The impact of outsourcing bed-based aged care services on quality of care: A multisite observational study.

BACKGROUND: Outsourcing health-care services has become popular globally, provided by both profit and non-for-profit organizations with varying degrees of quality. To date, few published studies have evaluated the quality of care in health services using outsourcing. OBJECTIVE: The purpose of this study was to determine if there were differences in quality of care (effectiveness, safety and patient experience) for a Transition Care Program designed to improve older people's independence and confidence after a hospital stay, when provided within a public health network compared to being outsourced to private facilities. METHODS: For clients discharged to a residential Transition Care Program operating across three sites from a large health service network (n = 1546), an audit of medical records was completed. Site 1 remained within the public health service (internally managed), whereas Sites 2 and 3 involved outsourcing to residential aged care facilities. The main outcome measures were discharge destination, length of stay and number of falls. Client demographics were analysed descriptively, and inferential statistics for continuous data and negative binomial regression for event data were used to examine differences between the sites. RESULTS: There were differences in quality of care between the internally and outsourced managed sites. One outsourced site discharged a smaller proportion to rehabilitation (P = 0.003) compared to the other two sites. There were differences in length of stay between the three sites. The length of stay was a mean of 4.8 days less at Site 1 (internally managed) (95% Confidence Interval (CI) 0.5 to 9.1) than Site 2 and 4.6 days less (95% CI 1.2 to 8.1) than Site 3. For those discharged to permanent residential care, the length of stay was 9.4 days less at the internal site than Site 2 (95% CI 3.5 to 15.2) and 7.0 days less than Site 3 (95% CI 1.9 to 12). Additionally, a lower rate of falls was recorded at Site 1 (internally managed) compared to Site 2 (outsourced) (incidence rate ratio = 0.44 (95% CI 0.32 to 0.60), P < 0.001). CONCLUSION: An internally managed Transition Care Program in a public health network was associated with better quality of care outcomes compared to outsourced services.

Delirium management: Let's get physical? A systematic review and meta-analysis.

OBJECTIVE: To investigate whether physical training (alone or in a multi-component intervention) is effective in preventing delirium or improving outcomes for adult patients with delirium in the hospital setting. METHODS: A systematic review, qualitative synthesis and meta-analysis of randomised controlled trials identified by searches of electronic databases, combining key concepts of delirium and physical training (the target intervention). Outcomes were incidence of delirium (for prevention trials) and delirium duration, delirium severity and hospital outcomes (for management trials). RESULTS: Seven trials were included, five of which were multi-component. The odds of developing delirium were lower for patients who received physical training compared with a control intervention [odds ratio 0.46 (95% confidence interval 0.32-0.65), P < 0.01] (moderate-quality evidence). There was insufficient evidence to draw conclusions about managing established delirium. CONCLUSIONS: Strategies incorporating physical training appear to prevent delirium in the hospital setting. More research is required regarding management of established delirium.

Dementia with Lewy bodies presenting as probable epileptic seizure.

We discuss the case of an 83-year-old man admitted to the hospital after losing control of his vehicle due to an unexplained episode of altered consciousness. This occurred on a background of multiple similar episodes associated with acute confusion, superimposed on a gradual cognitive decline spanning 6 years. Organic aetiologies for delirium were excluded and CT and MRI of the brain were negative for cerebrovascular accidents or other epileptogenic foci. Electroencephalogram (EEG) was negative for epileptiform activity. A diagnosis of seizure in the setting of dementia with Lewy bodies (DLB) was deemed probable. Subsequent brain single-photon emission computed tomography (SPECT) and flurodeoxy glucose-positron emission tomography (FDG-PET) studies supported the underlying diagnosis of DLB. Acute changes in consciousness or cognition are often related to strokes or seizures in the older person. As illustrated in this case, however, it is important to consider alternative comorbidities that may coexist.

Use of sentinel snails for the detection of Schistosoma haematobium transmission on Zanzibar and observations on transmission patterns.

Urogenital schistosomiasis is an important public health issue in Zanzibar. Transmission of the parasite to the human population is related to the distribution of the intermediate snail host, Bulinus globosus. We measured B. globosus abundance and Schistosoma haematobium prevalence within snails in a series of naturally occurring populations and compared prevalence detected by observing cercarial shedding for patent infections, and by PCR using DraI repeat. A total of 2146 B. globosus were collected throughout the study period from 2003 to 2007; of these 85 (3.96%) were shedding cercariae. The levels of infection detected by PCR were consistently higher (40-100 percent). Levels of exposure to miracidia in the field were measured using sentinel snails. B. globosus (a susceptible host) and B. nasutus (a non-susceptible host) were placed in cages at transmission sites for 72h to observe rates of penetration by miracidia. Both B. globosus and B. nasutus tested positive for S. haematobium by PCR (up to 24% infected) indicating frequent contamination of the waterbodies with S. haematobium miracidia. The use of sentinel snails coupled with PCR diagnostics could be a sensitive tool for mapping and monitoring transmission of schistosomiasis in areas of low prevalence.

Detection and quantification of schistosome DNA in freshwater snails using either fluorescent probes in real-time PCR or oligochromatographic dipstick assays targeting the ribosomal intergenic spacer.

Several DNA probes were designed for use in real-time polymerase chain reaction (PCR) assays to target sequence variation within the ribosomal intergenic spacer (IGS) of schistosomes. A sub-section of the IGS (∼300bp) was amplified, with cross-specific primers, after which group-specific fluorescent, locked nucleic acid probes were assessed for their ability to differentiate and quantify DNA from Schistosoma haematobium and Schistosoma mansoni group parasites. A number of fluorescent probe candidates were screened and validated against genomic DNA from adult schistosome worms and laboratory infected freshwater snails. Two fluorescent, locked nucleic acid probes ShaemLNA5 and SmanLNA2, of 20-26bp in length, were identified and found to be effective in providing evidence of infection in field-collected snails. To adapt these real-time PCR assays for more resource-poor laboratory settings, a PCR-restriction fragment length polymorphism (RFLP) assay was developed and primer/probe combinations were modified for use in oligochromatography, a DNA 'dipstick' technology. An appropriate dipstick was developed, inclusive of internal amplification and amplicon migration controls that could be of particular importance for assessing schistosome transmission dynamics. These assays and tools also have future potential for use in detection of schistosome infections in humans and livestock.

Parasitological and malacological surveys reveal urogenital schistosomiasis on Mafia Island, Tanzania to be an imported infection.

To confirm the local endemicity of Schistosoma haematobium on Mafia Island, Tanzania, conjoint parasitological and malacological surveys were undertaken in July 2006 with parasitological investigations supplemented with case-history questionnaires. A total of 238 children (125 girls and 113 boys, mean age of 13.9 years) across 9 primary schools were examined. The prevalence of micro-haematuria and egg-patent infection was 18.1% (CI95=9.6-33.6) and 4.2% (CI95=1.9-7.6), respectively but a strong female bias was observed for micro-haematuria (5.6F:1M) contrasting with a strong male bias for the presence of eggs (1F:4M). All egg-patent infections were of light-intensity (<10eggs/10ml). No clear associations between infection prevalence and local water-contact, by school, were found and all 10 of the egg-positive children had a travel history to the nearby mainland or Zanzibar. Inspection of community diagnostic registers at Kilindoni Hospital revealed a low proportion (<2%) of egg-patent infection for 20,306 samples tested in the 2000-2005 period. A total of 43 freshwater sites, a third of which were previously sampled in 1999 and 2002, were surveyed and 11 species of freshwater mollusc were found. Four species of Bulinus (B. nasutus, B. forskalii, B. barthi and B. sp.) were encountered across 13 sites with B. nasutus restricted to 3 of these towards the north of the island. No collected snail was observed to shed schistosome cercariae. Further characterisation of B. nasutus and S. haematobium included infection challenge on two occasions, with miracidia obtained from egg-patent children from Mafia and Unguja islands as well as DNA barcoding of snails and schistosomes. B. nasutus was shown refractory to infection. With the substantial travel to and from Mafia, the refractory nature of local snails and evidence from DNA barcoding in schistosomes and snails, we conclude that urogenital schistosomiasis is an imported infection.

Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting.

PURPOSE: To analyze nationwide trends in abdominal aortic aneurysm (AAA) repair and the use of endovascular abdominal aortic aneurysm repair (EVAR) in the emergency setting. MATERIALS AND METHODS: Data were obtained from the Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for open and endovascular repairs from 2001-2009. Trends in outcome parameters and hospital charges were compared. RESULTS: The number of emergency EVAR procedures increased from 382 in 2001 to 1,247 in 2009 (P < .001). During the study period, length of hospital stay associated with total number of EVAR procedures decreased from 3.8 days to 3.4 days (P < .05), and the in-hospital mortality decreased from 2.4% to 2% (P = .32). From 2001-2009, mean hospital charges associated with EVAR increased from $50,630 to $91,401 (74% increase), whereas charges associated with open repairs increased from $54,578 to $128,925 (136% increase). The proportion of patients needing rehabilitation or nursing home placement after EVAR increased from 5.8% to 7.7% (P < .01), and need for home health increased from 6.9% to 10.5% (P < .01). CONCLUSIONS: There was a significant increase in the number of emergency EVAR procedures during the study period; however, the overall in-hospital mortality associated with EVAR remained unchanged, and the length of hospital stay showed a decreasing trend. The total hospital charges for EVAR were lower than the charges for open abdominal aneurysm repair throughout the study period; the difference in charges between the procedures showed a significant increasing trend with time.

Early differential gene expression in haemocytes from resistant and susceptible Biomphalaria glabrata strains in response to Schistosoma mansoni.

The outcome of infection in the host snail Biomphalaria glabrata with the digenean parasite Schistosoma mansoni is determined by the initial molecular interplay occurring between them. The mechanisms by which schistosomes evade snail immune recognition to ensure survival are not fully understood, but one possibility is that the snail internal defence system is manipulated by the schistosome enabling the parasite to establish infection. This study provides novel insights into the nature of schistosome resistance and susceptibility in B. glabrata at the transcriptomic level by simultaneously comparing gene expression in haemocytes from parasite-exposed and control groups of both schistosome-resistant and schistosome-susceptible strains, 2 h post exposure to S. mansoni miracidia, using an novel 5K cDNA microarray. Differences in gene expression, including those for immune/stress response, signal transduction and matrix/adhesion genes were identified between the two snail strains and tests for asymmetric distributions of gene function also identified immune-related gene expression in resistant snails, but not in susceptible. Gene set enrichment analysis revealed that genes involved in mitochondrial electron transport, ubiquinone biosynthesis and electron carrier activity were consistently up-regulated in resistant snails but down-regulated in susceptible. This supports the hypothesis that schistosome-resistant snails recognize schistosomes and mount an appropriate defence response, while in schistosome-susceptible snails the parasite suppresses this defence response, early in infection.

Confirmed infection with intestinal schistosomiasis in semi-captive wild-born chimpanzees on Ngamba Island, Uganda.

BACKGROUND: Intestinal schistosomiasis, caused by Schistosoma mansoni, is endemic to Lake Victoria, with high prevalence of the disease observed in human lakeshore communities. However, nonhuman primates have recently been overlooked as potential hosts of the disease, despite known susceptibility. METHODS: Using a variety of stool, urine, and serological diagnostic methods, 39 semi-captive wild-born chimpanzees and 37 staff members at Ngamba Island Chimpanzee Sanctuary, Lake Victoria, Uganda, were examined for S. mansoni infection. Miracidia recovered from stool were DNA barcoded to investigate cross-over between humans and chimpanzees. The island was also surveyed for Biomphalaria intermediate host snails, which were examined for infection with S. mansoni. RESULTS: Chimpanzees were unequivocally shown to be infected with intestinal schistosomiasis with a seroprevalence in excess of 90%. Three egg-positive cases were detected, although the sensitivity of the diagnostic tests varied due to earlier prophylactic praziquantel treatment. Miracidia hatched from chimpanzee stool revealed three DNA haplotypes commonly found in humans living throughout Lake Victoria, including staff on Ngamba Island, as well as two novel haplotypes. At one site, a snail was observed shedding schistosome cercariae. CONCLUSIONS: The anthropozoonotic potential of intestinal schistosomiasis on Ngamba Island is greater than previously thought. Moreover, the ability of chimpanzees to void schistosome eggs capable of hatching into viable miracidia further suggests that these nonhuman primates may be capable of maintaining a local zoonotic transmission of schistosomiasis independently of humans. The implications for management of captive and wild primate populations at risk of exposure are discussed.

Biomphalaria glabrata transcriptome: cDNA microarray profiling identifies resistant- and susceptible-specific gene expression in haemocytes from snail strains exposed to Schistosoma mansoni.

BACKGROUND: Biomphalaria glabrata is an intermediate snail host for Schistosoma mansoni, one of the important schistosomes infecting man. B. glabrata/S. mansoni provides a useful model system for investigating the intimate interactions between host and parasite. Examining differential gene expression between S. mansoni-exposed schistosome-resistant and susceptible snail lines will identify genes and pathways that may be involved in snail defences. RESULTS: We have developed a 2053 element cDNA microarray for B. glabrata containing clones from ORESTES (Open Reading frame ESTs) libraries, suppression subtractive hybridization (SSH) libraries and clones identified in previous expression studies. Snail haemocyte RNA, extracted from parasite-challenged resistant and susceptible snails, 2 to 24 h post-exposure to S. mansoni, was hybridized to the custom made cDNA microarray and 98 differentially expressed genes or gene clusters were identified, 94 resistant-associated and 4 susceptible-associated. Quantitative PCR analysis verified the cDNA microarray results for representative transcripts. Differentially expressed genes were annotated and clustered using gene ontology (GO) terminology and Kyoto Encyclopaedia of Genes and Genomes (KEGG) pathway analysis. 61% of the identified differentially expressed genes have no known function including the 4 susceptible strain-specific transcripts. Resistant strain-specific expression of genes implicated in innate immunity of invertebrates was identified, including hydrolytic enzymes such as cathepsin L, a cysteine proteinase involved in lysis of phagocytosed particles; metabolic enzymes such as ornithine decarboxylase, the rate-limiting enzyme in the production of polyamines, important in inflammation and infection processes, as well as scavenging damaging free radicals produced during production of reactive oxygen species; stress response genes such as HSP70; proteins involved in signalling, such as importin 7 and copine 1, cytoplasmic intermediate filament (IF) protein and transcription enzymes such as elongation factor 1alpha and EF-2. CONCLUSION: Production of the first cDNA microarray for profiling gene expression in B. glabrata provides a foundation for expanding our understanding of pathways and genes involved in the snail internal defence system (IDS). We demonstrate resistant strain-specific expression of genes potentially associated with the snail IDS, ranging from signalling and inflammation responses through to lysis of proteinacous products (encapsulated sporocysts or phagocytosed parasite components) and processing/degradation of these targeted products by ubiquitination.

Molecular characterization of freshwater snails in the genus Bulinus: a role for barcodes?

BACKGROUND: Reliable and consistent methods are required for the identification and classification of freshwater snails belonging to the genus Bulinus (Gastropoda, Planorbidae) which act as intermediate hosts for schistosomes of both medical and veterinary importance. The current project worked towards two main objectives, the development of a cost effective, simple screening method for the routine identification of Bulinus isolates and the use of resultant sequencing data to produce a model of relationships within the group. RESULTS: Phylogenetic analysis of the DNA sequence for a large section (1009 bp) of the mitochondrial gene cytochrome oxidase subunit 1 (cox1) for isolates of Bulinus demonstrated superior resolution over that employing the second internal transcribed spacer (its2) of the ribosomal gene complex. Removal of transitional substitutions within cox1 because of saturation effects still allowed identification of snails at species group level. Within groups, some species could be identified with ease but there were regions where the high degree of molecular diversity meant that clear identification of species was problematic, this was particularly so within the B. africanus group. CONCLUSION: The sequence diversity within cox1 is such that a barcoding approach may offer the best method for characterization of populations and species within the genus from different geographical locations. The study has confirmed the definition of some accepted species within the species groups but additionally has revealed some unrecognized isolates which underlines the need to use molecular markers in addition to more traditional methods of identification. A barcoding approach based on part of the cox1 gene as defined by the Folmer primers is proposed.

An R package to compute commonality coefficients in the multiple regression case: an introduction to the package and a practical example.

Multiple regression is a widely used technique for data analysis in social and behavioral research. The complexity of interpreting such results increases when correlated predictor variables are involved. Commonality analysis provides a method of determining the variance accounted for by respective predictor variables and is especially useful in the presence of correlated predictors. However, computing commonality coefficients is laborious. To make commonality analysis accessible to more researchers, a program was developed to automate the calculation of unique and common elements in commonality analysis, using the statistical package R. The program is described, and a heuristic example using data from the Holzinger and Swineford (1939) study, readily available in the MBESS R package, is presented.

Biomphalaria glabrata transcriptome: identification of cell-signalling, transcriptional control and immune-related genes from open reading frame expressed sequence tags (ORESTES).

Biomphalaria glabrata is the major intermediate snail host for Schistosoma mansoni, one of the important schistosomes infecting man. Much remains to be discovered concerning specific molecules mediating the defence events in these intermediate hosts, triggered by invading schistosomes. An expressed sequence tag (EST) gene discovery strategy known as ORESTES has been employed to identify transcripts that might be involved in snail-schistosome interactions in order to examine gene expression patterns in infected B. glabrata. Over 3930 ESTs were sequenced from cDNA libraries made from both schistosome-exposed and unexposed snails using different tissue types, producing a database of 1843 non-redundant clones. The non-redundant set has been assessed for gene ontology and KEGG pathway assignments. This approach has revealed a number of signalling, antioxidant and immune-related gene homologues that, based on current understanding of molluscan and other comparative systems, might play an important role in the molluscan defence response towards infection.

Relative importance of PSA in prostate cancer treatment.

METHODS AND MATERIALS: A retrospective study was conducted to (1) determine the relationship between baseline prostate-specific antigen (PSA) levels and initial treatment decisions for prostate cancer (surgery, hormone therapy, radiation, or watchful waiting) and (2) estimate the impact of PSA progression (doubling or three consecutive rises) on subsequent treatment decisions. Patient records (n=1116) from three community urology practices and a large academic health system were reviewed. Multivariate models were fitted to assess the relationship between initial treatment and baseline PSA, Gleason score, race, number of comorbid conditions and age and between PSA progression and time to subsequent therapy (adjusted for other factors). RESULTS: Baseline PSA was a significant predictor of initial treatment among men with localized disease with the likelihood of hormone therapy increasing with higher PSA levels and the likelihood of surgery decreasing steadily with higher PSA levels. PSA was the strongest predictor of hormone therapy as first choice followed by age. Age followed by PSA was the strongest predictor of surgery as first treatment as well as radiation therapy. Initial PSA levels did not predict the choice of watchful waiting. Patients with PSA progression were eight times (95% CI: 5.3-12.1) more likely to initiate a subsequent therapy than patients who did not have PSA progression when controlling for other predictors. CONCLUSIONS: In clinical practice, PSA significantly impacts the urologist's primary therapy choice and determines when they introduce subsequent treatments.