Reported reasons for testing among hepatitis B virus infected patients, - Chronic Hepatitis Cohort Study (CHeCS), United States, 2006-2010
Gerbi GB , Rupp LB , Ko SC , Moorman A , Holmberg SD , Xu F . Liver Int 2014 34 (6) e162-3 Although 800,000-2 million persons in the United States have chronic hepatitis B virus (HBV) infection(1), only an estimated two-thirds of them have a diagnosis. We examined the reasons HBV-infected participants in the CheCS had been tested. CheCS is an observational cohort study created to assess the natural history and clinical encounters of chronic viral hepatitis in the United States. Of 3,358 patients aged ≥18 years who met the inclusion criteria for chronic hepatitis B virus (HBV) infection (2), 2,725(81.2%) were sampled randomly for survey. After the exclusion of 450 patients who died or could otherwise not be contacted, the remaining 2,275 (67.7%) patients were surveyed by U.S. mail or telephone. |
Trends in incidence of end-stage renal disease among persons with diagnosed diabetes - Puerto Rico, 1996-2010
Burrows NR , Hora I , Williams DE , Geiss LS . MMWR Morb Mortal Wkly Rep 2014 63 (9) 186-9 During 2010, approximately 6,091 persons aged ≥18 years in Puerto Rico were living with end-stage renal disease (ESRD) (i.e., kidney failure that requires regular dialysis or kidney transplantation for survival). This included 1,462 persons who began treatment for ESRD in 2010. Diabetes is the leading cause of ESRD in Puerto Rico, accounting for 66% of new cases in adults, followed by hypertension, which accounts for 15% of the cases. Although the number of adults initiating ESRD treatment (i.e., dialysis or kidney transplantation) in Puerto Rico each year who have diabetes listed as a primary cause (ESRD-D) has increased since 1996, ESRD-D incidence among adults with diagnosed diabetes has not shown a consistent trend. To assess recent trends in ESRD-D incidence among adults aged ≥18 years in Puerto Rico with diagnosed diabetes and to further examine trends by age group and sex, CDC analyzed 1996-2010 data from the U.S. Renal Data System (USRDS) and the Behavioral Risk Factor Surveillance System (BRFSS). After increasing in the late 1990s, ESRD-D incidence decreased during the 2000s among adult men and among persons aged 18-44 years with diagnosed diabetes in Puerto Rico. Throughout the period, ESRD-D incidence among adult women and among persons aged 45-64 and ≥75 years with diagnosed diabetes did not show a consistent trend, and ESRD-D incidence among persons aged 65-74 years with diagnosed diabetes increased. Increased awareness of the risk factors for kidney disease and implementation of effective interventions to prevent or delay kidney disease among persons with diagnosed diabetes might decrease ESRD incidence in Puerto Rico, particularly among women and older persons. |
Prevalence of and disparities in barriers to care experienced by youth with type 1 diabetes
Valenzuela JM , Seid M , Waitzfelder B , Anderson AM , Beavers DP , Dabelea DM , Dolan LM , Imperatore G , Marcovina S , Reynolds K , Yi-Frazier J , Mayer-Davis EJ . J Pediatr 2014 164 (6) 1369-75 e1 OBJECTIVE: To describe the prevalence of access and process barriers to health care and to examine their relationship to sociodemographic and disease factors in a large and diverse cohort of US youth with type 1 diabetes. STUDY DESIGN: A cross-sectional analysis of 780 youth who participated in the SEARCH for Diabetes in Youth Study and were diagnosed with type 1 diabetes in 2002-2005. Experience of barriers to care was collected from parent report on questionnaires. Analyses included multivariate regression models to predict the presence of specific barriers to care. RESULTS: Overall, 81.7% of participants reported at least one barrier; the 3 most common were costs (47.5%), communication (43.0%), and getting needed information (48.4%). Problems with access to care, not having a regular provider, and receiving contextual care (care that takes into account personal and family context) were associated with poorer glycated hemoglobin levels. Adjusted multivariate models indicated that barriers related to access (regular provider, cost) were most likely for youth with low family income and those without public health insurance. Barriers associated with the processes of quality care (contextual care, communication) were more likely for Hispanic youth and those whose parents had less education. CONCLUSIONS: This study indicates that a large proportion of youth with type 1 diabetes experience substantial barriers to care. Barriers to access and those associated with processes of quality care differed by sociodemographic characteristics. Future investigators should expand knowledge of the systemic processes that lead to disparate outcomes for some youth with diabetes and assess potential solutions. |
Preventive asthma medication discontinuation among children enrolled in fee-for-service Medicaid
Capo-Ramos DE , Duran C , Simon AE , Akinbami LJ , Schoendorf KC . J Asthma 2014 51 (6) 618-26 OBJECTIVE: Local-area studies demonstrate that preventive asthma medication discontinuation among Medicaid and Children's-Health-Insurance-Program (CHIP) enrolled children leads to adverse outcomes. We assessed time-to-discontinuation for preventive asthma medication and its risk factors among fee-for-service Medicaid/CHIP child beneficiaries. METHODS: National-Health-Interview-Survey participants (1997-2005) with ≥1 Medicaid- or CHIP-paid claims when 2-17 years-old (n=4262) were linked to Medicaid-Analytic-eXtract claims (1999-2008). Multivariate Cox proportional-hazards models to assess time-to-discontinuation (i.e., failing to refill prescriptions <30 days after previous supplies ran out) included demographic factors and medication regimen (inhaled corticosteroids [ICS], long-acting beta2-agonists, leukotriene modifiers, mast cell stabilizers, and monoclonal antibodies). RESULTS: Sixty-three percent discontinued preventive asthma medications by 90 days after the first prescription. Adolescents and toddlers had slightly higher hazards of discontinuation (adjusted hazard ratios [aHR], 1.13; 95% CI, 1.05-1.23; and 1.12; 1.03-1.21, respectively) versus 5-11 year-olds, as did Hispanics (aHR, 1.24; 1.13-1.35) and non-Hispanic blacks (aHR, 1.17; 1.07-1.28) versus non-Hispanic whites, children in households with one adult and ≥3 children (aHR, 1.17; 1.05-1.30) versus multiple adults and ≤2 children, and children with caregivers' educational-attainment ≤12th grade (aHR, 1.11; 1.02-1.20) versus caregivers with some college. Compared to regimens including both ICS and leukotriene modifiers, discontinuation was greater for those on ICS without leukotriene modifiers or on other preventive asthma medications (aHR, 1.67; 1.56-1.80; and 2.23; 1.78-2.80, respectively). CONCLUSION: More than 60% of children enrolled in fee-for-service Medicaid/CHIP discontinued preventive asthma medications by 90 days. Risk was increased for minorities and children from disadvantaged households. Understanding these factors may inform future pediatric asthma guidelines. |
Effect of food insecurity on chronic kidney disease in lower-income Americans
Crews DC , Kuczmarski MF , Grubbs V , Hedgeman E , Shahinian VB , Evans MK , Zonderman AB , Burrows NR , Williams DE , Saran R , Powe NR . Am J Nephrol 2014 39 (1) 27-35 BACKGROUND: The relation of food insecurity (inability to acquire nutritionally adequate and safe foods) and chronic kidney disease (CKD) is unknown. We examined whether food insecurity is associated with prevalent CKD among lower-income individuals in both the general US adult population and an urban population. METHODS: We conducted cross-sectional analyses of lower-income participants of the National Health and Nutrition Examination Survey (NHANES) 2003-2008 (n = 9,126) and the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study (n = 1,239). Food insecurity was defined based on questionnaires and CKD was defined by reduced estimated glomerular filtration rate or albuminuria; adjustment was performed with multivariable logistic regression. RESULTS: In NHANES, the age-adjusted prevalence of CKD was 20.3, 17.6, and 15.7% for the high, marginal, and no food insecurity groups, respectively. Analyses adjusting for sociodemographics and smoking status revealed high food insecurity to be associated with greater odds of CKD only among participants with either diabetes (OR = 1.67, 95% CI: 1.14-2.45 comparing high to no food insecurity groups) or hypertension (OR = 1.37, 95% CI: 1.03-1.82). In HANDLS, the age-adjusted CKD prevalence was 5.9 and 4.6% for those with and without food insecurity, respectively (p = 0.33). Food insecurity was associated with a trend towards greater odds of CKD (OR = 1.46, 95% CI: 0.98-2.18) with no evidence of effect modification across diabetes, hypertension, or obesity subgroups. CONCLUSION: Food insecurity may contribute to disparities in kidney disease, especially among persons with diabetes or hypertension, and is worthy of further study. |
Eye care use among a high-risk diabetic population seen in a public hospital's clinics
Maclennan PA , McGwin G Jr , Heckemeyer C , Lolley VR , Hullett S , Saaddine J , Shrestha SS , Owsley C . JAMA Ophthalmol 2014 132 (2) 162-7 IMPORTANCE: Little is known regarding eye care use among low-income persons with diabetes mellitus, especially African Americans. OBJECTIVE: To investigate eye care use among patients with diabetes who were seen in a county hospital clinic that primarily serves high-risk, low-income, non-Hispanic African American patients. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study with 2 years of follow-up examined eye care use among adult patients with diabetes seen in 2007 in an outpatient medical clinic of a large, urban county hospital that primarily serves low-income, non-Hispanic African American patients. Patients with a history of retinopathy and macular edema or a current diagnosis indicating ophthalmic complications were excluded. Eye care use was defined dichotomously as whether or not patients had a visit to the eye clinic for any eye care examination or procedure. We estimated crude and adjusted rate ratios (aRRs) and 95% CIs for the association between eye care use and selected clinical and demographic characteristics. RESULTS: There were 867 patients with diabetes identified: 61.9% were women, 76.2% were non-Hispanic African American, and 61.4% were indigent, with a mean age of 51.8 years. Eye care utilization rates were 33.2% within 1 and 45.0% within 2 years. For patients aged 19 to 39 years compared with those aged 65 years or older, significantly decreased eye care utilization rates were observed within 1 year (aRR, 0.48; 95% CI, 0.27-0.84) and within 2 years (aRR, 0.61; 95% CI, 0.38-0.99). CONCLUSIONS AND RELEVANCE: Overall eye care utilization rates were low. Additional education efforts to increase the perception of need among urban minority populations may be enhanced if focused on younger persons with diabetes. |
Hearing impairment associated with depression in US adults, National Health and Nutrition Examination Survey 2005-2010
Li CM , Zhang X , Hoffman HJ , Cotch MF , Themann CL , Wilson MR . JAMA Otolaryngol Head Neck Surg 2014 140 (4) 293-302 IMPORTANCE: Depression among hearing impaired US adults has not been studied previously. OBJECTIVE: To estimate the prevalence of and risk factors for depression among adults with hearing loss. DESIGN, SETTING, AND PARTICIPANTS: Adults aged 18 years or older (N = 18 318) who participated in the National Health and Nutrition Examination Survey (NHANES), 2005-2010, a nationally representative sample. INTERVENTIONS: Multistage probability sampling of US population. MAIN OUTCOMES AND MEASURES: Depression, assessed by the 9-item Patient Health Questionnaire (PHQ-9) scale, and hearing impairment (HI), assessed by self-report and audiometric examination for adults aged 70 years or older. RESULTS: The prevalence of moderate to severe depression (PHQ-9 score, ≥10) was 4.9% for individuals reporting excellent hearing, 7.1% for those with good hearing, and 11.4% for participants who reported a little trouble or greater HI. Using excellent hearing as the reference, after adjusting for all covariates, multivariate odds ratios (ORs) for depression were 1.4 (95% CI, 1.1-1.8) for good hearing, 1.7 (1.3-2.2) for a little trouble, 2.4 (1.7-3.2) for moderate trouble, 1.5 (0.9-2.6) for a lot of trouble, and 0.6 (0.1-2.6) for deaf. Moderate HI (defined by better ear pure-tone average of hearing thresholds at 0.5, 1, 2, and 4 kHz within the range 35- to 49-dB hearing level) was significantly associated with depression among older women (OR, 3.9; 95% CI, 1.3-11.3), after adjusting for age, sex, race/ethnicity, lifestyle characteristics, and selected health conditions. CONCLUSIONS AND RELEVANCE: After accounting for health conditions and other factors, including trouble seeing, self-reported HI and audiometrically determined HI were significantly associated with depression, particularly in women. Health care professionals should be aware of an increased risk for depression among adults with hearing loss. |
Barriers to eye care among people aged 40 years and older with diagnosed diabetes, 2006-2010
Chou CF , Sherrod CE , Zhang X , Barker LE , Bullard KM , Crews JE , Saaddine JB . Diabetes Care 2014 37 (1) 180-8 OBJECTIVE: We examine barriers to receiving recommended eye care among people aged ≥40 years with diagnosed diabetes. RESEARCH DESIGN AND METHODS: We analyzed 2006-2010 Behavioral Risk Factor Surveillance System data from 22 states (n = 27,699). Respondents who had not sought eye care in the preceding 12 months were asked the main reason why. We categorized the reasons as cost/lack of insurance, no need, no eye doctor/travel/appointment, and other (meaning everything else). We used multinomial logistic regression to control for race/ethnicity, education, income, and other selected covariates. RESULTS: Among adults with diagnosed diabetes, nonadherence to the recommended annual eye examinations was 23.5%. The most commonly reported reasons for not receiving eye care in the preceding 12 months were "no need" and "cost or lack of insurance" (39.7 and 32.3%, respectively). Other reasons were "no eye doctor," "no transportation" or "could not get appointment" (6.4%), and "other" (21.5%). After controlling for covariates, adults aged 40-64 years were more likely than those aged ≥65 years (relative risk ratio [RRR] = 2.79; 95% CI 2.01-3.89) and women were more likely than men (RRR = 2.33; 95% CI 1.75-3.14) to report "cost or lack of insurance" as their main reason. However, people aged 40-64 years were less likely than those aged ≥65 years to report "no need" (RRR = 0.51; 95% CI 0.39-0.67) as their main reason. CONCLUSIONS: Addressing concerns about "cost or lack of insurance" for adults under 65 years and "no perceived need" among those 65 years and older could help improve eye care service utilization among people with diabetes. |
Racial disparities in invasive Streptococcus pneumoniae infections, 1998-2009
Wortham JM , Zell E , Pondo T , Harrison L , Schaffner W , Lynfield R , Thomas A , Reingold A , Bennett N , Petit S , Aragon D , Bareta J , Juni B , Farley M , Beall B , Moore M . Clin Infect Dis 2014 58 (9) 1250-7 BACKGROUND: Before introduction of 7-valent pneumococcal conjugate vaccine (PCV7), invasive pneumococcal disease (IPD) rates among blacks were twice rates in whites. We measured the effects of trends in PCV7-type and non-PCV7-type IPD rates on racial disparities in overall IPD and estimated the proportion of IPD caused by serotypes included in 13-valent pneumococcal conjugate vaccine (PCV13). METHODS: We analyzed data from the Active Bacterial Core Surveillance (ABCs) System, which performs active, laboratory- and population-based surveillance for IPD for 29.2 million people in the United States during 1998-2009. For patients with unknown race, we multiply imputed race to calculate age-, race-, and serotype-specific IPD incidence rates. RESULTS: During 1998-2009, 47,449 IPD cases were identified; race was unknown for 5,419 (11%). After multiple imputation, 31,981 (67%) patients were considered white and 13,750 (29%) black. PCV7-type IPD rates in all ages in both races decreased to <1 case per 100,000 while there were no decreases in overall IPD rates after 2002. By 2009, PCV13 serotypes caused 71% of cases among whites <5 years old compared with 58% among blacks (p<0.01). PCV13 serotypes caused 50% of IPD cases in whites ≥5 years old compared with 43% among blacks (p<0.01). CONCLUSIONS: Despite near elimination of PCV7-type IPD in both races, overall disparities in IPD rates persisted because non-PCV7-type IPD rates are higher among blacks. While PCV13 introduction may reduce racial disparities in IPD, higher valency conjugate vaccines and strategies to directly address underlying causes are needed to eliminate IPD disparities. |
Rates of respiratory virus-associated hospitalization in children aged <5 years in rural northern India
Broor S , Dawood FS , Pandey BG , Saha S , Gupta V , Krishnan A , Rai S , Singh P , Erdman D , Lal RB . J Infect 2014 68 (3) 281-9 OBJECTIVES: Though respiratory viruses are thought to cause substantial morbidity globally in children aged <5 years, the incidence of severe respiratory virus infections in children is unknown in India where 20% of the world's children live. METHODS: During August 2009-July 2011, prospective population-based surveillance was conducted for hospitalizations of children aged <5 years in a rural community in Haryana State. Clinical data and respiratory specimens were collected. Swabs were tested by RT-PCR for influenza and parainfluenza viruses, respiratory syncytial virus (RSV), human metapneumovirus, coronaviruses, and adenovirus. Average annual hospitalization incidence was calculated using census data and adjusted for hospitalizations reported to occur at non-study hospitals according to a comunity healthcare utilization survey. RESULTS: Of 245 hospitalized children, respiratory viruses were detected among 98 (40%), of whom 92 (94%) had fever or respiratory symptoms. RSV accounted for the highest virus-associated hospitalization incidence (34.6/10,000, 95% CI 26.3-44.7) and 20% of hospitalizations. There were 11.8/10,000 (95% CI 7.9-18.4) influenza-associated hospitalizations (7% of hospitalizations). RSV and influenza virus detection peaked in winter (November-February) and rainy seasons (July), respectively. CONCLUSION: Respiratory viruses were associated with a substantial proportion of hospitalizations among young children in a rural Indian community. Public health research and prevention in India should consider targeting RSV and influenza in young children. |
A review of invasive Haemophilus influenzae disease in the indigenous populations of North America
Tsang RS , Bruce MG , Lem M , Barreto L , Ulanova M . Epidemiol Infect 2014 142 (7) 1-11 Historically, the highest incidence rates of invasive Haemophilus influenzae disease in the world were found in North American and Australian Indigenous children. Although immunization against H. influenzae type b (Hib) led to a marked decrease in invasive Hib disease in countries where it was implemented, this disease has not been eliminated and its rates in Indigenous communities remain higher than in the general North American population. In this literature review, we examined the epidemiology of invasive H. influenzae disease in the pre-Hib vaccine era, effect of carriage on disease epidemiology, immune response to H. influenzae infection and Hib vaccination in Indigenous and Caucasian children, and the changing epidemiology after Hib conjugate vaccine has been in use for more than two decades in North America. We also explored reasons behind the continued high rates of invasive H. influenzae disease in Indigenous populations in North America. H. influenzae type a (Hia) has emerged as a significant cause of severe disease in North American Indigenous communities. More research is needed to define the genotypic diversity of Hia and the disease burden that it causes in order to determine if a Hia vaccine is required to protect the vulnerable populations. |
Shifts in geographic distribution and antimicrobial resistance during a prolonged typhoid fever outbreak - Bundibugyo and Kasese Districts, Uganda, 2009-2011
Walters MS , Routh J , Mikoleit M , Kadivane S , Ouma C , Mubiru D , Mbusa B , Murangi A , Ejoku E , Rwantangle A , Kule U , Lule J , Garrett N , Halpin J , Maxwell N , Kagirita A , Mulabya F , Makumbi I , Freeman M , Joyce K , Hill V , Downing R , Mintz E . PLoS Negl Trop Dis 2014 8 (3) e2726 BACKGROUND: Salmonella enterica serovar Typhi is transmitted by fecally contaminated food and water and causes approximately 22 million typhoid fever infections worldwide each year. Most cases occur in developing countries, where approximately 4% of patients develop intestinal perforation (IP). In Kasese District, Uganda, a typhoid fever outbreak notable for a high IP rate began in 2008. We report that this outbreak continued through 2011, when it spread to the neighboring district of Bundibugyo. METHODOLOGY/PRINCIPAL FINDINGS: A suspected typhoid fever case was defined as IP or symptoms of fever, abdominal pain, and ≥1 of the following: gastrointestinal disruptions, body weakness, joint pain, headache, clinically suspected IP, or non-responsiveness to antimalarial medications. Cases were identified retrospectively via medical record reviews and prospectively through laboratory-enhanced case finding. Among Kasese residents, 709 cases were identified from August 1, 2009-December 31, 2011; of these, 149 were identified during the prospective period beginning November 1, 2011. Among Bundibugyo residents, 333 cases were identified from January 1-December 31, 2011, including 128 cases identified during the prospective period beginning October 28, 2011. IP was reported for 507 (82%) and 59 (20%) of Kasese and Bundibugyo cases, respectively. Blood and stool cultures performed for 154 patients during the prospective period yielded isolates from 24 (16%) patients. Three pulsed-field gel electrophoresis pattern combinations, including one observed in a Kasese isolate in 2009, were shared among Kasese and Bundibugyo isolates. Antimicrobial susceptibility was assessed for 18 isolates; among these 15 (83%) were multidrug-resistant (MDR), compared to 5% of 2009 isolates. CONCLUSIONS/SIGNIFICANCE: Molecular and epidemiological evidence suggest that during a prolonged outbreak, typhoid spread from Kasese to Bundibugyo. MDR strains became prevalent. Lasting interventions, such as typhoid vaccination and improvements in drinking water infrastructure, should be considered to minimize the risk of prolonged outbreaks in the future. |
Timely HIV diagnosis and HIV/TB comanagement among California patients in 2008
Kong D , Watt JP , Marks SM , Flood JM . Public Health Rep 2014 129 (2) 170-7 OBJECTIVE: National guidelines highlight the roles of early HIV diagnosis and effective comanagement for HIV and tuberculosis (TB) to prevent mortality and morbidity from HIV-related TB. We assessed HIV diagnosis timing and HIV/TB comanagement for California HIV/TB patients. METHODS: We reviewed and analyzed public health charts for California HIV/TB patients reported during 2008. HIV diagnoses fewer than three months before TB diagnosis were considered new HIV diagnoses. We determined the proportion of patients with new HIV diagnoses, risk factors for new HIV diagnoses, and proportion of patients receiving recommended CD4 cell count measurements, supervised TB therapy, and antiretroviral therapy (ART). RESULTS: Of 130 HIV/TB patients, 51% had new HIV diagnoses. Foreign-born patients were more likely than U.S.-born patients to have new HIV diagnoses. Supervised TB therapy and CD4 cell count measurements followed national recommendations for 91% and 74% of patients, respectively. At least 73% of patients started ART before completing TB therapy. Compared with patients who had previous HIV diagnoses, patients with new HIV diagnoses started ART later and had lower CD4 cell counts and higher viral loads at TB diagnosis. CONCLUSIONS: Although most HIV/TB patients received the recommended treatment, half had new HIV diagnoses. Compared with patients who had previous HIV diagnoses, patients with new HIV diagnoses had greater immunosuppression at TB diagnosis. A new diagnosis indicates that HIV could have been diagnosed earlier and ART or treatment for latent TB infection could have been initiated to prevent TB development. |
Treatment and outcomes among patients with Cryptococcus gattii infections in the United States Pacific Northwest
Smith RM , Mba-Jonas A , Tourdjman M , Schimek T , Debess E , Marsden-Haug N , Harris JR . PLoS One 2014 9 (2) e88875 BACKGROUND: Cryptococcus gattii is a fungal pathogen causing an emerging outbreak in the United States Pacific Northwest (PNW). Treatment guidelines for cryptococcosis are primarily based on data from C. neoformans infections; applicability to PNW C. gattii infection is unknown. We evaluated the relationship between initial antifungal treatment and outcomes for PNW C.gattii patients. METHODS: Cases were defined as culture-confirmed invasive C. gattii infections among residents of Oregon and Washington States during 2004-2011. Clinical data were abstracted from medical records through one year of follow-up. Recommended initial treatment for central nervous system (CNS), bloodstream, and severe pulmonary infections is amphotericin B and 5-flucytosine; for non-severe pulmonary infections, recommended initial treatment is fluconazole. Alternative initial treatment was defined as any other initial antifungal treatment. RESULTS: Seventy patients survived to diagnosis; 50 (71%) received the recommended initial treatment and 20 (29%) received an alternative. Fewer patients with pulmonary infections [21 (64%)] than CNS infections [25 (83%)] received the recommended initial treatment (p = 0.07). Among patients with pulmonary infections, those with severe infections received the recommended initial treatment less often than those with non-severe infections (11% vs. 83%, p<0.0001). Eight patients with severe pulmonary infections received alternative initial treatments; three died. Four patients with non-severe pulmonary infections received alternative initial treatments; two died. There was a trend towards increased three-month mortality among patients receiving alternative vs. recommended initial treatment (30% vs. 14%, p = 0.12), driven primarily by increased mortality among patients with pulmonary disease receiving alternative vs. recommended initial treatment (42% vs. 10%, p = 0.07). CONCLUSIONS: C.gattii patients with pulmonary infections - especially severe infections - may be less likely to receive recommended treatment than those with CNS infections; alternative treatment may be associated with increased mortality. Reasons for receipt of alternative treatment among C.gattii patients in this area should be investigated, and clinician awareness of recommended treatment reinforced. |
Zanamivir conjugated to poly-L-glutamine is much more active against influenza viruses in mice and ferrets than the drug itself
Weight AK , Belser JA , Tumpey TM , Chen J , Klibanov AM . Pharm Res 2014 31 (2) 466-74 PURPOSE: Previously, polymer-attached zanamivir had been found to inhibit influenza A viruses in vitro far better than did small-molecule zanamivir (1) itself. The aim of this study was to identify in vitro-using the plaque reduction assay-a highly potent 1-polymer conjugate, and subsequently test its antiviral efficacy in vivo. METHODS: By examining the structure-activity relationship of 1-polymer conjugates in the plaque assay, we have determined that the most potent inhibitor against several representative influenza virus strains has a neutral high-molecular-weight backbone and a short alkyl linker. We have examined this optimal polymeric inhibitor for efficacy and immunogenicity in the mouse and ferret models of infection. RESULTS: 1 attached to poly-L-glutamine is an effective therapeutic for established influenza infection in ferrets, reducing viral titers up to 30-fold for 6 days. There is also up to a 190-fold reduction in viral load when the drug is used as a combined prophylactic/therapeutic in mice. Additionally, we see no evidence that the drug conjugate stimulates an immune response in mice upon repeat administration. CONCLUSIONS: 1 attached to a neutral high-molecular-weight backbone through a short alkyl linker drastically reduced both in vitro and in vivo titers compared to those observed with 1 itself. Thus, further development of this polymeric zanamivir for the mitigation of influenza infection seems warranted. |
Neutralization of HIV subtypes A and D by breast milk IgG from women with HIV infection in Uganda
Palaia JM , McConnell M , Achenbach JE , Gustafson CE , Stoermer KA , Nolan M , Guay LA , Leitner TK , Matovu F , Taylor AW , Fowler MG , Janoff EN . J Infect 2014 68 (3) 264-72 OBJECTIVES: Among HIV-exposed infants in resource-limited countries, 8-12% are infected postnatally by breastfeeding. However, most of those uninfected at birth remain uninfected over time despite daily exposure to HIV in breast milk. Thus, we assessed the HIV-inhibitory activity of breast milk. METHODS: We measured cross-clade neutralization in activated PBMC of Ugandan subtype A (92UG031) and D (92UG005) primary HIV by breast milk or purified milk IgG and IgA from 25 HIV-infected Ugandan women. Isotype-specific antigen recognition was resolved by immunoblot. We determined HIV subtype from envelope population sequences in cells from 13 milk samples by PCR. RESULTS: Milk inhibited p24 production by ≥50% (dose-dependent) by subtype A (21/25; 84%) and subtype D (11/25; 44%). IgG consistently reacted with multiple HIV antigens, including gp120/gp41, but IgA primarily recognized p24 alone. Depletion of IgG (n = 5), not IgA, diminished neutralization (mean 78 +/- 33%) that was largely restored by IgG repletion. Mothers infected with subtype A more effectively neutralized subtype A than D. CONCLUSIONS: Breast milk from HIV-infected women showed homotypic and cross-subtype neutralization of HIV by IgG-dependent and -independent mechanisms. These data direct further investigations into mechanisms of resistance against postnatal transmission of HIV to infants from their mothers. |
Population-based incidence of severe acute respiratory virus infections among children aged <5 years in rural Bangladesh, June-October 2010
Nasreen S , Luby SP , Brooks WA , Homaira N , Mamun AA , Bhuiyan MU , Rahman M , Ahmed D , Abedin J , Rahman M , Alamgir AS , Fry AM , Streatfield PK , Rahman A , Bresee J , Widdowson MA , Azziz-Baumgartner E . PLoS One 2014 9 (2) e89978 BACKGROUND: Better understanding the etiology-specific incidence of severe acute respiratory infections (SARIs) in resource-poor, rural settings will help further develop and prioritize prevention strategies. To address this gap in knowledge, we conducted a longitudinal study to estimate the incidence of SARIs among children in rural Bangladesh. METHODS: During June through October 2010, we followed children aged <5 years in 67 villages to identify those with cough, difficulty breathing, age-specific tachypnea and/or danger signs in the community or admitted to the local hospital. A study physician collected clinical information and obtained nasopharyngeal swabs from all SARI cases and blood for bacterial culture from those hospitalized. We tested swabs for respiratory syncytial virus (RSV), influenza viruses, human metapneumoviruses, adenoviruses and human parainfluenza viruses 1-3 (HPIV) by real-time reverse transcription polymerase chain reaction. We calculated virus-specific SARI incidence by dividing the number of new illnesses by the person-time each child contributed to the study. RESULTS: We followed 12,850 children for 279,029 person-weeks (pw) and identified 141 SARI cases; 76 (54%) at their homes and 65 (46%) at the hospital. RSV was associated with 7.9 SARI hospitalizations per 100,000 pw, HPIV3 2.2 hospitalizations/100,000 pw, and influenza 1.1 hospitalizations/100,000 pw. Among non-hospitalized SARI cases, RSV was associated with 10.8 illnesses/100,000 pw, HPIV3 1.8/100,000 pw, influenza 1.4/100,000 pw, and adenoviruses 0.4/100,000 pw. CONCLUSION: Respiratory viruses, particularly RSV, were commonly associated with SARI among children. It may be useful to explore the value of investing in prevention strategies, such as handwashing and respiratory hygiene, to reduce respiratory infections among young children in such settings. |
The problem of Helicobacter pylori resistance to antibiotics: a systematic review in Latin America
Camargo MC , Garcia A , Riquelme A , Otero W , Camargo CA , Hernandez-Garcia T , Candia R , Bruce MG , Rabkin CS . Am J Gastroenterol 2014 109 (4) 485-95 OBJECTIVES: Latin America has a high prevalence of Helicobacter pylori infection and associated diseases, including gastric cancer. Antibiotic therapy can eradicate the bacterial infection and decrease associated morbidity and mortality. To tailor recommendations for optimal treatments, we summarized published literature and calculated region- and country-specific prevalences of antibiotic resistance. METHODS: Searches of PubMed and regional databases for observational studies evaluating H. pylori antibiotic resistance yielded a total of 59 independent studies (56 in adults, 2 in children, and 1 in both groups) published up to October 2013 regarding H. pylori isolates collected between 1988 and 2011. Study-specific prevalences of primary resistance to commonly prescribed antibiotics were summarized using random-effects models. Between-study heterogeneity was assessed by meta-regression. As a sensitivity analysis, we extended our research to studies of patients with prior H. pylori-eradication therapy. RESULTS: Summary prevalences of antimicrobial primary resistance among adults varied by antibiotic, including 12% for clarithromycin (n=35 studies), 53% for metronidazole (n=34), 4% for amoxicillin (n=28), 6% for tetracycline (n=20), 3% for furazolidone (n=6), 15% for fluoroquinolones (n=5), and 8% for dual clarithromycin and metronidazole (n=10). Resistance prevalence varied significantly by country, but not by year of sample collection. Analyses including studies of patients with prior therapy yielded similar estimates. Pediatric reports were too few to be summarized by meta-analysis. CONCLUSIONS: Resistance to first-line anti-H. pylori antibiotics is high in Latin American populations. In some countries, the empirical use of clarithromycin without susceptibility testing may not be appropriate. These findings stress the need for appropriate surveillance programs, improved antimicrobial regulations, and increased public awareness. |
High risk for HIV following syphilis diagnosis among men in Florida, 2000-2011
Peterman TA , Newman DR , Maddox L , Schmitt K , Shiver S . Public Health Rep 2014 129 (2) 164-9 OBJECTIVE: Multiple interventions have been shown to reduce the risk of HIV acquisition, including preexposure prophylaxis with antiretroviral medications, but high costs require targeting interventions to people at the highest risk. We identified the risk of HIV following a syphilis diagnosis for men in Florida. METHODS: We analyzed surveillance records of 13- to 59-year-old men in Florida who were reported as having syphilis from January 1, 2000, to December 31, 2009. We excluded men who had HIV infection reported before their syphilis diagnosis (and within 60 days after), then searched the database to see if the remaining men were reported as having HIV infection by December 31, 2011. RESULTS: Of the 9,512 men with syphilis we followed, 1,323 were subsequently diagnosed as having HIV infection 60-3,753 days after their syphilis diagnosis. The risk of a subsequent diagnosis of HIV infection was 3.6% in the first year after syphilis was diagnosed and reached 17.5% 10 years after a syphilis diagnosis. The risk of HIV was higher for non-Hispanic white men (3.4% per year) than for non-Hispanic black men (1.8% per year). The likelihood of developing HIV was slightly lower for men diagnosed with syphilis in 2000 and 2001 compared with subsequent years. Of men diagnosed with syphilis in 2003, 21.5% were reported as having a new HIV diagnosis by December 31, 2011. CONCLUSION: Men who acquire syphilis are at very high risk of HIV infection. |
An outbreak of influenza B in an isolated nomadic community in Jammu & Kashmir, India
Khan UH , Mir MA , Ahmad F , Mir MH , Bali NK , Lal RB , Broor SS , Koul PA . Indian J Med Res 2013 138 (6) 1012-5 BACKGROUND & OBJECTIVES: Community outbreaks of disease amongst nomadic populations generally remain undocumented. Following a reported increase in acute respiratory tract infections (ARI) in May 2011 in a nomadic population of Sangerwini in Jammu & Kashmir, India, we examined the patients with ARI symptoms and their nasal swabs were tested for influenza virus. METHODS: Patients with ARI (n=526) were screened from May 14 to 23, 2011 and nasopharyngeal swabs collected from 84 with Influenza like illness (ILI) for bacterial cultures and influenza virus testing. Samples were tested for influenza A and influenza B by real time (RT)-PCR. RESULTS: Twelve (14.3%) of the 84 patients tested positive for influenza B, compared to only one (0.9%) of 108 patients with ILI in a parallel survey performed in Srinagar during the same period, suggesting a localized outbreak in the isolated nomadic community. All presented with respiratory symptoms of less than seven days. Familial clustering was seen in 40 per cent (25% of influenza B positives). Average daytime temperatures ranged from 15-16 degrees C compared to 22 degrees C in Srinagar. Four patients developed pneumonia whereas others ran a mild course with a total recovery with oseltamivir and symptomatic therapy. INTERPRETATION & CONCLUSION: Our report of confirmed influenza B in this underprivileged nomadic population argues for routine surveillance with efforts to improve vaccination and infection control practices. |
Clinical differences between influenza A (H1N1) pdm09 & influenza B infections identified through active community surveillance in north India
Purakayastha DR , Gupta V , Broor S , Sullender W , Fowler K , Widdowson MA , Lal RB , Krishnan A . Indian J Med Res 2013 138 (6) 962-8 BACKGROUND & OBJECTIVES: Most studies on the clinical presentation with influenza viruses have been conducted in outpatient or inpatient medical facilities with only a few studies in community settings. Clinical differences between influenza A (H1N1) pdm 09 and influenza B virus infections have importance for community-based public health surveillance. An active community surveillance at the time of emergence of pandemic influenza provided us with an opportunity to compare the clinical features among patients infected with influenza A (H1N1) pdm09 virus and those with influenza B virus co-circulating in an active community-based weekly surveillance in three villages in Faridabad, Haryana, north India. METHODS: Active surveillance for febrile acute respiratory infection (FARI) was carried out in a rural community (n=16,182) in the context of an inactivated trivalent influenza vaccine trial (among children <11 yr). Individuals with FARI were assessed clinically by nurses and respiratory samples collected and tested for influenza viruses by real time RT-PCR from November 2009 to August 2010. Clinical symptoms of patients with influenza A (H1N1) pdm 09 and influenza B infection were compared. RESULTS: Of the 4796 samples tested, 822 (17%) were positive for influenza virus. Of these, 443 (54%) were influenza A (H1N1) pdm09, 373 (45%) were influenza B and six were other subtypes/mixed infections. The mean age was lower for patients with influenza B (16.4 yr) than influenza A (H1N1) pdm09 infection (18.7 yr; P=0.04). Among children aged 5-18 yr, chills/rigours (OR 4.0; CI 2.2, 7.4), sore throat (OR 6.8; CI 2.3, 27.3) and headache (OR2.0; CI 1.3, 3.3) were more common in influenza A (H1N1) pdm09 infection than in influenza B cases. Chills/rigours (OR 2.4; CI 1.4, 4.0) and headache (OR 1.7; CI 1.0, 2.7) were associated with influenza A (H1N1) pdm09 infection in those >18 yr. No significant differences were seen in children <5 yr. CONCLUSION: Our findings show that the differences in the clinical presentation of influenza A(H1N1)pdm09 and influenza B infections are not likely to be of clinical or public health significance. |
High-risk use by patients prescribed opioids for pain and its role in overdose deaths
Baumblatt JA , Wiedeman C , Dunn JR , Schaffner W , Paulozzi LJ , Jones TF . JAMA Intern Med 2014 174 (5) 796-801 IMPORTANCE: From January 1, 2003, through December 31, 2010, drug overdose deaths in Tennessee increased from 422 to 1059 per year. More of these deaths involved prescription opioids than heroin and cocaine combined. OBJECTIVE: To assess the contribution of certain opioid-prescribing patterns to the risk of overdose death. DESIGN, SETTING, AND PARTICIPANTS: We performed a matched case-control study that analyzed opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 1, 2007, through December 31, 2011, to identify risk factors associated with opioid-related overdose deaths from January 1, 2009, through December 31, 2010. Case patients were ascertained from death certificate data. Age- and sex-matched controls were randomly selected from among live patients in the TNCSMP. MAIN OUTCOMES AND MEASURES: We defined a high-risk number of prescribers or pharmacies as 4 or more per year and high-risk dosage as a daily mean of more than 100 morphine milligram equivalents (MMEs) per year. The main outcome was opioid-related overdose death. RESULTS: From January 1, 2007, through December 31, 2011, one-third of the population of Tennessee filled an opioid prescription each year, and opioid prescription rates increased from 108.3 to 142.5 per 100 population per year. Among all patients in Tennessee prescribed opioids during 2011, 7.6% used more than 4 prescribers, 2.5% used more than 4 pharmacies, and 2.8% had a mean daily dosage greater than 100 MMEs. Increased risk of opioid-related overdose death was associated with 4 or more prescribers (adjusted odds ratio [aOR], 6.5; 95% CI, 5.1-8.5), 4 or more pharmacies (aOR, 6.0; 95% CI, 4.4-8.3), and more than 100 MMEs (aOR, 11.2; 95% CI, 8.3-15.1). Persons with 1 or more risk factor accounted for 55% of all overdose deaths. CONCLUSIONS AND RELEVANCE: High-risk use of prescription opioids is frequent and increasing in Tennessee and is associated with increased overdose mortality. Use of prescription drug-monitoring program data to direct risk-reduction measures to the types of patients overrepresented among overdose deaths might reduce mortality associated with opioid abuse. |
What do we know of childhood exposures to metals (arsenic, cadmium, lead, and mercury) in Emerging Market countries?
Horton LM , Mortensen ME , Iossifova Y , Wald MM , Burgess P . Int J Pediatr 2013 2013 872596 Arsenic, cadmium, lead, and mercury present potential health risks to children who are exposed through inhalation or ingestion. Emerging Market countries experience rapid industrial development that may coincide with the increased release of these metals into the environment. A literature review was conducted for English language articles from the 21st century on pediatric exposures to arsenic, cadmium, lead, and mercury in the International Monetary Fund's (IMF) top 10 Emerging Market countries: Brazil, China, India, Indonesia, Mexico, Poland, Russia, South Korea, Taiwan, and Turkey. Seventy-six peer-reviewed, published studies on pediatric exposure to metals met the inclusion criteria. The reported concentrations of metals in blood and urine from these studies were generally higher than US reference values, and many studies identified adverse health effects associated with metals exposure. Evidence of exposure to metals in the pediatric population of these Emerging Market countries demonstrates a need for interventions to reduce exposure and efforts to establish country-specific reference values through surveillance or biomonitoring. The findings from review of these 10 countries also suggest the need for country-specific public health policies and clinician education in Emerging Markets. |
Evaluation of Internet-based dengue query data: Google dengue trends
Gluskin RT , Johansson MA , Santillana M , Brownstein JS . PLoS Negl Trop Dis 2014 8 (2) e2713 Dengue is a common and growing problem worldwide, with an estimated 70-140 million cases per year. Traditional, healthcare-based, government-implemented dengue surveillance is resource intensive and slow. As global Internet use has increased, novel, Internet-based disease monitoring tools have emerged. Google Dengue Trends (GDT) uses near real-time search query data to create an index of dengue incidence that is a linear proxy for traditional surveillance. Studies have shown that GDT correlates highly with dengue incidence in multiple countries on a large spatial scale. This study addresses the heterogeneity of GDT at smaller spatial scales, assessing its accuracy at the state-level in Mexico and identifying factors that are associated with its accuracy. We used Pearson correlation to estimate the association between GDT and traditional dengue surveillance data for Mexico at the national level and for 17 Mexican states. Nationally, GDT captured approximately 83% of the variability in reported cases over the 9 study years. The correlation between GDT and reported cases varied from state to state, capturing anywhere from 1% of the variability in Baja California to 88% in Chiapas, with higher accuracy in states with higher dengue average annual incidence. A model including annual average maximum temperature, precipitation, and their interaction accounted for 81% of the variability in GDT accuracy between states. This climate model was the best indicator of GDT accuracy, suggesting that GDT works best in areas with intense transmission, particularly where local climate is well suited for transmission. Internet accessibility (average approximately 36%) did not appear to affect GDT accuracy. While GDT seems to be a less robust indicator of local transmission in areas of low incidence and unfavorable climate, it may indicate cases among travelers in those areas. Identifying the strengths and limitations of novel surveillance is critical for these types of data to be used to make public health decisions and forecasting models. |
Evolution and structural organization of the C proteins of paramyxovirinae.
Lo MK , Sogaard TM , Karlin DG . PLoS One 2014 9 (2) e90003 The phosphoprotein (P) gene of most Paramyxovirinae encodes several proteins in overlapping frames: P and V, which share a common N-terminus (PNT), and C, which overlaps PNT. Overlapping genes are of particular interest because they encode proteins originated de novo, some of which have unknown structural folds, challenging the notion that nature utilizes only a limited, well-mapped area of fold space. The C proteins cluster in three groups, comprising measles, Nipah, and Sendai virus. We predicted that all C proteins have a similar organization: a variable, disordered N-terminus and a conserved, alpha-helical C-terminus. We confirmed this predicted organization by biophysically characterizing recombinant C proteins from Tupaia paramyxovirus (measles group) and human parainfluenza virus 1 (Sendai group). We also found that the C of the measles and Nipah groups have statistically significant sequence similarity, indicating a common origin. Although the C of the Sendai group lack sequence similarity with them, we speculate that they also have a common origin, given their similar genomic location and structural organization. Since C is dispensable for viral replication, unlike PNT, we hypothesize that C may have originated de novo by overprinting PNT in the ancestor of Paramyxovirinae. Intriguingly, in measles virus and Nipah virus, PNT encodes STAT1-binding sites that overlap different regions of the C-terminus of C, indicating they have probably originated independently. This arrangement, in which the same genetic region encodes simultaneously a crucial functional motif (a STAT1-binding site) and a highly constrained region (the C-terminus of C), seems paradoxical, since it should severely reduce the ability of the virus to adapt. The fact that it originated twice suggests that it must be balanced by an evolutionary advantage, perhaps from reducing the size of the genetic region vulnerable to mutations. |
Characterizing tuberculosis genotype clusters along the United States-Mexico border
Baker BJ , Moonan PK . Int J Tuberc Lung Dis 2014 18 (3) 289-291 We examined the growth of tuberculosis (TB) genotype clusters during 2005-2010 in the United States, categorized by country of origin and ethnicity of the index case and geographic proximity to the US-Mexico border at the time of TB diagnosis. Nationwide, 38.9% of cases subsequent to Mexico-born index cases were US-born. Among clusters following US-born Hispanic and USborn non-Hispanic index cases, respectively 29.2% and 5.3% of subsequent cluster members were Mexicoborn. In border areas, the majority of subsequent cases were Mexico-born following US-born Hispanic (56.4%) and US-born non-Hispanic (55.6%) index cases. These findings suggest that TB transmission commonly occurs between US-born and Mexico-born persons. Along the US-Mexico border, prioritizing TB genotype clusters following US-born index cases for investigation may prevent subsequent cases among both US-born and Mexico-born persons. |
Intravaginal cleansing among women attending a sexually transmitted infection clinic in Kingston, Jamaica
Carter M , Gallo M , Anderson C , Snead MC , Wiener J , Bailey A , Costenbader E , Legardy-Williams J , Hylton-Kong T . West Indian Med J 2013 62 (1) 56-61 OBJECTIVES: Although common worldwide, intravaginal cleansing is associated with poor health outcomes. We sought to describe intravaginal cleansing among women attending a sexually transmitted infection (STI) clinic in Jamaica. METHODS: We examined intravaginal cleansing ("washing up inside the vagina", douching, and products or materials used) among 293 participants in a randomized trial of counselling messages at an STI clinic in Kingston. We focussed on information on intravaginal cleansing performed in the 30 days and three days preceding their baseline study visit. We describe reported cleansing behaviours and used logistic regression to identify correlates of intravaginal cleansing. RESULTS: Fifty-eight per cent of participants reported intravaginal cleansing in the previous 30 days, and 46% did so in the three days before baseline. Among those who cleansed in the previous 30 days, 88% reported doing so for hygiene unrelated to sex, and three-fourths reported generally doing so more than once per day. Soap (usually with water) and water alone were the most common products used for washing; commercial douches or detergents were reported infrequently. Intravaginal cleansing in the three days before the baseline visit was positively associated with having more than one sex partner in the previous three months (adjusted odds ratio [AOR], 1.9; 95% CI, 1.1, 3.2), and negatively associated with experiencing itching in the genital area at baseline (AOR, 0.6; 95% CI, 0.4, 1.0). CONCLUSIONS: A large proportion of women attending STI clinics in Jamaica engage in frequent intravaginal cleansing, indicating a need for clinicians to discuss this topic with them accordingly. |
Promoting sexual health equity in the United States: implications from exploratory research with African-American adults
Friedman AL , Uhrig J , Poehlman J , Scales M , Hogben M . Health Educ Res 2014 29 (6) 993-1004 In an effort to inform communication efforts to promote sexual health equity in the United States, the Centers for Disease Control and Prevention sought to explore African-Americans' perceptions of the sexually transmitted disease (STD) problem in their communities, reactions to racially comparative STD data and opinions about dissemination of such information. Semi-structured triads and individual interviews were conducted with African-American adults (N = 158) in the Southeastern and Midwestern United States. Most participants believed that STDs are a problem in their communities but were unaware of the extent to which STDs disproportionately affect African Americans. Once informed about racial differences in STD rates, participants commonly reacted with shock, fear and despair; a minority raised questions about the information's source and credibility. Most felt it was critical to get the information out to African-American communities as a 'wake-up call' to motivate change, though some raised concerns about its dissemination. Findings suggest that information about racial differences in STD rates must be strategically crafted and delivered through targeted channels to be acceptable to African Americans. So as not to further harm communities burdened by other social/health inequities, alternative (strength-based) approaches should be considered for motivating positive change. |
Carbapenem-resistant Klebsiella pneumoniae producing New Delhi metallo-ß-lactamase at an acute care hospital, Colorado, 2012.
Epson EE , Pisney LM , Wendt JM , Maccannell DR , Janelle SJ , Kitchel B , Rasheed JK , Limbago BM , Gould CV , Kallen AJ , Barron MA , Bamberg WM . Infect Control Hosp Epidemiol 2014 35 (4) 390-7 OBJECTIVE: To investigate an outbreak of New Delhi metallo-beta-lactamase (NDM)-producing carbapenem-resistant Enterobacteriaceae (CRE) and determine interventions to interrupt transmission. Design, Setting, and Patients. Epidemiologic investigation of an outbreak of NDM-producing CRE among patients at a Colorado acute care hospital. METHODS: Case patients had NDM-producing CRE isolated from clinical or rectal surveillance cultures (SCs) collected during the period January 1, 2012, through October 20, 2012. Case patients were identified through microbiology records and 6 rounds of SCs in hospital units where they had resided. CRE isolates were tested by real-time polymerase chain reaction for blaNDM. Medical records were reviewed for epidemiologic links; relatedness of isolates was evaluated by pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). Infection control (IC) was assessed through staff interviews and direct observations. RESULTS: Two patients were initially identified with NDM-producing CRE during July-August 2012. A third case patient, admitted in May, was identified through microbiology records review. SC identified 5 additional case patients. Patients had resided in 11 different units before identification. All isolates were highly related by PFGE. WGS suggested 3 clusters of CRE. Combining WGS with epidemiology identified 4 units as likely transmission sites. NDM-producing CRE positivity in certain patients was not explained by direct epidemiologic overlap, which suggests that undetected colonized patients were involved in transmission. CONCLUSIONS: A 4-month outbreak of NDM-producing CRE occurred at a single hospital, highlighting the risk for spread of these organisms. Combined WGS and epidemiologic data suggested transmission primarily occurred on 4 units. Timely SC, combined with targeted IC measures, were likely responsible for controlling transmission. |
Validation and application of models to predict facemask influenza contamination in healthcare settings
Fisher EM , Noti JD , Lindsley WG , Blachere FM , Shaffer RE . Risk Anal 2014 34 (8) 1423-34 Facemasks are part of the hierarchy of interventions used to reduce the transmission of respiratory pathogens by providing a barrier. Two types of facemasks used by healthcare workers are N95 filtering facepiece respirators (FFRs) and surgical masks (SMs). These can become contaminated with respiratory pathogens during use, thus serving as potential sources for transmission. However, because of the lack of field studies, the hazard associated with pathogen-exposed facemasks is unknown. A mathematical model was used to calculate the potential influenza contamination of facemasks from aerosol sources in various exposure scenarios. The aerosol model was validated with data from previous laboratory studies using facemasks mounted on headforms in a simulated healthcare room. The model was then used to estimate facemask contamination levels in three scenarios generated with input parameters from the literature. A second model estimated facemask contamination from a cough. It was determined that contamination levels from a single cough ( approximately 19 viruses) were much less than likely levels from aerosols (4,473 viruses on FFRs and 3,476 viruses on SMs). For aerosol contamination, a range of input values from the literature resulted in wide variation in estimated facemask contamination levels (13-202,549 viruses), depending on the values selected. Overall, these models and estimates for facemask contamination levels can be used to inform infection control practice and research related to the development of better facemasks, to characterize airborne contamination levels, and to assist in assessment of risk from reaerosolization and fomite transfer because of handling and reuse of contaminated facemasks. |
Vital signs: improving antibiotic use among hospitalized patients
Fridkin S , Baggs J , Fagan R , Magill S , Pollack LA , Malpiedi P , Slayton R , Khader K , Rubin MA , Jones M , Samore MH , Dumyati G , Dodds-Ashley E , Meek J , Yousey-Hindes K , Jernigan J , Shehab N , Herrera R , McDonald CL , Schneider A , Srinivasan A . MMWR Morb Mortal Wkly Rep 2014 63 (9) 194-200 BACKGROUND: Antibiotics are essential to effectively treat many hospitalized patients. However, when antibiotics are prescribed incorrectly, they offer little benefit to patients and potentially expose them to risks for complications, including Clostridium difficile infection (CDI) and antibiotic-resistant infections. Information is needed on the frequency of incorrect prescribing in hospitals and how improved prescribing will benefit patients. METHODS: A national administrative database (MarketScan Hospital Drug Database) and CDC's Emerging Infections Program (EIP) data were analyzed to assess the potential for improvement of inpatient antibiotic prescribing. Variability in days of therapy for selected antibiotics reported to the National Healthcare Safety Network (NHSN) antimicrobial use option was computed. The impact of reducing inpatient antibiotic exposure on incidence of CDI was modeled using data from two U.S. hospitals. RESULTS: In 2010, 55.7% of patients discharged from 323 hospitals received antibiotics during their hospitalization. EIP reviewed patients' records from 183 hospitals to describe inpatient antibiotic use; antibiotic prescribing potentially could be improved in 37.2% of the most common prescription scenarios reviewed. There were threefold differences in usage rates among 26 medical/surgical wards reporting to NHSN. Models estimate that the total direct and indirect effects from a 30% reduction in use of broad-spectrum antibiotics will result in a 26% reduction in CDI. CONCLUSIONS: Antibiotic prescribing for inpatients is common, and there is ample opportunity to improve use and patient safety by reducing incorrect antibiotic prescribing. Implications for Public Health: Hospital administrators and health-care providers can reduce potential harm and risk for antibiotic resistance by implementing formal programs to improve antibiotic prescribing in hospitals. |
Microsporidiosis acquired through solid organ transplantation a public health investigation
Hocevar SN , Paddock CD , Spak CW , Rosenblatt R , Diaz-Luna H , Castillo I , Luna S , Friedman GC , Antony S , Stoddard RA , Tiller RV , Peterson T , Blau DM , Sriram RR , Da Silva A , De Almeida M , Benedict T , Goldsmith CS , Zaki SR , Visvesvara GS , Kuehnert MJ . Ann Intern Med 2014 160 (4) 213-220 BACKGROUND: Encephalitozoon cuniculi, a microsporidial species most commonly recognized as a cause of renal, respiratory, and central nervous system infections in immunosuppressed patients, was identified as the cause of a temporally associated cluster of febrile illness among 3 solid organ transplant recipients from a common donor. OBJECTIVE: To confirm the source of the illness, assess donor and recipient risk factors, and provide therapy recommendations for ill recipients. DESIGN: Public health investigation. SETTING: Two transplant hospitals and community interview with the deceased donor's family. PATIENTS: Three transplant recipients and the organ donor. MEASUREMENTS: Specimens were tested for microsporidia by using culture, immunofluorescent antibody, polymerase chain reaction, immunohistochemistry, and electron microscopy. Donor medical records were reviewed and a questionnaire was developed to assess for microsporidial infection. RESULTS: Kidneys and lungs were procured from the deceased donor and transplanted to 3 recipients who became ill with fever 7 to 10 weeks after the transplant. Results of urine culture, serologic, and polymerase chain reaction testing were positive for E. cuniculi of genotype III in each recipient; the organism was also identified in biopsy or autopsy specimens in all recipients. The donor had positive serologic test results for E. cuniculi. Surviving recipients received albendazole. Donor assessment did not identify factors for suspected E. cuniculi infection. LIMITATION: Inability to detect organism by culture or polymerase chain reaction in donor due to lack of autopsy specimens. CONCLUSION: Microsporidiosis is now recognized as an emerging transplant-associated disease and should be considered in febrile transplant recipients when tests for routinely encountered agents are unrevealing. Donor-derived disease is critical to assess when multiple recipients from a common donor are ill. |
NAP1 strain type predicts outcomes from Clostridium difficile infection
See I , Mu Y , Cohen J , Beldavs ZG , Winston LG , Dumyati G , Holzbauer S , Dunn J , Farley MM , Lyons C , Johnston H , Phipps E , Perlmutter R , Anderson L , Gerding DN , Lessa FC . Clin Infect Dis 2014 58 (10) 1394-400 BACKGROUND: Studies conflict regarding the importance of the fluoroquinolone-resistant North American pulsed-field gel electrophoresis type 1 (NAP1) strain in Clostridium difficile infection (CDI) outcome. We describe strain types causing CDI and evaluate their association with patient outcomes. METHODS: CDI cases were identified from population-based surveillance. Multivariate regression models were used to evaluate the associations of strain type with severe disease (ileus, toxic megacolon, or pseudomembranous colitis within 5 days; or white blood cell count ≥15,000/mm3 within one day of positive test), severe outcome (intensive care unit admission after positive test, colectomy for C. difficile infection, or death within 30 days of positive test), and death within 14 days of positive test. RESULTS: Strain typing results were available for 2,057 cases. Severe disease occurred in 363 (17.7%) cases, severe outcome in 100 (4.9%), and death within 14 days in 56 (2.7%). The most common strain types were NAP1 (28.4%), NAP4 (10.2%) and NAP11 (9.1%). In unadjusted analysis, NAP1 was associated with greater odds of severe disease than other strains. After controlling for patient risk factors, healthcare exposure, and antibiotic use, NAP1 was associated with severe disease (adjusted odds ratio [aOR] 1.74, 95% confidence interval [CI], 1.36-2.22), severe outcome (aOR 1.66, 95% CI, 1.09-2.54), and death within 14 days (aOR 2.12, 95% CI, 1.22-3.68). CONCLUSION: NAP1 was the most prevalent strain and a predictor of severe disease, severe outcome, and death. Strategies to reduce NAP1 prevalence, such as antibiotic stewardship to reduce fluoroquinolone use, might reduce CDI morbidity. |
Notes from the field: rapidly growing nontuberculous mycobacterium wound infections among medical tourists undergoing cosmetic surgeries in the Dominican Republic - multiple states, March 2013-February 2014
Schnabel D , Gaines J , Nguyen DB , Esposito DH , Ridpath A , Yacisin K , Poy JA , Mullins J , Burns R , Lijewski V , McElroy NP , Ahmad N , Harrison C , Parinelli EJ , Beaudoin AL , Posivak-Khouly L , Pritchard S , Jensen BJ , Toney NC , Moulton-Meissner HA , Nyangoma EN , Barry AM , Feldman KA , Blythe D , Perz JF , Morgan OW , Kozarsky P , Brunette GW , Sotir M . MMWR Morb Mortal Wkly Rep 2014 63 (9) 201-2 In August 2013, the Maryland Department of Health and Mental Hygiene (MDHMH) was notified of two persons with rapidly growing nontuberculous mycobacterial (RG-NTM) surgical-site infections. Both patients had undergone surgical procedures as medical tourists at the same private surgical clinic (clinic A) in the Dominican Republic the previous month. Within 7 days of returning to the United States, both sought care for symptoms that included surgical wound abscesses, clear fluid drainage, pain, and fever. Initial antibiotic therapy was ineffective. Material collected from both patients' wounds grew Mycobacterium abscessus exhibiting a high degree of antibiotic resistance characteristic of this organism. |
Infrastructure and contamination of the physical environment in three Bangladeshi hospitals: putting infection control into context
Rimi NA , Sultana R , Luby SP , Islam MS , Uddin M , Hossain MJ , Zaman RU , Nahar N , Gurley ES . PLoS One 2014 9 (2) e89085 OBJECTIVE: This paper describes the physical structure and environmental contamination in selected hospital wards in three government hospitals in Bangladesh. METHODS: The qualitative research team conducted 48 hours of observation in six wards from three Bangladeshi tertiary hospitals in 2007. They recorded environmental contamination with body secretions and excretions and medical waste and observed ward occupant handwashing and use of personal protective equipment. They recorded number of persons, number of open doors and windows, and use of fans. They measured the ward area and informally observed waste disposal outside the wards. They conducted nine focus group discussions with doctors, nurses and support staff. RESULTS: A median of 3.7 persons were present per 10 m(2) of floor space in the wards. A median of 4.9 uncovered coughs or sneezes were recorded per 10 m(2) per hour per ward. Floors in the wards were soiled with saliva, spit, mucous, vomitus, feces and blood 125 times in 48 hours. Only two of the 12 patient handwashing stations had running water and none had soap. No disinfection was observed before or after using medical instruments. Used medical supplies were often discarded in open containers under the beds. Handwashing with soap was observed in only 32 of 3,373 handwashing opportunities noted during 48 hours. Mosquitoes and feral cats were commonly observed in the wards. CONCLUSIONS: The physical structure and environment of our study hospitals are conducive to the spread of infection to people in the wards. Low-cost interventions on hand hygiene and cleaning procedures for rooms and medical equipment should be developed and evaluated for their practicality and effectiveness. |
CDC Grand Rounds: preventing hospital-associated venous thromboembolism
Streiff MB , Brady JP , Grant AM , Grosse SD , Wong B , Popovic T . MMWR Morb Mortal Wkly Rep 2014 63 (9) 190-3 Deep venous thrombosis (DVT) is a blood clot in a large vein, usually in the leg or pelvis. Sometimes a DVT detaches from the site of formation and becomes mobile in the blood stream. If the circulating clot moves through the heart to the lungs it can block an artery supplying blood to the lungs. This condition is called pulmonary embolism. The disease process that includes DVT and/or pulmonary embolism is called venous thromboembolism (VTE). Each year in the United States, an estimated 350,000-900,000 persons develop incident VTE, of whom approximately 100,000 die, mostly as sudden deaths, the cause of which often goes unrecognized. In addition, 30%-50% of persons with lower-extremity DVT develop postthrombotic syndrome (a long-term complication that causes swelling, pain, discoloration, and, in severe cases, ulcers in the affected limb). Finally, 10%-30% of persons who survive the first occurrence of VTE develop another VTE within 5 years. |
Survey of poliovirus antibodies in Kano, Northern Nigeria
Iliyasu Z , Nwaze E , Verma H , Mustapha AO , Weldegebriel G , Gasasira A , Wannemuehler KA , Pallansch MA , Gajida AU , Pate M , Sutter RW . Vaccine 2014 32 (12) 1414-20 INTRODUCTION: In 1988, the World Health Assembly resolved to eradicate poliomyelitis. Since then, much progress towards this goal has been made, but three countries including Nigeria remain polio-endemic as of end 2012. To assess the immunity level against poliomyelitis in young children in Northern Nigeria, we conducted a seroprevalence survey in the Kano Metropolitan Area (KMA) in May 2011. METHODS: Parents or guardians of infants aged 6-9 months or children aged 36-47 months presenting to the outpatient department of Murtala Mohammad Specialist Hospital were approached for participation, screened for eligibility and were asked to provide informed consent. After that, a questionnaire was administered and blood was collected for neutralization assay. RESULTS: A total of 327 subjects were enrolled. Of these, 313 (96%) met the study requirements and were analyzed (161 [51%] aged 6-9 months and 152 [49%] aged 36-47 months). Among subjects aged 6-9 months, seroprevalence was 81% (95% confidence interval [CI] 75-87%) to poliovirus type 1, 76% (95% CI 68-81%) to poliovirus type 2, and 73% (95% CI 67-80%) to poliovirus type 3. Among subjects aged 36-47 months, the seroprevalence was 91% (95% CI 86-95%) to poliovirus type 1, 87% (95% CI 82-92%) for poliovirus type 2, and 86% (95% CI 80-91%) to poliovirus type 3. Seroprevalence was associated with history of oral poliovirus vaccine (OPV) doses, maternal education and gender. CONCLUSIONS: Seroprevalence is lower than required levels for poliovirus interruption in the KMA. Persistence of immunity gaps in the 36-47 months group is a big concern. Since higher number of vaccine doses is associated with higher seroprevalence, it implies that failure-to-vaccinate and not vaccine failure accounts for the suboptimal seroprevalence. Intensified efforts are necessary to administer polio vaccines to all target children and surpass the threshold levels for herd immunity. |
Toward global prevention of sexually transmitted infections (STIs): The need for STI vaccines
Gottlieb SL , Low N , Newman LM , Bolan G , Kamb M , Broutet N . Vaccine 2014 32 (14) 1527-35 An estimated 499 million curable sexually transmitted infections (STIs; gonorrhea, chlamydia, syphilis, and trichomoniasis) occurred globally in 2008. In addition, well over 500 million people are estimated to have a viral STI such as herpes simplex virus type 2 (HSV-2) or human papillomavirus (HPV) at any point in time. STIs result in a large global burden of sexual, reproductive, and maternal-child health consequences, including genital symptoms, pregnancy complications, cancer, infertility, and enhanced HIV transmission, as well as important psychosocial consequences and financial costs. STI control strategies based primarily on behavioral primary prevention and STI case management have had clear successes, but gains have not been universal. Current STI control is hampered or threatened by several behavioral, biological, and implementation challenges, including a large proportion of asymptomatic infections, lack of feasible diagnostic tests globally, antimicrobial resistance, repeat infections, and barriers to intervention access, availability, and scale-up. Vaccines against HPV and hepatitis B virus offer a new paradigm for STI control. Challenges to existing STI prevention efforts provide important reasons for working toward additional STI vaccines. We summarize the global epidemiology of STIs and STI-associated complications, examine challenges to existing STI prevention efforts, and discuss the need for new STI vaccines for future prevention efforts. |
An unusual case of influenza-like illness after yellow fever vaccination
Lamson DM , Ramani R , Kleabonas M , Metcalfe M , Humphrey C , St George K . J Clin Virol 2014 60 (1) 67-9 Yellow fever (YF) is an important public health concern in areas where the disease is endemic. For more than 60 years a highly effective live attenuated vaccine has been available, its widespread use resulting in a dramatic decrease in the number of cases. On rare occasions, YF vaccine can cause mild to severe disease and rare adverse vaccine-associated events have been reported. Additionally, an average viremia of 3-5 days after administration of the YF vaccine has been published. Here we present a case where YF vaccine was isolated in cell culture from a respiratory swab collected from a patient presenting with influenza-like illness. To the best of our knowledge, this is the first report finding replicating YF vaccine in the respiratory sample of a post inoculated individual. |
Maternal influenza vaccine and risks for preterm or small for gestational age birth
Nordin JD , Kharbanda EO , Vazquez Benitez G , Lipkind H , Vellozzi C , Destefano F . J Pediatr 2014 164 (5) 1051-1057 e2 OBJECTIVE: To study the impact of influenza vaccine administered to pregnant women during all trimesters on the rates of preterm and small for gestational age (SGA) births, evaluating both increased and decreased risk. STUDY DESIGN: This retrospective observational matched cohort study involved 7 Vaccine Safety Datalink sites across the US for the 2004-05 through 2008-09 influenza seasons. Cohort eligibility and outcomes were determined from administrative, claims, medical records, and birth data. In propensity score- and vaccine exposure time-matched analyses, ORs for preterm and SGA births were calculated. RESULTS: Among 57 554 matched vaccinated and unvaccinated pregnant women, including 16 240 women in the first trimester, maternal vaccination was not associated with increased or decreased risk for preterm birth (OR for delivery at <37 weeks gestation, 0.97 [95% CI, 0.93-1.02]; for delivery at ≤32 weeks gestation, 0.98 [95% CI, 0.86-1.12]; and for delivery at ≤34 weeks gestation, 0.96 [95% CI, 0.88-1.04]) or SGA birth (OR for <5th percentile weight for gestational age, 1.02 [95% CI, 0.96-1.09], and for <10th percentile weight for gestational age, 1.00 [95% CI, 0.96-1.04]). Similarly, first trimester vaccination was not associated with increased or decreased risk for preterm or SGA birth. CONCLUSION: Receipt of trivalent inactivated influenza vaccine during pregnancy was not associated with increased or decreased risk of preterm or SGA birth. These findings support the safety of vaccinating pregnant women against influenza during the first, second, and third trimesters, and suggest that a nonspecific protective effect of the influenza vaccine for these outcomes does not exist. |
Neisseria meningitidis serogroup W, Burkina Faso, 2012
Macneil JR , Medah I , Koussoube D , Novak RT , Cohn AC , Diomande FV , Yelbeogo D , Kambou JL , Tarbangdo TF , Ouedraogo-Traore R , Sangare L , Hatcher C , Vuong J , Mayer LW , Djingarey MH , Clark TA , Messonnier NE . Emerg Infect Dis 2014 20 (3) 394-9 In 2010, Burkina Faso became the first country to introduce meningococcal serogroup A conjugate vaccine (PsA-TT). During 2012, Burkina Faso reported increases in Neisseria meningitidis serogroup W, raising questions about whether these cases were a natural increase in disease or resulted from serogroup replacement after PsA-TT introduction. We analyzed national surveillance data to describe the epidemiology of serogroup W and genotyped 61 serogroup W isolates. In 2012, a total of 5,807 meningitis cases were reported through enhanced surveillance, of which 2,353 (41%) were laboratory confirmed. The predominant organism identified was N. meningitidis serogroup W (62%), and all serogroup W isolates characterized belonged to clonal complex 11. Although additional years of data are needed before we can understand the epidemiology of serogroup W after PsA-TT introduction, these data suggest that serogroup W will remain a major cause of sporadic disease and has epidemic potential, underscoring the need to maintain high-quality case-based meningitis surveillance after PsA-TT introduction. |
Impact of requiring influenza vaccination for children in licensed child care or preschool programs - Connecticut, 2012-13 influenza season
Hadler JL , Yousey-Hindes K , Kudish K , Kennedy ED , Sacco V , Cartter ML . MMWR Morb Mortal Wkly Rep 2014 63 (9) 181-5 Preschool-aged children are at increased risk for severe influenza-related illness and complications. Congregate child care settings facilitate influenza transmission among susceptible children. To protect against influenza transmission in these settings, in September 2010, Connecticut became the second U.S. state (after New Jersey) to implement regulations requiring that all children aged 6-59 months receive at least 1 dose of influenza vaccine each year to attend a licensed child care program. To evaluate the impact of this regulation on vaccination levels and influenza-associated hospitalizations during the 2012-13 influenza season, vaccination data from U.S. and Connecticut surveys and the Emerging Infections Program (EIP) were analyzed. After the regulation took effect, vaccination rates among Connecticut children aged 6-59 months increased from 67.8% during the 2009-10 influenza season to 84.1% during the 2012-13 season. During the 2012-13 influenza season, among all 11 EIP surveillance sites, Connecticut had the greatest percentage decrease (12%) in the influenza-associated hospitalization rate from 2007-08 among children aged ≤4 years. Additionally, the ratio of the influenza-associated hospitalization rates among children aged ≤4 years to the overall population rate (0.53) was lower than for any other EIP site. Requiring vaccination for child care admission might have helped to increase vaccination rates in Connecticut and reduced serious morbidity from influenza. |
Influenza vaccine response in adults exposed to perfluorooctanoate and perfluorooctanesulfonate
Looker C , Luster MI , Calafat AM , Johnson VJ , Burleson GR , Burleson FG , Fletcher T . Toxicol Sci 2014 138 (1) 76-88 Supported by several epidemiological studies and a large number of animal studies, certain polyfluorinated alkyl acids are believed to be immunotoxic, affecting particularly humoral immunity. Our aim was to investigate the relationship between the antibody response following vaccination with an inactivated trivalent influenza vaccine and circulating levels of perfluorooctanoate (PFOA) and perfluorooctanesulfonate (PFOS). The study population consisted of 411 adults living in the mid-Ohio region of Ohio and West Virginia where public drinking water had been inadvertently contaminated with PFOA. They participated in a larger cross-sectional study in 2005/2006 and were followed up in 2010, by which time serum levels of PFOA had been substantially reduced but were still well above those found in the general population. Hemagglutination inhibition tests were conducted on serum samples collected preinfluenza vaccination and 21+/-3 days postvaccination in 2010. Serum samples were also analyzed for PFOA and PFOS concentrations (median: 31.5 and 9.2ng/ml, respectively). Questionnaires were conducted regarding the occurrence and frequency of recent (during the last 12 months) respiratory infections. Our findings indicated that elevated PFOA serum concentrations are associated with reduced antibody titer rise, particularly to A/H3N2 influenza virus, and an increased risk of not attaining the antibody threshold considered to offer long-term protection. Although the direct relationship between weakened antibody response and clinical risk of influenza is not clear, we did not find evidence for an association between self-reported colds or influenza and PFOA levels nor between PFOS serum concentrations and any of the endpoints examined. |
Exploring the feasibility of using electronic health records in the surveillance of fetal alcohol syndrome
Hansen C , Adams M , Fox DJ , O'Leary LA , Frias JL , Freiman H , Meaney FJ . Birth Defects Res A Clin Mol Teratol 2014 100 (2) 67-78 BACKGROUND: Explore the use of electronic health records (EHRs) in fetal alcohol syndrome (FAS) surveillance systems. METHODS: Using EHRs we identified diagnoses and anthropometric measurements related to the FAS criteria developed by the Fetal Alcohol Syndrome Surveillance Network (FASSNet) among children aged 0 to 12 years. RESULTS: There were 143,393 distinct children aged between 0 and 12 years enrolled in Kaiser Permanente, Georgia, during the study period. Based on diagnoses and anthropometric measurements, 20,101 children met at least one criterion of interest, and when grouped into combinations of different criteria there were 2285 who met GROWTH+CNS criteria, 76 children who met GROWTH+FACE criteria, 107 children who met CNS+FACE criteria, and 93 children who met GROWTH+CNS+FACE criteria. The prevalence of FAS as defined by FASSNet is 1.92 per 1000 children. We linked 17,084 (85.0%) children to their mothers in the health plan; only 3% of mothers of children in the GROWTH+CNS+FACE group had an indication of alcohol or drugs use, but they had the highest rate of depression (39%). CONCLUSION: Data of utility in identification of FAS are readily available in EHRs and may serve as a basis for intervention with at-risk children and in planning of future FAS surveillance programs. |
Systematic review of prognosis and return to play after sport concussion: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis
Cancelliere C , Hincapie CA , Keightley M , Godbolt AK , Cote P , Kristman VL , Stalnacke BM , Carroll LJ , Hung R , Borg J , Nygren-de Boussard C , Coronado VG , Donovan J , Cassidy JD . Arch Phys Med Rehabil 2014 95 S210-s229 OBJECTIVE: To synthesize the best available evidence on prognosis after sport concussion. DATA SOURCES: MEDLINE and other databases were searched (2001-2012) with terms including "craniocerebral trauma" and "sports." Reference lists of eligible articles were also searched. STUDY SELECTION: Randomized controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 concussion cases. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables. DATA SYNTHESIS: Evidence was synthesized qualitatively according to modified SIGN criteria, and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77,914 records were screened, 52 articles were eligible for this review, and 24 articles (representing 19 studies) with a low risk of bias were accepted. Our findings are based on exploratory studies of predominantly male football players at the high school, collegiate, and professional levels. Most athletes recover within days to a few weeks, and American and Australian professional football players return to play quickly after mild traumatic brain injury. Delayed recovery appears more likely in high school athletes, in those with a history of previous concussion, and in those with a higher number and duration of postconcussion symptoms. CONCLUSIONS: The evidence concerning sports concussion course and prognosis is very preliminary, and there is no evidence on the effect of return-to-play guidelines on prognosis. Our findings have implications for further research. Well-designed, confirmatory studies are urgently needed to understand the consequences of sport concussion, including recurrent concussion, across different athletic populations and sports. |
Systematic review of the risk of dementia and chronic cognitive impairment after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis
Godbolt AK , Cancelliere C , Hincapie CA , Marras C , Boyle E , Kristman VL , Coronado VG , Cassidy JD . Arch Phys Med Rehabil 2014 95 S245-s256 OBJECTIVE: To synthesize the best available evidence regarding the risk of dementia and chronic cognitive impairment (CCI) after mild traumatic brain injury (MTBI). DATA SOURCES: MEDLINE and other databases were searched (2001-2012) using a previously published search strategy and predefined criteria. Peer-reviewed reports in 6 languages were considered. STUDY SELECTION: Systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies, with a minimum of 30 MTBI cases in subjects of any age, assessing the risk of dementia or CCI after MTBI were selected. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed each study and extracted data from accepted articles (ie, with a low risk of bias) into evidence tables. DATA SYNTHESIS: Evidence from accepted studies was synthesized qualitatively according to modified Scottish Intercollegiate Guidelines Network criteria, and prognostic information was prioritized as exploratory or confirmatory according to design. Of 77,914 records screened, 299 articles were eligible and reviewed. Methodological quality was acceptable for 101 (34%) articles, of which 1 article considered dementia and 7 articles considered CCI. The study examining the risk of dementia after MTBI did not find an association. One randomized controlled trial found that being informed about possible cognitive dysfunction after MTBI was associated with worse cognitive performance on standard tests. Children with MTBI and intracranial pathology ("complicated" MTBI) performed worse than did children without intracranial pathology. Children showed higher rates of cognitive symptoms a year after MTBI than did a control group. CONCLUSIONS: There is a lack of evidence of an increased risk of dementia after MTBI. In children, objective evidence of CCI exists only for complicated MTBI. More definitive studies are needed to inform clinical decisions, assessment of prognosis, and public health policy. |
The association between demographic and behavioral characteristics and sunburn among U.S. adults - National Health Interview Survey, 2010
Holman DM , Berkowitz Z , Guy GP Jr , Hartman AM , Perna FM . Prev Med 2014 63 6-12 OBJECTIVE: To examine the association between demographic and behavioral characteristics and sunburn among U.S. adults. METHOD: We used 2010 National Health Interview Survey data (N=24,970) to conduct multivariable logistic regressions examining associations with having 1 or more sunburns in the past year and having 4 or more sunburns in the past year. RESULTS: Overall, 37.1% of adults experienced sunburn in the past year. The adjusted prevalence of sunburn was particularly common among adults aged 18-29 years (52.0%), those who repeatedly burn or freckle after 2 weeks in the sun (45.9%), whites (44.3%), indoor tanners (44.1%), those with a family history of melanoma (43.9%), and those who are US-born (39.5%). Physical activity, alcohol consumption, and overweight/obesity were positively associated with sunburn (all P<0.001); sun protection behaviors were not significantly associated with sunburn (P=0.35). Among those who were sunburned in the past year, 12.1% experienced 4 or more sunburns. CONCLUSION: Sunburn is common, particularly among younger adults, those with a more sun-sensitive skin type, whites, those with a family history of melanoma, the highly physically active, and indoor tanners. Efforts are needed to facilitate sun-safety during outdoor recreation, improve the consistency of sun protection practices, and prevent sunburn, particularly among these subgroups. |
Corrigendum to “Trends in Traumatic Brain Injury in the U.S. and the public health response: 1995–2009"
Greenspan A I , Coronado VG , McGuire LC , Sarmiento K , Bell J , Lionbarger MR , Jones CD , Geller AI , Khoury N , Xu L . J Safety Res 2014 48 117 In the article Trends in Traumatic Brain Injury in the U.S. and the public health response: 1995–2009, by Victor G. Coronado et al., (Journal of Safety Research, Vol 43/Issue 4, pp 299–307, September, 2012) an error was made in the calculation of total traumatic brain injury (TBI) burden. The authors incorrectly included the number of outpatient visits and office-based visits to an estimate of the total number of patients with a primary or secondary diagnosis of TBI in 2009. While an average of 1.2 million visits (annualized average between 2007 and 2009) are made each year to outpatient departments or to office-based physicians for treatment related to a TBI, either alone or in combination with other injuries, it is impossible to identify how many of these were incident visits versus repeat or follow-up visits. By including outpatient department and office-based visits we likely overestimated their contribution to the total TBI burden. While we recognize that excluding these visits from the overall estimate eliminates some incident cases and results in an underestimate of total TBI burden, the estimate of ED visits, hospitalizations, and deaths is more precise and should be presented separately from outpatient and office-based visits. Thus, the correct estimates should read: “In 2009, there were approximately 2.4 million hospital emergency department (ED) visits, hospitalizations, or deaths related to a TBI, either alone or in combination with other injuries. Further, between 2007 and 2009 there was an annualized average of 1.1 million office-based visits and 84,000 outpatient department visits with a TBI-related diagnosis either alone or in combination with other injuries.” Our incorrect calculation which combined outpatient and office-based visits with ED visits, hospitalizations, and deaths can be found in the first line of the Abstract, (page 299 of the printed version); in the second paragraph of section 5 (page 302); and in the third line of the Conclusions and recommendations section (page 305); these numbers (3.5 million, 3.6 million, and 3.6 million, respectively) were incorrect. The Centers for Disease Control and Prevention will be using the corrected estimate of 2.4 million to describe the national burden of TBI (ED visits, hospitalizations, and deaths) in future descriptions for 2009. We continue to pursue methods to identify incident cases of TBI that do not present to EDs to more comprehensively capture the full TBI burden. |
LDL cholesterol performance of beta quantification reference measurement procedure
Nakamura M , Kayamori Y , Iso H , Kitamura A , Kiyama M , Koyama I , Nishimura K , Nakai M , Noda H , Dasti M , Vesper HW , Miyamoto Y . Clin Chim Acta 2014 431 288-93 BACKGROUND: Accurate measurement of blood lipids is crucial in cardiovascular disease risk management. The Centers for Disease Control and Prevention (CDC) Cholesterol Reference Method Laboratory Network (CRMLN) has assured the accuracy of these measurements for >20 y using beta quantification (BQ) method as reference measurement procedure (RMP) for high- and low-density lipoprotein cholesterol (HDL-C, LDL-C). Only limited data exist about the performance of the BQ RMP. METHODS: Bottom fraction cholesterol (BFC), HDL-C, and LDL-C results after ultracentrifugation from the CDC lipid reference laboratory and the Japanese CRMLN laboratory were compared using 280 serum samples measured over the past 15 y. Data were compared statistically using method comparison and bias estimation analysis. RESULTS: Regression analysis between CDC (x) and Osaka (y) for BFC, HDL-C, and LDL-C were y=0.988x+1.794 (R2=0.997), y=0.980x+1.118 (R2=0.994), and y=0.987x+1.200 (R2=0.997), respectively. The Osaka laboratory met performance goals for 90% to 95% of the CDC reference values. CONCLUSIONS: The BQ method by the Osaka CRMLN laboratory is highly accurate and has been stable for over 15 years. Accurate measurement of BFC is critical for determination of LDL-C. |
Longitudinal evaluation of enteric protozoa in Haitian children by stool exam and multiplex serologic assay
Moss DM , Priest JW , Hamlin K , Derado G , Herbein J , Petri WA Jr , Lammie PJ . Am J Trop Med Hyg 2014 90 (4) 653-60 Haitian children were monitored longitudinally in a filariasis study. Included were stool samples examined for Giardia intestinalis and Entamoeba histolytica cysts, and serum specimens analyzed for immunoglobulin G (IgG) responses to eight recombinant antigens from G. intestinalis (variant-specific surface protein [VSP1-VSP5]), E. histolytica (lectin adhesion molecule [LecA]), and Cryptosporidium parvum (17- and 27-kDa) using a multiplex bead assay. The IgG responses to VSP antigens peaked at 2 years of age and then diminished and were significantly lower (P < 0.002) in children > 4.5 years than in children < 4.5 years. The IgG responses to Cryptosporidium tended to increase with age. The IgG responses to LecA and VSP antigens and the prevalence of stools positive for cysts were significantly higher (P < 0.037 and P < 0.035, respectively) in the rainy season than in the dry season. The multiplex bead assay provides a powerful tool for analyzing serologic responses to multiple pathogens. |
Malarial liver parasites awaken in culture
Barnwell JW , Galinski MR . Nat Med 2014 20 (3) 237-9 The cure and elimination of malaria caused by Plasmodium vivax is hindered by the threat of relapse infections from undetectable dormant forms of the parasite in the liver. In a new breakthrough, using a related parasite, Plasmodium cynomolgi, it has been shown that the small nongrowing forms of the parasite, termed hypnozoites, can be reactivated in primary simian hepatocytes that have been infected and maintained in culture for 40 days, providing a system to study this parasite form with the development of potential new antihypnozoite drugs in mind (pages 307–312). | When injected into the host by mosquitoes, the infecting sporozoites of certain malaria parasite species, such as P. vivax or P. cynomolgi, invade liver cells. There, some sporozoites typically transform into actively growing parasites that repeatedly divide, producing within a week's time thousands of merozoites, which invade red blood cells, whereas others remain as small ∼4-nm bodies known as hypnozoites and become metabolically quiescent (Fig. 1). Hypnozoites lurk undetected inside hepatocytes, awaiting some undefined internal or external signal weeks, months or years later to cause activation, growth and multiplication1. One infectious mosquito bite can result in multiple bouts of relapsing blood-stage illness and hypnozoites are undetectable in infected people with no other signs of disease, posing a challenge to the elimination of the parasite2. |
Postmortem diagnosis of invasive meningococcal disease
Ridpath AD , Halse TA , Musser KA , Wroblewski D , Paddock CD , Shieh WJ , Pasquale-Styles M , Scordi-Bello I , Del Rosso PE , Weiss D . Emerg Infect Dis 2014 2014 (3) 453-5 We diagnosed invasive meningococcal disease by using immunohistochemical staining of embalmed tissue and PCR of vitreous humor from 2 men in New York City. Because vitreous humor is less subject than other body fluids to putrefaction, it is a good material for postmortem analysis. |
An enhanced butyrylcholinesterase method to measure organophosphorus nerve agent exposure in humans
Pantazides BG , Watson CM , Carter MD , Crow BS , Perez JW , Blake TA , Thomas JD , Johnson RC . Anal Bioanal Chem 2014 406 (21) 5187-94 Organophosphorus nerve agent (OPNA) adducts to butyrylcholinesterase (BChE) can be used to confirm exposure in humans. A highly accurate method to detect G- and V-series OPNA adducts to BChE in 75 muL of filtered blood, serum, or plasma has been developed using immunomagnetic separation (IMS) coupled with liquid chromatography tandem mass spectrometry (LC-MS/MS). The reported IMS method captures > 88 % of the BChE in a specimen and corrects for matrix effects on peptide calibrators. The optimized method has been used to quantify baseline BChE levels (unadducted and OPNA-adducted) in a matched-set of serum, plasma, and whole blood (later processed in-house for plasma content) from 192 unexposed individuals to determine the interchangeability of the tested matrices. The results of these measurements demonstrate the ability to accurately measure BChE regardless of the format of the blood specimen received. Criteria for accepting or denying specimens were established through a series of sample stability and processing experiments. The results of these efforts are an optimized and rugged method that is transferrable to other laboratories and an increased understanding of the BChE biomarker in matrix. |
Improved early risk stratification with cystatin C-based estimated GFR
Pavkov ME , Nelson RG . Am J Kidney Dis 2014 63 (5) 745-8 Determination of glomerular filtration rate (GFR) is important in detecting kidney disease, monitoring its progression and making treatment decisions. Equations to estimate GFR (eGFR) that include the routinely obtained variables serum creatinine, age, sex, and race are widely used as a practical, low cost tradeoff for the more laborious measurement of GFR (mGFR) by infusion of special markers and measurement of their clearance from plasma or urine. Serum creatinine based estimates of GFR (eGFRcr) nevertheless have a number of important limitations, including confounding by muscle mass, tubular secretion, and extrarenal elimination of creatinine. Reliability of eGFRcr is particularly poor in individuals with hyperfiltration [1, 2], those who follow certain dietary habits, individuals with unusual or unpredictable changes in muscle mass or extremes of weight (e.g., BMI <20 kg/m2), or those who are pregnant [3–5]. | In contrast, serum cystatin C may better fulfill important characteristics of an ideal marker of GFR. Cystatin C is an endogenous low molecular mass protein that is produced at a constant rate and nearly completely cleared from the circulation by glomerular filtration with subsequent proximal tubular uptake and catabolism. Hence, cystatin C may be more sensitive and specific than eGFRcr for detecting early changes in kidney function [6, 7], and it improves precision of GFR estimation when used in combination with creatinine (eGFRcr-cys), particularly in persons with impaired kidney function [5, 8, 9]. Although current GFR estimating equations are biased in certain settings and imprecise in all, regardless of the filtration marker used, they still have considerable value as predictors of clinical outcomes. Shlipak and colleagues from the Chronic Kidney Disease Prognosis Consortium recently examined risk classification for all-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) according to levels of eGFR using estimating equations based on creatinine, cystatin C, or the combination of these markers in a meta-analysis of 16 international cohorts [10]. |
Automation of an interferon-gamma release assay and comparison to the tuberculin skin test for screening basic military trainees for Mycobacterium tuberculosis infection
Goodwin DJ , Mazurek GH , Campbell BH , Bohanon J , West KB , Bell JJ , Powell R , Toney S , Morris JA , Yamane GK , Sjoberg PA . Mil Med 2014 179 (3) 333-41 We automated portions of the QuantiFERON-TB Gold In-Tube test (QFT-GIT) and assessed its quality when performed concurrently with the tuberculin skin test (TST) among U.S. Air Force basic military trainees (BMTs). The volume of blood collected for QFT-GIT was monitored. At least one of the three tubes required for QFT-GIT had blood volume outside the recommended 0.8- to 1.2-mL range for 688 (29.0%) of 2,373 subjects who had their blood collected. Of the 2,124 subjects who had TST and QFT-GIT completed, TST was positive for 0.6%; QFT-GIT was positive for 0.3% and indeterminate for 2.0%. Among 2,081 subjects with completed TST and determinate QFT-GIT results, overall agreement was 99.5% but positive agreement was 5.6%. Specificity among the 1,546 low-risk BMTs was identical (99.7%). Indeterminate QFT-GIT results were 2.7 times more likely when mitogen tubes contained >1.2 mL blood than when containing 0.8- to 1.2-mL blood. Automation can facilitate QFT-GIT completion, especially if the recommended volume of blood is collected. Mycobacterium tuberculosis infection prevalence among BMTs based on TST and QFT-GIT is similar and low. Selectively testing those with significant risk may be more appropriate than universal testing of all recruits. |
Urbanicity and autism spectrum disorders
Lauritsen MB , Astrup A , Pedersen CB , Obel C , Schendel DE , Schieve L , Yeargin-Allsopp M , Parner ET . J Autism Dev Disord 2014 44 (2) 394-404 The etiology of autism spectrum disorders (ASD) is for the majority of cases unknown and more studies of risk factors are needed. Geographic variation in ASD occurrence has been observed, and urban residence has been suggested to serve as a proxy for etiologic and identification factors in ASD. We examined the association between urbanicity level and ASD at birth and during childhood. The study used a Danish register-based cohort of more than 800,000 children of which nearly 4,000 children were diagnosed with ASD. We found a dose-response association with greater level of urbanicity and risk of ASD. This association was found for residence at birth as well as residence during childhood. Further, we found an increased risk of ASD in children who moved to a higher level of urbanicity after birth. Also, earlier age of ASD diagnosis in urban areas was observed. While we could not directly examine the specific reasons behind these associations, our results demonstrating particularly strong associations between ASD diagnosis and post-birth migration suggest the influence of identification-related factors such as access to services might have a substantive role on the ASD differentials we observed. |
Youth violence and connectedness in adolescence: what are the implications for later sexually transmitted infections?
Steiner RJ , Michael SL , Hall JE , Barrios LC , Robin L . J Adolesc Health 2014 54 (3) 312-318.e1 PURPOSE: To examine associations between (1) youth violence victimization and perpetration and later sexually transmitted infections (STI) and (2) parent-family and school connectedness and later STI, and to explore the moderating role of connectedness on the associations between youth violence victimization and perpetration and later STI. METHODS: We used data from Waves I and IV of the National Longitudinal Study of Adolescent Health, which provided a baseline weighted sample of 14,800 respondents. We used logistic regression to examine associations between youth violence and connectedness with self-reported ever STI diagnosis, including gonorrhea, chlamydia, syphilis, genital herpes, genital warts or human papillomavirus, or human immunodeficiency virus. If participants reported having an STI at Wave I they were excluded from the analysis. RESULTS: Controlling for biological sex, race/ethnicity, age, parent's highest education level, and parent's marital status, both youth violence victimization and perpetration were associated with an increased risk of later STI (adjusted odds ratio [AOR], 1.27, 95% confidence interval [CI], 1.07-1.52; and AOR, 1.21, 95% CI, 1.04-1.41, respectively). Parent-family and school connectedness in adolescence were associated with a decreased risk for later STI (AOR, .96, 95% CI, .95-.98; and AOR, .97, 95% CI, .95-.99, respectively); however, connectedness did not moderate the associations between nonsexual violence involvement and later STI. CONCLUSIONS: These results indicate that youth violence victimization and perpetration may be risk factors for STI later in life. Conversely, parent-family and school connectedness in adolescence appear to protect against subsequent STI. The findings suggest that provider efforts to address youth violence and connectedness in adolescence can promote positive sexual health outcomes in adulthood. |
Hepatitis B virus infection among HIV-infected pregnant women in Malawi and transmission to infants
Chasela CS , Kourtis AP , Wall P , Drobeniuc J , King CC , Thai H , Teshale EH , Hosseinipour M , Ellington S , Codd MB , Jamieson DJ , Knight R , Fitzpatrick P , Kamili S , Hoffman I , Kayira D , Mumba N , Kamwendo DD , Martinson F , Powderly W , Teo CG , van der Horst C . J Hepatol 2014 60 (3) 508-14 BACKGROUND & AIMS: The extent of HBV infection to infants of HBV/HIV-coinfected pregnant women in sub-Saharan Africa is unknown. The aim of this study was to assess prevalence of HBV infection among antiretroviral-naive, HIV-infected pregnant women in Malawi and examine HBV transmission to their infants. METHODS: Plasma from 2048 HIV-infected, Malawian women and their infants were tested for markers of HBV infection. Study participants were provided standard-of-care health services, which included administration of pentavalent vaccine to infants at 6, 10, and 14weeks of age. RESULTS: One-hundred and three women (5%) were HBsAg-positive; 70 of these HBsAg-positive women were also HBV-DNA-positive. Sixteen women (0.8%) were HBV-DNA-positive but HBsAg-negative. Five of 51 infants (9.8%) born to HBsAg-positive and/or HBV-DNA-positive women were HBV-DNA-positive by 48weeks of age.HBV DNA concentrations of two infants of mothers who received extended lamivudine-containing anti-HIV prophylaxis were <4 log10 IU/ml compared to 8 log10 IU/ml in three infants of mothers who did not. CONCLUSIONS: HBV DNA was detected in nearly 10% of infants born to HBV/HIV-coinfected women. Antenatal testing for HIV and HBV, if instituted, can facilitate implementation of prophylactic measures against infant infection by both viruses. |
Changes in soluble transferrin receptor and hemoglobin concentrations in Malawian mothers are associated with those values in their exclusively breastfed, HIV-exposed infants
Widen EM , Bentley ME , Kayira D , Chasela CS , Daza EJ , Kacheche ZK , Tegha G , Jamieson DJ , Kourtis AP , van der Horst CM , Allen LH , Shahab-Ferdows S , Adair LS . J Nutr 2014 144 (3) 367-73 Infant iron status at birth is influenced by maternal iron status during pregnancy; however, there are limited data on the extent to which maternal iron status is associated with infant iron status during exclusive breastfeeding. We evaluated how maternal and infant hemoglobin and iron status [soluble transferrin receptors (TfR) and ferritin] were related during exclusive breastfeeding in HIV-infected women and their infants. The Breastfeeding, Antiretrovirals, and Nutrition Study was a randomized controlled trial in Lilongwe, Malawi, in which HIV-infected women were assigned with a 2 x 3 factorial design to a lipid-based nutrient supplement (LNS), or no LNS, and maternal, infant, or no antiretroviral drug, and followed for 24 wk. Longitudinal models were used to relate postpartum maternal hemoglobin (n = 1926) to concurrently measured infant hemoglobin, adjusting for initial infant hemoglobin values. In a subsample, change in infant iron status (hemoglobin, log ferritin, log TfR) between 2 (n = 352) or 6 wk (n = 167) and 24 wk (n = 519) was regressed on corresponding change in the maternal indicator, adjusting for 2 or 6 wk values. A 1 g/L higher maternal hemoglobin at 12, 18, and 24 wk was associated with a 0.06 g/L (P = 0.01), 0.10 g/L (P < 0.001), and 0.06 g/L (P = 0.01), respectively, higher infant hemoglobin. In the subsample, a reduction in maternal log TfR and an increase in hemoglobin from initial measurement to 24 wk were associated with the same pattern in infant values (log TfR beta = -0.18 mg/L, P < 0.001; hemoglobin beta = 0.13 g/L, P = 0.01). Given the observed influence of maternal and initial infant values, optimizing maternal iron status in pregnancy and postpartum is important to protect infant iron status. This trial was registered at clinicaltrials.gov as NCT00164736. |
Biomarkers of nanomaterial exposure and effect: current status
Iavicoli I , Leso V , Manno M , Schulte PA . J Nanopart Res 2014 16 (3) 1-33 Recent advances in nanotechnology have induced a widespread production and application of nanomaterials. As a consequence, an increasing number of workers are expected to undergo exposure to these xenobiotics, while the possible hazards to their health remain not being completely understood. In this context, biological monitoring may play a key role not only to identify potential hazards from and to evaluate occupational exposure to nanomaterials, but also to detect their early biological effects to better assess and manage risks of exposure in respect of the health of workers. Therefore, the aim of this review is to provide a critical evaluation of potential biomarkers of nanomaterial exposure and effect investigated in human and animal studies. Concerning exposure biomarkers, internal dose of metallic or metal oxide nanoparticle exposure may be assessed measuring the elemental metallic content in blood or urine or other biological materials, whereas specific molecules may be carefully evaluated in target tissues as possible biomarkers of biologically effective dose. Oxidative stress biomarkers, such as 8-hydroxy-deoxy-guanosine, genotoxicity biomarkers, and inflammatory response indicators may also be useful, although not specific, as biomarkers of nanomaterial early adverse health effects. Finally, potential biomarkers from “omic” technologies appear to be quite innovative and greatly relevant, although mechanistic, ethical, and practical issues should all be resolved before their routine application in occupational settings could be implemented. Although all these findings are interesting, they point out the need for further research to identify and possibly validate sensitive and specific biomarkers of exposure and effect, suitable for future use in occupational biomonitoring programs. A valuable contribution may derive from the studies investigating the biological behavior of nanomaterials and the factors influencing their toxicokinetics and reactivity. In this context, the application of the most recent advances in analytical chemistry and biochemistry to the biological monitoring of nanomaterial exposure may be also useful to detect and define patterns and mechanisms of early nanospecific biochemical alterations. |
A review of mine rescue ensembles for underground coal mining in the United States
Kilinc FS , Monaghan WD , Powell JB . J Eng Fiber Fabr 2014 9 (1) 174-185 The mining industry is among the top ten industries nationwide with high occupational injury and fatality rates, and mine rescue response may be considered one of the most hazardous activities in mining operations. In the aftermath of an underground mine fire, explosion or water inundation, specially equipped and trained teams have been sent underground to fight fires, rescue entrapped miners, test atmospheric conditions, investigate the causes of the disaster, or recover the dead. Special personal protective ensembles are used by the team members to improve the protection of rescuers against the hazards of mine rescue and recovery. Personal protective ensembles used by mine rescue teams consist of helmet, cap lamp, hood, gloves, protective clothing, boots, kneepads, facemask, breathing apparatus, belt, and suspenders. While improved technology such as wireless warning and communication systems, lifeline pulleys, and lighted vests have been developed for mine rescuers over the last 100 years, recent research in this area of personal protective ensembles has been minimal due to the trending of reduced exposure of rescue workers. In recent years, the exposure of mine rescue teams to hazardous situations has been changing. However, it is vital that members of the teams have the capability and proper protection to immediately respond to a wide range of hazardous situations. Currently, there are no minimum requirements, best practice documents, or nationally recognized consensus standards for protective clothing used by mine rescue teams in the United States (U.S.). The following review provides a summary of potential issues that can be addressed by rescue teams and industry to improve potential exposures to rescue team members should a disaster situation occur. However, the continued trending in the mining industry toward non-exposure to potential hazards for rescue workers should continue to be the primary goal. To assist in continuing this trend, the mining industry and regulatory agencies have been more information regarding atmospheric conditions and other hazards before exposing rescue workers and others in the aftermath of a mine disaster. In light of some of the more recent mine rescuer fatalities such as the Crandall Canyon Mine and Jim Walters Resources in the past years, the direction of reducing exposure is preferred. This review provides a historical perspective on ensembles used during mine rescue operations and summarizes environmental hazards, critical elements of mine rescue ensembles, and key problems with these elements. This study also identifies domains for improved mine rescue ensembles. Furthermore, field observations from several coal mine rescue teams were added to provide the information on the currently used mine rescue ensembles in the U.S. |
Genetic variation and recurrent parasitaemia in Peruvian Plasmodium vivax populations.
McCollum AM , Soberon V , Salas CJ , Santolalla ML , Udhayakumar V , Escalante AA , Graf PC , Durand S , Cabezas C , Bacon DJ . Malar J 2014 13 (1) 67 BACKGROUND: Plasmodium vivax is a predominant species of malaria in parts of South America and there is increasing resistance to drugs to treat infections by P. vivax. The existence of latent hypnozoites further complicates the ability to classify recurrent infections as treatment failures due to relapse, recrudescence of hyponozoites or re-infections. Antigen loci are putatively under natural selection and may not be an optimal molecular marker to define parasite haplotypes in paired samples. Putatively neutral microsatellite loci, however, offer an assessment of neutral haplotypes. The objective here was to assess the utility of neutral microsatellite loci to reconcile cases of recurrent parasitaemia in Amazonian P. vivax populations in Peru. METHODS: Patient blood samples were collected from three locations in or around Iquitos in the Peruvian Amazon. Five putatively neutral microsatellite loci were characterized from 445 samples to ascertain the within and amongst population variation. A total of 30 day 0 and day of recurrent parasitaemia samples were characterized at microsatellite loci and five polymorphic antigen loci for haplotype classification. RESULTS: The genetic diversity at microsatellite loci was consistent with neutral levels of variation measured in other South American P. vivax populations. Results between antigen and microsatellite loci for the 30 day 0 and day of recurrent parasitaemia samples were the same for 80% of the pairs. The majority of non-concordant results were the result of differing alleles at microsatellite loci. This analysis estimates that 90% of the paired samples with the same microsatellite haplotype are unlikely to be due to a new infection. CONCLUSIONS: A population-level approach was used to yield a better estimate of the probability of a new infection versus relapse or recrudescence of homologous hypnozoites; hypnozoite activation was common for this cohort. Population studies are critical with the evaluation of genetic markers to assess P. vivax biology and epidemiology. The additional demonstration of microsatellite loci as neutral markers capable of distinguishing the origin of the recurrent parasites (new infection or originating from the patient) lends support to their use in assessment of treatment outcomes. |
Quality of malaria case management in Malawi: results from a nationally representative health facility survey
Steinhardt LC , Chinkhumba J , Wolkon A , Luka M , Luhanga M , Sande J , Oyugi J , Ali D , Mathanga D , Skarbinski J . PLoS One 2014 9 (2) e89050 BACKGROUND: Malaria is endemic throughout Malawi, but little is known about quality of malaria case management at publicly-funded health facilities, which are the major source of care for febrile patients. METHODS: In April-May 2011, we conducted a nationwide, geographically-stratified health facility survey to assess the quality of outpatient malaria diagnosis and treatment. We enrolled patients presenting for care and conducted exit interviews and re-examinations, including reference blood smears. Moreover, we assessed health worker readiness (e.g., training, supervision) and health facility capacity (e.g. availability of diagnostics and antimalarials) to provide malaria case management. All analyses accounted for clustering and unequal selection probabilities. We also used survey weights to produce estimates of national caseloads. RESULTS: At the 107 facilities surveyed, most of the 136 health workers interviewed (83%) had received training on malaria case management. However, only 24% of facilities had functional microscopy, 15% lacked a thermometer, and 19% did not have the first-line artemisinin-based combination therapy (ACT), artemether-lumefantrine, in stock. Of 2,019 participating patients, 34% had clinical malaria (measured fever or self-reported history of fever plus a positive reference blood smear). Only 67% (95% confidence interval (CI): 59%, 76%) of patients with malaria were correctly prescribed an ACT, primarily due to missed malaria diagnosis. Among patients without clinical malaria, 31% (95% CI: 24%, 39%) were prescribed an ACT. By our estimates, 1.5 million of the 4.4 million malaria patients seen in public facilities annually did not receive correct treatment, and 2.7 million patients without clinical malaria were inappropriately given an ACT. CONCLUSIONS: Malawi has a high burden of uncomplicated malaria but nearly one-third of all patients receive incorrect malaria treatment, including under- and over-treatment. To improve malaria case management, facilities must at minimum have basic case management tools, and health worker performance in diagnosing malaria must be improved. |
Survival of blood transfusion recipients identified by a look-back investigation
Dorsey KA , Moritz ED , Notari Iv EP , Schonberger LB , Dodd RY . Blood Transfus 2014 12 (1) 67-72 BACKGROUND: Survival of blood transfusion recipients is a critical consideration in assessing the outcomes of transfusion. Data from the USA on the short- and long-term survival of recipients are limited. MATERIALS AND METHODS: Blood product recipients were identified through a look-back study of Creutzfeldt-Jakob disease. Survival data were obtained from searches of the National Death Index or the Social Security Death Master File. Short- and long-term survival of recipients was analysed through descriptive statistics, Kaplan-Meier survival analysis, and stratified Cox proportional hazard modelling. RESULTS: This study includes data from 575 blood product recipients. One half of the recipients died within the first year of transfusion and the median time to death was 1.1 years. Survival rates at 5, 10, 15, 20, and 25 years after transfusion were 32%, 22%, 15%, 12%, and 9%, respectively. Survival rates varied with age at transfusion and type of component received, but not by gender. Survival after transfusion varied by year of transfusion, with recipients transfused in 1980-1989 having longer post-transfusion survival than those transfused in 2000-2010 (p=0.049). In multivariate models, the type of component transfused, but not the year of transfusion, was a significant predictor of survival among recipients; this effect varied by age. DISCUSSION: We provide an estimate of survival time from a geographically diverse sample of blood product recipients in the USA. Predictors of post-transfusion survival are numerous and complex, and may include year of transfusion and type of component transfused. |
Future directions for postdoctoral training in cancer prevention: insights from a panel of experts
Nelson DE , Faupel-Badger J , Phillips S , Belcher B , Chang S , Abrams DB , Kramer BS , White MC , O'Malley M , Varanasi AP , Fabian CJ , Wiest JS , Colditz GA , Hall K , Shields PG , Weitzel JN . Cancer Epidemiol Biomarkers Prev 2014 23 (4) 679-83 Cancer prevention postdoctoral fellowships have existed since the 1970s. The National Cancer Institute facilitated a meeting by a panel of experts in April 2013 to consider four important topics for future directions for cancer prevention postdoctoral training programs: (i) future research needs; (ii) underrepresented disciplines; (iii) curriculum; and (iv) career preparation. Panelists proffered several areas needing more research or emphasis, ranging from computational science to culture. Health care providers, along with persons from nontraditional disciplines in scientific training programs such as engineers and lawyers, were among those recognized as being underrepresented in training programs. Curriculum suggestions were that fellows receive training in topics such as leadership and human relations, in addition to learning the principles of epidemiology, cancer biologic mechanisms, and behavioral science. For career preparation, there was a clear recognition of the diversity of employment options available besides academic positions, and that program leaders should do more to help fellows identify and prepare for different career paths. The major topics and strategies covered at this meeting can help form the basis for cancer prevention training program leaders to consider modifications or new directions, and keep them updated with the changing scientific and employment climate for doctoral degree recipients and postdoctoral fellows. |
Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, 2008-2011
Jones CM , Paulozzi LJ , Mack KA . JAMA Intern Med 2014 174 (5) 802-3 The health consequences of nonmedical use of prescription opioid pain relievers, such as oxycodone and hydrocodone, are significant.1 The commonly cited statistic that most nonmedical users obtain these medications from friends or family for free2 often serves as the basis for interventions focused onpatients. This statistic, however, reflects sources among all nonmedical users, from those who used the drug once or twice to more frequent users. Recent research indicates that frequent nonmedical users are increasing in numbers and differ from infrequent users with respect to high-risk behaviors.3,4 Little research has examined whether the source of opioid medication differs by frequency of nonmedical use. Such research can inform the development of appropriately targeted interventions. |
Per-pack price reductions available from different cigarette purchasing strategies: United States, 2009-2010
Pesko MF , Xu X , Tynan MA , Gerzoff RB , Malarcher AM , Pechacek TF . Prev Med 2014 63 13-9 OBJECTIVE: Following cigarette excise tax increases, smokers may use cigarette price minimization strategies to continue their usual cigarette consumption rather than reducing consumption or quitting. This reduces the public health benefits of the tax increase. This paper estimates the price reductions for a wide-range of strategies, compensating for overlapping strategies. METHOD: We performed regression analysis on the 2009-2010 National Adult Tobacco Survey (N=13,394) to explore price reductions that smokers in the United States obtained from purchasing cigarettes. We examined five cigarette price minimization strategies: 1) purchasing discount brand cigarettes, 2) using price promotions, 3) purchasing cartons, 4) purchasing on Indian reservations, and 5) purchasing online. Price reductions from these strategies were estimated jointly to compensate for overlapping strategies. RESULTS: Each strategy provided price reductions of between 26 to 99 cents per pack. Combined price reductions were possible. Additionally, price promotions were used with regular brands to obtain larger price reductions than when price promotions were used with generic brands. CONCLUSION: Smokers can realize large price reductions from price minimization strategies, and there are many strategies available. Policymakers and public health officials should be aware of the extent that these strategies can reduce cigarette prices. |
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