Secular trends in invasive meningococcal disease, Massachusetts, 1988-2011: what happened to invasive disease?

Invasive meningococcal disease (IMD) reported to the Massachusetts Department of Public Health from 1988 to 2011 was reviewed. The average annual incidence of IMD/100 000 decreased from 1·57 [95% confidence interval (CI) 1·42-1·73] for 1988-1991 to 0·22 (95% CI 0·17-0·29) for 2008-2011. The pattern of decreasing incidence over time differed by age group. There was a decrease in IMD/100 000 in the 0-4 years age group after 1991 from 10·92 (95% CI 8·08-14·70) in 1991 to 5·76 (95% CI 3·78-8·72) in 1992. Incidence in the 0-4 years age group remained below 5/100 000 per year on average thereafter. A substantial reduction in incidence in all age groups was observed between 2000 and 2009, which began before the introduction of conjugate meningococcal vaccine in 2005. Marked reductions in incidence of IMD in Massachusetts, and elsewhere, deserve further investigation with respect to potential factors that go beyond the introduction and deployment of improved meningococcal vaccines.

Pre-filled normal saline syringes to reduce totally implantable venous access device-associated bloodstream infection: a single institution pilot study.

Flushing totally implantable venous access devices (TIVADs) with manually filled saline syringes may increase contamination and catheter-related bloodstream infection (CRBSI). We used a retrospective cohort study to assess the impact of changing from manually filled syringes to manufactured pre-filled syringes on the frequency of CRBSI in 718 TIVADs. Manually filled syringes were used in 269 patients and pre-filled syringes in 449. The CRBSI rate was 2.7% in the pre-filled syringe group and 6.3% in the manually filled syringe group (P = 0.016). Sex, tumour type and stage, access site and access body side were not independent risk factors for CRBSI.

Pneumonia and influenza hospitalization in HIV-positive seniors.

HIV-positive persons and the elderly have increased risk for influenza-related complications, including pneumonia. Using claims data for pneumonia and influenza (P&I) hospitalization in the USA, we described the temporo-demographic trends and in-patient case-fatality in persons aged ≥ 65 years by HIV status. Our results showed a near doubling in the fraction of P&I admissions representing HIV-positive persons between 1991 and 2004 [relative risk (RR) 1·95, 95% confidence interval (CI) 1·80-2·13]. HIV-positive adults were younger (70·3 vs. 79·9 years, P<0·001), and had higher case-fatality (18·0% vs. 12·6%, P<0·001). Adjusting for other variables, case-fatality decreased by 5·8% in HIV-positive persons with the availability of highly active antiretroviral therapy (P=0·032). However, HIV-positive seniors were still 51% more likely to die during hospitalization than HIV-negative persons in 2004 (OR 1·51, 95% CI 1·23-1·85). HIV-infected persons represent a growing fraction of the elderly population hospitalized with P&I. Additional measures are needed to reduce case-fatality associated with P&I in this population.

Automated function imaging: a new operator-independent strain method for assessing left ventricular function.

BACKGROUND: Speckle tracking is a new technique based on pure 2D grayscale ultrasound acquisition allowing calculation of segmental strains. To facilitate clinical application, speckle tracking has been integrated into the most recent echocardiographic systems for quick, automated evaluation of left ventricular function (Automated Function Imaging, AFI). OBJECTIVE: To evaluate the feasibility, calculation time, accuracy and reproducibility of global longitudinal strain (GLS) from AFI in determining LV function in comparison to reference echocardiographic and angiographic methods-whatever the operator's experience. METHODS: Echocardiography was performed in 65 patients scheduled for cardiac catheterization using a Vivid 7 system. They were divided into 3 groups according to EF (>55%, 35< or =EF< or =55%,<35%). Image quality, global LV function parameters (ejection fraction, aortic flow, dp/dt) and segmental contraction were analyzed by one experienced operator and one beginner. GLS was obtained from apical 2, 3 and 4 chamber views. GLS was compared to both echocardiographic and angiographic EF, as well as to other echocardiographic parameters. RESULTS: GLS was obtained successfully in 97% of patients. Mean calculation time including correction of endocardial detection was less than 60 seconds. GLS was significantly different between the 3 groups, respectively -18.1+/-2.5%, -11.5+/-2.1% and -6.0+/-1.2% (p<0.01). Strong correlations were observed between GLS and LV function (r from 0.68 to 0.87) with a high level of reproducibility. No difference was observed between experienced and inexperienced operators. CONCLUSION: AFI is clinically applicable and an effective means of assessing LV function due to its short acquisition time, feasibility and accuracy, whatever the experience of the operator.

Seasonality in six enterically transmitted diseases and ambient temperature.

We propose an analytical and conceptual framework for a systematic and comprehensive assessment of disease seasonality to detect changes and to quantify and compare temporal patterns. To demonstrate the proposed technique, we examined seasonal patterns of six enterically transmitted reportable diseases (EDs) in Massachusetts collected over a 10-year period (1992-2001). We quantified the timing and intensity of seasonal peaks of ED incidence and examined the synchronization in timing of these peaks with respect to ambient temperature. All EDs, except hepatitis A, exhibited well-defined seasonal patterns which clustered into two groups. The peak in daily incidence of Campylobacter and Salmonella closely followed the peak in ambient temperature with the lag of 2-14 days. Cryptosporidium, Shigella, and Giardia exhibited significant delays relative to the peak in temperature (approximately 40 days, P<0.02). The proposed approach provides a detailed quantification of seasonality that enabled us to detect significant differences in the seasonal peaks of enteric infections which would have been lost in an analysis using monthly or weekly cumulative information. This highly relevant to disease surveillance approach can be used to generate and test hypotheses related to disease seasonality and potential routes of transmission with respect to environmental factors.

An outbreak of norovirus gastroenteritis associated with wedding cakes.

We sought to determine the source of a norovirus outbreak among attendees of 46 weddings taking place during a single weekend. Norovirus-compatible illness was experienced by 332 (39%) of wedding guests surveyed; the outbreak affected up to 2700 persons. Illness was associated with eating wedding cake provided by a bakery common to the weddings (adjusted RR 4.5, P<0.001). A cake requiring direct hand contact during its preparation accounted for the majority of illness. At least two bakery employees experienced norovirus-compatible illness during the week preceding the weddings. Identical sequence types of norovirus were detected in stool specimens submitted by two wedding guests, a wedding hall employee, and one of the ill bakery employees. It is likely that one or more food workers at the bakery contaminated the wedding cakes through direct and indirect contact. These findings reinforce the necessity of proper food-handling practices and of policies that discourage food handlers from working while ill.

Connecting health departments and providers: syndromic surveillance's last mile.

INTRODUCTION: A critical need exists for mechanisms to identify and report acute illness clusters to health departments. The Massachusetts Department of Public Health (MDPH) works with partner organizations to conduct syndromic surveillance. This effort is based on CDC's Health Alert Network program and includes automated generation and notification of signals and a mechanism to obtain detailed clinical information when needed. METHODS: Syndromic surveillance partners collect emergency department and ambulatory care data. The principal communications platform between syndromic surveillance partners and MDPH is the Massachusetts Homeland and Health Alert Network (HHAN). This Internet-based application serves as a portal for communication and collaboration and alerts predefined groups of users involved in emergency response. Syndromic surveillance partners' systems report to HHAN by using Public Health Information Network Messaging System events that meet thresholds selected by MDPH. Cluster summaries are automatically posted into a document library. HHAN notifies users by electronic mail, alphanumeric pager, facsimile, or voice communications; users decide how they want to be notified for each level of alert. Discussion threads permit real-time communication among all parties. RESULTS: This automated alert system became operational in July 2004. During July-December 2004, HHAN facilitated communication and streamlined investigation of 15 alerts. CONCLUSION: The system allows rapid, efficient alerting and bidirectional communication among public health and private-sector partners and might be applicable to other public health agencies.

Estimating the sensitivity and specificity of matching name-based with non-name-based case registries.

Because non-name-based case registries have recently been used for reporting human immunodeficiency virus infection, this study attempted to define the sensitivity, specificity and accuracy of case registry matches using non-name-based registries. The AIDS, sexually transmitted disease (STD), and tuberculosis (TB) case registries were matched using all available information to establish the standard. The registries were then matched again using five increasingly less specific criteria to compare sensitivity, specificity and accuracy. The registries were then also transformed into non-name-based codes as if they were the HIV registry and matched again. With name-based registries, sensitivities increased as the matching criteria became less exacting, while the accuracy declined slightly. Specificities remained close to 100% due to the relatively small number of matched cases. Results from matches of non-name-based registry matches were similar to those of the name-based registry matches. Non-name reporting can be used for data matching with acceptable accuracy.

Myocardial contrast echocardiography in the perfusion imaging in coronary occlusion and reperfusion.

The availability of myocardial contrast echocardiography (MCE) has potential for several applications in coronary diseases. Experimental studies have demonstrated a good correlation between measurements of myocardial blood flow and regional contrast intensity, and therefore capabilities of MCE in detecting myocardial ischemia during stress. Clinical studies must then demonstrate the value of such approaches in comparison with existing techniques such as stress echo and radionuclide imaging.

Epidemiology of congenital toxoplasmosis identified by population-based newborn screening in Massachusetts.

BACKGROUND: Fourteen years of newborn screening in Massachusetts for congenital toxoplasmosis infection identified subpopulations that appeared to have higher rates of infection. Elaborating an epidemiologic profile and risk correlates might aid implementing targeted prenatal education and newborn screening strategies with the goal of early postnatal treatment to prevent morbidity. OBJECTIVE: To describe the epidemiology of congenital toxoplasmosis in Massachusetts and risk correlates of infection using birth certificate data. METHODS: A case-control study was conducted based on Massachusetts birth certificate data. Cases were all infants with congenital toxoplasmosis identified by statewide universal newborn screening from 1988 to 1999. Controls were all children born on the same day as those infants in Massachusetts. RESULTS: Factors that strongly predicted congenital toxoplasmosis infection were mother's country of birth outside the US (especially the southeast Asian refugee origin countries of Cambodia and Laos), mother's educational level and higher gravidity. CONCLUSIONS: More extensive, culturally and linguistically appropriate, prenatal education is needed for pregnant women, regardless of a mother's educational level, especially for non-US-born mothers, and not focused only on primiparous women. Other states may be able to use their state-specific birth certificate data to compare risk profiles with those of Massachusetts to guide a toxoplasmosis screening policy on the basis of population similarities and differences.

Using automated medical records for rapid identification of illness syndromes (syndromic surveillance): the example of lower respiratory infection.

BACKGROUND: Gaps in disease surveillance capacity, particularly for emerging infections and bioterrorist attack, highlight a need for efficient, real time identification of diseases. METHODS: We studied automated records from 1996 through 1999 of approximately 250,000 health plan members in greater Boston. RESULTS: We identified 152,435 lower respiratory infection illness visits, comprising 106,670 episodes during 1,143,208 person-years. Three diagnoses, cough (ICD9CM 786.2), pneumonia not otherwise specified (ICD9CM 486) and acute bronchitis (ICD9CM 466.0) accounted for 91% of these visits, with expected age and sex distributions. Variation of weekly occurrences corresponded closely to national pneumonia and influenza mortality data. There was substantial variation in geographic location of the cases. CONCLUSION: This information complements existing surveillance programs by assessing the large majority of episodes of illness for which no etiologic agents are identified. Additional advantages include: a) sensitivity, uniformity and efficiency, since detection of events does not depend on clinicians' to actively report diagnoses, b) timeliness, the data are available within a day of the clinical event; and c) ease of integration into automated surveillance systems. These features facilitate early detection of conditions of public health importance, including regularly occurring events like seasonal respiratory illness, as well as unusual occurrences, such as a bioterrorist attack that first manifests as respiratory symptoms. These methods should also be applicable to other infectious and non-infectious conditions. Knowledge of disease patterns in real time may also help clinicians to manage patients, and assist health plan administrators in allocating resources efficiently.

Eustachian valve endocarditis: a case series and analysis of the literature.

Eustachian valve endocarditis (EVE) is a syndrome characterized by clinical signs and symptoms of right-sided infective endocarditis in association with an infective vegetation on the eustachian valve. EVE usually occurs without associated involvement of any other cardiac valves, and it is difficult to diagnose accurately by transthoracic echocardiography. Transesophageal echocardiography appears to be a more sensitive tool for the diagnosis of EVE, and it is recommended when a patient with typical signs of right-sided endocarditis has normal results on a transthoracic echocardiography study. In general, EVE responds well to conventional antibiotic therapy.

Accuracy and reproducibility of coronary flow rate assessment by real-time contrast echocardiography: in vitro and in vivo studies.

Real-time myocardial contrast echo (MCE) provides the potential to assess myocardial blood flow from time-intensity refilling curves after high-energy bubble destruction. This study validated the accuracy of this approach and the effect of specific examination variables and instrument settings on results. The effects of examination depth and angle as well as dynamic range, pulse repetition frequency, and line density were assessed with the use of in vitro incremental flow rates produced in an in vitro tissue phantom. In vivo recordings of real-time imaging with an infusion of a contrast agent (Optison) were obtained in 7 open-chest dogs with graded left anterior descending artery stenosis at baseline and during adenosine hyperemia, and were compared with flow probe measurements. After bubble destruction, time-intensity data were fitted to an exponential function, and the rate of intensity increase (b) and peak plateau intensity (A) were derived from refilling curves. In vivo real-time values for b, but not A, correlated closely with flow probe measures (r = 0.93). A similar correlation for b was observed in vitro (r = 0.98). The correlation between flow rate and b was influenced by several examination variables, including depth, angle, and instrument settings. Real-time MCE provides accurate quantification of coronary flow by assessing the rate of microbubble refilling. However, this parameter may be affected by several examination and instrument variables. Therefore, real-time MCE refilling measures are best applied by comparing baseline values with those of stress studies.

Aortic intramural hematoma: an increasingly recognized and potentially fatal entity.

Aortic intramural hematoma (IMH) is related to but is pathologically distinct from aortic dissection. In this potentially lethal entity, there is hemorrhage into the aortic media in the absence of an intimal tear. Although intimal disruption is not present, the prognosis is similar to that of classic aortic dissection; therefore, early diagnosis is critical. In this review, symptoms and prognosis of aortic IMH are discussed, as well as current diagnostic techniques and therapy.

Comparison of real-time and intermittent triggered myocardial contrast echocardiography for quantification of coronary stenosis severity and transmural perfusion gradient.

BACKGROUND: Both intermittent triggered and real-time myocardial contrast echocardiography (MCE) have been proposed to detect impaired myocardial perfusion. We compared the ability of these 2 methods to quantify altered myocardial blood flow (MBF) and transmural distribution of MBF produced by graded coronary stenoses. METHODS AND RESULTS: In 8 open-chest dogs, we created 4 graded left anterior descending coronary artery (LAD) stenoses: 3 levels of reduced adenosine hyperemia (non-flow-limiting at rest) and 1 grade of flow-limiting at rest. Real-time MCE was performed with SonoVue infusion using low-energy power pulse inversion (ATL) imaging, whereas ECG-gated intermittent triggered imaging used high energy at pulsing intervals from 1:1 to 1:10. LAD signal intensity (SI) was plotted versus time by real-time MCE and versus pulsing intervals by triggered MCE and was fitted to a 1-exponential function to obtain plateau SI (A) and the rate of SI rise (b). Visual detection of decreased opacification was equivalent by triggered and real-time MCE. Fluorescent microsphere-derived MBF ratio in LAD/left circumflex artery beds demonstrated close correlation with both real-time imaging (b, r=0.79; Axb, r=0.81) and triggered imaging (b, r=0.78; Axb, r=0.80). The endocardial/epicardial ratio of MBF in the LAD bed demonstrated closer correlation with the endocardial/epicardial ratios of b (r=0.71) and Axb (r=0.67) obtained by real-time than triggered imaging (b, r=0.42; Axb, r=0.52). CONCLUSIONS: Real-time and triggered MCE are equivalent in their ability to identify coronary stenosis and quantify altered MBF.

Utility of B-natriuretic peptide levels in identifying patients with left ventricular systolic or diastolic dysfunction.

PURPOSE: Although echocardiography is important for making the diagnosis of left ventricular dysfunction, its cost and lack of availability limit its use as a routine screening test. B-Natriuretic peptide levels accurately reflect ventricular pressure, and preliminary studies with a rapid assay have found that levels are sensitive and specific for diagnosing heart failure in patients with dyspnea. We hypothesized that B-natriuretic peptide levels obtained through the use of a rapid assay should correlate with echocardiographic abnormalities of ventricular function. SUBJECTS AND METHODS: We studied 400 patients who were referred for echocardiography at the San Diego Veteran's Healthcare System between June and August 2000 to evaluate ventricular function. B-natriuretic peptide levels were measured by a point-of-care immunoassay; cardiologists assessing left ventricular function were blinded to the assay results. Patients were grouped into those with normal ventricular function, systolic dysfunction only, diastolic dysfunction only, and both systolic and diastolic dysfunction. RESULTS: Mean (+/- SD) B-natriuretic peptide concentration was 416 +/- 413 pg/mL in the 253 patients diagnosed with abnormal left ventricular function, compared with 30 +/- 36 pg/mL in the 147 patients with normal left ventricular function. Patients with both systolic and diastolic dysfunction had the highest levels (675 +/- 423 pg/mL). The area under the receiver operating characteristic (ROC) curve for B-natriuretic peptide levels to detect any abnormal echocardiographic finding was 0.95 (91% confidence interval: 0.93 to 0.97). B-Natriuretic peptide levels were unable to differentiate systolic vs. diastolic dysfunction. In patients with symptoms of heart failure and normal systolic function, B-natriuretic peptide levels >57 pg/mL had a positive predictive value of 100% for diastolic abnormalities. CONCLUSIONS: A simple, rapid test for B-natriuretic peptide levels can reliably predict the presence or absence of left ventricular dysfunction on echocardiogram. For some patients, a normal level may preclude the need for echocardiography.

Screening cardiac ultrasonographic examination in patients with suspected cardiac disease in the emergency department.

BACKGROUND/OBJECTIVE: Our purpose was to evaluate the utility of a brief screening cardiac ultrasonographic (SCU) examination. We prospectively compared the SCU with conventional clinical evaluation in 124 emergency department (ED) patients with suspected cardiac disease. Furthermore, we assessed the impact and quality of SCU examinations as obtained by briefly trained ED personnel (EP). METHODS: Patients underwent clinical evaluation by an ED physician and SCU examination by a sonographer or cardiologist. Patient disposition, hospital stay length, and the number of full echo examinations were compared with the presence of significant findings on SCU. In patients who received a full echocardiogram during hospitalization, results of the initial clinical examination were compared with results of the SCU examination in the diagnosis of significant findings. A similar analysis, but with quality assessment, was performed on only those SCU examinations acquired by 4 EP. RESULTS: Of the 124 patients enrolled in the main study, 40 of 124 (32%) had significant findings on SCU. Of patients with abnormal SCUs versus normal SCUs, 16 of 40 (40%) versus 18 of 84 (21%) had hospital stay lengths >2 days (P < or =.05). Using the 36 inpatient full echo studies obtained for standard indications during hospitalization as a gold standard, initial clinical examination identified only 7 of 30 (23%) significant findings and had 16 false-positive diagnoses, whereas SCU identified 22 of 30 (73%) with 8 false positives. Although similar study results occurred with interpretation of 68 SCUs obtained by EP, quality was achieved in only 55% ED personnel versus 97% of sonographer-obtained SCUs (P <.05). CONCLUSIONS: An SCU examination detects significant findings misdiagnosed on initial clinical evaluation in the ED and provides prognostic data regarding length of hospital stay.

Comparative value of dobutamine and adenosine stress in the detection of coronary stenosis with myocardial contrast echocardiography.

BACKGROUND: Controversy continues as to whether adenosine or dobutamine is the superior pharmacological stress agent for myocardial contrast echocardiography (MCE). METHODS AND RESULTS: We compared real-time MCE refilling curves and wall thickening during adenosine and dobutamine stress in 14 open-chest dogs with left anterior descending and left circumflex coronary artery stenoses that reduced hyperemia by 40% to 60% and 70% to 90% (mild and severe non-flow-limiting stenosis, NFLS) and resting flow by 10% to 30% and 35% to 50% (mild and severe flow-limiting stenosis, FLS). MCE was performed with low-energy imaging during Optison infusion. After high-energy bubble destruction, time-intensity data from risk beds were fitted for an exponential function as y=A(1-e(-)(bt)), from which the rate of intensity increase (b) and maximal plateau intensity (A) were derived. Although severe NFLS and greater stenoses decreased b with both dobutamine and adenosine, with mild NFLS it was reduced in 58% of animals with dobutamine versus 8% with adenosine. The absolute decrease in b, however, was greater for adenosine than dobutamine with FLS. The A parameter was decreased with both adenosine and dobutamine only with the most severe FLS. Wall thickening was decreased with dobutamine in 33% of animals with severe NFLS and in all animals with any FLS; with adenosine, in all with severe FLS. CONCLUSIONS: Both dobutamine and adenosine significantly reduce MCE refilling rates in the setting of severe stenosis and in the absence of contractile abnormalities. Dobutamine decreases refilling rate and wall thickening at a less reduced flow grade than adenosine, but adenosine produces a greater magnitude of change than dobutamine.

Assessment of myocardial postreperfusion viability by intravenous myocardial contrast echocardiography: analysis of the intensity and texture of opacification.

BACKGROUND: Although defects on intracoronary myocardial contrast echocardiography (MCE) indicate loss of viability after reperfusion, opacified segments may also exhibit persistent dyssynergy. Therefore, we related the intensity and texture of opacification produced by an intravenous contrast agent to histological findings to determine the characteristics of necrotic tissue by postreperfusion MCE. METHODS AND RESULTS: MCE was performed by intravenous injection of 0.15 mL/kg QW7437 in 14 dogs who underwent 3-hour coronary occlusion followed by 3-hour reperfusion. At baseline and 3 hours after reperfusion, midventricular short-axis images were digitized and segmented. Infarction fraction (IF) for each segment was determined by triphenyltetrazolium chloride stain. Of 224 segments, 140 showed no or small infarction and served as a control group. Of 84 segments with significant infarction (IF>30%), 52 exhibited a defect on MCE, and 32 exhibited no defect. Echo texture was quantified by computing entropy based on the co-occurrence matrix analysis of gray-level pairs within each segment. Three hours after reperfusion, average and maximal entropies in the infarct segments without opacification defects were significantly higher than control levels. Histologically, the degree of intracapillary erythrocyte stasis was less in this group than in the infarcted segments with MCE defects with similar magnitude of tissue injuries. CONCLUSIONS: Opacification defects by MCE may be present or absent in myocardium with histologically confirmed infarction. The texture of MCE from opacified but infarcted myocardium differed significantly from control segments and may assist in determination of segmental viability after reperfusion.