Astrogliosis in CNS pathologies: is there a role for microglia?
Zhang D , Hu X , Qian L , O'Callaghan JP , Hong JS . Mol Neurobiol 2010 41 232-41 Astrogliosis, a cellular reaction with specific structural and functional characteristics, represents a remarkably homotypic response of astrocytes to all kinds of central nervous system (CNS) pathologies. Astrocytes play diverse functions in the brain, both harmful and beneficial. Mounting evidence indicates that astrogliosis is an underlying component of a diverse range of diseases and associated neuropathologies. The mechanisms that lead to astrogliosis are not fully understood, nevertheless, damaged neurons have long been reported to induce astrogliosis and astrogliosis has been used as an index for underlying neuronal damage. As the predominant source of proinflammatory factors in the CNS, microglia are readily activated under certain pathological conditions. An increasing body of evidence suggests that release of cytokines and other soluble products by activated microglia can significantly influence the subsequent development of astrogliosis and scar formation in CNS. It is well known that damaged neurons activate microglia very quickly, therefore, it is possible that activated microglia contribute factors/mediators through which damaged neuron induce astrogliosis. The hypothesis that activated microglia initiate and maintain astrogliosis suggests that suppression of microglial overactivation might effectively attenuate reactive astrogliosis. Development of targeted anti-microglial activation therapies might slow or halt the progression of astrogliosis and, therefore, help achieve a more beneficial environment in various CNS pathologies. |
Multidrug-resistant and extensively drug-resistant tuberculosis: a threat to global control of tuberculosis
Gandhi NR , Nunn P , Dheda K , Schaaf HS , Zignol M , van Soolingen D , Jensen P , Bayona J . Lancet 2010 375 (9728) 1830-43 Although progress has been made to reduce global incidence of drug-susceptible tuberculosis, the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis during the past decade threatens to undermine these advances. However, countries are responding far too slowly. Of the estimated 440,000 cases of MDR tuberculosis that occurred in 2008, only 7% were identified and reported to WHO. Of these cases, only a fifth were treated according to WHO standards. Although treatment of MDR and XDR tuberculosis is possible with currently available diagnostic techniques and drugs, the treatment course is substantially more costly and laborious than for drug-susceptible tuberculosis, with higher rates of treatment failure and mortality. Nonetheless, a few countries provide examples of how existing technologies can be used to reverse the epidemic of MDR tuberculosis within a decade. Major improvements in laboratory capacity, infection control, performance of tuberculosis control programmes, and treatment regimens for both drug-susceptible and drug-resistant disease will be needed, together with a massive scale-up in diagnosis and treatment of MDR and XDR tuberculosis to prevent drug-resistant strains from becoming the dominant form of tuberculosis. New diagnostic tests and drugs are likely to become available during the next few years and should accelerate control of MDR and XDR tuberculosis. Equally important, especially in the highest-burden countries of India, China, and Russia, will be a commitment to tuberculosis control including improvements in national policies and health systems that remove financial barriers to treatment, encourage rational drug use, and create the infrastructure necessary to manage MDR tuberculosis on a national scale. |
Urinary concentrations of metabolites of pyrethroid insecticides in the general U.S. population: National Health and Nutrition Examination Survey 1999-2002
Barr DB , Olsson AO , Wong LY , Udunka S , Baker SE , Whitehead RD , Magsumbol MS , Williams BL , Needham LL . Environ Health Perspect 2010 118 (6) 742-8 BACKGROUND: Pyrethroid insecticides are the most commonly used residential insecticides in the United States. OBJECTIVES: Our objective was to assess human exposure via biomonitoring to pyrethroid insecticides in a representative sample of the general U.S. population ≥ 6 years of age. METHODS: By using isotope-dilution high-performance liquid chromatography/electrospray chemical ionization/tandem mass spectrometry, we measured five urinary metabolites of pyrethroid insecticides in 5,046 samples collected as a part of the 1999-2002 National Health and Nutrition Examination Survey (NHANES). Univariate, multivariate, and Pearson correlation analyses were performed using SUDAAN and SAS software, incorporating the appropriate sample weights into the analyses. Multivariate analyses included age, sex, race/ethnicity, creatinine, fasting status, and urine collection time as covariates. RESULTS: We detected 3-phenoxybenzoic acid (3PBA), a metabolite common to many pyrethroid insecticides, in more than 70% of the samples. The least-squares geometric mean (LSGM) concentration (corrected for covariates) of 3PBA and the frequency of detection increased from 1999-2000 (0.292 ng/mL) to 2001-2002 (0.318 ng/mL) but not significantly. Non-Hispanic blacks had significantly higher LSGM 3PBA concentrations than did non-Hispanic whites and Mexican Americans in the 2001-2002 survey period and in the combined 4-year survey periods but not in the 1999-2000 survey period. Children had significantly higher LSGM concentrations of 3PBA than did adolescents in both NHANES periods and than adults in NHANES 1999-2000. Cis- and trans-(2,2-dichlorovinyl)-2,2-dimethylcyclopropane-1-carboxylic acid were highly correlated with each other and with 3PBA, suggesting that urinary 3PBA was derived primarily from exposure to permethrin, cypermethrin, or their degradates. CONCLUSIONS: Pyrethroid insecticide exposure in the U.S. population is widespread, and the presence of its metabolites in the urine of U.S. residents indicates that children may have higher exposures than adolescents and adults. EDITOR'S SUMMARY: Synthetic pyrethroid insecticides are being used with greater frequency in the United States to replace residential and some agricultural organophosphorus (OP) and carbamate insecticides. The pyrethroids are considered to be less toxic to humans than the OPs and carbamates, but like many other classes of insecticides, they are acute neurotoxicants. Barr et al. (p. 742) assessed human exposure to pyrethroid insecticides in a representative sample of the general U.S. population ≥ 6 years of age. 3-Phenoxybenzoic acid (3PBA), a metabolite common to many pyrethroid insecticides, was detected in > 70% of urine samples tested. Non-Hispanic blacks had significantly higher 3BPA concentrations than non-Hispanic whites and Mexican Americans, and children had significantly higher concentrations of 3PBA than adolescents and adults. Cis- and trans-(2,2-dichlorovinyl)-2,2-dimethylcyclopropane-1-carboxylic acid were highly correlated with each other and with 3PBA, suggesting that urinary 3PBA was primarily derived from exposure to permethrin, cypermethrin, or their degradates. The authors conclude that pyrethroid insecticide exposure in the U.S. population is widespread and that children may have higher exposures than adolescents and adults. |
Environmental metrics for community health improvement
Jakubowski B , Frumkin H . Prev Chronic Dis 2010 7 (4) A76 Environmental factors greatly affect human health. Accordingly, environmental metrics are a key part of the community health information base. We review environmental metrics relevant to community health, including measurements of contaminants in environmental media, such as air, water, and food; measurements of contaminants in people (biomonitoring); measurements of features of the built environment that affect health; and measurements of "upstream" environmental conditions relevant to health. We offer a set of metrics (including unhealthy exposures, such as pollutants, and health-promoting assets, such as parks and green space) selected on the basis of relevance to health outcomes, magnitude of associated health outcomes, corroboration in the peer-reviewed literature, and data availability, especially at the community level, and we recommend ways to use these metrics most effectively. |
Assessment of non-occupational exposure to polycyclic aromatic hydrocarbons through personal air sampling and urinary biomonitoring
Li Z , Mulholland JA , Romanoff LC , Pittman EN , Trinidad DA , Lewin MD , Sjodin A . J Environ Monit 2010 12 (5) 1110-1118 Non-occupational inhalation and ingestion exposure to polycyclic aromatic hydrocarbons (PAHs) has been studied in 8 non-smoking volunteers through personal air sampling and urinary biomonitoring. The study period was divided into 4 segments (2 days/segment), including weekdays with regular commute and weekends with limited traffic related exposures; each segment had a high or low PAH diet. Personal air samples were collected continuously from the subjects while at home, at work, and while commuting to and from work. All urine excretions were collected as individual samples during the study. In personal air samples, 28 PAHs were measured, and in urine samples 9 mono-hydroxylated metabolites (OH-PAHs) from 4 parent PAHs (naphthalene, fluorene, phenanthrene and pyrene) were measured. Naphthalene was found at higher concentrations in air samples collected at the subjects' residences, whereas PAHs with four or more aromatic rings were found at higher levels in samples taken while commuting. Urinary OH-PAH biomarker levels increased following reported high inhalation and/or dietary exposure. On days with a low PAH diet, the total amount of inhaled naphthalene during each 24-hour period was well correlated with the amount of excreted naphthols, as was, to a lesser extent, fluorene with its urinary metabolites. During days with a high dietary intake, only naphthalene was significantly correlated with its excreted metabolite. These findings suggest that this group of non-occupational subjects were exposed to naphthalene primarily through indoor air inhalation, and exposed to other PAHs such as pyrene mainly through ingestion. copyright 2010 The Royal Society of Chemistry. |
Distribution and determinants of pesticide mixtures in cord serum using principal component analysis
Neta G , Goldman LR , Barr D , Sjodin A , Apelberg BJ , Witter FR , Halden RU . Environ Sci Technol 2010 44 (14) 5641-8 We characterized the distribution and determinants of fetal exposures to pesticide mixtures using a cross-sectional study of 297 singletons delivered at Johns Hopkins Hospital in Baltimore, MD (2004-2005). Concentrations of nine persistent and twelve nonpersistent pesticides were measured in cord serum. Mixtures were identified using principal components analysis. Associations between mixtures and maternal and infant characteristics were evaluated using multivariate analysis. p,p'-DDE, p,p'-DDT, trans-nonachlor, oxychlordane, bendiocarb, propoxur, and trans- and cis-permethrin were detected in 100, 90, 93, 84, 73, 55, 52, and 41% of serum samples, respectively. There were four independent pesticide components: DDT (p,p'-DDT + p,p'-DDE), chlordane (trans-nonachlor + oxychlordane), permethrin (trans- and cis-permethrins + PBUT), and carbamate (bendiocarb + propoxur). DDT and chlordane were 6.1 (95%CI: 2.4, 15.5) and 2.1 (95%CI: 1.0, 4.2) times higher for infants of women >35, and 1.8 (95%CI: 1.2, 2.9) and 1.5 (95%CI: 1.1, 2.1) times higher in smoking mothers. DDT and carbamate were 15 (95%CI: 7, 30) and 2 (95%CI: 1, 4) times higher for infants of Asian compared with Caucasian mothers. No significant differences were observed for permethrin. Fetal exposures to pesticides are widespread, occur as mixtures, and differ by maternal race, age, and smoking status. |
Epidemiology of Colorado tick fever in Montana, Utah, and Wyoming, 1995-2003
Brackney MM , Marfin AA , Staples JE , Stallones L , Keefe T , Black WC , Campbell GL . Vector Borne Zoonotic Dis 2010 10 (4) 381-5 Colorado tick fever (CTF) is a biphasic, febrile illness caused by a Coltivirus and transmitted by the Rocky Mountain wood tick, Dermacentor andersoni, in the western United States and Canada. Symptoms generally include acute onset of fever, headache, chills, and myalgias; illness often lasts for 3 weeks or more. Laboratory-confirmed cases of CTF were identified from public health department records in Montana, Utah, and Wyoming, and from the Centers for Disease Control and Prevention diagnostic laboratory records. Additional descriptive epidemiologic data were obtained by medical record abstraction. Ninety-one cases were identified from 1995 to 2003, resulting in an overall annual incidence of 2.7 per 1,000,000 population. The annual incidence decreased over the 9-year study period. Cases were 2.5 times more frequent in males than females. The highest incidence of cases occurred in persons aged 51-70. Tick exposure prior to illness onset was reported in 90% of the cases in which a more detailed history was available. The most common symptoms were fever, headache, and myalgia; 18% of the case patients were hospitalized. While there has been an overall decline in the recognized incidence of CTF cases, the reasons for the decline are unknown. Possibilities include a reduced intensity of surveillance and a true decrease in incidence. As more people continue to visit, move to and work in endemic areas, CTF should be considered in anyone presenting with a febrile illness following tick exposure in an endemic area. Heightened awareness for the disease and tick prevention messages should be part of public health measures to further decrease the incidence of disease. |
Implementing integrated disease surveillance and response: four African countries' experience, 1998-2005
Nsubuga P , Brown WG , Groseclose SL , Ahadzie L , Talisuna AO , Mmbuji P , Tshimanga M , Midzi S , Wurapa F , Bazeyo W , Amri M , Trostle M , White M . Glob Public Health 2010 5 (4) 364-80 The Integrated Disease Surveillance and Response (IDSR) strategy was developed by the Africa Regional Office (AFRO) of the World Health Organisation (WHO) and proposed for adoption by member states in 1998. The goal was to build WHO/AFRO countries' capacity to detect, report and effectively respond to priority infectious diseases. This evaluation focuses on the outcomes in four countries that implemented this strategy. Major successes included: integration of the surveillance function of most of the categorical disease control programmes; implementation of standard surveillance, laboratory and response guidelines; improved timeliness and completeness of surveillance data and increased national-level review and use of surveillance data for response. The most challenging aspects were: strengthening laboratory networks; providing regular feedback and supervision on surveillance and response activities; routine monitoring of IDSR activities and extending the strategy to sub-national levels. |
Building a framework for global surveillance of the public health implications of adverse childhood experiences
Anda RF , Butchart A , Felitti VJ , Brown DW . Am J Prev Med 2010 39 (1) 93-8 In May 2009, the WHO and the National Center for Chronic Disease Prevention and Health Promotion (CDC, Atlanta GA) met in Geneva, Switzerland, to begin a collaborative effort to build a framework for public health surveillance that can be used to define the global health burden of adverse childhood experiences (ACEs). In addition to WHO and CDC staff, meeting participants included people working in the fields of public health and early child development from Canada, China, the former Yugoslav Republic of Macedonia, Philippines, Saudi Arabia, South Africa, Switzerland, and Thailand. Participants articulated their goal of forming a network aimed at advancing global understanding and measurement of ACEs through the exchange of information and the provision of technical expertise and support.1 | Viewing child maltreatment and related experiences as a set of exposures that have broad implications for human development and prevention of public health problems is a relatively new concept. Only since 2004 has child sexual abuse been included in the global burden of disease estimates of death and disability attributable to particular avoidable risk factors,2 and medical journals have recently begun to acknowledge the concept of abuse and related it as a major public health issue by raising awareness of the body of literature that supports this concept.3, 4 |
Distribution of 7-year risk of diabetes mellitus among United States adults
Ford ES , Li C , Zhao G , Pearson WS , Gregg EW . Diabetes Res Clin Pract 2010 89 (2) e19-21 Approximately 65% of 4739 United States adults had a 7-year risk of ≥21% during 1999-2004. Similar age-adjusted percentages of men and women were at high risk (≥21%). A larger age-adjusted percentage of Mexican Americans than whites and African Americans were at high risk. |
Riding in shopping carts and exposure to raw meat and poultry products: prevalence of, and factors associated with, this risk factor for salmonella and campylobacter infection in children younger than 3 years
Patrick ME , Mahon BE , Zansky SM , Hurd S , Scallan E . J Food Prot 2010 73 (6) 1097-100 Riding in a shopping cart next to raw meat or poultry is a risk factor for Salmonella and Campylobacter infections in infants. To describe the frequency of, and factors associated with, this behavior, we surveyed parents of children aged younger than 3 years in Foodborne Disease Active Surveillance Network sites. We defined exposure as answering yes to one of a series of questions asking if packages of raw meat or poultry were near a child in a shopping cart, or if a child was in the cart basket at the same time as was raw meat or poultry. Among 1,273 respondents, 767 (60%) reported that their children visited a grocery store in the past week and rode in shopping carts. Among these children, 103 (13%) were exposed to raw products. Children who rode in the baskets were more likely to be exposed than were those who rode only in the seats (odds ratio [OR], 17.8; 95% confidence interval [CI], 11.0 to 28.9). In a multivariate model, riding in the basket (OR, 15.5; 95% CI, 9.2 to 26.1), income less than $55,000 (OR, 1.8; 95% CI, 1.0 to 3.1), and Hispanic ethnicity (OR, 2.3; 95% CI, 1.2 to 4.5) were associated with exposure. Our study shows that children can be exposed to raw meat and poultry products while riding in shopping carts. Parents should separate children from raw products and place children in the seats rather than in the baskets of the cart. Retailer use of leak-proof packaging, customer placement of product in a plastic bag and on the rack underneath the cart, use of hand sanitizers and wipes, and consumer education may also be helpful. |
SNPs in CAST are associated with Parkinson disease: a confirmation study
Allen AS , Satten GA . Am J Med Genet B Neuropsychiatr Genet 2010 153B (4) 973-9 Using data from the National Institutes of Neurological disease and Stroke's (NINDS) study of Parkinson disease (PD), we recently reported that single nucleotide polymorphisms (SNPs) in a region containing the Calpastatin (CAST) gene were associated with PD. Here we follow up this finding with an analysis of the Center for Inherited Disease Research's (CIDR) genome-wide association study in familial PD. After adjusting for population stratification and multiple testing, we find a significant association (P = 0.0167) between PD and SNP rs1559085 in CAST. These findings confirm CAST/PD associations in a second, independent, dataset and suggest that CAST be prioritized for further investigation. |
Use of the prostate-specific antigen test among men aged 75 years or older in the United States: 2006 Behavioral Risk Factor Surveillance System
Li J , Zhao G , Pollack LA , Smith JL , Joseph DA . Prev Chronic Dis 2010 7 (4) A84 INTRODUCTION: In 2008, the US Preventive Services Task Force (USPSTF) updated prostate cancer screening guidelines to recommend against screening for prostate cancer in men aged 75 years or older. We describe the prevalence of prostate-specific antigen (PSA) testing in this population and identify factors that may be correlated with the use of this test. METHODS: Data came from the 2006 Behavioral Risk Factor Surveillance System. We assessed the status of PSA testing in the past year among 9,033 US men aged 76 or older who had no history of prostate cancer. We conducted descriptive and multiple logistic regression analyses to assess associations of PSA testing with certain sociodemographic and psychosocial factors. RESULTS: Overall, 60% of men aged 76 or older reported having a PSA test in the past year. Men who had health insurance, were satisfied with life, or always had emotional support were significantly more likely to report having a PSA test in the past year. However, men who had no routine health checkup; were divorced, widowed, or separated; or had less than a high school education were significantly less likely to report having had a PSA test. CONCLUSION: PSA testing is common among men aged 75 or older in the United States. Certain sociodemographic and psychosocial factors were associated with receipt of this test. This study may not only provide baseline data to evaluate acceptance and implementation of the USPSTF screening guidelines but may also help physicians and public health providers better understand these sociodemographic and psychosocial factors in this population. |
Influence of limit-setting and participation in physical activity on youth screen time
Carlson SA , Fulton JE , Lee SM , Foley JT , Heitzler C , Huhman M . Pediatrics 2010 126 (1) e89-96 OBJECTIVES:To examine the associations of demographics, rules associated with television-viewing, and physical activity with daily screen time (including television, non-school-related computer use, and video games) in children and adolescents. METHODS: We analyzed data from a telephone survey of 7415 youth aged 9 to 15 years from the Youth Media Campaign Longitudinal Survey. We used logistic regression models to calculate odds of exceeding recommended screen-time limits (>120 minutes/day) according to demographics, rules, and physical activity. RESULTS: Odds that children would exceed recommended screen-time limits were positively associated with age and black race/ethnicity and negatively associated with income level. Children and adolescents who reported that they really agreed that their parents had rules about time spent watching television and playing video games were less likely to exceed recommended limits than those who strongly disagreed that their parents had rules. Similarly, when parents reported always or very often having limits on television watching (versus rarely or never) and when parents correctly identified the recommended limits, children were less likely to exceed recommended limits. Children whose parents reported consistent limits and who themselves reported consistent rules about time spent watching television had the lowest prevalence of exceeding recommended limits. Odds that children would exceed recommended limits decreased as physical activity in the previous week increased. CONCLUSIONS: Parental rules regarding screen time and participation in physical activity play a role in the amount of screen time among children and adolescents. Programs that encourage limit-setting by parents and promote physical activity may reduce screen time among youth. |
Characteristics of complementary and alternative medicine use among adults with current asthma, 2006
Marino LA , Shen J . J Asthma 2010 47 (5) 521-5 BACKGROUND: Prevalence estimates of complementary and alternative medicine (CAM) use among persons with asthma vary widely; prior studies reported that patients do not discuss CAM use with their physicians. The authors examined the prevalence and characteristics of CAM use among adults with asthma to prepare physicians to discuss CAM use with their patients. METHODS: CAM use among adults with current asthma was analyzed using the 2006 Behavioral Risk Factor Surveillance System (BRFSS) data from a subset of 25 states that completed the follow-up Asthma Callback Survey. CAM use was defined as a "Yes" response to the use of one or more CAM therapies to control asthma during the previous 12 months. Statistics were calculated using SAS v9.2 Proc Surveyfreq to provide weighted estimates and account for complex sample design. RESULTS: The prevalence of CAM use among adults with asthma was 39.6% (95% confidence interval [CI] = 36.9-42.3). There was no significant association with CAM use by sex, race/ethnicity, age, education, or geographic region. After adjusting for demographics and region, CAM use was significantly higher among persons with (1) financial barriers to asthma care (odds ratio [OR] = 2.8, 95% CI = 1.9-4.1); (2) an emergency room (ER) visit due to asthma (OR = 1.7 95% CI = 1.1-2.6); and (3) ≥14 asthma-associated disability days during the previous year (OR = 2.1, 95% CI = 1.4-3.1). CONCLUSIONS: CAM use is common among adults with asthma. It is associated with financial barriers to asthma care and poor asthma control. Physicians should discuss CAM use with their asthma patients. |
Community perceptions of bloody diarrhoea in an urban slum in South Asia: implications for introduction of a Shigella vaccine
Arvelo W , Blum LS , Nahar N , von Seidlein L , Nahar L , Pack RP , Brooks AW , Pach A , Breiman RF , Luby SP , Ram PK . Epidemiol Infect 2010 139 (4) 1-7 Understanding local perceptions of disease causation could help public health officials improve strategies to prevent bloody diarrhoea. A cross-sectional survey was conducted in Dhaka, Bangladesh to elicit community beliefs about the causes of and prevention strategies for bloody diarrhoea. Between March and June 2003, we interviewed 541 randomly selected respondents. Overall, 507 (93%) respondents perceived that a vaccine could prevent bloody diarrhoea. If a vaccine provided lifetime protection, 445 (83%) respondents stated that they would opt to get the vaccine and would pay a median of $0.05 (range U.S.$0.01-0.15) for it, equivalent to <1% of their median weekly income. There was almost universal perception that an effective vaccine to prevent bloody diarrhoea was highly beneficial and acceptable. While respondents valued a vaccine for prevention of bloody diarrhoea, they were only willing to pay minimally for it. Therefore, achieving a high rate of Shigella vaccine coverage may require subsidy of vaccine purchase. |
The potential of black radio to disseminate health messages and reduce disparities
Hall IJ , Johnson-Turbes CA , Williams KN . Prev Chronic Dis 2010 7 (4) A87 Radio stations that target African American audiences ("black radio") reach a national African American audience daily, making black radio an ideal medium for health promotion and disparities reduction in the African American community. Black radio can be used to communicate public health messages and to recruit African Americans into public health research. |
Building trust through social media. CDC's experience during the H1N1 influenza response
Reynolds BJ . Mark Health Serv 2010 30 (2) 18-21 It was April 2009, and the Centers for | Disease Control and Prevention had | already been on the hunt for the next | pandemic influenza virus for nearly half | a century. Historical trends suggested a | pandemic influenza virus emerges about | every 30 years: We were long overdue. | While this public health agency had been | busy for some time honing its disease | detection and laboratory skills, in the last | decade it also had begun to concentrate | on its public emergency-risk communication skills. | The last decade also brought an | explosion of public communication | media. The 21st century that had started | with traditional media and a growing | Internet presence was transformed | within a decade into a world where traditional media and a mob of social | media vied for public attention. The | question was not only how would CDC | adapt to this new reality, but could it do | so during a public health emergency | and stay true to its core principles for | emergency-risk communication. |
Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients
Patel PR , Kallen AJ , Arduino MJ . Am J Kidney Dis 2010 56 (3) 566-77 Infections cause significant morbidity and mortality in patients undergoing hemodialysis. Bloodstream infections (BSIs) are particularly problematic, accounting for a substantial number of hospitalizations in these patients. Hospitalizations for BSI and other vascular access infections appear to have increased dramatically in hemodialysis patients since 1993. These infections frequently are related to central venous catheter (CVC) use for dialysis access. Regional initiatives that have shown successful decreases in catheter-related BSIs in hospitalized patients have generated interest in replicating this success in outpatient hemodialysis populations. Several interventions have been effective in preventing BSIs in the hemodialysis setting. Avoiding the use of CVCs in favor of access types with lower associated BSI risk is among the most important. When CVCs are used, adherence to evidence-based catheter insertion and maintenance practices can positively influence BSI rates. In addition, facility-level surveillance to detect BSIs and stimulate examination of vascular access use and care practices is essential to a comprehensive approach to prevention. This article describes the current epidemiology of BSIs in hemodialysis patients and effective prevention strategies to decrease the incidence of these devastating infections. |
Use of respiratory syncytial virus surveillance data to optimize the timing of immunoprophylaxis
Panozzo CA , Stockman LJ , Curns AT , Anderson LJ . Pediatrics 2010 126 (1) e116-23 OBJECTIVE: For children in the United States who are at high risk for severe respiratory syncytial virus (RSV) infection, the American Academy of Pediatrics (AAP) recommends administering immunoprophylaxis during the RSV season. We present an approach to using surveillance data to help guide application of AAP recommendations for immunoprophylaxis to local patterns of RSV outbreaks. METHODS: We analyzed data from laboratories that report consistently to the National Respiratory and Enteric Virus Surveillance System from 1992 to 2007. Local RSV seasons were defined and an immunoprophylaxis schedule was determined by using the median onset dates from each laboratory during 2002-2007. We applied these dates to 10 preceding years of RSV detection data. We compared how well the 5-year median-based method and a fixed date method were able to match the timing of immunoprophylaxis to the RSV season. RESULTS: Nineteen laboratories met our inclusion criteria and generally experienced only 1 RSV outbreak per season. Five years of data gave similar median onset/offset dates and season duration, as did 10 years and 15 years of data. The 5-year median schedule increased the number of seasons that children were protected at the season onset by 15% compared with a fixed start date of November 1 and identified communities that experienced RSV seasons with extended durations. CONCLUSIONS: The 5-year median method can be used to characterize timing of RSV seasons and optimally apply the current AAP recommendations for timing of palivizumab prophylaxis to the local community. |
A dynamic model of pneumococcal infection in the United States: implications for prevention through vaccination
Van Effelterre T , Moore MR , Fierens F , Whitney CG , White L , Pelton SI , Hausdorff WP . Vaccine 2010 28 (21) 3650-60 Universal infant vaccination with the 7-valent pneumococcal conjugate vaccine (PCV7) has nearly eliminated PCV7-serotype invasive pneumococcal disease (IPD) in young U.S. children, but has been accompanied by increases in the incidence of serotype 19A IPD. Because antibiotic-non-susceptible 19A has increased more than antibiotic-susceptible 19A, antibiotic selection pressure could be contributing to this trend. We developed a dynamic compartmental transmission model of pneumococcus to better understand the causes of this rise and to estimate the impact of vaccines or changes in antibiotic use on future IPD incidence in the U.S. in <2 year-olds. The model predicted that with current practices, serotype 19A IPD incidence will plateau at about the 2007 level over the next few years. The model suggests that antibiotic usage played a major role in the rise in antibiotic-non-susceptible 19A IPD, with a lesser contribution from PCV7 vaccination. However, hypothetical large decreases in antibiotic use starting in 2008 are predicted to yield only gradual decreases in antibiotic-non-susceptible 19A IPD. On the other hand, vaccines with modest (20%) effectiveness against 19A (or 6A or PCV7-serotypes) carriage are predicted to substantially (by 80%) decrease the incidence of IPD caused by those serotypes within 10 years of implementation. Our findings highlight that vaccine effects on colonization are key to their overall benefits. In addition, serotype changes following vaccine introduction may have multifactorial origins, with antibiotic use an important factor for resistant strains such as 19A. |
Unintentional child poisonings through ingestion of conventional and novel tobacco products
Connolly GN , Richter P , Aleguas Jr A , Pechacek TF , Stanfill SB , Alpert HR . Pediatrics 2010 125 (5) 896-9 OBJECTIVE: This study examines child poisonings resulting from ingestion of tobacco products throughout the nation and assesses the potential toxicity of novel smokeless tobacco products, which are of concern with their discreet form, candy-like appearance, and added flavorings that may be attractive to young children. METHODS: Data representing all single-substance, accidental poisonings resulting from ingestion of tobacco products by children <6 years of age, reported to poison control centers, were examined. Age association with ingestion of smokeless tobacco versus other tobacco products was tested through logistic regression. Total nicotine content, pH, and un-ionized nicotine level were determined, and the latter was compared with values for moist snuff and cigarettes. RESULTS: A total of 13,705 tobacco product ingestion cases were reported, >70% of which involved infants <1 year of age. Smokeless tobacco products were the second most common tobacco products ingested by children, after cigarettes, and represented an increasing proportion of tobacco ingestions with each year of age from 0 to 5 years (odds ratio: 1.94 [95% confidence interval: 1.86-2.03]). A novel, dissolvable, smokeless tobacco product with discreet form, candy-like appearance, and added flavorings was found to contain an average of 0.83 mg of nicotine per pellet, with an average pH of 7.9, which resulted in an average of 42% of the nicotine in the un-ionized form. CONCLUSION: In light of the novelty and potential harm of dissolvable nicotine products, public health authorities are advised to study these products to determine the appropriate regulatory approach. |
Most-probable-number rapid viability PCR method to detect viable spores of Bacillus anthracis in swab samples
Letant SE , Kane SR , Murphy GA , Alfaro TM , Hodges LR , Rose LJ , Raber E . J Microbiol Methods 2010 81 (2) 200-2 A comparison of Most-Probable-Number Rapid Viability (MPN RV) PCR and traditional culture methods for the quantification of Bacillus anthracis Sterne spores in macrofoam swabs from a multi-center validation study was performed. The purpose of the study was to compare environmental swab processing methods for recovery, detection, and quantification of viable B. anthracis spores from surfaces. Results show that spore numbers provided by the MPN RV-PCR method were typically within 1-log of the values from a plate count method for all three levels of spores tested (3.1x10(4), 400, and 40 spores sampled from surfaces with swabs) even in the presence of debris. The MPN method tended to overestimate the expected result, especially at lower spore levels. Blind negative samples were correctly identified using both methods showing a lack of cross contamination. In addition to detecting low levels of spores in environmental conditions, the MPN RV-PCR method is specific, and compatible with automated high-throughput sample processing and analysis protocols, enhancing its utility for characterization and clearance following a biothreat agent release. |
Improved molecular detection of Angiostrongylus cantonensis in mollusks and other environmental samples with a species-specific ITS1-based TaqMan assay
Qvarnstrom Y , da Silva AC , Teem JL , Hollingsworth R , Bishop H , Graeff-Teixeira C , da Silva AJ . Appl Environ Microbiol 2010 76 (15) 5287-9 Angiostrongylus cantonensis is the most common cause of human eosinophilic meningitis. Humans become infected by ingesting food items contaminated with 3(rd) stage larvae that develop in mollusks. We report the development of a real-time PCR assay for the species-specific identification of A. cantonensis in mollusk tissue. |
Characterization of the antiviral and inflammatory responses against Nipah virus in endothelial cells and neurons
Lo MK , Miller D , Aljofan M , Mungall BA , Rollin PE , Bellini WJ , Rota PA . Virology 2010 404 (1) 78-88 Nipah virus (NiV) is a highly pathogenic paramyxovirus which causes fatal encephalitis in up to 75% of infected humans. Endothelial cells and neurons are important cellular targets in the pathogenesis of this disease. In this study, viral replication and the innate immune responses to NiV in these cell types were measured. NiV infected endothelial cells generated a functionally robust IFN-beta response, which correlated with localization of the NiV W protein to the cytoplasm. There was no antiviral response detected in infected neuronal cells. NiV infection of endothelial cells induced a significant increase in secreted inflammatory chemokines, which corresponded with the increased ability of infected cell supernatants to induce monocyte and T-lymphocyte chemotaxis. These results suggest that pro-inflammatory chemokines produced by NiV infected primary endothelial cells in vitro is consistent with the prominent vasculitis observed in infections, and provide initial molecular insights into the pathogenesis of NiV in physiologically relevant cells types. |
Characterization of the human cervical mucous proteome
Panicker G , Ye Y , Wang D , Unger ER . Clin Proteomics 2010 6 18-28 INTRODUCTION: Cervical cancer is among the most common cancers in women worldwide. Discovery of biomarkers for the early detection of cervical cancer would improve current screening practices and reduce the burden of disease. OBJECTIVE: In this study, we report characterization of the human cervical mucous proteome as the first step towards protein biomarker discovery. METHODS: The protein composition was characterized using one- and two-dimensional gel electrophoresis, and liquid chromatography coupled with mass spectrometry. We chose to use this combination of traditional biochemical techniques and proteomics to allow a more comprehensive analysis. RESULTS AND CONCLUSION: A total of 107 unique proteins were identified, with plasma proteins being most abundant. These proteins represented the major functional categories of metabolism, immune response, and cellular transport. Removal of high molecular weight abundant proteins by immunoaffinity purification did not significantly increase the number of protein spots resolved. We also analyzed phosphorylated and glycosylated proteins by fluorescent post-staining procedures. The profiling of cervical mucous proteins and their post-translational modifications can be used to further our understanding of the cervical mucous proteome. |
Diagnostic accuracy and analytical sensitivity of IDEIA (TM) norovirus assay for routine screening of human norovirus
Costantini V , Grenz L , Fritzinger A , Lewis D , Biggs C , Hale A , Vinje J . J Clin Microbiol 2010 48 (8) 2770-8 Noroviruses (NoVs) are recognized as the leading cause of epidemic and sporadic acute gastroenteritis. Early detection of NoV is crucial to control the spread of the disease. In this study, we evaluated the diagnostic accuracy, analytical sensitivity, and analytical reactivity of the IDEIA(TM) Norovirus assay (EIA) in a prospective and retrospective study design. A total of 557 prospectively collected fecal samples and a panel of 97 archived fecal samples including 21 different GI and GII genotypes were tested by conventional RT-PCR/bi-directional sequencing, real-time RT-PCR and electron microscopy. The sensitivity and specificity of the EIA was 57.6% and 91.9%, respectively. The sensitivity for detecting NoV in fecal samples from outbreaks improved from 44.1% for 3 samples to 76.9% when 5 samples per outbreak were tested. The EIA was able to detect strains from 7 GI and 11 GII genotypes. The analytical sensitivity of the EIA was 3.1 x 10(6) and 1.6 x 10(7) virus particles g(-1) of fecal sample for NoV GI and GII strains, respectively. Most GII samples positive by EIA had a Ct < 26.5 and 50% of the GII samples negative by EIA had a Ct >25.6 suggesting that, although strains from genotypes GI.8, GII.10, GII.16 were not detected, the low sensitivity of the EIA is primarily caused by low virus concentration. In conclusion, the current EIA may be of use as a rapid screening test during a norovirus outbreak investigation when multiple fecal samples are available, however, sporadic samples should be tested by molecular methods. |
Risk factors for invasive pneumococcal disease in children in the era of conjugate vaccine use
Pilishvili T , Zell ER , Farley MM , Schaffner W , Lynfield R , Nyquist AC , Vazquez M , Bennett NM , Reingold A , Thomas A , Jackson D , Schuchat A , Whitney CG . Pediatrics 2010 126 (1) e9-17 OBJECTIVE: We conducted a case-control study to evaluate risk factors for invasive pneumococcal disease (IPD) among children who were aged 3 to 59 months in the era of pneumococcal conjugate vaccine (PCV7). METHODS: IPD cases were identified through routine surveillance during 2001-2004. We matched a median of 3 control subjects to each case patient by age and zip code. We calculated odds ratios for potential risk factors for vaccine-type and non-vaccine-type IPD by using multivariable conditional logistic regression. RESULTS: We enrolled 782 case patients (45% vaccine-type IPD) and 2512 matched control subjects. Among children who received any PCV7, children were at increased risk for vaccine-type IPD when they had underlying illnesses, were male, or had no health care coverage. Vaccination with PCV7 did not influence the risk for non-vaccine-type IPD. Presence of underlying illnesses increased the risk for non-vaccine-type IPD, particularly among children who were not exposed to household smoking. Non-vaccine-type case patients were more likely than control subjects to attend group child care, be male, live in low-income households, or have asthma; case patients were less likely than control subjects to live in households with other children. CONCLUSIONS: Vaccination with PCV7 has reduced the risk for vaccine-type IPD that is associated with race and group child care attendance. Because these factors are still associated with non-vaccine-type IPD risk, additional reductions in disparities should be expected with new, higher valency conjugate vaccines. |
QALY weights for neurosensory impairments in pediatric economic evaluations: case studies and a critique
Grosse SD , Prosser LA , Asakawa K , Feeny D . Expert Rev Pharmacoecon Outcomes Res 2010 10 (3) 293-308 The use of utility weights for the calculation of quality-adjusted life years is particularly problematic for pediatric health states. This article reviews variability in utility weights for intellectual disability and permanent hearing loss in economic evaluations of newborn screening and childhood immunizations. Utility weights for severe intellectual disability ranged from 0.06 to 0.74. Most studies either did not vary these utility weights in sensitivity analyses or assumed low variability; consequently, the robustness of cost-effectiveness estimates was not fully assessed. Two recently published catalogs of utility weights for pediatric health states also show wide divergences in estimates. More work is needed to establish measures of health utilities for childhood health states in order to allow for comparable assessments of pediatric interventions. |
Infant morbidity and mortality attributable to prenatal smoking in the U.S
Dietz PM , England LJ , Shapiro-Mendoza CK , Tong VT , Farr SL , Callaghan WM . Am J Prev Med 2010 39 (1) 45-52 BACKGROUND: Although prenatal smoking continues to decline, it remains one of the most prevalent preventable causes of infant morbidity and mortality in the U.S. PURPOSE: The aim of this study was to estimate the proportion of preterm deliveries, term low birth weight deliveries, and infant deaths attributable to prenatal smoking. METHODS: Associations were estimated for prenatal smoking and preterm deliveries, term low birth weight (<2500 g) deliveries, sudden infant death syndrome (SIDS), and preterm-related deaths among 3,352,756 singleton, live births using the U.S. Linked Birth/Infant Death Data Set, 2002 birth cohort. The 2002 data set is the most recent, in which 49 states used the same standardized smoking-related question on the birth certificate. Logistic regression models estimated ORs of prenatal smoking for each outcome, and the prenatal smoking population attributable fraction was calculated for each outcome. RESULTS: Prenatal smoking (11.5% of all births) was significantly associated with very (AOR=1.5, 95% CI=1.4, 1.6); moderate (AOR=1.4, 95% CI=1.4, 1.4); and late (AOR=1.2, 95% CI=1.2, 1.3) preterm deliveries; term low birth weight deliveries (AOR=2.3, 95% CI=2.3, 2.5); SIDS (AOR=2.7, 95% CI=2.4, 3.0); and preterm-related deaths (AOR=1.5, 95% CI=1.4, 1.6). It was estimated that 5.3%-7.7% of preterm deliveries, 13.1%-19.0% of term low birth weight deliveries, 23.2%-33.6% of SIDS, and 5.0%-7.3% of preterm-related deaths were attributable to prenatal smoking. Assuming prenatal smoking rates continued to decline after 2002, these PAFs would be slightly lower for 2009 (4.4%-6.3% for preterm-related deaths, 20.2%-29.3% for SIDS deaths). CONCLUSIONS: Despite recent declines in the prenatal smoking prevalence, prenatal smoking continues to cause a substantial number of infant deaths in the U.S. |
Fondly remembered: Marty Fishbein
Rietmeijer K , McFarlane M . Sex Transm Dis 2010 37 (6) 345-345 Dr. Martin Fishbein, world-renowned behavioral theorist who provided the basis for the development and study of behavioral interventions for a wide array of health behaviors, and who was the principal scientist of ground-breaking human immunodeficiency virus/sexually transmitted infection (HIV/STI) prevention studies in the 1980s and 1990s, died suddenly on November 27, 2009 while visiting London with his wife Debby. He was 73 years old. | After receiving his doctorate in psychology at the University of California, Los Angeles, Marty started his long and productive career at the University of Illinois, Urbana-Champaign. There he pursued his pioneering work on human behavior and cognitive factors associated with behavior change that ultimately culminated in the book, Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research, published in 1975. In this book, he formulated the Theory of Reasoned Action that has since been intrinsically linked to his name. In a 1996 Public Health Reports article, he described the theory as follows: | “According to the theory of reasoned action, performance or nonperformance of a given behavior is primarily determined by the strength of a person's intention to perform (or to not perform) that behavior, where intention is defined as the subjective likelihood that one will perform (or try to perform) the behavior in question. The intention to perform a given behavior is, in turn, viewed as a function of 2 basic factors: the person's attitude toward performing the behavior (one's overall positive or negative feeling about personally performing the behavior) and/or the person's subjective norm concerning the behavior (the person's perception of normative pressure to perform [or to not perform] the behavior in question). The theory of reasoned action also considers the determinants of attitudes and subjective norms. Attitudes are viewed as a function of behavioral belief (beliefs that performing the behavior will lead to certain outcomes) and their evaluative aspects (the evaluation of these outcomes); subjective norms are viewed as a function of normative beliefs (beliefs that a specific individual or group thinks one should or should not perform the behavior in question) and motivations to comply (the degree to which, in general, one wants [or does not want] to do what the referent thinks one should do). Generally, the more one believes that performing the behavior will lead to positive outcomes or will prevent negative outcomes, the more favorable will be one's attitude toward performing the behavior. Similarly, the more one believes that specific referents (individuals or groups) think that one should (or should not) perform the behavior, and the more one is motivated to comply with those referents, the stronger will be the perceived pressure (the subjective norm) to perform (or to not perform) that behavior.” |
Workplace spirometry monitoring for respiratory disease prevention: a methods review
Hnizdo E , Glindmeyer HW , Petsonk EL . Int J Tuberc Lung Dis 2010 14 (7) 796-805 This report reviews methods applicable in workplace spirometry monitoring for the identification of individuals with excessive lung function decline. Specific issues addressed include 1) maintaining longitudinal spirometry data precision at an acceptable level so that declines due to adverse physiological processes in the lung can be readily detected in an individual; 2) applying interpretative strategies that have a high likelihood of identifying workers at risk of developing lung function impairment; and 3) enhancing effectiveness of spirometry monitoring for intervention and disease prevention. Applications in ongoing computerized spirometry monitoring programs are described that demonstrate approaches to improving spirometry data precision and quality, and facilitating informed decision-making on disease prevention. |
Pressure distribution on the anatomic landmarks of the knee and the effect of kneepads
Porter WL , Mayton AG , Moore SM . Appl Ergon 2010 42 (1) 106-13 This study examines stress transmitted to anatomic landmarks of the knee (patella, combined patella tendon and tibial tubercle) while in static kneeling postures without kneepads and while wearing two kneepads commonly worn in the mining industry. Ten subjects (7 male, 3 female) simulated postures utilized in low-seam mines: kneeling in full flexion; kneeling at 90 degrees of knee flexion; and kneeling on one knee while in one of three kneepad states (no kneepads, non-articulated kneepads, and articulated kneepads). For each posture, peak and mean pressure on the anatomic landmarks of the knee were obtained. The majority of the pressure was found to be transmitted to the knee via the combined patellar tendon and tibial tubercle rather than through the patella. While the kneepads tested decreased the maximum pressure experienced at the combined patellar tendon and tibial tubercle, peak pressures of greater than 25psi were still experienced over structures commonly injured in mining (e.g. bursa sac - bursitis/Miner's Knee). The major conclusion of this study is that novel kneepad designs that redistribute the stresses at the knee across a greater surface area and to other regions of the leg away from key structures of the knee are needed. |
A bounding estimate of neutron dose based on measured photon dose around single pass reactors at the Hanford site
Taulbee TD , Glover SE , Macievic GV , Hunacek M , Smith C , DeBord GW , Morris D , Fix J . Health Phys 2010 99 (1) 26-38 Neutron and photon radiation survey records have been used to evaluate and develop a neutron to photon (NP) ratio to reconstruct neutron doses to workers around Hanford's single pass reactors that operated from 1945 to 1972. A total of 5,773 paired neutron and photon measurements extracted from 57 boxes of survey records were used in the development of the NP ratio. The development of the NP ratio enables the use of the recorded dose from an individual's photon dosimeter badge to be used to estimate the unmonitored neutron dose. The Pearson rank correlation between the neutron and photon measurements was 0.71. The NP ratio best fit a lognormal distribution with a geometric mean (GM) of 0.8, a geometric standard deviation (GSD) of 2.95, and the upper 95 th % of this distribution was 4.75. An estimate of the neutron dose based on this NP ratio is considered bounding due to evidence that up to 70% of the total photon exposure received by workers around the single pass reactors occurs during shutdown maintenance and refueling activities when there is no significant neutron exposure. Thus when this NP ratio is applied to the total measured photon dose from an individual film badge dosimeter, the resulting neutron dose is considered bounded. |
Directional control-response relationships for mining equipment
Burgess-Limerick R , Krupenia V , Wallis G , Pratim-Bannerjee A , Steiner L . Ergonomics 2010 53 (6) 748-57 A variety of directional control-response relationships are currently found in mining equipment. Two experiments were conducted in a virtual environment to determine optimal direction control-response relationships in a wide variety of circumstances. Direction errors were measured as a function of control orientation (horizontal or vertical), location (left, front, right) and directional control-response relationships. The results confirm that the principles of consistent direction and visual field compatibility are applicable to the majority of situations. An exception is that fewer direction errors were observed when an upward movement of a horizontal lever or movement of a vertical lever away from the participants caused extension (lengthening) of the controlled device, regardless of whether the direction of movement of the control is consistent with the direction in which the extension occurs. Further, both the control of slew by horizontally oriented controls and the control of device movements in a frontal plane by the perpendicular movements of vertical levers were associated with relatively high rates of directional errors, regardless of the directional control-response relationship, and these situations should be avoided. STATEMENT OF RELEVANCE: The results are particularly applicable to the design of mining equipment such as drilling and bolting machines, and have been incorporated into MDG35.1 Guideline for bolting & drilling plant in mines (Industry & Investment NSW, 2010). The results are also relevant to the design of any equipment where vertical or horizontal levers are used to control the movement of equipment appendages, e.g. cranes mounted to mobile equipment and the like. |
Evaluation of an innovative internet-based partner notification program for early syphilis case management, Washington, DC, January 2007-June 2008
Ehlman DC , Jackson M , Saenz G , Novak DS , Kachur R , Heath JT , Furness BW . Sex Transm Dis 2010 37 (8) 478-85 BACKGROUND: The Internet has become a common venue for meeting sex partners and planning participation in risky sexual behavior. In this article, we evaluate the first 18 months of the Washington, DC, Department of Health Internet-based Partner Notification (IPN) program for early syphilis infections, using the standard Centers for Disease Control and Prevention (CDC) Disease Investigation Specialist (DIS) disposition codes, as well as Washington, DC, Department of Health's IPN-specific outcomes for pseudonymous partners. METHODS: We analyzed DIS disposition codes and IPN-specific outcomes from all early syphilis investigations initiated January 2007-June 2008. Internet partners were defined as sex partners for whom syphilis exposure notification was initiated by e-mail because no other locating information existed. If the e-mails resulted in additional locating information, we used the standard CDC disposition codes. Alternatively, the following IPN-specific outcomes were used: Informed of Syphilis Exposure, Informed of General STD Exposure, Not Informed or Unable to Confirm Receipt of General STD Exposure. RESULTS: From the 361 early syphilis patients, a total of 888 sex partners were investigated, of which 381 (43%) were via IPN. IPN led to an 8% increase in the overall number of syphilis patients with at least one treated sex partner, 26% more sex partners being medically examined and treated if necessary, and 83% more sex partners notified of their STD exposure. CONCLUSIONS: IPN augmented traditional syphilis case management and aided in the location, notification, testing, and treatment of partners. Conversely, without IPN, these 381 partners would not have been investigated. |
Knowledge of interim recommendations and use of Hib vaccine during vaccine shortages
Kempe A , Babbel C , Wallace GS , Stokley S , Daley MF , Crane LA , Beaty B , Black SR , Barrow J , Dickinson LM . Pediatrics 2010 125 (5) 914-20 OBJECTIVES: The goals were to determine among pediatricians and family physicians (1) knowledge of interim recommendations regarding Haemophilus influenzae type b (Hib) vaccine administration, (2) current practices, and (3) factors associated with nonadherence. METHODS: An Internet-based survey was conducted in April 2008 among national samples. RESULTS: Response rates were 68% (220 of 325 physicians) among pediatricians and 51% (153 of 302 physicians) among family physicians. Seventy-three percent of pediatricians and 45% of family medicine physicians reported insufficient Hib vaccine supplies, and 22% to 24% reported having to defer doses for infants 2 to 6 months of age > or =10% of the time. Ninety-eight percent of pediatricians and 81% of family physicians were aware of the interim recommendations (P < or = .0001), and virtually all knew that the booster dose should be deferred; however, 22% of pediatricians and 33% of family medicine physicians reported not deferring this dose. Physicians in both specialties were less likely to adhere to recommendations to defer in this age group if they thought that their practice had sufficient vaccine supplies (pediatricians, odds ratio: 0.01 [95% confidence interval: 0.003-0.03]; family medicine physicians, odds ratio: 0.10 [95% confidence interval: 0.03-0.33]). Family medicine physicians were less likely to adhere to recommendations if they had not heard about the interim recommendations (odds ratio: 0.04 [95% confidence interval: 0.01-0.21]). CONCLUSIONS: Most primary care physicians experienced Hib vaccine shortages, and many have had to defer doses for 2- to 6-month-old children. Most are knowledgeable regarding interim recommendations, but one-fifth to one-third reported nonadherence. |
Cervical cancer screening with both human papillomavirus and Papanicolaou testing vs Papanicolaou testing alone: what screening intervals are physicians recommending?
Saraiya M , Berkowitz Z , Yabroff KR , Wideroff L , Kobrin S , Benard V . Arch Intern Med 2010 170 (11) 977-85 BACKGROUND: Guidelines recommend screening for cervical cancer among women 30 years or older 3 years after a normal Papanicolaou test (hereinafter referred to as Pap test) result or a combined normal screening result (normal Pap/negative human papillomavirus [HPV] test results). We assessed reported recommendations by US primary care physicians (PCPs) on screening intervals that incorporate HPV cotesting compared with Pap testing alone. METHODS: From September 1, 2006, through May 31, 2007, we conducted a mailed survey of a representative sample of 1212 PCPs, of whom 950 performed Pap tests and recommended the HPV test for screening or management. The main outcome measure included self-reported data on timing of screening intervals for women with normal results using clinical vignettes. RESULTS: Among Pap test providers who recommend HPV testing, 31.8% reported that they would conduct the next Pap test in 3 years for a 35-year-old woman with 3 normal Pap test results. For a 35-year-old woman with a normal Pap test result and a negative HPV test finding, only 19.0% would conduct the next Pap test in 3 years. Most remaining physicians would conduct the Pap test more frequently. Most PCPs did not recommend a second HPV test or recommended the next HPV test at the same frequency as the Pap test. Physician specialty was strongly associated with guideline-consistent recommendations for the next Pap or HPV test. CONCLUSIONS: A lower proportion of PCPs recommend extending screening intervals to 3 years with an HPV cotest than those screening with the Pap test alone. Implementation of effective interventions and strategies that improve physician adherence to recommendations will be important for efficient screening practices. |
Developing WHO guidelines with pragmatic, structured, evidence-based processes: a case study
Chang LW , Kennedy CE , Kennedy GE , Lindegren ML , Marston BJ , Kaplan JE , Sweat MD , Bunnell RE , O'Reilly K , Rutherford GW , Mermin JH . Glob Public Health 2010 5 (4) 395-412 Many guidelines, including those produced by the World Health Organisation (WHO), have failed to adhere to rigorous methodological standards. Operational examples of guideline development processes may provide important lessons learned to improve the rigour and quality of future guidelines. To this end, this paper describes the process of developing WHO guidelines on prevention and care interventions for adults and adolescents living with HIV. Using a pragmatic, structured, evidence-based approach, we created an organising committee, identified topics, conducted systematic reviews, identified experts and distributed evidence summaries. Subsequently, 55 global HIV experts drafted and anonymously submitted guideline statements at the beginning of a conference. During the conference, participants voted on statements using scales evaluating appropriateness of the statements, strength of recommendation and level of evidence. After review of voting results, open discussion, re-voting and refinement of statements, a draft version of the guidelines was completed. A post-conference writing team refined the guidelines based on pre-determined guideline writing principles and incorporated external comments into a final document. Successes and challenges of the guideline development process were identified and are used to highlight current issues and debates in developing guidelines with a focus on implications for future guideline development at WHO. |
Evaluating metrics to improve population health
Bilheimer LT . Prev Chronic Dis 2010 7 (4) A69 The 7 metrics articles in this issue of Preventing Chronic Disease address the following topics: public health policy (1), health care access and quality (2), social and economic determinants (3), health behaviors (4), environmental metrics (5), population health outcomes (6), and health inequalities (7). The articles differ in the degree to which they establish a conceptual framework for linking metrics to rewards to improve population health. Their different perspectives raise questions of whether these metrics should meet certain criteria, regardless of domain, or whether some flexibility in the criteria for assessing metrics is necessary and desirable. Questions that arise in establishing such criteria relate to structure and function as well as data availability. |
Nearest neighbor estimates of entropy for multivariate circular distributions
Misra N , Singh H , Hnizdo V . Entropy (Basel) 2010 12 (5) 1125-1144 In molecular sciences, the estimation of entropies of molecules is important for the understanding of many chemical and biological processes. Motivated by these applications, we consider the problem of estimating the entropies of circular random vectors and introduce non-parametric estimators based on circular distances between n sample points and their k th nearest neighbors (NN), where k (<= n - 1) is a fixed positive integer. The proposed NN estimators are based on two different circular distances, and are proven to be asymptotically unbiased and consistent. The performance of one of the circular-distance estimators is investigated and compared with that of the already established Euclidean-distance NN estimator using Monte Carlo samples from an analytic distribution of six circular variables of an exactly known entropy and a large sample of seven internal-rotation angles in the molecule of tartaric acid, obtained by a realistic molecular-dynamics simulation. |
Performance of using multiple stepwise algorithms for variable selection
Wiegand RE . Stat Med 2010 29 (15) 1647-1659 Some research studies in the medical literature use multiple stepwise variable selection (SVS) algorithms to build multivariable models. The purpose of this study is to determine whether the use of multiple SVS algorithms in tandem (stepwise agreement) is a valid variable selection procedure. Computer simulations were developed to address stepwise agreement. Three popular SVS algorithms were tested (backward elimination, forward selection, and stepwise) on three statistical methods (linear, logistic, and Cox proportional hazards regression). Other simulation parameters explored were the sample size, number of predictors considered, degree of correlation between pairs of predictors, p-value-based entrance and exit criteria, predictor type (normally distributed or binary), and differences between stepwise agreement between any two or all three algorithms. Among stepwise methods, the rate of agreement, agreement on a model including only those predictors truly associated with the outcome, and agreement on a model containing the predictors truly associated with the outcome were measured. These rates were dependent on all simulation parameters. Mostly, the SVS algorithms agreed on a final model, but rarely on a model with only the true predictors. Sample size and candidate predictor pool size are the most influential simulation conditions. To conclude, stepwise agreement is often a poor strategy that gives misleading results and researchers should avoid using multiple SVS algorithms to build multivariable models. More research on the relationship between sample size and variable selection is needed. Published in 2010 by John Wiley & Sons, Ltd. |
Content Index (Achived Edition)
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