Last data update: Sep 16, 2024. (Total: 47680 publications since 2009)
Records 1-11 (of 11 Records) |
Query Trace: Metzger ME [original query] |
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A forty-year review of Rocky Mountain spotted fever cases in California shows clinical and epidemiologic changes
Kjemtrup AM , Padgett K , Paddock CD , Messenger S , Hacker JK , Feiszli T , Melgar M , Metzger ME , Hu R , Kramer VL . PLoS Negl Trop Dis 2022 16 (9) e0010738 Rocky Mountain spotted fever (RMSF) is a life-threatening tick-borne disease documented in North, Central, and South America. In California, RMSF is rare; nonetheless, recent fatal cases highlight ecological cycles of the two genera of ticks, Dermacentor and Rhipicephalus, known to transmit the disease. These ticks occur in completely different habitats (sylvatic and peridomestic, respectively) resulting in different exposure risks for humans. This study summarizes the demographic, exposure, and clinical aspects associated with the last 40 years of reported RMSF cases to the California Department of Public Health (CDPH). Seventy-eight RMSF cases with onsets from 1980 to 2019 were reviewed. The incidence of RMSF has risen in the last 20 years from 0.04 cases per million to 0.07 cases per million (a two-fold increase in reports), though the percentage of cases that were confirmed dropped significantly from 72% to 25% of all reported cases. Notably, Hispanic/Latino populations saw the greatest rise in incidence. Cases of RMSF in California result from autochthonous and out-of-state exposures. During the last 20 years, more cases reported exposure in Southern California or Mexico than in the previous 20 years. The driver of these epidemiologic changes is likely the establishment and expansion of Rhipicephalus sanguineus sensu lato ticks in Southern California and on-going outbreaks of RMSF in northern Mexico. Analysis of available electronically reported clinical data from 2011 to 2019 showed that 57% of reported cases presented with serious illness requiring hospitalization with a 7% mortality. The difficulty in recognizing RMSF is due to a non-specific clinical presentation; however, querying patients on the potential of tick exposure in both sylvatic and peridomestic environments may facilitate appropriate testing and treatment. |
Impact of COVID-19 on Cervical Cancer Screening Rates Among Women Aged 21-65 Years in a Large Integrated Health Care System - Southern California, January 1-September 30, 2019, and January 1-September 30, 2020.
Miller MJ , Xu L , Qin J , Hahn EE , Ngo-Metzger Q , Mittman B , Tewari D , Hodeib M , Wride P , Saraiya M , Chao CR . MMWR Morb Mortal Wkly Rep 2021 70 (4) 109-113 On March 19, 2020, the governor of California issued a statewide stay-at-home order to contain the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19).* The order reduced accessibility to and patient attendance at outpatient medical visits,(†) including preventive services such as cervical cancer screening. In-person clinic visits increased when California reopened essential businesses on June 12, 2020.(§) Electronic medical records of approximately 1.5 million women served by Kaiser Permanente Southern California (KPSC), a large integrated health care system, were examined to assess cervical cancer screening rates before, during, and after the stay-at-home order. KPSC policy is to screen women aged 21-29 years every 3 years with cervical cytology alone (Papanicolaou [Pap] test); those aged 30-65 years were screened every 5 years with human papillomavirus (HPV) testing and cytology (cotesting) through July 15, 2020, and after July 15, 2020, with HPV testing alone, consistent with the latest recommendations from U.S. Preventive Services Task Force.(¶) Compared with the 2019 baseline, cervical cancer screening rates decreased substantially during the stay-at-home order. Among women aged 21-29 years, cervical cytology screening rates per 100 person-months declined 78%. Among women aged 30-65 years, HPV test screening rates per 100 person-months decreased 82%. After the stay-at-home order was lifted, screening rates returned to near baseline, which might have been aided by aspects of KPSC's integrated, organized screening program (e.g., reminder systems and tracking persons lost to follow-up). As the pandemic continues, groups at higher risk for developing cervical cancers and precancers should be evaluated first. Ensuring that women receive preventive services, including cancer screening and appropriate follow-up in a safe and timely manner, remains important. |
Characteristics of diagnosed concussions in children aged 0 to 4 years presenting to a large pediatric healthcare network
Podolak OE , Chaudhary S , Haarbauer-Krupa J , Metzger KB , Curry AE , Kessler RS , Pfeiffer MR , Breiding MJ , Master CL , Arbogast KB . Pediatr Emerg Care 2020 37 (12) e1652-e1657 OBJECTIVE: The aim of the study was to comprehensively describe the natural history of concussion in early childhood between 0 and 4 years. METHODS: Retrospective cohort study of 329 patients aged 0 to 4 years, with an International Classification of Diseases, Ninth Revision, concussion diagnosis in the Children's Hospital of Philadelphia healthcare network from October 1, 2013, to September 30, 2015. Clinical data were abstracted from the Children's Hospital of Philadelphia electronic health record, which captured all clinical care visits and injury characteristics. RESULTS: Nearly 9 (86.6%) of 10 patients sought care in the emergency department or urgent care setting, most commonly on the day of injury (56.2%) and as a result of a fall (64.4%). More than two-thirds (64.4%) of patients or their parent/caregiver reported somatic symptoms (ie, vomiting or headache), whereas close to half (49.2%) reported sleep issues. One of 5 patients identified emotional symptoms (21.9%) or visio-vestibular dysfunction (20.4%). Many patients also experienced symptoms not included in standard assessment tools including personality changes (34.0%) and change in appetite (12.8%). CONCLUSIONS: These results provide insight into the clinical characteristics of concussion in early childhood up to 4 years of age. Because assessment in this group relies heavily on parent/caregiver symptom reporting, rather than patient self-report, these results will aid clinicians with the challenge of diagnosing concussions in this population. These findings highlight the need to develop additional tools to adequately and systematically assess common signs and symptoms of concussion in early childhood that may not be included in standard assessment scales routinely used in older adolescents and adults. |
Characteristics of concussion in elementary school-aged children: Implications for clinical management
Master CL , Curry AE , Pfeiffer MR , Metzger KB , Kessler RS , Haarbauer-Krupa J , DePadilla L , Greenspan A , Breiding MJ , Arbogast KB . J Pediatr 2020 223 128-135 OBJECTIVE: To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes. STUDY DESIGN: A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients. RESULTS: Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations. CONCLUSIONS: Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion. |
Risk of repeat concussion among patients diagnosed at a pediatric care network
Curry AE , Arbogast KB , Metzger KB , Kessler RS , Breiding MJ , Haarbauer-Krupa J , DePadilla L , Greenspan A , Master CL . J Pediatr 2019 210 13-19 e2 OBJECTIVE: To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury. STUDY DESIGN: For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion. RESULTS: Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]). CONCLUSIONS: We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts. |
Variations in mechanisms of injury for children with concussion
Haarbauer-Krupa J , Arbogast KB , Metzger KB , Greenspan AI , Kessler R , Curry AE , Bell JM , DePadilla L , Pfeiffer MR , Zonfrillo MR , Master CL . J Pediatr 2018 197 241-248 e1 Objectives: To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system. Study design: All patients, age 0-17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Children's Hospital of Philadelphia's electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion-related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities. Results: Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0-4 were sports related, compared with greater proportions for older children (67% for age 5-11, 77% for age 12-14, and 73% for age 15-17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%). Conclusions: Sports-related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one-third of concussions were from non–sports-related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed. |
Minimizing mosquito larval habitat within roadside stormwater treatment best management practices in southern California through incremental improvements to structure
Metzger ME , Harbison JE , Burns JE , Kramer VL , Newton JH , Drews J , Hu R . Ecol Eng 2018 110 185-191 A five-year study was conducted in Orange County, California to document the presence of standing water and the presence or absence of larval mosquitoes within 23 stormwater treatment Best Management Practices (BMPs) installed along State Route 73 by the California Department of Transportation. Findings were used to guide incremental improvements to BMP design and function with the aim of reducing the occurrence of standing water that persisted more than 96 h after precipitation. During the first year of monitoring, a number of structural and non-structural factors were identified as causes for standing water within BMPs suitable for mosquitoes. Uneven grades, inlet design and construction, and novel structural features were most frequently responsible for standing water, often exacerbated by sediment and debris accumulations and periodic or perennial non-stormwater flows. Subsequent modifications to BMPs eliminated or reduced the size of persistent standing water pools. The study demonstrated that mosquito larval habitat can be mitigated in BMPs designed to remain dry between precipitation events by collecting field data that identifies where post-construction structural and managerial changes are needed to eliminate or reduce unintended sources of standing water. |
Improving primary care provider practices in youth concussion management
Arbogast KB , Curry AE , Metzger KB , Kessler RS , Bell JM , Haarbauer-Krupa J , Zonfrillo MR , Breiding MJ , Master CL . Clin Pediatr (Phila) 2017 56 (9) 9922817709555 Primary care providers are increasingly providing youth concussion care but report insufficient time and training, limiting adoption of best practices. We implemented a primary care-based intervention including an electronic health record-based clinical decision support tool ("SmartSet") and in-person training. We evaluated consequent improvement in 2 key concussion management practices: (1) performance of a vestibular oculomotor examination and (2) discussion of return-to-learn/return-to-play (RTL/RTP) guidelines. Data were included from 7284 primary care patients aged 0 to 17 years with initial concussion visits between July 2010 and June 2014. We compared proportions of visits pre- and post-intervention in which the examination was performed or RTL/RTP guidelines provided. Examinations and RTL/RTP were documented for 1.8% and 19.0% of visits pre-intervention, respectively, compared with 71.1% and 72.9% post-intervention. A total of 95% of post-intervention examinations were documented within the SmartSet. An electronic clinical decision support tool, plus in-person training, may be key to changing primary care provider behavior around concussion care. |
A multisite study of the prevalence of HIV with rapid testing in mental health settings
Blank MB , Himelhoch SS , Balaji AB , Metzger DS , Dixon LB , Rose CE , Oraka E , Davis-Vogel A , Thompson WW , Heffelfinger JD . Am J Public Health 2014 104 (12) 2377-84 OBJECTIVES: We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. METHODS: We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). RESULTS: Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. CONCLUSIONS: HIV prevalence for individuals receiving mental health services was more than 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care. |
Risk for transmission of Naegleria fowleri from solid organ transplantation
Roy SL , Metzger R , Chen JG , Laham FR , Martin M , Kipper SW , Smith LE , Lyon GM 3rd , Haffner J , Ross JE , Rye AK , Johnson W , Bodager D , Friedman M , Walsh DJ , Collins C , Inman B , Davis BJ , Robinson T , Paddock C , Zaki SR , Kuehnert M , DaSilva A , Qvarnstrom Y , Sriram R , Visvesvara GS . Am J Transplant 2013 14 (1) 163-71 Primary amebic meningoencephalitis (PAM) caused by the free-living ameba (FLA) Naegleria fowleri is a rare but rapidly fatal disease of the central nervous system (CNS) affecting predominantly young, previously healthy persons. No effective chemotherapeutic prophylaxis or treatment has been identified. Recently, three transplant-associated clusters of encephalitis caused by another FLA, Balamuthia mandrillaris, have occurred, prompting questions regarding the suitability of extra-CNS solid organ transplantation from donors with PAM. During 1995-2012, 21 transplant recipients of solid organs donated by five patients with fatal cases of PAM were reported in the United States. None of the recipients developed PAM, and several recipients tested negative for N. fowleri by serology. However, historical PAM case reports and animal experiments with N. fowleri, combined with new postmortem findings from four patients with PAM, suggest that extra-CNS dissemination of N. fowleri can occur and might pose a risk for disease transmission via transplantation. The risks of transplantation with an organ possibly harboring N. fowleri should be carefully weighed for each individual recipient against the potentially greater risk of delaying transplantation while waiting for another suitable organ. In this article, we present a case series and review existing data to inform such risk assessments. |
Antipsychotic and benzodiazepine use among nursing home residents: findings from the 2004 National Nursing Home Survey
Stevenson DG , Decker SL , Dwyer LL , Huskamp HA , Grabowski DC , Metzger ED , Mitchell SL . Am J Geriatr Psychiatry 2010 18 (12) 1078-92 OBJECTIVES: To document the extent and appropriateness of use of antipsychotics and benzodiazepines among nursing home residents using a nationally representative survey. METHODS: Cross-sectional analysis of the 2004 National Nursing Home Survey. Bivariate and multivariate analyses examined relationships between resident and facility characteristics and antipsychotic and benzodiazepine use by appropriateness classification among residents aged 60 years and older (N = 12,090). Resident diagnoses and information about behavioral problems were used to categorize antipsychotic and benzodiazepine use as appropriate, potentially appropriate, or having no appropriate indication. RESULTS: More than one quarter (26%) of nursing home residents used an antipsychotic medication, 40% of whom had no appropriate indication for such use. Among the 13% of residents who took benzodiazepines, 42% had no appropriate indication. In adjusted analyses, the odds of residents taking an antipsychotic without an appropriate indication were highest for residents with diagnoses of depression (odds ratio [OR] = 1.31; 95% confidence interval [CI]: 1.12-1.53), dementia (OR = 1.82; 95% CI: 1.52-2.18), and with behavioral symptoms (OR = 1.97, 95% CI: 1.56-2.50). The odds of potentially inappropriate antipsychotic use increased as the percentage of Medicaid residents in a facility increased (OR = 1.08, 95% CI: 1.02-1.15) and decreased as the percentage of Medicare residents increased (OR = 0.46, 95% CI: 0.25-0.83). The odds of taking a benzodiazepine without an appropriate indication were highest among residents who were female (OR = 1.44; 95% CI: 1.18-1.75), white (OR = 1.95; 95% CI: 1.47-2.60), and had behavioral symptoms (OR = 1.69; 95% CI: 1.41-2.01). CONCLUSION: Antipsychotics and benzodiazepines seem to be commonly prescribed to residents lacking an appropriate indication for their use. |
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