Multiple genome sequences of lactic acid bacteria, Carnobacterium divergens and Carnobacterium maltaromaticum strains, isolated from vacuum-packaged lamb meat.

Here, we report the whole-genome sequences of 11 Carnobacterium divergens and 2 Carnobacterium maltaromaticum bacteria isolated from vacuum-packed chill-stored lamb meat in New Zealand. Examination of these lactic acid bacteria (LAB) genomes will improve our knowledge of their potential antimicrobial activities and spoilage mechanisms of importance to the meat industry.

Medium-term storage of calf beddings affects bacterial community and effectiveness to inactivate zoonotic bacteria.

Land-spreading of animal faecal wastes -such as animal beddings- can introduce zoonotic enteropathogens into the food system environment. The study evaluated the effectiveness of animal beddings naturally contaminated by calf manure to reduce E. coli O157:H7 or Salmonella enterica. The two pathogens were introduced separately as a four strains-cocktail and at high (>6.5 Log10 g-1) concentration into bedding materials, and their inactivation over a 10 weeks-period was monitored by using a Most Probable Number (MPN) enumeration method. Inactivation of E. coli O157:H7 was more effective in the bedding inoculated immediately after collection from calf pens than in the beddings inoculated after a 2 months-pre-storage period: E. coli O157:H7 levels were reduced by 6.6 Log10 g-1 in unstored bedding (0.5 Log10 g-1 recovered; 95%CI: 0.0-1.2), and by 4.9 Log10 g-1 in pre-stored bedding (2.2 Log10 g-1 recovered; 95%CI: 1.5-2.8) with a significant (p<0.05) difference between unstored and pre-stored. S. enterica was inactivated less effectively as counts were reduced by one order of magnitude, with no significant difference in inactivation between unstored and pre-stored beddings. Low levels of naturally occurring E. coli O157 and Salmonella spp. were detected in the non-inoculated beddings, as well as in the straw prior to use in the animal facility. To better understand the possible biological processes involved, the bacterial community present in the beddings was characterised by short-read 16S rRNA sequencing. Pre-storage of the bedding affected the composition but not the diversity of the bacterial community. Analyses of the key bacterial phyla suggested that the presence of a diverse and stable bacterial community might facilitate inactivation of the introduced pathogens, and a possible role of bacterial orders associated with lignocellulolytic resources. Overall, the study contributed to the understanding of the fate of zoonotic bacteria introduced in animal beddings during storage and identified bedding storage practices pre-and post-use in animal facilities that could be important to prevent the risk of zoonosis dissemination to the environment or to the dairy herds.

Fecal excretion of Campylobacter jejuni by young dairy calves and the relationship with neonatal immunity and personality traits.

AIMS: Zoonotic pathogens in bovine herds are major concerns for human and animal health, but their monitoring in animals can be challenging in the absence of clinical signs. Our objective was to determine the association between fecal excretion of Campylobacter jejuni, neonatal immunity, and personality traits of calves. METHODS AND RESULTS: Forty-eight dairy calves were reared in three indoor pens from birth to 4 weeks of life. Microbial analyses of the fecal samples collected weekly revealed that the proportion of calves naturally contaminated with C. jejuni in each pen reached 70% after 3 weeks of life. High (>16 g l-1) levels of IgG levels in the serum of neonatal calves were negatively (P = .04) associated with fecal detection of C. jejuni over the trial period. Calves that spent more time interacting with a novel object tended to be positive (P = .058) for C. jejuni. CONCLUSIONS: Overall, the findings indicate that the immunity of neonatal dairy animals and possibly the animal's behavior may contribute to the fecal shedding of C. jejuni.

Association between changes in loneliness identified through screening and changes in depression or anxiety in older adults.

BACKGROUND: Changes in loneliness are associated with corresponding changes in depression, anxiety, and general health in population surveys, but few studies have assessed these associations through repeated screening in clinical settings. METHODS: Retrospective cohort study among individuals ≥age 65 in an integrated health care system who completed loneliness screening before two annual wellness visits, separated by a mean of 12.9 (SD 2.0) months, between 2013 and 2018. Their responses identified four subgroups: individuals who were persistently lonely; not lonely; experienced an increase (recently lonely); or decrease (previously lonely) in loneliness. Loneliness was assessed with a single item. Depression was assessed with the Patient Health Questionnaire-2. Anxiety was assessed with the Generalized Anxiety Disorder-2. Fair/poor general health was assessed by a single item. Linear mixed effects models assessed changes in outcomes after covariate adjustment. RESULTS: The cohort comprised 24,666 individuals (19.2% of older adults in the system). Mean age was 73.7 years (SD 6.4); 54.6% were female, and 11.6% were members of racial and ethnic minority groups. Of these individuals, 1936 (7.8%) were persistently lonely, 1687 (6.8%) were recently lonely, 1551 (6.3%) were previously lonely, and 19,492 (79.0%) were not lonely at either time point. After adjustment for sociodemographic, clinical and social variables, recent loneliness was associated with increases in depression (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.41-2.19) and anxiety (aOR 1.67, 95% CI 1.32-2.10). Previous loneliness was associated with decreases in depression (aOR, 0.46, 95% CI 0.36-0.58) and anxiety (aOR 0.69, 95% CI 0.54-0.90). Changes in loneliness were not associated with changes in general health. CONCLUSIONS: Changes in loneliness identified through screening were associated with corresponding changes in depression and anxiety. These findings support the potential value of identifying social risk factors in clinical settings among older adults.

Testing the added value of self-reported health and well-being in understanding healthcare utilization and costs.

PURPOSE: We investigated the relationship between measures of self-reported health and well-being and concurrent and prospective healthcare utilization and costs to assess the added value of these self-reported measures in understanding utilization and cost. METHODS: Kaiser Permanente members (N = 6752) completed a 9-item survey measuring life evaluation, financial situation, social support, meaning and purpose, physical health, and mental health. Responses were linked to medical record information during the period 12 months before and after the survey. RESULTS: Correlations between health and well-being measures and healthcare utilization and cost variables were generally weak, with stronger correlations for future life evaluation and selected health measures (ρ = .20-.33, ps < .001). Better overall life evaluation had a significant but weak association with lower total cost and hospital days in the following year after controlling for age, sex, and race/ethnicity (p < .001). Full multivariate models, adjusting for age, sex, race/ethnicity, prior utilization, and relative risk models, showed weak associations between health and well-being measures and following year total healthcare cost and utilization, though the associations were relatively stronger for the health variables than the well-being variables. CONCLUSION: Overall, the health and well-being variables added little to no predictive utility for future utilization and cost beyond prior utilization and cost and the inclusion of predictive models based on clinical information. Perceptions of well-being may be associated with factors beyond healthcare utilization. When information about prior use is unavailable, self-reported health items have some predictive utility.

Results of an Initiative Supporting Community-Based Organizations and Health Care Clinics to Assist Individuals With Enrolling in SNAP.

CONTEXT: Only 58% of eligible Coloradans are enrolled in the Supplemental Nutrition Assistance Program (SNAP). In recent years, more community-based organizations (CBOs) and health care clinics are incorporating screening for social needs into their workflows. PROGRAM: Seven Colorado-based CBOs and 3 clinics received funding (2016-2018) to screen for food insecurity (FI) and provide SNAP application assistance to their clients and patients. IMPLEMENTATION: Funded agencies were required to implement strategies focused on particular populations or settings based on Food Research and Action Center recommendations. EVALUATION: A 5-part care cascade from screening to SNAP enrollment was conceptualized to guide the evaluation. Funded CBOs and clinics were asked to submit de-identified individual-level data to the evaluation team (number and characteristics of individuals screened, screening results, interest in receiving assistance, submitted application, enrolled in SNAP). The purpose of the evaluation was to assess the proportion of individuals CBOs and clinics screen for FI and assist with completing a SNAP application and describe the characteristics of individuals who are not interested in receiving assistance to complete a SNAP application and the characteristics of individuals who enroll in SNAP. RESULTS: Thirty-five percent of individuals who reported FI participated in the care cascade and enrolled in SNAP. CBOs assisted a greater proportion of food-insecure individuals (55%) than clinics (22%) (P < .001). Males, adults 40 years or older, rural residents, and African Americans were more likely to be interested in receiving assistance, and adults 40 years or older, rural residents, and American Indians/Alaska Natives were more likely to enroll in SNAP. DISCUSSION: CBOs were more successful in assisting individuals along the care cascade than clinics. Certain subpopulations are more likely to be interested in receiving assistance and enrolling in SNAP. These findings can be used by public health practitioners to plan interventions to increase enrollment in SNAP.

Integrating Palliative Care Social Workers into Subacute Settings: Feasibility of the Assessing & Listening to Individual Goals and Needs Intervention Trial.

Objectives: Determine feasibility, acceptability, and preliminary effects of the Palliative Care Social Worker-led ALIGN (Assessing & Listening to Individual Goals and Needs) intervention in older persons admitted to Skilled Nursing Facility (SNF) and their caregivers. Design: A pilot pragmatic randomized stepped wedge design of ALIGN versus usual care in three SNFs. Setting and Participants: One hundred and twenty older adults and caregivers (optional) with advanced medical illnesses. Measures: Primary outcomes were feasibility and acceptability. We collected exploratory patient-/caregiver-centered outcomes at baseline and three months and conducted a medical record review at six months to assess documentation of Advance Directives (AD). We also collected exploratory health care utilization data, including hospitalizations, mortality, and hospice utilization. Results: Of 179 patients approached, 120 enrolled (60 ALIGN patients with 15 caregivers and 60 usual care patients and 21 caregivers). Four intervention patients refused ALIGN visits, 8 patients died or discharged before initial visit, and 48 intervention patients received ALIGN visits, with ∼80% having caregivers participating in visits, regardless of caregiver study enrollment. Quantitative exploratory outcomes were not powered to detect a difference between groups. We found 91% of ALIGN patients had a completed AD in medical record compared to 39.6% of usual care patients (p < 0.001). Qualitative feedback from participants and SNF staff supported high acceptability and satisfaction with ALIGN. Conclusion and Clinical Implications: A pragmatic trial of the ALIGN intervention is feasible and preliminary effects suggest ALIGN is effective in increasing AD documentation. Further research is warranted to understand effects on caregivers and health care utilization. The current model for SNF does not address the palliative care needs of patients. ALIGN has potential to be an effective, scalable, acceptable, and reproducible intervention to improve certain palliative care outcomes within subacute settings.

Importance of the Farm Environment and Wildlife for Transmission of Campylobacter jejuni in A Pasture-Based Dairy Herd.

Cattle are an established reservoir of the foodborne bacterial pathogen Campylobacter jejuni. Our six-month study aimed to evaluate sources and pathways governing long-term presence of C. jejuni in a pasture-based dairy herd. C. jejuni was detected in all sample types (soil, pasture, stock drinking water, bird, rodents and cow faeces). It was persistently detected from cow (54%; 49/90 samples) and bird (36%; 77/211) faeces. Genetic comparison of 252 C. jejuni isolates identified 30 Multi-Locus Sequence Types (ST). ST-61 and ST-42 were persistent in the herd and accounted for 43% of the cow isolates. They were also detected on pasture collected from fields both recently and not recently grazed, indicating that grazed pasture is an important pathway and reservoir for horizontal transmission among cows. ST-61 accounted for 9% of the bird isolates and was detected at four of the six sampling events, suggesting that bird populations might contribute to the cycling of ruminant-adapted genotypes on-farm. Overall, the results indicated that management of grazed pasture and supplementary feed contaminated by bird droppings could be targeted to effectively reduce transmission of C. jejuni to dairy herds, the farm environment and ultimately to humans.

No date for the PROM: the association between patient-reported health events and clinical coding in primary care.

OBJECTIVE: It is unclear whether data from patient-reported outcome measures (PROMs) are captured and used by clinicians despite policy initiatives. We examined the extent to which fall risk and urinary incontinence (UI) reported on PROMS and provided to clinicians prior to a patient visit are subsequently captured in the electronic medical record (EMR). Additionally, we aimed to determine whether the use of PROMs and EMR documentation is higher for visits where PROM data was provided to clinicians. DESIGN: We conducted a cross-sectional patient-reported risk assessment survey and semi-structured interviews with clinicians to identify themes related to the use of PROMs. SETTING: Fourteen primary care clinics in the US (eight intervention and six control clinics), between October 2013 and May 2015. PARTICIPANTS: Primary care clinicians and older adult (≥66 years) patients completing a 46-item health risk assessment, including PROMs for fall risk and UI. INTERVENTION: Risk assessment results provided to the clinician or nurse practitioners prior to the clinic visit in intervention clinics; data was not provided in control clinics. MAIN OUTCOME: 1) Agreement between ICD-9 codes of fall risk or UI in the EMR and patient-reports, and 2) clinician experience of PROMs use and impact on coding. RESULTS: A total of 505 older adult patients were included in the study, 176 at control clinics and 329 at intervention clinics. While patient reports of fall risk and UI were readily captured by PROMs, this information was only coded in the EMR between 3% - 14% of the time (poor Kappa agreement). Intervention clinics performed slightly better than control clinics. Clinician interviews (n = 16) revealed low use of PROMs data with multiple barriers cited including poor access to data, high quantity of data, interruption to workflow, and a lack of training on PROMs. CONCLUSIONS: Current strategies of providing PROMs data prior to clinic visits may not be an effective way of communicating important health information to busy clinicians; ultimately resulting in underuse. Better systems of presenting PROMs data, and clinician training on the importance of PROMs and their use, is needed.

Integration of data from a safety net health care system into the Vaccine Safety Datalink.

BACKGROUND: In 2013 the Institute of Medicine suggested that the Vaccine Safety DataLink (VSD) should broaden its population by including data of more patients from low income and racially and ethnically diverse backgrounds. In response, Kaiser Permanente Colorado (KPCO) partnered with Denver Health (DH), an integrated safety net health care system, to explore the integration of DH data. METHODS: We compared three different methods (reference date of September 1, 2013): "Empanelment" (any patient who has had a primary care visit in the past 18months), "Proxy-enrollment" (two health care visits in 3years separated by 90days), and "Enrollment" in a managed care plan. For each of these methods, we compared cohort size, vaccination rates, socio-demographic characteristics, and health care utilization. RESULTS: The empaneled population at DH provided the best comparison to KPCO. DH's empaneled population was 111,330 (57,173 adults; 54,157 children), while KPCO had 436,290 empaneled patients (336,462 adults; 99,828 children). Vaccination rates in both health care systems for empaneled patients were comparable. Two year-old up-to-date coverage rates were 83.2% (KPCO) and 86.9% (DH); rates for adolescent Tdap and MCV4 were 85.5% (KPCO) and 90.6% (DH). There were significant differences in the two populations in age, gender, race, preferred language, and % Federal Poverty Level (FPL) (DH 70.7%<100% FPL; KPCO 17.4%), as well as in healthcare utilization - for example pediatric emergency department utilization was twice as high at DH. CONCLUSIONS: Using a cohort of "empaneled" patients, it is possible to integrate data from a safety net health care system that does not have a uniform managed care population into the VSD, and to compare vaccination rates, socio-demographic characteristics, and health care utilization across the two systems. The KPCO-DH collaboration may serve as a model for incorporating data from a safety net healthcare system into the VSD.

Vaccine adverse events in a safety net healthcare system and a managed care organization.

BACKGROUND: The Institute of Medicine, in a 2013 report, recommended that the Vaccine Safety Datalink (VSD) expand collaborations to include more diversity in the study population. Kaiser Permanente Colorado (KPCO), an established VSD site, partnered with Denver Health (DH), an integrated safety net healthcare system, to demonstrate the feasibility of integrating DH data within the VSD. Prior to incorporating the data, we examined the identification of specific vaccine associated adverse events (VAEs) in these two distinct healthcare systems. METHODS: We conducted retrospective cohort analyses within KPCO and DH to compare select VAEs between the two populations. We examined the following associations between January 1, 2004 and December 31, 2013: Measles, Mumps, and Rubella (MMR) vaccine and febrile seizures in children 2years and younger, intussusception after rotavirus vaccine in infants 4-34weeks, syncope after adolescent vaccines (Tetanus, Diphtheria, acellular Pertussis; Meningococcal and Human Papillomavirus) in adolescents 13-17years and medically attended local reactions after pneumococcal polysaccharide (PPSV23) vaccine in adults 65years and older. Both sites used similar data procurement methods and chart review processes. RESULTS: For seizures after MMR vaccine (KPCO - 3.15vs. DH - 2.97/10,000 doses) and syncope after all adolescent vaccines (KPCO - 3.0vs. DH - 2.37/10,000 doses), the chart confirmed rates were comparable at the two sites. However, for medically attended local reactions after PPSV23, there were differences in chart confirmed rates between the sites (KPCO - 31.65vs. DH - 14.90/10,000 doses). For intussusception after rotavirus vaccine, the number of cases was too low to make a valid comparison (KPCO - 0vs. DH - 0.13/10,000 doses). CONCLUSION: We demonstrated that data on important targeted VAEs can be captured at DH and rates appear similar to those at KPCO. Work is ongoing on the optimal approach to assimilate DH data as a potential safety net healthcare system in the VSD.

Characterization of volatile metabolites associated with confinement odour during the shelf-life of vacuum packed lamb meat under different storage conditions.

Confinement odour was investigated. Volatiles were extracted directly from the pack, using solid phase microextraction and analysed by gas chromatography-mass spectrometry. Sensory evaluation and microbiological analysis of the meat surface were also performed. Commercial samples of vacuum packed lamb legs (n=85), from two meat processing plants, were kept for 7weeks at -1.5°C then at different regimes of temperature (-1.5 to +4°C) until 11, 12 or 13weeks. Persistent odour was observed in 66% of samples, confinement odour in 24% and no odour in 11%. Volatiles associated with confinement odour (3-methyl-butanal, 3-hydroxy-2-butanone and sulphur dioxide) corresponded with end/sub products of glucose fermentation and catabolism of amino acids by bacteria (all bacteria naturally found in meat and do not represent a risk to health). Confinement odour could indicate a stage at which the environment for bacteria growth is becoming favourable for the production of volatiles with strong odours that are noticed by the consumer.

Self-Rated Health Among Patients with Coronary Artery Disease Enrolled in a Cardiovascular Risk Reduction Service.

Little is known about the use of the single self-rated health (SRH) status item measuring health-related quality of life among people with coronary artery disease (CAD). The objective of this study was to assess relationships between SRH and recurrent coronary events, mortality, health care utilization, and intermediate clinical outcomes and to assess predictors of fair/poor SRH. A total of 5573 patients enrolled in a comprehensive cardiac risk reduction service managed by clinical pharmacy specialists were evaluated over a 2-year period. Regression modeling explored relationships among variables, modeling SRH separately as an independent and a dependent variable. The 1374 (24.7%) respondents reporting fair/poor SRH differed statistically from 4199 (75.3%) respondents reporting good/very good/excellent SRH in terms of age, sex, ethnicity, number of comorbid conditions, DxCG scores, lifestyle behaviors, blood pressure control, and inpatient and emergency department (ED) utilization. Respondents reporting fair/poor health were more likely to have recurrent major coronary events (MCE), including death. Fair/poor SRH was consistently statistically significant when it was included as a predictor in regression modeling for poor blood pressure control, health care utilization, MCE, and all-cause mortality. Variables associated with fair/poor SRH in regression modeling included females, Hispanic ethnicity, ≥1 baseline ED visit, and DxCG score. Exercising <30 minutes per week was strongly associated with fair/poor SRH. Single-item SRH status may help identify patients with CAD at higher risk of poor blood pressure control, recurrent MCE, and death and those who may benefit from interventions to increase physical activity.

Data Value in Patient Tracking Systems at Racing Events.

PURPOSE: With the growing popularity of long-distance running races, an emerging area of interest for race organizers is the ability to electronically track and understand participant status throughout events to optimize runner and spectator experience and to identify and respond to the dynamic needs of both communities. This study examines the potential value of developing real-time patient tracking systems (PTS) at marathons based on the Chicago Medical Patient Tracking System (CMPTS). METHODS: Data collected from the CMPTS and timing mats along the course for two running races in 2012 and 2013 were analyzed for data completeness and data value. Subjects consisted of patients who were tracked electronically in the system. RESULTS: A comparison of medical data collected by PTS and paper forms is provided. Once fully implemented, PTS have the potential to capture more accurate and more detailed information compared with paper forms. A significant amount of records obtained by paper forms lacks any time or diagnosis information. CONCLUSIONS: A set of best practices for tracking applications and data collection at marathons is proposed to improve accuracy based on CMPTS implementations from 2012 to 2013. Developing and conforming to standards for data collection at marathons and other mass-gathering events could improve data sets created from PTS, which can be used to improve operational decisions at such events and can provide the foundation for prediction models for enhancing planning and preparedness.

Acute incident rapid response at a mass-gathering event through comprehensive planning systems: a case report from the 2013 Shamrock Shuffle.

Planning and execution of mass-gathering events involves various challenges. In this case report, the Chicago Model (CM), which was designed to organize and operate such events and to maintain the health and wellbeing of both runners and the public in a more effective way, is described. The Chicago Model also was designed to prepare for unexpected incidents, including disasters, during the marathon event. The model has been used successfully in the planning and execution stages of the Bank of America Shamrock Shuffle and the Bank of America Chicago Marathon since 2008. The key components of the CM are organizational structure, information systems, and communication. This case report describes how the organizers at the 2013 Shamrock Shuffle used the key components of the CM approach in order to respond to an acute incident caused by a man who was threatening to jump off the State Street Bridge. The course route was changed to accommodate this unexpected event, while maintaining access to key health care facilities. The lessons learned from the incident are presented and further improvements to the existing model are proposed.

Mindfulness-based stress reduction in an integrated care delivery system: one-year impacts on patient-centered outcomes and health care utilization.

BACKGROUND: Mindfulness-based stress reduction (MBSR) programs have demonstrated clinical effectiveness for both mental and physical health conditions. Less research exists on health services utilization, self-efficacy, or work productivity outcomes. OBJECTIVE: To assess one-year outcomes of MBSR in patients with chronic pain, chronic illness, or stress-related problems, measuring functional status, pain, self-efficacy, depression, anxiety, somatization, psychological distress, work productivity, and changes in health services utilization. METHODS: A prospective single cohort design evaluated an eight-week MBSR program for Kaiser Permanente Colorado members. Patient-reported measures were collected at baseline, eight weeks, and one year following MBSR. Differences in health services utilization were compared from six months before MBSR to six months following the one-year anniversary of MBSR. RESULTS: Most of the 38 participants were white (28; 74%), female (30; 79%), employed part-time (35; 92%), and average age 52.6 years, with multiple comorbidities (averaging 16.4 unique diagnoses), the most common being joint or back pain (28; 74%) and psychological disorder (20; 53%). Repeated measures analyses at 8 weeks (n = 26) and at 1 year (n = 24) showed significant improvements in self-reported mental and physical function, pain, psychological symptoms, and self-efficacy, but not work productivity. Significant decreases at 1 year were observed for visits in primary care (-50%, p < 0.0001), specialty care (-38%, p = 0.0004), and the Emergency Department (-50%, p = 0.04), and for hospital admissions (-80%, p = 0.02). CONCLUSION: The MBSR program was associated with improvements in several patient-centered outcomes over 1 year and reductions in health services utilization up to 18 months.

Association of online patient access to clinicians and medical records with use of clinical services.

CONTEXT: Prior studies suggest that providing patients with online access to health records and e-mail communication with physicians may substitute for traditional health care services. OBJECTIVE: To assess health care utilization by both users and nonusers of online access to health records before and after initiation of MyHealthManager (MHM), a patient online access system. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of the use of health care services by members (≥18 years old) who were continuously enrolled for at least 24 months during the study period March 2005 through June 2010 in Kaiser Permanente Colorado, a group model, integrated health care delivery system. Propensity scores (using age, sex, utilization frequencies, and chronic illnesses) were used for cohort matching. Unadjusted utilization rates were calculated for both MHM users and nonusers and were the basis for difference-of-differences analyses. We also used generalized estimating equations to compare the adjusted rates of utilization of health care services before and after online access. MAIN OUTCOME MEASURES: Rates of office visits, telephone encounters, after-hours clinic visits, emergency department encounters, and hospitalizations between members with and without online access. RESULTS: Comparing the unadjusted rates for use of clinical services before and after the index date between the matched cohorts, there was a significant increase in the per-member rates of office visits (0.7 per member per year; 95% CI, 0.6-0.7; P < .001) and telephone encounters (0.3 per member per year; 95% CI, 0.2-0.3; P < .001). There was also a significant increase in per-1000-member rates of after-hours clinic visits (18.7 per 1000 members per year; 95% CI, 12.8-24.3; P < .001), emergency department encounters (11.2 per 1000 members per year; 95% CI, 2.6-19.7; P = .01), and hospitalizations (19.9 per 1000 members per year; 95% CI, 14.6-25.3; P < .001) for MHM users vs nonusers. CONCLUSION: Having online access to medical records and clinicians was associated with increased use of clinical services compared with group members who did not have online access.

Differences in the fecal concentrations and genetic diversities of Campylobacter jejuni populations among individual cows in two dairy herds.

Dairy cows have been identified as common carriers of Campylobacter jejuni, which causes many of the human gastroenteritis cases reported worldwide. To design on-farm management practices that control the human infection sourced from dairy cows, the first step is to acquire an understanding of the excretion patterns of the cow reservoir. We monitored the same 35 cows from two dairy farms for C. jejuni excretion fortnightly for up to 12 months. The objective was to examine the concentration of C. jejuni and assess the genetic relationship of the C. jejuni populations excreted by individual cows. Significant differences (P < 0.01) in C. jejuni fecal concentration were observed among the 35 cows, with median concentrations that varied by up to 3.6 log(10) · g(-1) feces. A total of 36 different genotypes were identified from the 514 positive samples by using enterobacterial repetitive intergenic consensus (ERIC)-PCR. Although 22 of these genotypes were excreted by more than one cow, the analysis of frequencies and distribution of the genotypes by model-based statistics revealed a high degree of individuality in the C. jejuni population in each cow. The observed variation in the frequency of excretion of a genotype among cows and the analysis by multilocus sequence typing (MLST) of these genotypes suggest that excretion of C. jejuni in high numbers is due to a successful adaptation of a particular genotype to a particular cow's gut environment, but that animal-related factors render some individual cows resistant to colonization by particular genotypes. The reasons for differences in C. jejuni colonization of animals warrant further investigation.