Improving Outreach and Surveillance Efforts Following a Large-Scale Carbon Monoxide Poisoning in Wisconsin.

OBJECTIVE: In December 2014, the largest carbon monoxide (CO) poisoning in Wisconsin's history occurred at an ice arena. Following this event, the Wisconsin Environmental Public Health Tracking (WI EPHT) Program sought to improve outreach and surveillance efforts. METHODS: WI EPHT designed and distributed educational materials on CO poisoning prevention and surveyed stakeholders to gauge the effectiveness of outreach efforts. To enhance surveillance, WI EPHT utilized data from the Wisconsin Poison Center (WPC) to generate real-time alerts of anomalous numbers of CO-related calls. RESULTS: WI EPHT found that 42% of stakeholders reviewed the outreach materials, and 1 ice arena had installed a CO detector as a result. CO alerts were developed using WPC data and are now routinely used in statewide public health surveillance. CONCLUSION: WI EPHT staff improved CO poisoning prevention outreach and saw a positive response among stakeholders. This work demonstrates ways that health agencies can improve outreach and surveillance for CO poisoning. Improvements in these areas can bolster public health response and may prevent CO-related illness and injury.

Taking Action With Data: Improving Environmental Public Health at the Community Level.

CONTEXT: The Wisconsin Environmental Public Health Tracking Program (Wisconsin Tracking) compiles and provides data on health endpoints and related environmental exposures as a resource to local health departments, tribes, academia, and other stakeholders. The goal of providing these data is that stakeholders use them to develop projects that improve environmental health in their communities-that is, moving from "data to action." OBJECTIVE: To encourage use of Wisconsin Tracking data, we developed a minigrants program and issued a funding opportunity to local health departments and tribes. The opportunity requested proposals for small projects using our data, with the goal of making public health improvements in those communities. Wisconsin Tracking evaluated the minigrants program after its completion. DESIGN/SETTING: Eight local health departments in Wisconsin were awarded up to $10 500 to develop and implement projects over a 9-month period. METHODS: Wisconsin Tracking created a funding opportunity announcement requiring utilization of our data to develop projects by local health departments in Wisconsin. We reviewed and scored applications, evaluating proposals on a range of criteria. During the 9-month project period, Wisconsin Tracking staff members provided a variety of technical assistance to grantees. An evaluation of the overall program followed. RESULTS: Funded communities used Wisconsin Tracking data to improve public health infrastructure, leverage partnerships, establish new initiatives, respond to emergencies, improve communication with stakeholders and residents, and make a variety of public health improvements in their communities. CONCLUSIONS: Efforts to increase use of our data catalyzed development of small-scale environmental health projects. This minigrants program was successful at building relationships between local health departments and Wisconsin Tracking, increasing awareness of Wisconsin Tracking data and resources, and contributing to numerous documented public health improvements throughout Wisconsin.

Exposure to Elevated Carbon Monoxide Levels at an Indoor Ice Arena--Wisconsin, 2014.

On December 13, 2014, the emergency management system in Lake Delton, Wisconsin, was notified when a male hockey player aged 20 years lost consciousness after participation in an indoor hockey tournament that included approximately 50 hockey players and 100 other attendees. Elevated levels of carbon monoxide (CO) (range = 45 ppm-165 ppm) were detected by the fire department inside the arena. The emergency management system encouraged all players and attendees to seek medical evaluation for possible CO poisoning. The Wisconsin Department of Health Services (WDHS) conducted an epidemiologic investigation to determine what caused the exposure and to recommend preventive strategies. Investigators abstracted medical records from area emergency departments (EDs) for patients who sought care for CO exposure during December 13-14, 2014, conducted a follow-up survey of ED patients approximately 2 months after the event, and conducted informant interviews. Ninety-two persons sought ED evaluation for possible CO exposure, all of whom were tested for CO poisoning. Seventy-four (80%) patients had blood carboxyhemoglobin (COHb) levels consistent with CO poisoning; 32 (43%) CO poisoning cases were among hockey players. On December 15, the CO emissions from the propane-fueled ice resurfacer were demonstrated to be 4.8% of total emissions when actively resurfacing and 2.3% when idling, both above the optimal range of 0.5%-1.0%. Incomplete fuel combustion by the ice resurfacer was the most likely source of elevated CO. CO poisonings in ice arenas can be prevented through regular maintenance of ice resurfacers, installation of CO detectors, and provision of adequate ventilation.

Serum selenium and lipid levels: Associations observed in the National Health and Nutrition Examination Survey (NHANES) 2011-2012.

Selenium is an essential micronutrient, and due to its antioxidant activity, is hypothesized to be beneficial to cardiovascular health. However, the evidence for an association between selenium and health markers such as lipid levels has been mixed. This may be due to substantial variability in the level of selenium intake between populations and potential non-linearity of selenium-health outcome associations. We used the 2011-2012 National Health and Nutrition Examination Survey (NHANES) to examine the relationship between serum selenium and lipid levels among participants aged 12 years and older. Associations were evaluated using both linear regression models, as well as ordinal logistic regression and quantile regression models to allow for potential non-linear relationships. In all models, potential confounders of sex, age group, race/ethnicity, educational attainment and cotinine were included. Overall, 40% of participants had total cholesterol levels classified as borderline or elevated, and total cholesterol increased with increasing selenium (p=0.01). A similar pattern was seen for triglycerides (p=0.02). LDL cholesterol was also associated with selenium but not in a linear fashion; HDL cholesterol did not vary with selenium. Multivariate quantile regression showed significant associations between selenium and total cholesterol, LDL cholesterol, and triglycerides. The effect of selenium was stronger with increasing quantile for total cholesterol and for triglycerides. In contrast, for LDL cholesterol the association was positive in the 10th and 50th percentiles, but (non-significant and) negative in the 90th percentile. These results show that while selenium may impact cardiovascular health via effects on lipid levels, the associations may not be linear.

Levels of nutrients in relation to fish consumption among older male anglers in Wisconsin.

Fish is an important source of nutrients including omega-3 fatty acids, which may reduce risk of adverse health outcomes such as cardiovascular disease; however, fish may also contain significant amounts of environmental pollutants. The Wisconsin Departments of Health Services and Natural Resources developed a survey instrument, along with a strategy to collect human biological samples to assess the risks and benefits associated with long-term fish consumption among older male anglers in Wisconsin. The target population was men aged 50 years and older, who fish Wisconsin waters and live in the state of Wisconsin. Participants provided blood and hair samples and completed a detailed (paper) questionnaire, which included questions on basic demographics, health status, location of catch and species of fish caught/eaten, consumption of locally caught and commercially purchased fish, and awareness and source of information for local and statewide consumption guidelines. Biological samples were used to assess levels of docosahexaenoic acid (DHA), docosapentaenoic acid (DPA), eicosapentaenoic acid (EPA); vitamin D; and selenium in blood. Quantile regression analysis was used to investigate the associations between biomarker levels and self-reported consumption of fish from the Great Lakes and other areas of concern, other locally caught fish, and commercially purchased fish (meals per year). Respondents were largely non-Hispanic white men in their 60's with at least some college education, and about half were retired. Fish consumption was high (median of 54.5 meals per year), with most fish meals coming from locally-caught fish. Multivariate regression models showed that the effect of supplement use was much greater than that of fish consumption, on nutrient levels, although consumption of fish from the Great Lakes and areas of concern was significantly associated with higher levels of vitamin D even after controlling for supplement usage.

Managing the physics of the economics of integrated health care.

The physics metaphor, as applied to the economics (and financial performance) of the integrated health system, seems appropriate when considered together with the nine principles of management framework provided. The nature of the integrated design enhances leaders' management potential as they consider organizational operations and strategy in the markets ahead. One question begged by this argument for the integrated design is the durability, efficiency and ultimate long-term survivability of the more "traditional" community health care delivery models, which, by design, are fragmented, internally competitive and less capital efficient. They also cannot exploit the leverage of teams, optimal access management or the pursuit of revenues made available in many forms. For those who wish to move from the traditional to the more integrated community health system designs (especially those who have not yet started the journey), the path requires: * Sufficient balance sheet capacity to fund the integration process-especially as the model requires physician practice acquisitions and electronic health record implementations * A well-prepared board13, 14 * A functional, durable and sustainable physician services enterprise design * A redesigned organizational and governance structure * Favorable internal financial incentives alignment design * Effective accountable physician leadership * Awareness that the system is not solely a funding strategy for acquired physicians, rather a fully -.. committed clinical and business model, one in which patient-centered integrated care is the core service (and not acute care hospital-based services) A willingness to create and exploit the implied and inherent potential of an integrated design and unified brand Last, it's important to remember that an integrated health system is a tool that creates a "new potential" (a physics metaphor reference, one last time). The design doesn't operate itself. Application of the management principles presented here are necessary as a complete recipe. Leaders of health systems moving toward integration are cautioned to apply the recipe in full. This article ends with two questions. First, if not an integrated model of health care, what's the alternative? Since it seems clear that many of the existing community-based models are excessively fragmented and inefficient, especially in a reforming U.S. health care marketplace, is there a new model that is superior to the integrated models and, if so, what is it and what are its functional principles? The second question: Is there more than one functional form of integration? This article argues for the most integrated form. Others would argue that clinical integration is sufficient,'s and full integration isn't required. The stability, durability and adaptability of the fully integrated models have, arguably, been tested. The lesser integrated models remain to be proven in an unstable health care marketplace seeking higher levels of economic efficiency.

Correlating novel variable and conserved motifs in the Hemagglutinin protein with significant biological functions.

BACKGROUND: Variations in the influenza Hemagglutinin protein contributes to antigenic drift resulting in decreased efficiency of seasonal influenza vaccines and escape from host immune response. We performed an in silico study to determine characteristics of novel variable and conserved motifs in the Hemagglutinin protein from previously reported H3N2 strains isolated from Hong Kong from 1968-1999 to predict viral motifs involved in significant biological functions. RESULTS: 14 MEME blocks were generated and comparative analysis of the MEME blocks identified blocks 1, 2, 3 and 7 to correlate with several biological functions. Analysis of the different Hemagglutinin sequences elucidated that the single block 7 has the highest frequency of amino acid substitution and the highest number of co-mutating pairs. MEME 2 showed intermediate variability and MEME 1 was the most conserved. Interestingly, MEME blocks 2 and 7 had the highest incidence of potential post-translational modifications sites including phosphorylation sites, ASN glycosylation motifs and N-myristylation sites. Similarly, these 2 blocks overlap with previously identified antigenic sites and receptor binding sites. CONCLUSION: Our study identifies motifs in the Hemagglutinin protein with different amino acid substitution frequencies over a 31 years period, and derives relevant functional characteristics by correlation of these motifs with potential post-translational modifications sites, antigenic and receptor binding sites.

Using a partnership barometer to evaluate environmental public health tracking activities.

High-quality environmental health surveillance is challenged by a system in which environmental and health agencies often function with insufficient coordination to routinely address critical issues. The Environmental Public Health Tracking program is working to build a more cohesive system with the capacity for integrated data and information. This work requires a significant amount of effort dedicated to establishing strong partnerships between agencies. Such a task requires skills and activities that differ significantly from the more technical skills needed to physically link data and information from environmental and health resources. Although the work to link people is different from linking data, it is of primary importance because the development of strong partnerships almost invariably provides the necessary foundation for the future integration of data and expertise. As such, the development of partnerships between environmental and health agencies needs to be recognized as a priority product. One approach for moving partnerships into the fore is the creation of assessment tools, or "partnership barometers," that objectively quantify the collaborative process for monitoring progress between and within partners over time. Such measurement would provide a realistic indicator of progress toward tangible products but more importantly emphasizes the importance of building sustainable relationships.

Monitoring and modeling of emissions from concentrated animal feeding operations: overview of methods.

Accurate monitors are required to determine ambient concentration levels of contaminants emanating from concentrated animal feeding operations (CAFOs), and accurate models are required to indicate the spatial variability of concentrations over regions affected by CAFOs. A thorough understanding of the spatial and temporal variability of concentration levels could then be associated with locations of healthy individuals or subjects with respiratory ailments to statistically link the presence of CAFOs to the prevalence of ill health effects in local populations. This workgroup report, which was part of the Conference on Environmental Health Impacts of Concentrated Animal Feeding Operations: Anticipating Hazards-Searching for Solutions, describes instrumentation currently available for assessing contaminant concentration levels in the vicinity of CAFOs and reviews plume dispersion models that may be used to estimate concentration levels spatially. Recommendations for further research with respect to ambient air monitoring include accurately determining long-term average concentrations for a region under the influence of CAFO emissions using a combination of instruments based on accuracy, cost, and sampling duration. In addition, development of instruments capable of accurately quantifying adsorbed gases and volatile organic compounds is needed. Further research with respect to plume dispersion models includes identifying and validating the most applicable model for use in predicting downwind concentrations from CAFOs. Additional data are needed to obtain reliable emission rates from CAFOs.

Selective laser trabeculoplasty in phakic and pseudophakic eyes.

BACKGROUND AND OBJECTIVE: To evaluate the effect of pseudophakia on the success of selective laser trabeculoplasty in lowering intraocular pressure (IOP). PATIENTS AND METHODS: In this retrospective, nonrandomized clinical trial, a chart review of all patients who underwent selective laser trabeculoplasty from September 2002 to June 2004 using a frequency-doubled Q-switched 532-nm Nd:YAG laser was performed. Changes in IOP and statistical significance were determined at each follow-up period. Average decrease in IOP and success rates for phakic and pseudophakic eyes were compared statistically at each time period. RESULTS: In the phakic group, mean IOP decreased from 18.1 to 15.5 mm Hg (P < .0005) and mean glaucoma medication use decreased from 2.1 to 1.6 medications after 24 months of follow-up. In the pseudophakic group, mean IOP decreased from 18.3 to 15.2 mm Hg (P < .005) and mean glaucoma medication use decreased from 2.2 to 1.6 medications. Success rates ranged from 54% to 67% in the phakic group and 52% to 65% in the pseudophakic group. No statistically significant difference between phakic and pseudophakic eyes in decreased IOP or success rates was seen at any time point (P > .05). No significant complications occurred in either group. CONCLUSIONS: Selective laser trabeculoplasty is effective in lowering IOP in both phakic and pseudophakic patients.

Linking childhood cancer with potential environmental exposure determinants.

Childhood chronic diseases, especially cancer, are of growing concern. Research has focused on 2 developmental periods, prenatal and postnatal. While it is hypothesized that chemical contaminants in the physical environment may play a role in the development and exacerbation of many chronic diseases, the role of environmental exposures in the etiology of these conditions remains uncertain. This can be somewhat attributed to the fact that it is very difficult to efficiently link chronic health effects with environmental exposures that are likely to have occurred temporally and spatially distant from diagnosis. This study explored the utility of linking childhood cancer cases with their birth certificate data as a method for increasing the number of geo-referenced data points available for linking health effect data with environmental monitoring data. This would begin to quantify the transiency of 1 subset of the population, and provide a basis for characterizing and estimating potentials for exposure to numerous environmental contaminants during prenatal and postnatal periods. A total of 441 unduplicated cancer diagnosis records of children who were both born and diagnosed with cancer in Wisconsin between 1995 and 2002 were linked with birth records to explore the variability between address at birth and diagnosis. The majority of records were matched to a birth record file (81.0%). Of these matched records, 86% moved <1 mile from birth to time of diagnosis. The results suggest that administrative and public health surveillance data can be used to quantify transiency. Data from the sample tested indicate that during the given time period children do not move far from their birth homes, suggesting minimal changes in exposure potential related to residence location from birth to diagnosis. This background is useful for future epidemiological investigations linking environmental factors with chronic health effects.

Levels of persistent contaminants in relation to fish consumption among older male anglers in Wisconsin.

Fish are an important source of nutrients which may reduce risk of adverse health outcomes such as cardiovascular disease; however, fish may also contain significant amounts of environmental pollutants such as mercury, polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), and perfluorinated compounds (PFCs, also called perfluoroalkyl compounds), which confer increased risk for adverse health effects. The Wisconsin Departments of Health Services and Natural Resources developed a survey instrument, along with a strategy to collect human biological samples to assess the risks and benefits associated with long-term fish consumption among older male anglers in Wisconsin. The target population was men aged 50 years and older, who fish Wisconsin waters and live in the state of Wisconsin. Participants provided blood and hair samples and completed a detailed (paper) questionnaire, which included questions on basic demographics, health status, location of catch and species of fish caught/eaten, consumption of locally caught and commercially purchased fish, and awareness and source of information for local and statewide consumption guidelines. Biological samples were used to assess levels of PCBs, PBDEs, PFCs (blood), and mercury (hair and blood). Quantile regression analysis was used to investigate the associations between biomarker levels and self-reported consumption of fish from the Great Lakes and other areas of concern, other locally caught fish, and commercially purchased fish (meals per year). Respondents had a median age of 60.5 (interquartile range: 56, 67) years. The median fish consumption was 54.5 meals per year, with most fish meals coming from locally-caught fish. Participants had somewhat higher mercury levels compared with the US general population, while levels of other contaminants were similar or lower. Multivariate regression models showed that consumption of fish from the Great Lakes and areas of concern was associated with higher levels of each of the contaminants with the exception of PBDEs, as was consumption of locally caught fish from other water bodies. All commercial fish consumption was also associated with both hair and blood mercury. When looking at specific PCB, PBDE and PFC analytes, consumption of fish from the Great Lakes and areas of concern was associated with higher levels of each of the individual PCB congeners examined, as well as higher levels of all of the PFCs examined, with the exception of PFHxS. Among the PFCs, locally caught fish from other water bodies was also associated with higher levels of each of the congeners examined except PFHxS. Finally, all commercial fish was associated with higher levels of PFHxS.

Isolated anisocoria from an endodermal cyst of the third cranial nerve mimicking an Adie's tonic pupil.

We present only the second reported case in the literature of a neuroenteric cyst involving the third cranial nerve. Our case is highlighted by the initial presentation of an isolated anisocoria, initially believed to represent an Adie's tonic pupil as interpreted by pharmacologic testing. False-positive results may occur with the dilute pilocarpine test.

Wisconsin's environmental public health tracking network: information systems design for childhood cancer surveillance.

In this article we describe the development of an information system for environmental childhood cancer surveillance. The Wisconsin Cancer Registry annually receives more than 25,000 incident case reports. Approximately 269 cases per year involve children. Over time, there has been considerable community interest in understanding the role the environment plays as a cause of these cancer cases. Wisconsin's Public Health Information Network (WI-PHIN) is a robust web portal integrating both Health Alert Network and National Electronic Disease Surveillance System components. WI-PHIN is the information technology platform for all public health surveillance programs. Functions include the secure, automated exchange of cancer case data between public health-based and hospital-based cancer registrars; web-based supplemental data entry for environmental exposure confirmation and hypothesis testing; automated data analysis, visualization, and exposure-outcome record linkage; directories of public health and clinical personnel for role-based access control of sensitive surveillance information; public health information dissemination and alerting; and information technology security and critical infrastructure protection. For hypothesis generation, cancer case data are sent electronically to WI-PHIN and populate the integrated data repository. Environmental data are linked and the exposure-disease relationships are explored using statistical tools for ecologic exposure risk assessment. For hypothesis testing, case-control interviews collect exposure histories, including parental employment and residential histories. This information technology approach can thus serve as the basis for building a comprehensive system to assess environmental cancer etiology.

The Pediatrician.

Alcohol consumption by pediatric patients and their parents can have significant impact on the health and development of the children and adolescents. The pediatrician can help prevent or reduce alcohol-induced impairments by providing education and guidance about the responsible use of alcohol and by initiating early intervention if necessary.

The effect of a literacy training program on family medicine residents.

BACKGROUND AND OBJECTIVES: Pediatric literacy promotion programs carried out in the primary care setting, such as Reach Out and Read (ROR), have been associated with improved language skills for preschool children. Primary care physicians have frequent contact with young families and may be well situated for a literacy promotion program for both children and adults. We examined whether introducing ROR and an adult literacy intervention improves family medicine residents' literacy knowledge, attitudes, and practices. METHODS: We conducted a single group pretest/posttest evaluation design study of residents in a family medicine residency program serving low-income families. Residents completed self-administered questionnaires assessing literacy knowledge, attitudes, and practice. Then, through educational conferences, precepting, and ROR, residents were trained to assess and counsel patients about literacy. The same questionnaire was readministered 8 months later. RESULTS: All 24 (100%) residents completed both the pre- and post-intervention questionnaires. Literacy knowledge mean scores increased from 74.5% to 83.1%. After the intervention, residents reported a greater sense of comfort in counseling about childhood and adult literacy. After the intervention, a greater proportion of residents reported usually or always asking about literacy milestones (30.2% to 79.2%) and parent-child reading (65.2% to 97.8%) during well-child visits. CONCLUSIONS: A family literacy promotion program improved family medicine residents' self-reported literacy knowledge, attitudes, and practices. Such interventions can be incorporated into the education of family medicine residents with meaningful results.

Principles of child health care financing. American Academy of Pediatrics Committee on Child Health Financing.

Child health care financing must maximize access to quality, comprehensive pediatric and prenatal health care. This policy statement replaces the 1998 policy statement by the same title. Changes reflect recent state and federal legislation that affect child health care financing. The principles outlined in the statement will be used to evaluate the changing structure of child health care financing.

Critical evaluation of historical occupational aerosol exposure records: applications to nickel and lead.

Published or unpublished data sets on individual occupational exposure situations are frequently combined and used for some wider purpose, either hazard evaluation or standards setting. This paper describes a model by which such individual data sets for occupational aerosol exposures might be evaluated in terms of their usefulness in this regard. For workplace aerosols, the model is centered around the particle size-selective framework for aerosol exposure assessment that has emerged in recent years as a rational basis for standards setting. In this paper, reported occupational exposures to airborne nickel and lead are used as examples. In a comprehensive review, 106 published peer-reviewed sources of potentially useful exposure data were found for nickel and 111 similar reports for lead. In addition, for lead 116 unpublished reports in the form of hazard evaluation reports from the US National Institute for Occupational Safety and Health were also examined. For both nickel and lead, a wide range of industry sectors was represented, and the data sets cover the period from 1930 to the present day. It was found that such published data sets are highly inconsistent in terms of the criteria by which the data were obtained, notably for the paucity of essential details of the methods that were used. In contrast, for the lead exposures, the unpublished government reports are more consistent, since they usually followed recognized exposure assessment standards. However, the latter may be misleading because they may have tended to represent high exposure situations. The evaluation model described in this paper provides not only a basis for the evaluation of historical exposure data but also guidelines for new exposure assessment to be carried out in the future. Meanwhile, although many of the historical exposure data sets were found to be generally quite weak in terms of their immediate usefulness, attention is drawn to some of their statistical properties that might allow their enhancement for the purposes of hazard evaluation and retrospective exposure assessment exercises.