A case report: Multaq-induced leukocytoclastic vasculitis.

A 71-year-old white male presented to the emergency department complaining of a worsening lower extremity rash. Thirteen days before presentation, the patient was placed on Multaq (dronedarone) for his paroxysmal atrial fibrillation. Biopsy-proven leukocytoclastic vasculitis (LV) was diagnosed, and causes for the condition other than drug-induced were investigated and ruled out. Rash has been cited as a possible side effect of Multaq; however, a literature search has revealed this to be the first documented case of likely multaq-induced LV. Other patients on Multaq therapy should be monitored for signs and symptoms of LV and be referred to an acute care setting as indicated.

Review of historical unusual mortality events (UMEs) in the Gulf of Mexico (1990-2009): providing context for the multi-year northern Gulf of Mexico cetacean UME declared in 2010.

An unusual mortality event (UME) was declared for cetaceans in the northern Gulf of Mexico (GoM) for Franklin County, Florida, west through Louisiana, USA, beginning in February 2010 and was ongoing as of September 2014. The 'Deepwater Horizon' (DWH) oil spill began on 20 April 2010 in the GoM, raising questions regarding the potential role of the oil spill in the UME. The present study reviews cetacean mortality events that occurred in the GoM prior to 2010 (n = 11), including causes, durations, and some specific test results, to provide a historical context for the current event. The average duration of GoM cetacean UMEs prior to 2010 was 6 mo, and the longest was 17 mo (2005-2006). The highest number of cetacean mortalities recorded during a previous GoM event was 344 (in 1990). In most previous events, dolphin morbillivirus or brevetoxicosis was confirmed or suspected as a causal factor. In contrast, the current northern GoM UME has lasted more than 48 mo and has had more than 1000 reported mortalities within the currently defined spatial and temporal boundaries of the event. Initial results from the current UME do not support either morbillivirus or brevetoxin as primary causes of this event. This review is the first summary of cetacean UMEs in the GoM and provides evidence that the most common causes of previous UMEs are unlikely to be associated with the current UME.

Designing competencies for chronic disease practice.

INTRODUCTION: Competencies are the cornerstone of effective public health practice, and practice specialties require competencies specific to their work. Although more than 30 specialty competency sets have been developed, a particular need remained to define competencies required of professionals who practice chronic disease prevention and control. To that end, the National Association of Chronic Disease Directors (NACDD) engaged a group of stakeholders in developing competencies for chronic disease practice. METHODS: Concept mapping was blended with document analysis of existing competencies in public health to develop a unique framework. Public health experts reviewed the results, providing extensive and richer understanding of the issues. RESULTS: The final product presents an integrated picture that highlights interrelationships among the specific skills and knowledge required for leading and managing state chronic disease programs. Those competencies fall into 7 clusters: 1) lead strategically, 2) manage people, 3) manage programs and resources, 4) design and evaluate programs, 5) use public health science, 6) influence policies and systems change, and 7) build support. CONCLUSION: The project yielded a framework with a categorization scheme and language that reflects how chronic disease practitioners view their work, including integrating communications and cultural competency skills into relevant job functions. Influencing policies and systems change has distinct relevance to chronic disease practice. We suggest uses of the competencies in the field.

End of life is a public health issue.

Public health activities to prevent and control disease have produced an extraordinary decline in mortality rates during the last century. This phenomenon has widespread implications, not the least of which is that death often occurs at a later age and frequently after a protracted illness. With a prolonged death due to technological advances now common in developed countries, quality of life at the end of life has become a societal concern. It is logical that public health should embrace the end of life as an area worthy of study and intervention. After all, the end of life has three characteristics of other public health priorities: high burden, major impact, and a potential for preventing the suffering associated with illness. In this paper, we propose three initial roles for the public health profession and a process for developing a public health agenda for the end of life.

Changes in health behaviors among older Americans, 1990 to 2000.

OBJECTIVES: The authors used a large population-based survey to examine changes from 1990 to 2000 in age distribution by sex and race or ethnicity, to estimate both state-specific and national trends in the proportion of older Americans, and to examine changes in risk factors and quality-of-life indicators among those Americans. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS), a cross-sectional telephone survey of adults aged > or =18 years. BRFSS data were analyzed for the District of Columbia and all states that participated from 1990 to 2000. SAS and SUDAAN were used in the analyses to account for the complex sampling design. RESULTS: The percentage of Americans aged > or =75 years increased 23.0% from 1990 to 2000, with the magnitude of the increase varying by state. In 2000, Florida had the highest percentage of persons aged > or =75 (10.27%) and Alaska the lowest (3.49%). Compared with 1990, older Americans in 2000 were more likely to be obese (16.3% vs. 13.5%) or diabetic (14.3% vs. 11.0%). Older Americans in 2000 were also more likely to exercise, consume more fruits and vegetables daily, and to have recently obtained a routine medical checkup. In addition, they were less likely to smoke tobacco or drink any alcohol. CONCLUSIONS: Increases in the population of older people will have a tremendous impact on health care in the states and will affect their future plans for serving the elderly. Although older Americans are living more healthfully than previously, there is an enormous need for targeted health promotion programs to prevent chronic diseases in this age group.

Population aging and implications for epidemic cardiovascular disease in Sub-Saharan Africa.

Within the clinical and public health communities, it is often unnoticed that the developing world is experiencing an aging population with its attendant increase in the burden of chronic, noncommunicable diseases. From July 1999 to July 2000, 77% of the world's net gain in elderly persons occurred in developing countries. In Sub-Saharan Africa alone, the number of persons aged 65 years and older is expected to increase by 50% in 2015, from 19.3 million to 28.9 million. This demographic change has profound implications for developing countries that already shoulder a huge burden of communicable diseases, especially the HIV/AIDS epidemic, and continue to be challenged by basic infrastructure needs and economic development. In the 30-year period from 2000 to 2030, the population of elderly persons is projected to double in many Sub-Saharan African countries including the Democratic Republic of Congo, Mozambique, Cameroon, and Ghana. The scale and magnitude of these demographic changes are unprecedented. Since advancing age is the most powerful independent predictor of cardiovascular morbidity and mortality, the impact of these demographic changes on heart disease and stroke will be substantial. Aggressive efforts in promoting healthy aging and the prevention of cardiovascular risk factors will be crucial in preventing an impending cardiovascular epidemic in these countries.

An incidentaloma: primitive neuroectodermal tumor of the thymus.

After presenting for a routine screening exam, and 57-year-old man was diagnosed with an incidentaloma-a primitive neuroectodermal tumor (PNET) of the thymus. A member of the Ewing sarcoma family of tumors, a PNET is typically regarded as a malignancy of childhood and adolescence, usually occurring in the central nervous system. In the case at hand, our patient had an extremely unusual presentation, given his age and tumor location. Initial presentation is the only predictor for long-term survival. Current treatment recommendations advocate complete surgical resection whenever possible, radiation therapy, and adjuvant versus neoadjuvant chemotherapy.

"Dermatitis" defined.

BACKGROUND: The term "dermatitis" can be defined narrowly or broadly, clinically or histologically. A common and costly condition, dermatitis is underresourced compared to other chronic skin conditions. The lack of a collectively understood definition of dermatitis and its subcategories could be the primary barrier. OBJECTIVE: To investigate how dermatologists define the term "dermatitis" and determine if a consensus on the definition of this term and other related terms exists. METHODS: A seven-question survey of dermatologists nationwide was conducted. RESULTS: Of respondents (n  =  122), half consider dermatitis to be any inflammation of the skin. Nearly half (47.5%) use the term interchangeably with "eczema." Virtually all (> 96%) endorse the subcategory "atopic" under the terms "dermatitis" and "eczema," but the subcategories "contact," "drug hypersensitivity," and "occupational" are more highly endorsed under the term "dermatitis" than under the term "eczema." Over half (55.7%) personally consider "dermatitis" to have a broad meaning, and even more (62.3%) believe that dermatologists as a whole define the term broadly. CONCLUSION: There is a lack of consensus among experts in defining dermatitis, eczema, and their related subcategories.

Consenting to uncertainty: challenges for informed consent to disease screening--a case study.

This paper uses chronic beryllium disease as a case study to explore some of the challenges for decision-making and some of the problems for obtaining meaningful informed consent when the interpretation of screening results is complicated by their probabilistic nature and is clouded by empirical uncertainty. Although avoidance of further beryllium exposure might seem prudent for any individual whose test results suggest heightened disease risk, we will argue that such a clinical precautionary approach is likely to be a mistake. Instead, advice on the interpretation of screening results must focus not on risk per se, but on avoidable risk, and must be carefully tailored to the individual. These points are of importance for individual decision-making, for informed consent, and for occupational health.

A randomized controlled trial of a cognitive-behavioral family intervention for pediatric recurrent abdominal pain.

OBJECTIVE: To investigate whether the combination of standard medical care (SMC) and short-term cognitive-behavioral family treatment (CBT) in the treatment of recurrent abdominal pain (RAP) was more effective than SMC alone. METHODS: Children recently diagnosed with RAP via physician examination were randomized into SMC (n = 29) and SMC plus CBT (n = 40) groups. Outcome measures included multiple dimensions of child and parent reported child pain, somatization, and functional disability, and school absences and physician contacts. RESULTS: Children and parents participating in the combined SMC + CBT intervention reported significantly less child and parent reported child abdominal pain than children in the SMC intervention immediately following the intervention and up to 1 year following study entry, as well as significantly fewer school absences. Significant differences in functional disability and somatization were not revealed. CONCLUSIONS: These results, in combination with previous studies, add support to the effectiveness of CBT intervention in reducing the sensory aspects of RAP. Results are discussed with respect to the cost-benefit of integrated medical and short-term psychological services.

The effects of a National Breast and Cervical Cancer Early Detection Program on social disparities in breast cancer diagnosis and treatment in Massachusetts.

OBJECTIVE: To assess social disparities in breast cancer diagnosis and treatment by comparing the stage at diagnosis and treatment of women diagnosed with breast cancer through a National Breast and Cervical Cancer Early Detection Program (NBCCEDP) for low income and uninsured women in Massachusetts, the Women's Health Network (WHN), to other breast cancer patients in the state. METHODS: We linked data from the WHN and the Massachusetts Cancer Registry (MCR). We compared 331 WHN women and 13,372 other breast cancer patients in Massachusetts diagnosed from 1995 to 1999. We used logistic regression, controlling for age, race/ethnicity, marital status, region of residence, and stage, where appropriate. RESULTS: Compared to other breast cancer patients reported to the MCR, WHN women were just as likely to be diagnosed at an advanced stage (III or IV), treated with surgery, chemotherapy, and hormone therapy, and treated with complete mastectomy versus partial mastectomy. WHN women were less likely to receive radiation therapy (odds ratio = 0.7; 95% confidence interval = 0.6-0.9), particularly after partial mastectomy, and had a slightly longer time from diagnosis to treatment than other breast cancer patients (p < 0.01). CONCLUSIONS: Women diagnosed with breast cancer through a NBCCEDP in Massachusetts had similar stage and treatment patterns as other breast cancer patients in the state, except for the use of radiation therapy.

State trends in uninsurance among individuals aged 18 to 64 years: United States, 1992-2001.

OBJECTIVES: We analyzed state-specific uninsurance trends among US adults aged 18 to 64 years. METHODS: We used logistic regression models to examine Behavioral Risk Factor Surveillance System data for uninsurance from 1992 to 2001 in 47 states. RESULTS: Overall, uninsurance rates increased in 35 states and remained unchanged in 12 states. Increases were observed among people aged 30 to 49 years (in 34 states) and 50 to 64 years (in 24 states), and increases were also observed among individuals at middle and low income levels (in 39 states and 19 states, respectively), individuals employed for wages (in 33 states), and the self-employed (in 18 states). CONCLUSIONS: Among adults aged 18-64, rates of uninsurance increased in most states from 1992 through 2001. Decreased availability of employer-sponsored health insurance, rising health care costs, and state fiscal crises are likely to worsen the growing uninsurance problem.