Reducing childhood obesity through policy change: acting now to prevent obesity
Frieden TR , Dietz W , Collins J . Health Aff (Millwood) 2010 29 (3) 357-63 Childhood obesity is epidemic in the United States, and is expected to increase the rates of many chronic diseases. Increasing physical activity and improving nutrition are keys to obesity prevention and control. But changing individual behavior is difficult. A comprehensive, coordinated strategy is needed. Policy interventions that make healthy dietary and activity choices easier are likely to achieve the greatest benefits. There is emerging evidence on how to address childhood obesity, but we must take action now to begin to reverse the epidemic. |
Venous thromboembolism in African-Americans: a literature-based commentary
Hooper WC . Thromb Res 2010 125 (1) 12-8 Among the cardiovascular diseases and after ischemic heart disease and stroke, venous thromboembolism (VTE) is the third leading cause of death in the U.S. (3). Although VTE is seen across most ethnic groups in the U.S. as well as throughout the world, the rate varies. In the U.S., American Indians/Alaskan Natives as well as Asians have been reported to have a significantly lower rate of deep vein thrombosis (DVT) and pulmonary embolism (PE) as compared to blacks and whites. In sharp conrast blacks appear to have much higher rates than whites. Although these rate differences are thought in part by some to be attributable to disparities in diagnosis and care as well as genetics, it nevertheless is important to define as well as to understand the true incidence and impact so that both public health and clinical resources can be maximally utilized. The purpose of this commentary is to review the VTE burden in the U.S. with respect to ethnicity in terms of clinical demographics and genetics with particular emphasis on blacks. |
Waist-to-thigh ratio and diabetes among US adults: the Third National Health and Nutrition Examination Survey
Li C , Ford ES , Zhao G , Kahn HS , Mokdad AH . Diabetes Res Clin Pract 2010 89 (1) 79-87 AIMS: We sought to examine whether waist-to-thigh ratio (WTR) performed better than waist-to-height ratio (WHtR), waist-to-hip ratio (WHpR), waist circumference (WC), or body mass index (BMI) in relation to diabetes among US adults. METHODS: Data of 6277 men and nonpregnant women 20 years or older from the Third National Health and Nutrition Examination Survey (1988-1994) were analyzed. RESULTS: In men, AUC of WTR (0.83) was larger than that of WHtR (0.78) (P=0.003), WHpR (0.79) (P<0.001), WC (0.76) (P<0.001), and BMI (0.72) (P<0.001) for diabetes. In women, the AUC of WTR (0.80) was similar to that of WHtR (0.80) (P=0.89), WHpR (0.79) (P=0.55), and WC (0.78) (P=0.36), but larger than that of BMI (0.73) (P=0.03) for diabetes. After adjustment for potential confounders, WTR had the strongest association with diabetes in men (OR, 2.13; 95% CI, 1.57-2.88; per 1 SD increment), whereas WHpR had the strongest association with diabetes in women (OR, 1.94; 95% CI, 1.60-2.35). CONCLUSIONS: WTR performed better than other four indices in men and WTR performed similarly to WHtR, WHpR, and waist circumference, but better than BMI in women for the association with diabetes. |
Tuberculosis in asymptomatic HIV-infected adults with abnormal chest radiographs screened for tuberculosis prevention
Agizew TB , Arwady MA , Yoon JC , Nyirenda S , Mosimaneotsile B , Tedla Z , Motsamai O , Kilmarx PH , Wells CD , Samandari T . Int J Tuberc Lung Dis 2010 14 (1) 45-51 BACKGROUND: Isoniazid preventive therapy (IPT) prevents tuberculosis (TB) in people living with HIV (human immunodeficiency virus, PLWH). Symptom screening without chest radiographs (CXRs) was established as the strategy for excluding TB disease among PLWH seeking IPT in Botswana's 2001 pilot project. This strategy was evaluated in 2004-2006 among candidates screened for an IPT clinical trial. METHODS: PLWH referred from clinics and HIV testing centers were screened for TB symptoms. All asymptomatic candidates received CXRs; those with abnormal CXRs were investigated further. RESULTS: Among 2732 asymptomatic candidates screened, 302 (11%) had abnormal CXRs potentially compatible with TB; TB disease was diagnosed in 43 of these 302 (14%), or 43 (1.6%) of the 2732 asymptomatic candidates. While not associated with CD4 lymphocyte counts < 200 cells/mm(3), TB was associated with a positive tuberculin skin test (relative risk 2.1, 95%CI 1.1-4.0). IPT was initiated in 113 (62%) of 182 asymptomatic PLWH with abnormal CXRs; 8/113 (7%) subsequently developed TB, and 7/8 (88%) successfully completed anti-tuberculosis treatment. CONCLUSIONS: The prevalences of abnormal CXRs and TB were respectively 2.6- and 8.9-fold higher among asymptomatic PLWH screened for the trial than in the pilot. A cost-effectiveness analysis is needed to determine whether the benefits of symptom screening alone are offset by the risk of inducing INH resistance by excluding CXRs during screening. |
Effectiveness of non-nucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in women previously exposed to a single intrapartum dose of nevirapine: a multi-country, prospective cohort study
Stringer JS , McConnell MS , Kiarie J , Bolu O , Anekthananon T , Jariyasethpong T , Potter D , Mutsotso W , Borkowf CB , Mbori-Ngacha D , Muiruri P , Ong'ech JO , Zulu I , Njobvu L , Jetsawang B , Pathak S , Bulterys M , Shaffer N , Weidle PJ . PLoS Med 2010 7 (2) e1000233 BACKGROUND: Intrapartum and neonatal single-dose nevirapine (NVP) reduces the risk of mother-to-child HIV transmission but also induces viral resistance to non-nucleoside reverse transcriptase inhibitor (NNRTI) drugs. This drug resistance largely fades over time. We hypothesized that women with a prior single-dose NVP exposure would have no more than a 10% higher cumulative prevalence of failure of their NNRTI-containing antiretroviral therapy (ART) over the first 48 wk of therapy than would women without a prior exposure. METHODS AND FINDINGS: We enrolled 355 NVP-exposed and 523 NVP-unexposed women at two sites in Zambia, one site in Kenya, and two sites in Thailand into a prospective, non-inferiority cohort study and followed them for 48 wk on ART. Those who died, discontinued NNRTI-containing ART, or had a plasma viral load >or=400 copies/ml at either the 24 wk or 48 wk study visits and confirmed on repeat testing were characterized as having failed therapy. Overall, 114 of 355 NVP-exposed women (32.1%) and 132 of 523 NVP-unexposed women (25.2%) met criteria for treatment failure. The difference in failure rates between the exposure groups was 6.9% (95% confidence interval [CI] 0.8%-13.0%). The failure rates of women stratified by our predefined exposure interval categories were as follows: 47 of 116 women in whom less than 6 mo elapsed between exposure and starting ART failed therapy (40%; p<0.001 compared to unexposed women); 25 of 67 women in whom 7-12 mo elapsed between exposure and starting ART failed therapy (37%; p = 0.04 compared to unexposed women); and 42 of 172 women in whom more than 12 mo elapsed between exposure and starting ART failed therapy (24%; p = 0.82 compared to unexposed women). Locally weighted regression analysis also indicated a clear inverse relationship between virologic failure and the exposure interval. CONCLUSIONS: Prior exposure to single-dose NVP was associated with an increased risk of treatment failure; however, this risk seems largely confined to women with a more recent exposure. Women requiring ART within 12 mo of NVP exposure should not be prescribed an NNRTI-containing regimen as first-line therapy. |
Polypharmacy in nursing home residents in the United States: results of the 2004 National Nursing Home Survey
Dwyer LL , Han B , Woodwell DA , Rechtsteiner EA . Am J Geriatr Pharmacother 2010 8 (1) 63-72 Background: Despite the need for and benefits of medications, polypharmacy (defined here as concurrent use of ≥9 medications) in nursing home residents is a concern. As the number of medications taken increases, so does the risk for adverse events. Monitoring polypharmacy in this population is important and can improve the quality of nursing home care. Objectives: The aims of this article were to estimate the use of polypharmacy in residents of nursing homes in the United States, to examine the associations between select resident and facility characteristics and polypharmacy, and to determine the leading therapeutic subclasses included in the polypharmacy received by these nursing home residents. Methods: This was a retrospective, cross-sectional study of a nationally representative sample of US nursing home residents in 2004; the outcome was use of polypharmacy. The 2004 National Nursing Home Survey was used to collect medication data and other resident and facility information. Resident characteristics included age, sex, race, primary payment source, number of comorbidities, number of activities of daily living (ADLs) for which the resident required assistance, and length of stay (LOS) since admission. Facility characteristics included ownership and size (number of beds). Results: Of 13,507 nursing home residents who received care, 13,403 had valid responses for all 9 independent variables in the analyses. The prevalence of polypharmacy among nursing home residents in 2004 was ~40%. A multiple regression model controlling for resident and facility factors revealed that the odds of receiving polypharmacy were higher for residents who were female (odds ratio [OR] = 1.10; 95% CI, 1.00-1.20), were white, had Medicaid as a primary payer, had >3 comorbidities (OR = 1.57-5.18; 95% CI, 1.36-6.15), needed assistance with <4 ADLs, had an LOS since admission of 3 to <6 months (OR = 1.25; 95% CI, 1.04-1.50), and received care in a small, not- for-profit facility (data not shown for reference levels [OR = 1.00]). The most frequently reported medications for residents who received polypharmacy included gastrointestinal agents (laxatives, 47.5%; agents for acid/peptic disorders, 43.3%), drugs that affect the central nervous system (antidepressants, 46.3%; antipsychotics or antimanics, 25.9%), and pain relievers (nonnarcotic analgesics, 43.6%; antipyretics, 41.2%; antiarthritics, 31.2%). Conclusions: Despite awareness of polypharmacy and its potential consequences in older patients, results of our analysis suggest that polypharmacy remains widespread in US nursing homes. Although complex medication regimens are often necessary for nursing home residents, monitoring polypharmacy and its consequences may improve the quality of nursing home care and reduce unnecessary health care spending related to adverse events. |
Molecular characterization of neuropeptide F from the eastern subterranean termite Reticulitermes flavipes (Kollar) (Isoptera: Rhinotermitidae)
Nuss AB , Forschler BT , Crim JW , TeBrugge V , Pohl J , Brown MR . Peptides 2010 31 (3) 419-28 Neuropeptide F (NPF)-like immunoreactivity was previously found to be abundant in the eastern subterranean termite, Reticulitermes flavipes. Purification of the NPF from a whole body extract of worker termites was accomplished in the current study by HPLC and heterologous radioimmunoassay for an NPF-related peptide, Helicoverpa zea Midgut Peptide-I. A partial amino acid sequence allowed determination of the corresponding cDNA that encoded an open reading frame deduced for authentic R. flavipes NPF (Ref NPF): KPSDPEQLADTLKYLEELDRFYSQVARPRFa. Effects of synthetic NPFs on muscle contractions were investigated for isolated foreguts and hindguts of workers, with Drm NPF inhibiting spontaneous contractions of hindguts. Phylogenetic analysis of invertebrate NPF sequences reveals two separate groupings, with Ref NPF occurring within a clade composed exclusively of arthropods. |
Rate of decline in serum PFOA concentrations after granular activated carbon filtration at two public water systems in Ohio and West Virginia
Bartell SM , Calafat AM , Lyu C , Kato K , Ryan PB , Steenland K . Environ Health Perspect 2010 118 (2) 222-8 Background: Drinking water in multiple water districts in the Mid-Ohio Valley has been contaminated with perfluorooctanoic acid (PFOA), which was released by a nearby DuPont chemical plant. Two highly contaminated water districts began granular activated carbon filtration in 2007. Objectives: To determine the rate of decline in serum PFOA, and its corresponding half-life, during the first year after filtration. Methods: Up to six blood samples were collected from each of 200 participants from May 2007 until August 2008. The primary source of drinking water varied over time for some participants; our analyses were grouped according to water source at baseline in MayJune 2007. Results: For Lubeck Public Service District customers, the average decrease in serum PFOA concentrations between MayJune 2007 and MayAugust 2008 was 32 ng/mL (26%) for those primarily consuming public water at home (n = 130), and 16 ng/mL (28%) for those primarily consuming bottled water at home (n = 17). For Little Hocking Water Association customers, the average decrease in serum PFOA concentrations between NovemberDecember 2007 and MayJune 2008 was 39 ng/mL (11%) for consumers of public water (n = 39) and 28 ng/mL (20%) for consumers of bottled water (n = 11). The covariate-adjusted average rate of decrease in serum PFOA concentration after water filtration was 26% per year (95% confidence interval, 2528% per year). Conclusions: The observed data are consistent with first-order elimination and a median serum PFOA half-life of 2.3 years. Ongoing follow-up will lead to improved half-life estimation. Editor's Summary: Release of perfluorooctanoic acid (PFOA) from a chemical plant in West Virginia contaminated drinking water in several water districts, but use of granular activated-carbon filtration in two water districts reduced PFOA concentrations to levels below the limit of detection. Bartell et al. (p. 222) measured serum PFOA concentrations in up to six blood samples collected over approximately 12 months from a stratified random sample of 200 eligible participants in the C8 Health Project cohort, including baseline samples collected before initiation of water filtration to remove PFOA. The authors report that the average covariate-adjusted average rate of decrease in serum PFOA concentration after water filtration was 26% per year [95% confidence interval (CI), 2528% per year], consistent with a median serum PFOA half-life of 2.3 years (95% CI, 2.12.4 years). However, the authors also noted substantial variation in estimated half-lives among individuals, which may reflect ongoing exposures among some participants (e.g., through consumption of contaminated home-grown produce) and/or individual differences in PFOA elimination rates. In addition, they suggest that the accuracy of half-life estimates will improve with longer follow-up. |
Transcriptional biomarkers of steroidogenesis and trophoblast differentiation in the placenta in relation to prenatal phthalate exposure
Adibi JJ , Whyatt RM , Hauser R , Bhat HK , Davis BJ , Calafat AM , Hoepner LA , Perera FP , Tang D , Williams PL . Environ Health Perspect 2010 118 (2) 291-6 Background: Phthalates can alter steroidogenesis and peroxisome proliferatoractivated receptor gamma (PPARgamma)mediated transcription in rodent tissues. The placenta offers a rich source of biomarkers to study these relationships in humans. Objective: We evaluated whether gestational phthalate exposures in humans were associated with altered human placental steroidogenesis and trophoblast differentiation as measured by markers of mRNA transcription. Methods: We measured seven target genes in placentas collected from 54 Dominican and African-American women at delivery in New York City using quantitative real-time polymerase chain reaction (qPCR), normalized to 18S rRNA. qPCR results for the target genes were log-transformed, converted to Z-scores, and grouped into two functional pathways: steroidogenesis (aromatase, cholesterol side chain cleavage enzyme, 17beta-hydroxysteroid dehydrogenase type 1, and cytochrome P450 1B1) and trophoblast differentiation (PPARgamma, aryl hydrocarbon receptor, and human chorionic gonadotropin). Repeated measures models were used to evaluate the association of phthalate metabolites measured in third-trimester urine samples with each group of target genes, accounting for correlation among the genes within a pathway. Results: Higher urinary concentrations of five phthalate metabolites were associated with lower expression of the target genes reflecting trophoblast differentiation. Results were less consistent for genes in the steroidogenesis pathway and suggested a nonlinear doseresponse pattern for some phthalate metabolites. Conclusions: We observed a significant association between prenatal exposure to phthalates and placental gene expression within two pathways. Further studies are warranted to understand the significance of this association with respect to fetal development and placental function. Editor's Summary: In vitro systems to identify and characterize effects of endocrine-active chemicals (EACs) may reduce screening costs, testing time, and animal use while providing an experimental platform to characterize molecular and biochemical effects of exposure. The human adrenocortical carcinoma cell line H295R expresses all key enzymes involved in the synthesis of adrenocorticol steroid hormones from cholesterol and is being evaluated as a potential screening assay for EACs with effects on steroid biosynthesis. Breen et al. (p. 265) developed a mechanistic computational model to estimate the synthesis and secretion of 14 adrenal steroids in H295R cells and biochemical responses to enzyme inhibition by the model EAC metryrapone (MET), and they compared model estimates with time-course measurements in control and MET-exposed H295R cells. The authors report that predictions corresponded well with observed effects overall and conclude that results support the utility of this approach. They suggest that additional model development can facilitate research on unknown mechanisms of action and effects of chemical mixtures, and may improve the accuracy of low-dose extrapolations for risk assessment. |
The effect of ambient air pollution on sperm quality
Hansen C , Luben TJ , Sacks JD , Olshan A , Jeffay S , Strader L , Perreault SD . Environ Health Perspect 2010 118 (2) 203-9 Background: Research has suggested an association with ambient air pollution and sperm quality. Objectives: We investigated the effect of exposure to ozone (O3) and particulate matter < 2.5 microm in aerodynamic diameter (PM2.5) on sperm quality. Methods: We reexamined a previous cohort study of water disinfection by-products to evaluate sperm quality in 228 presumed fertile men with different air pollution profiles. Outcomes included sperm concentration, total sperm per ejaculate (count), and morphology, as well as DNA integrity and chromatin maturity. Exposures to O3 and PM2.5 were evaluated for the 90-day period before sampling. We used multivariable linear regression, which included different levels of adjustment (i.e., without and with season and temperature) to assess the relationship between exposure to air pollutants during key periods of sperm development and adverse sperm outcomes. Results: Sperm concentration and count were not associated with exposure to PM2.5, but there was evidence of an association (but not statistically significant) with O3 concentration and decreased sperm concentration and count. Additionally, a significant increase in the percentage of sperm cells with cytoplasmic drop [beta = 2.64; 95% confidence interval (CI), 0.215.06] and abnormal head (beta = 0.47; 95% CI, 0.030.92) was associated with PM2.5 concentration in the base model. However, these associations, along with all other sperm outcomes, were not significantly associated with either pollutant after controlling for season and temperature. Overall, although we found both protective and adverse effects, there was generally no consistent pattern of increased abnormal sperm quality with elevated exposure to O3 or PM2.5. Conclusions: Exposures to O3 or PM2.5 at levels below the current National Ambient Air Quality Standards were not associated with statistically significant decrements in sperm outcomes in this cohort of fertile men. However, some results suggested effects on sperm concentration, count, and morphology. Editor's Summary: Adverse effects of air pollution on sperm quality have been reported, but few studies have evaluated ambient exposures consistent with U.S. regulatory guidelines. Hansen et al. (p. 203) studied levels of ozone (O3) and PM2.5 (particulate matter < 2.5 microm in aerodynamic diameter) in association with semen outcomes among 228 presumed-fertile men residing in three southeastern U.S. counties. Exposures were classified based on measurements averaged across fixed monitoring stations in each county during the 90 days before sample collection. Outcomes included sperm concentration, count (per ejaculate) and morphology, and proxy measures of DNA integrity (sperm chromatin structure assay) and chromatin maturity (CMA assay). Associations with exposures during key time windows of sperm development were estimated using multivariable linear regression. The authors report crude inverse associations for O3 and sperm concentration and count, and positive associations for PM2.5 and the proportion of sperm cells with cytoplasmic drop and abnormal heads; however, associations did not persist after adjustment for season and temperature. Overall, O3 and PM2.5 exposures in the study population were not clearly associated with adverse outcomes, but the authors conclude that better characterized exposure estimates are needed to clarify relations between air pollutants and sperm quality. |
Individual characteristics associated with PBDE levels in U.S. human milk samples
Daniels JL , Pan IJ , Jones R , Anderson S , Patterson DG Jr , Needham LL , Sjodin A . Environ Health Perspect 2010 118 (1) 155-60 BACKGROUND: Reported polybrominated diphenyl ether (PBDE) concentrations in human samples in the United States have been higher than in Europe and Asia. Little is known about factors that contribute to individual variability in body burden. OBJECTIVE: In this large study we measured PBDE concentrations in human milk from the United States during 2004-2006. We assessed characteristics associated with concentrations in milk and change in milk concentration between 3 and 12 months postpartum. METHODS: We analyzed 303 milk samples obtained 3 months postpartum for PBDEs. A second sample was analyzed for 83 women still lactating 12 months postpartum. PBDE concentrations in milk and variability by individual characteristics such as age, parity, and prepregnancy body mass index (BMI) were evaluated using generalized linear models. RESULTS: PBDE congeners BDEs 28, 47, 99, 100, and 153 were detected in > 70% of samples. BDE-47 concentrations were the highest, ranging from below the limit of detection to 1,430 ng/g lipid, with a median of 28 ng/g lipid. Concentrations of most individual PBDE congeners and the sum of BDEs 28, 47, 99, 100, and 153 (SigmaPBDE) were lower among mothers > 34 years of age compared with those 25-29 years of age and higher among mothers with high compared with normal BMI, after adjustment for other covariates. Parity was not associated with PBDE concentration. The change in SigmaPBDE concentration in milk between 3 and 12 months postpartum was highly variable (median increase, 14%; interquartile range, -26% to 50%). CONCLUSIONS: PBDEs were detected in nearly all human milk samples, varying by maternal weight and age and over the course of breast-feeding. |
Are neighborhood-level characteristics associated with indoor allergens in the household?
Rosenfeld L , Rudd R , Chew GL , Emmons K , Acevedo-Garcia D . J Asthma 2010 47 (1) 66-75 BACKGROUND: Individual home characteristics have been associated with indoor allergen exposure; however, the influence of neighborhood-level characteristics has not been well studied. We defined neighborhoods as community districts determined by the New York City Department of City Planning. OBJECTIVE: We examined the relationship between neighborhood-level characteristics and the presence of dust mite (Der f 1), cat (Fel d 1), cockroach (Bla g 2), and mouse (MUP) allergens in the household. METHODS: Using data from the Puerto Rican Asthma Project, a birth cohort of Puerto Rican children at risk of allergic sensitization (n = 261), we examined associations between neighborhood characteristics (percent tree canopy, asthma hospitalizations per 1,000 children, roadway length within 100 meters of buildings, serious housing code violations per 1000 rental units, poverty rates, and felony crime rates), and the presence of indoor allergens. Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 microg/g; cat: >1 microg/g; cockroach: >1 U/g; mouse: >1.6 microg/g. RESULTS: Serious housing code violations were statistically significantly positively associated with dust mite, cat, and mouse allergens (continuous variables), adjusting for mother's income and education, and all neighborhood-level characteristics. In multivariable logistic regression analyses, medium levels of housing code violations were associated with higher dust mite and cat allergens (1.81, 95%CI: 1.08, 3.03 and 3.10, 95%CI: 1.22, 7.92, respectively). A high level of serious housing code violations was associated with higher mouse allergen (2.04, 95%CI: 1.15, 3.62). A medium level of housing code violations was associated with higher cockroach allergen (3.30, 95%CI: 1.11, 9.78). CONCLUSIONS: Neighborhood-level characteristics, specifically housing code violations, appear to be related to indoor allergens, which may have implications for future research explorations and policy decisions. |
Biomonitoring data for 2,4-dichlorophenoxyacetic acid in the United States and Canada: interpretation in a public health risk assessment context using biomonitoring equivalents
Aylward LL , Morgan MK , Arbuckle TE , Barr DB , Burns CJ , Alexander BH , Hays SM . Environ Health Perspect 2010 118 (2) 177-81 Background: Several extensive studies of exposure to 2,4-dichlorophenoxyacetic acid (2,4-D) using urinary concentrations in samples from the general population, farm applicators, and farm family members are now available. Reference doses (RfDs) exist for 2,4-D, and Biomonitoring Equivalents (BEs; concentrations in urine or plasma that are consistent with those RfDs) for 2,4-D have recently been derived and published. Objective: We reviewed the available biomonitoring data for 2,4-D from the United States and Canada and compared them with BE values to draw conclusions regarding the margin of safety for 2,4-D exposures within each population group. Data sources: Data on urinary 2,4-D excretion in general and target populations from recent published studies are tabulated and the derivation of BE values for 2,4-D summarized. Data synthesis: The biomonitoring data indicate margins of safety (ratio of BE value to biomarker concentration) of approximately 200 at the central tendency and 50 at the extremes in the general population. Median exposures for applicators and their family members during periods of use appear to be well within acute exposure guidance values. Conclusions: Biomonitoring data from these studies indicate that current exposures to 2,4-D are below applicable exposure guidance values. This review demonstrates the value of biomonitoring data in assessing population exposures in the context of existing risk assessments using the BE approach. Risk managers can use this approach to integrate the available biomonitoring data into an overall assessment of current risk management practices for 2,4-D. Editor's Summary: Urinary concentrations of the herbicide 2,4-dichlorophenoxyacetic acid (2,4-D) have been measured in general populations, farm applicators, and farm family members, but until recently it has not been possible to relate these biomonitoring data to reference dose (RfD) guidelines for acceptable levels of acute or chronic 2,4-D exposure. Aylward et al. (p. 177) compare published biomonitoring data with recently derived Biomonitoring Equivalents (BEs; urinary 2,4-D concentrations that correspond to RfDs) to determine whether population exposures appear consistent with current guidelines. The authors report that median urinary 2,4-D concentrations in general U.S. populations were approximately 200 times lower than the guideline value for chronic exposure. Median 2,4-D exposures reported for pesticide applicators and family members were 25 times lower than the guideline value for acute (occupational) exposure, although the highest urinary concentration reported was above the occupational BE. The authors conclude that findings support the value of the BE approach for assessing population risks based on biomonitoring data and suggest that current 2,4-D exposures are generally below reference values for acceptable exposure levels. |
The National Exposure Registry: history and lessons learned
Schultz MG , Sapp JH 2nd , Cusack CD , Fink JM . J Environ Health 2010 72 (7) 20-5 The National Exposure Registry (NER) was created as a comprehensive group of data repositories that sought, over time, to relate specific environmental exposures to dioxin, trichloroethylene (TCE), benzene, and trichloroethane (TCA) to registrants' health conditions. Some parts of the NER were well conceived, whereas others were not. The most important design deficiency of the NER was its inability to adequately assess exposure. This was the key missing element and the Achilles heel of the NER program. At least three other important issues were never satisfactorily resolved in the design of the NER. They were unverified self-reporting, appropriate control groups, and the use of biomarkers. The many health effects that were observed to be in excess when compared with national norms might be explained by methodological differences in data analysis and reliance on self-reported nonverified data. Creating and maintaining a population-based chemical exposure registry is a more difficult challenge than creating and maintaining an outcome registry, such as a cancer registry. |
Newborn hearing screening and follow-up: are children receiving recommended services?
Gaffney M , Green DR , Gaffney C . Public Health Rep 2010 125 (2) 199-207 Objectives. Newborn hearing screening programs have been implemented by all 50 states and most U.S. territories to detect hearing loss in infants and prevent delays in speech, language, and social and emotional development. To monitor progress toward national goals, the Centers for Disease Control and Prevention (CDC) collects data from state and territorial programs. This article summarizes findings from the CDC Early Hearing Detection and Intervention (EHDI) Hearing Screening and Follow-up Survey (HSFS) and provides a summary of recent efforts to identify infants with hearing loss in the U.S. Methods. The HSFS was sent to representatives of U.S. EHDI programs to gather aggregate screening, diagnostic, intervention, and demographic data for 2005 and 2006. We analyzed these data to evaluate progress toward national goals. Results. In 2005 and 2006, more than 90% of infants were screened for hearing loss. Of these infants, 2% in both years did not pass their final screening. Out of those not passing the final screening, approximately two-thirds were not documented as having a diagnostic finding. In both years, the reason reported for the majority of infants was loss to follow-up/loss to documentation (LFU/LTD). Although the majority of infants with permanent hearing loss were receiving intervention, more than 30% were classified as LFU/LTD and could not be documented as receiving intervention services. Conclusions. The HSFS enables the collection of more complete data that highlight the progress in screening infants for hearing loss. However, data indicate improvements are needed to reduce LFU/LTD and meet the national benchmarks. |
Establishing a national chronic kidney disease surveillance system for the United States
Saran R , Hedgeman E , Plantinga L , Burrows NR , Gillespie BW , Young EW , Coresh J , Pavkov M , Williams D , Powe NR . Clin J Am Soc Nephrol 2010 5 (1) 152-61 Despite the recognized importance of chronic kidney disease (CKD), the United States currently lacks a comprehensive, systematic surveillance program that captures and tracks all aspects of CKD in the population. As part of its CKD Initiative, the Centers for Disease Control and Prevention (CDC) funded two teams to jointly initiate the development of a CKD surveillance system. Here, we describe the process and methods used to establish this national CDC CKD Surveillance System. The major CKD components covered include burden (incidence and prevalence), risk factors, awareness, health consequences, processes and quality of care, and health system capacity issues. Goals include regular reporting of the data collected, plus development of a dynamic project web site and periodic issuance of a CKD fact sheet. We anticipate that this system will provide an important foundation for widespread efforts toward primary prevention, earlier detection, and implementation of optimal disease management strategies, with resultant increased awareness of CKD, decreased rates of CKD progression, lowered mortality, and reduced resource utilization. Final success will be measured by usage, impact, and endorsement. |
Association between 9p21 genomic markers and heart disease: a meta-analysis.
Palomaki GE , Melillo S , Bradley LA . JAMA 2010 303 (7) 648-56 CONTEXT: Associations between chromosome 9p21 single-nucleotide polymorphisms (SNPs) and heart disease have been reported and replicated. If testing improves risk assessments using traditional factors, it may provide opportunities to improve public health. OBJECTIVES: To perform a targeted systematic review of published literature for effect size, heterogeneity, publication bias, and strength of evidence and to consider whether testing might provide clinical utility. DATA SOURCES: Electronic search via HuGE Navigator through January 2009 and review of reference lists from included articles. STUDY SELECTION: English-language articles that tested for 9p21 SNPs with coronary heart/artery disease or myocardial infarction as primary outcomes. Included articles also provided race, numbers of participants, and data to compute an odds ratio (OR). Articles were excluded if reporting only intermediate outcomes (eg, atherosclerosis) or if all participants had existing disease. Twenty-five articles were initially identified and 16 were included. A follow-up search identified 6 additional articles. DATA EXTRACTION: Independent extraction was performed by 2 reviewers and consensus was reached. Credibility of evidence was assessed using published Venice criteria. DATA SYNTHESIS: Forty-seven distinct data sets from the 22 articles were analyzed, including 35 872 cases and 95 837 controls. The summary OR for heart disease among individuals with 2 vs 1 at-risk alleles was 1.25 (95% confidence interval [CI], 1.21-1.29), with low to moderate heterogeneity. Age at disease diagnosis was a significant covariate, with ORs of 1.35 (95% CI, 1.30-1.40) for age 55 years or younger and 1.21 (95% CI, 1.16-1.25) for age 75 years or younger. For a 65-year-old man, the 10-year heart disease risk for 2 vs 1 at-risk alleles would be 13.2% vs 11%. For a 40-year-old woman, the 10-year heart disease risk for 2 vs 1 at-risk alleles would be 2.4% vs 2.0%. Nearly identical but inverse results were found when comparing 1 vs 0 at-risk alleles. Three studies showed net reclassification indexes ranging from -0.1% to 4.8%. CONCLUSION: We found a statistically significant association between 9p21 SNPs and heart disease that varied by age at disease onset, but the magnitude of the association was small. |
A Hardy-Weinberg equilibrium test for analyzing population genetic surveys with complex sample designs.
Moonesinghe R , Yesupriya A , Chang MH , Dowling NF , Khoury MJ . Am J Epidemiol 2010 171 (8) 932-41 Testing for deviations from Hardy-Weinberg equilibrium is a widely recommended practice for population-based genetic association studies. However, current methods for this test assume a simple random sample and may not be appropriate for sample surveys with complex survey designs. In this paper, the authors present a test for Hardy-Weinberg equilibrium that adjusts for the sample weights and correlation of data collected in complex surveys. The authors perform this test by using a simple adjustment to procedures developed to analyze data from complex survey designs available within the SAS statistical software package (SAS Institute, Inc., Cary, North Carolina). Using 90 genetic markers from the Third National Health and Nutrition Examination Survey, the authors found that survey-adjusted and -unadjusted estimates of the disequilibrium coefficient were generally similar within self-reported races/ethnicities. However, estimates of the variance of the disequilibrium coefficient were significantly different between the 2 methods. Because the results of the survey-adjusted tests account for correlation among participants sampled within the same cluster, and the possibility of having related individuals sampled from the same household, the authors recommend use of this test when analyzing genetic data originating from sample surveys with complex survey designs to assess deviations from Hardy-Weinberg equilibrium. |
Varicella-zoster virus vaccine: molecular genetics
Schmid DS . Curr Top Microbiol Immunol 2010 342 323-40 The genetic differences that potentially account for the attenuation of the Oka vaccine VZV preparation are more clearly defined than for perhaps any other vaccine in current use. This is due in large part to the small number of differences between the vaccine and the parental strain from which it was derived, and to the high level of genomic conservation that characterizes VZV. This information has been used with great success to develop methods that discriminate vaccine from wild-type strains, to begin determining which specific vaccine markers contribute to the attenuated phenotype, to improve evaluations of vaccine efficacy and safety, and to observe the behavior of the live, attenuated preparation as it becomes more prevalent through widespread immunization. |
Prostate cancer genes associated with TMPRSS2-ERG gene fusion and prognostic of biochemical recurrence in multiple cohorts
Barwick BG , Abramovitz M , Kodani M , Moreno CS , Nam R , Tang W , Bouzyk M , Seth A , Leyland-Jones B . Br J Cancer 2010 102 (3) 570-6 BACKGROUND: Recent studies have indicated that prostate cancer patients with the TMPRSS2-ERG gene fusion have a higher risk of recurrence. To identify markers associated with TMPRSS2-ERG fusion and prognostic of biochemical recurrence, we analysed a cohort of 139 men with prostate cancer for 502 molecular markers. METHODS: RNA from radical prostatectomy tumour specimens was analysed using cDNA-mediated, annealing, selection, extension and ligation (DASL) to determine mRNAs associated with TMPRSS2-ERG T1/E4 fusion and prognostic of biochemical recurrence. Differentially expressed mRNAs in T1/E4-positive tumours were determined using significance analysis of microarrays (false discovery rate (FDR) <5%). Univariate and multivariate Cox regression determined genes, gene signatures and clinical factors prognostic of recurrence (P-value <0.05, log-rank test). Analysis of two prostate microarray studies (GSE1065 and GSE8402) validated the findings. RESULTS: In the 139 patients from this study and from a 455-patient Swedish cohort, 15 genes in common were differentially regulated in T1/E4 fusion-positive tumours (FDR <0.05). The most significant mRNAs in both cohorts coded ERG. Nine genes were found prognostic of recurrence in this study and in a 596-patient Minnesota cohort. A molecular recurrence score was significant in prognosticating recurrence (P-value 0.000167) and remained significant in multivariate analysis of a mixed clinical model considering Gleason score and TMPRSS2-ERG fusion status. CONCLUSIONS: TMPRSS2-ERG T1/E4 fusion-positive tumours had differentially regulated mRNAs observed in multiple studies, the most significant one coded for ERG. Several mRNAs were consistently associated with biochemical recurrence and have potential clinical utility but will require further validation for successful translation. |
Comparison of paper-and-pencil versus Web administration of the Youth Risk Behavior Survey (YRBS): risk behavior prevalence estimates
Eaton DK , Brener ND , Kann L , Denniston MM , McManus T , Kyle TM , Roberts AM , Flint KH , Ross JG . Eval Rev 2010 34 (2) 137-53 The authors examined whether paper-and-pencil and Web surveys administered in the school setting yield equivalent risk behavior prevalence estimates. Data were from a methods study conducted by the Centers for Disease Control and Prevention (CDC) in spring 2008. Intact classes of 9th- or 10th-grade students were assigned randomly to complete a survey via paper-and-pencil or Web. Data from 5,227 students were analyzed using logistic regression to identify associations of mode with reporting of 74 risk behaviors. Mode was associated with reporting of only 7 of the 74 risk behaviors. Results indicate prevalence estimates from paper-and-pencil and Web school-based surveys are generally equivalent. |
Control of an outbreak of human parainfluenza virus 3 in hematopoietic stem cell transplant recipients
Maziarz RT , Sridharan P , Slater S , Meyers G , Post M , Erdman DD , Peret TC , Taplitz RA . Biol Blood Marrow Transplant 2010 16 (2) 192-8 Human parainfluenza virus 3 (HPIV3) infection can cause significant morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). There are no standard guidelines for the prevention and control of HPIV3 in the outpatient setting. After 2 HSCT inpatients diagnosed with HPIV3 were noted to have had multiple recent HSCT outpatient clinic (OPC) visits, an investigation of policy and procedures in the HSCT OPC was undertaken, and active surveillance for respiratory viral illness was instituted in the at-risk HSCT population. Between July 19 and August 30, 2005, 13 patients were diagnosed with HPIV3 infection. Morbidity in affected patients was significant, and mortality was high (38.5%) and not affected by antiviral therapy. Molecular typing identified several genetically distinct groups of the hemagglutinin-neuraminidase gene of the 11 available isolates. Based on sequence relatedness among the isolates and the demographic and exposure history of the patients, in many of these cases HPIV3 infection likely was acquired in the HSCT OPC. The major infection control interventions were introduced between August 20 and August 24. An epidemic curve revealed that HPIV3 infection frequency peaked between August 17 and August 26, with no cases identified after August 30. Prompt attention and focus on infection control interventions were associated with a rapid decrease in the number of incident cases. Policies and procedures regarding patients with respiratory viral illnesses in HSCT OPC populations should be formulated and universally reinforced with HSCT clinic staff to prevent the spread of these infections. |
Three-phase model harmonizes estimates of the maximal suppression of parathyroid hormone by 25-hydroxyvitamin D in persons 65 years of age and older
Durazo-Arvizu RA , Dawson-Hughes B , Sempos CT , Yetley EA , Looker AC , Cao G , Harris SS , Burt VL , Carriquiry AL , Picciano MF . J Nutr 2010 140 (3) 595-9 The concentration or threshold of 25-hydroxyvitamin D [25(OH)D] needed to maximally suppress intact serum parathyroid hormone (iPTH) has been suggested as a measure of optimal vitamin D status. Depending upon the definition of maximal suppression of iPTH and the 2-phase regression approach used, 2 distinct clusters for a single 25(OH)D threshold have been reported: 16-20 ng/mL (40-50 nmol/L) and 30-32 ng/mL (75-80 nmol/L). To rationalize the apparently disparate published results, we compared thresholds from several regression models including a 3-phase one to estimate simultaneously 2 thresholds before and after adjusting for possible confounding for age, BMI, glomerular filtration rate, dietary calcium, and season (April-September vs. October-March) within a single data set, i.e. data from the Tufts University Sites Testing Osteoporosis Prevention/Intervention Treatment study, consisting of 181 men and 206 women (total n = 387) ages 65-87 y. Plasma 25(OH)D and serum iPTH concentrations were (mean +/- SD) 22.1 +/- 7.44 ng/mL (55.25 +/- 18.6 nmol/L) and 36.6 +/- 16.03 pg/mL (3.88 +/- 1.7 pmol/L), respectively. The 3-phase model identified 2 thresholds of 12 ng/mL (30 nmol/L) and 28 ng/mL (70 nmol/L); similar results were found from the 2-phase models evaluated, i.e. 13-20 and 27-30 ng/mL (32.5-50 and 67.5-75 nmol/L) and with previous results. Adjusting for confounding did not change the results substantially. Accordingly, the 3-phase model appears to be superior to the 2-phase approach, because it simultaneously estimates the 2 threshold clusters found from the 2-phase approaches along with estimating confidence limits. If replicated, it may be of both clinical and public health importance. |
Partitioning of polybrominated diphenyl ethers (PBDEs) in serum and milk from the same mothers
Schecter A , Colacino J , Sjodin A , Needham L , Birnbaum L . Chemosphere 2010 78 (10) 1279-84 We and others have previously described partitioning of chemicals, including polychlorinated-p-dioxins, dibenzofurans, and biphenyls in different types of human tissues and fluids, including blood and milk. Additionally, we previously reported the blood to milk partitioning of polybrominated diphenyl ethers (PBDEs) in a group of 11 women. Partitioning is of importance in understanding the toxicokinetics of these compounds and also in clinical medicine in improving estimates of levels in different matrices including blood and milk. In this study we extend these findings, describing the levels of PBDEs detected in the serum and milk of 29 women from Texas. The median sum of the levels of the four most detected congeners (BDE 47, 99, 100, and 153) in serum was 27.8 ng g(-1) lipid (range 6.7-501.6 ng g(-1) lipid). In milk, the median sum of the levels of the same congeners was 39.7 ng g(-1) lipid (range 12.9-580.3 ng g(-1) lipid). The levels detected in breast milk in this study are similar to those we reported in 2003, where a median total PBDE level of 34 ng g(-1) lipid was reported. When congener specific blood to milk partitioning ratios were calculated for BDEs 47, 99, 100, and 153, the relatively small tetrabrominated congener, BDE 47, was found in higher concentrations in milk compared to blood, while the higher molecular weight hexabrominated congener, BDE 153, was found in approximately equal quantities in blood and milk, on a lipid normalized basis. The reason for the differential partitioning of PBDE congeners in milk and blood could be due to variation in toxicokinetics, specifically distribution based on molecular size or molecular weight. |
The characterization of phospholipid functional group probe species on respirable silicon-containing dusts by solid-state (13)c and (31)p nuclear magnetic resonance spectroscopy
Murray DK . Appl Spectrosc 2010 64 (3) 328-36 Solid-state nuclear magnetic resonance (NMR) spectroscopic studies are reported for the interactions of probe molecules with respirable silicon-containing dusts as experimental evidence complementing computational studies reported by Snyder and Madura recently in J. Phys. Chem. B 112, 7095 (2008). The selected probe molecules represent the individual functional groups of a model lung surfactant dipalmitoylphosphatidyl choline (DPPC) deposited on a respirable silica and kaolin from water solution. (13)C and (31)P solid-state NMR spectroscopies were employed to detect chemical shift, line width, and chemical shift anisotropy, providing experimental evidence of mobility and relaxation changes describing the site and orientation of surface-associated species. NMR results confirm that only the phosphate and adjacent carbons are immobilized by surface hydroxyls on kaolin, while these and the carbons of the cationic head group are likewise immobilized by surface silanols on Miu-U-Sil 5. The phosphates in phosphoryl- and phosphatidyl-cholines were the primary interaction sites, with additional weak coordination with the trimethylammonium cation species. Covalent Al-O-P formation is not likely a factor in in vivo or in vitro toxicity mechanisms of respirable silicon-containing materials, but is rather the result of dehydration or demethoxylation reactions occurring over time or during heating or reduced pressure used in preparing materials for NMR spectroscopic study. Hydration is a critical factor in the formation and preparation for spectroscopic observation of coated dusts. Care must be taken to ensure that products formed and studied correspond to species formed in vivo under suitable concentration and hydration conditions. |
Long-term survival of infants with atrioventricular septal defects
Miller A , Siffel C , Lu C , Riehle-Colarusso T , Frias JL , Correa A . J Pediatr 2010 156 (6) 994-1000 OBJECTIVE: To examine the variation in survival in infants with atrioventricular septal defects (AVSD) with demographic factors and clinical characteristics, including the presence of Down syndrome. STUDY DESIGN: We selected infants with all types of AVSD with Down syndrome (n = 177) and without Down syndrome (n = 161), born between Jan 1, 1979, and Dec 31, 2003 and identified through the Metropolitan Atlanta Congenital Defects Program (MACDP). Infants were classified by the complexity of their cardiac defects and presence of major non-cardiac malformations. Deaths (n = 111) were identified through 2004 with linkage with state vital records and the National Death Index. Kaplan-Meier survival probabilities and adjusted hazard ratios (HRs) were calculated in relation to demographic and clinical characteristics. RESULTS: Children with AVSD and Down syndrome had a similar overall survival probability (70%) as those without Down syndrome (69%). Mortality was higher in children with a complex AVSD (adjusted HR = 7.0; 95% CI, 3.1-15.5) and in children with ≥2 major non-cardiac malformations (adjusted HR = 3.4; 95% CI, 1.8-6.5) and was lower in children in the 1992 to 2003 birth cohort (adjusted HR = 0.6; 95% CI, 0.4-0.998). CONCLUSIONS: Down syndrome was not a prognostic factor. Our findings might be helpful in assessing the long-term prognosis of infants with AVSD. |
Non-cigarette tobacco use among women and adverse pregnancy outcomes
England LJ , Kim SY , Tomar SL , Ray CS , Gupta PC , Eissenberg T , Cnattingius S , Bernert JT , Tita AT , Winn DM , Djordjevic MV , Lambe M , Stamilio D , Chipato T , Tolosa JE . Acta Obstet Gynecol Scand 2010 89 (4) 454-464 Although cigarette smoking remains the most prevalent form of tobacco use in girls and in women of reproductive age globally, use of non-cigarette forms of tobacco is prevalent or gaining in popularity in many parts of the world, especially in low- and middle-income countries. Sparse but growing evidence suggests that the use of some non-cigarette tobacco products during pregnancy increases the risk of adverse pregnancy outcomes. In this paper we review the literature on the prevalence of non-cigarette tobacco product use in pregnant women and in women of reproductive age in high-, middle-, and low-income countries and the evidence that maternal use of these products during pregnancy has adverse health effects. In addition, we communicate findings from an international group of perinatal and tobacco experts that was convened to establish research priorities concerning the use of non-cigarette tobacco products during pregnancy. The working group concluded that attempts to develop a public health response to non-cigarette tobacco use in women are hindered by a lack of data on the epidemiology of use in many parts of the world and by our limited understanding of the type and magnitude of the health effects of these products. We highlight research gaps and provide recommendations for a global research agenda. |
Pulmonary alveolar proteinosis in workers at an indium processing facility
Cummings KJ , Donat WE , Ettensohn DB , Roggli VL , Ingram P , Kreiss K . Am J Respir Crit Care Med 2010 181 (5) 458-64 Two cases of pulmonary alveolar proteinosis, including one death, occurred in workers at a facility producing indium-tin oxide (ITO), a compound used in recent years to make flat panel displays. Both workers were exposed to airborne ITO dust and had indium in lung tissue specimens. One worker was tested for autoantibodies to granulocytemacrophage-colonystimulating factor (GM-CSF) and found to have an elevated level. These cases suggest that inhalational exposure to ITO causes pulmonary alveolar proteinosis, which may occur via an autoimmune mechanism. |
Bromide and N-acetyl-S-(n-propyl)-L: -cysteine in urine from workers exposed to 1-bromopropane solvents from vapor degreasing or adhesive manufacturing
Hanley KW , Petersen MR , Cheever KL , Luo L . Int Arch Occup Environ Health 2010 83 (5) 571-84 OBJECTIVES: 1-Bromopropane (1-BP) is an alternative for ozone depleting and other solvents; it is used in aerosol products, adhesives, and cleaning solvents. There is concern that 1-BP may be a reproductive and neurological toxicant. Mercapturic acid conjugates are excreted in urine from 1-BP metabolism involving debromination. The main objectives were to evaluate urinary bromide [Br((-))] and N-acetyl-S-(n-propyl)-L: -cysteine (AcPrCys) for assessing 1-BP exposure in workers with low exposure. METHODS: Workers' 1-BP exposures were measured in their breathing zones with gas chromatography-flame ionization detection via NIOSH 1025. Urine specimens were obtained over a 48-h period at five facilities using vapor degreasers and one adhesive manufacturer. All of the workers' urine was collected into composite samples and analyzed separately representing daily time intervals: at work, after work but before bedtime, and upon awakening. Urinary metabolites were analyzed using intra-coupled plasma-mass spectroscopy for Br((-)), and high-performance liquid chromatography and electro-spray ionization mass spectroscopy for AcPrCys. RESULTS: Time-weighted average (TWA) geometric mean (GM) breathing zone concentrations of 1-BP at vapor degreasing facilities were 2.6 and 0.31 ppm, respectively, for workers near degreasers and those remote from degreasers. Urine metabolites showed the same trend as TWA exposures: higher levels were observed for workers near degreasers (48-h GM Br((-)) = 8.9 vs. 3.7; 48-h GM AcPrCys = 1.3 vs. 0.12, respectively). Associations of Br((-)) and AcPrCys concentrations with 1-BP TWA were statistically significant near degreasers (p < 0.01). CONCLUSIONS: This study shows that urinary Br((-)) and AcPrCys are useful biomarkers of workers' 1-BP exposures using analyses sensitive enough to measure low exposure jobs. |
Reaching Every District (RED) approach to strengthen routine immunization services: evaluation in the African region, 2005
Ryman T , Macauley R , Nshimirimana D , Taylor P , Shimp L , Wilkins K . J Public Health (Oxf) 2010 32 (1) 18-25 BACKGROUND: This evaluation was undertaken in 2005, in the African region, to better understand the reaching every district (RED) implementation process that provides a framework for strengthening immunization services at the district level. METHODS: In June 2005, a convenience sample of five countries was selected to evaluate the implementation of RED. Evaluation teams consisting of key partners conducted site visits to the national, district and health facility levels using standardized qualitative questionnaires. RESULTS: RED was implemented in a similar manner in all five countries, i.e. starting with training and micro-planning. All RED components were implemented to some degree in the countries. Common implementation factors included development of plans, expanding outreach services (defined as services provided in sites outside fixed immunization sites), planning of supervisory visits and efforts to link with communities and utilize community volunteers. Monitoring tools such as wall charts and maps were observed and reportedly used. CONCLUSIONS: Evaluation of the RED implementation process provided evidence of improvement in delivery of routine immunization services. The RED framework should continue to be used to strengthen the immunization delivery system to meet continuing new demands, such as the introduction of new vaccines and integrated delivery of other child survival interventions. |
Evaluation of the Centers for Disease Control and Prevention's Concussion initiative for high school coaches: "Heads Up: Concussion in High School Sports"
Sarmiento K , Mitchko J , Klein C , Wong S . J Sch Health 2010 80 (3) 112-8 BACKGROUND: To reduce the number of sports-related concussions, the Centers for Disease Control and Prevention (CDC), with the support of partners and experts in the field, has developed a tool kit for high school coaches with practical, easy-to-use concussion-related information. This study explores the success of the tool kit in changing knowledge, attitudes, and practices related to the prevention and management of concussions. METHODS: A mail questionnaire was administered to all eligible high school coaches who received the tool kit. Follow-up focus groups were conducted for additional information. Both quantitative data from the surveys and qualitative data from the focus groups were analyzed to support the objectives of the study. RESULTS: Respondents self-reported favorable changes in knowledge, attitudes, and practices toward the prevention and management of concussions. Qualitative responses augmented the quantitative data. CONCLUSION: Barriers to concussion prevention and management are complex; however, these results highlight the role that coaches can play in school settings in establishing a safe environment for their athletes. |
Pay or play programs and ERISA section 514: proposals for amending the statutory scheme
Young CL . Yale J Health Policy Law Ethics 2010 10 (1) 197-237 ERISA section 514 preempts many state and local “pay or play” laws, which mandate employer contributions to their employees’ health insurance. Given the attention that health insurance received in the presidential election cycle, there is a reasonable likelihood of legislative action to achieve a national “pay or play” health care program in the coming years. But a national bill will leave gaps that states and localities may be able to fill – if they were not preempted by ERISA. Therefore, the negotiation of a national health insurance program should address ERISA preemption in order to enable state experimentation. The Article proposes and evaluates a number of options to amend section 514, ranging from targeted statutory changes to federal agency discretion to “de-preempt” state and local pay or play laws. |
Medical education for a healthier population: reflections on the Flexner Report from a public health perspective
Maeshiro R , Johnson I , Koo D , Parboosingh J , Carney JK , Gesundheit N , Ho ET , Butler-Jones D , Donovan D , Finkelstein JA , Bennett NM , Shore B , McCurdy SA , Novick LF , Velarde LD , Dent MM , Banchoff A , Cohen L . Acad Med 2010 85 (2) 211-9 Abraham Flexner's 1910 report is credited with promoting critical reforms in medical education. Because Flexner advocated scientific rigor and standardization in medical education, his report has been perceived to place little emphasis on the importance of public health in clinical education and training. However, a review of the report reveals that Flexner presciently identified at least three public-health-oriented principles that contributed to his arguments for medical education reform: (1) The training, quality, and quantity of physicians should meet the health needs of the public, (2) physicians have societal obligations to prevent disease and promote health, and medical training should include the breadth of knowledge necessary to meet these obligations, and (3) collaborations between the academic medicine and public health communities result in benefits to both parties. In this article, commemorating the Flexner Centenary, the authors review the progress of U.S. and Canadian medical schools in addressing these principles in the context of contemporary societal health needs, provide an update on recent efforts to address what has long been perceived as a deficit in medical education (inadequate grounding of medical students in public health), and provide new recommendations on how to create important linkages between medical education and public health. Contemporary health challenges that require a public health approach in addition to one-on-one clinical skills include containing epidemics of preventable chronic diseases, reforming the health care system to provide equitable high-quality care to populations, and responding to potential disasters in an increasingly interconnected world. The quantitative skills and contextual knowledge that will prepare physicians to address these and other population health problems constitute the basics of public health and should be included throughout the continuum of medical education. |
Core state preconception health indicators: a voluntary, multi-state selection process
Broussard DL , Sappenfield WB , Fussman C , Kroelinger CD , Grigorescu V . Matern Child Health J 2010 15 (2) 158-68 This report describes the consensus-based selection process undertaken by a voluntary committee of policy/program leaders and epidemiologists from seven states to identify core state indicators to monitor the health of reproductive age women (aged 18-44 years). Domains of preconception health were established based on priority areas within maternal and child health and women's health. Measures (i.e., potential indicators) addressing the domains were identified from population-based, state level data systems. Each indicator was evaluated on five criteria: public health importance, policy/program importance, data availability, data quality, and the complexity of calculating the indicator. Evaluations served as the basis for iterative voting, which was continued until unanimous consent or a super majority to retain or exclude each indicator was achieved. Eleven domains of preconception health were identified: general health status and life satisfaction; social determinants of health; health care; reproductive health and family planning; tobacco, alcohol and substance use; nutrition and physical activity; mental health; emotional and social support; chronic conditions; infections; and genetics/epigenetics. Ninety-six possible indicators were identified from which 45 core indicators were selected. The scope of preconception care and the public health components to address preconception health are still under development. Despite this challenge and other measurement limitations, preconception health and health care indicators are urgently needed. The proposed core indicators are a set of measures that all states can use to evaluate their preconception health efforts. Furthermore, the indicators serve as a basis for improving the surveillance of the health of reproductive age women. |
Supplement 2003-2007 (No. 47) to the White-Kauffmann-Le Minor scheme
Guibourdenche M , Roggentin P , Mikoleit M , Fields PI , Bockemuhl J , Grimont PA , Weill FX . Res Microbiol 2010 161 (1) 26-9 This supplement reports the characterization of 70 new Salmonella serovars recognized between 2003 and 2007 by the WHO Collaborating Center for Reference and Research on Salmonella: 44 were assigned to Salmonella enterica subspecies enterica, 11 to subspecies salamae, 5 to subspecies arizonae, 8 to subspecies diarizonae, one to subspecies houtenae and one to Salmonella bongori. One new serovar, Mygdal, displayed a new H factor, H:z(91). |
Participation in activities outside of school hours in relation to problem behavior and social skills in middle childhood
Howie LD , Lukacs SL , Pastor PN , Reuben CA , Mendola P . J Sch Health 2010 80 (3) 119-25 BACKGROUND: Research has shown that participating in activities outside of school hours is associated with lower dropout rates, enhanced school performance, improved social skills, and reduced problem behaviors. However, most prior studies have been limited to small populations of older children (>12 years). This analysis focuses on children aged 6 to 11 to assess the potential association between participation in activities outside of school hours and behavior in middle childhood in a nationally representative survey. METHODS: Estimates were based on 25,797 children from the 2003-2004 National Survey of Children's Health. Outside of school activity was defined as participating in sports teams/lessons, clubs/organizations, or both at least once in the past year. Analysis of variance was used to evaluate the differences in behavior problems and social skills adjusting for sociodemographic factors, among children classified by participation in outside of school activities. RESULTS: Seventy-five percent of children participated in outside of school activities: 23% in sports, 16% in clubs, and 36% in both clubs and sports. Activity participation differed by gender, race/ethnicity, type of school, poverty status, family structure, household education, and school and community safety. Children participating in both sports and clubs had higher social skills index scores, but no significant difference in problem behavior scores compared with children who did not participate in any outside of school activity. CONCLUSION: Children participating in both sports and clubs had greater social competence during middle childhood compared with children who did not participate in any outside of school activities. |
Internal psychometric properties of the Children with Special Health Care Needs Screener
Carle AC , Blumberg SJ , Poblenz C . Acad Pediatr 2010 11 (2) 128-35 OBJECTIVE: Insufficient research has established the measurement properties of the Children with Special Health Care Needs (CSHCN) Screener. This leaves unclear whether CSHCN Screener-based estimates reliably identify CSHCN. We used classical and modern test theory to establish the CSHCN Screener's internal psychometric properties. METHODS: Data came from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN), a nationally representative survey of US children (N = 359 154). RESULTS: Cronbach's alpha, a measure of internal reliability, equaled .76. Confirmatory factor analysis for ordered-categorical measures indicated that a single underlying trait that we label health-condition-complexity underlies CSHCN Screener responses. Item response theory showed that responses provide particularly precise measurement among children experiencing elevated health-condition-complexity trait levels. CONCLUSIONS: Findings demonstrate that responses to the CSHCN Screener as used in the NS-CSHCN have good internal psychometric properties and include minimal random measurement error. Epidemiologists, clinicians and others can rely on CSHCN Screener responses to reliably identify CSHCN experiencing 1 or more of the 5 consequences included on the CSHCN Screener. |
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