Reactions following Pfizer-BioNTech COVID-19 mRNA vaccination and related healthcare encounters among 7,077 children aged 5-11 years within an integrated healthcare system

BACKGROUND

Studies combining data from digital surveys and electronic health records (EHR) can be used to conduct comprehensive assessments on COVID-19 vaccine safety.

METHODS

We conducted an observational study using data from a digital survey and EHR of children aged 5-11 years vaccinated with Pfizer-BioNTech COVID-19 mRNA vaccine across Kaiser Permanente Southern California during November 4, 2021-February 28, 2022. Parents/guardians who enrolled their children were sent a 14-day survey on reactions. Survey results were combined with EHR, and medical encounters were described for children whose parents or guardians indicated seeking medical care for vaccine-related symptoms. This study describes self-reported reactions (local and systemic) and additional symptoms (chest pain, tachycardia, and pre-syncope).

RESULTS

The study recruited 7,077 participants aged 5-11 years who received the Pfizer-BioNTech COVID-19 mRNA vaccine. Of 6,247 participants with survey responses after dose 1, 2,176 (35 %) reported at least one systemic reaction, and 1,076 (32 %) of 3,401 respondents following dose 2 reported at least one systemic reaction. Local reactions were reported less frequently following dose 2 (1,113, 33 %) than dose 1 (3,140, 50 %). The most frequently reported reactions after dose 1 were pain at the injection site (48 %), fatigue (20 %), headache (12 %), myalgia (9 %) and fever (5 %). The most frequently reported symptoms after dose 2 were also pain at the injection site (30 %), fatigue (19 %), headache (13 %), myalgia (10 %) and fever (9 %). Post-vaccination reactions occurred most frequently-one day following vaccination. Chest pain or tachycardia were reported infrequently (1 %). EHR demonstrated that parents rarely sought care for post-vaccination symptoms, and among those seeking care, the most common symptoms documented in EHR were fever and nausea, comprising <0.5 % of children. No encounters were related to myocarditis.

CONCLUSION

While post-vaccination reactions to the Pfizer-BioNTech COVID-19 mRNA vaccine were common in children aged 5-11 years, our data showed that in most cases they were transient and did not require medical care.

Risk for Shoulder Conditions After Vaccination: A Population-Based Study Using Real-World Data

BACKGROUND

Although shoulder conditions have been reported as an adverse event after intramuscular vaccination in the deltoid muscle, epidemiologic data on shoulder conditions after vaccination are limited.

OBJECTIVE

To estimate the risk for shoulder conditions after vaccination and assess possible risk factors.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Southern California, a large integrated health care organization.

PARTICIPANTS

Kaiser Permanente Southern California members aged 3 years or older who had an intramuscular vaccination administered in the deltoid muscle between 1 April 2016 and 31 December 2017.

MEASUREMENTS

A natural language processing (NLP) algorithm was used to identify potential shoulder conditions among vaccinated persons with shoulder disorder diagnosis codes. All NLP-identified cases were manually chart confirmed on the basis of our case definition. The characteristics of vaccinated persons with and without shoulder conditions were compared.

RESULTS

Among 3 758 764 administered vaccinations, 371 cases of shoulder condition were identified, with an estimated incidence of 0.99 (95% CI, 0.89 to 1.09) per 10 000 vaccinations. The incidence was 1.22 (CI, 1.10 to 1.35) for the adult (aged ≥18 years) and 0.05 (CI, 0.02 to 0.14) for the pediatric (aged 3 to 17 years) vaccinated populations. In the adult vaccinated population, advanced age, female sex, an increased number of outpatient visits in the 6 months before vaccination, lower Charlson Comorbidity Index, and pneumococcal conjugate vaccine were associated with a higher risk for shoulder conditions. Among influenza vaccines, quadrivalent vaccines were associated with an increased risk for shoulder conditions. Simultaneous administration of vaccines was associated with a higher risk for shoulder conditions among elderly persons.

LIMITATION

Generalizability to other health care settings, use of administrative data, and residual confounding.

CONCLUSION

These population-based data suggest a small absolute risk for shoulder conditions after vaccination. Given the high burden of shoulder conditions, clinicians should pay attention to any factors that may further increase risks.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Association Between 2-Dose vs 3-Dose Hepatitis B Vaccine and Acute Myocardial Infarction

IMPORTANCE

The 2-dose hepatitis B vaccine with a cytosine phosphoguanine adjuvant (HepB-CpG vaccine; Heplisav-B) generated higher seroprotection in prelicensure trials than did a 3-dose hepatitis B vaccine with an aluminum hydroxide adjuvant (HepB-alum vaccine; Engerix-B). However, in 1 trial, a higher number of acute myocardial infarction (MI) events were observed among those who received the HepB-CpG vaccine than among those who received the HepB-alum vaccine, an outcome requiring further study.

OBJECTIVE

To compare the rate of acute MI between recipients of HepB-CpG vaccine and HepB-alum vaccine.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort noninferiority study was conducted at Kaiser Permanente Southern California (KPSC), an integrated health care system with 15 medical centers and approximately 4.7 million members. The study included 69 625 adults not undergoing dialysis who received at least 1 dose of a hepatitis B vaccine in either family medicine or internal medicine departments at KPSC from August 7, 2018, to October 31, 2019 (November 30, 2020, final follow-up).

EXPOSURES

Receipt of HepB-CpG vaccine vs HepB-alum vaccine. The first dose during the study period was the index dose.

MAIN OUTCOMES AND MEASURES

Individuals were followed up for 13 months after the index dose for occurrence of type 1 acute MI. Potential events were identified using diagnosis codes and adjudicated by cardiologists. The adjusted hazard ratio (HR) of acute MI was estimated comparing recipients of HepB-CpG vaccine with recipients of HepB-alum vaccine, with inverse probability of treatment weighting (IPTW) to adjust for demographic and clinical characteristics. The upper limit of the 1-sided 97.5% CI was compared with a noninferiority margin of 2.

RESULTS

Of the 31 183 recipients of HepB-CpG vaccine (median age, 49 years; IQR, 38-56 years), 51.2% (n = 15 965) were men, and 52.7% (n = 16 423) were Hispanic. Of the 38 442 recipients of HepB-alum (median age, 49 years; IQR, 39-56 years), 50.8% (19 533) were men, and 47.1% (n = 18 125) were Hispanic. Characteristics were well-balanced between vaccine groups after IPTW. Fifty-two type 1 acute MI events were confirmed among recipients of HepB-CpG vaccine for a rate of 1.67 per 1000-person-years, and 71 type 1 acute MI events were confirmed among recipients of HepB-alum vaccine for a rate of 1.86 per 1000 person-years (absolute rate difference, -0.19 [95% CI, -0.82 to 0.44]; adjusted HR, 0.92 [1-sided 97.5% CI, ∞ to 1.32], which was below the noninferiority margin; P < .001 for noninferiority).

CONCLUSIONS AND RELEVANCE

In this cohort study, receipt of HepB-CpG vaccine compared with HepB-alum vaccine did not meet the statistical criterion for increased risk of acute myocardial infarction.

Variation in SARS-CoV-2 molecular test sensitivity by specimen types in a large sample of emergency department patients

BACKGROUND

Provider-collected nasopharyngeal specimens for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) molecular testing are the standard of care in many clinical settings, but patient-collected saliva and anterior nares specimens are less invasive and more flexible alternatives. Prior studies comparing specimen types for SARS-CoV-2 molecular testing have been limited by small sample sizes and low pretest probability. We conducted a large observational study among symptomatic adults at 7 emergency departments of Kaiser Permanente Southern California to examine sensitivity of SARS-CoV-2 molecular tests by specimen type and patient characteristics.

METHODS

Provider-collected nasopharyngeal/oropharyngeal (NP/OP) specimens and patient-collected saliva and anterior nares specimens were collected at the same visit and analyzed with the Roche cobas® SARS-CoV-2 assay. Patients were considered truly positive for SARS-CoV-2 if any of the three specimens was positive and negative if all three specimens were negative. Factors associated with discordant and missed positive results were examined with multivariable logistic regression.

RESULTS

Of 2112 patients, 350 (16.6%) were positive for SARS-CoV-2. Sensitivity of NP/OP was 93.7% (95% confidence interval [CI] 90.6%-96.0%), sensitivity of saliva was 87.7% (83.8%-91.0%), and sensitivity of anterior nares was 85.4% (81.3%-89.0%). Patients ages 18-39 years versus ≥40 years were more likely to have discordant results [adjusted odds ratio (aOR) 1.97 (1.12-3.45)], as were patients with <4 symptoms versus ≥4 [aOR 2.43 (1.39-4.25)]. Cycle threshold values were higher for saliva and anterior nares than NP/OP specimens, as well as for specimens in discordant versus concordant sets and patients with fewer symptoms.

CONCLUSION

This study provides robust evidence that patient-collected saliva and anterior nares are sensitive for SARS-CoV-2 molecular testing in emergency department settings, particularly among adults ages ≥40 years and those with multiple symptoms. Higher sensitivity of provider-collected NP/OP specimens must be weighed against the benefits of patient-collected specimens in tailored strategies for SARS-CoV-2 testing.

Identifying Cases of Shoulder Injury Related to Vaccine Administration (SIRVA) in the United States: Development and Validation of a Natural Language Processing Method (Preprint)

Background

Shoulder injury related to vaccine administration (SIRVA) accounts for more than half of all claims received by the National Vaccine Injury Compensation Program. However, due to the difficulty of finding SIRVA cases in large health care databases, population-based studies are scarce.

Objective

The goal of the research was to develop a natural language processing (NLP) method to identify SIRVA cases from clinical notes.

Methods

We conducted the study among members of a large integrated health care organization who were vaccinated between April 1, 2016, and December 31, 2017, and had subsequent diagnosis codes indicative of shoulder injury. Based on a training data set with a chart review reference standard of 164 cases, we developed an NLP algorithm to extract shoulder disorder information, including prior vaccination, anatomic location, temporality and causality. The algorithm identified 3 groups of positive SIRVA cases (definite, probable, and possible) based on the strength of evidence. We compared NLP results to a chart review reference standard of 100 vaccinated cases. We then applied the final automated NLP algorithm to a broader cohort of vaccinated persons with a shoulder injury diagnosis code and performed manual chart confirmation on a random sample of NLP-identified definite cases and all NLP-identified probable and possible cases.

Results

In the validation sample, the NLP algorithm had 100% accuracy for identifying 4 SIRVA cases and 96 cases without SIRVA. In the broader cohort of 53,585 vaccinations, the NLP algorithm identified 291 definite, 124 probable, and 52 possible SIRVA cases. The chart-confirmation rates for these groups were 95.5% (278/291), 67.7% (84/124), and 17.3% (9/52), respectively.

Conclusions

The algorithm performed with high sensitivity and reasonable specificity in identifying positive SIRVA cases. The NLP algorithm can potentially be used in future population-based studies to identify this rare adverse event, avoiding labor-intensive chart review validation.

Association of Number of Doses With Hepatitis B Vaccine Series Completion in US Adults

IMPORTANCE

Receipt of hepatitis B virus vaccine is important to prevent infection. However, adherence to the hepatitis B vaccine series among adults at risk of infection has been low.

OBJECTIVE

To assess whether recipients of a 2-dose hepatitis B vaccine with cytosine phosphoguanine adjuvant (HepB-CpG vaccine; Heplisav-B) are more likely to complete their series compared with recipients of a 3-dose vaccine with alum adjuvant (comparator vaccine; Engerix-B [HepB-alum]).

DESIGN, SETTING, AND PARTICIPANTS

This nested cohort study was conducted from August 7 to December 31, 2018, at Kaiser Permanente Southern California, an integrated health care system with a diverse population of approximately 4.6 million members. Adults not receiving dialysis who received a first dose of a hepatitis B vaccine series in family practice or internal medicine departments of 15 Kaiser Permanente Southern California medical centers were followed up through electronic health records for up to 1 year after receipt of the first dose. Data were analyzed from March 16 to September 23, 2020.

EXPOSURES

Receipt of a first dose of the HepB-CpG vaccine (2-dose vaccine) vs receipt of a first dose of the HepB-alum vaccine (3-dose vaccine).

MAIN OUTCOMES AND MEASURES

Series completion within the recommended vaccine schedule plus 3 months (primary outcome) and series completion within 1 year after receipt of the first dose (secondary outcome).

RESULTS

Of 4727 individuals who initiated the HepB-CpG vaccine series and 6161 individuals who initiated the HepB-alum vaccine series included in the study, 2876 (60.8%) and 3789 (61.5%), respectively, were ages 40 to 59 years, 2415 (51.1%) and 3113 (50.5%) were male, and 2364 (50.0%) and 2881 (46.8%) were Hispanic. The vaccine series was completed within the recommended schedule plus 3 months for 2111 (44.7%) individuals who initiated the HepB-CpG vaccine series and 1607 (26.1%) individuals who initiated the HepB-alum vaccine series, and within 1 year for 2858 (60.5%) and 1989 (32.3%) individuals, respectively. The individuals who initiated the HepB-CpG vaccine series were significantly more likely to complete the series (adjusted relative risk, 1.77; 95% CI, 1.68-1.87). Results were consistent across clinical and demographic strata.

CONCLUSIONS AND RELEVANCE

In this study, use of the HepB-CpG vaccine was associated with hepatitis B vaccine series completion, but tailored strategies to increase completion of hepatitis B vaccine series are warranted.

The use of natural language processing to identify vaccine-related anaphylaxis at five health care systems in the Vaccine Safety Datalink

PURPOSE

The objective was to develop a natural language processing (NLP) algorithm to identify vaccine-related anaphylaxis from plain-text clinical notes, and to implement the algorithm at five health care systems in the Vaccine Safety Datalink.

METHODS

The NLP algorithm was developed using an internal NLP tool and training dataset of 311 potential anaphylaxis cases from Kaiser Permanente Southern California (KPSC). We applied the algorithm to the notes of another 731 potential cases (423 from KPSC; 308 from other sites) with relevant codes (ICD-9-CM diagnosis codes for anaphylaxis, vaccine adverse reactions, and allergic reactions; Healthcare Common Procedure Coding System codes for epinephrine administration). NLP results were compared against a reference standard of chart reviewed and adjudicated cases. The algorithm was then separately applied to the notes of 6 427 359 KPSC vaccination visits (9 402 194 vaccine doses) without relevant codes.

RESULTS

At KPSC, NLP identified 12 of 16 true vaccine-related cases and achieved a sensitivity of 75.0%, specificity of 98.5%, positive predictive value (PPV) of 66.7%, and negative predictive value of 99.0% when applied to notes of patients with relevant diagnosis codes. NLP did not identify the five true cases at other sites. When NLP was applied to the notes of KPSC patients without relevant codes, it captured eight additional true cases confirmed by chart review and adjudication.

CONCLUSIONS

The current study demonstrated the potential to apply rule-based NLP algorithms to clinical notes to identify anaphylaxis cases. Increasing the size of training data, including clinical notes from all participating study sites in the training data, and preprocessing the clinical notes to handle special characters could improve the performance of the NLP algorithms. We recommend adding an NLP process followed by manual chart review in future vaccine safety studies to improve sensitivity and efficiency.

Vaccine safety in HIV-infected adults within the Vaccine Safety Datalink Project

OBJECTIVES

We evaluate safety of routine vaccination among adults infected with human immunodeficiency virus (HIV) in five healthcare organizations in the United States.

METHODS

We conducted a retrospective cohort study of HIV-infected adults who received inactivated influenza vaccines, hepatitis B vaccines, pneumococcal vaccines, or tetanus, diphtheria, and acellular pertussis vaccines between 2002 and 2013. We conducted self-controlled case series analysis to estimate the relative risk (RR) for 11 pre-specified adverse events (AEs) requiring medical attention.

RESULTS

Among 20,417 HIV-infected adults (90.2% male), a total of 137,674 vaccine doses were administered. Based on ICD-9 codes, we detected an increased risk of cellulitis and infection (RR: 1.18, 95% CI: 1.03-1.35) among all patients, and an increased risk of stroke/cerebrovascular diseases among patients with an HIV viral load >10,000 copies/ml (adjusted RR: 3.94, 95% CI: 1.32-11.72). Further analyses on chart confirmed cases of stroke/cerebrovascular diseases indicated no statistically significant increased risk (adjusted RR: 1.72, 95% CI: 0.41-7.24). There was no evidence of increased risk for other AEs following routine vaccination in HIV-infected adults.

CONCLUSIONS

Routinely administered vaccines are generally safe for HIV-infected adults.

The use of natural language processing to identify Tdap-related local reactions at five health care systems in the Vaccine Safety Datalink

OBJECTIVE

Local reactions are the most common vaccine-related adverse event. There is no specific diagnosis code for local reaction due to vaccination. Previous vaccine safety studies used non-specific diagnosis codes to identify potential local reaction cases and confirmed the cases through manual chart review. In this study, a natural language processing (NLP) algorithm was developed to identify local reaction associated with tetanus-diphtheria-acellular pertussis (Tdap) vaccine in the Vaccine Safety Datalink.

METHODS

Presumptive cases of local reactions were identified among members ≥ 11 years of age using ICD-9-CM codes in all care settings in the 1-6 days following a Tdap vaccination between 2012 and 2014. The clinical notes were searched for signs and symptoms consistent with local reaction. Information on the timing and the location of a sign or symptom was also extracted to help determine whether or not the sign or symptom was vaccine related. Reactions triggered by causes other than Tdap vaccination were excluded. The NLP algorithm was developed at the lead study site and validated on a stratified random sample of 500 patients from five institutions.

RESULTS

The NLP algorithm achieved an overall weighted sensitivity of 87.9%, specificity of 92.8%, positive predictive value of 82.7%, and negative predictive value of 95.1%. In addition, using data at one site, the NLP algorithm identified 3326 potential Tdap-related local reactions that were not identified through diagnosis codes.

CONCLUSION

The NLP algorithm achieved high accuracy, and demonstrated the potential of NLP to reduce the efforts of manual chart review in vaccine safety studies.

Pneumococcal Conjugate Vaccine Safety in Elderly Adults

Background

The 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23) were both recommended to adults aged ≥65 years. The study examines adults ≥65 years for risk of adverse events (AEs) requiring medical attention following vaccination with PCV13 as compared with vaccination with PPSV23, a long-standing vaccine with a satisfactory safety profile.

Methods

The cohort study included 6 Vaccine Safety Datalink sites. The exposed person-time included follow-up time of the first PCV13 received by subjects age ≥65 years from January 1 to August 15, 2015. The comparator person-time included follow-up time after the first PPSV23 received by subjects of the same age during Janaury 1 to August 15 of each year of 2011–2015. The prespecified AEs included cardiovascular events, Bell’s palsy, Guillain-Barré syndrome, syncope, erythema multiforme, thrombocytopenia, cellulitis and infection, allergic reaction, and anaphylaxis. Inverse probability of treatment weighting–adjusted Poisson regression models was used to estimate the relative risk (RR) of each AE.

Results

A total of 313 136 doses of PCV13 and 232 591 doses of PPSV23 were included. The adjusted RRs comparing the incidence of AEs following PCV13 vs PPSV23 were all <1, except for anaphylaxis, which was insignificant with an RR of 1.32 (95% confidence interval, 0.30–5.79). Only 1 patient who received PCV13 and 4 other vaccines concomitantly was confirmed by medical chart review as having experienced anaphylaxis after vaccination.

Conclusions

These data do not support an increased rate of adverse events following PCV13 administration in elders compared with PPSV23 and should provide reassurance regarding continued use of PCV13.

Quality improvement pilot program for vulnerable elderly surgical patients

The elderly are a growing surgical population with more comorbidities and less physiological reserve compared with nonelderly patients. The objective of our study was to implement a quality improvement pilot program targeting the specific needs of the elderly. We prospectively enrolled consecutive patients aged 65 years or older undergoing inpatient general or vascular surgery operations. Patients completed a preoperative assessment including the Vulnerable Elder Survey (VES) to determine baseline functional status and incidence of polypharmacy (five or more medications). They were interviewed postdischarge Day 2 and Day 30 for changes in functional status. An intervention was implemented consisting of an elderly-specific postoperative order set and preoperative risk reports sent to the surgical team with instructions to order physical therapy consults and home health nursing on discharge for VES 3 or greater and geriatrics consults for patients with polypharmacy. The elderly-specific order set was used for 71 per cent of the postintervention group. There were no differences in the percentage of participants receiving physical therapy, geriatric, or home health nursing consults between the two groups. The postintervention group had significantly better functional status on postdischarge Day 30 (P < 0.01). Our preliminary data suggest that individualizing care for elderly patients is feasible and may improve postoperative outcomes.

Is social support associated with greater weight loss after bariatric surgery?: a systematic review

Social support may be associated with increased weight loss after bariatric surgery. The objective of this article is to determine impact of post-operative support groups and other forms of social support on weight loss after bariatric surgery. MEDLINE search (1988-2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened studies, 10 reported on social support and weight loss outcomes. Five studies reported on support groups and five studies reported on other forms of social support (such as perceived family support or number of confidants) and degree of post-operative weight loss (total n = 735 patients). All studies found a positive association between post-operative support groups and weight loss. One study found a positive association between marital status (being single) and weight loss, while three studies found a non-significant positive trend and one study was inconclusive. Support group attendance after bariatric surgery is associated with greater post-operative weight loss. Further research is necessary to determine the impact of other forms of social support. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may represent ways to improve post-operative outcomes.

Behavioral Factors Associated with Successful Weight Loss after Gastric Bypass

Patients undergoing bariatric surgery lose substantial weight (≥50% excess weight loss [EWL]), but an estimated 20 per cent fail to achieve this goal. Our objective was to identify behavioral predictors of weight loss after laparoscopic Roux-en-Y gastric bypass. We retrospectively surveyed 148 patients using validated instruments for factors predictive of weight loss. Success was defined as ≥50 per cent EWL and failure as <50 per cent EWL. Mean follow-up after laparoscopic Roux-en-Y gastric bypass was 40.1 ± 15.3 months, with 52.7 per cent of patients achieving successful weight loss. After controlling for age, gender, and preoperative body mass index, predictors of successful weight loss included surgeon follow-up (odds ratio [OR] 8.2, P < 0.01), attendance of postoperative support groups (OR 3.7, P = 0.02), physical activity (OR 3.5, P < 0.01), single or divorced marital status (OR 3.2, P = 0.03), self-esteem (OR 0.3, P = 0.02), and binge eating (OR 0.9, P < 0.01). These factors should be addressed in prospective studies of weight loss after bariatric surgery, as they may identify patients at risk for weight loss failure who may benefit from early tailored interventions.

Improving Breast Cancer Quality of Care with the Use of Patient Navigators

The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators ( P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.

Behavioral factors associated with successful weight loss after gastric bypass

Patients undergoing bariatric surgery lose substantial weight (> or = 50% excess weight loss [EWL]), but an estimated 20 per cent fail to achieve this goal. Our objective was to identify behavioral predictors of weight loss after laparoscopic Roux-en-Y gastric bypass. We retrospectively surveyed 148 patients using validated instruments for factors predictive of weight loss. Success was defined as > or =50 per cent EWL and failure as <50 per cent EWL. Mean follow-up after laparoscopic Roux-en-Y gastric bypass was 40.1 +/- 15.3 months, with 52.7 per cent of patients achieving successful weight loss. After controlling for age, gender, and preoperative body mass index, predictors of successful weight loss included surgeon follow-up (odds ratio [OR] 8.2, P < 0.01), attendance of postoperative support groups (OR 3.7, P = 0.02), physical activity (OR 3.5, P < 0.01), single or divorced marital status (OR 3.2, P = 0.03), self-esteem (OR 0.3, P = 0.02), and binge eating (OR 0.9, P < 0.01). These factors should be addressed in prospective studies of weight loss after bariatric surgery, as they may identify patients at risk for weight loss failure who may benefit from early tailored interventions.

Improving breast cancer quality of care with the use of patient navigators

The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators (P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.

Exercise following bariatric surgery: systematic review

The contribution of physical activity on the degree of weight loss following bariatric surgery is unclear. To determine impact of exercise on postoperative weight loss. Medline search (1988–2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened articles, 14 reported on exercise and weight loss outcomes. The most commonly used instruments to measure activity level were the Baecke Physical Activity Questionnaire, the International Physical Activity Questionnaire, and a variety of self-made questionnaires. The definition of an active patient varied but generally required a minimum of 30 min of exercise at least 3 days per week. Thirteen articles reported on exercise and degree of postoperative weight loss (n = 4,108 patients). Eleven articles found a positive association of exercise on postoperative weight loss, and two did not. Meta-analysis of three studies revealed a significant increase in 1-year postoperative weight loss (mean difference = 4.2% total body mass index (BMI) loss, 95% confidence interval (CI; 0.26–8.11)) for patients who exercise postoperatively. Exercise following bariatric surgery appears to be associated with a greater weight loss of over 4% of BMI. While a causal relationship cannot be established with observational data, this finding supports the continued efforts to encourage and support patients’ involvement in post-surgery exercise. Further research is necessary to determine the recommended activity guidelines for this patient population.

Quality of care in advanced ovarian cancer: the importance of provider specialty

BACKGROUND

One of the cornerstones of ovarian cancer therapy is cytoreductive surgery, which can be performed by surgeons with different specialty training. We examined whether surgeon specialty impacts quality of life (as proxied by presence of ostomy) and overall survival for women with advanced ovarian cancer.

METHODS

Stage IIIC/IV ovarian cancer patients were identified using 4 state cancer registries: California, Washington, New York, and Florida and linked records to the corresponding inpatient-hospital discharge file, AMA Masterfile, and 2000 U.S. Census SF4 File. Predictors of receipt of care by a general surgeon and creation of fecal ostomy were analyzed. Multivariate modeling was performed to assess the association of hospital volume (low volume (LV) [0-4 cases], middle volume (MV) [5-9], high volume (HV) [10-19], and very high volume (VHV) [20+]) and surgeon specialty training (gynecologic oncologists/gynecologists, general surgeons, and other specialty) on survival.

RESULTS

We identified 31,897 Stage IIIC/IV patients; mean age was 64 years. Treatment of patients by a general surgeon was predicted by LV, rural patient residence, poverty, and high level of comorbidity. Patients had lower hazard of death when treated in higher volume hospitals as compared to LV [VHV hazard ratio (HR)=0.79, P<.0001; HV HR=0.89, P<0.001]. Patients treated by a general surgeon had higher likelihood of an ostomy (OR=4.46, P<.0001) and hazard of death (HR=1.63, P<.0001) compared to gynecologic oncologist/gynecologist.

CONCLUSIONS

Advanced stage ovarian cancer patients have better survival when treated by gynecologic oncology/gynecology trained surgeons. Data suggest that referral to these specialists may optimize surgical debulking and minimize the creation of a fecal ostomy.

Quality of care in advanced ovarian cancer: How important is provider specialty?

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Background: Ovarian cancer is one of the most aggressive and deadly cancers in women. While the mainstay of therapy is surgery, ovarian cancer surgical procedures are performed by surgeons with different specialty training, including gynecology, gynecologic oncology, general surgery, and others. We examine the degree to which surgeon specialty impacts survival and other quality of life-related outcomes in advanced ovarian cancer patients. Methods: Analyses of Stage 3c/4 ovarian cancer patients were performed from 4 states (California, Washington, New York, Florida). Four databases were linked for each state: cancer registry, inpatient-hospital discharge, AMA masterfile, and 2000 U.S. Census SF4 File. Multivariate modeling was performed to identify predictors of survival as well as proxy quality of life-related outcomes, as measured by creation of a fecal ostomy. Hospital case volume was defined as low volume (LV) [0–4 cases], middle volume (MV) [5–9], high volume (HV) [10–19], and very high volume (VHV) [20+]. Results: 60,405 ovarian cancer patients were identified; 53% were Stage 3c/4. Mean age was 64 years. Patients had lower hazard of death when treated in higher volume hospitals as compared to LV [HV (Hazard Ratio) HR = 0.89, p < 0.0001; VHV HR = 0.79, p < 0.001]. Patients treated by gynecologists/gynecologic-oncologists had lower hazard of death (HR = 0.61, p < 0.0001) as compared to other surgeons (non-gynecologist), controlling for hospital type, case volume, comorbidity, and demographics. Also, patients treated by a trained gynecologist had the lowest chance of having an ostomy performed as compared to those of other specialties (HR = 0.22, p < 0.0001). Factors associated with receiving treatment from a non-gynecologist included low volume, rural patient residence, poverty, and high comorbidity. Conclusions: Stage 3c/4 ovarian cancer patients have better survival when treated by gynecology-trained surgeons. Our data suggest that gynecology-trained specialists optimize quality of life-related outcomes, specifically minimizing the creation of a fecal ostomy. Surgeon specialty was more important than procedure volume for these outcomes. Referral to gynecology-trained surgeons would improve survival and quality of life outcomes in advanced ovarian cancer patients.

No significant financial relationships to disclose.

Semen alterations in porcine rubulavirus-infected boars are related to viral excretion and have implications for artificial insemination

Porcine rubulavirus (PoRV), also known as blue eye disease (BED) of swine, causes respiratory and reproductive problems in pigs at several developmental stages. To study the effect of PoRV infection on semen production, five boars were infected with 1 x 10(6) TCID(50)/ml of PoRV strain PAC-3 and evaluated for 59 days post inoculation (DPI). Infected boars developed reproductive tract pathology that included swelling of the testes and epididymides. Analysis of the semen showed that the infection had little effect on semen production in four animals, but semen from one boar showed severe alterations in sperm concentration, motility, and morphology. When motility was analyzed in BTS-diluted semen after 24, 48, or 72 h, alterations were detected in all boars. Furthermore, viral antigen was detected in semen, the seminal plasma fraction, or sperm fraction from all boars. These results showed that PoRV is excreted via semen and, therefore, artificial insemination is a potential route of dissemination.

Porcine circovirus type 2 antibody detection in backyard pigs from Mexico City

PCV2 antibodies have been found in pigs from all continents. However, this finding has been mainly studied in domestic swine reared under intensive production conditions. Mexico City, with a human population over 19 million in 2005, has both urban and rural areas. The pig production in its rural area is based on small family backyard farms. Taking into account this rather unique form of rearing pigs, the objective of this study was to determine the seroprevalence in backyard pigs from the rural area of Mexico City. A total of 695 backyard pig serum samples from 108 small family farms belonging to seven municipal areas were studied by immunoperoxidase monolayer assay technique. One hundred six out of the 108 family farms (98.14%) had at least one positive serum sample. On the other hand, 136 (19.57%), 264 (37.99%) and 248 (34.82%) pigs had low, intermediate and high titres to PCV2, respectively. Only 53 samples (7.63%) were negative for PCV2 antibodies. No apparent differences in antibody titre groups were observed among backyard pigs from the different municipal areas. In conclusion, the present study, the first one performed in this kind of extensively produced pigs, indicates that PCV2 is ubiquitous in backyard pigs from Mexico City.

Persistence of Escherichia coli, Salmonella choleraesuis, Aujeszky's Disease virus and Blue Eye Disease virus in ensilages based on the solid fraction of pig faeces

AIMS

This study was carried out to determine the survival time of Escherichia coli, Salmonella choleraesuis, Aujeszky's Disease virus and Blue Eye Disease virus in ensilages based on the solid fraction of pig faeces.

METHODS AND RESULTS

The four micro-organisms were inoculated into microsilos based on the solid fraction of pig faeces, sorghum and molasses. They were left for 0, 7, 14, 28 and 56 days, after which the state of each microsilo was evaluated, and isolation of the inoculated agents was attempted. The four inoculated agents were isolated only on day 0 of ensilage. The viral agents were identified through the cytopathic effect and fluorescence.

CONCLUSIONS, SIGNIFICANCE AND IMPACT OF THE STUDY

It is concluded that ensilages based on the solid fraction of pig faeces appear to reduce the risk of the transmission of the agents inoculated in this study and help to reduce the environmental impact by using the solid in animal feed.

Mammographic Appearance of Axillary Lymph Node Calcification in Patients with Metastatic Ovarian Carcinoma

OBJECTIVE

We describe the mammographic appearance of axillary lymph node calcification in three patients with metastatic ovarian carcinoma.

CONCLUSION

Axillary lymph node calcification may be identified mammographically in patients with metastatic ovarian carcinoma and may be evidence of unsuspected metastatic disease. The pattern of calcification differs from that seen with metastatic breast carcinoma.

Comparative evaluation of the CD4+CD8+ and CD4+CD8- lymphocytes in the immune response to porcine rubulavirus

The porcine immune system is unique in the expression of CD4+CD8+ (double-positive, DP) lymphocytes. These cells have been associated with immunological memory due to their gradual increase with age, the expression of memory phenotype and their ability to respond to recall viral antigen. This work analyzes the biological function of CD4+CD8- and CD4+CD8+ lymphocytes in the immune response to porcine rubulavirus (PRv). CD4+CD8- cells isolated from pigs 3 weeks after infection with porcine rubulavirus proliferated in response to homologous virus and generated lymphoblasts which were predominantly of the CD4+CD8+ phenotype, whereas stimulation with mitogen induced proliferation but did not switch the phenotype. CD4+CD8- lymphocytes isolated after 10 weeks of infection proliferated in response to phytohemagglutinin (PHA) but did not proliferate in response to homologous virus and did not change their phenotype, whereas CD4+CD8+ lymphocytes proliferated in response to PHA and to viral antigen. The cytokine profile of both lymphocyte populations showed the presence of IL-2 and IL-10 transcripts, quantitation demonstrated that CD4+CD8+ cells expressed mainly IL-10, whereas CD4+CD8- lymphocytes expressed primarily IL-2. Our results show that CD4+CD8- lymphocytes in the early phase of porcine rubulavirus infection can be converted to double-positive cells expressing IL-10 in an antigen-dependent manner, and that CD4+CD8- T-cells late in infection do not acquire CD8.

Sustained levels of ascorbic acid are toxic and immunosuppressive for human T cells

Ascorbate (vitamin C) can protect from oxidative damage to DNA and lipids that may lead to aging, cancer, and other dysfunctions. However, we find that purified human T cells deteriorate if maintained in ascorbate in culture for 18 hrs. or more; viability and Il-2 synthesis are over 90% curtailed by ascorbate at 50 micrograms/ml. T cell proliferation and adhesion are severely suppressed at 10-25 micrograms/ml. Dihydro-ascorbate was much less toxic or suppressive. The suppressive effect of ascorbate appears irreversible, since removal of ascorbate after 18 hrs. did not restore the mitogenic response. Although moderate dietary levels of ascorbate often reach 250-1000 mg or more daily and appear beneficial, our data caution against sustained megadoses of ascorbate for treatment of patients with AIDS and cancer.

Cytochrome P450 CYP 2E1 induction during chronic alcohol exposure occurs by a two-step mechanism associated with blood alcohol concentrations in rats

Intragastric infusion of ethanol to male rats as part of a system of total enteral nutrition allows chronic ethanol treatment without the nutritional and feeding problems associated with traditional liquid diets. Even though ethanol was infused at a constant rate 24 h a day, blood alcohol concentrations were observed to cycle over a 5- to 7-day period from values less than 10 mg/dl to greater than 400 mg/dl. Examination of the hepatic microsomal mono-oxygenase system in animals chronically treated with ethanol using this model revealed variable induction of cytochrome P450 CYP 2E1, the principal component of the microsomal ethanol oxidizing system. Correlations were observed between urine alcohol concentrations (UACs) and 1) the level of expression of CYP 2E1 mRNA in Northern blot analysis, 2) the level of CYP 2E1 apoprotein in Western blot analysis and, 3) microsomal p-nitrophenol (PNP) hydroxylation. The data from ethanol-treated animals were expressed as low UAC group (UACs < 200 mg/dl) and a high UAC group (UACs > 300 mg/dl) and compared to total enteral nutrition controls. In the low UAC group, a 6- to 7-fold induction in microsomal PNP hydroxylase (a CYP 2E1-dependent activity) was accompanied by a 4- to 5-fold increase in CYP 2E1 apoprotein, but no increase in CYP 2E1 mRNA levels. In contrast, in the high UAC group, induction of PNP hydroxylase was 15- to 16-fold, induction of CYP 2E1 apoprotein was 12- to 13-fold and CYP 2E1 mRNA was elevated 5- to 6-fold.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of chronic ethanol on growth hormone secretion and hepatic cytochrome P450 isozymes of the rat

Growth hormone (GH) secretion is sexually dimorphic in the laboratory rat and the plasma GH profile is a determining factor in the regulation of the male-specific cytochrome P450 (CYP) 2C11. Acute ethanol has been reported previously to alter the secretion of GH, and in the present investigation, we have studied the effects of chronic (38 days) ethanol on plasma GH profiles, CYP 2C11 and the major ethanol-inducible cytochrome, CYP 2E1, using a total enteral nutrition system, where 35% of the total calories were ethanol. Ethanol-treated rats had elevated (P < or = .05) CYP 2E1 activities and apoprotein levels and increased steady-state mRNA levels encoding for CYP 2E1. Ethanol-treated rats also had reduced (P < or = .05) hydroxylation of testosterone at positions 2 alpha and 16 alpha, lower 2C11 apoprotein levels and lower steady-state mRNA levels encoding for 2C11. In addition, the plasma GH pulse profiles were altered in chronically treated rats by reducing (P < or = .05) the GH pulse amplitude and mean plasma GH concentrations. Our results suggest that: 1) the reduced CYP 2C11 activities, apoprotein levels and steady-state mRNA levels during chronic alcohol exposure are causally related to the alterations in GH secretion; and 2) chronic alcohol exposure elevated CYP 2E1 activities, apoprotein levels and steady-state mRNA levels, and these changes occurred primarily as the result of ethanol rather than undernutrition or as the combination of ethanol and undernutrition.

Inhibition of T cell mitogenesis by nitrofurans

A group of nitrofurans (5-nitro-2-furaldehyde, nifuroxime, nitrofurazone, nitrofurantoin, 5-nitro-2-furoic acid and 2-nitrofuran) were evaluated for inhibition of mitogenesis (DNA synthesis) in human peripheral blood T cells. T cells, either triggered by phorbol myristate acetate (PMA) or in the presence of accessory cells, were activated with a specified mitogen [phytohemagglutin (PHA), concanavalin A (ConA), or anti-CD3] and the amount of tritiated thymidine incorporated into DNA was determined. The results obtained indicate that nitrofurans inhibit mitogenesis irrespective of activator. 5-Nitro-2-furaldehyde was much more inhibitory than the other compounds, while 2-nitrofuran was less inhibitory. When the aldehyde group (5-nitro-2-furaldehyde) was replaced by a carboxyl group (5-nitro-2-furoic acid), the inhibitory activity was also reduced greatly. These results show that while the nitro group alone confers inhibitory activity to the furan ring, the group at the 2 position is crucial. In general, the mitogenic response of purified T cells (lacking accessory cells) triggered by PMA (phorbol ester) was inhibited less than that of the T cell-accessory cell system. With the latter, 50% inhibition of T cell mitogenesis was achieved by nifuroxime, nitrofurazone, and nitrofurantoin at 45-51 and 34-39 microM with PHA and ConA respectively. When purified T cells were used, the values were 71-85 and 55-60 microM respectively. For a given drug concentration, mitogenesis was more inhibited when induced by ConA or anti-CD3 than by PHA. The importance of using a single cell system (purified T cells) was emphasized by the interesting finding that only this system showed enhancement of mitogenesis, up to 35-40% at low drug levels. With the exception of the nitrofuraldehyde, the nitrofurans at strongly inhibitory levels were only moderately cytotoxic, exhibiting 62-85% cell survival after exposure to drug for 68 hr. Our results suggest that nitrofurans inhibit T cell mitogenesis by a relatively non-toxic mechanism; these results are comparable to those obtained for mammalian cells under aerobic conditions.

Silicone implant arthroplasty: a retrospective analysis

Fifteen patients totalling 19 first metatarsophalangeal implants were evaluated both subjectively and objectively. The average time of follow-up was 5.9 years. Sixteen implants were evaluated radiographically and the incidence of complications including implant deformation, bony erosions, and bony encroachment is reported. Postoperative clinical evaluation revealed several of the patients complained of pain and stiffness. Postoperative motion was restricted in most patients and toe purchase was present in only 6 of 16 patients. Despite the clinical objective findings, patient satisfaction was very favorable. Although the apparent complication rate appeared high, the authors recommend an effort be made to develop a multicentered retrospective analysis to find the true incidence of first metatarsophalangeal implant complications.