[Patient education for self-management of oral anticoagulation - situation in Hesse]. / Patientenschulungen zum Gerinnungsselbst-management - Angebotssituation in Hessen.

AIM: Oral anticoagulation (OAC) has been shown to be highly effective in preventing thromboembolic complications. Self-management can enable patients with a long-term indication for OAC to be actively involved in the therapy, but in Germany the implementation of self-management is linked to mandatory training. To illustrate significant structural disparities between education centres in Hesse, all such centres were identified and a list generated, specifying the differences. METHOD: Using our own questionnaire, we interviewed all known patient education centres in Hesse between January and July 2012, and conducted a descriptive analysis of their structural features. RESULTS: There were 44 datasets for statistical interpretation. We distinguished between centres with ASA certification (n=19) and centres without (n=25). On average, certified centres provide 6 h of training (range 2-9) compared to 5.5 h (range 1-12) in uncertified centers. Certified centres hold more group sessions per year (on average 17 vs. 8) and more individual training sessions (on average 10 vs. 5). Certified centres train 10-365 patients per year and uncertified centers between 5 and 77. Certified centres offer retraining more frequently (84% vs. 40%) and more often conclude the training with a written test (74% vs. 44%). Only 9 centres provide materials for patients with a migration background. CONCLUSION: The results show that in Hesse, severe structural discrepancies exist in training programmes for self-management of OAC, and it can be assumed that patients participating in trainings in different Hessian education centres face very differing conditions. To improve the quality of the trainings and to ensure patients have similar levels of knowledge, it is imperative that centres be regularly inspected with the help of proven quality indicators.

Practice-based depression case management in primary care: a qualitative study on family doctors' perspectives.

BACKGROUND: Case management provided by health care assistants (HCAs) is effective in improving primary care for depressive patients. Little is known on the implementation-related aspects of case management performed in small family practices. OBJECTIVE: To explore family doctors' perspectives on clinical and organizational aspects of implementation of case management and perceived practice-related aspects associated with patient care after 1 year's experience of HCAs providing case management for depressive patients in their practices. METHODS: This qualitative study was nested in a cluster-randomized trial on case management provided by practice-based HCAs for patients with major depression in Germany. We used semi-structured interview guides and performed audio-taped interviews with family doctors. Full transcription and thematic content analysis were carried out. RESULTS: Twenty-three family doctors were interviewed. The family doctors perceived case management as beneficial to patients and reported that it improved their consultation styles and doctor-patient relationships. They implemented case management elements into their everyday day work using 'concrete', 'subsumed' or 'progressive' implementation styles. CONCLUSIONS: Family doctors perceived practice-based case management by HCAs as beneficial for patient care. Different implementation styles may be appropriate, depending on the health care setting, and this requires further evaluation.

The Patient Assessment of Chronic Illness Care questionnaire: evaluation in patients with mental disorders in primary care.

The Chronic Care Model provides evidence-based recommendations to improve the care for patients with chronic conditions. The Patient Assessment of Chronic Illness Care questionnaire (PACIC) is an instrument to evaluate the patient's perspective on receipt of care delivered in the five domains patient activation, delivery system, goal setting, problem solving, and follow-up. The aim of this study was to assess the psychometric characteristics of the PACIC in 442 primary care patients with major depression. The psychometric properties were good. We found possible ceiling effects in the two subscales 'patient activation' (12.9%) and 'problem solving/contextual' (8.9%), as well as floor effects in 'goal setting/tailoring' (4.6%). The Cronbach's α coefficient for the total scale was excellent (0.91). We found two major factors, which we labeled according to the PACIC domains as composite factors 'patient activation and problem solving' as well as 'goal setting and coordination'. The perspective of patients with mental disorders, such as depression, on primary chronic illness care can be assessed adequately by the PACIC.

Release of Romanomermis culicivorax for the control of Anopheles albimanus in El Salvador I. Mass production of the nematode.

The mosquito parasite, Romanomermis culicivorax, was mass produced for the treatment of 144,000 m2 of Anopheles albimanus breeding area in El Salvador. The production of the necessary inoculum required the exposure of 1.6 X 10(6) first-instar Culex p. quinque-fasciatus larvae to 137 X 10(6) preparasites (1:14 ratio) each week for 6 weeks. The method employed produced an average 13.7 g (ca. 2,200/g) of postparasitic nematodes per rearing tray (20,000 mosquitoes), a total of 6,392 g (14.1 lb) for the 6-week period, and 425 cultures.

Release of Romanomermis culicivorax for the control of Anopheles albimanus in El Salvador II. Application of the nematode.

The mosquito breeding area of Lake Apastepeque, El Salvador, was treated 11 times over a 7-week period with Romanomermis culicivorax to control Anopheles albimanus and An. p. pseudopunctipennis. Parasitism averaged 58% but varied greatly from treatment to treatment and from site to site. However, three applications made during evening hours to avoid wind and wave action on the lake produced an average 86% parasitism. No significant differences in susceptibility to R. culicivorax were found between instars or between species. Also, no correlation was found between nematode dosage rates and levels of parasitism. Though the parasitism averaged about 60% of the desired level, Anopheles populations dropped from more than 10 per dip at the beginning of the release program to 0.6 per dip at the end of the release period (a 94% reduction). This is the first successful attempt to control mosquitoes on a large scale by using a parasite or pathogen.

Infectivity of Serratia marcescens (Eubacteriales: Enterobacteriaceae) in Stomoxys calcitrans (Diptera: Muscidae).

Serratia marcescens Bizio, a facultative pathogen of insects, was isolated from stable flies, Stomoxys calcitrans (L.), collected from Nebraska beef cattle feedlots and dairies. Infection rates in laboratory-reared stable flies infected by topical exposures to the bacterium were 57 and 64% in two experiments. Per os exposures to sucrose and water solutions, and bovine blood inoculated with S. marcescens, produced mortality rates of about 45 and 10%, respectively.

Evaluation of field propagation of Muscidifurax zaraptor (Hymenoptera: Pteromalidae) for control of flies associated with confined beef cattle.

The parasitic wasp Muscidifurax zaraptor Kogan & Legner was mass-reared in the field to control house flies, Musca domestica L., on two Nebraska beef cattle confinements. About 50,000 freeze-killed house fly pupae were exposed to a single release of M. zaraptor in the field. Placement of six additional cohorts of 50,000 freeze-killed pupae at the release sites at 2-wk intervals resulted in a mean parasite emergence of 56.4% over the study period. Mean fly mortality of 37.3 and 25.9% occurred in sentinel pupae placed around the perimeter of two release sites, compared with 3.9% for two control sites. We demonstrated a negative correlation between host reduction in sentinel cohorts and distances the cohorts were placed from parasite release sites. However, data indicated that other environmental factors also influenced the success of M. zaraptor in locating sentinel hosts. Correlation between mortality in sentinel pupae and numbers of parasites released was not evident. Temperatures above approximately 28 degrees C appeared to reduce the effectiveness of M. zaraptor.

Penetration and development of the mermithid nematode Reesimermis nielseni in eighteen species of mosquitoes.

The susceptibility of 18 species of mosquitoes to the infective stage of the mermithid nematode Reesimermis nielseni was compared to that of Culex pipiens quinquefasciatus. Thirteen species were more susceptible, with three Anopheles species and Culiseta inornata the most susceptible. Aedes triseriatus, Culex territans, and Psorophora ferox were highly resistant. Resistance to R. nielseni appeared to be behavioral, physical, or physiological, and some host species exhibited one or more types of defense mechanisms. No noticeable differences were apparent in the degree of susceptibility of a native-and a laboratory strain of C. p. quinquqfasciatus to R. nielseni.

Development and fecundity of Reesimermis nielseni, a nematode parasite of mosquitoes.

Maturation of the mermithid nematode Reesimermis nielseni to the adult stage began by the tenth day after emergence of the nematodes from their hosts at ambient temperatures (24-27 C). Most postparasitic males and females reached the adult stage after 50 and 70 days, respectively. The first females exhibiting egg development and oviposition were observed 25-30 days after emergence, but some oviposition was still taking place 150 days later. Reesimermis nielseni laid an average 2,480 eggs per female over an 18-day oviposition period. A majority of the mature eggs hatched within 7 h after the cultures were flooded. The preparasites are short-lived, and only a few were able to infect exposed hosts after 72 h.

Effects of host size and parasite burden on sex ratio in the mosquito parasite Octomyomermis muspratti.

The ratio of Octomyomermis muspratti to the host mosquito at the time of exposure had little effect on the ratio of male to female parasites that resulted. However, the ratio of males to females increased as the number of parasites/host increased. Hosts with a single nematode produced fewer than 1% males in comparison with hosts with 8 parasites which produced about 40% males; hosts with 10 or more nematodes generally produced more male than female nematodes. Males of O. muspratti usually emerged before females because of the earlier death of multiply-infected mosquitoes. The size of the host at the time of invasion bad no significant influence on nematode sex ratios. Since mating is apparently necessary for reproduction in O. muspratti, the low male to female ratios that occur will be important in developing successful mass production techniques.

Factor affecting sex ratios of a mermithid parasite of mosquitoes.

The ratio of male to female Reesimermis nielseni Tsai and Grundmann, a nematode parasite of mosquito larvae, increased as the number of parasites per host increased. Hosts with a single nematode produced 9% males compared with essentially 100% males in hosts with more than 7 parasites; hosts with 3 nematodes produced about equal numbers of males and females. Males of R. nielseni generally emerged before females because of the earlier death of multiple-infected mosquitoes. The species of the host mosquito influenced the sex ratio, but the size of a specific host at the time of invasion did not. Host diet also had a noticeable influence on the sex ratio of the nematode: singly infected hosts from a starved population produced 92% males compared with 13% in the normally fed group. The importance of these factors in the mass rearing of R. nielseni is discussed.

Mass Production of the Mosquito Parasite Romanomermis culicivorax: Effect of Density.

When numbers of Romanomermis culicivorax Ross and Smith were varied in containers with a constant surface area and depth of sand, densities of 12-24 nematodes per cm(2) yielded significantly more preparasites than higher densities. When container surface area and numbers of nematodes were constant and sand volume and depth were varied, yields did not differ significantly. When numbers of nematodes and sand volume were constant and surface area and sand depths were varied, yields were significantly higher for a density of 24 nematodes per cm(2). Yields of preparasites were tripled by simply setting up three cultures, each containing 5 g of nematodes, instead of a single culture containing 15 g.

Drilomermis leioderma n. gen., n. sp. (Mermithidae:Nematoda) parasitizing Cybister fimbriolatus (Say) (Dystiscidae-Coleoptera).

The nematode Drilomermis leioderma n. gen., n. sp. (Merrnithidae) is described from larvae of Cybister fimbriolatus (Say) (Dytiscidae: Coleoptera) in Louisiana. Diagnostic characters of the genus Drilomermis are: medium-sized nematodes with the cuticle appearing smooth (lacking cross fibers) under the light microscope, six cephalic papillae, without mouth papillae, six hypodermal cords at midbody, 2 extremely long spicules (longer than 10 times body width at anus) which are separate and parallel (not twisted), an S-shaped vagina, medium-sized amphids located near head papillae, and postparasitic juvenile with a tail appendage. D. leioderma possesses a ventrally displaced mouth, very long vagina, and male genital papillae arranged in 3 double rows in the vicinity of the cloacal opening. Even when containing multiple parasites, about 40% of the hosts sulwived emergence of the memithids and lived several more days. In nature, some of these hosts may be able to continue their development, which is unusual since most mermithid-parasitized hosts die soon after the nematode emerges.

Commercial development and future prospects for entomogenous nematodes.

Although entomogenous nenmtodes generally have many of the attributes of the ideal biocontrol agent, many of these attributes make the nematodes less than desirable for commercial production. Environmental limitations, lack of patent protection, "shelf life," shipping problems, and the need for users to receive specialized training are factors that have discouraged the involvement of larger companies. The future of these nematodes as commercially available biocontrol products appears to lie with the smaller "cottage industries" or with government-subsidized production. Problems encountered with attempts to produce commercially the mosquito parasite Romanomermis culicivorax are discussed.

Susceptibility of Psorophora columbiae Larvae over Time to Parasitism by Romanomermis culicivorax.

The ability of Romanomermis culicivorax preparasites to penetrate and infect Psorophora columbiae decreased substantially after ca. 28 hours. Parasitism at temperatures typical of Louisiana rice fields (i.e., 26, 29, and 32 +/- 0.5 C) showed a significant linear decrease (P < 0.01) as the percentage of older larval instars increased at the times of exposure. These data emphasize the need for a synchronous field application of preparasites to challenge the rapid development of early instars of Ps. columbiae. Applications of postparasites rather than insecticide treatments to potential mosquito breeding habitats may offer greater flexibility in larval mosquito control programs.

An Improved Method for Long-Distance Shipping the Mosquito Parasite Romanomermis culicivorax.

To prevent losses during long-distance shipment, a new delivery system was developed for the mosquito parasite Romanomermis culicivorax. A specially designed shipping container, two types of culture media (sand and a mixture of sand, vermiculite, and charcoal [SVC]), and two types of insert (polystyrene and polyester urethane foam [PUF]) were tested. Cultures shipped in SVC/PUF insert combination produced significantly higher yields of preparasites than did the other three combinations tested, and the sand/polystyrene combination produced significantly lower yields than did either sand or SVC media shipped with the PUF insert. Yields from cultures shipped in sand/PUF and SVC/PUF combinations were significantly lower than from unshipped controls. Maximum losses (52%) occurred in cultures shipped when 13-16-wk old. Also, yields of preparasites were significantly lower from cultures shipped singly when compared to similar cultures shipped in groups of eight. Techniques and procedures developed in this study did not completely solve the loss associated with delivery of R. culicivorax. For the first time, however, the system can guarantee the delivery of a quality product. The study defines the importance of the carrier medium, age of cultures, shipment size, and the restriction of the movement of the culture medium.