A framework for One Health research

The need for multidisciplinary research to address today's complex health and environmental challenges has never been greater. The One Health (OH) approach to research ensures that human, animal, and environmental health questions are evaluated in an integrated and holistic manner to provide a more comprehensive understanding of the problem and potential solutions than would be possible with siloed approaches. However, the OH approach is complex, and there is limited guidance available for investigators regarding the practical design and implementation of OH research. In this paper we provide a framework to guide researchers through conceptualizing and planning an OH study. We discuss key steps in designing an OH study, including conceptualization of hypotheses and study aims, identification of collaborators for a multi-disciplinary research team, study design options, data sources and collection methods, and analytical methods. We illustrate these concepts through the presentation of a case study of health impacts associated with land application of biosolids. Finally, we discuss opportunities for applying an OH approach to identify solutions to current global health issues, and the need for cross-disciplinary funding sources to foster an OH approach to research.

Atopic dermo-respiratory syndrome is a correlate of eczema herpeticum

BACKGROUND

Factors favoring the emergence of eczema herpeticum (EH) in patients with atopic dermatitis (AD) remain elusive. The aim of this work was to identify changes in clinical and laboratory parameters in acute EH patients, before and after 6 weeks of treatment, as well as differences between AD patients with and without a history of EH.

METHODS

A total of 235 adult subjects were included and subdivided into six groups: (i) AD patients with acute EH, (ii) AD patients with history of EH, (iii) AD without EH but with recurrent herpes simplex virus (HSV) infections, (iv) AD without EH or recurrent HSV infections and healthy non-AD controls (v) with and (vi) without recurrent HSV infections. Clinical examination of AD, assessment of atopic status and severity were performed. Total IgE, allergen-specific IgE and differential blood count were analyzed. Clinical diagnosis of acute EH was confirmed by PCR.

RESULTS

More male patients with AD were affected by EH than female patients. Acute episodes of EH are characterized by lower levels of lymphocytes and higher levels of monocytes. AD patients with history of EH display higher total IgE serum levels (ADEH(+) HSV(+) vs ADEH(-) HSV(+) , P < 0.001) and higher sensitization profiles and stronger severity of AD (EASI and SCORAD; ADEH(+) HSV(+) vs ADEH(-) HSV(+) , P < 0.001). Concomitant asthma and rhinitis were identified as correlates of EH.

CONCLUSION

From these data, we conclude that AD patients with EH display a distinct clinical and biological phenotype.

Gender moderates the effects of exercise therapy on health-related quality of life among COPD patients

STUDY OBJECTIVES

To determine whether long-term treatment with exercise therapy results in more favorable, disease-specific, health-related quality of life (HRQL) compared with short-term treatment with exercise therapy; and to determine whether there are gender differences in disease-specific HRQL among individuals randomized into the two treatment groups.

DESIGN

Randomized clinical trial.

SETTING

Center-based exercise therapy unit at a university.

PARTICIPANTS

One hundred forty patients with COPD; 118 completed trial.

INTERVENTIONS

Short-term exercise therapy (3 months); long-term exercise therapy (18 months).

MEASUREMENTS

Chronic Disease Respiratory Questionnaire (CRQ).

RESULTS

After 3 months of treatment, there were significant improvements in all CRQ scores for men and women (p < 0.01), and for the total sample (p < 0.01). At 18 months, individuals randomized into the long-term group had significantly more favorable scores than the short-term group for dyspnea (p = 0.03), fatigue (p < 0.01), emotional function (p = 0.04), and mastery (p = 0.04). However, these effects were moderated by gender. That is, men in the long-term group reported significantly more favorable scores than men in the short-term group for dyspnea (0.04), fatigue (p < 0.001), emotional function (p = 0.02), and mastery (p = 0.02). At the 18-month assessment, there were no differences between long-term and short-term exercise therapy for women on any of the subscales of the CRQ.

CONCLUSIONS

Taken collectively, the CRQ data demonstrate that long-term exercise therapy has little added benefit for women over short-term exercise therapy; however, men derive significant benefits from extended training.

Exercise rehabilitation and chronic obstructive pulmonary disease stage

To determine the extent to which patients with Stage I COPD experience improvements in physical performance and quality of life as a result of exercise training, and to compare these improvements with those seen in Stage I and II patients, 151 patients with COPD underwent a 12-wk exercise program. Outcomes were measured at baseline and follow-up. Physical performance was evaluated by means of a 6-min walk, treadmill time, an overhead task, and a stair climb. General health-related quality of life was assessed in terms of the domains of Social Function, Health Perceptions, and Life Satisfaction. Disease-specific health-related quality of life was assessed with the Chronic Respiratory Disease Questionnaire (CRQ). Six-minute walk distance increased significantly in Stage I (200.5 ft [95% CI: 165.4, 235.7]), Stage II (238.3 ft [143.3, 333.3]), and Stage III (112.1 ft [34.6, 189.6]) participants. Treadmill time increased significantly in Stage I (0.42 min [0.20, 0.64]) and Stage II (0.64 min [0.14, 1.4]) participants. Time to complete the overhead task decreased significantly in Stage I (0.91 s [1.72, 0. 11]) and Stage II (1.39 s [2.66, 0.13]) participants. None of the measures of general health-related quality of life improved in any of the three groups. Participants in Stages I, II, and III all experienced improvements in the CRQ domains of dyspnea (0.72 [0.53, 0.91], 0.47 [0.02, 0.91], and 0.46 [0.05, 0.87], respectively) and fatigue (0.49 [0.33, 0.66], 0.54 [0.20, 0.87], and 0.55 [0.05, 1.05], respectively). These results suggest that all patients with COPD will benefit from exercise rehabilitation. Berry MJ, Rejeski WJ, Adair NE, Zaccaro D. Exercise rehabilitation and chronic obstructive pulmonary disease stage.

Peripartum cardiomyopathy: summary of an international survey on peripartum cardiomyopathy

OBJECTIVE

The aim of this survey was to assess the evaluation, management, and future recommendations of patients with the diagnosis of peripartum cardiomyopathy and to evaluate the interest in the creation of a prospective database regarding this rare disorder.

STUDY DESIGN

A total of 116 surveys were sent to major teaching institutions in the United States (including Puerto Rico), Canada, Crete, and South Korea after a national conference held at the National Institutes of Health regarding peripartum cardiomyopathy. This was an open-ended survey containing 17 specific questions regarding this disorder and its management.

RESULTS

A total of 78 (67%) maternal-fetal specialists responded to the survey. Diuretics and digoxin were used as first-line treatment for this disorder. Only 6% used angiotensin-converting enzyme inhibitors during pregnancy. Fifty-eight percent of the perinatologists (58%) recommended either intrauterine contraceptive devices or foam and condoms, whereas oral contraceptives (progesterone-only pill or estrogen-progesterone mix) were recommended in 23% and 41%, respectively. Sixty-six percent (66%) of the respondents would recommend future pregnancy if ventricular function returned to normal.

CONCLUSIONS

Fundamental clinical and basic research is lacking regarding this rare but potentially devastating disorder. Major teaching institutions do not have significant numbers of patients with this disorder to provide concrete recommendations, and starting a database will be useful in the gathering of important epidemiologic information. A secondary aim of such a registry would be to establish a repository for tissue and blood samples to answer basic mechanistic questions about this disorder.

Cigarette smoking, environmental tobacco smoke exposure and insulin sensitivity: the Insulin Resistance Atherosclerosis Study

PURPOSE

To investigate whether active smoking and/or exposure to environmental tobacco smoke (ETS) is associated with insulin sensitivity.

METHODS

Insulin sensitivity and tobacco use history were measured in 1481 participants in the Insulin Resistance Atherosclerosis Study (IRAS). IRAS is a large mulitcenter epidemiologic study designed to explore the cross-sectional relationships among insulin resistance, cardiovascular disease risk factors and behaviors, and disease in African-American, Hispanic, and non-Hispanic white men and women, aged 40-69 years, selected to represent a broad range of glucose tolerance. Multiple linear regression models and linear contrasts were employed to describe the association between smoking history, as assessed via structured interview, and insulin sensitivity, as assessed by an insulin modified frequently sampled intravenous glucose tolerance test (FSIGT) with minimal model analysis.

RESULTS

Active smoking was not associated with insulin sensitivity. Exposure to ETS was associated with lower insulin sensitivity. Specifically, for all participants combined, levels of SI were lower, indicating reduced insulin sensitivity, for those exposed to ETS when compared to those who were not exposed (p = 0.019). This association persisted for female participants (p = 0.013) and exhibited the same trend for males but failed to achieve statistical significance (p = 0.264).

CONCLUSIONS

Our study did not reveal an association between active smoking and insulin sensitivity, as has been shown previously. The association between ETS exposure and insulin sensitivity is a puzzling finding which deserves further investigation in the longitudinal data from IRAS as well as in other populations.

Ventricular filling patterns of the right and left ventricles in normally grown fetuses: a longitudinal follow-up study from early intrauterine life to age 1 year

OBJECTIVE

Our goal was to determine the effects of advancing age on the Doppler diastolic filling indexes from early gestation to 1 year of life.

STUDY DESIGN

Seventy-nine fetuses were studied. Initial Doppler studies were started at about the 16th week of gestation and repeated every 4-6 weeks until term, on postnatal day 1 and 2, and at ages 6 weeks, 6 months, and 12 months. A minimum of 5 returning Doppler waveforms were traced and analyzed for (1) peak early flow velocity, (2) late peak atrial flow velocity, (3) total area area under the curve, and (4) the acceleration and deceleration phases. The stiffness of the ventricles was estimated. Slopes of the curves for each of the parameters were analyzed for differences across time periods and between right and left ventricles.

RESULTS

(1) Heart rate significantly decreased with advancing age. (2) Left ventricular and right ventricular peak early flow velocity and late peak atrial flow velocity significantly increased during fetal life but not during the 1st year. (3) Atrial predominance was found during fetal life but not during the first year. (4) The deceleration phase of filling significantly increased during the fetal period. (5) Ventricular stiffness progressively decreased during the fetal period. (6) Increased ventricular filling shifted from a right-sided dominance in utero to a left-sided dominance after birth.

CONCLUSIONS

(1) Fetuses have stiffer fetal ventricles than neonates. (2) The diastolic filling patterns in normally grown fetuses mimic those of the diseased adult heart. We speculate that this maturation process may be affected in fetuses born prematurely or small for gestational age.

Attitudes and practices of registered nurses toward women who have experienced abuse/domestic violence

OBJECTIVE

To compare the education, attitudes, and practices related to domestic violence of perinatal nurses from three types of practice sites.

DESIGN

A descriptive study of responses to a questionnaire administered to a convenience sample and through a mailing.

SETTING

Education conferences and responses to a mailing.

PARTICIPANTS

Two hundred seventy-five nurses in perinatal practice (87 public health, 71 hospital, 117 private office).

MAIN OUTCOME MEASURES

Primary outcomes were attitudes and beliefs about domestic violence and nursing behavior when domestic violence was identified. The effects of education about domestic violence on practice and the effect of a personal/family history of domestic violence on practice were examined.

RESULTS

Some differences were found in the attitudes and beliefs of nurses from different practice sites, but more differences were found in their behaviors. Only 54% of the total sample reported having education about domestic violence, received in formal or continuing education programs. Public health nurses were the most likely to have such education. Education affected both attitudes and behavior. In the total sample, 31% of nurses reported abuse of themselves or family members.

CONCLUSIONS

Nursing care for women who have experienced domestic violence includes assessment and appropriate counseling. Many nurses in this study lacked education about domestic violence. The provision of education about abuse and domestic violence is a first step toward a change in nursing practice.

Hyperemic response of the brachial artery during the second half of pregnancy

OBJECTIVE

To determine if women who developed preeclampsia had measurable differences in the vascular response postrelease of a 1-minute blood flow occlusion.

METHODS

A total of 33 nulliparous patients were enrolled in this study during the second half of the pregnancy. All had baseline Doppler flow velocities while resting in the left lateral decubitus. Subsequently, a blood pressure cuff was inflated for 60 seconds in the forearm so as to occlude blood flow. Doppler waveforms were analyzed immediately after the release of the blood pressure cuff and on a single beat occurring at 15 second intervals for a total of five readings. After a rest period, patients were asked to squeeze a handheld manometer at maximum strength as long as possible. Doppler waveforms were analyzed as above. The Doppler waveforms of all enrolled patients who subsequently developed preeclampsia any time after the study were compared to those who remained normotensive.

RESULTS

1) The "hyperemic response" that occurred immediately after release of the blood pressure occlusion of the forearm was significantly different between patients who subsequently developed preeclampsia compared with those who remained normotensive, 2) the hyperemic response that occurred after the isometric handgrip exercise was not significantly different between the two groups, and 3) sensitivity, specificity, and negative predictive values were high, but positive predictive values were low.

CONCLUSION

There was a significant difference in the hyperemic response of the brachial artery to a short period of ischemia of the forearm (blood pressure occlusion) between normotensive patients and a group of patients who subsequently developed preeclampsia.

Maternal right hypogastric artery blood flow during normal pregnancy and 6 weeks postpartum

OBJECTIVE

To document and quantify the temporal hemodynamic changes occurring in the pelvic circulation in normal human pregnancy, and to compare these changes with those found 6 weeks postpartum.

METHODS

Thirty-three patients had color pulsed Doppler evaluation of the right hypogastric artery six times during pregnancy and once 6 weeks postpartum. Pulsed Doppler waveforms were digitized to assess the time velocity integral (area under the Doppler curve = TVI) and the peak flow velocity (maximum velocity = PFV). The diameter of the vessel was determined during systole using high-resolution two-dimensional ultrasound from a longitudinal plane. A quantitative estimate of the blood flow through this vessel was calculated by multiplying the TVI by the calculated cross-sectional area of the vessel.

RESULTS

The cross-sectional area and the indexed volume of blood flow per minute of the hypogastric artery were significantly greater during pregnancy compared with the postpartum value. The estimated vascular resistance index was significantly decreased during pregnancy. Time velocity integral was significantly lower at the initial study compared with the postpartum value.

CONCLUSION

The hypogastric artery undergoes significant hemodynamic changes during pregnancy when compared to the postpartum period. Furthermore, the pelvic circulation displays these changes early in gestation.

Insulin sensitivity and atherosclerosis. The Insulin Resistance Atherosclerosis Study (IRAS) Investigators

BACKGROUND

Reduced insulin sensitivity has been proposed as an important risk factor in the development of atherosclerosis. However, insulin sensitivity is related to many other cardiovascular risk factors, including plasma insulin levels, and it is unclear whether an independent role of insulin sensitivity exists. Large epidemiological studies that measure insulin sensitivity directly have not been conducted.

METHODS AND RESULTS

The Insulin Resistance Atherosclerosis Study (IRAS) evaluated insulin sensitivity (SI) by the frequently sampled intravenous glucose tolerance test with analysis by the minimal model of Bergman. IRAS measured intimal-medial thickness (IMT) of the carotid artery as an index of atherosclerosis by use of noninvasive B-mode ultrasonography. These measures, as well as factors that may potentially confound or mediate the relationship between insulin sensitivity and atherosclerosis, were available in relation to 398 black, 457 Hispanic, and 542 non-Hispanic white IRAS participants. There was a significant negative association between SI and the IMT of the carotid artery both in Hispanics and in non-Hispanic whites. This effect was reduced but not totally explained by adjustment for traditional cardiovascular disease risk factors, glucose tolerance, measures of adiposity, and fasting insulin levels. There was no association between SI and the IMT of the carotid artery in blacks. The association between SI and the IMT was stronger for the internal carotid artery than for the common carotid artery in all ethnic groups.

CONCLUSIONS

Higher levels of insulin sensitivity are associated with less atherosclerosis in Hispanics and non-Hispanic whites but not in blacks. This effect is partially mediated by traditional cardiovascular risk factors.

Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence

OBJECTIVE

Our purpose was to define screening behaviors of obstetrician-gynecologists and barriers to screening their patients for domestic violence.

STUDY DESIGN

A questionnaire was developed to collect information on current practices and attitudes regarding screening for domestic violence. A randomly selected sample of obstetrician-gynecologists was surveyed. Respondents were also asked to rank a series of 19 potential barriers that may affect screening.

RESULTS

Of 6568 physicians sampled, 962 (14.6%) returned questionnaires. Of the respondents, 77.6% were male and 22.4% were female. Male physicians were less likely to screen for domestic violence (25.9% vs. 18.9%). Thirty-four percent said that they had no training in abuse. Physicians indicating they had received training in abuse were more likely to screen for domestic violence. The lack of education was identified as the most common barrier physicians have to screening. The feeling that abuse was not a problem in their patients (46%), lack of time to deal with abuse (39.2%), and frustration that the physician cannot help the victim (34.2%) were other common barriers.

CONCLUSION

The majority of obstetrician-gynecologists do not screen their patients for current or past domestic violence. If universal screening is to become a reality, educational tools and training materials are needed to overcome physician barriers.