Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the Brain Attack Coalition
Alberts MJ , Latchaw RE , Jagoda A , Wechsler LR , Crocco T , George MG , Connolly ES , Mancini B , Prudhomme S , Gress D , Jensen ME , Bass R , Ruff R , Foell K , Armonda RA , Emr M , Warren M , Baranski J , Walker MD . Stroke 2011 42 (9) 2651-2665 BACKGROUND AND PURPOSE: The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience. METHODS: We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices. RESULTS: Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures. CONCLUSIONS: Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center. |
Involvement of gynecologic oncologists in the treatment of patients with a suspicious ovarian mass
Goff BA , Miller JW , Matthews B , Trivers KF , Andrilla CH , Lishner DM , Baldwin LM . Obstet Gynecol 2011 118 (4) 854-62 OBJECTIVE: To identify the factors associated with inclusion of a gynecologic oncologist in managing the care of a woman with suspected ovarian cancer. METHODS: A vignette-based survey was mailed to 3,200 physicians aged 64 and younger who were randomly sampled from family physician, general internist, and obstetrician-gynecologist (ob-gyn) lists from the American Medical Association Physician Masterfile. The vignette described a 57-year-old woman with pain, bloating, and a suspicious right adnexal mass with ascites. Using multivariable analysis we evaluated patient, physician, and practice characteristics associated with a self-reported referral or inclusion of a gynecologic oncologist in the patient's care. RESULTS: The response rate was 61.7%. After exclusions we included 569 ob-gyns, 591 family physicians, and 414 general internists. Gynecologic oncologist referral and consultation was self reported by 39.3% of family physicians and 51.0% of general internists (P=.01). Among ob-gyns, 33.7% indicated they would perform surgery and 66.3% recommended consultation or referral. Factors associated with not referring and consulting included patients having Medicaid insurance (family physicians), providers' weekly average number of patients being more than 91 (family physicians and general internists), male sex (family physicians), a rural practice location (general internists), and solo practice (general internists). Factors associated with primary surgical management for ob-gyns were small and remote rural practice locations and Census division. CONCLUSION: When presented with a patient with a suspicious ovarian mass, the majority of primary care physicians do not self-report direct referral to a gynecologic oncologist. This may contribute to the high rates of noncomprehensive surgery for ovarian cancer patients in the United States. LEVEL OF EVIDENCE: II. |
Risk factors for tuberculosis after highly active antiretroviral therapy initiation in the United States and Canada: implications for tuberculosis screening
Sterling TR , Lau B , Zhang J , Freeman A , Bosch RJ , Brooks JT , Deeks SG , French A , Gange S , Gebo KA , John Gill M , Horberg MA , Jacobson LP , Kirk GD , Kitahata MM , Klein MB , Martin JN , Rodriguez B , Silverberg MJ , Willig JH , Eron JJ , Goedert JJ , Hogg RS , Justice AC , McKaig RG , Napravnik S , Thorne J , Moore RD . J Infect Dis 2011 204 (6) 893-901 BACKGROUND: Screening for tuberculosis prior to highly active antiretroviral therapy (HAART) initiation is not routinely performed in low-incidence settings. Identifying factors associated with developing tuberculosis after HAART initiation could focus screening efforts. METHODS: Sixteen cohorts in the United States and Canada contributed data on persons infected with human immunodeficiency virus (HIV) who initiated HAART December 1995-August 2009. Parametric survival models identified factors associated with tuberculosis occurrence. RESULTS: Of 37,845 persons in the study, 145 were diagnosed with tuberculosis after HAART initiation. Tuberculosis risk was highest in the first 3 months of HAART (20 cases; 215 cases per 100,000 person-years; 95% confidence interval [CI]: 131-333 per 100,000 person-years). In a multivariate Weibull proportional hazards model, baseline CD4+ lymphocyte count <200, black race, other nonwhite race, Hispanic ethnicity, and history of injection drug use were independently associated with tuberculosis risk. In addition, in a piece-wise Weibull model, increased baseline HIV-1 RNA was associated with increased tuberculosis risk in the first 3 months; male sex tended to be associated with increased risk. CONCLUSIONS: Screening for active tuberculosis prior to HAART initiation should be targeted to persons with baseline CD4 <200 lymphocytes/mm(3) or increased HIV-1 RNA, persons of nonwhite race or Hispanic ethnicity, history of injection drug use, and possibly male sex. |
Serodiagnosis of syphilis in the recombinant era: reversal of fortune
Hoover KW , Radolf JD . J Infect Dis 2011 204 (9) 1295-6 Treponema pallidum, the spirochete that causes syphilis, cannot be cultured. As a result, syphilis is usually diagnosed by tracking the immunologic footprints of its etiologic agent. Serodiagnosis of syphilis requires the detection of 2 distinct types of antibodies, nontreponemal and treponemal [1]. Nontreponemal antibodies, measured by the reactive rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL) tests, are directed against lipoidal antigens of the host and probably the organism; they rise during active infection and often decline following treatment. Their primary usefulness is as a biomarker of disease activity. Treponemal antibodies, detected by the fluorescent treponemal antibody absorbed (FTA-ABS) and Treponema. pallidum particle agglutination (TP-PA) tests, are directed against T. pallidum proteins; they rise early in the course of infection and usually remain detectable for life, even after successful treatment. Neither test should be used alone. “Biologic false positive” nontreponemal tests are associated with various medical conditions unrelated to syphilis; nontreponemal test reactivity, therefore, must be confirmed by treponemal testing. Conventional treponemal tests use whole organisms and may be falsely reactive because of cross-reacting serum antibodies that in most cases are thought to derive from commensal microorganisms [2]. In addition, a reactive treponemal test cannot distinguish active from inactive infection. Traditionally, serodiagnosis of syphilis has been performed using an algorithm in which sera are screened for nontreponemal antibodies and reactivity is confirmed by testing for treponemal antibodies [1, 3]. The traditional sequence, long recommended by the Centers for Disease Control and Prevention (CDC) [3], has performed well in identifying syphilis patients with active disease and who are most infectious. Along with serologic test results, a patient’s clinical history and physical examination are used to confirm the diagnosis and guide management [3]. |
WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update
Falzon D , Jaramillo E , Schunemann HJ , Arentz M , Bauer M , Bayona J , Blanc L , Caminero JA , Daley CL , Duncombe C , Fitzpatrick C , Gebhard A , Getahun H , Henkens M , Holtz TH , Keravec J , Keshavjee S , Khan AJ , Kulier R , Leimane V , Lienhardt C , Lu C , Mariandyshev A , Migliori GB , Mirzayev F , Mitnick CD , Nunn P , Nwagboniwe G , Oxlade O , Palmero D , Pavlinac P , Quelapio MI , Raviglione MC , Rich ML , Royce S , Rusch-Gerdes S , Salakaia A , Sarin R , Sculier D , Varaine F , Vitoria M , Walson JL , Wares F , Weyer K , White RA , Zignol M . Eur Respir J 2011 38 (3) 516-28 The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens. |
The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America
Bradley JS , Byington CL , Shah SS , Alverson B , Carter ER , Harrison C , Kaplan SL , Mace SE , McCracken GH Jr , Moore MR , St Peter SD , Stockwell JA , Swanson JT . Clin Infect Dis 2011 53 (7) e25-76 Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted. |
Missed opportunities for HIV testing in health care settings among young African American men who have sex with men: implications for the HIV epidemic
Dorell CG , Sutton MY , Oster AM , Hardnett F , Thomas PE , Gaul ZJ , Mena LA , Heffelfinger JD . AIDS Patient Care STDS 2011 25 (11) 657-64 Limited health care access and missed opportunities for HIV and other sexually transmitted infection (STI) education and testing in health care settings may contribute to risk of HIV infection. In 2008, we conducted a case-control study of African American men who have sex with men (MSM) in a southeastern city (Jackson, Mississippi) with an increase in numbers of newly reported HIV cases. Our aims were to evaluate associations between health care and HIV infection and to identify missed opportunities for HIV/STI testing. We queried 40 potential HIV-infected cases and 936 potential HIV-uninfected controls for participation in this study. Study enrollees included HIV-infected cases (n=30) and HIV-uninfected controls (n=95) who consented to participate and responded to a self-administered computerized survey about sexual risk behaviors and health care utilization. We used bivariate analysis and logistic regression to test for associations between potential risk factors and HIV infection. Cases were more likely than controls to lack health insurance (odds ratio [OR]=2.5; 95% confidence interval [CI]=1.1-5.7), lack a primary care provider (OR=6.3; CI=2.3-16.8), and to not have received advice about HIV or STI testing or prevention (OR=5.4; CI=1.3-21.5) or disclose their sexual identity (OR=7.0; CI=1.6-29.2) to a health care provider. In multivariate analysis, lacking a primary health care provider (adjusted odds ratio [AOR]=4.5; CI=1.4-14.7) and not disclosing sexual identity to a health care provider (AOR=8.6; CI=1.8-40.0) were independent risk factors for HIV infection among African American MSM. HIV prevention interventions for African American MSM should address access to primary health care providers for HIV/STI prevention and testing services and the need for increased discussions about sexual health, sexual identity, and sexual behaviors between providers and patients in an effort to reduce HIV incidence and HIV-related health disparities. |
Multidrug resistant tuberculous meningitis in the United States, 1993-2005
Vinnard C , Winston CA , Wileyto EP , Macgregor RR , Bisson GP . J Infect 2011 63 (3) 240-2 Multidrug resistant tuberculosis, defined as resistance to at least isoniazid and rifampin, is a threat to tuberculosis control programs worldwide. In the United States in 2008, multidrug resistance was seen in 1.2% of all culture-positive cases of tuberculosis where susceptibility testing was performed.1 The treatment of multidrug resistant tuberculosis requires longer, costlier, and more toxic regimens.2 HIV infection is a risk factor for the development of all forms of extrapulmonary tuberculosis, including tuberculous meningitis (TBM).3 Consequently, tuberculosis has become a leading cause of bacterial meningitis in areas where the HIV and tuberculosis epidemics have intersected.4 HIV infection may also be a risk factor for primary multidrug resistant tuberculosis.5 However, most previous descriptions of multidrug resistant TBM are from countries with high burdens of HIV and tuberculosis, and less is known about the epidemiology of multidrug resistant TBM in low burden areas. | We analyzed data from the National Tuberculosis Surveillance System (NTSS) at the Centers for Disease Control and Prevention (CDC). Since 1953, the NTSS has collected aggregate tuberculosis incidence data in the United States. Individual-level data (including anti-tuberculosis drug susceptibilities) has been collected since 1993. We studied the period from January 1, 1993, through December 31, 2005, during which time both drug susceptibility and treatment outcome data were available. We categorized treatment outcomes as completion, death, or other/loss to follow-up. |
A brief review of the estimated economic burden of sexually transmitted diseases in the United States: inflation-adjusted updates of previously published cost studies
Chesson HW , Gift TL , Owusu-Edusei K Jr , Tao G , Johnson AP , Kent CK . Sex Transm Dis 2011 38 (10) 889-91 We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars. |
The cost-effectiveness of pre-exposure prophylaxis in men who have sex with men in the United States: an epidemic model
Koppenhaver RT , Sorensen SW , Farnham PG , Sansom SL . J Acquir Immune Defic Syndr 2011 58 (2) e51-2 The HIV epidemic has disproportionately affected men who have sex with men (MSM). As recently as 2006, the Centers for Disease Control and Prevention reports that MSM in the United States accounted for more than 50% of new HIV infections although representing only 2% of the US population.1 The Centers for Disease Control and Prevention also reports that in 2008, HIV prevalence among MSM in 21 major US cities was 19% with 44% being unaware of their infection. A recent study suggests that chemoprophylaxis before exposure or pre-exposure prophylaxis (PrEP) may be an effective approach to combating the incidence of HIV in the MSM community. This study showed that a daily dose of tenofovir/emtricitabine reduced HIV incidence in susceptible MSM2 by 44% overall and 73% among those who were highly adherent (high adherence defined as taking >90% of doses, determined by pill count). This suggests that PrEP has the potential to significantly reduce the HIV epidemic in the Unite States, where MSM have the highest annual incidence rate among all risk groups. Preliminary study data also indicated that, among a small sample of participants, US participants were more likely to have detectable levels of tenofovir/emtricitabine than non-US participants, suggesting that adherence rates might be high in the United States.3 However, its cost-effectiveness and overall effect on the epidemic have not been addressed in the context of these findings. | We constructed a dynamic compartmental model of MSM in an urban setting that shows changes over time in the number of susceptible and infected individuals and the various disease stages of infected individuals. We used epidemic data from New York City and national-level behavioral data. We gathered costs of implementing PrEP,4 in addition to those for tenofovir/emtricitabine (valued at $22/day).5 Our model assumed all susceptible MSM received PrEP and quarterly HIV testing and monitoring for adverse events. We assumed a 20-year time horizon and discounted the future costs, infections averted, and quality-adjusted life-years saved (QALYs) reported in incremental cost-effectiveness ratios at 3% per year. We divided PrEP drug and implementation costs by the number of cases prevented to determine the cost per case prevented. We divided PrEP drug and implementation costs minus treatment costs associated with HIV cases prevented by quality-adjusted life-years saved to determine the incremental cost-effectiveness ratio. We assumed that the costs of PrEP were fully incurred, regardless of adherence. For the purposes of this model, we compared the PrEP program described above with a scenario in which about 25% of susceptible and undiagnosed MSM are tested per year based on model projections that correspond to current epidemic trends. |
County-level sexually transmitted disease detection and control in Texas: do sexually transmitted diseases and family planning clinics matter?
Owusu-Edusei K Jr , Doshi SR . Sex Transm Dis 2011 38 (10) 970-5 BACKGROUND: Sexually transmitted disease (STD) detection and control have traditionally been performed by STD and family planning (FP) clinics. However, the magnitude of their impact (or the lack thereof) has not been examined. We examine the association between having STD and/or FP clinics and county-level STD detection and control in the state of Texas. METHODS: We used county-level STD (chlamydia, gonorrhea, and primary and secondary syphilis) morbidity data from the National Electronic Telecommunications System for Surveillance for 2000 and 2007. We applied spatial regression techniques to examine the impact of the presence of STD/FP clinic(s) (included as dichotomous variables) on STD detection (i.e., morbidity) and control. We included county-level demographic characteristics as control variables. RESULTS: Our results indicated that counties with STD or FP clinics were associated with at least 8% (P < 0.05) increase in the transformed chlamydia and gonorrhea rates, 20% (P < 0.01) increase in transformed syphilis rates in 2000, and at least 6% (P < 0.05) increase in transformed gonorrhea and Chlamydia rates in 2007. From 2000 to 2007, the transformed incidence rates of chlamydia declined by 4% (P < 0.10), 8% (P < 0.01) for gonorrhea, and 8% (P < 0.05) for primary and secondary syphilis for the counties that had at least 1 STD or FP clinic. CONCLUSIONS: The results from this ecological study are associations and do not establish a causal relationship between having an STD/FP clinic and improved STD detection and control. Finer level analyses (such as census block or cities) may be able to provide more detail information. |
Avian hosts of West Nile virus in Puerto Rico
Komar N , Bessoff K , Diaz A , Amador M , Young G , Seda R , Perez T , Hunsperger E . Vector Borne Zoonotic Dis 2011 12 (1) 47-54 West Nile virus (WNV) ecology in neotropical ecosystems is poorly understood, and vertebrate hosts responsible for infecting mosquitoes remain unidentified throughout the Caribbean Basin. After a period of intense WNV transmission among sentinel chickens near Ceiba, Puerto Rico, we measured abundance of resident birds and species-specific prevalence of WNV infection. Taking the product of these measures indicates the relative number of WNV infections by species. Greater Antillean grackle (Quiscalus niger) accounted for the most WNV infections among birds in our 100-km(2) study site. In urban habitats, the house sparrow (Passer domesticus) was frequently infected. Immature birds less than one year of age were more likely to have detectable WNV-reactive antibodies than older birds of the same species. |
Domestic dogs (Canis familiaris) as reservoir hosts for Rickettsia conorii
Levin ML , Killmaster LF , Zemtsova GE . Vector Borne Zoonotic Dis 2011 12 (1) 28-33 Rickettsia conorii is the causative agent of Mediterranean spotted fever (MSF) and Israeli spotted fever (ISF) transmitted by the brown dog tick Rhipicephalus sanguineus. In areas where MSF or ISF are prevalent, dogs have high prevalence of R. conorii -neutralizing antibodies. However, the true role of dogs in the persistence of the R. conorii transmission cycle is unknown, and their reservoir competence for this pathogen has remained untested. We assessed the ability of dogs infected with R. conorii to transmit the pathogen to previously uninfected Rh. sanguineus ticks. Dogs were infected either via needle-inoculation of cultured rickettsiae or naturally via infected tick bite. Dogs were monitored for clinical signs of infection, for rickettsemia by PCR, and for seroconversion and were subjected to infestation with uninfected ticks at different time points. Rh. sanguineus larvae and nymphs successfully acquired the agent from both needle-inoculated and tick-infected dogs and transmitted it transtadially. Tick-infected dogs remained infectious to ticks for at least a month postinfection. The molted ticks were, in turn, infectious to naive dogs. These results demonstrate that dogs are capable of acquiring R. conorii from infected Rh. sanguineus ticks and transmitting infection to cohorts of uninfected ticks, thus confirming for the first time that dogs are indeed competent reservoirs for R. conorii. In addition, dogs with different genetic backgrounds appear to differ in their susceptibility to R. conorii infection. |
Use of infrared camera to understand bats' access to date palm sap: implications for preventing Nipah virus transmission
Khan MSU , Hossain J , Gurley ES , Nahar N , Sultana R , Luby SP . Ecohealth 2010 7 (4) 517-525 Pteropus bats are commonly infected with Nipah virus, but show no signs of illness. Human Nipah outbreaks in Bangladesh coincide with the date palm sap harvesting season. In epidemiologic studies, drinking raw date palm sap is a risk factor for human Nipah infection. We conducted a study to evaluate bats' access to date palm sap. We mounted infrared cameras that silently captured images upon detection of motion on date palm trees from 5:00 pm to 6:00 am. Additionally, we placed two locally used preventative techniques, bamboo skirts and lime (CaCO(3)) smeared on date palm trees to assess their effectiveness in preventing bats access to sap. Out of 20 camera-nights of observations, 14 identified 132 visits of bats around the tree, 91 to the shaved surface of the tree where the sap flow originates, 4 at the stream of sap moving toward the collection pot, and no bats at the tap or on the collection pots; the remaining 6 camera-nights recorded no visits. Of the preventative techniques, the bamboo skirt placed for four camera-nights prevented bats access to sap. This study confirmed that bats commonly visited date palm trees and physically contacted the sap collected for human consumption. This is further evidence that date palm sap is an important link between Nipah virus in bats and Nipah virus in humans. Efforts that prevent bat access to the shaved surface and the sap stream of the tree could reduce Nipah spillovers to the human population. |
Molecular identification and distribution of Cryptosporidium and Giardia duodenalis in raw urban wastewater in Harbin, China.
Liu A , Ji H , Wang E , Liu J , Xiao L , Shen Y , Li Y , Zhang W , Ling H . Parasitol Res 2011 109 (3) 913-8 Contamination of the water supply by protozoa often causes outbreaks of cryptosporidiosis and giardiasis. The goals of the present study was to investigate the level of Cryptosporidium and Giardia duodenalis in wastewater from wastewater treatment plants in Harbin, China, and to understand the endemic transmission characteristics of cryptosporidiosis and giardiasis. Forty-eight domestic wastewater specimens from the two wastewater treatment plants in Harbin City were collected from April 2009 to March 2010. Cryptosporidium spp. and G. duodenalis assemblages were identified by PCR and sequencing of the 18S ribosomal RNA and the triosephosphate isomerase genes, respectively. In total, 15 wastewater specimens were PCR positive for Cryptosporidium and 23 were PCR positive for G. duodenalis. The prevalence of contamination with G. duodenalis (47.9%) was higher than that of Cryptosporidium (31.3%). Molecular identification showed the presence of two Cryptosporidium spp. (14 belonging to Cryptosporidium andersoni and one belonging to Cryptosporidium ubiquitum) and two G. duodenalis assemblages (18 belonging to assemblage AII and six belonging to assemblage B). In addition, eight specimens contained both Cryptosporidium and G. duodenalis, and one specimen contained G. duodenalis assemblages AII and B. These results suggested humans might be the primary source of G. duodenalis contamination in wastewater in the studied area. In contrast, a low prevalence of C. ubiquitum suggested a reduced risk of human cryptosporidiosis caused by C. ubiquitum via waterborne route. This work provides basic experimental data needed for local wastewater treatment plants to develop protective strategies for water safety and to eliminate waterborne parasites. |
Trends in mortality of tuberculosis patients in the United States: the long-term perspective
Barnes RF , Moore ML , Garfein RS , Brodine S , Strathdee SA , Rodwell TC . Ann Epidemiol 2011 21 (10) 791-5 PURPOSE: To describe long-term trends in tuberculosis (TB) mortality and to compare trends estimated from two different sources of public health surveillance data. METHODS: Trends and changes in trend were estimated by joinpoint regression. Comparisons between data sets were made by fitting a Poisson regression model. RESULTS: Since 1900, TB mortality rates estimated from death certificates have declined steeply, except for a period of no change in the 1980s. This decade had long-term consequences resulting in more TB deaths in later years than would have occurred had there been no flattening of the trend. Recent trends in TB mortality estimated from National Tuberculosis Surveillance System (NTSS) data, which record all-cause mortality, differed from trends based on death certificates. In particular, NTSS data showed TB mortality rates flattening since 2002. CONCLUSIONS: Estimates of trends in TB mortality vary by data source, and therefore interpretation of the success of control efforts will depend on the surveillance data set used. The data sets may be subject to different biases that vary with time. One data set showed a sustained improvement in the control of TB since the early 1990s whereas the other indicated that the rate of TB mortality was no longer declining. |
Influence of familial risk on diabetes risk-reducing behaviors among U.S. adults without diabetes.
Chang MH , Valdez R , Ned RM , Liu T , Yang Q , Yesupriya A , Dowling NF , Meigs JB , Bowen MS , Khoury MJ . Diabetes Care 2011 34 (11) 2393-9 OBJECTIVE: To test the association of family history of diabetes with the adoption of diabetes risk-reducing behaviors and whether this association is strengthened by physician advice or commonly known factors associated with diabetes risk. RESEARCH DESIGN AND METHODS: We used cross-sectional data from the 2005-2008 National Health and Nutrition Examination Survey (NHANES) to examine the effects of family history of diabetes on the adoption of selected risk-reducing behaviors in 8,598 adults (aged ≥20 years) without diabetes. We used multiple logistic regression to model three risk reduction behaviors (controlling or losing weight, increasing physical activity, and reducing the amount of dietary fat or calories) with family history of diabetes. RESULTS: Overall, 36.2% of U.S. adults without diabetes had a family history of diabetes. Among them, ~39.8% reported receiving advice from a physician during the past year regarding any of the three selected behaviors compared with 29.2% of participants with no family history (P < 0.01). In univariate analysis, adults with a family history of diabetes were more likely to perform these risk-reducing behaviors compared with adults without a family history. Physician advice was strongly associated with each of the behavioral changes (P < 0.01), and this did not differ by family history of diabetes. CONCLUSIONS: Familial risk for diabetes and physician advice both independently influence the adoption of diabetes risk-reducing behaviors. However, fewer than half of participants with familial risk reported receiving physician advice for adopting these behaviors. |
A national initiative for women and healthcare providers: CDC's Inside Knowledge: Get the Facts About Gynecologic Cancer Campaign
Rim SH , Polonec L , Stewart SL , Gelb CA . J Womens Health (Larchmt) 2011 20 (11) 1579-85 The Inside Knowledge: Get the Facts About Gynecologic Cancer campaign raises awareness of the five main types of gynecologic cancer: cervical, ovarian, uterine, vaginal, and vulvar. It encourages women to pay attention to their bodies and know what is normal for them so they can recognize the warning signs of gynecologic cancers and seek medical care. This report provides an overview of the development of this national campaign. |
Guideline for the prevention and control of norovirus gastroenteritis outbreaks in healthcare settings
MacCannell T , Umscheid CA , Agarwal RK , Lee I , Kuntz G , Stevenson KB . Infect Control Hosp Epidemiol 2011 32 (10) 939-69 Norovirus gastroenteritis infections and outbreaks have been | increasingly described and reported in both non-healthcare | and healthcare settings during the past several years. In response, several states have developed guidelines to assist both | healthcare institutions and communities on preventing the | transmission of norovirus infections and helped develop the | themes and key questions to answer through an evidencebased review. This guideline addresses prevention and control | of norovirus gastroenteritis outbreaks in healthcare settings. | The guideline also includes specific recommendations for implementation, performance measurement, and surveillance. | Recommendations for further research are provided to address knowledge gaps identified during the literature review | in the prevention and control of norovirus gastroenteritis | outbreaks. Guidance for norovirus outbreak management and | disease prevention in non-healthcare settings can be found | at http://www.cdc.gov/mmwr/pdf/rr/rr6003.pdf. |
Importance of employee vaccination against influenza in preventing cases in long-term care facilities
Wendelboe AM , Avery C , Andrade B , Baumbach J , Landen MG . Infect Control Hosp Epidemiol 2011 32 (10) 990-7 OBJECTIVE: Employees of long-term care facilities (LTCFs) who have contact with residents should be vaccinated against influenza annually to reduce influenza incidence among residents. This investigation estimated the magnitude of the benefit of this recommendation. METHODS: The New Mexico Department of Health implemented active surveillance in all of its 75 LTCFs during influenza seasons 2006-2007 and 2007-2008. Information about the number of laboratory-confirmed cases of influenza and the proportion vaccinated of both residents and direct-care employees in each facility was collected monthly. LTCFs reporting at least 1 case of influenza (defined alternately by laboratory confirmation or symptoms of influenza-like illness [ILI]) among residents were compared with LTCFs reporting no cases of influenza. Regression modeling was used to obtain adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between employee vaccination coverage and the occurrence of influenza outbreaks. Covariates included vaccination coverage among residents, the staff-to-resident ratio, and the proportion of filled beds. RESULTS: Seventeen influenza outbreaks were reported during this 2-year period of surveillance. Eleven of these were laboratory confirmed ([Formula: see text] residents) and 6 were defined by ILI ([Formula: see text] residents). Mean influenza vaccination coverage among direct-care employees was 51% in facilities reporting outbreaks and 60% in facilities not reporting outbreaks ([Formula: see text]). Increased vaccination coverage among direct-care employees was associated with fewer reported outbreaks of laboratory-confirmed influenza (aOR, 0.97 [95% CI, 0.95-0.99]) and ILI (aOR, 0.98 [95% CI, 0.96-1.00]). CONCLUSIONS: High vaccination coverage among direct-care employees helps to prevent influenza in LTCFs. |
Improving risk-adjusted measures of surgical site infection for the National Healthcare Safety Network
Mu Y , Edwards JR , Horan TC , Berrios-Torres SI , Fridkin SK . Infect Control Hosp Epidemiol 2011 32 (10) 970-86 BACKGROUND: The National Healthcare Safety Network (NHSN) has provided simple risk adjustment of surgical site infection (SSI) rates to participating hospitals to facilitate quality improvement activities; improved risk models were developed and evaluated. METHODS: Data reported to the NHSN for all operative procedures performed from January 1, 2006, through December 31, 2008, were analyzed. Only SSIs related to the primary incision site were included. A common set of patient- and hospital-specific variables were evaluated as potential SSI risk factors by univariate analysis. Some ific variables were available for inclusion. Stepwise logistic regression was used to develop the specific risk models by procedure category. Bootstrap resampling was used to validate the models, and the c-index was used to compare the predictive power of new procedure-specific risk models with that of the models with the NHSN risk index as the only variable (NHSN risk index model). RESULTS: From January 1, 2006, through December 31, 2008, 847 hospitals in 43 states reported a total of 849,659 procedures and 16,147 primary incisional SSIs (risk, 1.90%) among 39 operative procedure categories. Overall, the median c-index of the new procedure-specific risk was greater (0.67 [range, 0.59-0.85]) than the median c-index of the NHSN risk index models (0.60 [range, 0.51-0.77]); for 33 of 39 procedures, the new procedure-specific models yielded a higher c-index than did the NHSN risk index models. CONCLUSIONS: A set of new risk models developed using existing data elements collected through the NHSN improves predictive performance, compared with the traditional NHSN risk index stratification. |
Molecular studies of the Oka varicella vaccine.
Quinlivan M , Breuer J , Schmid DS . Expert Rev Vaccines 2011 10 (9) 1321-36 Varicella zoster virus (VZV) is one of eight members of the Herpesviridae family for which humans are the primary host; it causes two distinct diseases, varicella (chickenpox) and zoster (shingles). Varicella results from primary infection, during which the virus establishes latency in sensory neurons, a characteristic of all members of the Alphaherpesvirinae subfamily. Zoster is caused by reactivation of latent virus, which typically occurs when cellular immunity is impaired. VZV is the first human herpesvirus for which a vaccine has been licensed. The vaccine preparation, v-Oka, is a live-attenuated virus stock produced by the classic method of tissue culture passage in animal and human cell lines. Over 90 million doses of the vaccine have been administered in countries worldwide, including the USA, where varicella morbidity and mortality has declined dramatically. Over the last decade, several laboratories have been committed to investigating the mechanism by which the Oka vaccine is attenuated. Mutations have accumulated across the genome of the vaccine during the attenuation process; however, studies of the contribution of these changes to vaccine attenuation have been hampered by the lack of a suitable animal model of VZV disease and by the heterogeneity that exists among the viral population within the vaccine preparation. Notwithstanding, a wealth of data has been generated using various laboratory methodologies. Studies of the vaccine virus in human xenografts implanted in severe combined immunodeficiency-hu mice, have enabled analyses of the replication dynamics of the vaccine in dorsal root ganglia, T lymphocytes and skin. In vitro assays have been used to investigate the effect of vaccine mutations on viral gene expression and sequence analysis of vaccine rash viruses has permitted investigations into spread of the vaccine virus in a human host. We present here a review of what has been learned thus far about the molecular and phenotypic characteristics of the Oka vaccine. |
Adverse events after tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine administered to adults 65 years of age and older reported to the Vaccine Adverse Event Reporting System (VAERS), 2005-2010
Moro PL , Yue X , Lewis P , Haber P , Broder K . Vaccine 2011 29 (50) 9404-8 BACKGROUND: Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine was not licensed for use in adults aged ≥65 years due to lack of sufficient efficacy and safety data. OBJECTIVE: To characterize reports to the Vaccine Adverse Event Reporting System (VAERS) among adults aged ≥65 years who received Tdap vaccine 'off-label' to assess for potential vaccine safety concerns. METHODS: We searched VAERS for US reports of adverse events (AEs) in subjects aged ≥65 years who received Tdap vaccine from 9/1/2005 to 9/08/2010. Medical records were requested for all reports coded as serious (death, hospitalization, prolonged hospitalization, permanent disability, life-threatening-illness). Proportional reporting ratio (PRR) was used to assess for higher proportionate reporting for AEs after Tdap compared with Td reports in subjects aged ≥65 years. RESULTS: VAERS received 243 reports following Tdap administered to persons aged ≥65 years. Eleven (4.5%) reports were serious, including two deaths. Most common AEs were local reactions in 100 (41.2%) reports. Seventy-eight (32.1%) reports contained coding terms that denoted inappropriate administration of vaccine. 'Cough' was the only term associated with disproportionately higher reporting after Tdap compared with Td. Six of seven Tdap reports containing the term 'Cough' were non-serious. Clinical review of serious reports identified no unusual patterns of AEs. CONCLUSION: Our VAERS review of the 'off-label' use of Tdap vaccine in adults ≥65 years did not find any safety concerns that warrant further study. These data will provide useful baseline information to assist CDC and FDA with monitoring efforts as permissive recommendations for Tdap in older persons are adopted. |
Sex differences in suicide incident characteristics and circumstances among older adults: surveillance data from the National Violent Death Reporting System-17 U.S. states, 2007-2009
Karch D . Int J Environ Res Public Health 2011 8 (8) 3479-95 Each year in the U.S. more than 7,000 adults aged 60 years and older die of suicide and as the population ages, these numbers are expected to increase. While sex is an important predictor of older adult suicide, differences between males and females are often overlooked due to low occurrence, particularly among women. The National Violent Death Reporting System (NVDRS) bridges this gap by providing detailed information on older adult suicide by sex in 17 US states (covering approximately 26% of the U.S. population). NVDRS data for 2007-2009 were used to characterize male (n = 5,004) and female (n = 1,123) suicide decedents aged 60 years and older, including incident characteristics and circumstances precipitating suicide. Stratification of NVDRS data by sex shows significant differences with regard to the presence of antidepressants (19% and 45% respectively), opiates (18%, 37%), and 14 precipitating circumstances concerning mental health, interpersonal problems, life stressors and a history of suicide attempts. No differences were found for alcohol problems, suicide/other death of family or friends, non-criminal legal problems, financial problems, or disclosure of intent to take their own life. The findings of this study demonstrate the value of using comprehensive surveillance data to understand sex-specific suicide circumstances so that opportunities for targeted prevention strategies may be considered. |
Potential Risk Estimation Drowning Index for Children (PREDIC): a pilot study from Matlab, Bangladesh
Borse NN , Hyder AA , Bishai D , Baker T , Arifeen SE . Accid Anal Prev 2011 43 (6) 1901-6 Childhood drowning is a major public health problem that has been neglected in many low- and middle-income countries. In Matlab, rural Bangladesh, more than 40% of child deaths aged 1-4 years are due to drowning. AIM: The main objective of this paper was to develop and evaluate a childhood drowning risk prediction index. METHODOLOGY: A literature review was carried out to document risk factors identified for childhood drowning in Bangladesh. The Newacheck model for special health care needs for children was adapted and applied to construct a childhood drowning risk index called "Potential Risk Estimation Drowning Index for Children" (PREDIC). Finally, the proposed PREDIC Index was applied to childhood drowning deaths and compared with the comparison group from children living in Matlab, Bangladesh. This pilot study used t-tests and Receiver Operating Characteristic (ROC) curve to analyze the results. RESULTS: The PREDIC index was applied to 302 drowning deaths and 624 children 0-4 years old living in Matlab. The results of t-test indicate that the drowned children had a statistically (t=-8.58, p=0.0001) significant higher mean PREDIC score (6.01) than those in comparison group (5.26). Drowning cases had a PREDIC score of 6 or more for 68% of the children however, the comparison group had 43% of the children with score of 6 or more which was statistically significant (t=-7.36, p<0.001). The area under the curve for the Receiver Operating Characteristic curve was 0.662. CONCLUSION: Index score construction was scientifically plausible; and the index is relatively complete, fairly accurate, and practical. The risk index can help identify and target high risk children with drowning prevention programs. PREDIC index needs to be further tested for its accuracy, feasibility and effectiveness in drowning risk reduction in Bangladesh and other countries. |
The association between different types of intimate partner violence experienced by women
Krebs C , Breiding M , Browne A , Warner T . J Fam Violence 2011 26 (6) 487-500 Those who experience intimate partner violence (IPV) are often subjected to multiple types of victimization such as physical violence, sexual violence, psychological aggression, and stalking. However, relatively few studies have used a national population-based sample and multivariate methods to analyze the associations between these different types of violence. This study uses multivariate methods to analyze a national population-based sample of women in order to document empirically the extent to which different types of IPV overlap, while controlling for personal and behavioral characteristics. Results indicated significant levels of overlap, with victims often experiencing more than one type of victimization by an intimate partner. Findings also indicated that women who had experienced violence by non-intimate partners were often more likely to experience violence by intimates. Finally, women who had experienced stalking by an intimate were more likely to experience more forms of IPV on average than those who had experienced physical violence, sexual violence, or emotional aggression. |
Prevalence of drug resistance-related polymorphisms in treatment-naive individuals infected with nonsubtype B HIV type 1 in Cameroon.
Fonjungo PN , Youngpairoj AS , Alemnji GA , Eno LT , Lyonga EJ , Eloundou MA , Shanmugam V , Mpoudi-Ngole E , Kalish ML , Folks TM , Pieniazek D . AIDS Res Hum Retroviruses 2011 28 (7) 675-84 Mutations associated with the use of protease (PR) and reverse transcriptase (RT) inhibitors have been mostly mapped for HIV-1 subtype B. The prevalence of these mutations in drug-naive HIV-1 subtype B infected individuals is low but occurs at high frequencies in treated individuals. To determine the prevalence of treatment-associated mutations in non-B viruses, we analyzed a 1613bp pol region of specimens collected from 57 HIV-1 infected treatment-naive individuals from Cameroon. Of the 57 HIV-1 sequences, 43 belonged to CRF02-AG, two to CRF11-cpx, six to subtype A, one to subtype D and five were unclassifiable. Of the 57 PR sequences, 100% contained at least one codon change giving substitutions at positions 10, 11, 16, 20, 33, 36, 60, 62, 64, 69, 77, and 89. These substitutions gave the following prevalence pattern, 36I/L (100%, 57/57) > 89M/I (98%, 56/57) > 69K/R (93%, 53/57) > 20I/R (89%, 51/57) > 16E (16%, 9/57) > 64M (12%, 7/57) > 10I (11%, 6/57) > 11V (5%, 3/57) = 62V (5%, 3/57) = 77I (5%, 3/57) > 233F/V (4%, 2/57) = 60E (4%), which differed significantly from subtype B at positions 20, 36, 69 and 89. All but one (98%) of the 57 RT sequences (438 amino acid residues) carried substitutions located at codons 39A (7%), 43E (7%), 122E (7%), 312Q (2%), 333E (2%), 335C/D (89%), 356K (89%), 358K (14%), 365I (2%), 371V (81%), 376S (11%) or 399D (4%); the frequency of these substitutions ranged from <0.5% to 4% in RT of subtype B. The high prevalence of minor mutations associated with protease inhibitors (PI) and reverse transcriptase inhibitors (RTI) represent natural polymorphisms. HIV-1 PR and RT sequences from ARV-naive HIV-infected persons in Cameroon are important for monitoring the development of resistance to PIs and RTIs as such mutations could lead to treatment failures in individuals undergoing ARV therapy. |
Serotyping of Streptococcus pneumoniae isolates from nasopharyngeal samples: use of an algorithm combining microbiologic, serologic, and sequential multiplex PCR techniques.
Miernyk K , Debyle C , Harker-Jones M , Hummel KB , Hennessy T , Wenger J , Rudolph K . J Clin Microbiol 2011 49 (9) 3209-14 We evaluated nasopharyngeal carriage of Streptococcus pneumoniae (pneumococci) in nine Alaskan communities and used an algorithm combining microbiologic, serologic, and sequential multiplex PCR (MP-PCR) techniques to serotype the isolates. After microbiological identification as pneumococci, isolates (n = 1,135) were serotyped using latex agglutination and Quellung tests (LA/Q) as well as a series of six sequential MP-PCR assays. Results from the two methods agreed for 94% (1,064/1,135) of samples. Eighty-six percent (61/71) of the discordant results were resolved. Discordant results occurred because (i) the MP-PCR gel was misread (31/61 [51%]), (ii) the LA/Q agglutination was misinterpreted (13/61 [21%]), (iii) two serotypes or sets of serotypes were identified by MP-PCR and only one of the two was identified by LA/Q (9/61 [15%]), (iv) different serotypes or sets of serotypes were identified by LA/Q and MP-PCR and both were correct (7/61 [11%]), and (v) the capsular polysaccharide locus (cps) did not amplify during the initial MP-PCR but was present upon retesting (1/61 [2%]). Overall, isolation of pneumococci followed by MP-PCR quickly and accurately identified pneumococcal serotypes in >97% of samples and made available isolates for additional tests such as antimicrobial susceptibility. Misinterpretation of the MP-PCR gel was identified as the main source of discordance. Increasing the number of MP-PCRs from six to seven and reducing the number of serotypes in each reaction may reduce this error. This method may be of use to laboratories characterizing large numbers of S. pneumoniae samples, especially when antimicrobial susceptibility data are needed. |
Measurement of ultra-trace beryllium in occupational hygiene samples by extraction and fluorescence detection
Ashley K . J Chem Health Saf 2011 18 (5) 26-33 Beryllium is widely used in industry and commercial products for its unique properties; however, occupational exposure to beryllium particles can cause dermal sensitization and a potentially fatal lung ailment, chronic beryllium disease (CBD). Consequently, exposure limits for beryllium particles in air and action levels on surfaces have been established in efforts to minimize exposure risks for workers. In recent research, a molecular fluorescence method for the determination of trace beryllium in workplace samples, i.e., air filters and dust wipes, was evaluated and validated through intra- and inter-laboratory testing. The procedure entails extraction of sampled beryllium in dilute ammonium bifluoride (aqueous), followed by fluorescence measurement of the complex formed between beryllium and hydroxybenzoquinoline sulfonate (HBQS). The estimated method detection limit is <1 ng Be per air filter or wipe sample, with a dynamic range up to greater than 10 mcg per sample. Interferences from numerous metals tested (in >400-fold excess concentration compared to that of beryllium) are negligible or minimal. The procedure is effective for the dissolution and quantitative determination of beryllium extracted from refractory beryllium oxide particles, and was successfully modified for measuring beryllium content in large BeO particles and in soil samples. The method performance compares favorably with methods employing sample digestion in acid mixtures that include hydrofluoric acid, followed by inductively coupled plasma-mass spectrometry. ASTM International voluntary consensus standards and US National Institute for Occupational Safety and Health methods based on the methodology have been promulgated. |
Mutations of the Listeria monocytogenes peptidoglycan N-deacetylase and O-acetylase result in enhanced lysozyme sensitivity, bacteriolysis, and hyperinduction of innate immune pathways
Rae CS , Geissler A , Adamson PC , Portnoy DA . Infect Immun 2011 79 (9) 3596-606 Listeria monocytogenes is a Gram-positive intracellular pathogen that is naturally resistant to lysozyme. Recently, it was shown that peptidoglycan modification by N-deacetylation or O-acetylation confers resistance to lysozyme in various Gram-positive bacteria, including L. monocytogenes. L. monocytogenes peptidoglycan is deacetylated by the action of N-acetylglucosamine deacetylase (Pgd) and acetylated by O-acetylmuramic acid transferase (Oat). We characterized Pgd(-), Oat(-), and double mutants to determine the specific role of L. monocytogenes peptidoglycan acetylation in conferring lysozyme sensitivity during infection of macrophages and mice. Pgd(-) and Pgd(-) Oat(-) double mutants were attenuated approximately 2 and 3.5 logs, respectively, in vivo. In bone-marrow derived macrophages, the mutants demonstrated intracellular growth defects and increased induction of cytokine transcriptional responses that emanated from a phagosome and the cytosol. Lysozyme-sensitive mutants underwent bacteriolysis in the macrophage cytosol, resulting in AIM2-dependent pyroptosis. Each of the in vitro phenotypes was rescued upon infection of LysM(-) macrophages. The addition of extracellular lysozyme to LysM(-) macrophages restored cytokine induction, host cell death, and L. monocytogenes growth inhibition. This surprising observation suggests that extracellular lysozyme can access the macrophage cytosol and act on intracellular lysozyme-sensitive bacteria. |
Evaluation of disk approximation and single-well broth tests for detection of inducible clindamycin resistance in Streptococcus pneumoniae
Jorgensen JH , McElmeel ML , Fulcher LC , McGee L , Glennen A . J Clin Microbiol 2011 49 (9) 3332-3 This study evaluated an agar disk diffusion D-zone test and an erythromycin-clindamycin (ERY + CLI) single-well broth test for inducible CLI resistance in Streptococcus pneumoniae. The standard CLSI disk approximation test and a single-well combination test incorporating 1 plus 0.5 mcg/ml ERY + CLI detected >96% of isolates containing the ermB determinant. |
Evaluation of three rapid screening assays for detection of antibodies to hepatitis C virus
Smith BD , Drobeniuc J , Jewett A , Branson BM , Garfein RS , Teshale E , Kamili S , Weinbaum CM . J Infect Dis 2011 204 (6) 825-31 BACKGROUND: The Centers for Disease Control and Prevention (CDC) estimates that 3.2 million Americans are living with chronic hepatitis C virus (HCV) infection and 50%-70% are unaware of their status. Although therapies are available that can suppress or eliminate infection, identifying persons infected with HCV is challenging. Rapid tests could help identify many of these persons more expeditiously. METHODS: Three manufacturers, Chembio, OraSure, and MedMira, submitted HCV antibody (anti-HCV) rapid screening assays to the CDC for evaluation and comparison with established anti-HCV screening assays. The panel consisted of 1100 specimens drawn during 1997-1999 from persons reporting injection drug use. Sensitivity and specificity were assessed using 2 reference approaches, one based on the reactivity of samples in an anti-HCV screening assay and the other based on CDC HCV testing algorithm. RESULTS: The sensitivities of the Chembio, MedMira, and OraSure assays across the 2 approaches were 96.2%-98.0%, 86.8%-88.3%, and 97.8%-99.3%, respectively. The 3 assays had specificity of 99.5% or higher with no differences between assays. False rapid assay results were associated with human immunodeficiency virus positivity for both approaches for Chembio and MedMira. CONCLUSIONS: Rapid anti-HCV tests can provide sensitive and specific anti-HCV results for high-risk patients. |
Beta interferon-mediated activation of signal transducer and activator of transcription protein 1 interferes with Rickettsia conorii replication in human endothelial cells
Colonne PM , Eremeeva ME , Sahni SK . Infect Immun 2011 79 (9) 3733-43 Infection of the endothelial cell lining of blood vessels with Rickettsia conorii, the causative agent of Mediterranean spotted fever, results in endothelial activation. We investigated the effects of R. conorii infection on the status of the Janus kinase (JAK)-signal transducer and activator of transcription protein (STAT) signaling pathway in human microvascular endothelial cells (HMECs), the most relevant host cell type, in light of rickettsial tropism for microvascular endothelium in vivo. R. conorii infection induced phosphorylation of STAT1 on tyrosine 701 and serine 727 at 24, 48, and 72 h postinfection in HMECs. Employing transcription profile analysis and neutralizing antibodies, we further determined that beta interferon (IFN-beta) production and secretion are critical for STAT1 activation. Secreted IFN-beta further amplified its own expression via a positive-feedback mechanism, while expression of transcription factors interferon regulatory factor 7 (IRF7) and IRF9, implicated in the IFN-beta-STAT1 feedback loop, was also induced. Metabolic activity of rickettsiae was essential for the IFN-beta-mediated response(s) because tetracycline treatment inhibited R. conorii replication, IFN-beta expression, and STAT1 phosphorylation. Inclusion of IFN-beta-neutralizing antibody during infection resulted in significantly enhanced R. conorii replication, whereas addition of exogenous IFN-beta had the opposite inhibitory effect. Finally, small interfering RNA-mediated knockdown further confirmed a protective role for STAT1 against intracellular R. conorii replication. In concert, these findings implicate an important role for IFN-beta-mediated STAT1 activation in innate immune responses of vascular endothelium to R. conorii infection. |
Characterization of isolates from a multi-drug resistant outbreak of Shiga toxin-producing Escherichia coli O145 infections in the United States
Folster JP , Pecic G , Taylor E , Whichard J . Antimicrob Agents Chemother 2011 55 (12) 5955-6 Shiga toxin-producing Escherichia coli (STEC) is an important cause of foodborne illness and several outbreaks of non-O157 serotype infections have been reported recently (10, 17).... |
Treatment of abnormal vaginal flora in early pregnancy with clindamycin for the prevention of spontaneous preterm birth: a systematic review and metaanalysis
Lamont RF , Nhan-Chang CL , Sobel JD , Workowski K , Conde-Agudelo A , Romero R . Am J Obstet Gynecol 2011 205 (3) 177-190 The purpose of this study was to determine whether the administration of clindamycin to women with abnormal vaginal flora at <22 weeks of gestation reduces the risk of preterm birth and late miscarriage. We conducted a systematic review and metaanalysis of randomized controlled trials of the early administration of clindamycin to women with abnormal vaginal flora at <22 weeks of gestation. Five trials that comprised 2346 women were included. Clindamycin that was administered at <22 weeks of gestation was associated with a significantly reduced risk of preterm birth at <37 weeks of gestation and late miscarriage. There were no overall differences in the risk of preterm birth at <33 weeks of gestation, low birthweight, very low birthweight, admission to neonatal intensive care unit, stillbirth, peripartum infection, and adverse effects. Clindamycin in early pregnancy in women with abnormal vaginal flora reduces the risk of spontaneous preterm birth at <37 weeks of gestation and late miscarriage. There is evidence to justify further randomized controlled trials of clindamycin for the prevention of preterm birth. However, a deeper understanding of the vaginal microbiome, mucosal immunity, and the biology of BV will be needed to inform the design of such trials. |
Trends in intussusception-associated deaths among US infants from 1979-2007
Desai R , Curns AT , Patel MM , Parashar UD . J Pediatr 2011 160 (3) 456-60 OBJECTIVE: We examined data from 1979-2007 to generate up-to-date baseline estimates of rotavirus intussusception mortality in US infants, to inform policy deliberations of the risks and benefits of vaccination. STUDY DESIGN: Secular trends in the infant intussusception mortality rate were evaluated using national multiple cause-of-death and natality data from 1979- 2007. Linked birth/infant death data from 1998-2006 were examined to identify risk factors for intussusception deaths. RESULTS: After declining from 1979-1996, the average annual intussusception mortality rate stabilized from 1997-2007 at 2.1 per 1 million live births (range, 1.0-3.0). In multivariate analysis, significant variables associated with intussusception deaths included no prenatal care (OR, 5.4; 95% CI, 1.9-15.4) and birth order (≥3rd) (OR, 2.4; 95% CI, 1.4-4.4 [reference: birth order (1st)]). CONCLUSIONS: Given the annual variation in intussusceptions mortality and low baseline rates, if a low vaccine-associated risk of death from intussusception exists in the United States, it would be difficult to assess using intussusception mortality trend data alone. Factors associated with intussusception mortality risk may be related to delayed or reduced health care access. |
Anogenital human papillomavirus in sexually abused and nonabused children: a multicenter study
Unger ER , Fajman NN , Maloney EM , Onyekwuluje J , Swan DC , Howard L , Beck-Sague CM , Sawyer MK , Girardet RG , Sautter RL , Hammerschlag MR , Black CM . Pediatrics 2011 128 (3) e658-65 OBJECTIVES: To characterize the epidemiology of genital human papillomavirus (HPV) infection in children without previous consensual sexual activity, comparing HPV prevalence by certainty of child sexual abuse (CSA). PATIENTS AND METHODS: Patients presenting for evaluation of CSA in 8 sites in Atlanta, Houston, Harrisburg, and New York City were recruited along with patients presenting for unrelated health visits. CSA certainty was classified as definite, probable, possible, or no evidence following published guidelines and the results of history, physical examination, and laboratory tests. Urine and swabs of external genitalia were tested for HPV using L1 consensus polymerase chain reaction. RESULTS: The study included 576 participants (89.9% female) aged 6 months to 13 years (mean: 7.9); 534 of whom were evaluated for CSA and 42 for unrelated reasons. Of those evaluated for CSA, 14 had genital warts. One or more HPV types were detected in 11.8% (61 of 517) of participants with adequate samples. HPV detection was more likely among abused participants (definite, probable, or possible) than among participants without evidence of CSA (13.7% and 1.3%, respectively; P < .0001) and increased with certainty of abuse (8.4%, 15.6%, and 14.5% in participants with possible, probable, and definite CSA, respectively; P < .0001). Participants aged 10 years or older had a higher prevalence of HPV (20.6%) than others (5.6%) (P < .0001). CSA, anogenital warts, and age were independently associated with HPV detection. CONCLUSIONS: HPV detection was associated with CSA and increased with CSA certainty. In this population, genital HPV seemed to behave as a sexually transmitted infection. |
Number of natural and prosthetic teeth impact nutrient intakes of older adults in the United States
Bethene Ervin R , Dye BA . Gerodontology 2011 29 (2) e693-702 OBJECTIVE: To examine the relationship between the number and type of teeth and nutrient intakes in adults, aged 60 years and above, in the National Health and Nutrition Examination Survey 1999-2004 using linear regression. METHODS: Four discrete dental status groups were created: complete natural dentition (reference group), incomplete natural dentition, complete mixed (natural and restored) dentition and incomplete mixed dentition. We ran both unadjusted and adjusted models, controlling for age, race/ethnicity, education and smoking status to examine the effect of these covariates on the association between dentition status and nutrient intakes. Separate models were run for men and women. RESULTS: There were significant associations between dental status and all the examined nutrients for men and for the carotenes and folate for women in the unadjusted model. Only caloric and vitamin C intakes were significant for men, and beta-carotene was significant for women in the adjusted model. For men for kilocalories and women for beta-carotene, those with a complete dentition had higher mean intakes than those with an incomplete dentition, regardless of the tooth type. Among men with an incomplete dentition, those with a mixed dentition had a significantly lower vitamin C intake than those with a natural dentition; there were no significant differences between the natural and mixed complete dentition groups. CONCLUSIONS: Demographic and behavioural variables explained many of the differences seen in nutrient intakes. After controlling for these variables, we found that a numeric threshold of teeth (i.e. a functional dentition) influenced some nutrient intakes while the number and type of teeth present affected other nutrient intakes. |
Respiratory protective equipment, mask use, and respiratory outcomes among World Trade Center rescue and recovery workers
Antao VC , Pallos LL , Shim YK , Sapp JH 2nd , Brackbill RM , Cone JE , Stellman SD , Farfel MR . Am J Ind Med 2011 54 (12) 897-905 BACKGROUND: Serious respiratory illnesses have been reported among rescue/recovery workers (RRW) following the World Trade Center (WTC) attacks. METHODS: We studied RRW enrolled in the WTC Health Registry to assess the effects of different respiratory protection equipment (RPE) types on respiratory outcomes, such as recurrent respiratory symptoms and diseases possibly associated with 9/11 exposures. We performed descriptive and multivariate analyses adjusting for demographics and exposure variables. RESULTS: A total of 9,296 RRW met inclusion criteria. The strongest predictors of using adequate RPE were being affiliated with construction, utilities or environmental remediation organizations and having received RPE training. Workers who used respirators were less likely to report adverse respiratory outcomes compared to those who reported no/lower levels of respiratory protection. CONCLUSIONS: Level of respiratory protection was associated with the odds of reporting respiratory symptoms and diseases. Training, selection, fit testing, and consistent use of RPE should be emphasized among emergency responders. Am. J. Ind. Med. (c) 2011 Wiley-Liss, Inc. |
Longitudinal lung function declines among California flavoring manufacturing workers
Kreiss K , Fedan KB , Nasrullah M , Kim TJ , Materna BL , Prudhomme JC , Enright PL . Am J Ind Med 2011 55 (8) 657-68 BACKGROUND: The California Department of Public Health received serial spirometry data for flavoring manufacturing workers at 20 companies at risk of bronchiolitis obliterans. METHODS: We graded spirometry quality; identified individual workers with excessive decline in forced expiratory volume in 1 s (FEV(1) ) using relative longitudinal limits of decline based on 4% average within-person variability; and analyzed declines by occupational risk factors. RESULTS: The quality of 1,697 spirometry tests from 725 workers varied by 18 providers, with poorer quality from commercial providers. Of 416 workers with at least two tests, 40 (9.6%) had abnormal FEV(1) decline. Of 289 workers with high quality spirometry, 21 (7.3%) had abnormal decline. Only one of the 21 had airways obstruction. Abnormal FEV(1) decline rates (per person-month) were greater among workers at companies using ≥800 lbs/year diacetyl than at companies using lesser amounts. Abnormal FEV(1) decline rates were greater at companies previously having four-person clusters of spirometric obstruction than at companies with no or only one worker with obstruction. CONCLUSIONS: Spirometric surveillance of flavoring workers can identify individual workers with an abnormal FEV(1) decline for preventive intervention, even when the FEV(1) itself remains within the normal range. Good quality spirometry and classification of abnormal with relative longitudinal limit of decline minimize misclassification of possible work-related health effects. Am. J. Ind. Med. (c) 2011 Wiley-Liss, Inc. |
Improvement of a mine fire simulation program – incorporation of smoke rollback into MFIRE 3.0
Zhou L , Smith AC . J Fire Sci 2011 30 (1) 29-39 Smoke rollback is a dangerous threat to miners and firefighters in an underground mine fire. The ability to predict smoke rollback can greatly improve the chances for safe miner evacuation and mine fire control and firefighting. A modified semi-empirical equation based on large-scale experiments conducted by the National Institute for Occupational Safety and Health (NIOSH) was developed to quantify smoke rollback during an underground mine fire. The equation was incorporated into a mine fire simulation program (MFIRE 3.0) to allow the user to predict the occurrence of smoke rollback and calculate the smoke rollback distance. This article describes the development of the equation and compares the experimental results with those predicted by MFIRE 3.0. The results indicate that the improved MFIRE 3.0 is capable of determining smoke rollback in a fire entry, not only to provide early warning for smoke rollback but also to verify the effectiveness of smoke rollback control efforts. |
Justifying research risks in a clinical trial for treatment of multidrug-resistant tuberculosis
Heilig CM , Chia D , El-Sadr WM , Hirsch-Moverman Y , Kenzie WR , Saukkonen J , Villarino ME , Padayatchi N . IRB 2011 33 (4) 10-7 Investigators and ethics review committees must ensure the proper justification of risks to participants | in clinical trials.1 Despite the existence of a systematic framework for analyzing the ethical evaluation | of research risks,2 the literature contains few worked | examples of such an analysis.3 This paper demonstrates | a step-by-step component analysis of the LiMiT Study, | a phase I–II randomized controlled trial designed to | evaluate once-daily (600 mg.) linezolid plus optimized | background therapy versus placebo plus optimized | background therapy for the first 16 weeks of study | therapy for multidrug-resistant tuberculosis (TB).4 This | example represents a fairly complex, early-stage trial | that we, as investigators, wanted to ensure met criteria for appropriate justification of research risks. Our | analytic framework helped to isolate and clarify a few | subtle issues that arise from using placebo in combination therapy among persons with difficult-to-treat | tuberculosis |
The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial
Zurovac D , Sudoi RK , Akhwale WS , Ndiritu M , Hamer DH , Rowe AK , Snow RW . Lancet 2011 378 (9793) 795-803 BACKGROUND: Health workers' malaria case-management practices often differ from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya. METHODS: From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. With a computer-generated sequence, health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for 6 months, or the control group, in which health workers did not receive any text messages. Health workers were not masked to the intervention, although patients were unaware of whether they were in an intervention or control facility. The primary outcome was correct management with artemether-lumefantrine, defined as a dichotomous composite indicator of treatment, dispensing, and counselling tasks concordant with Kenyan national guidelines. The primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, ISRCTN72328636. FINDINGS: 119 health workers received the intervention. Case-management practices were assessed for 2269 children who needed treatment (1157 in the intervention group and 1112 in the control group). Intention-to-treat analysis showed that correct artemether-lumefantrine management improved by 23.7 percentage-points (95% CI 7.6-40.0; p=0.004) immediately after intervention and by 24.5 percentage-points (8.1-41.0; p=0.003) 6 months later. INTERPRETATION: In resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices. FUNDING: The Wellcome Trust. |
Identifying opportunities for Chlamydia screening among American Indian women
Taylor MM , Reilley B , Tulloch S , Winscott M , Dunnigan A , Russell M , Redd JT . Sex Transm Dis 2011 38 (10) 947-8 Medical record review was used to identify missed opportunities for chlamydia screening among 103 American Indian/Alaska Native women. Of these, 69% had received a pregnancy test and 74% had received a urine test in the previous 12 months. Chlamydia screening may increase if linked to the other routine clinical testing. |
Chlamydia partner services for females in California family planning clinics
Yu YY , Frasure-Williams JA , Dunne EF , Bolan G , Markowitz L , Bauer HM . Sex Transm Dis 2011 38 (10) 913-8 BACKGROUND: Prompt treatment of exposed partners is critical for preventing further transmission of chlamydia, reinfection, and sequelae among females. Patient-delivered partner therapy (PDPT) has been allowable in California since 2001; however, few data are available regarding PDPT use and treatment outcomes. METHODS: Eight family planning clinics participated in a partner services evaluation from 2005 to 2006. Females aged 16 to 35 years with chlamydia were interviewed to determine the partner service received and partner treatment outcomes; a subset of partners was also interviewed. Determinants of reported partner treatment were assessed using multivariate logistic regression. Selected medical records were reviewed to assess reinfection rates. RESULTS: Overall, 743 female patients disclosed 952 partners; 58% of whom were identified as steady partners. Reported partner services included concurrent patient-partner treatment visits (15% of partners), PDPT (19%), patient referral (55%), health department referral (0.1%), and no partner management (11%). On the basis of patient report, 82% of partners were notified and 54% received treatment. Of the 166 (17%) partners interviewed, 139 (84%) reported that they had received treatment, which correlated well with patient report. Reported partner treatment was higher for concurrent treatment visits and PDPT (79% and 80%, respectively) compared to patient referral (44%, P < 0.0001). Adjusted for clinic and relationship status, partners managed with concurrent treatment visits or PDPT were more likely to receive treatment compared with partners managed with patient referral (adjusted odds ratios, 3.5; 95% confidence interval, 2.1-5.8 and adjusted odds ratios, 4.3; 95% confidence interval, 2.6-7.2, respectively). Among the patients retested within 6 months after treatment, 18% were reinfected; reinfection rates did not differ by type of partner service. CONCLUSIONS: Although overall rates of reported partner treatment were low, concurrent patient-partner treatment visits and PDPT were associated with significantly higher rates of partner treatment. However, these methods may be underutilized in California family planning settings. |
Condom use among US adults at last sexual intercourse, 1996-2008: an update from national survey data
Anderson JE , Warner L , Macaluso M . Sex Transm Dis 2011 38 (10) 919-21 The prevalence of condom use at last intercourse, estimated from questions added to a national survey, was estimated to be 20.2%. Use of condom was significantly higher for sex outside ongoing relationships and among those with 2 or more past-year sex partners and its use increased slightly but significantly from 1996 to 2008. |
Discordance between spermatozoa detection and self-reported semen exposure
Gallo MF , Sobel JD , Rompalo AM , Cu-Uvin S , Schoenbaum E , Jamieson DJ . Sex Transm Dis 2011 38 (10) 909-12 An analysis of data from a prospective study of 1257 high-risk women revealed 7 predictors of discordance between self-reported lack of recent exposure to semen and detection of spermatozoa on Gram stain, suggesting that inaccuracies in the reporting of sexual behaviors cannot be assumed to be distributed randomly. |
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