Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis.

OBJECTIVES: To compare acute nystagmus characteristics of posterior circulation stroke (PCS) and acute vestibular neuritis (AVN) in the emergency room (ER) within 24 h of presentation. METHODS: ER-based video-nystagmography (VNG) was conducted, recording ictal nystagmus in 101 patients with PCS (on imaging) and 104 patients with AVN, diagnosed on accepted clinical and vestibular test criteria. RESULTS: Patients with stroke in the brainstem (38/101, affecting midbrain (n = 7), pons (n = 19), and medulla (n = 12)), cerebellum (31/101), both (15/101) or other locations (17/101) were recruited. Common PCS territories included posterior-inferior-cerebellar-artery (41/101), pontine perforators (18/101), multiple-territories (17/101) and anterior-inferior-cerebellar-artery (7/101). In PCS, 44/101 patients had no spontaneous nystagmus. Remaining PCS patients had primary position horizontal (44/101), vertical (8/101) and torsional (5/101) nystagmus. Horizontal nystagmus was 50% ipsiversive and 50% contraversive in lateralised PCS. Most PCS patients with horizontal nystagmus (28/44) had unidirectional "peripheral-appearing" nystagmus. 32/101 of PCS patients had gaze-evoked nystagmus. AVN affected the superior, inferior or both divisions of the vestibular nerve in 55/104, 4/104 and 45/104. Most (102/104) had primary position horizontal nystagmus; none had gaze-evoked nystagmus. Two inferior VN patients had contraversive torsional-downbeat nystagmus. Horizontal nystagmus with SPV ≥ 5.8 °/s separated AVN from PCS with sensitivity and specificity of 91.2% and 83.0%. Absent nystagmus, gaze-evoked nystagmus, and vertical-torsional nystagmus were highly specific for PCS (100%, 100% and 98.1%). CONCLUSION: Nystagmus is often absent in PCS and always present in AVN. Unidirectional 'peripheral-appearing' horizontal nystagmus can be seen in PCS. ER-based VNG nystagmus assessment could provide useful diagnostic information when separating PCS from AVN.

Frequency of leukochimerism in Holstein and Jersey twinsets.

The current study was conducted to test breed difference in the frequency of leukochimerism. This study used leukochimerism as evidence of placental vascular anastomosis formation and compared its frequency in the Holstein and Jersey breeds. We test the null hypothesis that there is no difference in incidence of leukochimerism in the Holstein and Jersey breeds. Hair and blood samples were collected from 85 Jersey twinsets and 80 Holstein twinsets, ranging in age from 1 d to 8 yr. An additional 7 Holstein twinsets (6 complete and 1 partial where 1 twin died) were sampled originally 48 to 72 h after birth and resampled at 5 to 10 mo of age to provide an assessment of whether leukochimerism changed with age. DNA was extracted from white blood cells (potentially chimeric) and hair follicles (not chimeric). DNA samples were successfully genotyped for 19 SNP selected for high minor allele frequency in both breeds based on previous bovine 50K genotyping. The genotyping assays provided quantitative data that was used to assess chimerism in blood-derived DNA. Monozygotic twins, as a percentage of all twin births, were 3.5 and 9.1% for the Jersey and Holstein breeds, respectively. Jersey and Holstein breeds did not differ in proportion of nonchimeric twinsets at 20.1 and 15.7%, respectively ( > 0.05), providing no evidence for genetic variation in anastomosis. The degree of chimerism for members of a twinset was also evaluated with regard to representation of self vs. co-twin in the blood-derived DNA. For twinsets where the more chimeric twin was 45% or greater co-twin in its blood-derived DNA, there was a strong inverse relationship ( < 0.001) between percent co-twin in the blood-derived DNA of members of a twinset. For twinsets where the more chimeric twin was less than 45% co-twin, there was no significant relationship between the degrees of chimerism in members of the twinset. These results suggest that variation in chimerism in members of a twinset may be a function of degree of anastomosis and differences in timing of the migration of hematopoietic stem cells between members of the twinset.

Some preliminary observations on the susceptibility and resistance of different cattle breeds to Theileria parva infection.

Theileria parva-naïve Friesian (Bos taurus), Boran (Bos indicus) and Maasai Zebu steers (B. indicus) were infected with a T. parva sporozoite stabilate dose which had previously been shown to induce an estimated 50% mortality rate in Boran cattle. All the cattle developed patent infections with no significant differences in the length of the prepatent period to development of macroschizonts (P > 0.05) between the three groups. Clinical theileriosis occurred in all eight the Friesians (100%), five out of nine Borans (55.6%) and two out of five Zebus (40%). Three of the Friesians (37.5%), and two of the Borans (22.2%) died of theileriosis. The different cattle types were equally susceptible to the infective dose used as indicated by the length of the prepatent periods, but there was a marked difference in their development of clinical theileriosis. The gradation in resistance to disease confirms the findings of earlier less critical studies and identifies these cattle breeds as suitable for investigations into the mechanisms of resistance to theileriosis.

Survival of Theileria parva-infected adult Rhipicephalus appendiculatus under laboratory and quasi-natural conditions.

Adult Rhipicephalus appendiculatus Muguga, having high or low intensities of Theileria parva Muguga infection in their salivary glands, were exposed to 20 degrees C and 85% relative humidity in the laboratory or quasi-natural conditions. Survival of the ticks and T. parva infections in their salivary glands was then monitored over a two year period. Ticks, having an average infection level of 2 infected acini per female, survived for up to 70 or 106 weeks after moulting under the laboratory or quasi-natural conditions respectively. Those having an infection level of 26 infected acini per female, survived for a similar duration except that those under quasi-natural conditions survived for a slightly shorter duration (102 weeks). Similarly, T. parva parasites survived for much longer periods under quasi-natural conditions than under the laboratory conditions. They survived for up to 38 or 78 weeks post salivary gland infection under the laboratory or quasi-natural conditions respectively in both categories of infection levels. There was apparently a density dependent relationship in T. parva survival, with a dramatic fall in infection occurring in ticks with high levels of infection between weeks 10 and 18 or weeks 38 and 46 post salivary gland infection in those exposed to laboratory or quasi-natural conditions before levelling off.

Survival of Theileria parva in its nymphal tick vector, Rhipicephalus appendiculatus, under laboratory and quasi natural conditions.

Groups of nymphal Rhipicephalus appendiculatus Muguga, having a mean of 1 or 9 Theileria parva Muguga-infected salivary gland acini per tick, were kept under quasi-natural conditions at an altitude of 1950 m or 20 degrees C at a relative humidity of 85% in the laboratory and their survival and infection prevalence and abundance determined over time. Theileria parva infections for both categories of ticks survived in the nymphal ticks for 50 or 26 weeks post salivary gland infection under quasi-natural or laboratory conditions respectively. There was a distinct decline in infections in the more heavily infected nymphae under both conditions of exposure, reflecting an apparent density dependence in parasite survival. Nymphal ticks having an average infection level of 1 infected salivary gland acinus per tick, survived for up to 69 or 65 weeks post-repletion under quasi-natural or the laboratory conditions respectively. Nymphae having an average infection level of 9 infected salivary gland acini per tick survived for a similar duration under each of the 2 conditions. The infection level of 9 infected salivary gland acini per tick did not seem to significantly affect the survival of the tick vector compared to those having an average of 1 infected salivary gland acinus per tick.

The accuracy of medical record documentation in schizophrenia.

Medical records are commonly used to measure quality of care. However, little is known about how accurately they reflect patients' clinical condition. Even less is understood about what influences the accuracy of provider's documentation and whether patient characteristics impact documentation habits. Discrepancies between symptoms and side effects evaluated by direct assessment and medical records were examined for 224 patients with schizophrenia at two public mental health clinics. Multivariate regression was used to study the relationship between patient, provider, and treatment characteristics and documentation accuracy. Overall, documentation of symptoms and side effects was frequently absent. Documentation varied substantially between clinics, and it was generally less likely for patients who were severely ill, black, or perceived as noncompliant. The accuracy and consistency of medical record documentation should be demonstrated before using it to evaluate care at public mental health clinics.

Managed care in the public sector: lessons learned from the Los Angeles PARTNERS program.

PARTNERS is the Los Angeles County Department of Mental Health's capitated managed care treatment program. To explore the context in which public sector managed care reforms are occurring and to understand the obstacles to implementing such programs, qualitative data were collected from administrators, case managers, and clients. Administrators were found to need assistance in negotiating managed care contracts and in tracking costs. Case managers, although concerned about increased clinical demands, enjoyed the flexibility and creativity their new roles allowed. Clients were satisfied with their increased independence, even though many had to change their site of care. Beyond considering these concerns, the range of community stakeholders who may be affected by such interventions must be addressed.

The quality of care for depressive and anxiety disorders in the United States.

BACKGROUND: Depressive and anxiety disorders are prevalent and cause substantial morbidity. While effective treatments exist, little is known about the quality of care for these disorders nationally. We estimated the rate of appropriate treatment among the US population with these disorders, and the effect of insurance, provider type, and individual characteristics on receipt of appropriate care. METHODS: Data are from a cross-sectional telephone survey conducted during 1997 and 1998 with a national sample. Respondents consisted of 1636 adults with a probable 12-month depressive or anxiety disorder as determined by brief diagnostic interview. Appropriate treatment was defined as present if the respondent had used medication or counseling that was consistent with treatment guidelines. RESULTS: During a 1-year period, 83% of adults with a probable depressive or anxiety disorder saw a health care provider (95% confidence interval [CI], 81%-85%) and 30% received some appropriate treatment (95% CI, 28%-33%). Most visited primary care providers only. Appropriate care was received by 19% in this group (95% CI, 16%-23%) and by 90% of individuals visiting mental health specialists (95% CI, 85%-94%). Appropriate treatment was less likely for men and those who were black, less educated, or younger than 30 or older than 59 years (range, 19-97 years). Insurance and income had no effect on receipt of appropriate care. CONCLUSIONS: It is possible to evaluate mental health care quality on a national basis. Most adults with a probable depressive or anxiety disorder do not receive appropriate care for their disorder. While this holds across diverse groups, appropriate care is less common in certain demographic subgroups.

Mental disorders and the use of alternative medicine: results from a national survey.

OBJECTIVE: The study examined the relationship between mental disorders and the use of complementary and alternative medicine. METHOD: Data from a national household telephone survey conducted in 1997-1998 (N=9,585) were used to examine the relationships between use of complementary and alternative medicine during the past 12 months and several demographic variables and indicators of mental disorders. Structured diagnostic screening interviews were used to establish diagnoses of probable mental disorders. RESULTS: Use of complementary and alternative medicine during the past 12 months was reported by 16.5% of the respondents. Of those respondents, 21.3% met diagnostic criteria for one or more mental disorders, compared to 12.8% of respondents who did not report use of alternative medicine. Individuals with panic disorder and major depression were significantly more likely to use alternative medicine than those without those disorders. Respondents with mental disorders who reported use of alternative medicine were as likely to use conventional mental health services as respondents with mental disorders who did not use alternative medicine. CONCLUSIONS: We found relatively high rates of use of complementary and alternative medicine among respondents who met criteria for common mental disorders. Practitioners of alternative medicine should look for these disorders in their patients, and conventional medical providers should ask their depressed and anxious patients about the use of alternative medicine. More research is needed to determine if individuals with mental disorders use alternative medicine because conventional medical care does not meet their health care needs.

Identifying clinical competencies that support rehabilitation and empowerment in individuals with severe mental illness.

Individuals with severe mental illness often do not receive appropriate treatment or rehabilitation. One approach to improving their care begins by identifying competencies that clinicians should possess. This project developed a set of core clinical competencies that pertain to community-based care and support the goals of empowerment and rehabilitation. Development of the competency set began with review of existing literature and competency statements, and focus groups and interviews with clients, family members, clinicians, managers, experts, and advocates. Representatives from each of these groups participated in a national panel and used a structured process to identify 37 final competencies. Panel members agreed that these competencies are very important in determining outcomes and often are not present in current clinicians. This project demonstrates that it is possible to develop a core competency set that can be strongly supported by diverse groups of stakeholders. These competencies may be useful in clinician training, recruitment, and credentialing efforts.

Routine outcome monitoring in a public mental health system: the impact of patients who leave care.

OBJECTIVE: An interest exists in using patient outcome data to evaluate the performance of publicly financed mental health organizations. Because patients leave these organizations at a high rate, the impact of patient attrition on routinely collected outcome data was examined. METHODS: In one county mental health system, routinely collected data on a wide range of outcomes were examined, and a random sample of patients who left treatment was interviewed. RESULTS: Of the 1,769 patients in ongoing treatment during a one-year period, 554 (31 percent) were lost to follow-up. Among a random sample of 102 patients who left treatment, two had died and 47 were interviewed. Compared with patients who left treatment, patients who stayed were older, more likely to have schizophrenia, less likely to be married, more likely to be living in an institution, more satisfied with their relationships with friends and family, and less likely to have legal problems. Average outcomes improved both for patients who stayed and for patients who left. Patients who left and could be located for follow-up were less severely ill and showed the greatest improvement and the best outcomes. Patients who left and could not be located may have been more severely ill at baseline. CONCLUSIONS: Outcomes appear to vary substantially by whether patients stay in care and whether they can be located after leaving care. Public mental health systems that wish to evaluate treatment quality using outcome data should attend carefully to which patients are being assessed. Biases can result from convenience sampling and from patients leaving care.

The economic impact of capitated care for high utilizers of public mental health services: the Los Angeles PARTNERS program experience.

Los Angeles PARTNERS, or "people achieving rehabilitation together need empowering respectful support," is a treatment program that uses capitation to shift risk for treatment costs of high utilizers of public mental health services to private community-based treatment organizations. This analysis reveals two important findings from PARTNERS. First, the economic incentives created by capitation contributed to the dis-enrollment of PARTNERS clients; furthermore, factors such as not speaking English or Spanish or having schizophrenia increased the probability of dis-enrollment. Second, analyses of health costs for enrollees in the PARTNERS capitation program suggest that the program did not result in a change in total costs. However, the program increased the use of community-based care and increased treatment costs for clients with lower preprogram costs but decreased costs for the clients with high preprogram costs. These results suggest that future capitation programs for this severely ill population would benefit from using detailed clinical information to determine program eligibility and to set risk-adjusted capitation rates.

Performance of a general location model with an ignorable missing-data assumption in a multivariate mental health services study.

In a study of the impact of case management teams in a publicly funded mental health programme, mental health patients were interviewed about a variety of outcomes suggestive of successful community adaptation, such as support from family and friends and avoidance of legal problems. Because outcome data were missing for a number of patients, a follow-up study was carried out to obtain this information form previous non-responders whenever possible. Because the data of interest were multivariate and included both continuous and categorical variables, a candidate approach for handling incomplete data in the absence of follow-up data would have been to fit a general location model, presumably with log-linear constraints on cell probabilities to avoid overfitting of the data. Here, we use available follow-up data to investigate the performance of a series of general location models with ignorable non-response. We note some problems with this approach and embed the discussion of this example in a broader consideration of the role of ignorable and non-ignorable models in applied research.

The design of Healthcare for Communities: a study of health care delivery for alcohol, drug abuse, and mental health conditions.

There is a shortage of data to inform policy debates about the quickly changing health care system. This paper describes Healthcare for Communities (HCC), a component of the Robert Wood Johnson Foundation's Health Tracking Initiative that was designed to fill this gap for alcohol, drug abuse, and mental health care. HCC bridges clinical perspectives and economic/policy research approaches, links data at market, service delivery, and individual levels, and features a household survey of nearly 9,600 individuals with an employer follow-back survey. Public use files will be available in late 1999.

HIV and people with serious mental illness: the public sector's role in reducing HIV risk and improving care.

OBJECTIVE: The paper discusses issues related to the detection, prevention of transmission, and treatment of human immunodeficiency virus (HIV) infection among persons with serious mental illness and suggests ways public mental health systems can address these issues. METHODS: MEDLINE was searched from 1980 through 1998, and all pertinent references were reviewed. RESULTS: Persons with severe mental illness are at greatly increased risk of HIV infection due to increased likelihood of high-risk sexual behaviors and injection drug use. The formidable barriers to detection and effective treatment of HIV that exist in this population can be attributed to the unique characteristics of this population, lack of knowledge and expertise among mental and physical health care providers, and fragmented mental and physical health care systems. CONCLUSIONS: In the last five years, treatments for HIV that are far more efficacious than earlier treatments have become available, making it more important for HIV infection be detected and treated among persons with serious mental illness. Public mental health systems need to implement active prevention policies and practices, educate both mental health and physical health care providers about key treatment issues, and develop effective linkages between mental and physical health care providers and systems.

Patient, provider, and treatment factors associated with poor-quality care for schizophrenia.

Interventions are needed to improve the quality of care for schizophrenia. However, in designing these interventions it would be helpful to understand better which patients are at highest risk for poor-quality care and why care for this disorder is often of poor quality. We study the extent to which patient and treatment factors are associated with poor-quality care in 224 patients randomly sampled from two mental health clinics. Quality of medication management is evaluated using an established method based on national treatment recommendations. Multivariate regression is used to study the effect of patient and treatment factors on treatment quality, controlling for provider. Risk for poor-quality care was greater for patients who were more severely ill, older, and less compliant with treatment recommendations. There were trends toward poor management of symptoms in men and substance abusers, and poor management of side effects in Black patients. Provision of poor-quality care was associated with failure to document symptoms and side effects in the medical record. Interventions to improve care for schizophrenia should attend to the need for accurate clinical assessment and strategies for managing challenging clinical situations.

The effect of provider characteristics on case management activities.

The authors investigated the impact of provider characteristics on the performance of clinical case managers. Case managers in a large California county were interviewed using a structured instrument that assessed service linkage, assertive outreach, and family management. Findings indicate that assertive outreach was done more often by more experienced case managers, and less often by those with larger caseloads. Belief in the efficacy of an activity was associated with doing it much more frequently.

Suicidal ideation and suicide attempts in recent-onset schizophrenia.

The objective of this study was to predict suicidality in people with schizophrenia. Ninety-six patients with recent-onset schizophrenia were rated every 2 weeks for 1 year to examine (1) the temporal course of suicidal ideation and suicide attempts and (2) the extent to which anxiety, depression, and mild suicidal ideation were followed by significant suicidal ideation or a suicide attempt. The severity of suicidality changed rapidly. Low levels of suicidal ideation increased the risk for significant suicidal ideation or a suicide attempt during the subsequent 3 months. Depression was moderately correlated with concurrent suicidality, but not independently associated with future suicidality. Therefore, low levels of suicidal ideation may predict future suicidal ideation or behavior better than depressed mood in individuals with schizophrenia.