The ACE I/D polymorphism in US adults: limited evidence of association with hypertension-related traits and sex-specific effects by race/ethnicity.
Ned RM , Yesupriya A , Imperatore G , Smelser DT , Moonesinghe R , Chang MH , Dowling NF . Am J Hypertens 2011 25 (2) 209-15 BACKGROUND: The insertion/deletion (I/D) variant (rs4646994) of the angiotensin I-converting enzyme (ACE) gene is one of the most studied polymorphisms in relation to blood pressure and essential hypertension in humans. The evidence to date, however, on an association of this variant with blood pressure-related outcomes has been inconclusive. METHODS: We examined 5,561 participants of the Third National Health and Nutrition Examination Survey (NHANES III), a population-based and nationally representative survey of the United States, who were ≥20 years of age and who self-identified as non-Hispanic white, non-Hispanic black, or Mexican American. Within each race/ethnicity, we assessed genetic associations of the I/D variant with systolic blood pressure (SBP), diastolic blood pressure (DBP), and hypertension, as well as genotype-sex interactions, in four genetic models (additive, dominant, recessive, and codominant). RESULTS: The frequency of the I/D variant differed significantly by race/ethnicity (P = 0.001). Among non-Hispanic blacks, the D allele was significantly associated (P < 0.05) with increased SBP in additive and dominant covariate-adjusted models and was also associated with increased DBP in dominant models when participants taking ACE inhibitors were excluded from the analyses. No other significant associations were observed in any race/ethnic group. Significant genotype-sex interactions were detected among Mexican Americans, for whom positive associations with SBP and hypertension were seen among females, but not males. CONCLUSIONS: This study gives limited support for association of the ACE I/D variant with blood pressure and for sex-specific effects among particular race/ethnic groups, though we cannot rule out the role of genetic or environmental interactions. |
Risk of cardiovascular mortality in relation to optimal low-density lipoprotein cholesterol combined with hypertriglyceridemia: is there a difference by gender?
Kuklina EV , Keenan NL , Callaghan WM , Hong Y . Ann Epidemiol 2011 21 (11) 807-14 PURPOSE: The objectives of the present study were to determine whether an optimal low-density lipoprotein cholesterol (LDL-C) combined with hypertriglyceridemia was associated with cardiovascular disease (CVD) mortality and whether these associations differ by gender. METHODS: A cohort of 2903 U.S. adults aged ≥45 years (men) and ≥55 years (women) at baseline (1988-1994) was followed through December 2006 for CVD mortality. Baseline data were collected through the Third National Health and Nutrition Examination Survey (NHANES III). The definitions of high LDL-C and high triglycerides (TG) (hypertriglyceridemia) levels were based on the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines. Cox proportional hazard models were used to estimate the hazard ratio (HR) with 95% confidence interval (CI) of death. RESULTS: After adjusting for age, race/ethnicity, and traditional CVD risk factors, the risk of CVD death was approximately two times as high among women with optimal LDL-C/hypertriglyceridemia (2.42, 95% CI = 1.35-4.33) compared to women with optimal LDL-C/normal TG. In contrast, no significant difference was found among men on this comparison. CONCLUSIONS: Judging from this study, hypertriglyceridemia is associated with an increased risk of CVD mortality in women but not in men. The association is independent of abnormal LDL-C effect. |
How are symptoms of ovarian cancer managed? A study of primary care physicians
Goff BA , Matthews B , Andrilla CH , Miller JW , Trivers KF , Berry D , Lishner DM , Baldwin LM . Cancer 2011 117 (19) 4414-23 BACKGROUND: A study was undertaken to identify the diagnostic approaches that primary care physicians and gynecologists undertake in women with symptoms associated with ovarian cancer. METHODS: A vignette-based survey was mailed to 3200 primary care physicians from the American Medical Association Physician Masterfile. The vignette described a 55-year-old woman with symptoms associated with ovarian cancer, although ovarian cancer was never mentioned. The authors evaluated patient, physician, and practice characteristics associated with a workup that could detect ovarian cancer. RESULTS: The survey response rate was 61.7%. After exclusions, 1532 physicians were included. Overall, 89.5% of physicians reported that they would recommend testing that can detect ovarian cancer (71.2% ultrasound; 25.4% pelvic computed tomography; 26.5% CA125). In adjusted analysis, the only patient factor associated with ovarian cancer testing was symptom type, genitourinary versus gastrointestinal (risk ratio, 1.07; 95% confidence interval, 1.03-1.11). Physician and practice characteristics associated with recommending of ovarian cancer testing included specialty (gynecologists > family physicians and internists); type of practice (group > solo); clinical teaching (yes > no); and within Census division, location of practice, with all Central (East, West, North, and South) and Atlantic (Middle and South) areas having a lower likelihood than New England. CONCLUSIONS: On the basis of a vignette in which a woman reported symptoms associated with ovarian cancer, the majority of primary care physicians and gynecologists would not recommend CA125, but would recommend imaging of the pelvis. Gynecologists, physicians involved with clinical teaching, and those in group practices were significantly more likely to recommend testing that could lead to an ovarian cancer diagnosis. Cancer 2011;. (c) 2011 American Cancer Society. |
Dissemination and translation: a frontier for cancer survivorship research
Pollack LA , Hawkins NA , Peaker BL , Buchanan N , Risendal BC . Cancer Epidemiol Biomarkers Prev 2011 20 (10) 2093-8 As the field of survivorship research grows, the need for translation is imperative to expand new knowledge into arenas that directly impact survivors. This commentary seeks to encourage research focused on dissemination and translation of survivorship interventions and programs, including practice-based research. We overview diffusion, dissemination and translation in the context of cancer survivorship and present the RE-AIM and Knowledge to Action frameworks as approaches that can be used to expand research into communities. Many academic, governmental, and community-based organizations focus on cancer survivor. Future survivorship research should contribute to harmonizing these assets to identify effective interventions, maximize their reach and adoption, and integrate promising practices into routine care. Cancer Epidemiol Biomarkers Prev; 20(10); 2093-8. (c)2011 AACR. |
Host genetic risk factors for West Nile virus infection and disease progression.
Bigham AW , Buckingham KJ , Husain S , Emond MJ , Bofferding KM , Gildersleeve H , Rutherford A , Astakhova NM , Perelygin AA , Busch MP , Murray KO , Sejvar JJ , Green S , Kriesel J , Brinton MA , Bamshad M . PLoS One 2011 6 (9) e24745 West Nile virus (WNV), a category B pathogen endemic in parts of Africa, Asia and Europe, emerged in North America in 1999, and spread rapidly across the continental U.S. Outcomes of infection with WNV range from asymptomatic to severe neuroinvasive disease manifested as encephalitis, paralysis, and/or death. Neuroinvasive WNV disease occurs in less than one percent of cases, and although host genetic factors are thought to influence risk for symptomatic disease, the identity of these factors remains largely unknown. We tested 360 common haplotype tagging and/or functional SNPs in 86 genes that encode key regulators of immune function in 753 individuals infected with WNV including: 422 symptomatic WNV cases and 331 cases with asymptomatic infections. After applying a Bonferroni correction for multiple tests and controlling for population stratification, SNPs in IRF3 (OR 0.54, p = 0.035) and MX1, (OR 0.19, p = 0.014) were associated with symptomatic WNV infection and a single SNP in OAS1 (OR 9.79, p = 0.003) was associated with increased risk for West Nile encephalitis and paralysis (WNE/P). Together, these results suggest that genetic variation in the interferon response pathway is associated with both risk for symptomatic WNV infection and WNV disease progression. |
Human infection with novel G3P[25] rotavirus strain in Taiwan.
Wu FT , Banyai K , Huang JC , Wu HS , Chang FY , Hsiung CA , Huang YC , Lin JS , Hwang KP , Jiang B , Gentsch JR . Clin Microbiol Infect 2011 17 (10) 1570-1573 Genotype P[25] rotaviruses are rare and to date have been reported to occur only in a few countries of mainland Asia. Here we report the molecular characterization of a novel human rotavirus genotype combination, G3P[25], detected in a 17-month-old child hospitalized due to severe gastroenteritis during 2009 in central Taiwan. Sequencing and phylogenetic analysis of the VP4 gene demonstrated a distinct origin from other strains bearing the P[25] VP4 gene, whereas the VP7, VP6 and NSP4 gene phylogenies identified common origins with cognate genes of other, presumed human-porcine reassortment Taiwanese strains. These results suggest that interactions between human and animal strains appear to contribute to the generation of genetic and antigenic diversity of rotavirus strains, with potential public health importance in Taiwan. Clin Microbiol Infect 2011; 17: 1570-1573 |
Prevalence of herpes simplex virus type 2 infection, human immunodeficiency virus/herpes simplex virus type 2 coinfection, and associated risk factors in a national, population-based survey in Kenya
Mugo N , Dadabhai SS , Bunnell R , Williamson J , Bennett E , Baya I , Akinyi N , Mohamed I , Kaiser R . Sex Transm Dis 2011 38 (11) 1059-1066 BACKGROUND: Herpes simplex virus type 2 (HSV-2) is a known biologic cofactor for human immunodeficiency virus (HIV) transmission and acquisition. The Kenya AIDS Indicator Survey 2007 provided Kenya's first nationally representative estimate of HSV-2 prevalence and risk factors. METHODS: KAIS was a household serosurvey among women and men aged 15 to 64 years. The survey included a behavioral interview and serum testing for HSV-2, HIV, and syphilis infections. Results were weighted for sampling design and nonresponse. RESULTS: Of 19,840 eligible individuals, 90% completed an interview and 80% consented to testing. In all, 35% were infected with HSV-2, of which 42% were women and 26% were men. Between 15 and 24 years of age, HSV-2 prevalence increased from 7% to 34% in women and 3% to 14% in men. Among couples, 30% were HSV-2 concordant-positive, 21% were discordant, and 49% were concordant-negative. In all, 81% of HIV-infected persons were coinfected with HSV-2. HIV prevalence was 16% among those with HSV-2 and 2% among those without HSV-2. Women with circumcised partners had an HSV-2 prevalence of 39% compared to 77% of women with uncircumcised partners. CONCLUSIONS: One-third of Kenyans were HSV-2 infected. HIV-1 infection, age, female sex, and lack of male circumcision were population-level predictors for HSV-2 infection. Targeted prevention interventions are needed, including an effective vaccine. |
A prospective study of the psychosocial impact of a positive Chlamydia trachomatis laboratory test
Gottlieb SL , Stoner BP , Zaidi AA , Buckel C , Tran M , Leichliter JS , Berman SM , Markowitz LE . Sex Transm Dis 2011 38 (11) 1004-11 BACKGROUND: Few data exist on potential harms of chlamydia screening. We assessed the psychosocial impact of receiving a positive Chlamydia trachomatis test result. METHODS: We prospectively studied women ≥16 years of age undergoing chlamydia testing in 2 Midwestern family planning clinics. We surveyed women at baseline and about 1 month after receiving test results, using 9 validated psychosocial scales/subscales and chlamydia-specific questions. Changes in scale scores were calculated for each woman. Mean percent changes in scores for chlamydia-positive and -negative women were compared using a t test. RESULTS: We enrolled 1807 women (response rate, 84%). Of the 1688 women with test results, 149 (8.8%) tested positive. At follow-up, chlamydia-positive women (n = 71) had a 75% increase in anxiety about sexual aspects of their life on the Multidimensional Sexual Self-Concept Questionnaire (P < 0.001), significantly greater than the 26% increase among 280 randomly selected chlamydia-negative women (P = 0.02). There were no differences for the other 8 scales/subscales, including general measures of anxiety, depression, and self-esteem. Chlamydia-positive women were more likely than chlamydia-negative women to be "concerned about chlamydia" (80% vs. 40%, P < 0.001) and to report breaking up with a main partner (33% vs. 11%, P < 0.001) at follow-up. Women testing positive reported a range of chlamydia-specific concerns. CONCLUSIONS: Chlamydia-positive women had significant increases in anxiety about sex and concern about chlamydia, but did not have marked changes in more general measures of psychosocial well-being about 1 month after diagnosis. Chlamydia diagnoses were associated with some disruption of relationships with main partners. Chlamydia-specific concerns may guide counseling messages to minimize psychosocial impact. |
Establishing the diagnosis of HIV infection: new tests and a new algorithm for the United States
Branson BM , Mermin J . J Clin Virol 2011 52 Suppl 1 S3-4 With the introduction of third generation antibody assays that detect both immunoglobulin (Ig) G and IgM class antibodies, and fourth generation antigen/antibody (Ag/Ab) combination assays, the ability of screening tests to detect early HIV infection has improved substantially over the past decade.1, 2, 3 Selecting the optimal tests to confirm the presence of HIV infection, however, poses a challenge for the laboratory. The traditional confirmatory tests, Western blot, line immunoassay, and indirect immunofluorscence assay, are highly specific and play a central role in diagnostic algorithms,4, 5, 6, 7 but they detect only IgG class antibodies.8 Thus, up to 3 weeks might elapse after a reactive third or fourth generation assay before the confirmatory tests produce a positive result. Molecular RNA assays, highly sensitive during early infection, yield negative results in 3–5% of specimens that are positive by Western blot.2, 9 Differentiating HIV-1 from HIV-2 poses another challenge. Almost all screening assays now incorporate antigens to detect both HIV-1 and HIV-2, but because of cross-reactivity, the HIV-1 Western blot is often positive in patients with HIV-2, and no HIV-2 confirmatory test is currently approved by the U.S. Food and Drug Administration (FDA).10, 11 “Cryptic” HIV-2 infection is thus often investigated only after patients with an HIV-1 diagnosis manifest clinical deterioration despite a repeatedly undetectable HIV-1 viral load.10 |
Increased mortality among publicly insured participants in the HIV Outpatient Study despite HAART treatment
Palella FJ Jr , Baker RK , Buchacz K , Chmiel JS , Tedaldi EM , Novak RM , Durham MD , Brooks JT . AIDS 2011 25 (15) 1865-1876 OBJECTIVE: Understanding mortality differences among HIV-infected patients can focus efforts to improve survival. DESIGN: We evaluated death rates, causes, and associated factors among treated patients in the HIV Outpatient Study (HOPS), a large, prospective, multicenter observational cohort of HIV-infected persons seen at a diverse set of US sites of care. METHODS: Among 3754 HOPS participants seen during 1996-2007 with at least 6 months of follow-up after initiating HAART and receiving HAART at least 75% of time under observation ('substantially treated'), we calculated hazard ratios for death using proportional hazards regression models. We also examined death causes and comorbidities among decedents. RESULTS: Substantially treated participants, followed a median 4.7 years (interquartile range, 2.2-8.5), experienced 331 deaths. In multivariable analyses, higher mortality was associated with an index CD4 cell count less than 200 cells/mcl [adjusted hazard ratio (aHR), 2.86; 95% confidence interval (CI) 1.95-4.21], older age (aHR, 1.50 per 10 years; 95% CI 1.33-1.70), log10HIV RNA (aHR, 1.67 per log10; 95% CI 1.51-1.85), but not race/ethnicity (aHR, 0.99 for blacks vs. whites, P = 0.92). Mortality was increased among publicly insured (PUB) vs. privately insured participants (PRV) when index CD4 cell count was at least 200 cells/mcl (aHR, 2.03; 95% CI 1.32-3.14) but not when index CD4 cell count was less than 200 cells/mcl (aHR, 1.3, P = 0.13). By death cause, PUB had significantly more cardiovascular events and hepatic disorders than PRV. Comorbidities more frequent among PUB vs. PRV decedents included cardiovascular disease, renal impairment, and chronic hepatitis. CONCLUSION: Among HAART-treated participants with CD4 cell counts at least 200 cells/mcl, PUB experienced higher death rates than PRV. Non-AIDS death and disease causes predominated among publicly insured decedents, suggesting that treatable comorbidities contributed to survival disparities. |
Chlamydia positivity trends among women attending family planning clinics: United States, 2004-2008
Satterwhite CL , Grier L , Patzer R , Weinstock H , Howards PP , Kleinbaum D . Sex Transm Dis 2011 38 (11) 989-94 BACKGROUND: Annual chlamydia screening is recommended for all sexually active women aged <25 years. Substantial limitations exist in ascertaining chlamydia trends. Reported case rates have increased likely due to increased screening and improved test technology. Other data suggest that prevalence has decreased. METHODS: Data from the Infertility Prevention Project (IPP), a national chlamydia screening program, were used to assess trends in chlamydia positivity from 2004 to 2008 among women aged 15 to 24 years who were tested in family planning clinics reporting data to IPP. Using the clinic as the unit of analysis, a correlated, longitudinal data analysis with a random intercept was conducted among clinics reporting ≥3 years of data during the analysis timeframe. Sensitivity analyses were performed to address the impact of various clinic participation levels in addition to the assessment of various correlation structures. RESULTS: Over 5 million chlamydia tests were reported to IPP family planning clinics from 2004 to 2008. A majority of tests were conducted among white women (clinic-specific mean: 63.2%, interquartile range: 37.6%-91.5%); the clinic-specific mean percent of tests conducted among black women was 17.9% (interquartile range: 0.8%-25.7%). Overall chlamydia positivity from 2004 to 2008 was 7.0%. The odds ratio associated with a single year change (1.00; 95% confidence interval: 0.99, 1.00) suggested that chlamydia positivity did not change from 2004 to 2008, after controlling for clinic-specific population factors (age, race, test usage, and geography). CONCLUSIONS: Findings support previous analyses suggesting that chlamydia prevalence is not increasing despite apparent increasing rates based on case reports. |
The cost and cost-effectiveness of expedited partner therapy compared with standard partner referral for the treatment of chlamydia or gonorrhea
Gift TL , Kissinger P , Mohammed H , Leichliter JS , Hogben M , Golden MR . Sex Transm Dis 2011 38 (11) 1067-73 BACKGROUND: Partner treatment is an important component of sexually transmitted disease control. Several randomized controlled trials have compared expedited partner treatment (EPT) to unassisted standard partner referral (SR). All of these trials found that EPT significantly increased partner treatment over SR, whereas some found that EPT significantly lowered reinfection rates in index patients. METHODS: We collected cost data to assess the payer-specific, health care system, and societal-level cost of EPT and SR. We used data on partner treatment and index patient reinfection rates from 2 randomized controlled trials examining EPT and SR for patients diagnosed with chlamydia or gonorrhea. Additional elements were estimated or drawn from the literature. We used a Monte Carlo simulation to assess the impact on cost and effectiveness of varying several variables simultaneously, and calculated threshold values for selected variables at which EPT and SR costs per patient were equal. RESULTS: From a health care system or societal perspective, EPT was less costly and it treated more partners than SR. From the perspective of an individual payer, EPT was less costly than SR if ≥32% to 37% of male index patients' female partners or ≥29% of female index patients' male partners received care from the same payer. CONCLUSIONS: EPT has a lower cost from a societal or health care system perspective than SR and treats more partners. Individual payers may find EPT to be more costly than SR, depending on how many of their patients' partners receive care from the same payer. |
Cost-effectiveness of a dual non-treponemal/treponemal syphilis point-of-care test to prevent adverse pregnancy outcomes in Sub-Saharan Africa
Owusu-Edusei K Jr , Gift TL , Ballard RC . Sex Transm Dis 2011 38 (11) 997-1003 BACKGROUND: A dual nontreponemal/treponemal point-of-care test (Dual-POC) that simultaneously detects both nontreponemal and treponemal antibodies has been developed and evaluated. In this study, we compare the health and economic outcomes of the new test with existing syphilis tests/testing algorithms in a high prevalence setting. METHODS: We used a cohort decision analysis model to examine 4 testing/screening algorithms; the Dual-POC test, the laboratory-based rapid plasma reagin and Treponema pallidum haemagglutination assay (RPR+TPHA) algorithm, an onsite RPR testing, and point-of-care treponemal immunochromatographic strip (ICS) testing. Outcomes included miscarriage, stillbirth, congenital syphilis, low birth weight, and neonatal death. Disability-adjusted life-years were estimated for all health outcomes. The analytic horizon was the life expectancy for the mother and child. RESULTS: For a cohort of 1000 pregnant women in a historically high syphilis prevalence population (10% infected and 15% previously infected), the model predicted a total of 39 adverse pregnancy outcomes if no serologic screening were performed; 13 for the laboratory-based RPR+TPHA; 11 for the on-site RPR strategy; 5 for the Dual-POC strategy; and 2 for the ICS strategy. On the basis of assumption that the cost of ICS and the Dual-POC tests were the same, the ICS strategy was the most cost saving (saved $30,000) followed by the Dual-POC strategy (saved $27,000). CONCLUSIONS: The dual-POC test may help save cost in resource-poor settings where disease prevalence (and loss to follow-up) is high, while substantially reducing overtreatment. |
Ancient ancestry of KFDV and AHFV revealed by complete genome analyses of viruses isolated from ticks and mammalian hosts.
Dodd KA , Bird BH , Khristova ML , Albarino CG , Carroll SA , Comer JA , Erickson BR , Rollin PE , Nichol ST . PLoS Negl Trop Dis 2011 5 (10) e1352 BACKGROUND: Alkhurma hemorrhagic fever virus (AHFV) and Kyasanur forest disease virus (KFDV) cause significant human disease and mortality in Saudi Arabia and India, respectively. Despite their distinct geographic ranges, AHFV and KFDV share a remarkably high sequence identity. Given its emergence decades after KFDV, AHFV has since been considered a variant of KFDV and thought to have arisen from an introduction of KFDV to Saudi Arabia from India. To gain a better understanding of the evolutionary history of AHFV and KFDV, we analyzed the full length genomes of 16 AHFV and 3 KFDV isolates. METHODOLOGY/PRINCIPAL FINDINGS: Viral genomes were sequenced and compared to two AHFV sequences available in GenBank. Sequence analyses revealed higher genetic diversity within AHFVs isolated from ticks than human AHFV isolates. A Bayesian coalescent phylogenetic analysis demonstrated an ancient divergence of AHFV and KFDV of approximately 700 years ago. CONCLUSIONS/SIGNIFICANCE: The high sequence diversity within tick populations and the presence of competent tick vectors in the surrounding regions, coupled with the recent identification of AHFV in Egypt, indicate possible viral range expansion or a larger geographic range than previously thought. The divergence of AHFV from KFDV nearly 700 years ago suggests other AHFV/KFDV-like viruses might exist in the regions between Saudi Arabia and India. Given the human morbidity and mortality associated with these viruses, these results emphasize the importance of more focused study of these significant public health threats. |
Outbreak of Shiga-toxigenic Escherichia coli O157:H7 infections associated with rodeo attendance, Utah and Idaho, 2009
Lanier WA , Hall JM , Herlihy RK , Rolfs RT , Wagner JM , Smith LH , Hyytia-Trees EK . Foodborne Pathog Dis 2011 8 (10) 1131-3 OBJECTIVES: In summer 2009, the Utah Department of Health investigated an outbreak of Shiga-toxigenic Escherichia coli (STEC) O157:H7 (O157) illness associated with attendance at multiple rodeos. MATERIALS AND METHODS: Patients were interviewed regarding exposures during the week before illness onset. A ground beef traceback investigation was performed. Ground beef samples from patient homes and a grocery store were tested for STEC O157. Rodeo managers were interviewed regarding food vendors present and cattle used at the rodeos. Environmental samples were collected from rodeo grounds. Two-enzyme pulsed-field gel electrophoresis (PFGE) and multiple-locus variable-number tandem repeat analysis (MLVA) were performed on isolates. RESULTS: Fourteen patients with primary STEC O157 illness were reported in this outbreak. Isolates from all patients were indistinguishable by PFGE. Isolates from nine patients had identical MLVA patterns (main outbreak strain), and five had minor differences. Thirteen (93%) patients reported ground beef consumption during the week before illness onset. Results of the ground beef traceback investigation and ground beef sampling were negative. Of 12 primary patients asked specifically about rodeo attendance, all reported having attended a rodeo during the week before illness onset; four rodeos were mentioned. All four rodeos had used bulls from the same cattle supplier. An isolate of STEC O157 identified from a dirt sample collected from the bullpens of one of the attended rodeos was indistinguishable by PFGE and MLVA from the main outbreak strain. DISCUSSION: Recommendations were provided to rodeo management to keep livestock and manure separate from rodeo attendees. This is the first reported STEC O157 outbreak associated with attendance at multiple rodeos. Public health officials should be aware of the potential for rodeo-associated STEC illness. |
Integrating environmental health into medical education
Gehle KS , Crawford JL , Hatcher MT . Am J Prev Med 2011 41 S296-301 Although environmental factors contribute to more than 25% of all global disease, and toxic agents ranked fifth in underlying causes of U.S. deaths in 2000, environmental medicine education is largely omitted in the continuum of U.S. medical education. The paucity of specialists trained in environmental medicine (i.e., occupational medicine and other preventive medicine specialties and subspecialties), coupled with the lack of adequate general medical education on how to prevent, diagnose, refer, or treat patients exposed to hazardous substances in the environment, contributes to lost opportunities for primary prevention or early intervention to mitigate or minimize environmentally related disease burden. Survey findings of graduating medical students over the past few years have identified environmental health as a medical school topic area that can be improved. This article reflects a panel presentation on the challenge of including environmental health in general medical education. It was given at the 2010 "Patients and Populations: Public Health in Medical Education" conference cosponsored by the CDC and the American Association of Medical Colleges. A variety of educational strategies, models, and educational resources are presented that illustrate how recommended competency-based environmental health content can be integrated into medical education to better prepare medical students and physicians without specialized expertise in environmental medicine to provide or facilitate environmental preventive or curative patient care. |
Trends in emergency department visits among Medicaid patients
Sonnenfeld N , Decker SL , Schappert SM . JAMA 2011 306 (11) 1202-3; author reply 1203 Dr Tang and colleagues1 concluded that emergency department (ED) visit rates have been increasing most among Medicaid patients. We believe this conclusion may be unwarranted. The analysis does not appear to have incorporated changes that occurred over the years in the coding of the variable “primary expected source of payment” in the data source used by the authors, the National Hospital Ambulatory Medical Care Survey (NHAMCS) conducted by the National Center for Health Statistics (NCHS). The only information on payment sources that NHAMCS collected from 1997 through 2004 was the primary expected source of payment.2 Starting in 2005, hospital respondents could indicate multiple expected sources of payment per visit and did not designate a primary source. From 2005 through 2007, the data files included separate variables for each expected payment source plus a variable that assigned the primary expected source using a hierarchy with Medicaid first, followed by Medicare, private insurance, worker's compensation, self-payment, and no charge. | We suspect that many hospital respondents from 1997 through 2004 reported Medicare as the primary expected payment source for patients dually eligible for Medicare and Medicaid. It appears that for 2007, Tang et al used NHAMCS’ hierarchical payment variable that classified dual eligibles as having Medicaid. This approach led to a report of ED visit rates between 1997 and 2007 that increased by 36.5% for adult patients with Medicaid and decreased by 2.5% for Medicare (Table in the article). We recomputed the number of visits by coding the primary payment source for dually eligible patients as Medicare instead of Medicaid for 2007. Using information in the Table1 to generate denominators for the visit rate, the estimated number of ED visits for Medicaid patients would be 14.2 million and the visit rate 759.9 per 1000; for Medicare, the number of visits would be 19.9 million and the visit rate 485.9 per 1000. Therefore, the visit rate for adults from 1997 through 2007 would increase 9.5% for Medicaid and 17.6% for Medicare. These latter estimates may be more realistic than those presented by Tang et al. |
Lessons from the 2006 Louisiana Health and Population Survey
Stone GS , Henderson AK , Davis SI , Lewin M , Shimizu I , Krishnamurthy R , Bisgard K , Lee R , Jumaan A , Marziale E , Bryant M , Williams C , Mason K , Sirois M , Hori M , Chapman J , Bowman DJ . Disasters 2011 36 (2) 270-90 The 2005 hurricane season caused extensive damage and induced a mass migration of approximately 1.1 million people from southern Louisiana in the United States. Current and accurate estimates of population size and demographics and an assessment of the critical needs for public services were required to guide recovery efforts. Since forecasts using pre-hurricane data may produce inaccurate estimates of the post-hurricane population, a household survey in 18 hurricane-affected parishes was conducted to provide timely and credible information on the size of these populations, their demographics and their condition. This paper describes the methods used, the challenges encountered, and the key factors for successful implementation. This post-disaster survey was unique because it identified the needs of the people in the affected parishes and quantified the number of people with these needs. Consequently, this survey established new population and health indicator baselines that otherwise would have not been available to guide the relief and recovery efforts in southern Louisiana. |
Economic feasibility of a new method to estimate mortality in crisis-affected and resource-poor settings
Roberts B , Morgan OW , Sultani MG , Nyasulu P , Rwebangila S , Sondorp E , Chandramohan D , Checchi F . PLoS One 2011 6 (9) e25175 INTRODUCTION: Mortality data provide essential evidence on the health status of populations in crisis-affected and resource-poor settings and to guide and assess relief operations. Retrospective surveys are commonly used to collect mortality data in such populations, but require substantial resources and have important methodological limitations. We evaluated the feasibility of an alternative method for rapidly quantifying mortality (the informant method). The study objective was to assess the economic feasibility of the informant method. METHODS: The informant method captures deaths through an exhaustive search for all deaths occurring in a population over a defined and recent recall period, using key community informants and next-of-kin of decedents. Between July and October 2008, we implemented and evaluated the informant method in: Kabul, Afghanistan; Mae La camp for Karen refugees, Thai-Burma border; Chiradzulu District, Malawi; and Lugufu and Mtabila refugee camps, Tanzania. We documented the time and cost inputs for the informant method in each site, and compared these with projections for hypothetical retrospective mortality surveys implemented in the same site with a 6 month recall period and with a 30 day recall period. FINDINGS: The informant method was estimated to require an average of 29% less time inputs and 33% less monetary inputs across all four study sites when compared with retrospective surveys with a 6 month recall period, and 88% less time inputs and 86% less monetary inputs when compared with retrospective surveys with a 1 month recall period. Verbal autopsy questionnaires were feasible and efficient, constituting only 4% of total person-time for the informant method's implementation in Chiradzulu District. CONCLUSIONS: The informant method requires fewer resources and incurs less respondent burden. The method's generally impressive feasibility and the near real-time mortality data it provides warrant further work to develop the method given the importance of mortality measurement in such settings. |
Differentiating cause-of-death terminology for deaths coded as sudden infant death syndrome, accidental suffocation, and unknown cause: an investigation using US death certificates, 2003-2004
Kim SY , Shapiro-Mendoza CK , Chu SY , Camperlengo LT , Anderson RN . J Forensic Sci 2011 57 (2) 364-9 We compared written text on infant death certificates for deaths coded as sudden infant death syndrome (R95), unknown cause (R99), and accidental suffocation (W75). Using US mortality files supplemented with the death certifiers' written text for all infant deaths with International Classification of Diseases (ICD)-10 assigned codes R95, R99, and W75, we formed cause-of-death subcategories from common themes identified from the written text. Among all infant deaths in 2003-2004, the underlying cause of death was listed as R99 for 2128 deaths, R95 for 4408 deaths, and W75 for 931 deaths. Among the postneonatal deaths, the differences in subcategories varied between assigned ICD-10 codes: for R99-coded deaths, 45.8% were categorized as "Unknown" and 48.6% as "Pending"; for R95-coded deaths, 67.7% were categorized as "sudden infant death syndrome (SIDS)"; and for W75-coded deaths, 76.4% were categorized as "Suffocation." Examination of the written text on the death certificates demonstrates variability in the assigned ICD-10 codes which could have an important effect on the estimates of SIDS cases in the United States. |
Current practice in Staphylococcus aureus screening and decolonization
Diekema D , Johannsson B , Herwaldt L , Beekmann S , Jernigan J , Kallen A , Berrios-Torres S , Polgreen P . Infect Control Hosp Epidemiol 2011 32 (10) 1042-4 We surveyed infectious disease physicians to determine their preoperative Staphylococcus aureus screening and decolonization practices. Sixty percent reported preoperative screening for S. aureus. However, specific screening and decolonization practices are highly variable, are focused almost exclusively on methicillin-resistant S. aureus, and do not include testing for mupirocin or chlorhexidine resistance. |
Rotavirus vaccine and health care utilization for diarrhea in U.S. children
Cortes JE , Curns AT , Tate JE , Cortese MM , Patel MM , Zhou F , Parashar UD . N Engl J Med 2011 365 (12) 1108-17 BACKGROUND: Routine vaccination of U.S. infants with pentavalent rotavirus vaccine (RV5) began in 2006. METHODS: Using MarketScan databases, we assessed RV5 coverage and diarrhea-associated health care use from July 2007 through June 2009 versus July 2001 through June 2006 in children under 5 years of age. We compared the rates of diarrhea-associated health care use in unvaccinated children in the period from January through June (when rotavirus is most prevalent) in 2008 and 2009 with the prevaccine rates to estimate indirect benefits. We estimated national reductions in the number of hospitalizations for diarrhea, and associated costs, by extrapolation. RESULTS: By December 31, 2008, at least one dose of RV5 had been administered in 73% of children under 1 year of age, 64% of children 1 year of age, and 8% of children 2 to 4 years of age. Among children under 5 years of age, rates of hospitalization for diarrhea in 2001-2006, 2007-2008, and 2008-2009 were 52, 35, and 39 cases per 10,000 person-years, respectively, for relative reductions from 2001-2006 by 33% (95% confidence interval [CI], 31 to 35) in 2007-2008 and by 25% (95% CI, 23 to 27) in 2008-2009; rates of hospitalization specifically coded for rotavirus infection were 14, 4, and 6 cases per 10,000 person-years, respectively, for relative reductions in the rate from 2001-2006 by 75% (95% CI, 72 to 77) in 2007-2008 and by 60% (95% CI, 58 to 63) in 2008-2009. In the January-June periods of 2008 and 2009, the respective relative rate reductions among vaccinated children as compared with unvaccinated children were as follows: hospitalization for diarrhea, 44% (95% CI, 33 to 53) and 58% (95% CI, 52 to 64); rotavirus-coded hospitalization, 89% (95% CI, 79 to 94) and 89% (95% CI, 84 to 93); emergency department visits for diarrhea, 37% (95% CI, 31 to 43) and 48% (95% CI, 44 to 51); and outpatient visits for diarrhea, 9% (95% CI, 6 to 11) and 12% (95% CI, 10 to 15). Indirect benefits (in unvaccinated children) were seen in 2007-2008 but not in 2008-2009. Nationally, for the 2007-2009 period, there was an estimated reduction of 64,855 hospitalizations, saving approximately $278 million in treatment costs. CONCLUSIONS: Since the introduction of rotavirus vaccine, diarrhea-associated health care utilization and medical expenditures for U.S. children have decreased substantially. |
Development of multiplexed species specific polymerase chain reaction assays for identification of the Culex (Melanoconion) species (Diptera: Culicidae) of the southeastern United States based on rDNA.
Williams MR , Savage HM . J Med Entomol 2011 48 (5) 961-6 Adult female mosquitoes within the subgenus Culex (Melanoconion) Theobald (Diptera: Culicidae) are difficult to identify to species using external morphological features. We present two multiplexed polymerase chain reaction assays that quickly and accurately identify specimens from the southeastern United States based on sequence differences in the internal transcribed spacers of the ribosomal DNA gene array. One assay identifies all species that occur only in Florida, whereas the second assay identifies species that may occur in other southeastern states. These assays require small amounts of DNA, such as DNA from two sonicated legs, or an individual specimen. These assays also may be run as multiple singleplex reactions to determine the mosquito species composition of virus-positive mosquito pools. Reaction volumes may be as low as 10 mcl, which reduces assay cost. |
A naturally occurring human adenovirus type 7 variant with a 1743 bp deletion in the E3 cassette.
Marinheiro JC , Dos Santos TG , Siqueira-Silva J , Lu X , Carvalho D , da Camara AA , Arruda E , Arruda K , Erdman DD , Harsi CM . J Gen Virol 2011 92 2399-404 Human adenovirus type 7 (HAdV-7) is an important cause of acute respiratory disease (ARD). Different genomic variants of HAdV-7 have been described, designated 7a-7l. In a previous study to investigate risk factors for ARD and wheezing, nasopharyngeal samples were collected from 90 ill children seeking medical attention in Ribeirao Preto, Sao Paulo, Brazil. HAdVs were identified in 31 samples and were characterized by serum neutralization and genome restriction analysis. Eleven HAdVs were identified as being HAdV-7, five of which were classified as being of genome type 7p (Gomen). Six other HAdV-7 isolates gave new restriction profiles with all enzymes used and were classified as being a new genomic variant, 7m. These isolates were further characterized by sequencing. The hexon and fiber genes of the 7m variant were nearly identical to the prototype, 7p. However, nucleotide sequences from the E3 cassette revealed a 1743 bp deletion affecting the 16.1K, 19K, 20.1K and 20.5K ORFs. |
Utility of antimicrobial susceptibility testing in Trichomonas vaginalis-infected women with clinical treatment failure
Bosserman EA , Helms DJ , Mosure DJ , Secor WE , Workowski KA . Sex Transm Dis 2011 38 (10) 983-7 BACKGROUND: Antimicrobial resistance is one of the causes of treatment failure in women after standard nitroimidazole therapy for Trichomonas vaginalis infections. The Centers for Disease Control and Prevention provides drug susceptibility testing and guidance for treatment failures but the efficacy of the alternate recommendations has not been assessed. METHODS: T. vaginalis isolates from women who had failed at least 2 courses of standard therapy for trichomoniasis were submitted to the Centers for Disease Control and Prevention for susceptibility testing. Alternative treatment recommendations were provided based on in vitro drug susceptibility results and clinical outcomes were collected. RESULTS: Drug susceptibility results were available for 175 women tested between January 2002 and January 2008. In vitro, 115 of the 175 isolates demonstrated metronidazole resistance. For all isolates resistant to metronidazole, in vitro resistance to tinidazole was similar or lower. Clinical treatment outcomes were available for 72 women. Of the women receiving an alternative recommended nitroimidazole regimen, 30 (83%) of 36 were cured compared with 8 (57%) of 14 women who received a lower dose than recommended. Clinical and microbiologic success was attained in 59 (82%) of 72 women whose follow-up information was available, with some women requiring multiple treatment courses. CONCLUSIONS: Clinical and microbiologic cure rates were higher for women who were treated in accordance with the recommendation provided after in vitro testing compared with those who received a lower dose or a different drug. Susceptibility testing leading to tailored treatment may have a beneficial role for management of women with persistent trichomoniasis. |
Pubertal delay in male nonhuman primates (Macaca mulatta) treated with methylphenidate
Mattison DR , Plant TM , Lin HM , Chen HC , Chen JJ , Twaddle NC , Doerge D , Slikker W Jr , Patton RE , Hotchkiss CE , Callicott RJ , Schrader SM , Turner TW , Kesner JS , Vitiello B , Petibone DM , Morris SM . Proc Natl Acad Sci U S A 2011 108 (39) 16301-6 Juvenile male rhesus monkeys treated with methylphenidate hydrochloride (MPH) to evaluate genetic and behavioral toxicity were observed after 14 mo of treatment to have delayed pubertal progression with impaired testicular descent and reduced testicular volume. Further evaluation of animals dosed orally twice a day with (i) 0.5 mL/kg of vehicle (n = 10), (ii) 0.15 mg/kg of MPH increased to 2.5 mg/kg (low dose, n = 10), or (iii) 1.5 mg/kg of MPH increased to 12.5 mg/kg (high dose, n = 10) for a total of 40 mo revealed that testicular volume was significantly reduced (P < 0.05) at months 15 to 19 and month 27. Testicular descent was significantly delayed (P < 0.05) in the high-dose group. Significantly lower serum testosterone levels were detected in both the low- (P = 0.0017) and high-dose (P = 0.0011) animals through month 33 of treatment. Although serum inhibin B levels were increased overall in low-dose animals (P = 0.0328), differences between groups disappeared by the end of the study. Our findings indicate that MPH administration, beginning before puberty, and which produced clinically relevant blood levels of the drug, impaired pubertal testicular development until approximately 5 y of age. It was not possible to resolve whether MPH delayed the initiation of the onset of puberty or reduced the early tempo of the developmental process. Regardless, deficits in testicular volume and hormone secretion disappeared over the 40-mo observation period, suggesting that the impact of MPH on puberty is not permanent. |
Evaluation of the performance of the Abbott ARCHITECT HIV Ag/Ab Combo Assay
Chavez P , Wesolowski L , Patel P , Delaney K , Owen SM . J Clin Virol 2011 52 Suppl 1 S51-5 BACKGROUND: Worldwide, many countries test for HIV infection using combination assays that simultaneously detect p24 antigen and HIV antibodies. One such assay, the ARCHITECT((R)) HIV Ag/Ab Combo Assay (ARCHITECT), has recently been approved by the Food and Drug Administration (FDA) for use in the United States. OBJECTIVE: To evaluate the performance of ARCHITECT on well-characterized specimens from four CDC-funded studies. STUDY DESIGN: We evaluated 3386 HIV-infected, 7551 HIV-uninfected, and 58 acute HIV infection (AHI) specimens. HIV-infected specimens were repeatedly reactive by enzyme immunoassay (EIA) and Western blot (WB) or positive by nucleic acid amplification testing (NAAT). HIV-uninfected specimens were EIA- and NAAT-negative. AHI specimens were seronegative or indeterminate (using antibody-based EIAs, rapid tests or WB) and NAAT-positive. All specimens were de-identified and sent to Abbott Diagnostics for testing with ARCHITECT. ARCHITECT test results were compared to original study characterizations and were used to assess overall sensitivity and specificity and also sensitivity for AHI. ARCHITECT false-positive specimens with sufficient quantity were retested. RESULTS: Based on results from the initial ARCHITECT test, sensitivity was 99.94% (95% confidence interval [CI]: 99.79, 99.99) and specificity was 98.78% (95% CI: 98.51-99.01). Repeat testing resulted in corrected specificity of 99.50% (95% CI: 99.31, 99.64). Also, 48 AHI specimens (83%) were detected by this screening assay. CONCLUSION: The sensitivity and specificity of the ARCHITECT combination assay are very high and most AHIs were detected by the assay. Use of Ag/Ab combination assays may improve the number of AHIs identified relative to existing FDA-approved HIV-antibody only based serologic assays, particularly in high incidence populations. |
Global phospholipidomics analysis reveals selective pulmonary peroxidation profiles upon inhalation of single-walled carbon nanotubes
Tyurina YY , Kisin ER , Murray A , Tyurin VA , Kapralova VI , Sparvero LJ , Amoscato AA , Samhan-Arias AK , Swedin L , Lahesmaa R , Fadeel B , Shvedova AA , Kagan VE . ACS Nano 2011 5 (9) 7342-53 It is commonly believed that nanomaterials cause nonspecific oxidative damage. Our mass spectrometry-based oxidative lipidomics analysis of all major phospholipid classes revealed highly selective patterns of pulmonary peroxidation after inhalation exposure of mice to single-walled carbon nanotubes. No oxidized molecular species were found in the two most abundant phospholipid classes: phosphatidylcholine and phosphatidylethanolamine. Peroxidation products were identified in three relatively minor classes of anionic phospholipids, cardiolipin, phosphatidylserine, and phosphatidylinositol, whereby oxygenation of polyunsaturated fatty acid residues also showed unusual substrate specificity. This nonrandom peroxidation coincided with the accumulation of apoptotic cells in the lung. A similar selective phospholipid peroxidation profile was detected upon incubation of a mixture of total lung lipids with H(2)O(2)/cytochrome c known to catalyze cardiolipin and phosphatidylserine peroxidation in apoptotic cells. The characterized specific phospholipid peroxidation signaling pathways indicate new approaches to the development of mitochondria-targeted regulators of cardiolipin peroxidation to protect against deleterious effects of pro-apoptotic effects of single-walled carbon nanotubes in the lung. |
Comparison of alternative interpretive criteria for the HIV-1 Western blot and results of the Multispot HIV-1/HIV-2 Rapid Test for classifying HIV-1 and HIV-2 infections
Nasrullah M , Ethridge SF , Delaney KP , Wesolowski LG , Granade TC , Schwendemann J , Boromisa RD , Heffelfinger JD , Owen SM , Branson BM . J Clin Virol 2011 52 Suppl 1 S23-7 BACKGROUND: HIV-1 Western blot (WB) may be positive in specimens from persons with HIV-2 infection due to cross-reactive antibodies. HIV-1 and HIV-2 infections may be identified using assays designed to differentiate HIV-1 and HIV-2 antibody reactivity. OBJECTIVES: To evaluate the ability of the current CDC WB criteria, alternative more stringent HIV-1 WB criteria (2 env plus one gag or pol band) and the Multispot HIV-1/HIV-2 Rapid Test to accurately differentiate HIV-1 and HIV-2 infections. STUDY DESIGN: Two panels were used to determine the ability of each method to properly classify HIV-1 and HIV-2 infections: an HIV-2 panel (n=114) determined to be HIV-2 antibody-positive by both Multispot and by a validated HIV-2 WB, and 2135 HIV-1/HIV-2 immunoassay repeatedly reactive (IA-RR) specimens from the New York State Department of Health Laboratory (NYS). RESULTS: By CDC WB criteria, 53 (46.5%) HIV-2 panel specimens were HIV-1 WB positive, 60 (52.6%) were indeterminate, and 1 (0.9%) was negative; the alternative WB criteria re-classified 75.5% of the positives as indeterminate. Among 2135 NYS IA-RR specimens, the alternative WB criteria increased the proportion of indeterminates by 0.8%. Only 6 (0.3%) of the NYS specimens were determined to be HIV-2 infections; all 6 were classified either as HIV-1 positive or indeterminate by both WB criteria, but were classified as HIV-2 (n=4) or HIV-1/2 undifferentiated (n=2) by Multispot. CONCLUSIONS: The alternative WB criteria classified most of the HIV-2 specimens that were HIV-1 positive by CDC criteria as indeterminate, but also slightly increased the proportion of HIV-1 specimens classified as indeterminate. The WB indeterminate specimens would require further testing or follow-up to resolve the infection status, whereas Multispot directly distinguished HIV-1 from HIV-2. |
Silicosis mortality with respiratory tuberculosis in the United States, 1968-2006
Nasrullah M , Mazurek JM , Wood JM , Bang KM , Kreiss K . Am J Epidemiol 2011 174 (7) 839-48 The presence of tuberculosis (TB) in patients with silicosis increases mortality risk. To characterize silicosis-respiratory TB comortality in the United States, the authors used 1968-2006 National Center for Health Statistics multiple cause-of-death data for decedents aged ≥25 years. The authors calculated proportionate mortality ratios (PMRs) using available information on decedents' industries and occupations reported from 26 states from 1985 through 1999. Among 16,648 silicosis deaths, 2,278 (13.7%) had respiratory TB listed on the death certificate. Of silicosis-respiratory TB deaths, 1,666 decedents (73.1%) were aged ≥65 years, 2,255 (99.0%) were male, and 1,893 (83.1%) were white. Silicosis-respiratory TB deaths declined 99.5% during the study period (P < 0.001 for time-related trend), from 239.8 per year during 1968-1972 to 1.2 per year during 2002-2006, with no reported deaths in 2006. Silicosis-respiratory TB deaths reported from Pennsylvania (n = 525; 1.29 per million population), Ohio (n = 258; 0.81 per million), and West Virginia (n = 146; 2.35 per million) accounted for 40.8% of all such deaths in the United States. The highest PMR for silicosis-respiratory TB death was associated with the "miscellaneous nonmetallic mineral and stone products" industry (PMR = 73.7, 95% confidence interval: 33.8, 139.8). In the United States, 2006 marked the first year since 1968 with no silicosis-respiratory TB deaths. The substantial decline in silicosis-respiratory TB comortality probably reflects prevention and control measures for both diseases. |
Performance evaluation of 26 combinations of chemical protective clothing materials and chemicals after repeated exposures and decontaminations
Gao P , Tomasovic B , Stein L . J Occup Environ Hyg 2011 8 (11) 625-35 Effective decontamination of chemical protective clothing (CPC) is essential for reducing occupational skin diseases and disorders during a reuse scenario. To protect the workforce, the efficacy of decontamination methods and the reusability of CPC need to be evaluated. In this study, performance of 14 CPC materials against 12 liquid chemicals was evaluated based on standardized breakthrough time (BT) and steady-state permeation rate (SSPR). Thermal and water-detergent decontamination methods were used. Exposure/decontamination was repeated up to 11 cycles, or until the material failed, so that further testing became impossible. Changes in BT and SSPRs were determined for each material and chemical combination. There were 20 and 13 combinations that were able to complete 11 cycles with thermal and detergent methods, respectively. By comparing the beginning and ending cycles, mean BT increased 9% with the thermal method but slightly decreased (3.3%) with the detergent method, while mean SSPR decreased 2% with the thermal method, but slightly increased (1.4%) with the detergent method. Less than half of the changes were found statistically different (p < 0.05). Generally, the thermal method had higher decontamination efficacy than the detergent method. |
Beryllium: a paradigm for occupational lung disease and its prevention
Kreiss K . Occup Environ Med 2011 68 (11) 787-8 In this issue of the journal, Van Dyke and colleagues have shown that the supra-typic genetic marker, HLA-DPB1(E69), has an additive and independent contribution with beryllium exposure to cell-mediated beryllium sensitisation and chronic beryllium disease in a cohort at a US nuclear weapons plant.1 This finding of statistical independence between required beryllium exposure and genetic characteristics is quantitatively consistent with an earlier finding in a small beryllia ceramics operation,2 and is extended by a concurrent publication in a second, larger nuclear weapons plant population.3 In the latter case–control study, Van Dyke et al showed that the subset of rare HLA-DPB1(E69) alleles (non-*02), most with greater electronegativity in the antigen-binding groove,4 conferred much higher risk of sensitisation and disease than the more common *02 HLA-DPB1(E69) genotypes: Both sensitisation and chronic beryllium disease risks were equally associated with genotype, but these two health outcomes differed with respect to exposure risk. Cumulative and average lifetime beryllium exposures were associated with chronic beryllium disease but not with beryllium sensitisation. Other recent studies of newly exposed beryllium workers demonstrate that sensitisation often occurs within months of employment, presumably before a beryllium lung burden sufficient for chronic beryllium disease is attained.5–7 Although the Van Dyke paper in this issue did not have sufficient numbers to analyse beryllium sensitisation and beryllium disease cases separately, it showed compatible results, with the beryllium-sensitised cases having much lower indices of beryllium exposure compared with the chronic beryllium disease cases. The inference of these two Van Dyke papers is that early and repeated screening for beryllium sensitisation during employment, followed by curtailing further beryllium exposure among those sensitised, can lessen the risk of chronic beryllium disease. |
Cause-specific mortality among a cohort of U.S. flight attendants
Pinkerton LE , Waters MA , Hein MJ , Zivkovich Z , Schubauer-Berigan MK , Grajewski B . Am J Ind Med 2011 55 (1) 25-36 BACKGROUND: We evaluated mortality among 11,311 former U.S. flight attendants. The primary a priori outcomes of interest were breast cancer and melanoma. METHODS: Vital status was ascertained through 2007, and life table analyses was conducted. Cumulative exposure to cosmic radiation and circadian rhythm disruption were estimated from work history data and historical published flight schedules. RESULTS: All-cause mortality was less than expected among women but was elevated among men, primarily due to elevated HIV-related disease mortality. Mortality from breast cancer among women and melanoma was neither significantly elevated nor related to metrics of exposure. Mortality was elevated for non-Hodgkin's lymphoma among men; for alcoholism, drowning, and intentional self-harm among women; and for railway, water, and air transportation accidents. CONCLUSIONS: We found no evidence of increased breast cancer or melanoma mortality. Limitations include reliance on mortality data and limited power resulting from few melanoma deaths and relatively short employment durations. Am. J. Ind. Med. (c) 2011 Wiley Periodicals, Inc. |
Adherence to treatment with artemether-lumefantrine for uncomplicated malaria in rural Malawi
Mace KE , Mwandama D , Jafali J , Luka M , Filler SJ , Sande J , Ali D , Kachur SP , Mathanga DP , Skarbinski J . Clin Infect Dis 2011 53 (8) 772-9 BACKGROUND: In 2007, Malawi replaced the first-line medication for uncomplicated malaria, sulfadoxine-pyrimethamine-a single-dose regimen-with artemether-lumefantrine (AL)-a 6-dose, 3-day regimen. Because of concerns about the complex dosing schedule, we assessed patient adherence to AL 2 years after routine implementation. METHODS: Adults and children with uncomplicated malaria were recruited at 3 health centers. We conducted both pill counts and in-home interviews on medication consumption 72 hours after patients received AL. Complete adherence was defined as correctly taking all 6 AL doses, as assessed by pill count and dose recall. We used logistic regression to identify factors associated with complete adherence. RESULTS: Of 386 patients, 65% were completely adherent. Patients were significantly more likely to be completely adherent if they received their first dose of AL as directly observed therapy at the health center (odds ratio [OR], 2.4; P < .01), received instructions using the medication package as a visual aid (OR, 2.5; P = .02), and preferred AL over other antimalarials (OR, 2.7; P < .001). In contrast, children <5 years of age were significantly less likely to be adherent (OR, 0.5; P = .05). CONCLUSION: Adherence to AL treatment for uncomplicated malaria was moderate, and children, who are the most likely to die of malaria, were less adherent than adults. Efforts to improve adherence should be focused on this vulnerable group. Interventions including the introduction of child-friendly antimalarial formulations, direct observation of the first dose, use of the AL package as a visual aid for instructions, and enhancing patient preference for AL could potentially increase AL adherence and overall effectiveness. |
Relationship of the job tenure of nursing home top management to the prevalence of pressure ulcers, pain, and physical restraint use
Decker FH , Castle NG . J Appl Gerontol 2011 30 (5) 539-561 The association of job tenure among nursing home administrators (NHAs) and directors of nursing (DONs) with the prevalence of pressure ulcers, pain, and physical restraint use was examined. Data sources included the 2004 National Nursing Home Survey and quality measures from the Centers for Medicare and Medicaid Services. Regression models examined NHA tenure (n = 787) and DON tenure (n = 703). Control variables included prior prevalence of the respective outcome, NHA/DON education, and facility characteristics among others. Increasing NHA and DON tenure were both associated with decreases in the prevalence of pressure ulcers and pain but not restraint use. DON tenure had more impact on outcomes in earlier stages of tenure than NHA tenure. Effects of NHA tenure were in later stages of tenure. Increasing tenure among NHAs and DONs may influence better resident outcomes within their facility. Southern Gerontological Society 2011. |
Exploring the context: contemporary public health
Monroe JA . Am J Prev Med 2011 41 S155-9 Contemporary public health is faced with numerous challenges including health disparities, a rise in chronic conditions, non-intentional and intentional injuries, premature birth, disabilities, and unsafe environments. The economic recession has led to cuts in state public health budgets, and medical expenditures have risen exponentially. Health departments are more effective when they have strong clinical partners, and physicians need the support of public health services. Socioeconomic conditions and public policy have larger impacts on health threats than clinical interventions and individual counseling. Integrating public health education across the spectrum of medical education is a strategy for achieving greater collaboration between medicine and public health. The imperative for this collaboration is even greater with the passage of the Affordable Care Act and the advancement of information technology. Our nation needs the physician workforce to understand the determinants of health and the policies and environmental changes that will alter the context to make the healthy choice the default choice. We need more physicians playing an active role in policy advocacy and in leadership roles in their communities, states, and nationally. And we need more physicians to understand prevention and population health. | My experience as a family physician practicing in Appalachia, directing a residency program, serving as a state health official, and now in a leadership role at the CDC, has afforded me the opportunity to experience both worlds of medicine and public health. |
Integration of public health into medical education: an introduction to the supplement
Maeshiro R , Koo D , Keck CW . Am J Prev Med 2011 41 S145-8 Twelve years ago, the Association of American Medical Colleges (AAMC) and the CDC established a formal relationship through a cooperative agreement “to strengthen collaborations between academic medicine and public health.” A consistent focus of cooperative agreement activities has been improving the public health, population health, and prevention aspects of medical education. Historically, these subjects were often omitted from the training of physicians. Contemporary medical educators continue to struggle to secure the time and resources to effectively integrate this content into the curricula, despite the urgent need for physicians with a better appreciation for these issues to help address complex public health challenges that include rising chronic disease burdens, persistent health disparities, and healthcare financing that encourages treatment over prevention. | The cooperative agreement has supported the Regional Medicine–Public Health Education Centers (RMPHECs)1 initiative, an effort to integrate public/population and prevention education into medical school and residency curricula through partnerships with local and state public health agencies and other public health partners, as well as reports focusing on public health topics that have not traditionally been included in medical school curricula.2, 3 To help disseminate the lessons learned by the RMPHEC grantees and to identify other promising efforts, the AAMC and the CDC convened the “Patients and Populations: Public Health in Medical Education” conference in Cleveland, Ohio, on September 14 and 15, 2010. More than 190 medical and public health educators and public health practitioners from the U.S. and Canada gathered to share innovative curricular models and strategies to integrate public health into the continuum of medical education. The papers in this supplement to the American Journal of Preventive Medicine4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 are based on many of the presentations and discussions that occurred during the conference. |
Propensity score methods for creating covariate balance in observational studies
Pattanayak CW , Rubin DB , Zell ER . Rev Esp Cardiol 2011 64 (10) 897-903 Randomization of treatment assignment in experiments generates treatment groups with approximately balanced baseline covariates. However, in observational studies, where treatment assignment is not random, patients in the active treatment and control groups often differ on crucial covariates that are related to outcomes. These covariate imbalances can lead to biased treatment effect estimates. The propensity score is the probability that a patient with particular baseline characteristics is assigned to active treatment rather than control. Though propensity scores are unknown in observational studies, by matching or subclassifying patients on estimated propensity scores, we can design observational studies that parallel randomized experiments, with approximate balance on observed covariates. Observational study designs based on estimated propensity scores can generate approximately unbiased treatment effect estimates. Critically, propensity score designs should be created without access to outcomes, mirroring the separation of study design and outcome analysis in randomized experiments. This paper describes the potential outcomes framework for causal inference and best practices for designing observational studies with propensity scores. We discuss the use of propensity scores in two studies assessing the effectiveness and risks of antifibrinolytic drugs during cardiac surgery. |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
- Communicable Diseases
- Disease Reservoirs and Vectors
- Environmental Health
- Epidemiology and Surveillance
- Healthcare Associated Infections
- Immunity and Immunization
- Laboratory Sciences
- Occupational Safety and Health
- Parasitic Diseases
- Public Health Leadership and Management
- Public Health, General
- Statistics as Topic
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