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.

Measuring the quality of outpatient treatment for schizophrenia.

BACKGROUND: Consumers and policy makers are increasingly interested in measuring treatment quality. We developed a standardized approach to measuring the quality of outpatient care for schizophrenia and used it to evaluate routine care. METHODS: We randomly sampled 224 patients in treatment for schizophrenia at 2 public mental health clinics. Appropriate medication management was defined according to criteria derived from national treatment recommendations, and focused on recent management of symptoms and side effects. Adequate psychosocial care was defined as the recent provision of case management or family management to patients for whom it is indicated. Care was evaluated using patient interviews and medical records abstractions. RESULTS: Although patients at the 2 clinics had similar illnesses, the treatment they received was quite different. In total, 84 (38%) of patients received poor-quality medication management, and 117 (52%) had inadequate psychosocial care. Clinics differed in the proportion of patients receiving poor-quality medication management not attributable to patient factors (28% vs 16%). The clinic with better-quality medication management provided case management to fewer severely ill patients (48% vs 81%). More than half of the cases of poor care would not have been detected if we had used only medical records data. CONCLUSIONS: At these clinics, many schizophrenic patients were receiving poor-quality care and most poor care was likely due to factors that can be modified. One approach to improving care begins by developing systems that monitor quality. These systems may require improved medical records and patient-reported symptoms and side effects.

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.

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.

The entry of sporozoites of Theileria parva into bovine lymphocytes in vitro. Electron microscopic observations.

The entry of sporozoites of Theileria parva into bovine lymphoid cells in vitro was studied with the electron microscope. Endocytosis is completed in less than 10 min. No local mobilization of actin or other cytoskeletal elements is detected in the cytoplasm of the cell being invaded and no engulfing pseudopods are formed. At the site of initial contact, the membranes of parasite and host cell come into very close apposition. As the zippering up of the membranes spreads laterally, the sporozoite sinks into a progressively deepening recess in the surface of the host cell until the rim of the invagination closes and fuses over the parasite. The observation that sporozoites are interiorized at 1-2 degrees C as well as at 37 degrees C suggests that endocytosis depends mainly upon a ligand-receptor interaction of the parasite and host cell membranes and requires little energy. Sporozoites may enter in any orientation, unlike other sporozoan parasites in which the membrane overlying an apical complex is invariably the site of attachment. 24 h after entry, the sporozoite is located in the Golgi region and the investing host cell membrane acquired during endocytosis has disappeared. The Golgi complex has been activated to form small lysosomes which gather around the parasite but are ineffective for lack of a membrane which they can fuse. It is suggested that removal of the investing host-cell membrane permits the parasite to evade destruction by the phagolysosomal system of the host cell. Persistence of micronemes after entry of the sporozoite and their subsequent disappearances invites the speculation that these parasite organelles may play a role in dispersal of the invaginated host cell membrane.

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.

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.

Community-based care of individuals with schizophrenia. Combining psychosocial and pharmacologic therapies.

The treatment and rehabilitation of individuals with schizophrenia has undergone rapid change during the past decade. We now accept that individuals with this illness are able to regain a modest degree of social and occupational functioning if optimal care is provided. To design and implement such care, we believe that the treatment setting and system, as well as the content of the treatment, are key to success. Treatment systems should ensure that care is provided continuously and without interruption across service settings and should employ a comprehensive array of interventions. The comprehensive array of interventions should be arranged in a user friendly format so that patients and their families can access care that is appropriate to their contemporary needs. This set of available services includes pharmacotherapy linked with psychosocial interventions including clinical case management, social skills training, vocational rehabilitation, and family support and treatment.

Neuroleptic nonresponse and affective symptoms: a 2-year prospective study of schizophrenic outpatients.

For 2 years we assessed clinical state, and plasma neuroleptic and prolactin levels every 6 months in 105 male schizophrenic outpatients. The patients took a variety of neuroleptics at clinically determined doses. Those who had psychotic symptoms at 50% or more of their visits had higher neuroleptic doses, more tardive dyskinesia, and more affective symptoms than the other patients. These groups were not, however, significantly different in their age of onset, years of education, duration of illness, duration of neuroleptic exposure, or negative symptoms.

Implementing publicly funded risk contracts with community mental health organizations.

The study analyzed the experience of the Los Angeles County Department of Mental Health with implementation of new contractual arrangements for services for patients with severe mental illness. The arrangements shifted the financial risk for treatment to community organizations and paid a fixed annual rate per enrolled patient without further adjustment for severity of illness. Patients were assigned to the program based on high prior treatment costs. The new contractual approach enhanced programs' flexibility and accountability and increased their emphasis on principles of psychosocial rehabilitation. Challenges in implementation included disenrollment of the majority of assigned patients by the community organizations at risk for high treatment costs. Prior treatment costs for continuing cases, while high, were lower than those for disenrolled cases. Existing information systems provided limited clinical and cost data, making it difficult to monitor providers' performance. Risk contracting required substantial clinical, fiscal, and management changes at community organizations and the mental health authority. The analysis suggests that mental health authorities that are planning to institute risk contracts need to balance fiscal incentives with performance guarantees and to pay particular attention to information systems requirements and to the severity of patients' illness. Although risk contracts present challenges, they can lead to improvements in service delivery that persist beyond the implementation phase.

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.

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.

Epidemiology of theileriosis in calves in an endemic area of Kenya.

Thirty-one calves born into five Maasai zebu cattle herds over a period of 1 month in the Trans-Mara Division of Kenya, endemic for theileriosis, were recruited for an intensive study of theileriosis. No calves up to 6 months of age died but all developed Theileria infections as judged by slide examination and serology. Parasitosis by T. mutans schizonts in lymph node smears was usually higher than that of T. parva. The T. mutans schizonts usually occurred at an earlier age but persisted at a patent level for a shorter time than those of T. parva. Serological findings using the indirect fluorescent antibody test confirmed the parasitological findings. It was evident that colostral transfer of Theileria antibodies was frequent. Theileria piroplasm parasitaemia had developed in all calves by 111 days of age. The earlier parasitosis by T. mutans reflected the higher infection rates in Amblyomma spp. than in Rhipicephalus appendiculatus. The mean number of R. appendiculatus on the ears of calves during the observations was 9.1 adults and 1.5 nymphs. Clinical episodes of T. mutans and T. parva infection were associated with febrile responses, enlarged lymph nodes, anaemia and other symptoms and about 80% of calves had poor weight gains or weight losses during either clinical infection. It would appear that theileriosis is one of the most important factors in the stunting of calf development in the area.

Human interferon alpha fails to inhibit the development of Babesia bigemina and Anaplasma marginale infections in cattle.

Studies were undertaken to determine whether human interferon alpha (HuIFN-alpha) administered orally could inhibit the development of clinical disease caused by the intraerythrocytic protozoan Babesia bigemina and the intraerythrocytic rickettsia Anaplasma marginale in cattle. HuIFN-alpha did not inhibit intraerythrocytic multiplication of either of the two parasites, suggesting that there is no role for HuIFN-alpha administered orally in the control of these pathogens.

Low doses of natural human interferon alpha inhibit the development of Babesia microti infection in BALB/c mice.

Studies were undertaken to determine whether treatments with low doses of natural human interferon alpha (HuIFN-alpha) administered by various routes could inhibit the development of the intra-erythrocytic protozoan Babesia microti in BALB/c mice. HuIFN-alpha treatment given intramuscularly significantly inhibited development of the parasitaemia of the parasite compared with infections in control mice.

Chemotherapy of East Coast fever: parvaquone treatment of clinical disease induced by isolates of Theileria parva.

Two experiments were carried out in which parvaquone was used to treat experimentally-induced acute clinical East Coast fever infections. In the first experiment, infections with Theileria parva parva (Kiambu 5) were induced by applying infected Rhipicephalus appendiculatus ticks or by inoculation of triturated infected-tick stabilate. The character of the disease was similar with both methods of infection and following a single treatment with parvaquone at 20 mg kg-1, 5 of 7 cattle in each group recovered. All untreated control cattle died. In the second experiment, 5 stabilate isolates from different locations within East Africa, and representative of the challenge likely to be met in the field, were used. Treatment was administered in 2 X 10 mg kg-1 doses 48 h apart. The isolates used were T. p. parva (Mbita), T. p. parva (Pugu), T. p. parva (Entebbe), T. p. lawrencei (Mara) and T. p. lawrencei/(Manyara); following treatment 3/7, 6/6, 6/7, 5/7 and 6/7 animals recovered, respectively. All untreated control cattle died. There was evidence of a difference in susceptibility of isolates to treatment, and some animals showed prolonged disease episodes. The nature of the response to treatment and the problems in treating a lympho-destructive disease are discussed.

Evaluation of infection and treatment methods in immunization of improved cattle against theileriosis in an endemic area of Kenya.

Five experiments were carried out to determine the efficacy of immunization against theileriosis in an endemic area of Kenya using artificial infection with a mixture of stabilates of Theileria parva stock or natural infection and treatment with parvaquone or several formulations of oxytetracyclines. For the first four experiments, introduced, susceptible Sahiwal/Friesian crosses were used and in the fifth, calves of Boran/Maasai zebu crosses born on the site. Cattle were infected either artificially with sporozoite stabilates of local isolates of T. parva parva derived from cattle and T. parva lawrencei derived from African buffalo or exposed to natural tick challenge on the ranch mostly derived from buffalo. The cattle were then given various treatment regimens using either parvaquone or long- and short-acting formulations of oxytetracycline. Treatment of natural infections, although it can be effective, was not considered a practical method on a large scale because of the need for intensive monitoring in the case of parvaquone treatment and the possibility of cattle not becoming infected in the case of prolonged application of long-acting formulations of oxytetracycline. Both methods were relatively expensive. Artificial infection treatment proved more practical and methods were developed where the monitoring of cattle was not required during the immunization procedure. Out of a total of 16 drug regimens investigated, one (consisting of two treatments of a short-acting formulation of oxytetracycline at 10 mg kg-1 body weight on Days 0 and 3 or 4 after infection) was found to be the most efficacious and the cheapest, and has now been used on a routine basis. This method can be used successfully on calves greater than 1 month of age.

Transformation of Theileria parva derived from African buffalo (Syncerus caffer) by tick passage in cattle and its use in infection and treatment immunization.

A sporozoite stabilate (St. 199) of Theileria parva was obtained by feeding nymphal Rhipicephalus appendiculatus on an African buffalo (Syncerus caffer) and was used to immunize cattle by the infection and treatment method. Nymphal ticks were applied to one of the steers 90 days later and it was shown that the resultant adult tick had become infected. Using tick/cattle passage, two passage lines of T. parva were established. By the fifth tick/cattle passage, the parasite stocks had changed their behaviour to that of T. parva derived from cattle as the parasite produced relatively high schizont parasitosis and piroplasm parasitaemia in cattle, and had become highly infective to ticks. At various passage levels the parasite populations were characterized by behaviour and by monoclonal antibodies against T. parva schizonts using infected cell culture isolates from cattle during acute infections. The monoclonal antibody profile showed little evidence of antigen change of the parasite during passage through cattle, which was confirmed in a two-way cross-immunity experiment using sporozoite stabilate derived from ticks obtained from the buffalo and fourth passage in cattle. The implication of these results, particularly in relationship to immunization of cattle against T. parva derived from buffalo, is discussed.

Further evaluation of the use of buparvaquone in the infection and treatment method of immunizing cattle against Theileria parva derived from African buffalo (Syncerus caffer).

Three experiments were undertaken to determine the efficacy of different doses of buparvaquone in the infection and treatment immunization of cattle against Theileria parva derived from African buffalo (Syncerus caffer). Two of these experiments also compared buparvaquone with standard doses of long- and short-acting formulations of oxytetracycline. In addition, different dilutions of stabilates were used in the experiments. In the first experiment, a 10(-1.0) dilution of stabilate was used to infect groups of cattle treated with buparvaquone at doses of between 5 and 0.625 mg kg-1 body weight (bwt) on Day 0 after infection. All control cattle developed severe theileriosis and none of the treatment regimes (including those utilizing long-acting oxytetracycline) prevented the development of theileriosis. Treatment with buparvaquone at 2.5 mg kg-1 bwt or oxytetracycline gave the most satisfactory results. In the second experiment when the sporozoite dose was reduced to 10(-2.0) dilution, buparvaquone treatment at 5 and 2.5 mg kg-1 bwt and short- and long-acting formulations of oxytetracycline reduced reactions greatly. While all the oxytetracycline treated animals produced a serological response and were immune to a 50-fold higher challenge with the immunizing stabilate, several animals in the buparvaquone groups did not show a serological response and were not immune to challenge. In the third experiment, groups of cattle were infected with 10(-1.2), 10(-1.4) and 10(-1.6) dilutions of stabilate and were treated with 2.5 mg kg-1 bwt of buparvaquone. No animals developed severe theileriosis and all seroconverted. On homologous challenge, however, two out of 14 cattle showed severe reactions. It was concluded that further work on immunization using buparvaquone treatment at 2.5 mg kg-1 bwt and 10(-1.6) dilution of the stabilate would have to be carried out before such a system could be used in the field.