Nonfreezing Cold Injuries Among Long-Distance Polar Rowers.

INTRODUCTION: Nonfreezing cold injury (NFCI) is a peripheral cold injury that occurs when the extremities are exposed to cold temperatures, at or near the freezing point, for sustained periods of time (48-96 h at temperatures of usually around 0 to 6°C with associated wind chill). Although NFCI often goes unreported and may be underdiagnosed, it is a cause of significant morbidity in those working in cold conditions, particularly those in the military. Thus, further research into the prevention, recognition, and treatment of NFCI is warranted. METHODS: The height, body weight, and body composition of 6 rowers taking part in 1 or 2 legs of the 2017 Polar Row expedition were measured. The weather conditions of the 2 legs of the journey were recorded, and symptoms relating to NFCI were documented. RESULTS: All incidences of NFCI occurred during Leg 2 of the expedition, which was colder and wetter. Of the Leg 2 rowers, those who developed NFCI had a trend toward higher pre-row body weight and body mass index and a trends toward losing more weight and body water relative to those who did not. CONCLUSIONS: The main factor contributing to the incidence of NFCI appeared to be weather; NFCI only occurred during the colder and wetter leg of the expedition. We also tentatively suggest that nutrition and dehydration may be linked to the incidence of NFCI as predisposing factors. More work, with sample sizes greater than those reported here, is required to investigate these associations to further characterize risk factors.

Diagnostic accuracy of point-of-care tests for acute respiratory infection: a systematic review of reviews.

Background: Acute respiratory infections are a common reason for consultation with primary and emergency healthcare services. Identifying individuals with a bacterial infection is crucial to ensure appropriate treatment. However, it is also important to avoid overprescription of antibiotics, to prevent unnecessary side effects and antimicrobial resistance. We conducted a systematic review to summarise evidence on the diagnostic accuracy of symptoms, signs and point-of-care tests to diagnose bacterial respiratory tract infection in adults, and to diagnose two common respiratory viruses, influenza and respiratory syncytial virus. Methods: The primary approach was an overview of existing systematic reviews. We conducted literature searches (22 May 2023) to identify systematic reviews of the diagnostic accuracy of point-of-care tests. Where multiple reviews were identified, we selected the most recent and comprehensive review, with the greatest overlap in scope with our review question. Methodological quality was assessed using the Risk of Bias in Systematic Reviews tool. Summary estimates of diagnostic accuracy (sensitivity, specificity or area under the curve) were extracted. Where no systematic review was identified, we searched for primary studies. We extracted sufficient data to construct a 2 × 2 table of diagnostic accuracy, to calculate sensitivity and specificity. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 tool. Where possible, meta-analyses were conducted. We used GRADE to assess the certainty of the evidence from existing reviews and new analyses. Results: We identified 23 reviews which addressed our review question; 6 were selected as the most comprehensive and similar in scope to our review protocol. These systematic reviews considered the following tests for bacterial respiratory infection: individual symptoms and signs; combinations of symptoms and signs (in clinical prediction models); clinical prediction models incorporating C-reactive protein; and biological markers related to infection (including C-reactive protein, procalcitonin and others). We also identified systematic reviews that reported the accuracy of specific tests for influenza and respiratory syncytial virus. No reviews were found that assessed the diagnostic accuracy of white cell count for bacterial respiratory infection, or multiplex tests for influenza and respiratory syncytial virus. We therefore conducted searches for primary studies, and carried out meta-analyses for these index tests. Overall, we found that symptoms and signs have poor diagnostic accuracy for bacterial respiratory infection (sensitivity ranging from 9.6% to 89.1%; specificity ranging from 13.4% to 95%). Accuracy of biomarkers was slightly better, particularly when combinations of biomarkers were used (sensitivity 80-90%, specificity 82-93%). The sensitivity and specificity for influenza or respiratory syncytial virus varied considerably across the different types of tests. Tests involving nucleic acid amplification techniques (either single pathogen or multiplex tests) had the highest diagnostic accuracy for influenza (sensitivity 91-99.8%, specificity 96.8-99.4%). Limitations: Most of the evidence was considered low or very low certainty when assessed with GRADE, due to imprecision in effect estimates, the potential for bias and the inclusion of participants outside the scope of this review (children, or people in hospital). Future work: Currently evidence is insufficient to support routine use of point-of-care tests in primary and emergency care. Further work must establish whether the introduction of point-of-care tests adds value, or simply increases healthcare costs. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR159948.

Respiratory infections are a common cause of illness. Currently, healthcare professionals use clinical experience to decide whether an infection is caused by a virus or bacteria, and whether antibiotics are needed. However, this is not always easy to establish. We tried to identify the effectiveness of rapid tests (with results in under 45 minutes) at distinguishing between viral and bacterial respiratory infections. We identified and summarised all the existing reviews and studies in this area. We looked at many different tests which aim to distinguish between bacterial and viral causes of respiratory infections. In particular, we assessed: individual symptoms and signs (such as the presence of cough, or a fever) combinations of symptoms and signs (the presence or absence of multiple symptoms) various 'biomarker' tests (blood tests for evidence that the body has used its defence mechanisms) We also looked at specific tests for flu and respiratory syncytial virus, which are common causes of viral infection. The reviews we found showed symptoms and signs were not able to identify bacterial infections in people accurately. The accuracy of biomarker tests was slightly better, particularly when multiple markers were used. The accuracy of rapid tests for flu and respiratory syncytial virus varied; the most accurate tests were those that detect viral genetic material. We also found studies showing that genetic tests that identify many viruses at once (multiplex tests) were very accurate. However, most of the evidence we identified was not robust. There were concerns about the conduct of some of the studies. In some cases there was uncertainty whether a test was really accurate enough to be useful. Therefore there is still doubt about whether any of these tests will be useful additions to current clinical care.

Shared decision making between older people with multimorbidity and GPs: a qualitative study.

BACKGROUND: Shared decision making (SDM), utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate SDM, yet few studies have explored this dynamic for older patients with multimorbidity in general practice. AIM: To explore factors influencing SDM from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care. DESIGN AND SETTING: Qualitative study. General practices (rural and urban) in Devon, England. METHOD: Four focus groups: two with patients (aged ≥65 years with multimorbidity) and two with GPs. Data were coded inductively by applying thematic analysis. RESULTS: Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to SDM, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to SDM. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for SDM. Increasing consultation duration and improving continuity were viewed as facilitators. CONCLUSION: Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to SDM and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of SDM training. The incorrect perception that most clinicians already effectively facilitate SDM should be addressed to improve the uptake of personalised care interventions.

Molecular typing of Trypanosoma cruzi isolates, United States.

Studies have characterized Trypanosoma cruzi from parasite-endemic regions. With new human cases, increasing numbers of veterinary cases, and influx of potentially infected immigrants, understanding the ecology of this organism in the United States is imperative. We used a classic typing scheme to determine the lineage of 107 isolates from various hosts.

A Dietary Intervention in Urban African Americans: Results of the "Five Plus Nuts and Beans" Randomized Trial.

INTRODUCTION: Unhealthy diets, often low in potassium, likely contribute to racial disparities in blood pressure. We tested the effectiveness of providing weekly dietary advice, assistance with selection of higher potassium grocery items, and a $30 per week food allowance on blood pressure and other outcomes in African American adults with hypertension. DESIGN: We conducted an 8-week RCT with two parallel arms between May 2012 and November 2013. SETTING/PARTICIPANTS: We randomized 123 African Americans with controlled hypertension from an urban primary care clinic in Baltimore, Maryland, and implemented the trial in partnership with a community supermarket and the Baltimore City Health Department. Mean (SD) age was 58.6 (9.5) years; 71% were female; blood pressure was 131.3 (14.7)/77.2 (10.5) mmHg; BMI was 34.5 (8.2); and 28% had diabetes. INTERVENTION: Participants randomized to the active intervention group (Dietary Approaches to Stop Hypertension [DASH]-Plus) received coach-directed dietary advice and assistance with weekly online ordering and purchasing of high-potassium foods ($30/week) delivered by a community supermarket to a neighborhood library. Participants in the control group received a printed DASH diet brochure along with a debit account of equivalent value to that of the DASH-Plus group. MAIN OUTCOME MEASURES: The primary outcome was blood pressure change. Analyses were conducted in January to October 2014. RESULTS: Compared with the control group, the DASH-Plus group increased self-reported consumption of fruits and vegetables (mean=1.4, 95% CI=0.7, 2.1 servings/day); estimated intake of potassium (mean=0.4, 95% CI=0.1, 0.7 grams/day); and urine potassium excretion (mean=19%, 95% CI=1%, 38%). There was no significant effect on blood pressure. CONCLUSIONS: A program providing dietary advice, assistance with grocery ordering, and $30/week of high-potassium foods in African American patients with controlled hypertension in a community-based clinic did not reduce BP. However, the intervention increased consumption of fruits, vegetables, and urinary excretion of potassium.

Acrophobia and pathological height vertigo: indications for vestibular physical therapy?

BACKGROUND AND PURPOSE: Acrophobia (fear of heights) may be related to a high degree of height vertigo caused by visual dependence in the maintenance of standing balance. The purpose of this case report is to describe the use of vestibular physical therapy intervention following behavioral therapy to reduce a patient's visual dependence and height vertigo. CASE DESCRIPTION: Mr N was a 37-year-old man with agoraphobia (fear of open spaces) that included symptoms of height phobia. Exposure to heights triggered symptoms of dizziness. Intervention. Mr N underwent 8 sessions of behavioral therapy that involved exposure to heights using a head-mounted virtual reality device. Subsequently, he underwent 8 weeks of physical therapy for an individualized vestibular physical therapy exercise program. OUTCOMES: After behavioral therapy, the patient demonstrated improvements on the behavioral avoidance test and the Illness Intrusiveness Rating Scale, but dizziness and body sway responses to moving visual scenes did not decrease. After physical therapy, his dizziness and sway responses decreased and his balance confidence increased. DISCUSSION: Symptoms of acrophobia and sway responses to full-field visual motion appeared to respond to vestibular physical therapy administered after completion of a course of behavioral therapy. Vestibular physical therapy may have a role in the management of height phobia related to excessive height vertigo.

Seroprevalence of Trypanosoma cruzi among eleven potential reservoir species from six states across the southern United States.

Trypanosoma cruzi, the causative agent of Chagas' disease, is a substantial public health concern in Latin America. Although rare in humans and domestic animals in the United States, T. cruzi is commonly detected in some wildlife species, most commonly raccoons (Procyon lotor) and Virginia opossums (Didelphis virginiana). To increase our understanding of the reservoir host species range and geographic distribution, 11 species of mammals from six states spanning the known range of T. cruzi (Arizona, California, Florida, Georgia, Missouri, and Virginia) were tested for antibodies to T. cruzi using indirect immunofluorescent antibody testing. In addition, culture isolation attempts were conducted on a limited number of animals from Georgia and Florida. Evidence of T. cruzi was found in every state except California; however, low numbers of known reservoirs were tested in California. In general, the highest seroprevalence rates were found in raccoons (0-68%) and opossums (17-52%), but antibodies to T. cruzi were also detected in small numbers of striped skunks (Mephitis mephitis) from Arizona and Georgia, bobcats (Lynx rufus) from Georgia, two coyotes (Canis latrans) from Georgia and Virginia, and a ringtail (Bassariscus astutus) from Arizona. Culture-based prevalence rates for raccoons were significantly greater than those for opossums; however, seroprevalences of raccoons and opossums from several geographic locations in Georgia and Florida were not different, indicating that exposure rates of these two species are similar within these areas. For both raccoons and opossums, seroprevalence was significantly higher in females than in males. No difference was detected in seroprevalence between adults and juveniles and between animals caught in urban and rural locations. Our results indicate that T. cruzi prevalence varies by host species, host characteristics, and geographic region and provides data to guide future studies on the natural history of T. cruzi in the United States.

Evaluation of the Chagas Stat-Pak assay for detection of Trypanosoma cruzi antibodies in wildlife reservoirs.

An immunochromatographic assay (Chagas Stat-Pak) was evaluated for the detection of Trypanosoma cruzi antibodies in 4 species of wildlife reservoirs. Antibodies to T. cruzi were detected in raccoons (Procyon lotor) (naturally and experimentally infected) and degus (Octodon degu) (experimentally-infected) using the Chagas Stat-Pak. In naturally exposed wild raccoons, the Chagas Stat-Pak had a sensitivity and specificity of 66.7-80.0% and 96.3%, respectively. Compared with indirect immunofluorescent antibody assay results, seroconversion as determined by Chagas Stat-Pak was delayed for experimentally infected raccoons, but occurred sooner in experimentally infected degus. The Chagas Stat-Pak did not detect antibodies in naturally or experimentally infected Virginia opossums (Didelphis virginiana) or in experimentally infected short-tailed opossums (Monodelphis domestica). These data suggest that the Chagas Stat-Pak might be useful in field studies of raccoons and degus when samples would not be available for more-conventional serologic assays. Because this assay did not work on either species of marsupial, the applicability of the assay should be examined before it is used in other wild species.