Consequences of Undervaccination - Measles Outbreak, New York City, 2018-2019.

BACKGROUND: Measles was declared eliminated in the United States in 2000, but the risk of outbreaks owing to international importations remains. An outbreak of measles in New York City began when one unvaccinated child returned home from Israel with measles; onset of rash occurred on September 30, 2018, 9 days after the child returned home. METHODS: We investigated suspected cases of measles by conducting interviews, reviewing medical and immunization records, identifying exposed persons, and performing diagnostic testing. Measles-mumps-rubella (MMR) vaccine (given as either MMR or measles-mumps-rubella-varicella vaccine and collectively referred to as MMR vaccine) uptake was monitored with the use of the Citywide Immunization Registry. The total direct cost to the New York City Department of Health and Mental Hygiene was calculated. RESULTS: A total of 649 cases of measles were confirmed, with onsets of rash occurring between September 30, 2018, and July 15, 2019. A majority of the patients (93.4%) were part of the Orthodox Jewish community, and 473 of the patients (72.9%) resided in the Williamsburg area of Brooklyn, New York. The median age was 3 years; 81.2% of the patients were 18 years of age or younger, and 85.8% of the patients with a known vaccination history were unvaccinated. Serious complications included pneumonia (in 37 patients [5.7%]) and hospitalization (in 49 patients [7.6%]); among the patients who were hospitalized, 20 (40.8%) were admitted to an intensive care unit. As a result of efforts to promote vaccination, the percentage of children in Williamsburg who received at least one dose of MMR vaccine increased from 79.5% to 91.1% among children 12 to 59 months of age. As of September 9, 2019, a total of 559 staff members at the Department of Health and Mental Hygiene (7% of the agency) had been involved in the measles response. The cost of the Department of Health and Mental Hygiene response was $8.4 million. CONCLUSIONS: Importation of measles and vaccination delays among young children led to an outbreak of measles in New York City. The outbreak response was resource intensive and caused serious illness, particularly among unvaccinated children.

Myocardial tissue salvage is correlated with ischemic border region temperature at reperfusion.

OBJECTIVES: Our pilot study investigated the association between region-specific myocardial tissue temperature and tissue salvage using a novel tri-lumen cooling catheter to provide rapid localized cooling directly to the heart in an open-chest porcine model of ischemia-reperfusion. BACKGROUND: Therapeutic hypothermia remains a promising strategy to limit reperfusion injury following myocardial ischemia. METHODS: Large swine underwent 60 min of coronary occlusion followed by 3 hr of reperfusion. Prior to inducing ischemia, six temperature probes were placed directly on the heart, monitoring myocardial temperatures in different locations. Hemodynamic parameters and core temperature were also collected. Approximately 15 min prior to reperfusion, the cooling catheter was inserted via femoral artery and the distal tip advanced proximal to the occluded coronary vessel under fluoroscopic guidance. Autologous blood was pulled from the animal via femoral sheath and delivered through the central lumen of the cooling catheter, delivering at 50 ml/min, 27°C at the distal tip. Cooling was continued for an additional 25 min after reperfusion followed by a 5-min controlled rewarming. Hearts were excised and assessed for infarct size per area at risk. RESULTS: Although cooling catheter performance was consistent throughout the study (38 W), the resulting tissue cooling was not. Our results show a correlation between myocardial tissue salvage and ischemic border region (IBR) temperature at the time of reperfusion (R2 = 0.59, p = 0.027). IBR tissue is the tissue located at the boundary between healthy and ischemic tissues. CONCLUSIONS: Our findings suggest that localized, rapid, short-term myocardial tissue cooling has the potential to limit reperfusion injury in humans.

The Legacy of 1987 Boreali v. Axelrod: Board of Health Rule-Making Under Siege.

We explore how a 1987 New York State court decision-Boreali v. Axelrod-affected public health rule-making nationally and, with considerable impact, locally in New York City (NYC).We discuss the history of the origin of the NYC Board of Health (BOH), and establish that legislatures can be challenging venues in which to enact public health-related laws. We describe how, as the NYC Department of Health and Mental Hygiene began to tackle modern public health problems (e.g., chronic diseases caused by food and tobacco), the regulatory power of its BOH was challenged.In an era when industry funds political causes and candidates, the weakening of the independence of rule-making boards of health, such as the NYC BOH, might result in illness and death.

New York City's window guard policy: four decades of success.

BACKGROUND: Preventing child falls from windows is easily accomplished by installing inexpensive window-limiting devices but window falls remain a common cause of child injuries. This article describes the history and evolution of the New York City (NYC) window guard rule,which requires building owners to install window guards in apartments housing children aged ≤10 years. The NYC window guard rule was the first directive of its kind in the USA when it was adopted in 1976, and it has led to a dramatic and long-lasting reduction in child window fall-related injuries and deaths. METHODS: Data about the history of the window guard rule were obtained by reviewing programmatic records, correspondence, legal decisions and the published literature. In addition, key informant interviews were conducted with programme staff. RESULTS AND DISCUSSION: This article describes each stage of policy development, starting with epidemiological studies defining the scope of the problem in the 1960s and pilot-testing of the window guard intervention. We describe the adoption, implementation and enforcement of the rule. In addition, we show how the rule was modified over time and document the rule's impact on window fall incidence in NYC. We describe litigation that challenged the rule's constitutionality and discuss the legal arguments used by opponents of the rule. Finally, we discuss criminal and tort liability as drivers of compliance and summarise lessons learnt.

Assessing Provider Partnerships For Accountable Care Organizations.

PURPOSE: Understand current provider approaches to the evaluation of various partnerships under accountable care contracts and create a framework to help accountable care organizations (ACOs) better assess their partnerships. DESIGN: Study included (1) an in-depth literature review of materials describing high-value health care organizations as a foundation for draft framework development, (2) an expert panel convened to evaluate the framework and help prioritize provider types to evaluate, and (3) interviews with representatives of ACOs and entities representing various types of health care providers. METHODOLOGY: Authors created a draft partnership framework derived from the literature review for expert panel feedback. An updated draft framework was then shared with active ACO leaders prior to qualitative interviews. All interviews were transcribed and coded using a mixed-methods analysis platform. RESULTS: We found little research that took a comprehensive view of health care provider competencies and characteristics and by extension few resources to help ACOs fill competency gaps through partnerships. The ACOs interviewed were all actively engaged in provider partnerships and were learning and establishing best practices for provider partnerships. CONCLUSIONS: Accountable care offers incentives for entities to improve the cost and quality of health care. To accomplish this in an effective way, ACOs must recognize the needs of their assigned populations and work to provide comprehensive care management across the spectrum of provider types. Accomplishing this will also require ACOs to create novel partnership arrangements and learn how to manage populations most effectively. ACOs need a framework for evaluating potential partners that will help risk-bearing providers establish the partnerships that will enable them to achieve their goals. This paper makes specific recommendations on how state and federal policy could facilitate better and more effective provider partnerships.

Selective brain cooling with a novel catheter reduces infarct growth after recanalization in a canine large vessel occlusion model.

BACKGROUND: Therapeutic hypothermia has shown potential in cardiac intervention for years; however, its adoption into the neurovascular space has been limited. Studies have pointed to slow cooling and limited depth of hypothermia yielding negative outcomes. Here we present an insulated catheter that allows for consistent infusion of chilled saline directly to the brain. Direct delivery of cold saline allows a faster depth of hypothermia, which could have a benefit to the growth of ischemic lesions. METHODS: Ten canines were randomized to either receive selective brain cooling or no additional therapy. Eight animals were successfully enrolled (n = 4 per group). Each animal underwent a temporary middle cerebral artery occlusion (MCAO) for a total of 45 min. Five minutes prior to flow restoration, chilled saline was injected through the ipsilateral internal carotid artery using an insulated catheter to ensure delivery temperature. The treatment continued for 20 min, after which the animal was transferred to an MRI scanner for imaging. RESULTS: Of the 8 animals that were successfully enrolled in the study, 3 were able to survive to the 30-day endpoint with no differences between the cooled and control animals. There was no difference in the initial mean infarct size between the groups; however, animals that did not receive cooling had infarcts continuing to progress more rapidly after the MCAO was removed (13.8% vs 161.3%, p = 0.016, cooled vs control). CONCLUSIONS: Selective hypothermia was able to reduce the post-MCAO infarct progression in a canine model of temporary MCAO.

25 Years Ago in the JBPA/JBP.

In this column, we look back at the content and imagery found in the Journal of the Biological Photographic Association (JBPA), later renamed the Journal of Biological Photography (JBP). This column examines important articles from 25 years ago. In doing so, we gain some insight into those legacy photography techniques of that time.

25 Years Ago in the JBPA/JBP.

In this column, we look back at the content and imagery found in the Journal of the Biological Photographic Association (JBPA), later renamed the Journal of Biological Photography (JBP). This column examines important articles and imagery from 25 years ago. In doing so, we gain some insight into those legacy photographic tools and techniques of that time.

25 Years Ago in the JBPA/JBP.

In this column, we look back at the content and imagery found in the Journal of the Biological Photographic Association (JBPA, later renamed the Journal of Biological Photography (JBP). This column explores important articles from 25 years ago. In doing so, we gain some insight into those legacy photography techniques of that time.

Focal cooling of brain parenchyma in a transient large vessel occlusion model: proof-of-concept.

INTRODUCTION: The neuroprotective benefit of therapeutic hypothermia (TH) has been demonstrated, but systemic side effects and time required to achieve effective TH in acute ischemic stroke (AIS) care limits clinical use. We investigate rapid and localized cooling using a novel insulated catheter in an ischemia-reperfusion model. METHODS: In phase I (n=4), cold saline was delivered to the canine internal carotid artery via an insulated catheter. Temperature was measured using intracerebral thermocouples. The coolant flow rate was varied to meet a target temperature of 31-32°C in the hemisphere infused. In phase II (n=8), a temporary middle cerebral artery occlusion was created. Five dogs underwent localized TH at the optimal flow rate from phase I, and the remaining animals were untreated controls. Cooling was initiated 5 min before recanalization and continued for an additional 20 min following 45 min of occlusion duration. The outcome was infarct volume and neurological function. RESULTS: Ipsilateral tissue cooling rates were 2.2±2.5°C/min at a flow rate of 20-40 mL/min with an observed minimum of 23.8°C. Tissue cooling was localized to the ipsilateral side of the infusion with little impact on temperatures of the core or contralateral hemisphere of the brain. In phase II, animals tolerated TH with minimal systemic impact. Infarct volume in treated animals was 0.2±0.2 cm3, which was smaller than in sham animals (3.8±1.0 cm3) as well as six untreated historical control animals (4.0±2.8 cm3) (p=0.013). CONCLUSIONS: Proof-of-concept data show that localised brain TH can be quickly and safely achieved through a novel insulated catheter. The small infarct volumes suggest potential benefit for this approach.

25 Years Ago in the JBPA/JBP.

In this column, we look back at the content and imagery found in the Journal of the Biological Photographic Association (JBPA), later renamed the Journal of Biological Photography (JBP). This column examines important articles from 25 years ago. In doing so, we gain some insight into those legacy photography techniques of that time.

Novel use of syndromic surveillance to monitor the impact of synthetic cannabinoid control measures on morbidity.

BACKGROUND: Using data from syndromic surveillance, the New York City Department of Health and Mental Hygiene (DOHMH) identified an increase in the number of emergency department (ED) visits related to synthetic cannabinoids. Syndromic surveillance data were used to target community-level interventions and assess the real-time impact of control measures in reducing synthetic cannabinoid ("K2")-related morbidity. METHODS: From April 2015 through September 2015, DOHMH implemented 3 separate interventions to reduce K2-related morbidity by limiting the availability of K2 products. Difference-in-difference analyses compared pre- and post-intervention differences in cannabinoid-related ED visit rates between neighborhoods and controls for Interventions A and B. City-wide count data were used to compare K2-related ED visits before and after Intervention C. RESULTS: Syndromic data showed a reduction in K2-related ED visits following the 3 interventions. Respective decreases in rates of synthetic cannabinoid-related ED visits of 33 and 38% were detected at the neighborhood-level due to Interventions A and B, respectively. A decrease of 29% was calculated at the city level following Intervention C. CONCLUSIONS: In addition to identifying emerging public health concerns, syndromic data can provide valuable real-time evidence on the effectiveness of public health interventions.

Infusion warm during selective hypothermia in acute ischemic stroke.

INTRODUCTION: Mechanical thrombectomy (MT) has dramatically improved the prognosis for acute ischemic stroke (AIS) patients. Despite high recanalization rates, up to half of the patients will not present a good neurological outcome after MT. Therapeutic hypothermia is perhaps the most robust neuroprotectant studied preclinically. MATERIALS AND METHODS: We explored various warming effects that can reduce the effectiveness or potency of selective hypothermia during AIS under conditions similar to actual clinical care. Four different selective hypothermia layouts were chosen. Layouts 1 and 2 used a single catheter without and with an insulated IV bag. Layouts 3 and 4 used two catheters arrange coaxially, without and with an insulated IV bag. Independent variables measured were IV bag exit temperature, catheter inlet temperature, and catheter outlet temperature at four different flow rates ranging from 8 to 25 ml/min over an infusion duration of 20 min. RESULTS: Dominant warming occurs along the catheter pathway compared to warming along the infusion line pathway, ranging from 66% to 72%. Coaxial configurations provided an approximate 4°C cooler temperature benefit on delivered infusate over a single catheter. Brain tissue temperature predictions show that the maximum cooling layout, Layout 4 at maximum flow provides a 1°C within 5 min. CONCLUSION: Significant rewarming effects occur along the infusate flow path from IV bag to site of injury in the brain. Previous selective hypothermia clinical work, using flow rates and equipment at conditions similar to our study, likely produced rapid but not deep tissue cooling in the brain (~ 1°C).

Patient-centered care innovations by accountable care organizations: Lessons from leaders.

Although there is a widespread belief that ACOs must be patient-centered to be successful, evidence to guide them in achieving that goal has been lacking. This case report examines four ACO innovators in patient-centered care that together represent urban, suburban and rural populations with a broad range of economic, racial, ethnic and geographic diversity. Seven patient-centeredness strategies emerged: transform primary care practices into patient-centered medical homes; move upstream to address social and economic issues; use both high-tech and high-touch to identify and engage high-risk patients; practice a whole-person orientation; optimize patient-reported measures; treat patients like valued customers; and incorporate patient voices into governance and operations. Exemplars prioritized direct care interventions perceived as central to financial and clinical success, and organizational maturity played a role. Activities that decreased the traditional system's authority, such as incorporating patient voices, were less popular. Local practice factors were important, and a mixture of mission and margin energized front-line staff in implementing patient-centered care as "the right thing to do." Unresolved questions remain that are related to the impact of individual and multiple interventions and how successful interventions can be disseminated widely. In order for patient-centeredness innovations to enable transformation, providers, payers and policymakers alike must consciously adopt strategies that nurture it.

25 Years Ago in the JBPA/JBP.

In this column, we look back at the content and imagery found in the Journal of the Biological Photographic Association (JBPA), later renamed the Journal of Biological Photography (JBP). This column examines important articles from 25 years ago. In doing so, we gain some insight into those legacy photography techniques of that time.

Hospital participation in ACOs associated with other value-based program improvement.

OBJECTIVES: This paper analyzes whether hospital participation in an accountable care organization (ACO) impacts a hospital's quality improvement and cost reduction outcomes in other value-based purchasing (VBP) programs, including the Hospital Value-Based Purchasing Program (HVBP), the Hospital Readmissions Reduction Program (HRRP), and the Hospital-Acquired Conditions (HAC) Reduction Program. STUDY DESIGN: Using VBP performance data and Leavitt Partners' ACO data, 2 analyses were performed: 1) a descriptive comparison of VBP performance of hospital ACOs compared with non-ACO hospitals, and 2) a longitudinal analysis of hospitals that became part of an ACO during the second year of performance data. METHODS: In the descriptive analysis, we compared VBP scores for hospital ACOs with non-ACO hospitals. To estimate the effect that becoming an ACO had on a hospital, we evaluated the performance of hospitals that became part of an ACO to all hospitals that never became part of an ACO. RESULTS: For fiscal year 2016, hospital ACOs performed better than non-ACO hospitals for the HRRP, but not on the HVBP and the HAC Reduction Programs. Longitudinal analysis, however, reveals that results are varied, with evidence that hospitals joining ACOs did increasingly better than their peers for the HRRP, but had inconsistent results year-over-year with the HVBP. CONCLUSIONS: Despite similar goals, hospital participation in an ACO is not correlated with improved performance in all Medicare VBP programs. Organizations pursuing accountable care and also attempting to maximize Medicare VBP program performance must recognize the differences in program objectives and create strategies unique to each.

Heat transfer analysis of catheters used for localized tissue cooling to attenuate reperfusion injury.

Recent revascularization success for ischemic stroke patients using stentrievers has created a new opportunity for therapeutic hypothermia. By using short term localized tissue cooling interventional catheters can be used to reduce reperfusion injury and improve neurological outcomes. Using experimental testing and a well-established heat exchanger design approach, the ɛ-NTU method, this paper examines the cooling performance of commercially available catheters as function of four practical parameters: (1) infusion flow rate, (2) catheter location in the body, (3) catheter configuration and design, and (4) cooling approach. While saline batch cooling outperformed closed-loop autologous blood cooling at all equivalent flow rates in terms of lower delivered temperatures and cooling capacity, hemodilution, systemic and local, remains a concern. For clinicians and engineers this paper provides insights for the selection, design, and operation of commercially available catheters used for localized tissue cooling.