Nutrient exports from watersheds with varying septic system densities in the North Carolina Piedmont.

Septic systems (SSs) have been shown to be a significant source of nitrogen and phosphorus to nutrient-sensitive coastal surface and groundwaters. However, few published studies have quantified the effects of SSs on nutrient inputs to water supply watersheds in the Piedmont region of the USA. This region consists of rolling hills at the surface underlain by clayey soils. There are nearly 1 million SSs in this region, which accounts for approximately 50% of all SSs in North Carolina. The goal of this study was to determine if significant differences in nutrient concentrations and exports exist between Piedmont watersheds with different densities of SSs. Water quality was assessed in watersheds with SSs (n = 11) and a sewer and a forested watershed, which were designated as controls. Stream flow and environmental readings were recorded and water samples were collected from the watersheds from January 2015-December 2016. Additional samples were collected from sand filter watersheds in April 2015-March 2016 to compare to septic and control watersheds. Samples were analyzed for total dissolved nitrogen (TDN) and orthophosphate (PO4-P). Results indicated that watersheds served by a high-density (HD) of SSs (4.9 kg-N yr-1 ha-1; 0.2 kg-P yr-1 ha-1) exported more than double the median masses of TDN and PO4-P, respectively, relative to low-density (1.0 kg-N yr-1 ha-1; <0.1 kg-P yr-1 ha-1) and control watersheds (1.4 kg-N yr-1 ha-1; <0.1 kg-P yr-1 ha-1) during baseflow. Isotopic analysis indicated that wastewater was the most likely source of nitrate-N in HD watersheds. In all other watersheds, isotopic results suggested non-wastewater sources as the dominant nitrate-N provider. These findings indicated that SS density was a significant factor in the delivery of septic-derived nutrients to these nutrient-sensitive, water supply watersheds of the North Carolina Piedmont.

Modelling interrupted time series to evaluate prevention and control of infection in healthcare.

The most common methods for evaluating interventions to reduce the rate of new Staphylococcus aureus (MRSA) infections in hospitals use segmented regression or interrupted time-series analysis. We describe approaches to evaluating interventions introduced in different healthcare units at different times. We compare fitting a segmented Poisson regression in each hospital unit with pooling the individual estimates by inverse variance. An extension of this approach to accommodate potential heterogeneity allows estimates to be calculated from a single statistical model: a 'stacked' model. It can be used to ascertain whether transmission rates before the intervention have the same slope in all units, whether the immediate impact of the intervention is the same in all units, and whether transmission rates have the same slope after the intervention. The methods are illustrated by analyses of data from a study at a Veterans Affairs hospital. Both approaches yielded consistent results. Where feasible, a model adjusting for the unit effect should be fitted, or if there is heterogeneity, an analysis incorporating a random effect for units may be appropriate.

Exposure of pregnant mice to chromium picolinate results in skeletal defects in their offspring.

BACKGROUND: Chromium(III) picolinate, [Cr(pic)(3)], is a widely marketed dietary supplement. However, Cr(pic)(3) has been associated with oxidative damage to DNA in rats and mutations and DNA fragmentation in cell cultures. In isolated case reports, Cr(pic)(3) supplementation has been said to cause adverse effects, such as anemia, renal failure, liver dysfunction, and neuronal impairment. To date, no studies have been published regarding the safety of chromium picolinate supplementation to a developing fetus, although Cr(pic)(3) has been recommended for pregnant women who are diagnosed with gestational diabetes. METHODS: From gestation days (GD) 6-17, pregnant CD-1 mice were fed diets containing either 200 mg/kg Cr(pic)(3), 200 mg/kg CrCl(3), 174 mg/kg picolinic acid, or the diet only to determine if Cr(pic)(3), CrCl(3), or picolinic acid could cause developmental toxicity. Dams were sacrificed on GD 17, and their litters were examined for adverse effects. RESULTS: The incidence of bifurcated cervical arches was significantly increased in fetuses from the Cr(pic)(3) group as compared to the diet-only group. Fetuses in the picolinic acid-treated group had an incidence double that of the control group; however, this increase was not statistically significant. Fetuses in the CrCl(3) group did not differ from the controls in any variable examined. No maternal toxicity was observed in any of the treatment groups. CONCLUSIONS: High maternal oral exposures to chromium picolinate can cause morphological defects in developing offspring of mice.

Discovery of the short gamma-ray burst GRB 050709.

Gamma-ray bursts (GRBs) fall into two classes: short-hard and long-soft bursts. The latter are now known to have X-ray and optical afterglows, to occur at cosmological distances in star-forming galaxies, and to be associated with the explosion of massive stars. In contrast, the distance scale, the energy scale and the progenitors of the short bursts have remained a mystery. Here we report the discovery of a short-hard burst whose accurate localization has led to follow-up observations that have identified the X-ray afterglow and (for the first time) the optical afterglow of a short-hard burst; this in turn led to the identification of the host galaxy of the burst as a late-type galaxy at z = 0.16 (ref. 10). These results show that at least some short-hard bursts occur at cosmological distances in the outskirts of galaxies, and are likely to be caused by the merging of compact binaries.

Prospective study of etiologic agents of community-acquired pneumonia in patients with HIV infection.

OBJECTIVES: To study prospectively HIV-positive patients admitted to the hospital because of pneumonia by extensive laboratory tests to determine specific microbiologic diagnoses and to establish the best clinical diagnosis after review of all available data by expert clinicians. METHODS: Patients admitted to one of two hospitals had extensive questionnaires completed and defined diagnostic tests performed on blood, sputum, urine and bronchoalveolar lavage specimens, when available. RESULTS: A total of 230 patients had a diagnosis of pneumonia verified. A definite or probable etiologic diagnosis was made in 155 (67%) of these patients. Pneumocystis carinii caused 35% of all cases of pneumonia. Twenty-seven percent of cases of pneumonia with a single etiology had a definite or probable bacterial etiology. 'Atypical agents' were distinctly uncommon. Few clinical or laboratory parameters could differentiate specific etiologies. CONCLUSIONS: P. carinii continues to be a common cause of pneumonia in these patients. The rarity of 'atypical agents' could simplify the empiric approach to therapy. Despite the use of extensive testing we did not find a definite etiology in a large number of cases.

Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States.

From October 4 to November 2, 2001, the first 10 confirmed cases of inhalational anthrax caused by intentional release of Bacillus anthracis were identified in the United States. Epidemiologic investigation indicated that the outbreak, in the District of Columbia, Florida, New Jersey, and New York, resulted from intentional delivery of B. anthracis spores through mailed letters or packages. We describe the clinical presentation and course of these cases of bioterrorism-related inhalational anthrax. The median age of patients was 56 years (range 43 to 73 years), 70% were male, and except for one, all were known or believed to have processed, handled, or received letters containing B. anthracis spores. The median incubation period from the time of exposure to onset of symptoms, when known (n=6), was 4 days (range 4 to 6 days). Symptoms at initial presentation included fever or chills (n=10), sweats (n=7), fatigue or malaise (n=10), minimal or nonproductive cough (n=9), dyspnea (n=8), and nausea or vomiting (n=9). The median white blood cell count was 9.8 X 10(3)/mm(3) (range 7.5 to 13.3), often with increased neutrophils and band forms. Nine patients had elevated serum transaminase levels, and six were hypoxic. All 10 patients had abnormal chest X-rays; abnormalities included infiltrates (n=7), pleural effusion (n=8), and mediastinal widening (seven patients). Computed tomography of the chest was performed on eight patients, and mediastinal lymphadenopathy was present in seven. With multidrug antibiotic regimens and supportive care, survival of patients (60%) was markedly higher (<15%) than previously reported.

Factors that influence cancer screening in older African American men and women: focus group findings.

Cancer incidence and mortality rates are highest among African Americans. A series of focus groups were conducted with older African American men and women to identify and examine psychosocial factors that influence screening behavior. Facilitators and barriers to screening as well as other factors that impact screening behaviors were explored. Study results indicate that African American men and women perceive screening in different ways. While there were similarities in the perceptions and facilitators to cancer screening, distinct gender differences were identified in the barriers and specific factors that influence cancer screening.

Possible horizontal transfer of the vanB2 gene among genetically diverse strains of vancomycin-resistant Enterococcus faecium in a Korean hospital.

A total of 25 isolates of vanB-containing Enterococcus faecium were recovered from patients in a single Korean hospital over a 20-month period. There were two distinct vanB2 patterns among the 11 pulsed-field gel electrophoresis types; 17 contained the prototype vanB2 and 8 contained a novel vanB2 with a 177-bp deletion in vanY(B). Both vanB2 genes were transmissible in vitro at a mean frequency of 1.1 x 10(-8) transconjugants/donor. These results suggest the horizontal spread of vanB2 is occurring among genetically diverse strains of E. faecium in Korean hospitals.

Correlates of mental health service utilization and unmet need among a sample of male adolescents.

The authors sought to identify the correlates of mental health services utilization and unmet need for these services among a sample of adolescent males. We hypothesized that our findings would replicate and extend those of the recent Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study, which found that parental factors play a major role in their children's unmet mental health care needs. Our study involved an evaluation of mental health service utilization and unmet need during the prior 2 years, as reported by the subjects at a follow-up assessment at age 16. Four factors were found to predict increased mental health services utilization, including attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) among the adolescent males, the father's alcohol use disorder, and the mother's amphetamine use disorder. One factor was found to predict decreased utilization, the father's cannabis use disorder. Four factors significantly predicted unmet treatment need, including conduct disorder, the mother's amphetamine use disorder, a higher number of siblings, and a parental history of having had a childhood anxiety disorder. The results of this study suggest that parental psychopathology, parental substance abuse, the presence of conduct disorder, and an increased number of siblings act as barriers to adequate mental health treatment among adolescents. These findings confirm the crucial role that parental factors play in the treatment utilization and the unmet treatment need of their children, and also suggest that an increased number of siblings can also be associated with unmet treatment need.

Incubation period and sources of exposure for cutaneous Mycobacterium marinum infection: case report and review of the literature.

The diagnosis of cutaneous Mycobacterium marinum infection is often delayed for months after presentation, perhaps because important clinical clues in the patient's history are frequently overlooked. Knowledge of the incubation period allows the clinician to target questions about the patient's history. Prompted by a case with a prolonged incubation period, we sought to determine more precisely the incubation period of M. marinum infection. The MEDLINE database for the period 1966-1996 was searched for information regarding incubation period and type of exposure preceding M. marinum infection. Ninety-nine articles were identified, describing 652 cases. Forty cases had known incubation periods (median, 21 days; range, 5-270 days). Thirty-five percent of cases had an incubation period > or =30 days. Of 193 infections with known exposures, 49% were aquarium-related, 27.4% were related to fish or shellfish injuries, and 8.8% were related to injuries associated with saltwater or brackish water. Because the incubation period for cutaneous M. marinum infection can be prolonged, patients with atypical cutaneous infections should be questioned about high-risk exposures that may have occurred up to 9 months before the onset of symptoms.

Risk factors for community-acquired pneumonia among persons infected with human immunodeficiency virus.

Two hundred eleven adults with human immunodeficiency virus (HIV) infection hospitalized for community-acquired pneumonia, including Pneumocystis carinii pneumonia (PCP; patients), and 192 matched HIV-infected hospitalized patients without pneumonia (controls) were interviewed to determine risk factors for pneumonia. Multivariate logistic regression showed that patients were less likely than controls to have used trimethoprim-sulfamethoxazole (TMP-SMZ) prophylaxis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.12-0.41) and more likely to have been hospitalized previously with pneumonia (OR, 6.25; CI, 3.40-11.5). Patients were also more likely than controls to have gardened (OR, 2.24; CI, 1.00-5.02) and to have camped or hiked (OR, 4.95; CI, 1.31-18.7), but stratified analysis by etiologic agent showed this association only for PCP. These findings reconfirm the efficacy of TMP-SMZ in preventing community-acquired pneumonia. In addition, hospitalization for pneumonia might represent a missed opportunity to encourage HIV-infected patients to enter into regular medical care and to adhere to prescribed antiretroviral and prophylaxis medications.

Black participation in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial.

The primary goal of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial is to learn whether widespread use of screening tests to detect these cancers will reduce associated mortality. Blacks have the highest age-adjusted cancer incidence and mortality rates of any population group in the United States, but several barriers to their participation in clinical research such as the PLCO trial exist. These barriers involve sociocultural, economic, and individual factors, as well as factors inherent in trial designs. Population diversity in the PLCO trial is necessary to preserve scientific validity and generalizability of trial results. Therefore, the National Cancer Institute and the Centers for Disease Control and Prevention are collaborating to ensure adequate representation of blacks in the PLCO trial. For example, the agencies have funded several new activities designed to better understand and overcome barriers to participation in the trial. These activities include the African American Men Project, a randomized trial designed to evaluate the efficacy of three increasingly intensive recruitment interventions in recruiting black men; the establishment of a minority-focused PLCO trial screening center, a study to identify factors that influenced the decisions of black women recruited to participate in the PLCO trial; and a study to examine the psychosocial factors that influence blacks' decision making to engage in cancer screening and participation in research similar to the PLCO trial. The results of these activities will allow for a more thorough examination of cancer-related issues of importance to blacks and will help shed light on factors that influence their decisions to participate in cancer screening and prevention clinical trials.

Association between mucositis severity and vancomycin-resistant enterococcal bloodstream infection in hospitalized cancer patients.

OBJECTIVE: To determine the role of mucositis severity in the development of vancomycin-resistant enterococcal (VRE) bloodstream infection (BSI). SETTING: A tertiary-care university medical center. PARTICIPANTS: Hematology-oncology-unit inpatients. DESIGN: Patients with VRE BSI (case-patients) were compared with VRE-colonized (control) patients from September 1994 through August 1997. Oral mucositis severity was recorded on the day of VRE BSI for case-patients and on hospital day 22 (median day of hospitalization of case-patient VRE BSI) for controls. There were 19 case-patients and 31 controls. RESULTS: In univariate analysis, case-patients were significantly more likely than controls to have a higher mucositis severity score, diarrhea, or a higher severity of illness score. In multivariate analysis, only mucositis remained as an independent risk factor, and increasing mucositis score was significantly associated with VRE BSI. CONCLUSIONS: Mucositis severity was independently associated with an increasing risk for VRE BSI. Interventions to alter mucositis severity may help to prevent VRE BSI in hospitalized cancer patients.

Prosecutors and end-of-life decision making.

OBJECTIVE: To examine personal beliefs and professional behavior of state criminal prosecutors toward end-of-life decisions. DESIGN: Mail survey. SETTING: District attorney offices nationwide. PARTICIPANTS: All prosecuting attorneys who are members of the National District Attorneys Association. A total of 2844 surveys were mailed with 2 follow-up mailings at 6-week intervals; 761 surveys were returned for a response rate of 26.8%. The majority of respondents were white men, Protestant, and served in rural areas. INTERVENTIONS: None. MAIN OUTCOME MEASURES: On the basis of 4 case scenarios, (1) professional behavior as determined by respondents' willingness to prosecute and what criminal charges they would seek; and (2) personal beliefs as determined by whether prosecutors believed the physicians' actions were morally wrong and whether they would want the same action taken if they were in the patient's condition. RESULTS: Most respondents would not seek prosecution in 3 of the 4 cases. In the fourth case, involving physician-assisted suicide, only about one third of the respondents said that they definitely would prosecute. Those who would prosecute would most often seek a charge of criminal homicide. A majority of respondents believed that the physicians' actions were morally correct in each of the 4 cases and would want the same action taken if they were in the patient's position. There was a strong correlation between personal beliefs and professional behaviors. CONCLUSIONS: A large majority of responding prosecutors were unwilling to prosecute physicians in cases that clearly fall within currently accepted legal and professional boundaries. In the case of physician-assisted suicide, results reflected a surprisingly large professional unwillingness to prosecute and an even greater personal acceptance of physician-assisted suicide.

A randomized crossover study of disposable thermometers for prevention of Clostridium difficile and other nosocomial infections.

OBJECTIVE: To test the hypothesis that use of disposable thermometers would result in lower rates of nosocomial Clostridium difficile diarrhea and of total nosocomial infections, compared with electronic thermometers. DESIGN: Prospective randomized crossover trial. SETTING: A 700-bed university hospital providing primary and tertiary care. PATIENTS: All patients admitted to a group of 20 inpatient nursing units. INTERVENTIONS: 20 nursing units were randomized into two groups. One group randomly was assigned exclusive use of single-use disposable thermometers for patient temperature measurement, and the other group was assigned exclusive use of electronic thermometers. After 6 months, the assignments were reversed. MAIN OUTCOME MEASURES: Rates of C difficile infections, total nosocomial diarrheal episodes, and total nosocomial infections were prospectively followed in each study unit over 11 months. RESULTS: 26,350 patients were admitted to the study units and hospitalized for 120,529 patient days. There were 947 nosocomial infections (7.86 per 1,000 patient days). Nosocomial C difficile-associated diarrhea defined by positivity to both toxin B (titer > or = 1:10) and toxin A was detected in 32 patients (3.4% of all nosocomial infections). A significantly lower rate of nosocomial C difficile-associated diarrhea was observed with disposable thermometer use (0.16 per 1,000 patient days) compared with electronic thermometer use (0.37 per 1,000 patient days, relative risk [RR] = 0.44; 95% confidence interval [CI95], 0.21-0.93, P = .026). There was no difference in overall rates of nosocomial infection between the disposable and electronic groups (8.03 and 7.68 infections per 1,000 patient days, respectively; RR, 1.04; CI95, 0.92-1.19; P = .52) or in the overall rate of nosocomial diarrhea (3.34 and 3.40 per 1,000 patient days, respectively; RR, .98; CI95, 0.81-1.19; P = .87). CONCLUSIONS: The incidence of nosocomial C difficile diarrhea was reduced significantly by using single-use, disposable thermometers as compared with electronic thermometers, but there was no effect on either the overall rate of nosocomial diarrhea or the rate of total nosocomial infections.

A survey of operative airway management practices for midface fractures.

We surveyed 218 Level I trauma centers to determine operative airway management preferences for patients with midface fractures requiring maxillomandibular fixation. A two-page survey was distributed to anesthesiologists, plastic surgeons, otolaryngologists, and oral surgeons participating in the management of major craniofacial trauma at each center. Specific fracture patterns were described, and the preferences for endotracheal intubation for operative management were surveyed among the respondents. We analyzed 105 responses from surgeons and 51 responses from anesthesiologists. Although there were differences in the preferences expressed by surgeons compared with anesthesiologists, more than 50% of the respondents in each practice category chose some form of nasotracheal intubation for fracture patterns involving the midface. Tracheostomy was a first choice for patients with panfacial fractures or those with loss of consciousness and midface fractures. This report serves as a basis for surgeons and anesthesiologists to review their practices and discuss planning of operative airway management for the patients with these fracture patterns. On the basis of this survey, midface fractures need not prohibit any consideration of nasotracheal intubation.

Tuberculosis in a young baseball player.

This report of a 19-year-old pitcher with chest pain illustrates how an atypical presentation of pulmonary tuberculosis in an athlete can delay diagnosis. In addition to a history, physical examination, and chest radiographs, the tuberculin skin test is the key to diagnosis of this disease. Laboratory work includes blood tests, liver and renal function studies, analysis of aspirated fluids, and sputum cultures. Treatment generally consists of daily doses of isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin. Screening close contacts such as teammates is essential; prophylaxis using isoniazid must be initiated for those who test positive.

Intraoperative hypothermia associated with lower extremity tourniquet deflation.

STUDY OBJECTIVE: To determine the rapidity and extent of core temperature decrease following release of a lower extremity pneumatic tourniquet. DESIGN: Prospective study. SETTING: Inpatient surgery in a university trauma center. PATIENTS: 11 ASA status I and II adults undergoing unilateral lower extremity fracture fixation in which a tourniquet was used, with general anesthesia. INTERVENTIONS: Temperature was measured in the esophagus before and after lower extremity tourniquet release. MEASUREMENTS AND MAIN RESULTS: Tourniquet times ranged from 41 to 129 minutes (mean 98.5 +/- 9.1 minutes). Following tourniquet deflation core temperature decreased in all patients, with a maximal decline at 10 minutes, the termination of measurements, although trending downward. Esophageal temperature decreased an average of 0.46 degree C +/- 0.2 degree C at 5 minutes, and 0.67 degree C +/- 0.2 degree C at 10 minutes following tourniquet release, respectively. Temperature changes were significant (p = 0.0001) at both time intervals. CONCLUSION: Core temperature drops significantly immediately following release of the tourniquet at the esophageal temperature monitoring site. This decrease is the result of cooling of systemic blood reperfusing the hypothermic limb, and mixing of cool, "washed out" blood with the systemic circulation. As the consequences of hypothermia are well-known, we recommend core temperature monitoring in all patients having lower extremity tourniquet placed during general anesthesia, as well as vigilant monitoring for prolonged effects of anesthetics in the postoperative period.

Clonazepam for the treatment of lancinating phantom limb pain.

OBJECTIVE: To propose clonazepam for use in the empiric treatment of shooting/shocking phantom limb pain. SETTING: Outpatient pain clinic associated with a university hospital. PATIENTS: Two patients with phantom limb pain after total hip disarticulation. INTERVENTIONS: Treatment with clonazepam. RESULTS AND CONCLUSIONS: Clonazepam provided effective relief for > 6 months in two patients with shooting/shocking phantom limb pain. Although clonazepam therapy is not new, it appears to have been omitted from current pain texts and journals as a treatment option for phantom limb pain.