Concurrent Outbreaks of Hepatitis A, Invasive Meningococcal Disease, and Mpox, Florida, USA, 2021-2022

In 2022, concurrent outbreaks of hepatitis A, invasive meningococcal disease (IMD), and mpox were identified in Florida, USA, primarily among men who have sex with men. The hepatitis A outbreak (153 cases) was associated with hepatitis A virus genotype IA. The IMD outbreak (44 cases) was associated with Neisseria meningitidis serogroup C, sequence type 11, clonal complex 11. The mpox outbreak in Florida (2,845 cases) was part of a global epidemic. The hepatitis A and IMD outbreaks were concentrated in Central Florida and peaked during March--June, whereas mpox cases were more heavily concentrated in South Florida and had peak incidence in August. HIV infection was more common (52%) among mpox cases than among hepatitis A (21%) or IMD (34%) cases. Where feasible, vaccination against hepatitis A, meningococcal disease, and mpox should be encouraged among at-risk groups and offered along with program services that target those groups.

Maternal and Perinatal Outcomes Associated With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection During Pregnancy, Florida, 2020-2021: A Retrospective Cohort Study

BACKGROUND

The objective was to estimate risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy and assess adverse maternal and perinatal outcomes.

METHODS

We used a population-based, retrospective cohort of all pregnancies with a live birth or fetal death in Florida from 1 March 2020 to 30 April 2021. Coronavirus disease 2019 (COVID-19) case reports were matched to vital registries. Outcomes assessed were risk of infection in pregnancy, preterm birth, maternal or neonatal admission to an intensive care unit (ICU), perinatal or fetal death, and maternal death. Modified Poisson and multinomial logistic regression models were used to derive relative risk estimates.

RESULTS

Of 234 492 women with a live birth or fetal death during the study period, 12 976 (5.5%) were identified with COVID-19 during pregnancy. Risk factors for COVID-19 in pregnancy included Hispanic ethnicity (relative risk [RR] = 1.89), Black race (RR = 1.34), being unmarried (RR = 1.04), and being overweight or obese pre-pregnancy (RR = 1.08-1.32). COVID-19 during pregnancy was associated with preterm birth (RR = 1.31), Cesarean delivery (RR = 1.04), and neonatal (RR = 1.17) and maternal (RR = 3.10) ICU admission; no association was found with increased risk of perinatal (RR = 0.72) or fetal death (RR = 0.86). Women infected during any trimester showed increased risk of preterm birth. Fourteen maternal deaths were identified among COVID-19 cases; of those who died, 12 were obese. The death rate per 10 000 was 22.09 among obese and 1.22 among non-obese gravida with COVID-19 during pregnancy (RR = 18.99, P = .001).

CONCLUSIONS

Obesity is a risk factor for SARS-CoV-2 infection in pregnancy and for more severe COVID-19 illness among pregnant women. SARS-CoV-2 infection is associated with preterm birth.

Outbreak of Listeriosis in South Africa Associated with Processed Meat

BACKGROUND

An outbreak of listeriosis was identified in South Africa in 2017. The source was unknown.

METHODS

We conducted epidemiologic, trace-back, and environmental investigations and used whole-genome sequencing to type Listeria monocytogenes isolates. A case was defined as laboratory-confirmed L. monocytogenes infection during the period from June 11, 2017, to April 7, 2018.

RESULTS

A total of 937 cases were identified, of which 465 (50%) were associated with pregnancy; 406 of the pregnancy-associated cases (87%) occurred in neonates. Of the 937 cases, 229 (24%) occurred in patients 15 to 49 years of age (excluding those who were pregnant). Among the patients in whom human immunodeficiency virus (HIV) status was known, 38% of those with pregnancy-associated cases (77 of 204) and 46% of the remaining patients (97 of 211) were infected with HIV. Among 728 patients with a known outcome, 193 (27%) died. Clinical isolates from 609 patients were sequenced, and 567 (93%) were identified as sequence type 6 (ST6). In a case-control analysis, patients with ST6 infections were more likely to have eaten polony (a ready-to-eat processed meat) than those with non-ST6 infections (odds ratio, 8.55; 95% confidence interval, 1.66 to 43.35). Polony and environmental samples also yielded ST6 isolates, which, together with the isolates from the patients, belonged to the same core-genome multilocus sequence typing cluster with no more than 4 allelic differences; these findings showed that polony produced at a single facility was the outbreak source. A recall of ready-to-eat processed meat products from this facility was associated with a rapid decline in the incidence of L. monocytogenes ST6 infections.

CONCLUSIONS

This investigation showed that in a middle-income country with a high prevalence of HIV infection, L. monocytogenes caused disproportionate illness among pregnant girls and women and HIV-infected persons. Whole-genome sequencing facilitated the detection of the outbreak and guided the trace-back investigations that led to the identification of the source.

Description of a Mass Poisoning in a Rural District in Mozambique: The First Documented Bongkrekic Acid Poisoning in Africa

Background

On 9 January 2015, in a rural town in Mozambique, >230 persons became sick and 75 died of an illness linked to drinking pombe, a traditional alcoholic beverage.

Methods

An investigation was conducted to identify case patients and determine the cause of the outbreak. A case patient was defined as any resident of Chitima who developed any new or unexplained neurologic, gastrointestinal, or cardiovascular symptom from 9 January at 6:00 am through 12 January at 11:59 pm. We conducted medical record reviews, healthcare worker and community surveys, anthropologic and toxicologic investigations of local medicinal plants and commercial pesticides, and laboratory testing of the suspect and control pombe.

Results

We identified 234 case patients; 75 (32%) died and 159 recovered. Overall, 61% of case patients were female (n = 142), and ages ranged from 1 to 87 years (median, 30 years). Signs and symptoms included abdominal pain, diarrhea, vomiting, and generalized malaise. Death was preceded by psychomotor agitation and abnormal posturing. The median interval from pombe consumption to symptom onset was 16 hours. Toxic levels of bongkrekic acid (BA) were detected in the suspect pombe but not the control pombe. Burkholderia gladioli pathovar cocovenenans, the bacteria that produces BA, was detected in the flour used to make the pombe.

Conclusions

We report for the first time an outbreak of a highly lethal illness linked to BA, a deadly food-borne toxin in Africa. Given that no previous outbreaks have been recognized outside Asia, our investigation suggests that BA might be an unrecognized cause of toxic outbreaks globally.

South Africa field epidemiology training program: developing and building applied epidemiology capacity, 2007-2016

In 2007, South Africa (SA) launched a field epidemiology training program (SAFETP) to enhance its capacity to prevent, detect, and respond to public health threats through training in field epidemiology. The SAFETP began as a collaboration between the SA National Department of Health (NDOH), National Institute for Communicable Diseases (NICD), and the University of Pretoria (UP), with technical and financial support from the U.S. Centers for Disease Control and Prevention (CDC). In 2010, the CDC in collaboration with the NICD, established a Global Disease Detection (GDD) Center in SA, and the SAFETP became a core activity of the GDD center. Similar to other FETPs globally, the SAFETP is a 2-year, competency-based, applied epidemiology training program, following an apprenticeship model of ‘learn by doing’. SAFETP residents spend approximately 25% of the training in classroom-based didactic learning activities, and 75% in field activities to attain core competencies in epidemiology, biostatistics, outbreak investigation, scientific communication, surveillance evaluation, teaching others, and public health leadership. Residents earn a Master’s in Public Health (MPH) degree from UP upon successfully completing a planned research study that serves as a mini-dissertation.

Since 2007, SAFETP has enrolled an average of 10 residents each year and, in 2017, enrolled its 11th cohort. During the first 10 years of the program, 98 residents have been enrolled, 89% completed the 2-year program, and of these, 76 (87%) earned an MPH degree. Of those completing the program, 88% are employed in the public health sector, and work at NICD, NDOH, Provincial Health Departments, foreign health institutions, or non-governmental organizations. In the first 10 years of the program, the combined outputs of trainees included over 130 outbreak investigations, more than 150 abstracts presented at national and international scientific conferences, more than 80 surveillance system evaluations, and more than 45 manuscripts published in peer-reviewed scientific journals. The SAFETP is having an impact in building epidemiology capacity for public health in South Africa. Developing methods to directly link and measure the impact of the program is planned for the future.

Clinical and Epidemiological Characterization of the First Recognized Outbreak of Dengue Virus-Type 2 in Mozambique, 2014

Since the first reported epidemic of dengue in Pemba, the capital of Cabo Delgado province, in 1984-1985, no further cases have been reported in Mozambique. In March 2014, the Provincial Health Directorate of Cabo Delgado reported a suspected dengue outbreak in Pemba, associated with a recent increase in the frequency of patients with nonmalarial febrile illness. An investigation conducted between March and June detected a total of 193 clinically suspected dengue patients in Pemba and Nampula, the capital of neighboring Nampula Province. Dengue virus-type 2 (DENV-2) was detected by reverse transcriptase polymerase chain reaction in sera from three patients, and 97 others were classified as probable cases based on the presence of DENV nonstructural protein 1 antigen or anti-DENV immunoglobulin M antibody. Entomological investigations demonstrated the presence of Aedes aegypti mosquitos in both Pemba and Nampula cities.

Sleeping arrangements and mass distribution of bed nets in six districts in central and northern Mozambique

Objective

Universal coverage with insecticide‐treated bed nets is a cornerstone of modern malaria control. Mozambique has developed a novel bed net allocation strategy, where the number of bed nets allocated per household is calculated on the basis of household composition and assumptions about who sleeps with whom. We set out to evaluate the performance of the novel allocation strategy.

Methods

A total of 1994 households were visited during household surveys following two universal coverage bed net distribution campaigns in Sofala and Nampula provinces in 2010–2013. Each sleeping space was observed for the presence of a bed net, and the sleeping patterns for each household were recorded. The observed coverage and efficiency were compared to a simulated coverage and efficiency had conventional allocation strategies been used. A composite indicator, the product of coverage and efficiency, was calculated. Observed sleeping patterns were compared with the sleeping pattern assumptions.

Results

In households reached by the campaign, 93% (95% CI: 93–94%) of sleeping spaces in Sofala and 84% (82–86%) in Nampula were covered by campaign bed nets. The achieved efficiency was high, with 92% (91–93%) of distributed bed nets in Sofala and 93% (91–95%) in Nampula covering a sleeping space. Using the composite indicator, the novel allocation strategy outperformed all conventional strategies in Sofala and was tied for best in Nampula. The sleeping pattern assumptions were completely satisfied in 66% of households in Sofala and 56% of households in Nampula. The most common violation of the sleeping pattern assumptions was that male children 3–10 years of age tended not to share sleeping spaces with female children 3–10 or 10–16 years of age.

Conclusions

The sleeping pattern assumptions underlying the novel bed net allocation strategy are generally valid, and net allocation using these assumptions can achieve high coverage and compare favourably with conventional allocation strategies.

Transgenerational Effects of Di-(2-Ethylhexyl) Phthalate (DEHP) on Stress Hormones and Behavior

Exposure to di-(2-ethylhexyl) phthalate (DEHP) has been linked to male reproductive abnormalities. Here, we assessed transgenerational actions of DEHP on several behaviors and stress responses. We used 2 doses of DEHP (150- and 200-mg/kg body weight) and a treatment regimen previously shown to produce transgenerational effects on male reproduction. Mice, 3 generations removed from DEHP exposure (F3), were tested for social behavior and anxiety on the elevated plus maze. We collected blood and pituitaries from undisturbed and restrained mice. Body weights, anogenital distances, and reproductive organ weights were collected at killing. In social interaction tests juvenile males from the DEHP lineage (200 mg/kg) displayed more digging and less self-grooming than did controls. Interestingly, 150-mg/kg lineage males, killed in early puberty, had smaller seminal vesicle weights than their controls. However, the 200-mg/kg males (killed on average 10 d later) did not show this effect. Females from a DEHP lineage had lower corticosterone concentrations than controls after restraint stress. We also found sex- and DEHP-specific mRNA expression changes in the pituitary in 2 of the 6 stress-related genes we measured. In particular, Gnas mRNA was elevated by the combination of DEHP lineage and stress. Thus, transgenerational effects of DEHP are noted in male behavior, and in females, DEHP had transgenerational effects on levels of corticosterone. Both of these results may be related to transgenerational modifications in the expression of several pituitary hormones involved in the hypothalamic-pituitary-adrenal axis.

Maternal and neonatal outcomes among pregnant women with 2009 pandemic influenza A(H1N1) illness in Florida, 2009-2010: a population-based cohort study

Introduction

Pregnant women have been identified as a high risk group for severe illness with 2009 pandemic influenza A(H1N1) virus infection (pH1N1). Obesity has also been identified as a risk factor for severe illness, though this has not been thoroughly assessed among pregnant women. The objectives of this study were to provide risk estimates for adverse maternal and neonatal outcomes associated with pH1N1 illness during pregnancy and to assess the role of obesity in these outcomes.

Methods

We established a retrospective population-based cohort of all live births occurring in Florida during the first 15 months of the pandemic. Illness with pH1N1 during pregnancy was ascertained through record linkage with the Florida state notifiable disease surveillance database. Data from the birth record, including pre-pregnancy body mass index, were analyzed to assess risk of adverse outcomes associated with pH1N1 illness.

Results

A total of 194 women were identified through surveillance with pH1N1 illness during pregnancy. Children born to women with pH1N1 illness during pregnancy were at increased risk for low birth weight [OR (95%CI): 1.78 (1.11-2.860)], premature birth [2.21 (1.47-3.330)], and infant death [4.46 (1.80-11.00)], after adjusting for other factors. Women with pH1N1 illness during pregnancy were at increased risk for severe outcomes including admission to an intensive care unit. Obesity was an observed risk factor, both for the more severe pH1N1 illness detected through surveillance, and for severe maternal outcomes.

Conclusions

Case-patients in this analysis likely represent the most severely ill subset of all women infected with pH1N1 during pregnancy, limiting the generalizability of these findings to more severely ill patients rather than influenza infection in general. Nevertheless, these results suggest that more severe pH1N1 illness during pregnancy is associated with adverse neonatal outcomes and that pregnant women should continue to be targeted for appropriate prophylaxis and early treatment.

Transgenerational effects of di-(2-ethylhexyl) phthalate on testicular germ cell associations and spermatogonial stem cells in mice

Recent evidence has linked human phthalate exposure to abnormal reproductive and hormonal effects. Phthalates are plasticizers that confer flexibility and transparency to plastics, but they readily contaminate the body and the environment. In this study, timed pregnant CD1 outbred mice were treated with di-(2-ethylhexyl) phthalate (DEHP) from Embryonic Day 7 (E7) to E14. The subsequent generation (F1) offspring were then bred to produce the F2, F3, and F4 offspring, without any further DEHP treatment. This exposure scheme disrupted testicular germ cell association and decreased sperm count and motility in F1 to F4 offspring. By spermatogonial transplantation techniques, the exposure scheme also disrupted spermatogonial stem cell (SSC) function of F3 offspring. The W/W(V) recipient testes transplanted with F3 offspring germ cells from the DEHP-treated group had a dramatically lower percentage of donor germ cell-derived spermatogenic recovery in seminiferous tubules when compared to the recipient testes transplanted with CD1 control germ cells. Further characterization showed that the major block of donor germ cell-derived spermatogenesis was before the appearance of undifferentiated spermatogonia. Interestingly, the testes transplanted with the F3 offspring germ cells from the DEHP-treated group, when regenerated, replicated testis morphology similar to that observed in the testes from the F1 to F3 offspring of the DEHP-treated group, suggesting that the germ cell disorganization phenotype originates from the stem cells of F3 offspring. In conclusion, embryonic exposure to DEHP was found to disrupt testicular germ cell organization and SSC function in a transgenerational manner.

Immunoprotective properties of primary Sertoli cells in mice: potential functional pathways that confer immune privilege

Primary Sertoli cells isolated from mouse testes survive when transplanted across immunological barriers and protect cotransplanted allogeneic and xenogeneic cells from rejection in rodent models. In contrast, the mouse Sertoli cell line (MSC-1) lacks immunoprotective properties associated with primary Sertoli cells. In this study, enriched primary Sertoli cells or MSC-1 cells were transplanted as allografts into the renal subcapsular area of naive BALB/c mice, and their survival in graft sites was compared. While Sertoli cells were detected within the grafts with 100% graft survival throughout the 20-day study, MSC-1 cells were rejected between 11 and 14 days, with 0% graft survival at 20 days posttransplantation. Nonetheless, the mechanism for primary Sertoli cell survival and immunoprotection remains unresolved. To identify immune factors or functional pathways potentially responsible for immune privilege, gene expression profiles of enriched primary Sertoli cells were compared with those of MSC-1 cells. Microarray analysis identified 2369 genes in enriched primary Sertoli cells that were differentially expressed at ±4-fold or higher levels than in MSC-1 cells. Ontological analyses identified multiple immune pathways, which were used to generate a list of 340 immune-related genes. Three functions were identified in primary Sertoli cells as potentially important for establishing immune privilege: suppression of inflammation by specific cytokines and prostanoid molecules, slowing of leukocyte migration by controlled cell junctions and actin polymerization, and inhibition of complement activation and membrane-associated cell lysis. These results increase our understanding of testicular immune privilege and, in the long-term, could lead to improvements in transplantation success.

An outbreak of epidemic keratoconjunctivitis at an outpatient ophthalmology clinic

Epidemic keratoconjunctivitis (EKC) is an acute eye infection caused by adenovirus. We investigated an outbreak of EKC at an outpatient ophthalmology practice in the context of a suspected community wide increase in EKC activity. A site visit was made to the facility reporting the outbreak. A line list was created of patients clinically diagnosed with EKC at the practice during the previous 5 months. A questionnaire was faxed to all other licensed ophthalmologists in the county regarding recent EKC activity in their facility. Descriptive data analyses were conducted. The outbreak facility reported 37 patients clinically diagnosed with EKC during the previous 5 months. In addition, the single ophthalmologist at the practice also had symptoms compatible with EKC during the outbreak period. Specimens were collected on 4 patients and all were positive for adenovirus serotype 8. Forty percent of ophthalmologists surveyed in the county saw at least one EKC patient in the previous 3 months, and 20% reported a perceived increase in EKC activity in recent months over normal seasonal patterns. The outbreak at the facility likely began as part of a widespread community increase in EKC that may have been amplified at the facility through nosocomial transmission. Medical providers experiencing increases in EKC activity above seasonally expected norms should contact their public health department for assistance with etiologic diagnoses and outbreak control.

Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States

CONTEXT

Early data on pandemic 2009 influenza A(H1N1) suggest pregnant women are at increased risk of hospitalization and death.

OBJECTIVE

To describe the severity of 2009 influenza A(H1N1) illness and the association with early antiviral treatment among pregnant women in the United States.

DESIGN, SETTING, AND PATIENTS

Surveillance of 2009 influenza A(H1N1) in pregnant women reported to the Centers for Disease Control and Prevention (CDC) with symptom onset from April through December 2009.

MAIN OUTCOME MEASURES

Severity of illness (hospitalizations, intensive care unit [ICU] admissions, and deaths) due to 2009 influenza A(H1N1) among pregnant women, stratified by timing of antiviral treatment and pregnancy trimester at symptom onset.

RESULTS

We received reports on 788 pregnant women in the United States with 2009 influenza A(H1N1) with symptom onset from April through August 2009. Among those, 30 died (5% of all reported 2009 influenza A[H1N1] influenza deaths in this period). Among 509 hospitalized women, 115 (22.6%) were admitted to an ICU. Pregnant women with treatment more than 4 days after symptom onset were more likely to be admitted to an ICU (56.9% vs 9.4%; relative risk [RR], 6.0; 95% confidence interval [CI], 3.5-10.6) than those treated within 2 days after symptom onset. Only 1 death occurred in a patient who received treatment within 2 days of symptom onset. Updating these data with the CDC's continued surveillance of ICU admissions and deaths among pregnant women with symptom onset through December 31, 2009, identified an additional 165 women for a total of 280 women who were admitted to ICUs, 56 of whom died. Among the deaths, 4 occurred in the first trimester (7.1%), 15 in the second (26.8%), and 36 in the third (64.3%);

CONCLUSIONS

Pregnant women had a disproportionately high risk of mortality due to 2009 influenza A(H1N1). Among pregnant women with 2009 influenza A(H1N1) influenza reported to the CDC, early antiviral treatment appeared to be associated with fewer admissions to an ICU and fewer deaths.

Cluster of serogroup W135 meningococci, southeastern Florida, 2008-2009

Recently, 14 persons in southeastern Florida were identified with Neisseria meningitidis serogroup W135 invasive infections. All isolates tested had matching or near-matching pulsed-field gel electrophoresis patterns and belonged to the multilocus sequence type 11 clonal complex. The epidemiologic investigation suggested recent endemic transmission of this clonal complex in southeastern Florida.

Temporal profiling of rat transcriptomes in retinol-replenished vitamin A-deficient testis

At least in mammals, retinoic acid is a pivotal factor in maintaining the functionality of the testis, in particular, for the progression of germ cells from mitosis to meiosis. Removal of dietary vitamin A or a targeted deletion of retinoic acid receptor alpha gene (Rara), the receptor for retinoic acid, in mice, led to testicular degeneration by a dramatic loss of germ cells and a loss of control of the spermatogenic cycle. The germ cells that remained in the vitamin A deficient (VAD) rat testis were spermatogonia and a few preleptotene spermatocytes. Spermatogenesis can be reinitiated by injection of VAD rats with retinol, the metabolic precursor of retinoic acid, but to date, the functions of retinoic acid in the testis remain elusive. We have applied DNA microarray technology to investigate the time-dependent transcriptome changes that occur 4 to 24 h after retinol replenishment in the VAD rat testis. The retinol-regulated gene expression occurred both in germ cells and Sertoli cells. Bioinformatic analyses revealed time-dependent clusters of genes and canonical pathways that may have critical functions for proper progression through spermatogenesis. In particular, gene clusters that emerged dealt with: (1) cholesterol and oxysterol homeostasis, * (2) the regulation of steroidogenesis, (3) glycerophospholipid metabolism, (4) the regulation of acute inflammation, (5) the regulation of the cell cycle including ubiquitin-mediated degradation of cell cycle proteins and control of centrosome and genome integrity, and (6) the control of membrane scaffolding proteins that can integrate multiple small GTPase signals within a cell. These results provide insights into the potential role of retinoic acid in the testis.

Potential functions of retinoic acid receptor A in Sertoli cells and germ cells during spermatogenesis

Elucidation of the retinoid signaling circuitry in the testis is critical to understanding how male germ cells develop to spermatozoa. Retinoic acid receptor A protein (RARA) is an essential mediator of retinoid signaling in the testis, as shown by a sterility phenotype observed for retinoic acid receptor A gene (Rara) knockout male mice. The seminiferous tubules of Rara knockout mice showed varying degrees of germ-cell degeneration. A dramatic increase in apoptosis of early meiotic prophase spermatocytes was observed in these tubules compared to the wild-type tubules. Germ-cell loss was dependent on the stages of the spermatogenic cycle: germ-cell loss was negligible in stages I-V, but severe after stages VIII and IX of the spermatogenic cycle. Using spermatogonial transplantation, the individual function of RARA in Sertoli cells or germ cells was determined. The wild-type donor germ cells, transplanted into Rara knockout testes, colonized and proliferated in the RARA-deficient microenvironment. The donor-derived cells were mostly early meiotic prophase spermatocytes, with few more advanced germ cells detected. Conversely, when Rara-deficient germ cells were injected into the microenvironment that express RARA, establishment of donor-derived germ-cell colonies was rare, but remarkably, once colonized, Rara-deficient germ cells progressed normally through spermatogenesis. These results together suggest that RARA may function in Sertoli cells to promote the survival and development of early meiotic prophase spermatocytes, whereas RARA in germ cells functions to increase the proliferation and differentiation of spermatogonia, prior to meiotic prophase.

Retinoic acid regulation of eye and testis-specific transcripts within a complex locus

We previously used a yeast-based enhancer trap to identify a strong, retinoic acid response element (RARE). We have now characterized testis and eye transcripts that are adjacent to this regulatory element. Bioinformatics analysis of expressed sequence tag (EST) clones and RNase protection, reverse transcription-PCR, and Northern blot assays indicate that these two RNAs are transcribed from the same locus on opposite template strands. This positions the RARE upstream of the testis transcript and downstream of the eye transcript. Additionally, these two RNAs are embedded within the third intron of the 329kbp gene that encodes the Zinc Finger and BTB domain containing 7C protein (Zbtb7C). We present evidence indicating that the testis transcript is expressed primarily in spermatocytes and/or early round spermatids. Furthermore, our analyses of transcript levels in eyes and testes isolated from vitamin A deficient mice or from mice with defects in retinoid storage or signaling indicate that retinoids are required for expression in vivo.

PHSkb: a knowledgebase to support notifiable disease surveillance

BACKGROUND

Notifiable disease surveillance in the United States is predominantly a passive process that is often limited by poor timeliness and low sensitivity. Interoperable tools are needed that interact more seamlessly with existing clinical and laboratory data to improve notifiable disease surveillance.

DESCRIPTION

The Public Health Surveillance Knowledgebase (PHSkb) is a computer database designed to provide quick, easy access to domain knowledge regarding notifiable diseases and conditions in the United States. The database was developed using Protégé ontology and knowledgebase editing software. Data regarding the notifiable disease domain were collected via a comprehensive review of state health department websites and integrated with other information used to support the National Notifiable Diseases Surveillance System (NNDSS). Domain concepts were harmonized, wherever possible, to existing vocabulary standards. The knowledgebase can be used: 1) as the basis for a controlled vocabulary of reportable conditions needed for data aggregation in public health surveillance systems; 2) to provide queriable domain knowledge for public health surveillance partners; 3) to facilitate more automated case detection and surveillance decision support as a reusable component in an architecture for intelligent clinical, laboratory, and public health surveillance information systems.

CONCLUSIONS

The PHSkb provides an extensible, interoperable system architecture component to support notifiable disease surveillance. Further development and testing of this resource is needed.

Clinical features that discriminate inhalational anthrax from other acute respiratory illnesses

Inhalational anthrax (IA) is a rapidly progressive disease that frequently results in sepsis and death, and prompt recognition is critical. To distinguish IA from other causes of acute respiratory illness, patients who had IA were compared with patients in an ambulatory clinic who had influenza-like illness (ILI) and with hospitalized patients who had community-acquired pneumonia (CAP) at the initial health care visit. Compared with patients who had ILI, patients who had IA were more likely to have tachycardia, high hematocrit, and low albumin and sodium levels and were less likely to have myalgias, headache, and nasal symptoms. Scoring systems were devised to compare IA with ILI or CAP on the basis of strength of association. For ILI, a score of > or =4 captured all 11 patients with IA and excluded 664 (96.1%) of 691 patients with ILI. Compared with patients who had CAP, patients with IA were more likely to have nausea or vomiting, tachycardia, high transaminase levels, low sodium levels, and normal white blood cell counts. For CAP, a score of > or =3 captured 9 (81.8%) of 11 patients with IA and excluded 528 (81.2%) of 650 patients with CAP. In conclusion, selected clinical features of patients with IA differ from those of patients with ILI and are more similar to those of patients with CAP.

Centrifugal versus roller head pumps for cardiopulmonary bypass: effect on early neuropsychologic outcomes after coronary artery surgery

OBJECTIVE

To test the hypothesis that routine use of a centrifugal pump in the cardiopulmonary bypass circuit would result in a lower incidence of early neuropsychologic deficit when compared with conventional roller pumps.

DESIGN

Prospective, randomized, double-blind.

SETTING

University teaching hospital.

PARTICIPANTS

Patients (n = 103) scheduled for elective coronary artery surgery.

INTERVENTIONS

Patients were randomized into group C (centrifugal pump for cardiopulmonary bypass; n = 54) and group R (roller pump for cardiopulmonary bypass; n = 49).

MEASUREMENTS AND MAIN RESULTS

A neuropsychologic test battery of 6 standard tests was administered before surgery and 5 days after surgery. An abnormal test result was defined as deterioration by >1 group SD from an individual's preoperative test performance. There were no significant differences between groups in preoperative or surgical parameters, intensive care unit stay, or hospital stay. There were no significant differences in the incidence of neuropsychologic deficit for patients with a deficit in at least 1 test (group C, 33%; group R, 51%; odds ratio, 0.48; 95% confidence interval, 0.22 to 1.06) or patients with a deficit in >/=2 tests (group C, 6%; group R, 18%; odds ratio, 0.26; 95% confidence interval, 0.07 to 1.03). In group R, there were more individual test deficits per patient than in group C (p = 0.04).

CONCLUSION

There was no significant difference in the incidence of neuropsychologic deficit postoperatively with routine use of centrifugal pumps. The larger number of individual test deficits in the roller pump group suggest that further studies to assess the potential neuropsychologic benefits of the use of centrifugal pumps are warranted.

Completeness of notifiable infectious disease reporting in the United States: an analytical literature review

Despite state and local laws requiring medical providers to report notifiable infectious diseases to public health authorities, reporting is believed to be incomplete. Through means of an analytical literature review, the authors synthesize current knowledge on the completeness of disease reporting and identify factors associated with reporting completeness. The review was limited to published studies, conducted in the United States between 1970 and 1999, that quantitatively assessed infectious disease reporting completeness. Thirty-three studies met the inclusion criteria. Reporting completeness, expressed between 0% and 100%, was treated as the dependent outcome variable in statistical analysis; disease, study location, time period, study design, and study size were treated as independent variables. Fifty-six distinct measures of reporting completeness were identified for 21 diseases. Reporting completeness varied from 9% to 99% and was most strongly associated with the disease being reported. The mean reporting completeness for acquired immunodeficiency syndrome, sexually transmitted diseases, and tuberculosis as a group was significantly higher (79%) than for all other diseases combined (49%) (p < 0.01).

Introduction of a hierarchy to LOINC to facilitate public health reporting

Public health reporting of laboratory results requires unambiguous identification of the test performed and the result observed. Some laboratories are currently using Logical Observation Identifier Names and Codes (LOINC) for the electronic reporting of laboratory tests and their results to public health departments. Initial use revealed inconsistent identification and use of LOINC concepts by laboratories and public health agencies and an inability to systematically extend, for public health use, the tables when adding new concepts. We applied simple, logical rules to existing LOINC concepts to facilitate the creation of a hierarchy of concepts and to allow the identification and specification of appropriate terms for public health reporting and subsequent data aggregation. The hierarchy also allows the systematic addition of new concepts further supporting public health reporting. Application of the hierarchy is illustrated by using all laboratory LOINC concepts assigned to the subset of microbiology test types (CLASS MICRO).

Virulence plasmid-borne spvB and spvC genes can replace the 90-kilobase plasmid in conferring virulence to Salmonella enterica serovar Typhimurium in subcutaneously inoculated mice

In a mouse model of systemic infection, the spv genes carried on the Salmonella enterica serovar Typhimurium virulence plasmid increase the replication rate of salmonellae in host cells of the reticuloendothelial system, most likely within macrophages. A nonpolar deletion in the spvB gene greatly decreased virulence but could not be complemented by spvB alone. However, a low-copy-number plasmid expressing spvBC from a constitutive lacUV5 promoter did complement the spvB deletion. By examining a series of spv mutations and cloned spv sequences, we deduced that spvB and spvC could be sufficient to confer plasmid-mediated virulence to S. enterica serovar Typhimurium. The spvBC-bearing plasmid was capable of replacing all of the spv genes, as well as the entire virulence plasmid, of serovar Typhimurium for causing systemic infection in BALB/c mice after subcutaneous, but not oral, inoculation. A point mutation in the spvBC plasmid preventing translation but not transcription of spvC eliminated the ability of the plasmid to confer virulence. Therefore, it appears that both spvB and spvC encode the principal effector factors for Spv- and plasmid-mediated virulence of serovar Typhimurium.

Neuropsychologic testing within 18 hours after cardiac surgery

OBJECTIVE

To undertake neuropsychologic testing within 18 hours of cardiac surgery after fast-track anesthesia.

DESIGN

Prospective study.

SETTING

University hospital, single center.

PARTICIPANTS

Fifty patients undergoing first-time elective coronary artery surgery.

INTERVENTIONS

A neuropsychologic test battery was administered preoperatively and 18 hours and 5 days after surgery.

MAIN RESULTS

Seven patients were withdrawn, and 9 patients did not attempt the postoperative tests (on both occasions) because of medical complications. Thirty patients completed > or =4 tests at both postoperative occasions. Of these, 9 patients (30%) showed a deficit in > or =2 tests at 18 hours postoperatively, and 3 (10%) showed a deficit at 5 days postoperatively.

CONCLUSION

In the absence of medical complications and despite the difficulties, early postoperative neuropsychologic testing is possible after fast-track anesthesia. Such testing has the potential to more clearly define the course of cognitive decline after cardiac surgery.

Infectious disease morbidity in the US region bordering Mexico, 1990-1998

The United States and Mexico share an international boundary approximately 3000 km long. This border separates 2 nations with great differences in health status. The objective of this study was to assess morbidity due to infectious diseases in the US region bordering Mexico. The incidence between 1990 and 1998 of 22 nationally notifiable infectious diseases was compared between border and nonborder regions. Disease rates, reflected as rate ratios, were higher in the border region for botulism, brucellosis, diphtheria, hepatitis A, measles, mumps, rabies, rubella, salmonellosis, and shigellosis than in either of 2 nonborder comparison regions. These data indicate that incidence rates for a variety of infectious diseases of public health importance are significantly higher in the United States along the Mexican border than in nonborder regions. These results suggest that an inadequate public health infrastructure may contribute to excess morbidity due to infectious diseases in the border region.

Pathogenesis of infection by clinical and environmental strains of Vibrio vulnificus in iron-dextran-treated mice

Vibrio vulnificus is an opportunistic pathogen that contaminates oysters harvested from the Gulf of Mexico. In humans with compromising conditions, especially excess levels of iron in plasma and tissues, consumption of contaminated seafood or exposure of wounds to contaminated water can lead to systemic infection and disfiguring skin infection with extremely high mortality. V. vulnificus-associated diseases are noted for the rapid replication of the bacteria in host tissues, with extensive tissue damage. In this study we examined the virulence attributes of three virulent clinical strains and three attenuated oyster or seawater isolates in mouse models of systemic disease. All six V. vulnificus strains caused identical skin lesions in subcutaneously (s.c.) inoculated iron dextran-treated mice in terms of numbers of recovered CFU and histopathology; however, the inocula required for identical frequency and magnitude of infection were at least 350-fold higher for the environmental strains. At lethal doses, all strains caused s. c. skin lesions with extensive edema, necrosis of proximate host cells, vasodilation, and as many as 10(8) CFU/g, especially in perivascular regions. These data suggest that the differences between these clinical and environmental strains may be related to growth in the host or susceptibility to host defenses. In non-iron dextran-treated mice, strains required 10(5)-fold-higher inocula to cause an identical disease process as with iron dextran treatment. These results demonstrate that s.c. inoculation of iron dextran-treated mice is a useful model for studying systemic disease caused by V. vulnificus.

Using remotely sensed data to identify areas at risk for hantavirus pulmonary syndrome

The 1993 U.S. hantavirus pulmonary syndrome (HPS) outbreak was attributed to environmental conditions and increased rodent populations caused by unusual weather in 1991- 92. In a case-control study to test this hypothesis, we estimated precipitation at 28 HPS and 170 control sites during the springs of 1992 and 1993 and compared it with precipitation during the previous 6 years by using rainfall patterns at 196 weather stations. We also used elevation data and Landsat Thematic Mapper satellite imagery collected the year before the outbreak to estimate HPS risk by logistic regression analysis. Rainfall at case sites was not higher during 1992-93 than in previous years. However, elevation, as well as satellite data, showed association between environmental conditions and HPS risk the following year. Repeated analysis using satellite imagery from 1995 showed substantial decrease in medium- to high-risk areas. Only one case of HPS was identified in 1996.

Hantavirus pulmonary syndrome in pregnancy

This comprehensive case review of hantavirus pulmonary syndrome (HPS) during pregnancy in 5 women characterizes the effect of Sin Nombre virus infection on maternal and fetal outcomes. Histopathologic, serological, and clinical information were evaluated for evidence of vertical transmission. Maternal ages ranged from 20 to 34 years and gestational ages from 13 to 29 weeks. Symptoms, physical findings, and laboratory values other than those related to pregnancy were not noticeably different from those of nonpregnant patients with HPS, although fevers were somewhat lower. One maternal death and 2 fetal losses occurred. Gross, microscopic, and immunohistochemical examination for hantavirus antigen were done on 2 fetal autopsies and 3 placentas showing no evidence of transplacental hantavirus transmission. There was no serological evidence of conversion in the 3 surviving children. Maternal and fetal outcomes of HPS appear similar to those of nonpregnant HPS patients and of pregnant patients with other causes of acute respiratory distress syndrome. No evidence of vertical transmission of Sin Nombre virus was found.

Growth of Staphylococcus aureus in Diprivan and Intralipid: implications on the pathogenesis of infections

BACKGROUND

The incidence and severity of infections are increased when Intralipid or Diprivan are administered to patients. Intralipid promotes infection, presumably by inhibiting the reticuloendothelial system, thereby suppressing the host's constitutive immunity, whereas Diprivan supposedly promotes infection by supporting bacterial growth and increasing the inoculating dose. This study considers whether bacterial replication alone in Intralipid and Diprivan adequately explains the increased risk of infection associated with these agents or whether other factors might also be involved.

METHODS

Staphylococcus aureus was cultured in 10% Intralipid or Diprivan at clinically relevant conditions or in Intralipid containing 0.005% (w/v) sodium EDTA, a current additive, to measure growth. To determine whether Intralipid affected infection, New Zealand white rabbits were injected intravenously with S. aureus with or without Intralipid. Twenty-four hours later, bacteria in lung, liver, spleen, and kidney tissues were enumerated.

RESULTS

S. aureus failed to grow in Diprivan or Intralipid containing 0.005% EDTA. Whereas S. aureus did replicate in plain Intralipid, growth was delayed until the bacteria conditioned the media. Once initiated, growth was slow at clinically relevant temperatures. The administration of Intralipid to rabbits significantly increased the recovery of staphylococci from the kidneys, P < 0.001, relative to the other tissues 24 h after an intravenous inoculation with S. aureus, compared with rabbits receiving S. aureus with no Intralipid.

CONCLUSIONS

These results suggest that Diprivan, and possibly Intralipid, represent poor media for the growth of S. aureus and may promote infection through mechanisms other than increased inoculum size.

An EMS approach to psychiatric emergencies

Psychiatric patients present challenges not only to EMS, but in the ED as well. As we have tried to indicate in the case report, the presentation is not always clear-cut. There may not be a definite solution, and each case can be different. As an EMT or paramedic, how should you approach these issues? First, always make sure the scene is safe for you and your team. If you have doubts, contact law enforcement. With regard to patient care, err on the side of safety and what is in the best interest of the patient (which may include restraints). Follow established procedures and guidelines, and always document well. If you have any questions on scene, contact medical control, and document doing so. If there is a question, let the physician decide on competency issues.

Analysis of host cells associated with the Spv-mediated increased intracellular growth rate of Salmonella typhimurium in mice

The 90-kb virulence plasmid of Salmonella typhimurium encodes five spv genes which increase the growth rate of the bacteria within host cells within the first week of systemic infection of mice (P. A. Gulig and T. J. Doyle, Infect. Immun. 61:504-511, 1993). The presently described study was aimed at identifying the host cells associated with Spv-mediated virulence by manipulating the mouse host and the salmonellae. To test the effects of T cells and B cells on the Spv phenotype, salmonellae were orally inoculated into nude and SCID BALB/c mice. Relative to normal BALB/c mice, nude and SCID BALB/c mice were unaffected for splenic infection with either the Spv+ or Spv- S. typhimurium strains at 5 days postinoculation. When mice were pretreated with cyclophosphamide to induce granulocytopenia, there was a variable increase in total salmonella infection, but the relative splenic CFU of Spv+ versus Spv- S. typhimurium was not changed after oral inoculation. In contrast, depletion of macrophages from mice by treatment with cyclophosphamide plus liposomes containing dichloromethylene diphosphate resulted in equivalent virulence of Spv+ and Spv- salmonellae. To examine if the spv genes affected the growth of salmonellae in nonphagocytic cells, an invA::aphT mutation was transduced into Spv+ and Spv- S. typhimurium strains. InvA- Spv+ salmonellae were not significantly affected for splenic infection after subcutaneous inoculation compared with the wild-type strain, and InvA- Spv- salmonellae were only slightly attenuated relative to InvA+ Spv- salmonellae. Invasion-defective salmonellae still exhibited the Spv phenotype. Therefore, infection of nonphagocytes is not involved with the Spv virulence function. Taken together, these data demonstrate that macrophages are essential for suppressing the infection by Spv- S. typhimurium, by serving as the primary host cell for Spv-mediated intracellular replication and possibly by inhibiting the replication of salmonellae within other macrophages.

Viral hemorrhagic fevers and hantavirus infections in the Americas

Several arenaviruses and hantaviruses have been isolated in the Americas during the last 4 decades. These are rodent-borne viruses responsible for the South American hemorrhagic fevers (SAHF) and hantavirus pulmonary syndrome (HPS). Although rare, SAHF and HPS are serious illnesses with high mortality rates. Most viral isolates found in the Americas represent New World lineages of their respective viral families. Their presence in the Western hemisphere is likely ancient, their relationship with their rodent hosts is likely coevolutionary, and their recent detection forebodes the likelihood of detecting additional arena- and hantaviral species in the Americas.

Serial proton magnetic resonance spectroscopic imaging, contrast-enhanced magnetic resonance imaging, and quantitative lesion volumetry in multiple sclerosis

Serial magnetic resonance (MR) studies that included proton MR spectroscopic imaging (MRSI), contrast-enhanced MR imaging (MRI), and lesion volumetric studies were performed on 25 multiple sclerosis (MS) patients with mild to modest clinical deficits. Each patient was scanned at varying intervals for up to 2 years, resulting in a total of 124 usable MR sessions. In these longitudinal studies, metabolic changes were observed on MRSI for some subjects before the appearance of lesions on MRI scanning. Regional changes in metabolite levels were observed to be dynamic and reversible in some patients. Transient changes in N-acetylaspartate (NAA) levels were sometimes found in acute plaques and indicate that a reduced NAA level does not necessarily imply axonal loss. An inverse correlation between the average NAA within the spectroscopic volume and the total lesion volume in the whole brain was observed. This negative correlation implies that NAA can serve as an objective marker of the disease burden. Strong lipid peaks in the absence of gadolinium enhancement and MRI-defined lesions were observed in 4 patients. This observation suggests that demyelination can occur independent of perivenous inflammatory changes and supports the presence of more than one pathophysiological process leading to demyelination in MS.

Systemic infection of mice by wild-type but not Spv- Salmonella typhimurium is enhanced by neutralization of gamma interferon and tumor necrosis factor alpha

The spv genes of the virulence plasmid of Salmonella typhimurium and other nontyphoidal serovars of S. enterica are involved in systemic infection by increasing the replication rate of the bacteria in host tissues beyond the intestines. We considered the possibility that the Spv virulence function is to evade suppression by the host response to infection. To examine this possibility, gamma interferon (IFN-gamma) and/or tumor necrosis factor alpha (TNF-alpha) were neutralized in BALB/c mice by intraperitoneal administration of monoclonal antibodies. Neutralization of IFN-gamma and/or TNF-alpha resulted in increased splenic infection with wild-type salmonellae after oral inoculation; however, Spv- salmonellae were defective at increasing splenic infection in cytokine-depleted mice. The use of a temperature-sensitive marker plasmid, pHSG422, indicated that neutralization of IFN-gamma caused less killing of wild-type S. typhimurium, while neutralization of TNF-alpha resulted in an increased in vivo replication rate for wild-type salmonellae. These results demonstrate that the Spv virulence function is not to evade suppression of bacterial infection normally mediated by IFN-gamma or TNF-alpha.

The association of drinking water source and chlorination by-products with cancer incidence among postmenopausal women in Iowa: a prospective cohort study

OBJECTIVES

This study assessed the association of drinking water source and chlorination by-product exposure with cancer incidence.

METHODS

A cohort of 28,237 Iowa women reported their drinking water source. Exposure to chlorination by-products was determined from statewide water quality data.

RESULTS

In comparison with women who used municipal ground-water sources, women with municipal surface water sources were at an increased risk of colon cancer and all cancers combined. A clear dose-response relation was observed between four categories of increasing chloroform levels in finished drinking water and the risk of colon cancer and all cancers combined. The relative risks were 1.00, 1.06, 1.39, and 1.68 for colon cancer and 1.00, 1.04, 1.24, and 1.25 for total cancers. No consistent association with either water source or chloroform concentration was observed for other cancer sites.

CONCLUSIONS

These results suggest that exposure to chlorination by-products in drinking water is associated with increased risk of colon cancer.

Officers, trustees, directors beware! IRS-imposed 'intermediate' sanctions can be severe

The IRS pushed for intermediate sanctions for some time. It now has them, and we should assume that it will use them. If you're an insider to a 501(c)(3) or 501(c)(4) organization, who is compensated by or has business dealings with the organization, or if you are an officer, director, or trustee of such an organization, study the intermediate sanctions law and congressional comment on it. Think through its possible applications and ramifications. With the assistance of legal counsel, you may also want to carefully review your organization's indemnification policies and understand how they relate to intermediate sanctions taxes. Finally, keep your ear to the ground for further IRS interpretations and application of this important new tax law.

Tea consumption and cancer incidence in a prospective cohort study of postmenopausal women

Tea has consistently been shown to inhibit the occurrence of tumors in experimental animals. The evidence for such a beneficial effect in humans, however, is limited. The authors examined the association between non-herbal tea consumption and cancer incidence in a prospective cohort study of 35,369 postmenopausal Iowa women. In this cohort, information on the frequency of tea drinking and other dietary and lifestyle factors was collected by mailed survey in 1986. After 8 years of follow-up, 2,936 incident non-skin cancer cases were ascertained in this cohort through the State Health Registry of Iowa. Proportional hazards regressions were used to derive adjusted relative risks and 95% confidence intervals for the association between tea consumption and cancer incidence. After controlling for confounding factors, the authors found that regular tea consumption was related to a slight, but not statistically significant, reduced incidence of all cancers combined. Inverse associations with increasing frequency of tea drinking were seen for cancers of the digestive tract (p for trend, 0.04) and the urinary tract (p for trend, 0.02). For women who reported drinking > or = 2 cups (474 ml) of tea per day, compared with those who never or occasionally drank tea, the relative risk for digestive tract cancers was 0.68 (95% confidence interval (CI) 0.47-0.98) and for urinary tract cancers, 0.40 (95% CI 0.16-0.98). Similar inverse associations were seen for specific digestive and urinary tract cancers, although site-specific analyses were not statistically significant. No appreciable association of tea drinking was found with melanoma, non-Hodgkin's lymphoma, or cancers of the pancreas, lung, breast, uterine corpus, or ovary. This study suggests that tea, one of the most popular beverages consumed worldwide, may protect against some cancers in postmenopausal women.

Retinol, antioxidant vitamins, and cancers of the upper digestive tract in a prospective cohort study of postmenopausal women

Very few prospective studies have reported previously on the association of micronutrient intake and the risk of cancers of the upper digestive tract (mouth, pharynx, esophagus, and stomach) in western populations. During 7 years of follow-up in the Iowa Women's Health Study, from 1986-1992, 59 of the 34,691 at-risk cohort members developed cancers of the upper digestive tract. The association of retinol and antioxidant vitamins (carotene and vitamins C and E) were evaluated separately for cancers of the mouth/pharynx/esophagus (n = 33) and stomach (n = 26). After adjustment for age, smoking, and total energy intake, higher intakes of carotene and vitamins C and E were related to lower risks of both oral/pharyngeal/esophageal and gastric cancers, while retinol was associated with lower risk of gastric cancer only. The dose-response relation between gastric cancer risk and intake of carotene was clear and statistically significant, with relative risks of 0.6 and 0.3, respectively, observed among women in the upper two versus the lowest tertiles of intake. This study provides further evidence that higher intake of antioxidant vitamins may be important in the prevention of cancers of the upper digestive organs.

Retinol, antioxidant vitamins, and cancers of the upper digestive tract in a prospective cohort study of postmenopausal women

Very few prospective studies have reported previously on the association of micronutrient intake and the risk of cancers of the upper digestive tract (mouth, pharynx, esophagus, and stomach) in western populations. During 7 years of follow-up in the Iowa Women's Health Study, from 1986-1992, 59 of the 34,691 at-risk cohort members developed cancers of the upper digestive tract. The association of retinol and antioxidant vitamins (carotene and vitamins C and E) were evaluated separately for cancers of the mouth/pharynx/esophagus (n = 33) and stomach (n = 26). After adjustment for age, smoking, and total energy intake, higher intakes of carotene and vitamins C and E were related to lower risks of both oral/pharyngeal/esophageal and gastric cancers, while retinol was associated with lower risk of gastric cancer only. The dose-response relation between gastric cancer risk and intake of carotene was clear and statistically significant, with relative risks of 0.6 and 0.3, respectively, observed among women in the upper two versus the lowest tertiles of intake. This study provides further evidence that higher intake of antioxidant vitamins may be important in the prevention of cancers of the upper digestive organs.

Accelerated fractionation radiotherapy and concomitant chemotherapy in patients with stage IV inoperable head and neck cancer

BACKGROUND

Stage IV inoperable head and neck cancer has a 2-year mortality rate of greater than 70% when treated with conventional radiotherapy. A Phase II study was undertaken to evaluate the effects of concomitant chemotherapy and accelerated, interrupted, twice-a-day radiotherapy on tumor response, locoregional control, survival, and morbidity.

METHODS

Thirty-four patients with Stage IV inoperable squamous cell carcinoma of the head and neck and a minimum follow-up of 36 months were evaluated. Concomitant chemoradiotherapy was administered during weeks 1, 3, and 5 (with planned breaks during weeks 2 and 4), consisting of cisplatin 60 mg/m2 on day 1, continuous 5-day infusion of 5-fluorouracil, 750 mg/m2 per day, and radiotherapy, 2 Gy twice a day, more than 6 hours apart, followed by 3 days of radiation therapy alone (final "boost") in week 6, for a total dose of 70 Gy and treatment duration of 5 1/2 weeks (38 days).

RESULTS

Twenty-seven patients achieved a clinical complete response (82%). Actuarial locoregional control at 3 years was 73% and the actuarial 3-year survival probability, including all deaths, was 38%. All locoregional recurrences were manifested within 12 months. Of the 20 deaths, 12 were tumor related (locoregional and/or metastatic), 3 were treatment related, and 5 were due to other causes. Acute toxicity consisted of grade 3 mucositis and dysphagia and grade 2-3 leukopenia, not requiring treatment interruption or cessation.

CONCLUSION

Concomitant accelerated radiation therapy and chemotherapy is a feasible treatment approach in this prognostically poor patient population, yielding dramatic tumor responses and impressive locoregional control at the cost of somewhat increased acute toxicity. Although serious late complications have not been observed, caution should be exercised in view of the relatively short follow up.

Dietary intake of energy and animal foods and endometrial cancer incidence. The Iowa women's health study

To assess the relations of dietary intake of energy and animal foods to endometrial cancer risk, dietary analyses were performed using data from a prospective cohort study of over 23,000 postmenopausal Iowa women who responded to a mailed questionnaire in 1986 and were followed through the end of 1992 for cancer incidence and total mortality. Usual intakes of 127 food items were measured by a semiquantitative food frequency questionnaire. After 7 years of follow-up, 216 incident endometrial cancer cases had been ascertained. There was no statistically significant association of dietary intake of energy and most animal foods with endometrial cancer incidence over the 7-year follow-up period. Stratified analyses, however, suggested that intake of energy from plant foods may be inversely associated with endometrial cancer risk in the latter years of follow-up (trend test, p = 0.03), while high intake of energy and foods from animal sources related to slightly, but not statistically significantly, elevated risks of this cancer in the earlier years of follow-up. The only significant dose-response relation observed in food group analyses was for processed meat and fish, for which a significant 50% excess risk of endometrial cancer was found among women in the highest versus the lowest tertile of intake. This study suggests that dietary intake of energy and most animal foods is not related to or is only weakly related to the risk of endometrial cancer among postmenopausal US women.

Relative concentrations of proton MR visible neurochemicals in gray and white matter in human brain

The relative distributions of N-acetylaspartate (NAA) + N-acetylaspartylglutamate (NAAG), creatine + phosphocreatine (Cr/PCr), and choline (Cho) in the gray and white matter of human brain were determined by utilizing proton magnetic resonance spectroscopic imaging (SI). The SI data was processed using an automated spectroscopic image processing algorithm, and image segmentation was performed using a supervised technique. Linear regression analysis indicated that the NAA + NAAG (2.01 ppm) and Cr/PCr (3.02 ppm) peaks are greater in gray matter compared with white matter. The large intersubject variation observed in the Cho (3.20 ppm) resonance prevented the assessment of its regional distribution with confidence.