increase in the absolute number of PMN, lymphocytes, monocytes and platelets was observed, suggesting activity on multiple cell lineages. The latter is the primary difference in activity as compared to G-CSF which has activity predominantly on PMN.

In vivo haemoprotective activity of tetrapeptide AcSDKP combined with granulocyte-colony stimulating factor following sublethal irradiation.

We report that acetyl-N-Ser-Asp-Lys-Pro (AcSDKP), which removes progenitor cells from cell cycle, in combination with granulocyte-colony stimulating factor (G-CSF) can significantly improve myelorestoration following irradiation (7 Gy). Peripheral blood, spleen and bone marrow (BM) cell recovery and progenitor cell reconstitution [IL-3-responsive colony-forming cells (CFC) and high proliferative potential colony-forming cells (HPP-CFC)] were studied. Studies on the optimal schedule of AcSDKP administration revealed maximal effects on progenitor cells when AcSDKP was administered as a continuous infusion for 3 d starting 24 h prior to irradiation and used in combination with G-CSF. The numbers of CFC and HPP-CFC in the BM were significantly increased following irradiation in mice receiving AcSDKP and G-CSF as compared to either drug alone. The numbers of CFC in the spleen were significantly increased in mice receiving AcSDKP and G-CSF on days 10 and 14 as compared to AcSDKP alone, but not G-CSF. Similarly, CFC and HPP-CFC in the spleen were significantly increased in mice receiving AcSDKP and G-CSF on day 18 as compared to mice receiving PBS and G-CSF. These studies suggest that AcSDKP in combination with G-CSF may have potential for the protection of progenitor cells in patients undergoing intensive chemo- and/or radiotherapy.

In vivo protective effects of tetrapeptide AcSDKP, with or without granulocyte colony-stimulation factor, on murine progenitor cells after sublethal irradiation.

Acetyl-N-Ser-Asp-Lys-Pro (AcSDKP) demonstrated hemato-protective activity in mice after sublethal irradiation (7 GY). Bone marrow interleukin-3 (IL-3)-responsive colony-forming cells (CFC and high proliferative potential colony-forming cells (HPP-CFC) were significantly (p < 0.05) increased by day 10 after irradiation in mice receiving a continuous infusion of 1000 ng/day of AcSDKP compared to irradiated control mice. The maximum protective effect for bone marrow progenitors was achieved when AcSDKP was administered for 3 days beginning 24 hours before irradiation. Other dosages and schedules in relationship to irradiation were less active. Further, when granulocyte colony-stimulating factor (G-CSF) was administered for 10 days beginning 24 hours before irradiation. Other dosages and schedules in relationship to irradiation were less active. Further, when granulocyte colony-stimulating factor (G-CSF) was administered for 10 days after AcSDKP infusion in irradiated mice, significantly increased numbers of IL-3 responsive CSF-only control mice. In addition, platelets were significantly (p < 0.05) increased in mice receiving AcSDKP and G-CSF on days 18 and 21 after irradiation compared with mice receiving G-CSF alone. We conclude that ACSDKP has a radioprotective effect in vivo for progenitor cells, and that time of initiation and duration of AcSDKP administration relative to irradiation are crucial for these effects. Further, AcSDKP has a significant additive protective effect not only for progenitor cells but also for platelets when given in combination with G-CSF. We suggest that these in vivo observations provide a basis on which to design optimal clinical hypothesis and protocols.

Studies on optimal dose and administration schedule of a hematopoietic stimulatory beta-(1,4)-linked mannan.

Several complex carbohydrates have been found to significantly stimulate hematopoiesis. CARN 750, a polydispersed beta-(1,4)-linked acetylated mannan isolated from the Aloe vera plant, has been shown to have activity in wound repair, to function as a antineoplastic, and to activate macrophages. We report, herein, the hematoaugmenting properties of CARN 750 and its optimal dose and timing of administration in an animal model of irradiation-induced myelosuppression. We observed that subcutaneous injections of 1 mg/animal of CARN 750 had equal or greater stimulatory activity for white blood cell (WBC) counts and spleen cellularity as well as on the absolute numbers of neutrophils, lymphocytes, monocytes and platelets than did higher or lower doses of CARN 750 or an optimal dose of granulocyte-colony stimulating factor (G-CSF). Hematopoietic progenitors, measured as interleukin-3-supported colony forming units-culture (CFU-C) and high proliferative potential colony-forming cells (HPP-CFC) assays, were similarly increased by CARN 750 in the spleen but not in the bone marrow. The frequency of splenic HPP-CFCs and absolute number of splenic HPP-CFCs and CFU-Cs were optimally increased by 1 mg/animal of CARN 750. In contrast, bone marrow cellularity, frequency and absolute number of HPP-CFCs and CFU-Cs had as a dosage optimum 2 mg/animal of CARN 750. These parameters were similarly increased by G-CSF. In studies to determine the optimal protocol for the administration of CARN 750 we found that the hematopoietic activity of CARN 750 increased with the frequency of administration. The greatest activity in myelosuppressed mice was observed for all hematopoietic parameters except the platelet number in mice receiving daily administration of 1 mg/animal of CARN 750 with activity equal to or greater than G-CSF.

Expert systems restructure managed care practice: implementation and ethics.

The development of computerized decision support technologies is having a profound impact on the management of patient care. This article describes different types of clinical decision support software, examines appropriate usage and current examples of implementation, and reviews a range of ethical considerations. The authors are in the midst of implementing a computerized decision support system for care management in their managed care organization.