Effectiveness and implementation of a multidisciplinary lifestyle focused approach in the treatment of inpatients with mental illness (MULTI +): a stepped wedge study protocol.

BACKGROUND: People with mental illness have a reduced life expectancy compared to the general population. Despite the increasing evidence for the efficacy of lifestyle interventions there is little change in routine clinical care. This discrepancy is often referred to as the implementation gap and has caused a need for effectiveness and implementation research in real-world settings. Our study assesses the effectiveness and implementation of a multidisciplinary lifestyle focused approach in the treatment of inpatients with mental illness (MULTI +). METHODS: An open cohort stepped wedge cluster randomized trial in inpatients psychiatric wards of GGz Centraal, the Netherlands. The wards are divided into three clusters based on geographical region. These clusters are randomly allocated to one of the three pre-defined steps to integrate MULTI + . MULTI + can be tailored to fit individual psychiatric wards and includes 10 core components aimed at improving lifestyle factors. The primary outcome is to investigate the difference in the mean QRISK3 score of patients receiving MULTI + compared to patients receiving TAU. Secondary outcomes include somatic and mental health outcomes, lifestyle factors, and implementation factors. Findings will be analysed using mixed model analyses. DISCUSSION: The MULTI + study is the first large-scale study evaluating the long-term effects of a multidisciplinary, multicomponent approach aimed at improving lifestyle factors in routine inpatient mental health care. A limitation of this study is the risk of missing data due to the large-scale, real-world setting of this study. Furthermore, implementation monitoring and external events that may influence outcomes could be difficult to account for. Strengths of this study are the focus on effectiveness as well as implementation and the inclusion of both patient and health care professionals' perspectives. Effectiveness studies in routine clinical care can advance our knowledge on lifestyle interventions in real-world settings. TRIAL REGISTRATION: ClinicalTrials.gov registration. Identifier: NCT04922749 . Retrospectively registered 3th of June 2021.

Inactivation rates of Cronobacter spp. and selected other bacterial strains in powdered infant formulae stored at different temperatures.

The aim of this study was to determine the survival of two strains of Cronobacter (Enterobacter sakazakii) and six other bacterial strains inoculated into dry powdered infant formula (PIF) stored for 22 weeks at several temperatures between 7 and 42 degrees C. The experimental setup involved a relatively high initial concentration of bacteria, around 10(4) CFU/g of powder, and enumeration of survivors with a minimum detection level of 100 CFU/g. For all strains tested, it was found that the number of bacterial cells decreased faster with increasing temperature. Cronobacter spp. cells generally survived better at high temperatures (37 and 42 degrees C) than the other bacteria, while such a difference in survival was not apparent at other temperatures. To describe the effect of temperature on survival, both the Weibull distribution model and the log-linear model were tested. At 22 degrees C, decline rates of 0.011 and 0.008 log units per day were found for Cronobacter sakazakii ATCC 29544 and Cronobacter strain MC10, respectively. Assuming a linear relationship between log-transformed D-values and temperature, z-values estimated for C. sakazakii ATCC 29544 and Cronobacter MC10 were 13.3 and 23.5 degrees C, respectively. Such differences found in resistance among Cronobacter spp. would be relevant to consider when establishing quantitative risk assessments on consumer risks related to PIF.

Effects of preculturing conditions on lag time and specific growth rate of Enterobacter sakazakii in reconstituted powdered infant formula.

Enterobacter sakazakii can be present, although in low levels, in dry powdered infant formulae, and it has been linked to cases of meningitis in neonates, especially those born prematurely. In order to prevent illness, product contamination at manufacture and during preparation, as well as growth after reconstitution, must be minimized by appropriate control measures. In this publication, several determinants of the growth of E. sakazakii in reconstituted infant formula are reported. The following key growth parameters were determined: lag time, specific growth rate, and maximum population density. Cells were harvested at different phases of growth and spiked into powdered infant formula. After reconstitution in sterile water, E. sakazakii was able to grow at temperatures between 8 and 47 degrees C. The estimated optimal growth temperature was 39.4 degrees C, whereas the optimal specific growth rate was 2.31 h(-1). The effect of temperature on the specific growth rate was described with two secondary growth models. The resulting minimum and maximum temperatures estimated with the secondary Rosso equation were 3.6 degrees C and 47.6 degrees C, respectively. The estimated lag time varied from 83.3 +/- 18.7 h at 10 degrees C to 1.73 +/- 0.43 h at 37 degrees C and could be described with the hyperbolic model and reciprocal square root relation. Cells harvested at different phases of growth did not exhibit significant differences in either specific growth rate or lag time. Strains did not have different lag times, and lag times were short given that the cells had spent several (3 to 10) days in dry powdered infant formula. The growth rates and lag times at various temperatures obtained in this study may help in calculations of the period for which reconstituted infant formula can be stored at a specific temperature without detrimental impact on health.

A new protocol for the detection of Enterobacter sakazakii applied to environmental samples.

Enterobacter sakazakii is a motile, peritrichous, gram-negative rod that was previously known as a yellow pigmented Enterobacter cloacae. It is documented as a rare cause of outbreaks and sporadic cases of life-threatening neonatal meningitis, necrotizing enterocolitis, and sepsis. E. sakazakii has been isolated from milk powder-based formulas, and there is thus a need to investigate whether and where E. sakazakii occurs in these manufacturing environments. For this purpose, a simple detection method was developed based on two features of E. sakazakii: its yellow pigmented colonies when grown on tryptone soy agar and its constitutive alpha-glucosidase, which is detected in a 4-h colorimetric assay. Using this screening method, E. sakazakii strains were isolated from three individual factories from 18 of 152 environmental samples, such as scrapings from dust, vacuum cleaner bags, and spilled product near equipment. The method is useful for routine screening of environmental samples for the presence of E. sakazakii.

Practical Approaches to Risk Assessment †.

The aim of microbiological risk assessment is to facilitate decision making at various levels of food safety management. At the personal level, the decision concerns what to eat and what not to eat. Knowledge concerning the potential risks of certain foods and the degree of satisfaction derived from eating a food are important criteria in making the decision. Food suppliers must make the decision for their customers or consumers. They will limit the risk that someone may get ill as much as possible. Hazard analysis and critical control point (HACCP) is the system of choice to produce or prepare safe food. During the elaboration of an HACCP plan, many decisions must be made, and risk assessment may be a useful tool in this process. Governments should use risk assessment to select risk management measures for both the internal market and the export market because the GATT/SPS agreement stipulates that standards used for food in international trade should be established on scientific principles and risk assessment. A practical approach to the risk assessment of Listeria monocytogenes is given as an example.

Standardisation of microbiological methods. The Salmonella example.

The results of studies carried out under the leadership of Prof. Kampelmacher to elaborate a reliable Salmonella isolation method are highlighted. The strategy which was successfully followed is summarised in a table. This strategy can also be applied in attempts at standardisation of other microbiological methods.

Malachite green pre-enrichment medium for improved salmonella isolation from heavily contaminated samples.

Large numbers of competitive bacteria may hinder the isolation of salmonellas from food and environmental samples when a pre-enrichment method is used. The addition of 0.1 g/l of malachite green (MG) to buffered peptone water (BPW) inhibited the multiplication of Gram-positive bacteria. Brilliant green had a similar effect but only when the normal recommended concentration of 0.02 g/l was raised to 0.05 g/l. Pure strains of salmonellas were inhibited by MG in BPW, but addition of non fat dried milk (NFDM) (5 g/l or more) counteracted this effect. MG did not affect the recovery of salmonellas injured by heat, freezing, low water activity or acidity in BPW with NFDM. It was concluded that addition of MG to BPW may improve the possibility of isolating salmonellas from heavily contaminated materials by limiting the competitive growth of Gram-positive bacteria and the subsequent lowering of the pH of the broth.

Collaborative study on the isolation of salmonella from artificially contaminated milk powder.

The suitability of artificially contaminated milk powder as a substrate for salmonella reference samples and its stability under different storage conditions were studied. The need for a reconstitution step in the standard isolation method for salmonellas from milk powders was also investigated. When milk powder was examined in this way with a reconstitution step, differences in laboratory methods and/or storage times had no significant effect on the results after storage at 4 degrees C. With powder stored at room temperature there was a systematic decrease in the number of samples positive as the storage time increased. It is concluded therefore that milk powder contaminated with salmonellas should be stored at 4 degrees C. Examination of such milk powder with a reconstitution step yielded better results than without it and this step is therefore necessary for improving the reproducibility of the method. No significant differences were encountered between the standard isolation method and that used in the authors' laboratories. The results of this study indicate that milk powder is suitable as basic material for reference samples and that a reconstitution step should be included in the standard salmonella isolation procedure.

Enterobacteriaceae as indicators of good manufacturing practices in rendering plants.

Finished products and samples from the environment of the production line in rendering plants were checked for Enterobacteriaceae and salmonellae. Improvements in hygiene and measures taken to limit multiplication of microorganisms in the dry area of the production lines resulted in reduction of both numbers of Enterobacteriaceae in environmental samples and frequency of their occurrence in finished products. Simultaneously, there was an equivalent reduction of salmonellae positives in environmental samples and finished products. Consequently, the determination of Enterobacteriaceae can be used as an effective tool to assess the improvements in good manufacturing practices.

Dynamics of salmonella isolation with modified Rappaport's medium (R10).

Enhanced growth of salmonellas in Rappaport's medium as modified by Vassiliadis et al. (1976) after pre-enrichment in buffered peptone water during the first 6 h was obtained by replacement of tryptone by soya peptone. The competing bacteria, i.e. those which grow on brilliant green agar and which may interfere with the isolation of salmonellas when Rappaport's medium (R10) incubated at 43 degrees C is used for enrichment were inhibited or reduced in numbers when the normal amount of 5 g soya peptone/litre was used. When the amount was increased to 10 g/l, growth occurred, mainly of Enterobacter and Klebsiella species. The isolation of salmonellas was found to be largely dependent on the number and the ratio of their competitors. Every measure taken to reduce the number of competitive bacteria increases the possibility of isolating salmonellas. This explains the effect of improved selectivity of Rappaport's medium when small inocula are used. Rapid onset of growth of salmonellas by employing soya peptone introduces the possibility of using shorter incubation times 48 h.

Epidemiological studies on Salmonella in a certain area ("Walcheren Project") V. Studies into the possibility of fattening pigs free from Salmonella.

Studies performed some years ago showed that Salmonella-free pigs for slaughter could be produced under experimental conditions if a number of hygienic measures were taken, such as the purchase of Salmonella-free piglets, the use of properly pelletized feed, thorough cleaning and disinfecting of the pigsty and the prevention of all contamination from the surroundings. In this paper four trials are described which examined whether pigs could also be fattened free from Salmonella under practical conditions on the farm. For this purpose one pigsty on a Salmonella-contaminated farm was used, in which the aforementioned hygienic measures were taken. Despite all these precautions it proved impossible to obtain Salmonella-free pigs. In fact, in three of the four experiments a massive Salmonella infection became manifest among the pigs. The experiments revealed a number of ways in which contamination might have occurred. The existence of these routes of infection was caused by the fact that the measures described above were not carried out accurately, an indication that it will be very difficult to meet the hygiene requirements under farming conditions. Further experiments will have to ascertain whether this is generally the case. In the third and fourth trials, the investigations were not confined to the farm, but were also extended to the period of slaughtering. These made it clear that transportation as well as the waiting time in the slaughterhouse also provided many opportunities for contamination of the pigs, in spite of extensive cleaning and disinfecting of both the cattle-truck and the lairages.

[Epidemiological studies on Salmonella in a particular area ('Walcheren Project'). V. Studies on the possibility of fattening pigs free from Salmonella (author's transl)]. / Epidemiologisch Salmonella-onderzoek in een bepaald gebied ('Project Walcheren'). V. Onderzoek naar de mogelijkheid varkens onder praktijkomstandigheden Salmonella-vrij te mesten.

Four trials were made to study the possibility of fattening pigs free from Salmonella under field conditions. One pig-sty on a Salmonella-contaminated farm was used in these studies. Previous studies had shown that Salmonella-free fattening pigs could be produced under experimental conditions. A number of hygienic measures were adopted on the farm, such as the purchase of Salmonella-free piglets, the use of correctly pelleted feed, thorough cleaning and disinfecting of the pig-sty, and the prevention of all infections originating from the environment. Notwithstanding all these measures, completely Salmonella-free pigs could not be obtained. In three out of four experiments, even a mass infection with Salmonella even became apparent among the pigs. During the experiments a number of possible routes of infection were detected. The presence of these possible routes of infection was due to the fact that the measures referred to were not carried out accurately. This suggests that it will be very difficult to satisfy the requirements of strict hygiene under field conditions. Further experimental studies will have to show whether this is usually the case. During the third and fourth trial, studies were not confined to the farm, but also extended to the period of slaughter. From these investigations it became apparent that transport to as well as the period of waiting in the slaughter-house also provide several opportunities for contamination of the pigs, in spite of extensive cleaning and disinfection of both cattle-truck and lairages.

Microbiological quality of frozen precooked and peeled shrimp from South-East Asia and from the North Sea.

The microbiological quality of frozen precooked and peeled shrimp is largely dependent upon the method of processing. The investigations were carried out in order to study the difference between the microbiological quality of shrimp from South-East Asia and from the North Sea and to determine whether both can meet draft FAO/WHO and ICMSF-specifications; 100 samples of frozen precooked and peeled shrimp from South-East Asia and 50 samples of shrimp from the North Sea were examined. In 45% of the shrimp samples from South-East Asia and in 78% of the samples of North Sea shrimp the number of aerobic mesophiles was over 10(6) per g. The number of Staph. aureus was higher in the samples of shrimp from South-East Asia than in those from the North Sea: 34% of the samples from South-East Asia had over 2 x 10(3) Staph. aureus per g., whereas only 6% of the samples of North Sea shrimp exceeded this number. Gram-positive mesophilic cocci were predominant in shrimp from South-East Asia. Gram-negative psychrophilic bacteria were predominant in North Sea shrimp. This difference in bacterial flora is caused by a difference in processing. The number of Enterobacteriaceae was usually low (less than 2 x 10(2) per g) in both kinds of shrimp. In three lots of South-East Asian shrimp Salmonella was detected. Vibrio parahaemolyticus was not found. On the basis of draft FAO/WHO endproduct specifications all lots of both South-East Asian and North Sea shrimp would have been rejected. On the basis of ICMSF specifications the rejection amounted to 90 and 80% of the lots, for the two types of shrimp respectively. Preservatives were not detected in shrimp from South-East Asia, whereas benzoic acid was present in all samples of North Sea shrimp. It was concluded that the ammonia content is a valuable objective quality index only in case of North Sea shrimp.

Epidemiological studies on Salmonella in a certain area ("Walcheren Project"). IV. The incidence of Salmonella in the sewage system, in the faeces of man and pets as well as in shops, kitchens and lavatories in the village of Aagtekerke.

As part of the epidemiological investigations on Salmonella ion the former island of Walcheren, the contamination of sewage water in the village of Aagtekerke was studied over a prolonged period of time. These studies showed that this sewage water was frequently contaminated by large numbers of Salmonella. In the present study efforts were made to find the source of this contamination and for this purpose the incidence of Salmonella in the sewage system, in the faeces of man and pets as well as in shops, kitchens and lavatories in the village of Aagtekerke was studied for a period of three weeks in June 1977. Salmonella was only isolated from a few samples of faecal material of human and animal origin, and from the sewage system (including the inlet water and effluents of the sewage works). Serotyping showed that the strains isolated from human faeces were similar to those found to be present in the sewage system. This fact taken in conjunction with the results of the bacterial counts, suggests that the sewage system was only contaminated by a small number of carriers. The reduction of contamination observed in the sewage system during the period of investigation could be evidence that Salmonella organisms cannot survive by themselves in an environment of this type, at least not at the temperatures recorded when collecting samples from the sewage water. Growth of organisms under more favourable conditions cannot be ruled out. A questionnaire about the dietary habits and kitchen hygiene of the local population showed that contamination within households, originating with the food, is a real possibility.

In vitro inactivation of Clostridium botulinum toxins types B, C and E by digestive juices of man and ducks.

Inactivation of botulinum toxins type B-L, B-M, C-L and E in the digestive juices of man and ducks was determined. Botulinum toxins of the M size (B-M and E) lost their toxicity completely in the gastric juices of both man and ducks, but toxins of the L size (B-L and C-L) lost their toxicity only partially. The toxins were hardly affected by duodenal fluid even after exposure to gastric juice. The toxins were not inactivated by cecal fluid from ducks. Since human digestive juices and those from ducks appeared to have comparable effects on the inactivation of toxin, differences in susceptibilities of the animal species to orally acquired toxins are in all probability not caused by digestive action of those species.

Removing faecal contamination of broilers by spray-cleaning during evisceration.

1. The faecal contamination of broiler carcasses during evisceration results in an increase in contamination with Enterobacteriaceae, including any salmonellas present. 2. This increase can be prevented completely by spray-cleaning carcasses during the various stages of evisceration. 3. If the carcasses are cleaned only at the end of the evisceration process, the numbers of Enterobacteriaceae are not reduced to initial levels and Salmonella contamination is less efficiently removed.