Examining Clinical Features and Severe Neurologic Disease of Parechovirus Infection in Young Infants: A Multi-State Cohort Study.

BACKGROUND: Human parechovirus (HPeV) infection can result in severe disease in infants, including sepsis, seizures, brain injury, and death. In 2022, a resurgence of HPeV was noted in young infants. Spectrum of illness and outcomes remain to be fully described. METHODS: A multi-state retrospective cohort study was conducted to evaluate hospitalizations and outcomes of infants aged ≤6 months admitted in 2022 with laboratory-confirmed HPeV infection. Infants with severe disease were defined as having clinical seizures, or abnormalities on MRI or EEG during admission. Infants with severe vs non-severe disease were compared using descriptive statistics. RESULTS: 124 U.S. infants were identified with HPeV in 11 states. Cases of HPeV peaked in May and presented at a median of 25.8 days of life (0-194 d) with fever, fussiness, and poor feeding. Bacterial and other viral co-infections were rare. 33 (27%) of infants had severe neurologic disease, were more likely to present at an earlier age (13.9 vs 30 days of life, p<0.01), have preterm gestation (12% vs. 1%, p = 0.02), and present with respiratory symptoms (26% vs. 8%, p = 0.01) or apnea (41% vs. 1%, p <0.001). Subcortical white matter cytoxic cerebral edema was common in severe cases. Two infants with HPeV died during admission with severe neurologic HPeV disease; no infant with mild HPeV disease died. CONCLUSIONS: This is the largest, geographically-diverse U.S. study to describe the 2022 HPeV outbreak among infants. Longitudinal follow up of infants is needed to define predictors and outcomes of severe HPeV disease.

Core outcome measurement set for research and clinical practice in post-COVID-19 condition (long COVID) in children and young people: an international Delphi consensus study "PC-COS Children".

The coronavirus disease 2019 (COVID-19) pandemic substantially impacted different age groups, with children and young people not exempted. Many have experienced enduring health consequences. Presently, there is no consensus on the health outcomes to assess in children and young people with post-COVID-19 condition. Furthermore, it is unclear which measurement instruments are appropriate for use in research and clinical management of children and young people with post-COVID-19. To address these unmet needs, we conducted a consensus study, aiming to develop a core outcome set (COS) and an associated core outcome measurement set (COMS) for evaluating post-COVID-19 condition in children and young people. Our methodology comprised of two phases. In phase 1 (to create a COS), we performed an extensive literature review and categorisation of outcomes, and prioritised those outcomes in a two-round online modified Delphi process followed by a consensus meeting. In phase 2 (to create the COMS), we performed another modified Delphi consensus process to evaluate measurement instruments for previously defined core outcomes from phase 1, followed by an online consensus workshop to finalise recommendations regarding the most appropriate instruments for each core outcome. In phase 1, 214 participants from 37 countries participated, with 154 (72%) contributing to both Delphi rounds. The subsequent online consensus meeting resulted in a final COS which encompassed seven critical outcomes: fatigue; post-exertion symptoms; work/occupational and study changes; as well as functional changes, symptoms, and conditions relating to cardiovascular, neuro-cognitive, gastrointestinal and physical outcomes. In phase 2, 11 international experts were involved in a modified Delphi process, selecting measurement instruments for a subsequent online consensus workshop where 30 voting participants discussed and independently scored the selected instruments. As a result of this consensus process, four instruments met a priori consensus criteria for inclusion: PedsQL multidimensional fatigue scale for "fatigue"; PedsQL gastrointestinal symptom scales for "gastrointestinal"; PedsQL cognitive functioning scale for "neurocognitive" and EQ-5D for "physical functioning". Despite proposing outcome measurement instruments for the remaining three core outcomes ("cardiovascular", "post-exertional malaise", "work/occupational and study changes"), a consensus was not achieved. Our international, consensus-based initiative presents a robust framework for evaluating post-COVID-19 condition in children and young people in research and clinical practice via a rigorously defined COS and associated COMS. It will aid in the uniform measurement and reporting of relevant health outcomes worldwide.

Expedited Partner Therapy: A Multicomponent Initiative to Boost Provider Counseling.

BACKGROUND: Expedited partner therapy prescription remains low and highly variable throughout the United States, leading to frequent reinfections with Chlamydia trachomatis and Neisseria gonorrhoeae . We examined provider counseling on expedited partner therapy before and after an electronic smart tool-based initiative. METHODS: In this quasi-experimental interrupted time-series study, we implemented an initiative of electronic smart tools and education for expedited partner therapy in March 2020. We reviewed the records of patients with chlamydia and/or gonorrhea at an urban, academic obstetrics and gynecology clinic in the preimplementation (March 2019-February 2020) and postimplementation (March 2020-February 2021) groups. Descriptive statistics and an interrupted time-series model were used to compare the percent of expedited partner therapy offered by clinicians to patients in each group. RESULTS: A total of 287 patient encounters were analyzed, 155 preintervention and 132 postintervention. An increase in expedited partner therapy counseling of 13% (95% confidence interval [CI], 2%-24%) was observed before the intervention (27.1% [42 of 155]) versus after the intervention (40.2% [53 of 132]). Significant increases in provider counseling were seen for patients who were single (15%; 95% CI, 3%-26%), 25 years or older (21%; 95% CI, 6%-37%), receiving public insurance (15%; 95% CI, 3%-27%), seen by a registered nurse (18%; 95% CI, 4%-32%), or seen for an obstetrics indication (21%; 95% CI, 4%-39%). No difference was seen in patients' acceptance of expedited partner therapy ( P = 1.00). CONCLUSIONS: A multicomponent initiative focused on electronic smart tools is effective at increasing provider counseling on expedited partner therapy. Further research to understand patient perceptions and acceptance of expedited partner therapy is critical.

International Care programs for Pediatric Post-COVID Condition (Long COVID) and the way forward.

BACKGROUND: Pediatric Post-COVID-Condition (PPCC) clinics treat children despite limited scientific substantiation. By exploring real-life management of children diagnosed with PPCC, the International Post-COVID-Condition in Children Collaboration (IP4C) aimed to provide guidance for future PPCC care. METHODS: We performed a cross-sectional international, multicenter study on used PPCC definitions; the organization of PPCC care programs and patients characteristics. We compared aggregated data from PPCC cohorts and identified priorities to improve PPCC care. RESULTS: Ten PPCC care programs and six COVID-19 follow-up research cohorts participated. Aggregated data from 584 PPCC patients was analyzed. The most common symptoms included fatigue (71%), headache (55%), concentration difficulties (53%), and brain fog (48%). Severe limitations in daily life were reported in 31% of patients. Most PPCC care programs organized in-person visits with multidisciplinary teams. Diagnostic testing for respiratory and cardiac morbidity was most frequently performed and seldom abnormal. Treatment was often limited to physical therapy and psychological support. CONCLUSIONS: We found substantial heterogeneity in both the diagnostics and management of PPCC, possibly explained by scarce scientific evidence and lack of standardized care. We present a list of components which future guidelines should address, and outline priorities concerning PPCC care pathways, research and international collaboration. IMPACT: Pediatric Post-COVID Condition (PPCC) Care programs have been initiated in many countries. Children with PPCC in different countries are affected by similar symptoms, limiting many to participate in daily life. There is substantial heterogeneity in diagnostic testing. Access to specific diagnostic tests is required to identify some long-term COVID-19 sequelae. Treatments provided were limited to physical therapy and psychological support. This study emphasizes the need for evidence-based diagnostics and treatment of PPCC. The International Post-COVID Collaboration for Children (IP4C) provides guidance for guideline development and introduces a framework of priorities for PPCC care and research, to improve PPCC outcomes.

Reduction in Unindicated Cervical Cancer Screening in Adolescents in a Large Health Care System.

OBJECTIVES/PURPOSE: Evidence-based guidelines recommend against screening for cervical cancer (Pap testing) in average-risk adolescents <21 years old. Despite this, many still undergo unindicated screenings with subsequent detrimental reproductive health and economic consequences. Our aim was to reduce unindicated cervical cancer screening in individuals <21 years old in a large health care system by utilizing an electronic provider notification. METHODS: Starting in July 2020, a Best Practice Advisory (BPA) appeared in the electronic medical record (EMR) if providers ordered Pap testing on individuals <21 years old. This BPA reiterated that screening was not indicated for average-risk adolescents and prompted users to choose an indication if they wanted to proceed.A retrospective chart review, pre/post intervention study was performed comparing individuals <21 years old with Pap testing performed before and after intervention (January 2019-June 2020 and July 2020-June 2021, respectively). Patient characteristics were extracted from the EMR and analyzed using Fisher exact tests, Kruskal-Wallis tests, and logistic regression. RESULTS: There were 140 subjects included: 106 preintervention and 34 postintervention. There were no differences in baseline characteristics. Neither Pap nor human papillomavirus testing results differed between the groups. Preintervention, 6.6% of cytology tests were indicated compared to 20.6% postintervention ( p = .042). The proportion of indicated human papillomavirus testing did not differ preintervention and postintervention at 65% and 45%, respectively ( p = .295). The overall reduction in unindicated cervical cancer screening postintervention was 13.9% (95% CI = 4.0-23.7). CONCLUSIONS: We demonstrated that incorporating a BPA to the EMR reduces unindicated cervical cancer screening.

Disparities in adherence to retesting guidelines in women with Trichomonas vaginalis infection.

BACKGROUND: Trichomoniasis is the most prevalent nonviral sexually transmitted infection in the United States. Numerous studies have shown disproportionately higher prevalence rates in non-Hispanic Black women. Because of the high rates of reinfection, the Centers for Disease Control and Prevention recommends retesting women treated for trichomoniasis. Despite these national guidelines, there are few studies examining adherence to retesting recommendations for patients with trichomoniasis. Adherence to retesting guidelines has been shown in other infections to be an important determinant of racial disparities. OBJECTIVE: This study aimed to describe Trichomonas vaginalis infection rates, evaluate adherence to retesting guidelines, and examine characteristics of women who were not retested according to the guidelines in an urban, diverse, hospital-based obstetrics and gynecology clinic population. STUDY DESIGN: We conducted a retrospective cohort study of patients from a single hospital-based obstetrics and gynecology clinic who were tested for Trichomonas vaginalis between January 1, 2015 and December 31, 2019. Descriptive statistics were used to examine guideline-concordant testing for reinfection among patients with trichomoniasis. Multivariable logistic regression was used to identify characteristics associated with testing positive and with appropriate retesting. Subgroup analyses were performed for patients who were pregnant and tested positive for Trichomonas vaginalis. RESULTS: Among the 8809 patients tested for Trichomonas vaginalis, 799 (9.1%) tested positive at least once during the study. Factors associated with trichomoniasis included identifying as non-Hispanic Black (adjusted odds ratio, 3.13; 95% confidence interval, 2.52-3.89), current or former tobacco smoking (adjusted odds ratio, 2.27; 95% confidence interval, 1.94-2.65), and single marital status (adjusted odds ratio, 1.96; 95% confidence interval, 1.51-2.56). Similar associated factors were found in the pregnant subgroup analysis. For women with trichomoniasis, guideline-concordant retesting rates were low across the entire population, with only 27% (214/799) of patients retested within the recommended time frame; 42% (82/194) of the pregnant subgroup underwent guideline-concordant retesting. Non-Hispanic Black women had significantly lower odds of undergoing guideline-recommended retesting than non-Hispanic White women (adjusted odds ratio, 0.54; 95% confidence interval, 0.31-0.92). Among patients tested according to guideline recommendations, we found a high rate of Trichomonas vaginalis positivity at retesting: 24% in the entire cohort (51/214) and 33% in the pregnant subgroup (27/82). CONCLUSION: Trichomonas vaginalis infection was identified at a high frequency in a diverse, urban hospital-based obstetrics and gynecology clinic population. Opportunities exist to improve on equitable and guideline-concordant retesting of patients with trichomoniasis.

Clinical Epidemiology of Pediatric Coronavirus Disease 2019 and its Postacute Sequelae.

The coronavirus disease 2019 (COVID-19) pandemic has affected individuals of all ages across. Although children generally experience a benign illness from COVID-19, the emergence of novel variants of the virus has resulted in significant changes in the morbidity and mortality rates for this age group. Currently, COVID-19 is the eighth leading cause of pediatric deaths in the United States. In addition to acute respiratory illness, some children can develop a severe postinfectious condition known as a multisystem inflammatory syndrome in children, which can progress to rapid-onset cardiogenic shock. Recovery from COVID-19 can also be slow for some children, resulting in persistent or reoccurring symptoms for months, commonly referred to as long COVID. These postinfectious sequelae are often distressing for children and their parents, can negatively impact the quality of life, and impose a considerable burden on the health care system. In this article, we review the clinical epidemiology of pediatric COVID-19 and outline the management considerations for its acute and postacute manifestations.

Severe Acute Respiratory Syndrome Coronavirus 2 Clinical Syndromes and Predictors of Disease Severity in Hospitalized Children and Youth.

OBJECTIVE: To characterize the demographic and clinical features of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) syndromes and identify admission variables predictive of disease severity. STUDY DESIGN: We conducted a multicenter, retrospective, and prospective study of pediatric patients hospitalized with acute SARS-CoV-2 infections and multisystem inflammatory syndrome in children (MIS-C) at 8 sites in New York, New Jersey, and Connecticut. RESULTS: We identified 281 hospitalized patients with SARS-CoV-2 infections and divided them into 3 groups based on clinical features. Overall, 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations including gastrointestinal illness or fever. Patients with MIS-C were more likely to identify as non-Hispanic black compared with patients with respiratory disease (35% vs 18%, P = .02). Seven patients (2%) died and 114 (41%) were admitted to the intensive care unit. In multivariable analyses, obesity (OR 3.39, 95% CI 1.26-9.10, P = .02) and hypoxia on admission (OR 4.01; 95% CI 1.14-14.15; P = .03) were predictive of severe respiratory disease. Lower absolute lymphocyte count (OR 8.33 per unit decrease in 109 cells/L, 95% CI 2.32-33.33, P = .001) and greater C-reactive protein (OR 1.06 per unit increase in mg/dL, 95% CI 1.01-1.12, P = .017) were predictive of severe MIS-C. Race/ethnicity or socioeconomic status were not predictive of disease severity. CONCLUSIONS: We identified variables at the time of hospitalization that may help predict the development of severe SARS-CoV-2 disease manifestations in children and youth. These variables may have implications for future prognostic tools that inform hospital admission and clinical management.

Unindicated cervical cancer screening in adolescent females within a large healthcare system in the United States.

BACKGROUND: Current consensus recommendations are to not initiate cervical cancer screening for immunocompetent adolescent females before 21 years of age. This is in part because of the very low rate of 0.8 per 100,000 new cervical cancer cases diagnosed among women aged between 20 to 24 years. Timely human papillomavirus vaccination further decreases the incidence of cervical cancer to 4 cases per 100,000 persons by the age of 28 years. Screening before 21 years of age has demonstrated no clear benefit in cancer risk reduction or outcomes. In addition, unindicated screening among adolescents can lead to patient harm and increasing costs to the healthcare system. OBJECTIVE: It is important to assess the rates of overutilization of cervical cancer screening and to identify areas where improvements have occurred and where further opportunities exist. This study aimed to assess the trends over time and the practice and provider factors associated with unindicated cervical cancer screening tests in adolescent females within the largest healthcare system in the state. STUDY DESIGN: Cross-sectional data from patients aged 13 to 20 years who underwent cervical cancer screening between January 1, 2012, and December 31, 2018, across a large multihospital health system were reviewed. All cervical cancer screening results were included. The incidence rate of unindicated screening was analyzed over 6-month intervals using the Poisson regression analysis. RESULTS: The study included data from 118 providers and 794 women. Among the 900 screening results, most (90%) were unindicated: 87% with unindicated cytology testing alone and 14% with unindicated human papillomavirus testing. Screening tests were collected from patients aged 13 to 20 years, many of whom had multiple unindicated cytology tests, with 25 patients having ≥3 tests before the age of 21 years. Most results of cytology testing were negative for intraepithelial lesion or malignancy (77%). Moreover, 52 invasive diagnostic or therapeutic procedures (49 colposcopies and 3 conizations) were performed, of which 45 (87%) followed an unindicated screening test. Between 2012 and 2018, the incidence rate of unindicated cytology decreased by 33% (12.6 to 8.5 unindicated cytology per 1000 encounters). The incidence rate of unindicated screening was lower in the academic setting than in the community setting (incidence rate ratio, 0.43; P<.01). Even with decreases in the overall rates of unindicated screening throughout the study period, there were still 58 unindicated screening tests performed in the final year of this study. CONCLUSION: Despite substantial reductions in unindicated screening for women aged <21 years, there remained areas for improvement. Our data reflected practices of guideline nonadherence up to 7 years after the 2012 guideline. Now, with a new series of changes to the guidelines, which may be even more challenging for patients and providers, it is more important than ever to utilize evidence-based strategies to improve guideline dissemination and adherence.

Angiotensin II modulates the murine hematopoietic stem cell and progenitors cocultured with stromal S17 cells.

Although the existence of the renin-angiotensin system (RAS) in the bone marrow is clear, the exact role of this system in hematopoiesis has not yet been fully characterized. Here the direct role of angiotensin II (AngII) in hematopoietic stem cells (HSCs), common myeloid progenitors (CMPs), granulocyte/monocyte progenitors (GMPs), and megakaryocytes/erythroid progenitors (MEPs), using a system of coculture with stromal S17 cells. Flow cytometry analysis showed that AngII increases the percentage of HSC and GMP, while reducing CMP with no effect on MEP. According to these data, AngII increased the total number of mature Gr-1+ /Mac-1+ cells without changes in Terr119+ cells. AngII does not induce cell death in the population of LSK cells. In these populations, treatment with AngII decreases the expression of Ki67+ protein with no changes in the Notch1 expression, suggesting a role for AngII on the quiescence of immature cells. In addition, exposure to AngII from murine bone marrow cells increased the number of CFU-GM and BFU-E in a clonogenic assay. In conclusion, our data showed that AngII is involved in the regulation of hematopoiesis with a special role in HSC, suggesting that AngII should be evaluated in coculture systems, especially in cases that require the expansion of these cells in vitro, still a significant challenge for therapeutic applications in humans.

Monitoring HPV vaccine impact on cervical disease: Status and future directions for the era of cervical cancer elimination.

Post-licensure monitoring of the impact of HPV vaccines is critical to track the progress being made toward cervical cancer elimination and to identify areas where further progress can accelerate the achievement of this important public health goal. Over the past decade, a large body of evidence has revealed convincing benefits of HPV vaccination in preventing cervical infections and precancers at the individual-level (i.e., direct effectiveness) as well as in reducing the population-level burden of disease (i.e., overall effectiveness). At this time, effectiveness of the vaccines on preventing cervical cancer is just beginning to emerge given that there is a prolonged latency period for invasive disease. As we enter the era of cervical cancer elimination, these early and promising results may be expected in other countries in the near future. Thus, monitoring the direct and overall effectiveness for cervical cancer is an urgent research priority. In this article, we summarize what is known about the effectiveness of HPV vaccines on precancerous outcomes, and we highlight considerations for continuing these important public health activities going forward to monitor progress toward cervical cancer elimination.

The clinical epidemiology of coronavirus disease 2019 in children and adolescents mirrors the widening gap in healthcare disparities.

PURPOSE OF REVIEW: The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has exacerbated the longstanding racial/ethnic health disparities in the USA, with a disproportionately negative effect on children of color. This review summarizes recently published studies that describe the clinical epidemiology and racial/ethnic disparities associated with SARS-CoV-2 in children. RECENT FINDINGS: Children with SARS-CoV-2 infections manifest with a wide spectrum of disease. Most are either asymptomatic or mildly symptomatic with fever, gastrointestinal, and/or upper respiratory disease. Some children can progress to develop severe lower respiratory disease or a hyper-inflammatory, Kawasaki-like syndrome leading to cardiovascular shock. Although SARS-CoV-2-related deaths in children are rare, more children died within the first nine months of the pandemic than have died during any influenza season over the last decade.Black and Hispanic children represent less than 41% of the US population but account for three out of every four SARS-CoV-2-related hospitalizations and deaths in the USA. The drivers of these disparities in children are complex and likely a combination of societal, biological, and behavioral influences. SUMMARY: This pandemic brought to light longstanding health disparities in historically marginalized populations, and minority children have suffered tremendously. It provides an opportunity to understand how a virus hijacked deep-rooted inequities, address these inequities, and work to prevent this outcome in future pandemics/epidemics.

Patterns of recommended vaccine receipt among women ages 24-45 years: a cross-sectional analysis.

BACKGROUND: Vaccine receipt among mid-adults remains low, with only one quarter of adults being up to date for all recommended vaccines. It is important to understand the myriad factors that influence vaccine receipt among mid-adult women to address these low rates. METHODS: We conducted a cross-sectional analysis of data from women ages 24-45 years collected as part of an ongoing case-control study of the effectiveness of HPV vaccine. We examined associations between demographic characteristics and healthcare utilization and receipt of individual vaccines and combinations of multiple vaccines using logistic regression analyses for three routinely recommended vaccines: tetanus, influenza and HPV. RESULTS: Among the 309 women enrolled in the study, only 19 (6.2%) were up to date for all three recommended vaccines and 41 (13.3%) had not received any of the recommended vaccines. A greater number of health care visits in the past year was associated with receipt of influenza (aOR = 6.37, 95% CI = 2.53, 16.1) and tetanus (aOR = 2.17, 95% CI = 1.14, 4.12) vaccines. White women were more likely to have received HPV vaccine (aOR = 2.39, 95% CI = 1.07, 5.36). CONCLUSIONS: Uptake of recommended vaccines is low among young and mid-adult women. There is a need for greater understanding of the underlying factors influencing vaccine receipt in this population.

One-step fiber post cementation and core build-up in endodontically treated tooth: A clinical case report.

OBJECTIVE: This clinical case report addresses the step-by-step of the application of a core-and-post system that uses a single resin composite material to fiber post cementation and core build-up in a maxillary left central incisor. CLINICAL CONSIDERATIONS: The literature reports several materials and methods for the restoration of endodontically treated teeth with coronal destruction that require an intra-radicular fiber post for the core build-up. The present case report describes a core-and-post or "monoblock" technique. A dual resin composite (Core-X Flow; Dentsply DeTrey) highly filled material and cement was used for luting the fiber post (Blue X-Post) and build-up the core structure in an easy application. CONCLUSIONS: The "core-and-post" technique that uses a single material system protocol minimizes the material interfaces, steps of procedures, and chair-time in comparison to conventional techniques. CLINICAL SIGNIFICANCE: The use of different materials for post cementation and core build-up requires more steps, which increases the chair-time and number of interfaces among the materials. Since the "monoblock" technique uses only one material, it can streamline the clinical procedures, thus, saving time and materials. Moreover, techniques based on core-and-post systems are easily applied, versatile, and esthetics, and can be applicable to posterior and anterior teeth.

Human Papillomavirus Vaccination and Anogenital Warts: A Systematic Review of Impact and Effectiveness in the United States.

BACKGROUND: Assessing the impact and effectiveness of HPV vaccines on anogenital warts in the United States can provide early indication of the success of vaccination programs as well as identify potential areas for improvement. METHODS: Articles were identified from the PubMed, Medline, and Embase databases. Exclusion criteria were applied, and remaining studies were then classified as impact or effectiveness studies. RESULTS: Eight eligible studies published through March 2018 were included. Population-based impact studies examining trends in diagnoses reported consistent declines in females ages 25 years and younger after 2006 when routine female vaccination began in the United States. Declines in males ages 25 years and younger were also seen; however, these declines were lower than those in females and more evident after routine male vaccination began in 2011. Among females and males older than 25 years, little to no change has been seen in the trends of anogenital warts since 2006. Studies that included the pre-vaccine era (before 2006) reported increasing trends during this period. After vaccine introduction, a reversal in these trends was observed. Effectiveness studies that included individual-level vaccination histories consistently demonstrated a lower risk of anogenital warts for those receiving at least one dose of the vaccine compared to those unvaccinated. CONCLUSIONS: These findings suggest that the degree of HPV vaccine impact has varied substantially by age and sex. Achieving the full prevention potential of HPV vaccines will likely require greater coverage among both females and males. Post-licensure estimates of effectiveness demonstrate the real-world benefit of the vaccine.

Missed opportunities for HPV immunization among young adult women.

BACKGROUND: Despite the availability of a safe and efficacious vaccine against human papillomavirus, uptake of the vaccine in the United States is low. Missed clinical opportunities to recommend and to administer human papillomavirus vaccine are considered one of the most important reasons for its low uptake in adolescents; however, little is known about the frequency or characteristics of missed opportunities in the young adult (18-26 years of age) population. OBJECTIVE: The objective of the study was to assess both the rates of and the factors associated with missed opportunities for human papillomavirus immunization among young adult women who attended an urban obstetrics and gynecology clinic. STUDY DESIGN: In this cross-sectional study, medical records were reviewed for all women 18-26 years of age who were underimmunized (<3 doses) and who sought care from Feb. 1, 2013, to January 31, 2014, at an urban, hospital-based obstetrics and gynecology clinic. A missed opportunity for human papillomavirus immunization was defined as a clinic visit at which the patient was eligible to receive the vaccine and a dose was due but not administered. Multivariable logistic regression was used to test associations between sociodemographic variables and missed opportunities. RESULTS: There were 1670 vaccine-eligible visits by 1241 underimmunized women, with a mean of 1.3 missed opportunities/person. During the study period, 833 of the vaccine eligible women (67.1%) had at least 1 missed opportunity. Overall, the most common types of visits during which a missed opportunity occurred were postpartum visits (17%) or visits for either sexually transmitted disease screening (21%) or contraception (33%). Of the patients with a missed opportunity, 26.5% had a visit at which an injectable medication or a different vaccine was administered. Women who identified their race as black had higher adjusted odds of having a missed opportunity compared with white women (adjusted odds ratio, 1.61 [95% confidence interval, 1.08-2.41], P < .02). Women who reported a non-English- or non-Spanish-preferred language had lower adjusted odds of having a missed opportunity (adjusted odds ratio, 0.25 [95% confidence interval, 0.07-0.87], P = .03). No other patient characteristics assessed in this study were significantly associated with having a missed opportunity. CONCLUSION: A majority of young-adult women in this study had missed opportunities for human papillomavirus immunization, and significant racial disparity was observed. The greatest frequency of missed opportunities occurred with visits for either contraception or for sexually transmitted disease screening.

Influenza-like illness in an urban community of Salvador, Brazil: incidence, seasonality and risk factors.

BACKGROUND: Our understanding of the epidemiology of influenza is limited in tropical regions, which in turn has hampered identifying optimal region-specific policy to diminish disease burden. Influenza-like illness (ILI) is a clinical diagnosis that can be used as a surrogate for influenza. This study aimed to define the incidence and seasonality of ILI and to assess its association with climatic variables and school calendar in an urban community in the tropical region of Salvador, Brazil. METHODS: Between 2009 and 2013, we conducted enhanced community-based surveillance for acute febrile illnesses (AFI) among patients ≥ 5 years of age in a slum community emergency unit in Salvador, Brazil. ILI was defined as a measured temperature of ≥ 37.8 °C or reported fever in a patient with cough or sore throat for ≤ 7 days, and negative test results for dengue and leptospirosis. Seasonality was analyzed with a harmonic regression model. Negative binomial regression models were used to correlate ILI incidence with rainfall, temperature, relative humidity and the number of days per month that schools were in session while controlling for seasonality. RESULTS: There were 2,651 (45.6% of 5,817 AFI patients) ILI cases with a mean annual incidence of 60 cases/1,000 population (95% CI 58-62). Risk of ILI was highest among 5-9 year olds with an annual incidence of 105 cases/1,000 population in 2009. ILI had a clear seasonal pattern with peaks between the 35-40th week of the year. ILI peaks were higher and earlier in 5-9 year olds compared with > 19 year olds. No association was seen between ILI and precipitation, relative humidity or temperature. There was a significant association between the incidence of ILI in children 5-9 years of age and number of scheduled school days per month. CONCLUSIONS: We identified a significant burden of ILI with distinct seasonality in the Brazilian tropics and highest rates among young school-age children. Seasonal peaks of ILI in children 5-9 years of age were positively associated with the number of school days, indicating that children may play a role in the timing of seasonal influenza transmission.

Update on persistent symptoms associated with Lyme disease.

PURPOSE OF REVIEW: Lyme disease, caused by Borrelia burgdorferi, is the most common vector-borne illness in the United States. The pathogenesis, ecology, and epidemiology of Lyme disease have been well described, and antimicrobial treatment is very effective. There has been controversy about whether infection can persist and cause chronic symptoms despite treatment with antimicrobials. This review summarizes recent studies that have addressed this issue. RECENT FINDINGS: The pathogenesis of persistent nonspecific symptoms in patients who were treated for Lyme disease is poorly understood, and the validity of results of attempts to demonstrate persistent infection with B. burgdorferi has not been established. One study attempted to use xenodiagnosis to detect B. burgdorferi in patients who have been treated for Lyme disease. Another study assessed whether repeated episodes of erythema migrans were due to the same or different strains of B. burgdorferi. A possible cause of persistent arthritis in some treated patients is slow clearance of nonviable organisms that may lead to prolonged inflammation. The results of all of these studies continue to provide evidence that viable B. burgdorferi do not persist in patients who receive conventional antimicrobial treatment for Lyme disease. SUMMARY: Patients with persistent symptoms possibly associated with Lyme disease often provide a challenge for clinicians. Recent studies have provided additional evidence that viable B. burgdorferi do not persist after conventional treatment with antimicrobials, indicating that ongoing symptoms in patients who received conventional treatment for Lyme disease should not be attributed to persistent active infection.

Brain magnetic resonance imaging of infants with bacterial meningitis.

OBJECTIVES: To describe the results of brain magnetic resonance imaging (MRI) of infants with bacterial meningitis and how the findings affected clinical management. STUDY DESIGN: This retrospective study included all infants <12 months of age who were hospitalized at Children's Medical Center, Dallas and had culture-confirmed bacterial meningitis and a brain MRI from January 1, 2001 to December 1, 2011. Infants were identified by review of all positive bacterial cultures of cerebrospinal fluid (CSF) from the Children's Medical Center Microbiology Laboratory. Demographic, clinical, laboratory, and neuroimaging data were reviewed. Infants with ventriculoperitoneal shunt or whose CSF culture yielded skin commensals were excluded. A neuroradiologist blinded to clinical information reviewed all MRI studies. RESULTS: Of the 440 infants who had a positive CSF culture result, 111 (25%) had a pathogen isolated from CSF and were enrolled in the study. Of these, 68% (75/111) had a brain MRI performed during the hospitalization; abnormalities included leptomeningeal enhancement (57%), cerebral infarct (43%), subdural empyema (52%), cerebritis (26%), hydrocephalus (20%), and abscess (11%). By multiple logistic regression analysis, infants with late seizures and an abnormal neurologic examination were more likely to have an abnormal MRI (P < .05). MRI results led to neurosurgical intervention in 23% of infants; a positive bacterial culture of CSF obtained >48 hours after initiation of antibiotic therapy was associated with neurosurgical intervention (P = .01). Fourteen (19%) infants with bacterial meningitis had a normal brain MRI. CONCLUSIONS: Brain MRIs were performed frequently and often were abnormal in infants with bacterial meningitis, leading to changes in clinical management.