Records of fleas (Siphonaptera) from Delaware.

We present an annotated checklist of fleas (Siphonaptera) known to occur in the state of Delaware based on an examination of Siphonaptera collections at the University of Delaware and the Carnegie Museum of Natural History, as well as new specimens of fleas we collected from wildlife, other hosts, and tick flags. We review published records and compile them herein with our new records, which include 3 species previously unreported from Delaware. With these additions, there are now 18 flea species from 19 avian and mammalian hosts documented from Delaware.

Five human pathogens detected by tick surveillance in New York City parks, 2014-2015.

A total of 2,504 ticks of 5 species (Ixodes scapularis, Dermacentor variabilis, Amblyomma americanum, Haemaphysalis leporispalustris, and H. longicornis) were collected over 2 yr (2014-2015) in New York City parks. Specimens were collected via tick-dragging, identified to species, and tested for pathogens of human diseases. The causative agents of 5 human diseases (Lyme borreliosis, ehrlichiosis, babesiosis, anaplasmosis, and Rocky Mountain spotted fever) were detected in a subset of samples. Results of this surveillance effort further illustrate that risk of tick-borne disease is considerable even in parks located adjacent to densely populated areas.

Earliest records of the Asian longhorned tick (Acari: Ixodidae) in Staten Island, New York, and subsequent population establishment, with a review of its potential medical and veterinary importance in the United States.

Three Asian longhorned ticks (Haemaphysalis longicornis) were collected on Staten Island, Richmond County, New York, in 2014-2015 as part of a tick-borne disease surveillance program conducted by the New York City Department of Health and Mental Hygiene and the Defense Centers of Public Health - Aberdeen Tick-Borne Disease Laboratory. These records mark the earliest known occurrence of H. longicornis in New York State outside of quarantine areas, predating previously reported detections by several years. Robust populations of H. longicornis were collected in subsequent years at the Staten Island site where these few ticks were found, demonstrating that small infestations have the potential to proliferate quickly. Haemaphysalis longicornis is a 3-host ixodid tick native to eastern Asia but now established in the United States, as well as Australasia and several Pacific islands. Although H. longicornis has not yet been associated with human disease transmission in the United States, it warrants attention as a potential vector, as it is demonstrated to harbor various pathogens of medical and veterinary interest across its native and introduced range.

Prevalence of Borrelia burgdorferi and diversity of its outer surface protein C (ospC) alleles in blacklegged ticks (Ixodes scapularis) in Delaware.

Characterizing the diversity of genes associated with virulence and transmission of a pathogen across the pathogen's distribution can inform our understanding of host infection risk. Borrelia burgdorferi is a vector-borne bacterium that causes Lyme disease in humans and is common in the United States. The outer surface protein C (ospC) gene of B. burgdorferi exhibits substantial genetic variation across the pathogen's distribution and plays a critical role in virulence and transmission in vertebrate hosts. In fact, B. burgdorferi infections that disseminate across host tissues in humans are associated with only a subset of ospC alleles. Delaware has a high incidence of Lyme disease, but the diversity of ospC in B. burgdorferi in the state has not been evaluated. We used PCR to amplify ospC in B. burgdorferi-infected blacklegged ticks (Ixodes scapularis) in sites statewide and used short-read sequencing to identify ospC alleles. B. burgdorferi prevalence in blacklegged ticks varied across sites, but not significantly so. We identified 15 previously characterized ospC alleles accounting for nearly all of the expected diversity of alleles across the sites as estimated using the Chao1 index. Nearly 40% of sequenced infections (23/58) had more than one ospC allele present suggesting mixed strain infections and the relative frequencies of alleles in single infections were positively correlated with their relative frequencies in mixed infections. Turnover of ospC alleles was positively related to distance between sites with closer sites having more similar allele compositions than more distant sites. This suggests a degree of B. burgdorferi dispersal limitation or habitat specialization. OspC alleles known to cause disseminated infections in humans were found at the highest frequencies across sites, corresponding to Delaware's high incidence of Lyme disease.

Emoji Identification and Emoji Effects on Sentence Emotionality in ASD-Diagnosed Adults and Neurotypical Controls.

We investigated ASD-diagnosed adults' and neurotypical (NT) controls' processing of emoji and emoji influence on the emotionality of otherwise-neutral sentences. Study 1 participants categorised emoji representing the six basic emotions using a fixed-set of emotional adjectives. Results showed that ASD-diagnosed participants' classifications of fearful, sad, and surprised emoji were more diverse and less 'typical' than NT controls' responses. Study 2 participants read emotionally-neutral sentences; half paired with sentence-final happy emoji, half with sad emoji. Participants rated sentence + emoji stimuli for emotional valence. ASD-diagnosed and NT participants rated sentences + happy emoji as equally-positive, however, ASD-diagnosed participants rated sentences + sad emoji as more-negative than NT participants. We must acknowledge differential perceptions and effects of emoji, and emoji-text inter-relationships, when working with neurodiverse stakeholders.

Recently Evolved Francisella-Like Endosymbiont Outcompetes an Ancient and Evolutionarily Associated Coxiella-Like Endosymbiont in the Lone Star Tick (Amblyomma americanum) Linked to the Alpha-Gal Syndrome.

Background: Ticks are hematophagous arthropods that transmit various bacterial, viral, and protozoan pathogens of public health significance. The lone star tick (Amblyomma americanum) is an aggressive human-biting tick that transmits bacterial and viral pathogens, and its bites are suspected of eliciting the alpha-gal syndrome, a newly emerged delayed hypersensitivity following consumption of red meat in the United States. While ongoing studies have attempted to investigate the contribution of different tick-inherent factors to the induction of alpha-gal syndrome, an otherwise understudied aspect is the contribution of the tick microbiome and specifically obligate endosymbionts to the establishment of the alpha-gal syndrome in humans. Materials and Methods: Here we utilized a high-throughput metagenomic sequencing approach to cataloging the entire microbial communities residing within different developmental stages and tissues of unfed and blood-fed ticks from laboratory-maintained ticks and three new geographical locations in the United States. The Quantitative Insights Into Microbial Ecology (QIIME2) pipeline was used to perform data analysis and taxonomic classification. Moreover, using a SparCC (Sparse Correlations for Compositional data) network construction model, we investigated potential interactions between members of the microbial communities from laboratory-maintained and field-collected ticks. Results: Overall, Francisellaceae was the most dominant bacteria identified in the microbiome of both laboratory-raised and field-collected Am. americanum across all tissues and developmental stages. Likewise, microbial diversity was seen to be significantly higher in field-collected ticks compared with laboratory-maintained ticks as seen with a higher number of both Operational Taxonomic Units and measures of species richness. Several potential positive and negative correlations were identified from our network analysis. We observed a strong positive correlation between Francisellaceae, Rickettsiaceae, and Midichloriaceae in both developmental stages and tissues from laboratory-maintained ticks, whereas ovarian tissues had a strong positive correlation of bacteria in the family Xanthobacteraceae and Rhizobiaceae. A negative interaction was observed between Coxiellaceae and Francisellaceae in Illinois, and all the bacteria detected from ticks from Delaware were negatively correlated. Conclusion: This study is the first to catalog the microbiome of Am. americanum throughout its developmental stages and different tissue niches and report the potential replacement of Coxiellaceae by Francisellaceae across developmental stages and tissues tested except in ovarian tissues. These unique and significant findings advance our knowledge and open a new avenue of research to further understand the role of tick microbiome in tick-borne diseases and develop a holistic strategy to control alpha-gal syndrome.

First records of Ixodes brunneus (Acari: Ixodidae) in Delaware.

Eight adult specimens of Ixodes brunneus (Acari: Ixodidae) were collected in Delaware via a combination of methods. The first was an engorged female recovered from a deceased Northern Mockingbird (Mimus polyglottos), a window strike victim, in Kent County. The other seven were four males and three females, all apparently unfed, collected by flagging and dragging vegetation in Kent, New Castle, and Sussex Counties during routine tick surveillance. These collections represent a new host record as well as new state and county records, and indicate a statewide presence of this species.

Lone Star Ticks (Amblyomma americanum):: An Emerging Threat in Delaware.

Public health messaging in the eastern United States has historically underemphasized the risks posed by lone star ticks (Amblyomma americanum), focusing instead on blacklegged ticks (Ixodes scapularis). This gap persists despite mounting evidence that lone star ticks also play an important role in disease ecology as confirmed vectors for a wide variety of tick-borne pathogens. These pathogens include several distinct bacterial agents that cause ehrlichiosis and tularensis in humans and dogs, a protozoal agent that causes cytauxzoonosis in cats, and emerging viruses such as Heartland, Bourbon, and Tacaribe. Lone star ticks are additionally linked to Rocky Mountain spotted fever, southern tick-associated rash illness, and alpha-gal syndrome, a condition marked by immune reactions to ingestion of mammalian meat. Moreover, their distribution in North America is expanding due to changing climatic factors and land use patterns. Lone star ticks are the most commonly encountered tick in Delaware, especially in Sussex and Kent Counties, and make up the vast majority of ticks collected in the first two years of the state's tick surveillance program. Given the magnitude of lone star ticks' medical and veterinary import, it is vital for healthcare professionals and health educators to devote more attention to this emerging threat.

Carios kelleyi (Acari: Ixodida: Argasidae) Infected With Rickettsial Agents Documented Infesting Housing in Kansas, United States.

During September-December 2018, 25 live ticks were collected on-post at Fort Leavenworth, Kansas, in a home with a history of bat occupancy. Nine ticks were sent to the Army Public Health Center Tick-Borne Disease Laboratory and were identified as Carios kelleyi (Cooley and Kohls, 1941), a species that seldom bites humans but that may search for other sources of blood meals, including humans, when bats are removed from human dwellings. The ticks were tested for numerous agents of human disease. Rickettsia lusitaniae was identified by multilocus sequence typing to be present in two ticks, marking the first detection of this Rickettsia agent in the United States and in this species of tick. Two other Rickettsia spp. were also detected, including an endosymbiont previously associated with C. kelleyi and a possible novel Rickettsia species. The potential roles of C. kelleyi and bats in peridomestic Rickettsia transmission cycles warrant further investigation.

Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial.

OBJECTIVES: The primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF). DESIGN: Appropriate ED attendance was defined by the requirement for an electrical or chemical cardioversion and/or an attendance resulting in hospitalisation or administration of intravenous medications for ventricular rate control. Quantitative and qualitative responses were recorded and analysed using descriptive statistics and content analysis, respectively. Random effects logistic regression was performed to estimate the OR of inappropriate ED attendance based on clinically relevant patient characteristics. PARTICIPANTS: Participants ≥18 years with a documented history of AF were approached in one of eight centres partaking in the study across Canada (Ontario, Nova Scotia, Alberta and British Columbia). RESULTS: Of the 356 patients enrolled (67±13, 45% female), the majority (271/356, 76%) had inappropriate reasons for presentation and did not require urgent ED treatment. Approximately 50% of patients(172/356, 48%) were driven to the ED due to symptoms, while the remainder presented on the basis of general fear or anxiety (67/356, 19%) or prior medical advice (117/356, 33%). Random effects logistic regression analysis showed that patients with a history of congestive heart failure were significantly more likely to seek urgent care for appropriate reasons (p=0.03). Likewise, symptom-related concerns for ED presentation were significantly less likely to result in inappropriate visitation (p=0.02). When patients were surveyed on alternatives to ED care, the highest proportion of responses among both groups was in favour of specialised rapid assessment outpatient clinics (186/356, 52%). Qualitative content analysis confirmed these results. CONCLUSIONS: Improved education focused on symptom management and alleviating disease-related anxiety as well as the institution of rapid access arrhythmias clinics may reduce the need for unnecessary healthcare utilisation in the ED and subsequent hospitalisation. TRIAL REGISTRATION NUMBER: NCT03127085.

Sleep reductions associated with illicit opioid use and clinic-hour changes during opioid agonist treatment for opioid dependence: Measurement by electronic diary and actigraphy.

Sleep problems are commonly reported during opioid agonist treatment (OAT) for opioid use disorders. Inpatient studies have found both sleep disturbances and improved sleep during OAT. Illicit opioids can also disrupt sleep, but it is unclear how they affect sleep in outpatients receiving OAT. Therefore, we used electronic diary entries and actigraphy to measure sleep duration and timing in opioid-dependent participants (n = 37) treated with methadone (n = 15) or buprenorphine (n = 22). For 16 weeks, participants were assigned to attend our clinic under different operating hours in a crossover design: Early hours (07:00-09:00) vs. Late hours (12:00-13:00) for 4 weeks each in randomized order, followed for all participants by our Standard clinic hours (07:00-11:30) for 8 weeks. Throughout, participants made daily electronic diary self-reports of their sleep upon waking; they also wore a wrist actigraph for 6 nights in each of the three clinic-hour conditions. Drug use was assessed by thrice-weekly urinalysis. In linear mixed models controlling for other sleep-relevant factors, sleep duration and timing differed by drug use and by clinic hours. Compared to when non-using, participants slept less, went to bed later, and woke later when using illicit opioids and/or both illicit opioids and cocaine. Participants slept less and woke earlier when assigned to the Early hours. These findings highlight the role OAT clinic schedules can play in structuring the sleep/wake cycles of OAT patients and clarify some of the circumstances under which OAT patients experience sleep disruption in daily life.

Mechanistic reasoning and informed consent.

Evidence-based medicine (EBM) proponents have argued that mechanistic evidence concerning medical treatments should be considered secondary to evidence derived from randomized controlled trials (RCTs). One common criticism of RCTs is that they often do not yield results that are generalizable to clinical practice, and that for clinical practice application, mechanistic evidence is needed. However, proponents of EBM have argued that mechanistic reasoning is often unreliable and thus not very useful. Here we suggest an important role of mechanistic explanation that has been left out of this discussion entirely, namely, its importance in a patient's decision of whether or not to take certain drugs. We argue that in certain cases, knowing how a treatment works is just as important for the patient as knowing whether it does. In this paper, we explore how and why giving patients mechanistic information can be an important factor in obtaining informed consent for medical treatment, focusing on the example case of hormonal contraceptives.

A review of New World Malaxa (Hemiptera: Fulgoroidea: Delphacidae).

The New World species attributed to the genus Malaxa Melichar (Hemiptera: Fulgoroidea: Delphacidae) are reviewed with special reference to the type species Malaxa acutipennis from the Philippines. We provide an amended diagnosis for Malaxa acutipennis contrasted with the genus delineation presented for Chinese Malaxa, most recently by Hou et al. (2013). We find Malaxa to be an Old World genus and segregate New World species into two new genera, Lamaxa and Xalama, diagnosed most readily by proportions of the antennae and features of the terminalia. Both Lamaxa and Xalama are uncommonly encountered. Lamaxa is distributed widely through the Neotropics, whereas Xalama is heretofore known only from Bolivia and Peru.

Assessment of pioglitazone and proinflammatory cytokines during buprenorphine taper in patients with opioid use disorder.

BACKGROUND: Preliminary evidence suggested that the PPARγ agonist pioglitazone reduces opioid-withdrawal symptoms, possibly by inhibiting increases in proinflammatory cytokines. METHODS: A randomized, placebo-controlled clinical trial was conducted utilizing two different study designs (entirely outpatient, and a combination of inpatient and outpatient) to evaluate the safety and efficacy of pioglitazone as an adjunct medication for people with opioid physical dependence undergoing a buprenorphine taper. Participants were stabilized on buprenorphine/naloxone (sublingual, up to 16/4 mg/day), then randomized to receive oral pioglitazone (up to 45 mg/day) or placebo before, during, and after buprenorphine taper. Outcome measures included the Subjective Opiate Withdrawal Scale (SOWS) and Clinical Opiate Withdrawal Scale, use of rescue medications to alleviate opioid withdrawal symptoms, and opioid-positive urine specimens. Cerebrospinal fluid (CSF) and plasma were collected during the taper in a subset of participants for measurement of proinflammatory cytokines. RESULTS: The clinical trial was prematurely terminated due to slow enrollment; 40 participants per group were required for adequate statistical power to test study hypotheses. Twenty-four participants enrolled; 17 received at least one dose of study medication (6 pioglitazone, 11 placebo). SOWS scores were higher in the pioglitazone arm than in the placebo arm after adjusting for use of rescue medications; participants in the pioglitazone arm needed more rescue medications than the placebo arm during the post-taper phase. SOWS scores were positively correlated with monocyte chemoattractant protein-1 (MCP-1) in CSF (r = 0.70, p = 0.038) and plasma (r = 0.77, p = 0.015). Participants having higher levels of plasma MCP-1 reported higher SOWS, most notably after the buprenorphine taper ended. CONCLUSIONS: Results from this study provide no evidence that pioglitazone reduces opioid withdrawal symptoms during buprenorphine taper. High correlations between MCP-1 and opioid withdrawal symptoms support a role of proinflammatory processes in opioid withdrawal. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01517165.

Foods and Beverages Available at SNAP-Authorized Drugstores in Sections of North Carolina.

OBJECTIVE: To assess healthy food availability in Supplemental Nutrition Assistance Program-authorized drugstores by store chain and neighborhood income level in 3 regions of North Carolina. DESIGN: Cross-sectional, descriptive study. SETTING: Twenty-five counties in North Carolina. PARTICIPANTS: A total of 108 drugstores (36 CVS Health, 36 Rite Aid, and 36 Walgreens). MAIN OUTCOME MEASURE(S): Fifty foods and beverages offered at drugstores, categorized as healthier and less healthy. ANALYSIS: Kruskal-Wallis tests were used to test differences in the availability of foods and beverages by chain and neighborhood income. RESULTS: Of the 50 foods/beverages observed, 11 were available at all drugstores. Three of the 36 (8%) healthier items were available at all stores (100% fruit juice, water, and high-fiber cereal) whereas 8 of the 14 less healthy items (57%) were available at all stores (chips, sports drinks, energy drinks, regular soda, diet soda, sugar-sweetened beverages, beer, and wine). Only 3% of drugstores offered fresh vegetables and 4% offered fresh fruits. Less than 20% offered frozen chicken or beef. For 36 healthier foods, 11 differed by chain (28%); for less healthy foods 2 of 14 differed by chain (7%). Foods and beverages offered did not vary by neighborhood income. CONCLUSIONS AND IMPLICATIONS: Although drugstores offer some healthier items, few offer fresh produce. As the drugstore industry changes, it is important for the nutrition community to study the impact of these changes on food purchasing behavior and ultimately health.

Managing uncertainty in diagnostic practice.

In spite of the large medical literature devoted to a discussion of the topic, uncertainty, particularly in diagnostic practice, is sometimes mishandled by clinicians. This, I will argue, can in turn lead to medical and ethical problems in patient care. Via the analysis of two recent case studies, I will propose an explanation for why this kind of uncertainty is sometimes not appropriately dealt with during the process of differential diagnosis in the clinic. Furthermore, I will also give recommendations for improving diagnostic practice by highlighting some representative elements of diagnostic uncertainty and reminding clinicians to be aware of the tendency to overlook this uncertainty in routine clinical cases.

Effect of the CRF1-receptor antagonist pexacerfont on stress-induced eating and food craving.

RATIONALE: In rodents, antagonism of receptors for corticotropin-releasing factor (CRF) blocks stress-induced reinstatement of drug or palatable food seeking. OBJECTIVE: To test anticraving properties of the CRF1 antagonist pexacerfont in humans. METHODS: We studied stress-induced eating in people scoring high on dietary restraint (food preoccupation and chronic unsuccessful dieting) with body-mass index (BMI) >22. In a double-blind, between-groups trial, 31 "restrained" eaters were stabilized on either pexacerfont (300 mg/day for 7 days, then 100 mg/day for 21 days) or placebo. On day 15, they underwent a math-test stressor; during three subsequent visits, they heard personalized craving-induction scripts. In each session, stress-induced food consumption and craving were assessed in a bogus taste test and on visual analog scales. We used digital video to monitor daily ingestion of study capsules and nightly rating of food problems/preoccupation on the Yale Food Addiction Scale (YFAS). RESULTS: The study was stopped early due to an administrative interpretation of US federal law, unrelated to safety or outcome. The bogus taste tests suggested some protective effect of pexacerfont against eating after a laboratory stressor (r effect = 0.30, 95 % CL = -0.12, 0.63, Bayes factor 11.30). Similarly, nightly YFAS ratings were lower with pexacerfont than placebo (r effect = 0.39, CI 0.03, 0.66), but this effect should be interpreted with caution because it was present from the first night of pill ingestion, despite pexacerfont's slow pharmacokinetics. CONCLUSIONS: The findings may support further investigation of the anticraving properties of CRF1 antagonists, especially for food.

Evaluating diagnostic tests.

Although much has been written on the role of randomized controlled trials and mechanistic reasoning in the evaluation of therapeutic treatments, philosophers of medicine have not yet turned their attention to the question of how diagnostic tests and procedures should be evaluated. I aim to begin to fill this gap by examining each of the following questions: What is the best way to determine the accuracy of a diagnostic test? What is the best way to determine the clinical effectiveness of a diagnostic test? Can an accurate diagnostic test be considered medically valuable even if it is not clinically effective? I argue that while diagnostic accuracy is a minimum requirement for both clinical effectiveness and medical value, accuracy and effectiveness are not sufficient for determining the value of a diagnostic test, because diagnostic value extends beyond patient outcomes.