International chicken trade and increased risk for introducing or reintroducing highly pathogenic avian influenza A (H5N1) to uninfected countries.

Every year billions of chickens are shipped thousands of miles around the globe in order to meet the ever increasing demands for this cheap and nutritious protein source. Unfortunately, transporting chickens internationally can also increase the chance for introducing zoonotic viruses, such as highly pathogenic avian influenza A (H5N1) to new countries. Our study used a retrospective analysis of poultry trading data from 2003 through 2011 to assess the risk of H5N1 poultry infection in an importing country. We found that the risk of infection in an importing country increased by a factor of 1.3 (95% CI: 1.1-1.5) for every 10-fold increase in live chickens imported from countries experiencing at least one H5N1 poultry case during that year. These results suggest that the risk in a particular country can be significantly reduced if imports from countries experiencing an outbreak are decreased during the year of infection or if biosecurity measures such as screening, vaccination, and infection control practices are increased. These findings show that limiting trade of live chickens or increasing infection control practices during contagious periods may be an important step in reducing the spread of H5N1 and other emerging avian influenza viruses.

The differential associations of preexisting conditions with trauma-related outcomes in the presence of competing risks.

INTRODUCTION: Pre-existing chronic conditions (PECs) pose a unique problem for the care of aging trauma populations. However, the relationships between specific conditions and outcomes after injury are relatively unknown. Evaluation of trauma patients is further complicated by their discharge to care facilities, where mortality risk remains high. Traditional approaches for evaluating in-hospital mortality do not account for the discharge of at-risk patients, which constitutes a competing risk event to death. The objective of this study was to evaluate associations between 40 PECs and two clinical outcomes in the context of competing risks among older trauma patients. METHODS: This retrospective study evaluated blunt-injured patients aged 55 years and older admitted to a level I trauma centre in 2006-2012. Outcomes were hospital length of stay (HLOS) and in-hospital mortality. Survivors were classified as discharges home or discharges to care facilities. Competing risks regression was used to evaluate each PEC with in-hospital mortality, accounting for discharges to care facilities as competing events. Competing risk estimates were compared to Cox model estimates, for which all survivors to discharge were non-events. Analyses were stratified using injury-based mortality risk at a 50% cutpoint (high versus low). RESULTS: Among 4653 patients, 176 died in-hospital, 3059 were discharged home, and 1418 were discharged to a care facility. Most patients (98%) were classified with a low mortality risk. Only haemophilia and coagulopathy were consistently associated with longer HLOS. In the low-risk subgroup, in-hospital mortality was most strongly associated with liver diseases, haemophilia, and coagulopathy. In the high-risk group, Parkinson's disease, depression, and cancers showed the strongest associations. Accounting for the competing event altered estimates for 12 of 19 significant conditions. CONCLUSIONS: Excess mortality among patients expected to survive their injuries may be attributable to complications resulting from PECs. Discharges to care facilities constitute a bias in the evaluation of in-hospital mortality and should be considered for the accurate calculation of risk. In conjunction with injury measures, consideration of PECs provides physicians with a foundation to plan clinical decisions in older trauma patients.

Disease Severity and Pregnancy Outcomes in Women with Rheumatoid Arthritis: Results from the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project.

OBJECTIVE: To determine the effect of rheumatoid arthritis (RA) disease severity on pregnancy outcomes in pregnant women with and without autoimmune diseases. METHODS: A prospective cohort study was conducted using the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project. Pregnant women with RA enrolled between 2005 and 2013 were selected if they (1) delivered a live-born singleton infant; and (2) completed 3 telephone-based measures of RA disease severity prior to 20 weeks' gestation, including the Health Assessment Questionnaire Disability Index (HAQ-DI), pain score, and patient's global scale. Associations between RA disease severity and preterm delivery, small for gestational age (SGA), or cesarean delivery were tested in unadjusted and multivariate analyses using modified Poisson regression models. RESULTS: The sample consisted of 440 women with RA. Several unadjusted comparisons yielded significant associations. After adjustment for covariates, increasing disease severity was associated with risk for preterm delivery and SGA. For each unit increase in HAQ-DI (0-1), the adjusted relative risk (aRR) for preterm delivery increased by 58% (aRR 1.58, 95% CI 1.17-2.15). Among those with HAQ-DI > 0.5, the aRR for SGA was 1.81 (95% CI 1.01-3.33). CONCLUSION: RA disease severity in early pregnancy, as measured in this study, was predictive of preterm delivery and SGA. These findings suggest that the risk of preterm delivery and SGA in women with RA might be lowered if RA is well controlled early in pregnancy.

Epidemiology of pathogen-specific respiratory infections among three US populations.

BACKGROUND: Diagnostic tests for respiratory infections can be costly and time-consuming. Improved characterization of specific respiratory pathogens by identifying frequent signs, symptoms and demographic characteristics, along with improving our understanding of coinfection rates and seasonality, may improve treatment and prevention measures. METHODS: Febrile respiratory illness (FRI) and severe acute respiratory infection (SARI) surveillance was conducted from October 2011 through March 2013 among three US populations: civilians near the US-Mexico border, Department of Defense (DoD) beneficiaries, and military recruits. Clinical and demographic questionnaire data and respiratory swabs were collected from participants, tested by PCR for nine different respiratory pathogens and summarized. Age stratified characteristics of civilians positive for influenza and recruits positive for rhinovirus were compared to other and no/unknown pathogen. Seasonality and coinfection rates were also described. RESULTS: A total of 1444 patients met the FRI or SARI case definition and were enrolled in this study. Influenza signs and symptoms varied across age groups of civilians. Recruits with rhinovirus had higher percentages of pneumonia, cough, shortness of breath, congestion, cough, less fever and longer time to seeking care and were more likely to be male compared to those in the no/unknown pathogen group. Coinfections were found in 6% of all FRI/SARI cases tested and were most frequently seen among children and with rhinovirus infections. Clear seasonal trends were identified for influenza, rhinovirus, and respiratory syncytial virus. CONCLUSIONS: The age-stratified clinical characteristics associated with influenza suggest that age-specific case definitions may improve influenza surveillance and identification. Improving identification of rhinoviruses, the most frequent respiratory infection among recruits, may be useful for separating out contagious individuals, especially when larger outbreaks occur. Overall, describing the epidemiology of pathogen specific respiratory diseases can help improve clinical diagnoses, establish baselines of infection, identify outbreaks, and help prioritize the development of new vaccines and treatments.

Abscess and self-treatment among injection drug users at four California syringe exchanges and their surrounding communities.

This study aimed to identify the prevalence and determinants of soft tissue infections and self-treatment among injection drug users (IDUs) in California. The study interviewed 864 IDUs in California using computer-assisted personal interview (CAPI) from 2003 to 2005. Multiple logistic regression analyses were performed to examine adjusted associations for recent abscess and abscess self-treatment. In these analyses, Latinos had higher odds than African Americans to self-treat, while IDUs reporting a usual place of health care had lower odds of self-treatment. Findings suggest an expansion of wound care facilities to mitigate the self-treatment of abscesses, with special consideration to Latinos.

The role of social support and acculturative stress in health-related quality of life among day laborers in Northern San Diego.

There is evidence to suggest that Latino day laborers experience higher levels of acculturative stress than Latinos in employment sectors in the US. Given the stress-buffering role that social support plays in minimizing the negative physical and mental health outcomes of stress, this study examined this relationship in a sample of 70 Latino Day laborers in the northern San Diego area(100% male, mean age = 27.7, SD = 9.1). Results from multivariate regression analyses showed that there was a significant interaction effect between social support and acculturative stress (P = 0.025) on physical health, indicating that higher levels of social support buffered the negative effects of acculturative stress on physical health.Acculturative stress and social support were not associated with mental health status. Overall, these findings suggest that fostering social support may be an essential strategy for promoting health among Latino male day laborers.

Increasing hookah use in California.

Hookah use is gaining popularity nationwide. We determined the correlates and trends for hookah use from the California Tobacco Survey. Between 2005 and 2008 hookah use increased more than 40%, and in 2008, 24.5% of young men reported ever using a hookah. Hookah use was more common among the young (18-24 years), the educated, the non-Hispanic Whites, and the cigarette smokers. Hookah use is increasing in California, especially among young adults, and in 2008 reached the highest prevalence ever reported for both genders.

Determinants of hookah use among high school students.

INTRODUCTION: Hookah use is increasing among young people, but there are limited data on its use among high school-age populations. We examined hookah use initiation, prevalence, cessation, and psychosocial risk factors of hookah use among high school students. METHODS: A cross-sectional survey of 689 students from three high schools in San Diego County was used to compare characteristics of hookah ever-users to nonusers and factors associated with current and former hookah use. RESULTS: Hookah ever-use in the study population was 26.1%, previous month hookah use was 10.9%, and current hookah use was 10.3%. Most students first learned about hookah from friends (50.3%) or saw a hookah lounge (20.9%). Students believed hookah to be more socially acceptable than cigarettes and less harmful than cigarettes, cigars, and smokeless tobacco. Hookah ever-users were significantly more likely than nonusers to have smoked cigarettes, to know of a hookah lounge in their community, and to believe hookah is safer and more socially acceptable than cigarettes. In comparison to former users, current users were more likely to have recently smoked a cigarette, to know of a hookah lounge in their community, and to believe hookah is more socially acceptable than cigarettes. CONCLUSIONS: Hookah use is becoming a commonly acceptable behavior among adolescents, and risk perception is a significant factor. Presence of hookah lounges are associated with increased hookah use among high school students and should be a target of further regulation.

The association between family meals, TV viewing during meals, and fruit, vegetables, soda, and chips intake among Latino children.

OBJECTIVE: Examine the relationship of family meals to children's consumption of fruit and vegetables as well as soda and chips. Additionally, to assess the relationship between viewing TV during family meals and children's diet. DESIGN: Cross-sectional study that used a questionnaire completed by parents. SETTING: Thirteen schools in San Diego, California. PARTICIPANTS: Seven hundred ninety-four children and their parents. ANALYSIS: Ordinal regression assessed associations between children's intake of fruit, vegetables, soda, and chips with family meal frequency and TV viewing during family meals. RESULTS: Children who consumed breakfast, lunch, or dinner with their family at least 4 days per week ate fruit and vegetables 5 or more times a week 84%, 85%, and 80%, respectively. Of those children who ate breakfast, lunch, or dinner with their family at least 4 days per week, 40%, 44%, and 43% consumed soda and chips 5 or more times a week, respectively. Children who ate breakfast with their families at least 4 times a week were more likely to consume fruit and vegetables, and children whose TV was never or rarely on during family meals were less likely to consume soda and chips (P = .04 and P < .001, respectively). CONCLUSIONS: Interventions geared at increasing the frequency of eating breakfast as a family and decreasing the amount of TV watched during family meals are needed, especially among acculturating Latino families.

Missed and missing cases of abusive injuries: the magnitude and the measurement of the problem.

OBJECTIVE: The authors' objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children. METHOD: Determination, comparison, and explanation of the case-fatality-rate disparity in four injury databases were derived from hospitalized injury cases. RESULTS: The CFR disparity is 6-14-fold in the 4 injury databases. The CFR disparity varies strongly and inversely with the observed incidence of inflicted injuries in the databases. CONCLUSIONS: A large disparity between the case fatality rates (CFRs) of inflicted and unintentional injuries exists in a number of injury databases. Inflicted injuries have much higher CFRs than unintentional injuries. The disparity can be accounted for by "missed" (incorrectly diagnosed) and "missing" (unseen) cases. PRACTICE IMPLICATIONS: Present diagnostic criteria for physically abusive (inflicted) injuries are forensically-driven and too conservative for public health purposes. New public-health-oriented case definitions for "inflicted injury" are needed. Programs to reduce injury recidivism in young children should be a part of overall injury prevention.

Prevalence and psychological correlates of traumatic brain injury in operation iraqi freedom.

OBJECTIVE: To describe the prevalence and psychological correlates of traumatic brain injury (TBI) among injured male combatants in the Iraq conflict. PARTICIPANTS: A total of 781 men injured during military combat between September 2004 and February 2005. MAIN OUTCOME MEASURES: Mental health diagnosis (ICD-9 290-319), particularly posttraumatic stress disorder and mood/anxiety disorders, assigned through November 2006. RESULTS: 15.8% met criteria for TBI (13.4% mild, 2.4% moderate-severe TBI), 35.0% other head injury, and 49.2% non-head injury. Multivariate logistic regression suggested lower rates of posttraumatic stress disorder and mood/anxiety disorders among those with mild and moderate-severe TBI. CONCLUSIONS: These findings could reflect a problem with differential diagnosis or, conversely, a low rate of self-presentation for symptoms. Further research is needed to elucidate the psychological consequences, clinical implications, and overall impact of TBI among military combat veterans.

Injury-specific predictors of posttraumatic stress disorder.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is an important source of morbidity in military personnel, but its relationship with characteristics of battle injury has not been well defined. The aim of this study was to characterise the relationship between injury-related factors and PTSD among a population of battle injuries. PATIENTS AND METHODS: A total of 831 American military personnel injured during combat between September 2004 and February 2005 composed the study population. Patients were followed through November 2006 for diagnosis of PTSD (ICD-9 309.81) or any mental health outcome (ICD-9 290-319). RESULTS: During the follow-up period, 31.3% of patients received any type of mental health diagnosis and 17.0% received a PTSD diagnosis. Compared with minor injuries those with moderate (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.61-3.48), serious (OR, 4.07; 95% CI, 2.55-6.50), and severe (OR, 5.22; 95% CI, 2.74-9.96) injuries were at greater risk of being diagnosed with any mental health outcome. Similar results were found for serious (OR, 3.03; 95% CI, 1.81-5.08) and severe (OR, 3.21; 95% CI, 1.62-6.33) injuries with PTSD diagnosis. Those with gunshot wounds were at greater risk of any mental health diagnosis, but not PTSD, in comparison with other mechanisms of injury (OR 2.07; 95% CI, 1.35, 3.19). Diastolic blood pressure measured postinjury was associated with any mental health outcome, and the effect was modified by injury severity. CONCLUSIONS: Injury severity was a significant predictor of any mental health diagnosis and PTSD diagnosis. Gunshot wounds and diastolic blood pressure were significant predictors of any mental health diagnosis, but not PTSD. Further studies are needed to replicate these results and elucidate potential mechanisms for these associations.

Psychological correlates of battle and nonbattle injury among Operation Iraqi Freedom veterans.

Limited research exists on the relationship between physical injury and PTSD within military populations. The present study assessed postinjury rates of PTSD and other psychological correlates among battle and non-battle injuries. A total of 1,968 men (831 battle injuries and 1,137 nonbattle injuries) injured between September 2004 and February 2005 during Operation Iraqi Freedom (OIF) composed the study sample. Patients were followed through November 2006 for mental health diagnosis (ICD-9 290-319). Compared with nonbattle injuries, those with battle injuries had a greater risk of PTSD and other mental health diagnosis, and there was a positive association with injury severity. Self-reported mental health symptoms were significantly higher for both minor and moderate-severe battle injury in comparison to nonbattle injury and previous population estimates from an earlier OIF period. More research is needed to further define this relationship by examining potential mechanisms and addressing the possible contributing effect of combat exposure.

Comparison of overall obesity and body fat distribution in predicting risk of mortality.

Results of studies comparing overall obesity and abdominal adiposity or body fat distribution with risk of mortality have varied considerably. We compared the relative importance and joint association of overall obesity and body fat distribution in predicting risk of mortality. Participants included 5,799 men and 6,429 women aged 30-102 years enrolled in the third National Health and Nutrition Examination Survey who completed a baseline health examination during 1988-1994. During a 12-year follow-up (102,172 person-years), 1,188 men and 925 women died. In multivariable-adjusted analyses, waist-to-thigh ratio (WTR) in both sexes (Ptrend<0.01 for both) and waist-to-hip ratio (WHR) in women (Ptrend 0.001) were positively associated with mortality in middle-aged adults (30-64 years), while BMI and waist circumference (WC) exhibited U- or J-shaped associations. Risk of mortality increased with a higher WHR and WTR among normal weight (BMI 18.5-24.9 kg/m2) and obese (BMI>or=30.0 kg/m2) adults. In older adults (65-102 years), a higher BMI in both sexes (Ptrend<0.05) and WC in men (Ptrend 0.001) were associated with increased survival, while remaining measures of body fat distribution exhibited either no association or an inverse relation with mortality. In conclusion, ratio measures of body fat distribution are strongly and positively associated with mortality and offer additional prognostic information beyond BMI and WC in middle-aged adults. A higher BMI in both sexes and WC in men were associated with increased survival in older adults, while a higher WHR or WTR either decreased or did not influence risk of death.

Overall obesity and abdominal adiposity as predictors of mortality in u.s. White and black adults.

PURPOSE: The association of overall obesity and abdominal adiposity in predicting risk of all-cause mortality in white and black adults was compared. METHODS: This prospective study included a national sample of 3219 non-Hispanic white and 2,561 non-Hispanic black adults 30 to 64 years of age enrolled in the third National Health and Nutrition Examination Survey during 1988-1994. Multiple measures of adiposity were measured and calculated, including body mass index (BMI), waist circumference, waist-to-hip ratio (WHR), and waist-to-thigh ratio (WTR). Vital status was ascertained with the National Death Index through 2000. RESULTS: During 12 years of follow-up (51,133 person-years), 188 white and 222 black adults died. After adjustment for age, education, smoking, and existing disease, positive dose-response associations between WTR and mortality in both sexes and races, and WHR in white and black women were observed (p(trend) < 0.05 for all). These results were unchanged after additional adjustment for BMI. In contrast, BMI and waist circumference alone exhibited curvilinear-shaped associations with mortality. A higher WTR was associated with a higher risk of mortality among normal weight (BMI: 18.5-24.9 kg/m(2)) and obese (BMI: > or =30.0 kg/m(2)) white and black adults. CONCLUSIONS: These results suggest ratio measures of abdominal adiposity, particularly WTR in both sexes and WHR in women, strongly and positively predict mortality, independent of BMI, among white and black adults. Furthermore, WTR offers additional prognostic information beyond that provided by BMI alone.

The relation of leptin and insulin with obesity-related cardiovascular risk factors in US adults.

Previous studies of leptin with cardiovascular disease (CVD) risk factors have been limited by clinical samples or lack of representation of the general population. This cross-sectional study, designed to examine whether leptin or insulin may mediate the endogenous relation of obesity with metabolic, inflammatory, and thrombogenic cardiovascular risk factors, included 522 men and 514 women aged >or=40 years who completed a physical examination during the third National Health and Nutrition Examination Survey. Participants were free of existing CVD, cancer (except non-melanoma skin cancer), diabetes, or respiratory disease. In multivariable analyses adjusted for race/ethnicity and lifestyle factors, waist circumference (WC) was positively associated with blood pressure, triglyceride, LDL cholesterol, total cholesterol:HDL ratio, apolipoprotein B, C-reactive protein (CRP), and fibrinogen concentrations, and negatively associated with HDL cholesterol and apolipoprotein A1 levels. The associations of WC with the metabolic CVD risk factors were largely attenuated after adjustment for insulin levels, while the associations of WC with the inflammatory and thrombogenic factors (CRP and fibrinogen, respectively) were largely explained by adjustment for leptin concentrations. However, leptin levels were not independently associated with CRP and fibrinogen in men and CRP in women when adjusted for WC. Positive associations of leptin and insulin with fibrinogen in women, independent of WC, were noted. These results suggest that insulin may be an important mediator of the association of obesity with metabolic but not inflammatory or thrombogenic CVD risk factors, while leptin does not appear to influence cardiovascular risk through a shared association with these risk factors. However, we cannot rule out the possibility that leptin and insulin influence cardiovascular risk in women through independent effects on fibrinogen concentrations.

Impact of the San Diego Serial Inebriate Program on use of emergency medical resources.

STUDY OBJECTIVE: We determine the impact of a treatment strategy called the San Diego Serial Inebriate Program on the use of emergency medical services (EMS) and emergency department (ED) and inpatient services by individuals repeatedly arrested for public intoxication. METHODS: This was a retrospective review of health care utilization records (EMS, ED, and inpatient) of 529 individuals from 2000 to 2003. Judges offered individuals a 6-month outpatient treatment program in lieu of custody (Serial Inebriate Program). Demographics and health care utilization are reported overall and by treatment acceptance. RESULTS: From 2000 to 2003, 308 of 529 (58%) individuals were transported by EMS 2,335 times; 409 of 529 (77%) individuals amassed 3,318 ED visits, and 217 of 529 (41%) individuals required 652 admissions, resulting in 3,361 inpatient days. Health care charges totaled $17.7 million (EMS, $1.3 million; ED, $2.5 million; and inpatient, $13.9 million). Treatment was offered to 268 individuals, and 156 (58%) accepted. Use of EMS, ED, and inpatient services declined by 50% for clients who chose treatment, resulting in an estimated decrease in total monthly average charges of $5,662 (EMS), $12,006 (ED), and $55,684 (inpatient). There was no change in use of services for individuals who refused treatment. There was a significant increasing trend in acceptance among individuals with longer jail sentences (<0.001). Treatment acceptance was 20% among those with sentences of 0 to 30 days and reached 63% for those with sentences longer than 150 days. Operational costs and alternate care at clinics and nonparticipating hospitals were not analyzed. CONCLUSION: This community-supported treatment strategy reduced the use of EMS, ED, and inpatient resources by individuals repeatedly intoxicated in public.

Pragmatic strategies that enhance the reliability of data abstracted from medical records.

The processes and procedures used to promote interrater reliability in the abstraction of data from medical records are described. Several proactive strategies that serve the purpose of leading to standard interpretations of clinical data are discussed. These include (a) establishment of priorities for the sources of information; (b) creation of orders of value for the likeliness of validity of recorded data; (c) standardization of terminology; and (d) reaffirmation of decisions, based on an evolving body of evidence. Lessons learned from this project can assist nurse researchers to develop high-quality information retrieval methods, when multiple observers (or abstractors) are used during a medical record abstraction data collection process.

Lower rates of low birthweight and preterm births in the California Black Infant Health Program.

OBJECTIVES: The objective of this study was to determine the impact of prenatal interventions in the California Black Infant Health (BIH) Program on low birthweight (LBW) and preterm births (PTB) outcomes. METHODS: A prospective observational study design with a comparison group was used. BIH participants with a delivery recorded between July 1996 and September 1998 were included in the birthweight and PTB analyses. These outcomes for BIH participants who entered the BIH program prior to 32 weeks' gestation (n=1,553) were compared to those of all African-American women in the BIH Program targeted ZIP codes (n=11,633). RESULTS: No statistically significant differences in LBW and PTB were found between the BIH population and the comparison group. However, a comparison of the BIH infant VLBW (<1,500 g) rate (1.9%) with the VLBW rate for the comparison group (3.0%) shows that the BIH rate is 63% of the comparison group rate. For very PTB (<32 weeks), the BIH rate (3.5%) is 81% of the comparison group rate (4.3%). BIH participants had higher risk profiles (pregnancy history, current pregnancy, and psychosocial; p=<0.01) than women in the comparison group. CONCLUSIONS: The BIH Program retained high-risk women in the program to delivery and assisted them with maintenance of prenatal care. Even though the program participants were higher risk, their LBW and PTB outcomes were comparable to the geographic area overall. More importantly, there was a trend among women in the BIH Program toward better outcomes than the comparison group in both VLBW and VPTB.

Four-year review of the use of race and ethnicity in epidemiologic and public health research.

To determine how current researchers address the use of race and ethnicity as variables in epidemiologic and public health studies, the authors conducted a comprehensive review of 1,198 articles published in the American Journal of Epidemiology and the American Journal of Public Health from 1996 to 1999. Seventy-seven percent (n = 919) of the articles referred to race or ethnicity. The number of variable categories ranged from 0 to 24, with an average of 3.14 per article. An enormous diversity of terms was used to describe the concepts of race and ethnicity as variables as well as to describe the categories used to assess these variables. Researchers frequently failed to differentiate between the concepts of race and ethnicity, to state the context in which these variables were used, to state the study methods used to assess these variables, and to discuss significant study results based on race or ethnicity. Continued professional commitment is needed to ensure the scientific integrity of race and ethnicity as variables. At a minimum, researchers should clearly state the context in which these valuable epidemiologic and public health study variables are being used, describe the method used to assess and categorize these variables, and discuss all significant findings.