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Biomedical subjects

R S Green

Publications and source records attributed to R S Green.

At least 19 recordsLinked to original sources

The transfer of maternal IgE and other immunoglobulins specific for Trichostrongylus colubriformis larval excretory/secretory product to the neonatal lamb.

The transference of immunoglobulins from six New Zealand Romney ewes to their lambs was examined. Immunoglobulin levels were determined in ewe plasma, colostrum and lamb plasma shortly after birth and before the lambs fed, in lamb plasma 2 days after birth, and lamb plasma, ewe plasma and milk 30 days after parturition. Levels of total IgE, and IgE, IgG1, IgG2, IgM, and IgA with specificity for Trichostronglus colubriformis third stage larval secretory/excretory products (TcL3E/S) were determined. Mean levels of total IgE were three times higher in colostrum than in parturient ewe plasma while only trace amounts were detected in milk at 30 days after birth (107.7, 34.3, and 0.2U ml(-1), respectively, differences between means P< or =0.01). Mean total IgE in lamb plasma rose from being undetectable before suckling to levels comparable to those of the ewes by 2 days after birth (21.7U ml(-1)) and then declined to low levels by 30 days (0.4U ml(-1)). Total IgE levels in lamb plasma were significantly correlated with levels in ewe plasma and colostrum (r=0.91, P< or =0.01; r=0.96, P< or =0.003, respectively). The transference of TcL3E/S-specific IgE, IgG1 and IgA was substantial with mean levels of these antibodies in lamb plasma at 2 days comparable to that in parturient ewe plasma (absorbance levels in lamb plasma of 0.283, 0.537, and 0.334, respectively). Proportionally less maternal IgM and IgG2 appeared to be transferred to the lambs (absorbance of 0.112 and 0.081, respectively). Levels of TcL3E/S-specific IgE and IgG1 in lamb plasma at 2 days were significantly correlated with levels in parturient ewe plasma and colostrum (r=0.89 and 0.82, 0.85 and 0.96; all P< or =0.05, respectively). These results indicate that IgE is concentrated in ewe colostrum and that substantial amounts of maternal IgE are transferred to lambs via colostrum. Further, the results suggest that humoral immunity against gastro-intestinal nematode parasites and potentially other parasites in colostrum-fed lambs may approximate that of the ewe. The implications of the transference of humoral immunity through colostrum in ruminants for the passive protection and the development of active immunity against parasites remains to be fully explored.

Animals↗

Nonfatal occupational injury among California farm operators.

We conducted a population-based telephone survey addressing farm-work-related (FWR) injuries among California farm operators. Of 1947 participants (80.4% response), 135 farm operators reported 160 FWR injuries in the preceding year, yielding a one-year cumulative incidence for any FWR injury of 6.9% (95% CI 5.8%-8.2%), or a mean 8.2 FWR injuries per 100 farmers in the preceding year (95% CI 6.8-9.7). Multiple injury events in the same individual occurred more frequently than predicted by chance. Sprains and strains (29.4%) were the most frequently reported injury and predominantly involved the back. Overexertion represented the most frequent external cause (24.2%), followed by machinery (14.3%), falls (13.0%), and animals (12.4%). Factors associated with FWR injury included white ethnicity (OR 3.19; 95% CI 1.38-7.36), increased annual hours worked on the farm, low levels of administrative work, and increased percentage of time working with livestock. FWR injury experience of California farm operators is comparable with that reported for other agricultural populations. Above-expected frequency of multiple injuries supports involvement of personal or environmental risk factors. Preventive efforts should focus on higher-risk groups and preventing overexertion and muscle strain and injury related to machinery, falls, and animals, especially livestock.

Accidents, Occupational↗

Production and immunological responses associated with controlled-release-capsule vs 5-drench preventive anthelmintic programmes for parasite control in lambs.

AIMS: To determine whether: a) using a controlled-release anthelmintic capsule (CRC) instead of a programme of 5 oral drenches administered at 3-4 week intervals, would delay the development of anti-parasite immunity in lambs; b) the use of ivermectin instead of albendazole, administered either as a CRC or as a programme of 5 oral drenches, would delay the development of anti-parasite immunity in lambs; c) lambs treated with CRCs would have higher liveweight gains than lambs drenched orally 5 times at 3-4 week intervals, and; d) delayed onset of anti-parasite immunity is associated with reduced liveweight gains in the period following anthelmintic treatment. METHODS: Three field trials were conducted, 1 on a research farm and 2 on commercial sheep farms, in which groups of 30 lambs were treated with either a CRC containing albendazole, a CRC containing ivermectin, 5 oral drenches with albendazole, or 5 oral drenches with ivermectin, administered at 3-4 week intervals. Liveweights and faecal nematode egg counts (FECs) were recorded in all trials. Immunoglobulin-G (IgG) antibody levels to Ostertagia circumcincta and Trichostrongylus colubriformis adult and larval antigens were measured in Trials 1 and 3, and fleece weights and resistance of animals to nematode challenge infection were measured in Trial 1. RESULTS: CRC-treated lambs had higher levels of antibodies to O. circumcincta infective-stage larvae (L3) than orally drenched lambs in Trial 3, but no other immunological differences due to mechanism of delivery were detected. Antibody levels were lower in lambs treated with ivermectin than albendazole, as a CRC or oral drench in Trial 1, but this was not associated with any measurable effects on FEC or productivity. No significant differences (p>0.05) were detected between drench types (albendazole vs ivermectin) or delivery mechanisms (CRC vs oral drenching) in any of the production parameters measured, in any of the trials. Albendazole-CRCs failed to control FECs in all 3 trials. CONCLUSIONS: Although some differences between treatments in antibody levels were detected these were not associated with measurable differences in level of parasitism or productivity of lambs. CRC use did not appear to offer substantial gains in productivity over a structured programme of 5 oral drenches administered at 3-4 week intervals.

Journal Article↗

Death as a complication of peripherally inserted central catheters in neonates.

We report 2 neonatal deaths caused by cardiac tamponade related to peripherally inserted central catheters (PICCs). A total of 3 deaths were noted for 390 PICCs placed, giving an incidence of 0.76%. To determine the magnitude of neonatal death related to PICCs, directors of neonatal intensive care units in the United States were surveyed by means of a questionnaire. Myocardial perforation and pericardial effusion were reported by 29% and 43%, respectively. Deaths were attributed to PICCs by 24% of the respondents. Uniform guidelines need to be formulated to avoid this complication.

Cardiac Tamponade↗

The immune response of sheep to larval challenge with Ostertagia circumcincta and O. ostertagi.

One of three groups of sheep was challenged twice-weekly with infective-stage larvae (L3) of the sheep parasite O. circumcincta, another with the cattle parasite O. ostertagi while the third received no larval challenge. Positive faecal egg counts (FEC) and a rise in plasma pepsinogen levels were observed only in those animals given O. circumcincta. Anti-O. circumcincta L3 IgG titres were rapidly elevated during parasite challenge with either O. circumcincta or O. ostertagi. Throughout the experiment, no rise in anti-adult IgG titres or eosinophil numbers was observed in peripheral blood in any group. On evidence of self-cure of the trickle-infection, determined by a reduction in FEC, all groups were drenched and challenged with 15,000 O. circumcincta L3. No effect of previous challenge on parasite establishment or FEC was observed, although egg viability was significantly reduced in both groups given prior challenge. Significant differences in adult female worm length were observed between groups. Those recovered from animals previously challenged with O. circumcincta were shorter than from those given O. ostertagi which were in turn shorter than those from previously unchallenged animals. In utero egg counts were significantly lower in worms from animals previously challenged with O. circumcincta than in those from unchallenged control animals. The results indicate that a level of immunity to O. circumcincta can be conferred by exposure to O. ostertagi.

Abomasum↗

The effect of continuous drug exposure on the immune response of lambs challenged with drug-susceptible or drug-resistant nematode larvae.

Groups of lambs either with or without controlled-release albendazole (ABZ) capsules (CRCs) were challenged twice weekly for 6 weeks with either drug-susceptible or drug-resistant Ostertagia circumcincta and Trichostrongylus colubriformis. Groups with and without CRCs remained unchallenged as controls. There was minimal establishment of drug-susceptible parasites of either species in those lambs with CRCs. However, drug-resistant parasites of both species established adult worm burdens in the presence of the capsules. The humoral immune response, as measured by the serum antilarval (L3) antibody (Ab) titre, was pooled for weeks 4-6 and compared for each group. With the exception of anti-T. colubriformis Ab in group 2, anti-L3 Ab titres were significantly higher in all the parasite-challenged groups as compared to the control animals. Also, with the exception of anti-resistant O. circumcincta Ab levels in the CRC-treated animals (group 5), no significant difference was observed in Ab titres between the four groups challenged with either resistant or susceptible larvae. The results demonstrate the inability of CRCs to prevent establishment of drug-resistant parasites and that immune stimulation is not inhibited by the capsules.

Albendazole↗

A health statistic for length of stay by reporting period.

Managers of long-term care organizations lack usable information about patterns of stay, because the time spent by residents typically exceeds the length of reporting and reimbursement periods. Formulas for estimating lengths of stay often yield unstable estimates of long-term stays. Consequently, little insight is gained into changes that may be occurring in stay patterns as the organization adapts its service processes to shifts in markets. An alternative length of stay statistic is proposed from which patterns of stay can be more clearly discerned. Examples utilizing both simulated and field data are presented to highlight the advantages associated with the new statistic.

Bed Occupancy↗

Serum mast cell proteinase responses of sheep to challenge with Trichostrongylus colubriformis and the effect of dexamethasone treatment.

Eight-month-old random bred Romney wethered lambs were reared nematode-free in pens and assigned to 4 groups of 5 lambs. Lambs in 2 groups were dosed orally, twice a week, with 5000 Trichostrongylus colubriformis infective larvae (L3) for the duration of the experiment. These 2 groups were treated weekly with dexamethasone (0.5 mg kg(-1) body-weight), one between days -7 and 70, the other between days 77 and 147. A third group was dosed with L3 until anthelmintic treatment on day 133. A fourth group remained uninfected throughout and served as a control group. Nematode eggs in sheep faeces (FEC) were monitored at weekly intervals. Serum samples were taken twice a week and assayed for sheep mast cell proteinase (SMCP). Serum levels of SMCP in uninfected control sheep were 459 +/- 190 pg ml(-1). Twenty-eight days after nematode dosing commenced, SMCP levels were significantly above control sheep levels and after 49 days reached a plateau level of 1154 +/- 364 pg ml(-1). The SMCP response persisted even after cessation of dosing, and SMCP levels remained significantly above control levels to the end of the experiment (day 213). Dexamethasone treatment prevented elevation of SMCP and resulted in a rapid reduction of extent SMCP levels in resistant sheep. Overall, serum levels of SMCP were significantly correlated (P<0.001) with specific anti-T. colubriformis L3 antibody in serum (r = 0.601, d.f. = 78), blood eosinophils (r = 0.609, d.f. = 78) and log(FEC+15) (r = -0.521, d.f. = 78). These results show that serum levels of SMCP correlate with other indicators of parasitism and may have potential use as a non-invasive indicator of gastrointestinal mast cell responses to nematode infection.

Animals↗

Antibody responses of grazing alpacas (Lama pacos) in New Zealand to intestinal nematodes.

Alpaca (Lama pacos) were grazed for 10 months (October 1992-June 1993) on pasture with sheep or on pasture which had been recently grazed by sheep. The alpaca, of various age groups, totalled 94 at the beginning of the experiment and during the course of the experiment 32 progeny (cria) were born, 10 in spring 1992 and 22 in autumn 1993. Serum levels of specific antibodies to excretory/secretory antigens of the third larval stage (L3) of Cooperia curticei, Ostertagia circumcincta or Trichostrongylus colubriformis and somatic antigens from adult T. colubriformis were determined at monthly intervals by ELISA. Faecal egg count and live-weight were determined monthly and fleece-weight was measured at shearing. Three days after the birth of the cria, serum antibody levels ranged from 0.46-0.85 optical density units for the L3 antigens and averaged 0.22 for the adult T. colubriformis antigen. These levels declined to 0.1-0.24 and 0.06 respectively by 2-3 months of age. Subsequently, antibody levels increased steadily to reach maximal adult levels at approximately 23-26 months. Antibody levels were negatively correlated with FEC, but positively correlated with live-weight at 7 months although at 15 months antibodies and live-weight were negatively correlated. A positive correlation was found between weight and FEC. Fleece-weight showed no correlation with antibody level, a positive correlation with weight and a negative correlation with FEC. The relationships among antibody responses, FEC, live-weight and fleece-weight observed for alpaca in this experiment suggest that antibody responses might provide a useful indicator of alpaca immuno-responsiveness and has potential for use as a parameter for selection of alpaca with reduced FEC.

Aging↗

Sequential cellular and humoral responses in the abomasal mucosa and blood of Romney sheep dosed with Trichostrongylus axei.

Abomasal cannulae were surgically placed in 7 2-year-old New Zealand Romney sheep which had been maintained parasite-free from birth. Four of these sheep were randomly selected and dosed orally with 10,000 infective Trichostrongylus axei larvae per week for 8 weeks, while the remaining 3 sheep served as uninfected controls. Abomasal biopsy, blood and faecal samples were obtained from all sheep at regular intervals from 5 days before and until 58 days after the first infection. The sheep were then killed, worm burdens assessed and abomasal and small intestinal samples collected Faecal egg counts of all 4 dosed sheep were low and only one (No. 701) had a substantial worm burden (8400) post mortem. Overall, levels of mucosal mast cells/globule leukocytes, eosinophils, T19+ cells and larval migration inhibitory activity increased significantly in the abomasal mucosa of the dosed sheep compared to the controls. The CD4+:CD8+ cell ratio in the abomasal mucosa of the dosed sheep also increased compared to that of the controls (P = 0.06). In blood, T. axei-specific antibody (total and IgG1) and eosinophil numbers increased significantly in the dosed sheep. Mucosal cells staining for IgE (IgE+), and blood and mucosal eosinophils showed the earliest substantive increases in number followed by increases in specific serum antibody levels, numbers of mucosal cells fluorescing under UV light (UVf) and T19+ cells. The difference in the IgE+ and UVf cell responses indicated that expansion of globule leukocyte numbers lagged behind that of mucosal mast cells. The results supported the concept of CD4+ T cell help in the abomasal mucosa and defined the sequential expression of components of the immunological responses potentially mediating resistance to T. axei. In sheep No. 701, persistence of adult worms was associated with lower mucosal IgE+ cell and eosinophil responses compared with the other dosed sheep.

Abomasum↗

Immune responsiveness of nematode-resistant or susceptible Romney line-bred sheep to continuous infection with Trichostrongylus axei.

Two divergent lines of Romney sheep have been selected on the basis of differences in faecal egg counts (FEC) to natural poly-generic parasite challenge in New Zealand. However, it is not known if the expression of resistance or susceptibility extends to parasitic nematodes that were not a major part of the selection challenge. To examine this, the immune response to infection with Trichostrongylus axei was examined in these sheep lines. Changes in the proportions of CD5+, CD4+, CD8+, T19+ and CD45R+ lymphocytes and parasite specific antibody titres in peripheral blood were monitored each week in six resistant and six susceptible line lambs that were maintained indoors in pens during the course of 14 weekly infections with 10,000 T. axei larvae. No difference in FEC was observed. Similarly, no significant difference in T. axei specific antibody titre between sheep lines was seen although antibody titre increased steadily from Week 4. Significant increases in the proportions of CD5+, CD4+, CD8+ and T19+ cells occurred in both resistant and susceptible line lambs during Weeks 1-4 of infection. Following peak levels, proportions of CD5+, CD4+ and CD8+ cells fell with the rate of decline of CD5+ and CD4+ cells significantly greater in the resistant line lambs. Proportions of CD45R+ cells showed significant changes with time that were the inverse of those of CD5+, CD4+ and CD8+ cells. Susceptible line lambs showed higher proportions of CD5+ and lower proportions of CD45R+ cells than resistant lambs before infection with T. axei. Overall, during infection, these differences were maintained while CD4+ and T19+ levels were higher in the susceptible line lambs.

Analysis of Variance↗

Nematode burdens and immunological responses following natural challenge in Romney lambs selectively bred for low or high faecal worm egg count.

Breeding lines of Romney sheep, selected as lambs for consistently low or high faecal nematode egg count (FEC) following periods of natural challenge, have been maintained at Wallaceville for some years. In order to determine the extent to which FECs in low and high genotypes reflected their ability to resist the establishment of gastro-intestinal nematode burdens, we investigated the infection status and immune responses in 8- to 9-month-old progeny of selected rams from low and high FEC breeding lines following a period of grazing without anthelmintic treatment in autumn/early winter. In each of the 2 years of the study, outcross male progeny of the two lowest FEC (LFEC) (i.e. most 'resistant') and two highest FEC (HFEC) (i.e. most 'susceptible') rams from the divergent lines were slaughtered shortly after autumn/early winter FECs had been analysed. Post-mortem worm counts and examination of intestinal histology were then undertaken. Blood samples collected before slaughter in the second year of the study were assayed to measure serum levels of Trichostrongylus colubriformis-specific antibody and immunoglobulins (IgG1 and IgM), and numbers of circulating eosinophils. Overall, correlations between pre-slaughter FEC and total trichostrongyle burdens in the lambs proved to be very high (0.91 and 0.85, respectively, for the 2 years studied). In the first year, LFEC lambs, which were shedding only 28.6% as many strongyle eggs as their HFEC counterparts at slaughter, were found to harbour 37.6% as many adult trichostrongyle worms, while in the second year, LFEC lambs, which were shedding 16.1% as many strongyle eggs as their HFEC counterparts at slaughter, were found to harbour 33.5% as many adult trichostrongyle worms. Results, particularly in the second year, confirmed that significantly fewer worms of most of the important abomasal and small intestinal nematode species which infest lambs in New Zealand (i.e. Haemonchus contortus, Ostertagia circumcincta, Cooperia curticei, Nematodirus spathiger, T. colubriformis, and Trichostrongylus vitrinus) had established in the LFEC genotypes than in their HFEC counterparts. In addition, in utero egg counts of female intestinal Trichostrongylus spp. were significantly lower in LFEC lambs than in their HFEC counterparts, indicating a reduction in fecundity of those worms which did establish. There was also some evidence of an effect of host response on the developmental composition of burdens in the case of some worm species. In relation to host responses, numbers of globule leucocytes/mucosal mast cells in the intestinal mucosa were significantly higher (P < 0.01) in LFEC lambs than in HFEC lambs in both years of the study. Numbers of connective tissue type mast cells and eosinophils in the intestinal mucosa were also significantly higher in LFEC lambs but only in the second year of the study (P < 0.01 and P < 0.05, respectively). Numbers of circulating eosinophils did not differ significantly between the genotypes. T. colubriformis-specific antibodies, IgG1 and IgM to both L3 and adult worm antigens were all significantly higher (P < 0.01 or P < 0.05) in LFEC lambs than in HFEC lambs.

Abattoirs↗

The PCR typing of MHC-DRB genes in the sheep using primers for an intronic microsatellite: application to nematode parasite resistance.

The strong association between polymorphisms in an intronic microsatellite and the coding sequences for (BoLA)-DRB3 genes, previously described for demonstrating alleles of class II major histocompatibility complex (MHC) in the cow, was examined in sheep to see if similar polymorphisms could be demonstrated in the DRB region of the MHC. The bovine primes LA53 and LA54, previously used to amplify the bovine DRB3 microsatellites, were used with DNA from Australian sheep, eight DRB alleles were identified by length polymorphisms of polymerase chain reaction (PCR) products amplified from the DRB microsatellite region. Incomplete amplification of both alleles was sometimes found for sheep DNA samples using bovine primers, so a modified primer (LA53b) was used, and found to amplify the microsatellite next to intron 2 of the MHC more reliably than the LA53 primer. Two additional primers (LA31 and LA32), used in amplification of the exon 2 region of bovine DRB3, were used in the sheep, and the PCR products were analysed by single-stranded conformation polymorphism (SSCP). These primers successfully amplified the variable region of the ovine DRB region coded by exon 2, and the SSCP technique demonstrated polymorphisms with sheep DNA. Family studies demonstrated the segregation of alleles, by amplification both of intronic microsatellites and of the exon 2 variable region. Close correspondence was found between the two regions for several alleles, suggesting that the intronic microsatellites were closely linked to DRB-variable region alleles. Three families of Merino sheep with different antibody responses to intestinal nematode parasites were examined. The sire group with the highest antibody levels possessed two microsatellite alleles of closely similar length (alleles 3 and 4) inherited from the sire and present in high frequency in the lambs. In contrast, the other two sires did not possess these two alleles and the alleles were in low frequency in their progeny. Further studies are required in unrelated sheep to confirm whether these two alleles are associated with resistance to nematode parasites.

Alleles↗

Historical cohort investigation of spontaneous abortion in the Semiconductor Health Study: epidemiologic methods and analyses of risk in fabrication overall and in fabrication work groups.

The risk of spontaneous abortion (SAB) in the semiconductor industry was examined in a historical cohort study of pregnancies at 14 companies. We identified female employees who had worked for at least 6 months and whose ages ranged from 18 to 44 years during the 1986-1989 study period. Using company records, we included all fabrication-room (fab) employees and an approximately equal number of nonfabrication (nonfab) employees, for a total sample of 7,269. Telephone interviews with 6,088 women (84%) identified 904 eligible pregnancies and 113 SABs. Exposure classification was based on questionnaire and industrial hygiene assessments of tasks the women performed during the first trimester of pregnancy. Using logistic regression to control for age, smoking, ethnicity, education, income, year of pregnancy, and stress, we found a higher risk of SAB in fab employees than in nonfab employees (15.0% of fab pregnancies ended in SAB vs. 10.4% of nonfab pregnancies, adjusted relative risk [RR] = 1.43, 95% CI = 0.95-2.09). Analysis of fab work groups showed that the highest relative risk was in masking employees (17.5% SAB rate, adjusted RR = 1.78, 95% CI = 1.17-2.62 in comparison with nonfab employees). Within masking, the highest risk was found in etching-related process employees (22.2% SAB rate, adjusted RR = 2.08, 95% CI = 1.27-3.19 in comparison to nonfab employees.

Abortion, Spontaneous↗

Historical cohort study of spontaneous abortion among fabrication workers in the Semiconductor Health Study: agent-level analysis.

Risk of spontaneous abortion (SAB) was examined in relation to chemical and physical agents in a retrospective study of employees of 14 seminconductor manufacturers: After screening over 6,000 employees, 506 current and 385 former workers were eligible. If a woman had multiple eligible pregnancies, one was selected at random. Telephone interviews provided data on demographics and occupational and other exposures during the first trimester. Two groups of chemicals accounted for the 45% excess risk of SAB among fabrication-room (fab) workers: photoresist and developed solvents (PDS), including glycol ethers, and fluoride compounds used in etching. Women exposed to high levels of both these agents were at greater risk (RR = 3.21, 95% confidence interval [CI] = 1.29-5.96). In fab workers without these exposures, SAB rates were not elevated (adjusted relative risk [RR] = 0.98, 95% CI = 0.55-1.69). An association was seen with workplace stress, which was not limited to women exposed to PDS or fluoride, nor did stress explain the associations between these chemicals and SAB.

Abortion, Spontaneous↗

Communication issues in a multicomponent study of semiconductor employees.

A variety of methods were used to address communication problems in the Semiconductor Health Study (SHS). The diverse employee population required investigators to consider language, ethnic, and cultural differences in planning and implementing the study design. Studies of reproductive health in the workplace raise special concerns, including the critical need to preserve confidentiality and privacy of subjects. Notification of results of epidemiological studies reporting workplace hazards requires sensitivity to needs of workers. SHS investigators directly communicated overall results of this multicomponent study to participating employees at all sites and notified subjects of results of individual industrial hygiene monitoring and endocrine hormone assays.

Communication↗

The California Adult Performance Outcome Survey: preliminary evidence on reliability and validity.

Recent legislation in California mandated the development of an outcome measure suitable for measuring changes in quality of life associated with treatment in the public mental health system. The measure, known as the California Adult Performance Outcome Survey (CAPOS), relies on clinician and client reports of objective and subjective indicators of quality of life. The present study sought to determine whether the clinician-administered CAPOS would agree with that administered by trained research assistants, and whether the CAPOS would agree with an established quality of life measure. A sample of sixty-four severely mentally ill subjects were assessed by their regular mental health provider using the CAPOS. One week later they were assessed by a trained research assistant using the CAPOS and Lehman's Quality of Life Interview (QOLI). For most outcome domains, the CAPOS exhibited moderate to excellent agreement across occasions and raters. Correlations with the QOLI indicated a good degree of overlap among corresponding domains. Outcome measurement procedures for routine use in clinical settings are in their infancy. The CAPOS appears promising in this role because of its brevity, ease of administration, and adequate interrater reliability. The CAPOS affords state and local mental health authorities with an efficient means of tracking key quality of life indicators within the public mental health system.

Activities of Daily Living↗