Effect of applied shading during fruit ripening on tannin structure-activity relationships of grape skin extracts

BACKGROUND

Historically, the effect of wine grape shading on flavonoids has investigated the impact of light incidence on proanthocyanidin (PA), flavonol, or anthocyanin concentration. In addition to concentration, the current experiment was designed to look at changes in PA composition, size and tannin activity through ripening. Tannin activity is a methodology for assessing the impact of structure and size on the affinity of tannin towards a hydrophobic surface and is considered to be a proxy for predicted astringency descriptive quality. In 2016 a shade cloth study was imposed on Cabernet Sauvignon on Mt Veeder, within the larger Napa Valley viticultural area. A control, which was unshaded, and two treatments consisting of 40% and 80% shade were applied at the onset of veraison.

RESULTS

Results showed significant differences in the composition and concentration of anthocyanins throughout ripening. Compositional differences in PA were also observed, where shaded treatments had a significantly higher proportion of galloylated subunits. The molecular mass of the extracted tannin was significantly lower in the unshaded control than in the 80% shade treatment. These factors led to a lower measured tannin activity in extracts from exposed fruit.

CONCLUSION

This work suggests that manipulation of canopy architecture, such as artificial shading, leads to changes in berry pigmentation, tannin composition and activity. These results show that the astringency and mouthfeel characteristics of a wine may be altered by vineyard management practices. © 2023 Society of Chemical Industry.

Outcomes of Hospitalized Patients With Fecal Occult Positive Stool Prior to Cardiac Catheterization in Acute Coronary Syndrome (ACS)

Introduction Cardiac catheterization is an essential component of patient care in Acute Coronary Syndrome (ACS). Fecal occult blood testing (FOBT) has been used in the inpatient setting to evaluate the risk of bleeding with dual anti-platelet therapy prior to cardiac catheterization although no guidelines exist for this indication and FOBT testing in the inpatient setting is not recommended for evaluation of GI blood loss. We sought to assess the outcomes of patients with fecal occult positive stool prior to cardiac catheterization compared to those that did not undergo FOBT during admission for non-ST-elevation myocardial infarction (NSTEMI). Methods We identified patients between 18 and 90 years old with admission for NSTEMI in the Trinetx Research Network from January 1, 2019 to December 31, 2020. Patients were then divided into those who had an FOBT prior to cardiac catheterization and those that did not have an FOBT. We compared all-cause mortality, bleeding, troponin levels, and length of stay between propensity-matched (PSM) pairs of patients. Results We identified 46,349 that met inclusion criteria, of which 1,728 had an FOBT (3.7%) and 44,621 (96.3%) had no FOBT prior to cardiac catheterization. Patients in the FOBT group were older and had a higher prevalence of hypertension, coronary artery disease, heart failure, diabetes, chronic obstructive pulmonary disease, and higher BMI. Two well-matched groups of n=1,728/1,728 were used for comparing outcomes. The FOBT group had similar 30-day mortality (4.45% vs 4.01, P=0.56) as well as similar bleeding events (0.98% vs 0.69%, P=0.35). Troponin levels in the FOBT group were on average lower (0.41 vs 0.95, P=0.04). The FOBT groups also had a similar average length of stay of (14.1 days vs 14.2 days, P=0.42). 233 patients who received FOBT underwent endoscopic evaluation with either upper endoscopy or colonoscopy (13.5%), and there was no significant difference in 30-day mortality (6.86% vs 4.7%, P=0.321). Among patients who underwent endoscopy, 72 had some form of endoscopic intervention (30.9%). There was no difference in 30-day mortality between patients undergoing endoscopy with intervention and without intervention (14.49%/14.49%) P=1.00. Readmission was similar between patients undergoing endoscopy with and without intervention. Conclusions In a large multi-center national database, we observed similar outcomes in patients who were admitted with NSTEMI and had FOBT and those not receiving FOBT in terms of all-cause mortality and bleeding events. In patients with positive FOBT, endoscopy with and without intervention we observed no significant difference in 30-day mortality. We conclude that there is no compelling evidence for FOBT testing in patients with NSTEMI.

Exploration of PCORnet Data Resources for Assessing Use of Molecular-Guided Cancer Treatment

PURPOSE

Examine the ability of PCORnet data resources to investigate molecular-guided cancer treatment.

PATIENTS AND METHODS

Patients (N = 86,154) had single primary solid tumors (diagnosed 2013-2017) from hospital oncology registries linked to the PCORnet Common Data Model (CDM) at 11 medical institutions. Molecular and anatomic test procedures and oral and infused therapies were identified with Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, RxNorm Concept Unique Identifier, and National Drug Codes from CDM tables. Chart review (2 institutions, n = 213) for advanced colorectal cancer and Medicare claims linkages (7 institutions, n = 1,731) for breast cancer explored options for increasing electronic data capture.

RESULTS

Molecular testing prevalence detected via analyte-specific molecular CPT/HCPCS codes was 5.5% (n = 4,784); for the nonspecific anatomic pathology codes, for which only some testing is performed to guide therapy selection, it was an additional 44.8% (n = 38,610). Molecular-guided therapy prevalence was 5% (n = 4,289). Testing and treatment were most common with stage IV disease and varied across cancer types and study institutions (testing, 0%-10.4%; treatment, 0.8%-8.4%). Therapy-concordant test results were found in charts for all 36 treated patients with colorectal cancer at the 2 institutions, 3 (8.3%) of whom received treatment outside the institution. Breast cancer Medicare claims linkage increased rates of identified testing from 62.7%-98.9% and treatment from 3.9%-8.2%.

CONCLUSION

Although a minority of patients received molecular-guided therapies, the majority had testing that could guide cancer treatment. Claims data extended electronic data capture for therapies and test orders but often was uninformative for types of test ordered. Test results continue to require text data curation from narrative pathology reports.

Anthocyanin Addition Alters Tannin Extraction from Grape Skins in Model Solutions via Chemical Reactions

Condensed tannin extraction and stable color formation are two of the cornerstones of red wine production. Without condensed tannin, red wine would lack the tactile feeling of astringency, and without the formation of modified pigments, it would lack color stability for long-term aging. To understand how malvidin-3,5-diglucoside interacts with condensed tannin under nonoxidative conditions, an experiment was designed conducting model-wine skin extractions of Sauvignon blanc grapes harvested at various dates of maturity. Monomeric malvidin-3,5-diglucoside was isolated from color concentrate and added during these extractions. Following a 72 h extraction, solutions were evaluated for recovery of monomeric anthocyanins, skin tannin concentration, skin tannin extractability, and impact of anthocyanins on condensed tannin size. Anthocyanins showed a significant impact on the extraction of flavan-3-ol material in the early stages of ripening that declined in the latter stages of ripening. Furthermore, anthocyanins significantly decreased the size of the condensed tannin extracted. These results suggest that anthocyanins are not only enhancing the extractability of condensed tannin but also readily incorporating into the polymeric material, leading to a decrease in the average molecular mass of the condensed tannin polymer. The extent of reaction in 72 h suggests that the rate of interflavan bond cleavage may be higher than previously reported and merits closer scrutiny.

Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease

BACKGROUND

The appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy.

METHODS

Using an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis.

RESULTS

A total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]).

CONCLUSIONS

In this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily. (Funded by the Patient-Centered Outcomes Research Institute; ADAPTABLE ClinicalTrials.gov number, NCT02697916.).

Interventions to reduce losses in the cascade of care for latent tuberculosis: a systematic review and meta-analysis

BACKGROUND: Losses can occur throughout the latent tuberculosis infection (LTBI) cascade of care. This can result in suboptimal rates of effective treatment for LTBI. We conducted a systematic review and meta-analysis to estimate the effect of different interventions to reduce losses in the LTBI cascade before treatment completion.METHODS: We searched several databases for articles reporting outcomes for interventions designed to strengthen the LTBI cascade. We included papers published in English from January 1990 until February 2018. Where possible, estimates were pooled using random-effects meta-analysis.RESULTS: We identified 30 studies that evaluated 32 different interventions aimed at reducing losses in the LTBI cascade. In pooled analysis, interventions that improved completion of cascade steps included patient incentives (respectively 42 [95% CI 34-51] and 48 [95% CI 15-81] additional patients completing initial assessment and medical evaluation per 100 starting); health care worker education (28 [95% CI 4-52] additional patients initiating initial assessment per 100 identified; home visits (additional 13 [95% CI 4-21] patients completing initial assessment per 100 starting); digital solutions (additional 11 [95% CI 4-21] patients initiating initial assessment per 100 identified); and patient reminders (additional 7 [95% CI 0.3-13] patients completing initial assessment per 100 starting). Several other interventions reduced losses at specific cascade steps, but evidence for these interventions came from single studies and could not be pooled.CONCLUSIONS: Although there is limited evidence that any single intervention significantly improves the LTBI cascade, many studies provide information about effective ways to strengthen it.

Fully Automated Light Precipitation Detection from MPLNET and EARLINET Network Lidar Measurements

The water cycle strongly influence life on Earth and precipitation especially modifies the atmospheric column thermodynamics through the evaporation process and serving as a proxy for latent heat modulation. For this reason, a correct light precipitation parameterization at global scale, it is of fundamental importance, bedsides improving our understanding of the hydrological cycle, to reduce the associated uncertainty of the global climate models to correctly forecast future scenarios. In this context we developed a full automatic algorithm based on morphological filters that, once operational, will make available a new rain product for the NASA Micropulse Lidar Network (MPLNET) and the European Aerosol Research Lidar Network (EARLINET) in the frame of WMO GALION Project

Using SNOMED CT-encoded problems to improve ICD-10-CM coding-A randomized controlled experiment

OBJECTIVE

Clinical problems in the Electronic Health Record that are encoded in SNOMED CT can be translated into ICD-10-CM codes through the NLM's SNOMED CT to ICD-10-CM map (NLM Map). This study evaluates the potential benefits of using the map-generated codes to assist manual ICD-10-CM coding.

METHODS

De-identified clinic notes taken by the physician during an outpatient encounter were made available on a secure web server and randomly assigned for coding by professional coders with usual coding or map-assisted coding. Map-assisted coding made use of the problem list maintained by the physician and the NLM Map to suggest candidate ICD-10-CM codes to the coder. A gold standard set of codes for each note was established by the coders using a Delphi consensus process. Outcomes included coding time, coding reliability as measured by the Jaccard coefficients between codes from two coders with the same method of coding, and coding accuracy as measured by recall, precision and F-score according to the gold standard.

RESULTS

With map-assisted coding, the average coding time per note reduced by 1.5 min (p = 0.006). There was a small increase in coding reliability and accuracy (not statistical significant). The benefits were more pronounced in the more experienced than less experienced coders. Detailed analysis of cases in which the correct ICD-10-CM codes were not found by the NLM Map showed that most failures were related to omission in the problem list and suboptimal mapping of the problem list terms to SNOMED CT. Only 12% of the failures was caused by errors in the NLM Map.

CONCLUSION

Map-assisted coding reduces coding time and can potentially improve coding reliability and accuracy, especially for more experienced coders. More effort is needed to improve the accuracy of the map-suggested ICD-10-CM codes.

A Model Information Management Plan for Molecular Pathology Sequence Data Using Standards: From Sequencer to Electronic Health Record

Incorporating genetic variant data into the electronic health record (EHR) in discrete computable fashion has vexed the informatics community for years. Genetic sequence test results are typically communicated by the molecular laboratory and stored in the EHR as textual documents. Although text documents are useful for human readability and initial use, they are not conducive for data retrieval and reuse. As a result, clinicians often struggle to find historical gene sequence results on a series of oncology patients within the EHR that might influence the care of the current patient. Second, identification of patients with specific mutation results in the EHR who are now eligible for new and/or changing therapy is not easily accomplished. Third, the molecular laboratory is challenged to monitor its sequencing processes for nonrandom process variation and other quality metrics. A novel approach to address each of these issues is presented and demonstrated. The authors use standard Health Level 7 laboratory result message formats in conjunction with international standards, Systematized Nomenclature of Medicine Clinical Terms and Human Genome Variant Society nomenclature, to represent, communicate, and store discrete gene sequence data within the EHR in a scalable fashion. This information management plan enables the support of the clinician at the point of care, enhances population management, and facilitates audits for maintaining laboratory quality.

Quantifying the direct radiative effect of absorbing aerosols for numerical weather prediction: a case study

We conceptualize aerosol radiative transfer processes arising from the hypothetical coupling of a global aerosol transport model and a global numerical weather prediction model by applying the US Naval Research Laboratory Navy Aerosol Analysis and Prediction System (NAAPS) and the Navy Global Environmental Model (NAVGEM) meteorological and surface reflectance fields. A unique experimental design during the 2013 NASA Studies of Emissions and Atmospheric Composition, Clouds and Climate Coupling by Regional Surveys (SEAC⁴RS) field mission allowed for collocated airborne sampling by the high spectral resolution Lidar (HSRL), the Airborne Multi-angle SpectroPolarimetric Imager (AirMSPI), up/down shortwave (SW) and infrared (IR) broadband radiometers, as well as NASA A-Train support from the Moderate Resolution Imaging Spectroradiometer (MODIS), to attempt direct aerosol forcing closure. The results demonstrate the sensitivity of modeled fields to aerosol radiative fluxes and heating rates, specifically in the SW, as induced in this event from transported smoke and regional urban aerosols. Limitations are identified with respect to aerosol attribution, vertical distribution, and the choice of optical and surface polarimetric properties, which are discussed within the context of their influence on numerical weather prediction output that is particularly important as the community propels forward towards inline aerosol modeling within global forecast systems.

Wildfire-driven thunderstorms cause a volcano-like stratospheric injection of smoke

Intense heating by wildfires can generate deep, smoke-infused thunderstorms, known as pyrocumulonimbus (pyroCb), which can release a large quantity of smoke particles above jet aircraft cruising altitudes. Injections of pyroCb smoke into the lower stratosphere have gained increasing attention over the past 15 years due to the rapid proliferation of satellite remote sensing tools. Impacts from volcanic eruptions and other troposphere-to-stratosphere exchange processes on stratospheric radiative and chemical equilibrium are well recognized and monitored. However, the role of pyroCb smoke in the climate system has yet to be acknowledged. Here, we show that the mass of smoke aerosol particles injected into the lower stratosphere from five near-simultaneous intense pyroCbs occurring in western North America on 12 August 2017 was comparable to that of a moderate volcanic eruption, and an order of magnitude larger than previous benchmarks for extreme pyroCb activity. The resulting stratospheric plume encircled the Northern Hemisphere over several months. By characterizing this event, we conclude that pyroCb activity, considered as either large singular events, or a full fire season inventory, significantly perturb the lower stratosphere in a manner comparable with infrequent volcanic intrusions.

Status of the NASA Micro Pulse Lidar Network (MPLNET): overview of the network and future plans, new version 3 data products, and the polarized MPL

The NASA Micro Pulse Lidar Network (MPLNET) is a global federated network of Micro-Pulse Lidars (MPL) co-located with the NASA Aerosol Robotic Network (AERONET). MPLNET began in 2000, and there are currently 17 long-term sites, numerous field campaigns, and more planned sites on the way. We have developed a new Version 3 processing system including the deployment of polarized MPLs across the network. Here we provide an overview of Version 3, the polarized MPL, and current and future plans.

Latent tuberculosis diagnostic tests to predict longitudinal tuberculosis during dialysis: a meta-analysis

SETTING

Tuberculosis (TB) rates in dialysis patients are more than 10 times greater than in the general population. Recent recommendations advise the use of interferon-gamma release assays (IGRAs) over the tuberculin skin test (TST) to aid in the diagnosis of latent tuberculous infection (LTBI); however, their longitudinal predictive ability for TB development has not been assessed.

OBJECTIVE

To determine whether the TST or IGRA are able to predict longitudinal TB development in dialysis patients.

DESIGN

We performed a systematic review to determine the longitudinal risk of TB in dialysis patients. Random-effects meta-analysis was used to determine the incidence rate ratio (IRR) of longitudinal TB development and the predictive value of such tests.

RESULTS

Eight studies were included. An IRR of 2.59 (95%CI 1.20-5.57) for longitudinal TB was seen in patients with a TST ⩾ 10 mm compared to patients with a TST < 10 mm. The positive predictive value (PPV) of a TST ⩾ 10 mm was 11.93% and the negative predictive value was 94.03%. We were unable to analyse the studies that used IGRAs, as only one study had TB events.

CONCLUSION

A TST with a 10 mm cut-off point appears to offer the capability to distinguish long-term risk of TB, with a modest PPV. The predictive value of IGRAs could not be quantified.

Minimum aerosol layer detection sensitivities and their subsequent impacts on aerosol optical thickness retrievals in CALIPSO level 2 data products

Due to instrument sensitivities and algorithm detection limits, level 2 (L2) Cloud-Aerosol Lidar with Orthogonal Polarization (CALIOP) 532nm aerosol extinction profile retrievals are often populated with retrieval fill values (RFVs), which indicate the absence of detectable levels of aerosol within the profile. In this study, using 4 years (2007-2008 and 2010-2011) of CALIOP version 3 L2 aerosol data, the occurrence frequency of daytime CALIOP profiles containing all RFVs (all-RFV profiles) is studied. In the CALIOP data products, the aerosol optical thickness (AOT) of any all-RFV profile is reported as being zero, which may introduce a bias in CALIOP-based AOT climatologies. For this study, we derive revised estimates of AOT for all-RFV profiles using collocated Moderate Resolution Imaging Spectroradiometer (MODIS) Dark Target (DT) and, where available, AErosol RObotic NEtwork (AERONET) data. Globally, all-RFV profiles comprise roughly 71% of all daytime CALIOP L2 aerosol profiles (i.e., including completely attenuated profiles), accounting for nearly half (45 %) of all daytime cloud-free L2 aerosol profiles. The mean collocated MODIS DT (AERONET) 550 nm AOT is found to be near 0.06 (0.08) for CALIOP all-RFV profiles. We further estimate a global mean aerosol extinction profile, a so-called "noise floor", for CALIOP all-RFV profiles. The global mean CALIOP AOT is then recomputed by replacing RFV values with the derived noise-floor values for both all-RFV and non-all-RFV profiles. This process yields an improvement in the agreement of CALIOP and MODIS over-ocean AOT.

A computable pathology report for precision medicine: extending an observables ontology unifying SNOMED CT and LOINC

Background

The College of American Pathologists (CAP) introduced the first cancer synoptic reporting protocols in 1998. However, the objective of a fully computable and machine-readable cancer synoptic report remains elusive due to insufficient definitional content in Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC). To address this terminology gap, investigators at the University of Nebraska Medical Center (UNMC) are developing, authoring, and testing a SNOMED CT observable ontology to represent the data elements identified by the synoptic worksheets of CAP.

Methods

Investigators along with collaborators from the US National Library of Medicine, CAP, the International Health Terminology Standards Development Organization, and the UK Health and Social Care Information Centre analyzed and assessed required data elements for colorectal cancer and invasive breast cancer synoptic reporting. SNOMED CT concept expressions were developed at UNMC in the Nebraska Lexicon© SNOMED CT namespace. LOINC codes for each SNOMED CT expression were issued by the Regenstrief Institute. SNOMED CT concepts represented observation answer value sets.

Results

UNMC investigators created a total of 194 SNOMED CT observable entity concept definitions to represent required data elements for CAP colorectal and breast cancer synoptic worksheets, including biomarkers. Concepts were bound to colorectal and invasive breast cancer reports in the UNMC pathology system and successfully used to populate a UNMC biobank.

Discussion

The absence of a robust observables ontology represents a barrier to data capture and reuse in clinical areas founded upon observational information. Terminology developed in this project establishes the model to characterize pathology data for information exchange, public health, and research analytics.

Management practices associated with pain in cattle on western Canadian cow-calf operations: A mixed methods study

The implementation of on-farm pain mitigation strategies is dependent on feasibility and importance to producers. Currently, there is a lack of information regarding adoption of management practices associated with pain in cattle within the Canadian beef industry. The objective of this mixed methods study was to describe pain-associated practices implemented on farm and producer perceptions toward pain mitigation strategies. A questionnaire about calving management and calf processing was delivered to 109 cow-calf producers in western Canada. In addition, 15 respondents were purposively selected based on questionnaire responses to participate in individual semistructured, on-farm interviews. The prevalence of pain mitigation strategies used for dystocia and cesarean section by respondents were 46 and 100%, respectively. The majority of operations reported castrating and dehorning calves before 3 mo of age (95 and 89%, respectively). The majority of operations did not use pain mitigation strategies for castration and dehorning (90 and 85%, respectively). Branding was practiced by 57% of respondents, 4% of which used pain mitigation. Thematic content analysis revealed that producers' perception of pain were influenced by what they referred to as "common sense," relatability to cattle, visual evidence of pain, and age of the animal. Factors that influenced participant rationale for the implementation of pain mitigation practices included access to information and resources, age of the animal, benefit to the operation, cost and logistics, market demands, and personal conscience. Overall, management practices were generally in compliance with published Canadian guidelines. Results of this study may provide direction for future policy making, research, and extension efforts to encourage the adoption of pain mitigation strategies.

Management practices associated with stress in cattle on western Canadian cow-calf operations: A mixed methods study

Handling, weaning, and euthanasia are some of the most stressful practices performed on cow-calf operations. Although strategies to minimize stress exist, their use on western Canadian cow-calf operations is unknown. The objectives were to describe current stress-associated practices on western Canadian cow-calf operations, describe producer and operation demographics associated with the use of nonabrupt weaning methods, and explore producer perceptions toward these practices. A questionnaire focusing on stressful management practices was delivered to 109 cow-calf producers in western Canada. Fifteen respondents were purposively selected for individual interviews. The majority of producers reported calves less than 1 wk of age were handled by manual restraint (87%) and those older than 1 wk of age were handled using a cattle squeeze or table. Most producers performed abrupt weaning (70%). Interviewees often mentioned that cost and logistics were major factors in deciding on a weaning strategy. Pasture availability and facilities were viewed as constraints toward the adoption of a nonabrupt weaning method. Animal stress was considered, as producers expressed concern that nonabrupt weaning methods may cause increased stress because of the additional handling required. Producers conveyed that animal age was a major factor that impacted weaning stress and that improved animal performance might motivate them to adopt a nonabrupt weaning strategy. Producers also expressed reluctance to change previously successful traditional approaches. Of respondents, 13% did not euthanize cattle on farm and 8% did not confirm death. Producers interviewed reported that the decision to euthanize cattle on farm was difficult and that veterinary advice was often considered. Factors that influenced their decision to euthanize included the animal's likelihood of recovery and degree of pain and distress. Finally, producers explained that they considered whether the animal was salvageable and able to be transported. Identification of common methods of handling provides focus for future research to determine optimal handling strategies. Identified barriers to nonabrupt weaning may be addressed through research, extension, or policy to encourage the adoption of weaning methods that could improve animal welfare. Confirmation of death after euthanasia was identified as an area that needs to be addressed by producer education to minimize animal stress during on-farm euthanasia.

An Extended SNOMED CT Concept Model for Observations in Molecular Genetics

Molecular genetics laboratory reports are multiplying and increasingly of clinical importance in diagnosis and treatment of cancer, infectious disease and managing of public health. Little of this data is structured or maintained in the EHR in format useful for decision support or research. Structured, computable reporting is limited by non-availability of a domain ontology for these data. The IHTSDO and Regenstrief Institute(RI) have been collaborating since 2008 to develop a unified concept model and ontology of observable entities - concepts which represent the results of laboratory and clinical observations. In this paper we report the progress we have made to apply that unified concept model to the structured recording of observations in clinical molecular genetic pathology including immunohistochemistry and sequence variant findings. The primary use case for deployment is the structured and coded reporting of Cancer checklist

Overview of MPLNET Version 3 Cloud Detection

The National Aeronautics and Space Administration Micropulse Lidar Network Version 3 cloud detection algorithm is described and its differences relative to the previous version highlighted. Clouds are identified from normalized Level 1 signal profiles using two complementary methods. The first considers signal derivatives vertically for resolving low-level clouds. The second, which resolves high-level clouds like cirrus, is based on signal uncertainties given the relatively low signal-to-noise ratio exhibited in the upper troposphere by eye-safe network instruments, especially during daytime. Furthermore, a multi-temporal averaging scheme is used to improve cloud detection under conditions of weak signal-to-noise. Diurnal and seasonal cycles of cloud occurrence frequency based on one year of measurements at the Goddard Space Flight Center (Greenbelt, MD) site are compared for the new and previous versions. The largest differences, and perceived improvement, in detection occurs for high clouds (above 5-km, mean sea level) which increase in occurrence by nearly 6%. There is also an increase in the detection of multi-layered cloud profiles from 9% to 20%. Macrophysical properties and estimates of cloud optical depth are presented for a transparent cirrus dataset. However, the limit to which molecular signal can be reliably retrieved above cirrus clouds occurs between cloud optical depths of 0.5 and 0.8.

Daytime Cirrus Cloud Top-of-Atmosphere Radiative Forcing Properties at a Midlatitude Site and their Global Consequence

One-year of continuous ground-based lidar observations (2012) are analyzed for single-layer cirrus clouds at the NASA Micro Pulse Lidar Network site at the Goddard Space Flight Center to investigate top-of-atmosphere (TOA) annual net daytime radiative forcing properties. A slight positive net daytime forcing is estimated (i.e., warming) : 0.07 - 0.67 W/m² in relative terms, which reduces to 0.03 - 0.27 W/m² in absolute terms after normalizing to unity based on approximated 40% midlatitude occurrence frequency rate estimated from satellite. Results are based on bookend solutions for lidar extinction-to-backscatter (20 and 30 sr) and corresponding retrievals for 532 nm cloud extinction coefficient. Uncertainties due to cloud undersampling, attenuation effects, sample selection and lidar multiple scattering are described. A net daytime cooling effect is found from the very thinnest clouds (cloud optical depth ≤ 0.01) that is attributed to relatively high solar zenith angles. A relationship between positive/negative daytime cloud forcing is demonstrated as a function of solar zenith angle and cloud top temperature. These properties, combined with the influence of varying surface albedos, are used to conceptualize how daytime cloud forcing likely varies with latitude and season, with cirrus clouds exerting less positive forcing and potentially net TOA cooling approaching the summer poles (non-ice and snow covered) versus greater warming at the equator. The existence of such a gradient would lead cirrus to induce varying daytime TOA forcing annually and seasonally, making it a far greater challenge than presently believe to constrain daytime and diurnal cirrus contributions to global radiation budgets.

Agreement between Three Serological Tests for Neospora Caninum in Beef Cattle

During 1999, serum samples were collected from beef cows on pastures in western Canada. Some of the herds had a history of confirmed abortions associated with Neospora caninum infection. All these samples were initially analyzed using a single application of 1 common commercial enzyme-linked immunosorbent assay (ELISA) for antibodies to N. caninum. From these initial results, 239 positive and 250 negative samples were randomly selected for further testing. This group of samples was retested using the 3 commercially available ELISA tests for N. caninum as per the manufacturer's recommendations. The agreement between 2 of the ELISAs was good (k = 0.76); agreement of these 2 tests with the third test was much lower (k = 0.46 and 0.60). Quantitative agreement between tests measured by intraclass correlation coefficients was also acceptable between the first 2 tests but was almost zero when the first 2 tests were compared with the third. This information is necessary to understand the differences in seroprevalence reported in different regions from laboratories using different methods.

The Greater Plains Collaborative: a PCORnet Clinical Research Data Network

The Greater Plains Collaborative (GPC) is composed of 10 leading medical centers repurposing the research programs and informatics infrastructures developed through Clinical and Translational Science Award initiatives. Partners are the University of Kansas Medical Center, Children's Mercy Hospital, University of Iowa Healthcare, the University of Wisconsin-Madison, the Medical College of Wisconsin and Marshfield Clinic, the University of Minnesota Academic Health Center, the University of Nebraska Medical Center, the University of Texas Health Sciences Center at San Antonio, and the University of Texas Southwestern Medical Center. The GPC network brings together a diverse population of 10 million people across 1300 miles covering seven states with a combined area of 679 159 square miles. Using input from community members, breast cancer was selected as a focus for cohort building activities. In addition to a high-prevalence disorder, we also selected a rare disease, amyotrophic lateral sclerosis.

Semantic analysis of SNOMED CT for a post-coordinated database of histopathology findings

Objective

This research investigated the use of SNOMED CT to represent diagnostic tissue morphologies and notable tissue architectures typically found within a pathologist's microscopic examination report to identify gaps in expressivity of SNOMED CT for use in anatomic pathology.

Methods

24 breast biopsy cases were reviewed by two board certified surgical pathologists who independently described the diagnostically important tissue architectures and diagnostic morphologies observed by microscopic examination. In addition, diagnostic comments and details were extracted from the original diagnostic pathology report. 95 unique clinical statements were extracted from 13 malignant and 11 benign breast needle biopsy cases.

Results

75% of the inventoried diagnostic terms and statements could be represented by valid SNOMED CT expressions. The expressions included one pre-coordinated expression and 73 post-coordinated expressions. No valid SNOMED CT expressions could be identified or developed to unambiguously assert the meaning of 21 statements (ie, 25% of inventoried clinical statements). Evaluation of the findings indicated that SNOMED CT lacked sufficient definitional expressions or the SNOMED CT concept model prohibited use of certain defined concepts needed to describe the numerous, diagnostically important tissue architectures and morphologic changes found within a surgical pathology microscopic examination.

Conclusions

Because information gathered during microscopic histopathology examination provides the basis of pathology diagnoses, additional concept definitions for tissue morphometries and modifications to the SNOMED CT concept model are needed and suggested to represent detailed histopathologic findings in computable fashion for purposes of patient information exchange and research.

Trial registration number

UNMC Institutional Review Board ID# 342-11-EP.

C-reactive protein and brain natriuretic peptide as predictors of adverse events after lower extremity endovascular revascularization

BACKGROUND

High-sensitivity C-reactive protein (hsCRP) and brain natriuretic peptide (BNP) have been shown to be independent predictors of adverse cardiovascular outcomes and increased risk of secondary interventions or limb loss in patients with peripheral arterial disease (PAD). To assist clinicians in decision-making about treatment approaches and predicting postprocedure mortality and morbidity, we retrospectively examined patients with preprocedure hsCRP and BNP levels who underwent elective angioplasty or stent placement for lower extremity PAD.

METHODS

The study period was from January 1, 2007, to December 31, 2012, and patients were included who had angioplasty or stenting for PAD. Minimal required follow-up for study inclusion was at least one postoperative ankle-brachial index, contrast angiography, or duplex imaging of the treated limb. Events of interest included major adverse limb events (MALE), defined as target vessel revascularization, amputation, or disease progression by 1 year, and major adverse cardiovascular events (MACE; stroke, myocardial infarction, or death) by 2 years. Elevated/abnormal values for our biomarkers of interest were established by the upper limits of our institution's clinical laboratory reference range (hsCRP, >0.80 mg/dL; BNP, >100 pg/mL).

RESULTS

A total of 159 limbs in 118 patients were included in analysis (42% men; median age [range], 64 [42-87] years). All limbs were symptomatic (Rutherford classification: 1-6). Iliac artery revascularization without other adjunct lower extremity intervention was performed in 60% of the limbs. High hsCRP levels (>0.80 mg/dL) were present in 32 patients (27%) and high BNP values (>100 pg/mL) in 24 patients (20%). Kaplan-Meier analysis with log-rank comparison demonstrated that elevated hsCRP levels were associated with MALE but only in limbs receiving interventions distal to the iliac arteries (P = .005). High BNP levels did not affect MALE rates (P = .821). Conversely, both elevated BNP levels (hazard ratio, 5.6; 95% confidence interval [CI], 2.0-5.8; P = .001) and hsCRP levels (hazard ratio, 2.9; 95% CI, 1.1-7.6; P = .034) predicted MACE at 2 years in the presence of confounders in Cox proportional hazards multivariate analysis. Patients with high preintervention values of hsCRP and BNP were 10.6 times (95% CI, 2.6-42.9; P = .001) more likely to experience MACE than were patients with normal hsCRP and BNP values.

CONCLUSIONS

After lower extremity endovascular interventions, elevated preprocedural hsCRP levels are associated with MALE (femoral-popliteal interventions), and elevated levels of hsCRP and BNP are associated with late cardiovascular events.

Estimating surface visibility at Hong Kong from ground-based LIDAR, sun photometer and operational MODIS products

Hong Kong's surface visibility has decreased in recent years due to air pollution from rapid social and economic development in the region. In addition to deteriorating health standards, reduced visibility disrupts routine civil and public operations, most notably transportation and aviation. Regional estimates of visibility solved operationally using available ground and satellite-based estimates of aerosol optical properties and vertical distribution may prove more effective than standard reliance on a few existing surface visibility monitoring stations. Previous studies have demonstrated that such satellite measurements correlate well with near-surface optical properties, despite these sensors do not consider range-resolved information and indirect parameterizations necessary to solve relevant parameters. By expanding such analysis to include vertically resolved aerosol profile information from an autonomous ground-based lidar instrument, this work develops six models for automated assessment of surface visibility. Regional visibility is estimated using co-incident ground-based lidar, sun photometer visibility meter and MODerate-resolution maging Spectroradiometer (MODIS) aerosol optical depth data sets. Using a 355 nm extinction coefficient profile solved from the lidar MODIS AOD (aerosol optical depth) is scaled down to the surface to generate a regional composite depiction of surface visibility. These results demonstrate the potential for applying passive satellite depictions of broad-scale aerosol optical properties together with a ground-based surface lidar and zenith-viewing sun photometer for improving quantitative assessments of visibility in a city such as Hong Kong.

Semantic interoperation and electronic health records: context sensitive mapping from SNOMED CT to ICD-10

An important case for successful deployment of a lifetime electronic health record is reuse of clinical data from the electronic health record (EHR) for epidemiology, reimbursement, and research. We report a collaboration between the IHTSDO and the WHO to develop knowledge-based tools supporting translation of data from SNOMED CT to the ICD-10 classification. These tools have been vetted by an international community and are available for system vendors to enhance the interoperability of their products. The maps we created are also informing the development of the next generation of classifications which will employ a common ontology base between SNOMED CT and ICD-11 to promote interoperability.

Antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary vascular surgical site infections

OBJECTIVE

This study assessed the efficacy of antibiotic-loaded polymethylmethacrylate (PMMA) beads in the treatment of lower extremity vascular surgical site infections (VSSIs).

METHODS

This was a retrospective review of all patients with a VSSI of a lower extremity bypass treated with antibiotic-loaded PMMA beads and culture-specific antibiotics during a 4.5-year period. Data collected included patient demographics, comorbidities, site of initial graft infection, symptoms and signs at presentation, initial and additional surgical debridement, wound culture results, type of antibiotic beads implanted, and graft treatment strategy, comprising conduit preservation or in situ replacement, with associated soft tissue management by muscle flap or vacuum-assisted closure. Primary outcome measures included death, recurrent infection, and limb salvage.

RESULTS

Forty patients developed 42 extracavitary lower extremity VSSIs (bilateral groin infections in two). Patients were treated according to our treatment algorithm with antibiotic-impregnated PMMA beads. Previous reconstructions included nine aortofemoral bypasses (groin infection only), 20 infrainguinal bypasses, five extra-anatomic bypasses, five femoral interpositions, two combined inflow-outflow bypass procedures, and one patch angioplasty with VSSI. Cultures isolated 59 pathogens (39 gram-positive, 18 gram-negative, 2 Candida spp). Methicillin-resistant Staphylococcus aureus was cultured from 10 VSSs (23.8%) overall and from 27.7% of those patients with attempted graft preservation or in situ reconstructions. Two patients (4.8%) had no growth despite clinical signs of infection. Repeat VSS exploration and culture results led to an average of 1.4 bead replacements before definitive treatment. Final treatment strategy included graft preservation of patent bypasses in 28, partial graft excision with in situ replacement in eight, graft removal only with residual graft remaining at implant site (ie, incorporated anastomotic conduit, 11.9%) in five, and extra-anatomic reconstruction in one. Sartorius muscle flap was performed in 14 groin infections (37.8%). The 30-day mortality was 0%, and limb loss was 7.1% (n = 3). At the median follow-up of 17 months, the limb loss was 21.4% and the recurrent infection rate was 19.4% (seven of 36) in those with attempted graft preservation or in situ replacement.

CONCLUSIONS

Antibiotic-loaded PMMA beads may serve as an adjunct in the management of VSSIs and may also expand treatment options for graft preservation or in situ reconstruction, with expected recurrent infection rate approaching 20%. Further experience with this adjunct may help elucidate its role in the management of this complicated problem, including the need for bead exchanges, until perigraft cultures are free of microbes.

Can SNOMED CT fulfill the vision of a compositional terminology? Analyzing the use case for problem list

We analyzed 598 of 63,952 terms employed in problem list entries from seven major healthcare institutions that were not mapped with UMLS to SNOMED CT when preparing the NLM UMLS-CORE problem list subset. We intended to determine whether published or post-coordinated SNOMED concepts could accurately capture the problems as stated by the clinician and to characterize the workload for the local terminology manager. From the terms we analyzed, we estimate that 7.5% of the total terms represent ambiguous statements that require clarification. Of those terms which were unambiguous, we estimate that 38.1% could be encoded using the SNOMED CT January 2011 pre-coordinated (published core) content. 60.4% of unambiguous terms required post-coordination to capture the term meaning within the SNOMED model. Approximately 28.5% of post-coordinated content could not be fully defined and required primitive forms. This left 1.5% of unambiguous terms which were expressed with meaning which could not be represented in SNOMED CT. We estimate from our study that 98.5% of clinical terms unambiguously suggested for the problem list can be equated to published concepts or can be modeled with SNOMED CT but that roughly one in four SNOMED modeled expressions fail to represent the full meaning of the term. Implications for the business model of the local terminology manager and the development of SNOMED CT are discussed.

Blood lead levels of refugee children resettled in Massachusetts, 2000 to 2007

OBJECTIVES

We described elevated blood lead level (BLL; ≥ 10 μg/dL) prevalence among newly arrived refugee children in Massachusetts. We also investigated the incidence of BLL increases and BLLs newly elevated to 20 μg/dL or higher in the year following initial testing, along with associated factors.

METHODS

We merged data from the Massachusetts Department of Public Health's Refugee and Immigrant Health Program and the Childhood Lead Poisoning Prevention Program on 1148 refugee children younger than 7 years who arrived in Massachusetts from 2000 to 2007.

RESULTS

Elevated BLL prevalence was 16% among newly arrived refugee children. The rate ratio for BLL elevation to 20 μg/dL or higher after arrival was 12.3 (95% confidence interval [CI] = 6.2, 24.5) compared with children in communities the state defines as high-risk for childhood lead exposure. Residence in a census tract with older housing (median year built before 1950) was associated with a higher rate of BLL increases after resettlement (hazard ratio = 1.7; 95% CI = 1.2, 2.3).

CONCLUSIONS

Refugee children are at high risk of lead exposure before and after resettlement in Massachusetts. A national surveillance system of refugee children's BLLs following resettlement would allow more in-depth analysis.

Bone lead levels are associated with measures of memory impairment in older adults

Accumulating evidence suggests a link between lead exposure and memory impairment but assessments based on predictive and validated measures are lacking. We conducted a pilot study of 47 healthy subjects 55-67 years of age to examine associations between bone lead levels and 4 tests sensitive to the natural history of Mild Cognitive Impairment (MCI) and Alzheimer's disease (AD). These include three subtests of the Cambridge Neuropsychological Test Automated Battery (delayed match-to-sample, paired associates learning and spatial recognition memory) and the Montreal Cognitive Assessment Test. Bone lead concentrations were measured at the mid-shaft of the tibia and the calcaneus with K X-ray fluorescence. Higher tibial and calcaneal bone lead values were significantly (p<0.05) associated with lower performance levels on delayed match-to-sample and paired associates learning in unadjusted analyses with Spearman rank correlation coefficients of about 0.4. Multiple linear regression analyses (i.e., least-squares means of cognitive test scores across tertiles of lead exposure) adjusted for age, education and smoking status continued to show an association of higher calcaneal lead levels with increasing memory impairments on delayed match-to-sample (p=0.07). As might be expected, additional adjustment for history of hypertension reduced the strength of this association (p=0.19). Given the demonstrated impact of lead exposure on hypertension and the vascular etiology of certain dementias, we speculate that hypertension could play a mediating role in the association between lead exposure and memory impairment.

The SAGE Guideline Model: achievements and overview

The SAGE (Standards-Based Active Guideline Environment) project was formed to create a methodology and infrastructure required to demonstrate integration of decision-support technology for guideline-based care in commercial clinical information systems. This paper describes the development and innovative features of the SAGE Guideline Model and reports our experience encoding four guidelines. Innovations include methods for integrating guideline-based decision support with clinical workflow and employment of enterprise order sets. Using SAGE, a clinician informatician can encode computable guideline content as recommendation sets using only standard terminologies and standards-based patient information models. The SAGE Model supports encoding large portions of guideline knowledge as re-usable declarative evidence statements and supports querying external knowledge sources.

The association between blood lead levels and osteoporosis among adults--results from the third national health and nutrition examination survey (NHANES III)

BACKGROUND

Osteoporosis is a reduction in bone mass sufficient to increase the risk of fracture. Lead exposure during childhood may be a risk factor for low bone mineral density (BMD). Basic-science research demonstrates that lead exposure is associated with a decrease in BMD in animals. However, human studies are limited.

OBJECTIVE

Our objective was to conduct a secondary analysis of a national database to explore the association between lead exposure and osteoporosis in adult humans.

METHODS

In this study we used data from the Third National Health and Nutrition Examination Survey (NHANES III). We analyzed subjects who were >/= 50 years of age. A concurrent venous blood lead level defined lead exposure. The primary outcome variable was the BMD of the total hip. We conducted analyses on four groups: non-Hispanic white men, non-Hispanic white women, African-American men, and African-American women. We conducted bivariate analyses between covariates known to be associated with bone density (i.e., age, body mass index, calcium intake, ethanol/tobacco consumption, physical activity, socioeconomic status) and the total hip BMD. The significant covariates were introduced into analysis of covariance to determine the association between BMD and blood lead level tercile.

RESULTS

The adjusted mean total hip BMD among non-Hispanic white males with a blood lead level in the lowest tercile versus the highest tercile was 0.961 g/cm(2) and 0.934 g/cm(2), respectively (p < 0.05). We also found a similar association among white females, but the difference was marginally significant (0.05 < p < 0.10).

CONCLUSIONS

We found a significant inverse association between lead exposure and BMD, but only among white subjects. However, because of the cross-sectional design of NHANES, we cannot make inferences about the temporal sequence of this association. With the large number of adults who had lead exposure in the past and the morbidity associated with osteoporosis, further inquiry is necessary on the possible casusal association between lead exposure and osteoporosis in humans.

Erratum To: The burden of diarrhoea, shigellosis, and cholera in North Jakarta, Indonesia: findings from 24 months surveillance

This is a correction of an earlier published article.

Creating interoperable guidelines: requirements of vocabulary standards in immunization decision support

Interoperable support of electronic health records and clinical decision support technology are central to the vision of sustainable information infrastructure. Efforts to implement interoperable clinical guidelines for immunization practice have been sparse. We used the SAGE knowledge workbench to develop a knowledge base to provide immunization decision support in primary care. We translated the written clinical guideline into a structured decision logic format. The semantic content to completely capture CDC clinical decision logic required 197 separate concepts but was completely captured with SNOMED CT and LOINC. Although 88% of concepts employed precoordinated codes, 6% of guideline concepts required expanded vocabulary services employing Boolean logical definition using two or more SNOMED concepts. Postcoordination requirements were modest, representing just 6% of guideline semantic concepts. We conclude that creation of interoperable knowledge bases employing clinical vocabulary standards is achievable and realistic. Employment of information model (HL7 RIM) and vocabulary (SNOMED CT, LOINC) standards is a necessary and feasible requirement to achieve interoperability in clinical decision support.

Structuring order sets for interoperable distribution

A major portion of patient care planning occurs during the process of writing orders. Computerized order entry can present collections of predefined orders to the user during the ordering process. These order sets are useful for promoting standards of care, and provide one element of structured clinical knowledge to be used by Computerized Provider Order Entry (CPOE) systems at the point of care. Since the creation, confirmation and maintenance of order sets is resource intensive, sharing order sets is a useful goal. We describe a standard representation of order sets that supports maintenance, sharing and interoperation of pre-defined order sets. A dialogue within the HL7 community seeks to harmonize this proposal with the Clinical Document Architecture and the HL7 Reference Information Model.

Use of declarative statements in creating and maintaining computer-interpretable knowledge bases for guideline-based care

Developing computer-interpretable clinical practice guidelines (CPGs) to provide decision support for guideline-based care is an extremely labor-intensive task. In the EON/ATHENA and SAGE projects, we formulated substantial portions of CPGs as computable statements that express declarative relationships between patient conditions and possible interventions. We developed query and expression languages that allow a decision-support system (DSS) to evaluate these statements in specific patient situations. A DSS can use these guideline statements in multiple ways, including: (1) as inputs for determining preferred alternatives in decision-making, and (2) as a way to provide targeted commentaries in the clinical information system. The use of these declarative statements significantly reduces the modeling expertise and effort required to create and maintain computer-interpretable knowledge bases for decision-support purpose. We discuss possible implications for sharing of such knowledge bases.

Renal artery angiography: “The right ipsilateral oblique” Myth

BACKGROUND

Finding the optimal image intensifier angle of obliquity during renal intervention is important for accurate stent placement but can require multiple catheter rotations and test injections of contrast.

OBJECTIVE

Explore the usefulness of axial magnetic resonance angiography (MRA) as a roadmap for predicting image intensifier position during subsequent renal intervention.

METHODS

MRA images were reviewed in 137 consecutive patients (255 renal arteries) undergoing workup for renal artery stenosis. The axial angle of renal artery incidence perpendicular to the spine was estimated by two operators and results averaged.

RESULTS

The average angle of incidence for the renal artery ostia was +21.24 degrees +/-2.31 degrees for the right and +8.81 degrees +/-2.0 degrees for the left (P < .0001). The positive numbers correlate with left anterior oblique (LAO) and negative right anterior oblique (RAO).

CONCLUSIONS

MRA can be used to define the origin of the renal artery and is most likely to predict an LAO image window for subsequent angiography of the left and right renal arteries displacing the "ipsilateral oblique" axiom. In patients without baseline MRA the 10 to 20 degree LAO "empiric" position will allow coaxial imaging of both renal ostia in 75% of cases. However, there can be extreme variation in the renal origin (53 degrees RAO to 85 degrees LAO) and we advocate using the simple technique reported herein to define the renal origin in patients with pre-procedure MRA.

The burden of diarrhoea, shigellosis, and cholera in North Jakarta, Indonesia: findings from 24 months surveillance

Background

In preparation of vaccines trials to estimate protection against shigellosis and cholera we conducted a two-year community-based surveillance study in an impoverished area of North Jakarta which provided updated information on the disease burden in the area.

Methods

We conducted a two-year community-based surveillance study from August 2001 to July 2003 in an impoverished area of North Jakarta to assess the burden of diarrhoea, shigellosis, and cholera. At participating health care providers, a case report form was completed and stool sample collected from cases presenting with diarrhoea.

Results

Infants had the highest incidences of diarrhoea (759/1 000/year) and cholera (4/1 000/year). Diarrhea incidence was significantly higher in boys under 5 years (387/1 000/year) than girls under 5 years (309/1 000/year; p < 0.001). Children aged 1 to 2 years had the highest incidence of shigellosis (32/1 000/year). Shigella flexneri was the most common Shigella species isolated and 73% to 95% of these isolates were resistant to ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol and tetracycline but remain susceptible to nalidixic acid, ciprofloxacin, and ceftriaxone. We found an overall incidence of cholera of 0.5/1 000/year. Cholera was most common in children, with the highest incidence at 4/1 000/year in those less than 1 year of age. Of the 154 V. cholerae O1 isolates, 89 (58%) were of the El Tor Ogawa serotype and 65 (42%) were El Tor Inaba. Thirty-four percent of patients with cholera were intravenously rehydrated and 22% required hospitalization. V. parahaemolyticus infections were detected sporadically but increased from July 2002 onwards.

Conclusion

Diarrhoea causes a heavy public health burden in Jakarta particularly in young children. The impact of shigellosis is exacerbated by the threat of antimicrobial resistance, whereas that of cholera is aggravated by its severe manifestations.

The association between environmental lead exposure and bone density in children

Osteoporosis is a decrease in bone mineral density (BMD) that predisposes individuals to fractures. Although an elderly affliction, a predisposition may develop during adolescence if a sufficient peak BMD is not achieved. Rat studies have found that lead exposure is associated with decreased BMD. However, human studies are limited. We hypothesized that the BMD of children with high lead exposure would be lower than the BMD of children with low lead exposure. We collected data on 35 subjects; 16 had low cumulative lead exposure (mean, 6.5 microg/dL), and 19 had high exposure (mean, 23.6 micro g/dL). All were African American; there was no difference between the groups by sex, age, body mass index, socioeconomic status, physical activity, or calcium intake. Significant differences in BMD between low and high cumulative lead exposure were noted in the head (1.589 vs. 1.721 g/cm2), third lumbar vertebra (0.761 vs. 0.819 g/cm2), and fourth lumbar vertebra (0.712 vs. 0.789 g/cm2). Contrary to our hypothesis, subjects with high lead exposure had a significantly higher BMD than did subjects with low lead exposure. This may reflect a true phenomenon because lead exposure has been reported to accelerate bony maturation by inhibiting the effects of parathyroid hormone-related peptide. Accelerated maturation of bone may ultimately result in a lower peak BMD being achieved in young adulthood, thus predisposing to osteoporosis in later life. Future studies need to investigate this proposed model.