The new normal: a UK fertility clinic experience of universal RT-PCR SARS-CoV-2 testing.

Following the temporary closure of fertility clinics in 2020 in many countries across the world, the SARS-CoV-2 pandemic has meant that the sector has had to rapidly adapt to novel ways of operating. The aim of this study was to investigate the efficacy and feasibility of universal real-time polymerase chain reaction testing at an IVF clinic within a UK tertiary referral centre. Between March and December 2020, we performed 2,401 SARS-CoV-2 RT-PCR tests on 1,215 individual patients, of which eight were positive (0.3%). Appropriate positive case identification allowed for delay in treatment initiation or cancellation as applicable. This has allowed our unit to continue to operate safely and efficiently.

Group B Streptococcus in the urine in nonpregnant adults: Disease or distraction?

In this large, retrospective cohort study, we used administrative data to evaluate nonpregnant adults with group B Streptococcus (GBS) bacteriuria. We found greater all-cause mortality in those with urinary tract infections compared to asymptomatic bacteriuria. Differences in patients' baseline characteristics and the 1-year mortality rate raise the possibility that provider practices contribute to differences observed.

Expanding the definition beyond surveillance criteria reveals a large burden of osteomyelitis caused by group B Streptococcus in the United States Veterans Health Administration.

BACKGROUND: Population-based surveillance studies may underestimate osteomyelitis caused by Group B Streptococcus (GBS). We analyzed cases of GBS osteomyelitis, including patients diagnosed using an expanded case definition that incorporates cultures from non-sterile sites, as well as cultures from normally sterile sites. METHODS: We retrospectively examined a cohort of veterans with the diagnosis of osteomyelitis between 2008 and 2017. Cases of definite GBS osteomyelitis required GBS isolation from normally sterile sites, (e.g., blood or bone). Cases of probable GBS osteomyelitis permitted GBS isolation from non-sterile sites (e.g., surgical sites, wounds). We compared comorbid conditions, lower extremity amputation and mortality rates in these groups. RESULTS: Among 1281 cases of GBS osteomyelitis, the median age was 63 years, 87% had diabetes mellitus and 37% had peripheral vascular disease. Similar characteristics were found in 768 (60%) cases classified as definite and 513 (40%) classified as probable GBS osteomyelitis. Polymicrobial infection was less frequent in patients with definite than with probable GBS osteomyelitis (45% vs. 85%; P < 0.001). Mortality rates within 1-year were similar for definite and probable GBS osteomyelitis (12% vs. 10%). Amputation within 1-year occurred in 21% of those with definite and 10% of those with probable GBS osteomyelitis of the lower extremity, with comparable rates in the subset with monomicrobial infection. CONCLUSIONS: Expanding the definition of GBS osteomyelitis to include cases with cultures from non-sterile sites may be warranted, increasing the estimated burden of GBS osteomyelitis. This can help guide preventive efforts to reduce the impact of GBS osteomyelitis.

Similar Mortality Among United States Veterans With Invasive and Noninvasive Pneumonia due to Group B Streptococcus.

BACKGROUND: The nosology of noninvasive pneumonia due to group B Streptococcus (GBS) is not well defined. This study compared clinical characteristics and outcomes of patients with invasive pneumonia and noninvasive pneumonia caused by GBS. METHODS: We conducted a retrospective cohort study among Veterans Affairs (VA) healthcare users between 2008 and 2017. Using data from electronic health records, we identified patients who had blood or respiratory cultures that grew GBS and had invasive pneumonia or noninvasive pneumonia. We analyzed patient and infection characteristics associated with all-cause mortality, including among the subset of patients with cultures that were monomicrobial for GBS. RESULTS: Among 1791 patients with GBS pneumonia, 646 (36%) cases were invasive and 1145 (64%) were noninvasive. Among those, 535 and 424 cases of invasive and noninvasive pneumonia, respectively, had cultures that were monomicrobial for GBS. All-cause 30-day mortality among those with monomicrobial GBS pneumonia was 15% for both those with invasive and noninvasive disease, respectively. Increasing age, severity of illness, healthcare exposure in the previous 90 days, and polymicrobial infection with Staphylococcus aureus were independently associated with all-cause mortality at 30 days. CONCLUSIONS: In this large cohort, even when considering cases for which GBS was the only pathogen recovered, >40% of GBS pneumonia cases were noninvasive. All-cause mortality was comparable for invasive and noninvasive pneumonia. These findings suggest that the burden of GBS pneumonia may be greater than previously recognized by surveillance of invasive GBS disease and may inform treatment and prevention efforts.

Impact of fever thresholds in detection of COVID-19 in Department of Veterans Affairs Community Living Center residents.

BACKGROUND: Among nursing home residents, for whom age and frailty can blunt febrile responses to illness, the temperature used to define fever can influence the clinical recognition of COVID-19 symptoms. To assess the potential for differences in the definition of fever to characterize nursing home residents with COVID-19 infections as symptomatic, pre-symptomatic, or asymptomatic, we conducted a retrospective study on a national cohort of Department of Veterans Affairs (VA) Community Living Center (CLC) residents tested for SARS-CoV-2. METHODS: Residents with positive SARS-CoV-2 tests were classified as asymptomatic if they did not experience any symptoms, and as symptomatic or pre-symptomatic if the experienced a fever (>100.4°F) before or following a positive SARS-CoV-2 test, respectively. All-cause 30-day mortality was assessed as was the influence of a lower temperature threshold (>99.0°F) on classification of residents with positive SARS-CoV-2 tests. RESULTS: From March 2020 through November 2020, VA CLCs tested 11,908 residents for SARS-CoV-2 using RT-PCR, with a positivity of rate of 13% (1557). Among residents with positive tests and using >100.4°F, 321 (21%) were symptomatic, 425 (27%) were pre-symptomatic, and 811 (52%) were asymptomatic. All-cause 30-day mortality among residents with symptomatic and pre-symptomatic COVID-19 infections was 24% and 26%, respectively, while those with an asymptomatic infection had mortality rates similar to residents with negative SAR-CoV-2 tests (10% and 5%, respectively). Using >99.0°F would have increased the number of residents categorized as symptomatic at the time of testing from 321 to 773. CONCLUSIONS: All-cause 30-day mortality was similar among VA CLC residents with symptomatic or pre-symptomatic COVID-19 infection, and lower than rates reported in non-VA nursing homes. A lower temperature threshold would increase the number of residents recognized as having symptomatic infection, potentially leading to earlier detection and more rapid implementation of therapeutic interventions and infection prevention and control measures.

A positive pneumococcal urinary antigen test promotes narrow spectrum antibiotic use in patients with non-invasive pneumococcal pneumonia.

BACKGROUND: We compared changes in antibiotics in patients diagnosed with noninvasive pneumococcal pneumonia (NPP) by pneumoccocal urinary antigen tests or respiratory cultures. METHODS: We compared patients diagnosed by pneumococcal urinary antigen tests or respiratory cultures that grew Streptococcus pneumoniae. We assessed the time from sample receipt to final result and antibiotic regimens, including an Antibiotic Spectrum Index (ASI). RESULTS: Seventy-two cases of NPP were diagnosed by pneumococcal urinary antigen and 87 by respiratory cultures, with a median time from sample receipt to final result of 0.21 days (interquartile range (IQR) 0.17-1.17) and 3.21 days (IQR 3.17-4.21 days), respectively. Among 123 cases without antibiotic allergies, between days 0 and 2, the ASI decreased in 36% (18/50) of cases diagnosed by urinary antigen compared to 10% (7/73) of cases diagnosed by respiratory culture (P < 0.01). CONCLUSIONS: Positive pneumococcal urinary antigen tests lead to early deescalation of antibiotics more frequently than respiratory cultures.

Risk Factors and Mortality Rates Associated With Invasive Group B Streptococcus Infections Among Patients in the US Veterans Health Administration.

Importance: The incidence of invasive infections caused by group B Streptococcus (GBS) continues to increase in the United States. Although diabetes is a key risk factor for invasive GBS, the influence of long-term glycemic control is not well characterized; other risk factors and mortality rates associated with specific types of invasive GBS infections are unknown. Objective: To investigate risk factors and mortality rates associated with specific invasive GBS infectious syndromes. Design, Setting, and Participants: This cohort study used US Veterans Health Administration data to assess active users of the Veterans Affairs health care system between January 1, 2008, and December 31, 2017. Data analysis was conducted from April 2018 to August 2019. Exposures: Invasive GBS infections. Main Outcomes and Measures: The specific types of infectious syndromes and comorbid conditions among patients with an invasive GBS infection were evaluated. Results: Between 2008 and 2017, 5175 patients in the Veterans Affairs health care system experienced 5497 invasive GBS infections (5027 [97.1%] men, 3737 [72.2%] white, and 4545 [87.8%] non-Latino); all-cause 30-day mortality was 8.7% (451 of 5175). The most frequently observed infections were osteomyelitis (1171 [21.3%]), bacteremia without focus (1009 [18.4%]), skin or soft-tissue infections (919 [16.7%]), and pneumonia or empyema (694 [12.6%]). All-cause 30-day mortality following the index infection for each patient was highest among patients with peritonitis (38 of 138 [27.5%]) and pneumonia or empyema (116 of 664 [17.5%]) and lowest among those with osteomyelitis (15 of 1075 [1.4%]) or joint infection (17 of 501 [3.4%]). The most common comorbid conditions among patients with invasive GBS infections were diabetes (3364 [65.0%]), obesity (2669 [51.6%]), and chronic heart conditions (1633 [31.6%]). From 2008 to 2017, the incidence of invasive GBS infections increased from 9.23 to 11.67 cases per 100 000 person-years (P = .049). Stratification by body mass index showed the highest incidence of infections among patients at the extremes of body mass index (body mass index <18.5, 25.1 cases per 100 000 person-years; body mass index ≥40, 31.0 cases per 100 000 person-years). The incidence among patients with diabetes and poor long-term glycemic control (ie, hemoglobin A1c ≥9.5%) was 4-fold greater than among patients with diabetes and good glycemic control (ie, hemoglobin A1c <7.5%) (78.3 cases vs 19.0 cases per 100 000 person-years; unadjusted incident rate ratio, 4.1; 95% CI, 3.7-4.4; P < .001). Conclusions and Relevance: In this cohort study, comorbid conditions and 30-day mortality varied among types of invasive GBS infections. Obesity and poor long-term glycemic control were associated with invasive GBS infections. Efforts to reverse the trend of an increased incidence of invasive GBS infections should continue to support reducing obesity and focus on improving glycemic control.

Changes in antibiotic use following implementation of a telehealth stewardship pilot program.

Starting in 2016, we initiated a pilot tele-antibiotic stewardship program at 2 rural Veterans Affairs medical centers (VAMCs). Antibiotic days of therapy decreased significantly (P < .05) in the acute and long-term care units at both intervention sites, suggesting that tele-stewardship can effectively support antibiotic stewardship practices in rural VAMCs.

A pilot study using telehealth to implement antimicrobial stewardship at two rural Veterans Affairs medical centers.

OBJECTIVE: To test the feasibility of using telehealth to support antimicrobial stewardship at Veterans Affairs medical centers (VAMCs) that have limited access to infectious disease-trained specialists. DESIGN: A prospective quasi-experimental pilot study. SETTING: Two rural VAMCs with acute-care and long-term care units.InterventionAt each intervention site, medical providers, pharmacists, infection preventionists, staff nurses, and off-site infectious disease physicians formed a videoconference antimicrobial stewardship team (VAST) that met weekly to discuss cases and antimicrobial stewardship-related education. METHODS: Descriptive measures included fidelity of implementation, number of cases discussed, infectious syndromes, types of recommendations, and acceptance rate of recommendations made by the VAST. Qualitative results stemmed from semi-structured interviews with VAST participants at the intervention sites. RESULTS: Each site adapted the VAST to suit their local needs. On average, sites A and B discussed 3.5 and 3.1 cases per session, respectively. At site A, 98 of 140 cases (70%) were from the acute-care units; at site B, 59 of 119 cases (50%) were from the acute-care units. The most common clinical syndrome discussed was pneumonia or respiratory syndrome (41% and 35% for sites A and B, respectively). Providers implemented most VAST recommendations, with an acceptance rate of 73% (186 of 256 recommendations) and 65% (99 of 153 recommendations) at sites A and B, respectively. Qualitative results based on 24 interviews revealed that participants valued the multidisciplinary aspects of the VAST sessions and felt that it improved their antimicrobial stewardship efforts and patient care. CONCLUSIONS: This pilot study has successfully demonstrated the feasibility of using telehealth to support antimicrobial stewardship at rural VAMCs with limited access to local infectious disease expertise.

A virtual clinic improves pneumococcal vaccination coverage among patients living with HIV at a Veterans Affairs Medical Center.

People living with the human immunodeficiency virus (HIV) should receive pneumococcal vaccinations as part of their routine health maintenance. Our goal was to create a "virtual clinic" to help increase rates of pneumococcal vaccination among people living with HIV without adding substantially to the workload of primary providers. We used administrative data from our Veterans Affairs (VA) medical center to identify a cohort of veterans living with HIV who were not current with either the 13-valent pneumococcal conjugate vaccine (PCV13), the 23-valent pneumococcal polysaccharide vaccine (PPSV23) or both. We enrolled these individuals (n = 99) into a virtual clinic, notified providers via the electronic medical record and mailed letters to the veterans recommending they receive a pneumococcal vaccine. We also wrote orders for the appropriate pneumococcal vaccine that expired after 90 days. Among the virtual clinic cohort, 38% (38/99) of patients received the recommended vaccine within 180 days. Concurrent with our intervention, the Veterans Health Administration deployed a system-wide pneumococcal vaccine clinical reminder that incorporated recent PCV13 recommendations. To discern any effect of the virtual clinic beyond that of the clinical reminder, we compared the rate of PCV13 vaccinations among all HIV-positive veterans at our institution to the equivalent population from 2 other VA medical centers in Ohio. With consideration of the VHA's system-wide clinical reminder, the proportion of HIV-positive patients who received PCV13 in the first 90 days following the virtual clinic intervention was greater at our facility compared to another Ohio VA medical center (P < 0.05). The virtual clinic improved the pneumococcal vaccine coverage among HIV-positive veterans. These outcomes suggest that even in conjunction with a system-wide clinical reminder, the virtual clinic strategy improves vaccination rates among a high-risk population.

Preexisting Immunity, Not Frailty Phenotype, Predicts Influenza Postvaccination Titers among Older Veterans.

Both preexisting immunity to influenza and age have been shown to be correlates of influenza vaccine responses. Frailty, an indicator of functional impairment in older adults, was also shown in one study to predict lower influenza vaccine responses among nonveterans. In the current study, we aimed to determine the associations between frailty, preexisting immunity, and immune responses to influenza vaccine among older veterans. We studied 117 subjects (age range, 62 to 95 years [median age, 81 years]), divided into three cohorts based on the Fried frailty test, i.e., nonfrail (NF) (n = 23 [median age, 68 years]), prefrail (n = 50 [median age, 80 years]), and frail (n = 44 [median age, 82 years]), during the 2010-2011 and 2011-2012 influenza seasons. Subjects received the seasonal trivalent inactivated influenza vaccine, and baseline and postvaccination samples were obtained. Anti-influenza humoral immunity, as measured by hemagglutination inhibition (HI) and microneutralization assays, was measured for influenza B, A(H1N1)pdm09, and A(H3N2) viruses. Postvaccination titers were not different between frail and NF subjects overall in this older subset of veterans. However, preexisting HI titers were strongly correlated with postvaccination titers among all functional status groups. When microneutralization titers were compared, the association between preexisting immunity and vaccine responses varied by frailty status, with the strongest correlation being observed for the NF group. In conclusion, preexisting immunity rather than frailty appeared to predict postvaccination titers in this older veteran cohort.

A Virtual Clinic Improves Pneumococcal Vaccination for Asplenic Veterans at High Risk for Pneumococcal Disease.

We developed a "virtual clinic" to improve pneumococcal vaccination among asplenic adults. Using an electronic medical record, we identified patients, assessed their vaccination status, entered orders, and notified patients and providers. Within 180 days, 38 of 76 patients (50%) received a pneumococcal vaccination. A virtual clinic may optimize vaccinations among high-risk patients.

Age-related differences in polyfunctional T cell responses.

BACKGROUND: A reduced number of naïve T cells along with an accumulation of differentiated cell types in aging have been described but little is known about the polyfunctionality of the T cell responses. In this study we compared the individual and polyfunctional expression of IFN-γ, MIP-1α, TNF-α, perforin, and IL-2 by T cell subsets, including the newly described stem cell like memory T cells (TSCM), in response to stimulation with superantigen staphylococcal enterotoxin B (SEB) in older (median age 80, n = 23) versus younger (median age 27; n = 23) adults. RESULTS: Older age was associated with a markedly lower frequency of CD8+ naïve T cells (11% vs. 47%; p < 0.0001) and an expansion in memory T cell subsets including central memory (p < 0.05), effector memory and effector T cells (p < 0.001 for both). There was also a decline in CD4+ naïve T cells in older subjects (33% vs. 45%; p = 0.02). There were no differences in frequencies or polyfunctional profiles of TSCM between groups. CD8+ naïve cells in the older group had increased expression of all functional parameters measured compared to the younger subjects and exhibited greater polyfunctionality (p = 0.04). CD4+ naïve T cells in the older group also showed greater polyfunctionality with a TNF-α and IL-2 predominance (p = 0.005). CD8+ effector memory and effector T cells exhibited increased polyfunctionality in the older group compared with younger (p = 0.01 and p = 0.003). CONCLUSIONS: These data suggest that aging does not have a negative effect on polyfunctionality and therefore this is likely not a major contributor to the immunesenescence described with aging.

Relationship between perceptions about neighborhood environment and prevalent obesity: data from the Dallas Heart Study.

OBJECTIVES: Although psychosocial stress can result in adverse health outcomes, little is known about how perceptions of neighborhood conditions, a measure of environment-derived stress, may impact obesity. The association between perceptions of neighborhood environment and obesity (defined as body mass index [BMI] ≥ 30 kg/m(2) ) among 5,907 participants in the Dallas Heart Study, a multi-ethnic, probability-based sample of Dallas County residents was examined. DESIGN AND METHODS: Participants were asked to respond to 18 questions about perceptions of their neighborhood. Factor analysis was used to identify three factors associated with neighborhood perceptions: neighborhood violence, physical environment, and social cohesion. Logistic regression analyses were performed to determine the relationship between each factor (higher quintile = more unfavorable perceptions) and the odds of obesity. RESULTS: Decreasing age, income, and education associated with unfavorable overall neighborhood perceptions and unfavorable perceptions about specific neighborhood factors (P trend <0.05 for all). Increasing BMI was associated with unfavorable perceptions about physical environment (P trend <0.05) but not violence or social cohesion. After adjustment for race, age, sex, income, education, and length of residence, physical environment perception score in the highest quintile remained associated with a 25% greater odds of obesity (OR 1.25, [95% CI 1.03-1.50]). Predictors of obesity related to environmental perceptions included heavy traffic (OR 1.39, [1.17-1.64]), trash/litter in neighborhood (OR 1.27, [1.01-1.46]), lack of recreational areas (OR 1.21, [1.01-1.46]), and lack of sidewalks (OR 1.25, [95% CI 1.04-1.51]). CONCLUSIONS: Thus, unfavorable perceptions of environmental physical conditions are related to increased obesity. Efforts to improve the physical characteristics of neighborhoods, or the perceptions of those characteristics, may assist in the prevention of obesity in this community.

Churches as targets for cardiovascular disease prevention: comparison of genes, nutrition, exercise, wellness and spiritual growth (GoodNEWS) and Dallas County populations.

BACKGROUND: We compared cardiovascular (CV) risk factors (CVRFs) of community-based participatory research (CBPR) participants with the community population to better understand how CBPR participants relate to the population as a whole. METHODS: GoodNEWS participants in 20 African-American churches in Dallas, Texas were compared with age/sex-matched African-Americans in the Dallas Heart Study (DHS), a probability-based sample of Dallas County residents. DHS characteristics were sample-weight adjusted to represent the Dallas County population. RESULTS: Despite having more education (college education: 75 versus 51%, P< 0.0001), GoodNEWS participants were more obese (mean body mass index: 34 versus 31 kg/m(2), P< 0.001) and had more diabetes (23 versus 12%, P< 0.001) and hyperlipidemia (53 versus 14%, P< 0.001) compared with African-Americans in Dallas County. GoodNEWS participants had higher rates of treatment and control of most CVRFs (treated hyperlipidemia: 95 versus 64%, P< 0.001; controlled diabetes: 95 versus 21%, P< 0.001; controlled hypertension: 70 versus 52%, P= 0.003), were more physically active (233 versus 177 metabolic equivalent units-min/week, P< 0.0001) and less likely to smoke (10 versus 30%, P< 0.001). CONCLUSIONS: Compared with African-Americans in Dallas County, CBPR participants in church congregations were more educated, physically active and had more treatment and control of most CVRFs. Surprisingly, this motivated population had a greater obesity burden, identifying them as a prime target for CBPR-focused obesity treatment.

Disparities in counseling for lifestyle modification among obese adults: insights from the Dallas Heart Study.

Clinician counseling is a catalyst for lifestyle modification in obesity. Unfortunately, clinicians do not appropriately counsel all obese patients about lifestyle modification. The extent of disparities in clinician counseling is not well understood. Obese participants (BMI ≥30 kg/m(2), N = 2097) in the Dallas Heart Study (DHS), a probability-based sample of Dallas County residents ages 18-65, were surveyed regarding health-care utilization and lifestyle counseling over the year prior to DHS enrollment. Health-care utilization and counseling were compared between obese participants across three categories based on the presence of 0, 1, or 2+ of the following cardiovascular (CV) risk factors: hypertension, hypercholesterolemia, or diabetes. Logistic regression modeling was used to determine likelihood of counseling in those with 0 vs. 1+ CV risk factors, stratified by race, adjusting for age, sex, insurance status, and education. Among obese subjects who sought medical care, those with 0 CV risk factors, compared to those with 1 or 2+ CV risk factors, were less likely to report counseling about losing weight (41% vs. 67% vs. 87%, P trend <0.001), dietary changes (44% vs. 71% vs. 85%, P trend <0.001), and physical activity (46% vs. 71% vs. 86%, P trend <0.001). Blacks and Hispanics without CV risk factors had a lower odds of receiving counseling than whites without risk factors on weight loss (adjusted odds ratio (OR), 95% confidence interval (CI) for nonwhites 0.19, [0.13-0.28], whites 0.48, [0.26-0.87]); dietary changes (nonwhites 0.19, [0.13-0.27], whites 0.37, [0.21-0.64]); and physical activity (nonwhites 0.22, [0.16-0.32], whites 0.32, [0.18-0.57]). Lifestyle counseling rates by clinicians are suboptimal among obese patients without CV risk factors, especially blacks and Hispanics. Systematic education about and application of lifestyle interventions could capitalize on opportunities for primary CV risk prevention.

The GoodNEWS (Genes, Nutrition, Exercise, Wellness, and Spiritual Growth) Trial: a community-based participatory research (CBPR) trial with African-American church congregations for reducing cardiovascular disease risk factors--recruitment, measurement, and randomization.

INTRODUCTION: Although cardiovascular diseases (CVD) are the leading cause of death among Americans, significant disparities persist in CVD prevalence, morbidity, and mortality based on race and ethnicity. However, few studies have examined risk factor reduction among the poor and ethnic minorities. METHODS: Community-based participatory research (CBPR) study using a cluster randomized design--African-American church congregations are the units of randomization and individuals within the congregations are the units of analysis. Outcome variables include dietary change (Diet History Questionnaire), level of physical activity (7-Day Physical Activity Recall), lipoprotein levels, blood pressure, fasting glucose, and hemoglobin A1c. RESULTS: Eighteen (18) church congregations were randomized to either a health maintenance intervention or a control condition. Complete data were obtained on 392 African-American individuals, 18 to 70 years of age, predominantly employed women with more than a high school diploma. Treatment and intervention groups were similar at baseline on saturated fat intake, metabolic equivalent of tasks (METS) per day, and other risk factors for CVD. CONCLUSIONS: The GoodNEWS trial successfully recruited and evaluated CVD-related risk among African-American participants using a CBPR approach. Several logistical challenges resulted in extending the recruitment, preliminary training, and measurement periods. The challenges were overcome with the assistance of a local community consultant and a professional event planner. Our experience supports the need for incorporating non-traditional community-based staff into the design and operational plan of CBPR trials.

A comprehensive multilocus phylogeny for the wood-warblers and a revised classification of the Parulidae (Aves).

The birds in the family Parulidae-commonly termed the New World warblers or wood-warblers-are a classic model radiation for studies of ecological and behavioral differentiation. Although the monophyly of a 'core' wood-warbler clade is well established, no phylogenetic hypothesis for this group has included a full sampling of wood-warbler species diversity. We used parsimony, maximum likelihood, and Bayesian methods to reconstruct relationships among all genera and nearly all wood-warbler species, based on a matrix of mitochondrial DNA (5840 nucleotides) and nuclear DNA (6 loci, 4602 nucleotides) characters. The resulting phylogenetic hypotheses provide a highly congruent picture of wood-warbler relationships, and indicate that the traditional generic classification of these birds recognizes many non-monophyletic groups. We recommend a revised taxonomy in which each of 14 genera (Seiurus, Helmitheros, Mniotilta, Limnothlypis, Protonotaria, Parkesia, Vermivora, Oreothlypis, Geothlypis, Setophaga, Myioborus, Cardellina, Basileuterus, Myiothlypis) corresponds to a well-supported clade; these nomenclatural changes also involve subsuming a number of well-known, traditional wood-warbler genera (Catharopeza, Dendroica, Ergaticus, Euthlypis, Leucopeza, Oporornis, Parula, Phaeothlypis, Wilsonia). We provide a summary phylogenetic hypothesis that will be broadly applicable to investigations of the historical biogeography, processes of diversification, and evolution of trait variation in this well studied avian group.

Tuberculosis risk in US Peace Corps Volunteers, 1996 to 2005.

BACKGROUND: With the popularity of international travel increasing, more travelers in endemic areas may increase their risk of tuberculosis (TB). We analyzed Peace Corps data to assess the risk of TB in long-term travelers from the United States. METHODS: We analyzed purified protein derivative (PPD) conversion and acute TB case data from the Peace Corps Epidemiological Surveillance System as well as postservice claims data. We calculated the risk of PPD conversion and active TB in all countries with Peace Corps Volunteers between 1996 and 2005 and compared these risks with other published data. RESULTS: The overall incidence rates for positive PPD conversions and active TB cases are 1.283 and 0.057 per 1,000 Volunteer-months, respectively. The Africa region had the highest PPD conversion rate of 1.467 conversions per 1,000 Volunteer-months as well as the highest active TB rate of 0.089 cases per 1,000 Volunteer-months. Per-country incidence rates for PPD conversions and active TB cases ranged widely from 0.000 to 5.514 cases and 0.000 to 2.126 cases per 1,000 Volunteer-months, respectively. In countries identified as "high risk," there were 1.436 cases of PPD conversions and 0.084 cases of active TB per 1,000 Volunteer-months. CONCLUSIONS: Peace Corps Volunteers have significantly higher rates of TB when compared to the average US population but much lower than those reported for travelers to highly endemic countries. Volunteers assigned to highly endemic countries still have a lower risk compared to other travelers to those same countries. Keeping in mind that Peace Corps Volunteers are a unique population, these data may be useful in providing medical advice to long-term travelers.