Are There Differences between the Stress Responses of Philippine Men and Women to the COVID-19 Pandemic?

The SARS-CoV-2 pandemic has had a deleterious impact on human health since its beginning in 2019. The purpose of this study was to examine the psychosocial impact of the COVID-19 pandemic in the Philippines and determine if there were differential impacts on women compared to men. A web-based survey was conducted in the Luzon Islands of the Philippines, during the pandemic quarantine. A total of 1879 participants completed online surveys between 28 March-12 April 2020. A bivariate analysis of both men and women for each psychological measure (stress, anxiety, depression, and impact of COVID-19) was conducted. Multivariable logistic regression models were built for each measure, dichotomized as high or low, separately for men and women. Younger age (p < 0.001), being married (p < 0.001), and being a parent (p < 0.004) were associated with women's poor mental health. Marriage and large household size are protective factors for men (p < 0.002 and p < 0.0012, respectively), but marriage may be a risk factor for women (p < 0.001). Overall, women were disproportionately negatively impacted by the pandemic compared to men.

Understanding child disability: Factors associated with child disability at the Iganga-Mayuge Health and Demographic Surveillance Site in Uganda.

INTRODUCTION: There is scarcity of data on children with disabilities living in low-and-middle-income countries, including Uganda. This study describes disability prevalence and explores factors associated with different disability categories. It highlights the value of using a standardized, easy-to-use tool to determine disability in children and contextualizing disability in children in light of their developmental needs. METHODS: A cross-sectional study was conducted between September 2018-January 2019 at the Iganga-Mayuge Health and Demographic Surveillance Site in Uganda. Respondents were caregivers of children between 5-17 years and were administered an in-depth Child Functioning Module (CFM). The outcome variable, disability, was defined as an ordered categorical variable with three categories-mild, moderate, and severe. Generalized ordered logit model was applied to explore factors associated with disability categories. RESULTS: Out of 1,842 caregivers approached for the study, 1,439 (response: 78.1%) agreed to participate in the study. Out of these 1,439, some level of disability was reported by 67.89% (n = 977) of caregivers. Of these 977 children with disability, 48.01% (n = 692) had mild disability and 15.84% (n = 228) had moderate disability, while 3.96% (n = 57) had severe disability. The mean (SD) score for mild disability was 2.22±1.17, with a median of 2. The mean and median for moderate disability was 5.26±3.28 and 4 (IQR:3-6), and for severe disability was 14.23±9.51 and 12 (IQR:6-22). The most common disabilities reported were depression (54.83%) and anxiety (50.87%). Statistically significant association was found for completion of immunization status and school enrollment when controlled for a child's age, sex, having a primary caregiver, age of mother at child's birth, family system, family size and household wealth quintile. CONCLUSION: This study suggests association between incomplete immunization status and school enrollment for children with disability. These are areas for further exploration to ensure inclusive health and inclusive education of children with disabilities in Uganda.

Assessing Residential Exposure to Microbes from Industrial Hog Operations in Rural North Carolina: Methods and Lessons Learned.

BACKGROUND: Recent advances in molecular source tracking make answering questions from residents regarding their exposure to microbial contaminants from industrial hog operations (IHOs) possible. Associations between residential distance to IHOs and exposure can be addressed by measuring livestock-associated (Staphylococcus aureus) and pig-specific bacteria in the air, on household surfaces, and in participants' nasal and saliva swabs. OBJECTIVES: Here we assess the mechanics, feasibility, capacity-building, and lessons learned during a pilot study employing this novel technology in community-based participatory research of bacterial exposure and human health. METHODS: Together, our team of academics and community members designed a field- and laboratory-based pilot study. Air samples, surface and human swabs, and questionnaires from households at varying distances from IHOs were collected. Data were assessed for completeness and quality by two independent reviewers. These metrics were defined as: missingness (completeness), incorrect data type (validity), out of range (validity), and outliers (accuracy). LESSONS LEARNED: While critical field equipment was obtained, and knowledge exchange occurred, leading to an increased capacity for future work, after review, 38 of 49 households were deemed eligible for inclusion in the study. Of eligible participants, 98% of required electronic survey questions were complete and 100% were valid; an improvement over prior work which employed paper surveys. While all human microbial and air samples were collected from eligible households (n = 231), (5%) of environmental swabs were reported missing. CONCLUSIONS: Using community-appropriate sampling protocols, a pilot study of residential exposure to bacteria from IHOs was completed. While high-quality data was collected from those eligible, we learned the necessity of early and continual data review.

Personal protective equipment use during industrial hog operation work activities and acute lung function changes in a prospective worker cohort, North Carolina 2014-2015.

INTRODUCTION: Occupational activities related to industrial hog operation (IHO) worker lung function are not well defined. Therefore, we aimed to identify IHO work activities associated with diminished respiratory function and the effectiveness, if any, of personal protective equipment (PPE) use on IHOs. METHODS: From 2014 to 2015, 103 IHO workers were enrolled and followed for 16 weeks. At each biweekly visit, work activities and PPE use were self-reported via questionnaire and lung function measurements were collected via spirometry. Generalized linear and linear fixed-effects models were fitted to cross-sectional and longitudinal data. RESULTS: Increasing years worked on an IHO were associated with diminished lung function, but baseline and longitudinal work activities were largely inconsistent in direction and magnitude. Unexpectedly, a -0.3 L (95% confidence interval: -0.6, -0.04) difference in forced expiratory volume in the first second (FEV1 ) was estimated when workers wore PPE consistently (≥80% of the time at work) versus those weeks they did not. In post-hoc analyses, we found that coveralls and facemasks were worn less consistently when workers experienced worse barn conditions and had more contact with pigs, but coveralls were worn more consistently as cleaning activities increased. CONCLUSIONS: Similar to past studies, baseline estimates were likely obscured by healthy worker effect bias, but showed decrements in worker lung function as years of work increased. A challenge to disentangling the effect of work activities on lung function was the discovery that IHO workers used PPE differently according to the work task. These data suggest that interventions may be targeted toward improving barn conditions so that workers can consistently utilize IHO-provided PPE.

Self-reported work activities, eye, nose, and throat symptoms, and respiratory health outcomes among an industrial hog operation worker cohort, North Carolina, USA.

INTRODUCTION: Respiratory disease among industrial hog operation (IHO) workers is well documented; however, it remains unclear whether specific work activities are more harmful and if personal protective equipment (PPE), as used by workers, can reduce adverse health outcomes. METHODS: IHO workers (n = 103) completed baseline and up to eight bi-weekly study visits. Workers reported typical (baseline) and transient (bi-weekly) work activities, PPE use, and physical health symptoms. Baseline and longitudinal associations were assessed using generalized logistic and fixed-effects logistic regression models, respectively. RESULTS: At baseline, reports of ever versus never drawing pig blood, applying pesticides, and increasing years worked at any IHO were positively associated with reports of eye, nose, and/or throat irritation. Over time, transient exposures, associated with dustiness in barns, cleaning of barns, and pig contact were associated with increased odds of sneezing, headache, and eye or nose irritation, particularly in the highest categories of exposure. When PPE was used, workers had lower odds of symptoms interfering with sleep (odds ratio [OR]: 0.1; 95% confidence interval [CI]: 0.01-0.8), and eye or nose irritation (OR: 0.1; 95% CI: 0.02-0.9). Similarly, when they washed their hands eight times or more per shift (median frequency) versus less frequently, the odds of any respiratory symptom were reduced (OR: 0.3; 95% CI: 0.1-0.8). CONCLUSIONS: In this healthy volunteer worker population, increasingly unfavorable IHO activities were associated with self-reported eye, nose, throat, and respiratory health symptoms. Strong protective associations were seen between PPE use and handwashing and the odds of symptoms, warranting further investigation.

Five-year longitudinal changes in quantitative spinal cord MRI in multiple sclerosis.

BACKGROUND: The spinal cord (SC) is highly relevant to disability in multiple sclerosis (MS), but few studies have evaluated longitudinal changes in quantitative spinal cord magnetic resonance imaging (SC-MRI). OBJECTIVES: The aim of this study was to characterize the relationships between 5-year changes in SC-MRI with disability in MS. METHODS: In total, 75 MS patients underwent 3 T SC-MRI and clinical assessment (expanded disability status scale (EDSS) and MS functional composite (MSFC)) at baseline, 2 and 5 years. SC-cross-sectional area (CSA) and diffusion-tensor indices (fractional anisotropy (FA), mean, perpendicular, parallel diffusivity (MD, λ⊥, λ||) and magnetization transfer ratio (MTR)) were extracted at C3-C4. Mixed-effects regression incorporating subject-specific slopes assessed longitudinal change in SC-MRI measures. RESULTS: SC-CSA and MTR decreased (p = 0.009, p = 0.03) over 5.1 years. There were moderate correlations between 2- and 5-year subject-specific slopes of SC-MRI indices and follow-up EDSS scores (Pearson's r with FA = -0.23 (p < 0.001); MD = 0.31 (p < 0.001); λ⊥ = 0.34 (p < 0.001); λ|| = -0.12 (p = 0.05), MTR = -0.37 (p < 0.001); SC-CSA = -0.47 (p < 0.001) at 5 years); MSFC showed similar trends. The 2- and 5-year subject-specific slopes were robustly correlated (r = 0.93-0.97 for FA, λ⊥, SC-CSA and MTR, all ps < 0.001). CONCLUSION: In MS, certain quantitative SC-MRI indices change over 5 years, reflecting ongoing tissue changes. Subject-specific trajectories of SC-MRI index change at 2 and 5 years are strongly correlated and highly relevant to follow-up disability. These findings suggest that individual dynamics of change should be accounted for when interpreting longitudinal SC-MRI measures and that measuring short-term change is predictive of long-term clinical disability.

Measuring child functioning: Assessing correlation and agreement between caregiver and child responses at the Iganga-Mayuge health and demographic surveillance site in Uganda.

INTRODUCTION: Empirical data is scare on assessment of concordance between caregiver-child responses on child functioning. OBJECTIVE: To assess correlation and agreement between children (11-17 years old) and their caregivers' responses to the UNICEF/Washington Group Child Functioning Module (CFM) at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Uganda. METHODS: CFM with 24-questions corresponding to 13 domains of functioning was administered to children between 11 and 17 years of age and their caregivers. Descriptive analyses of the child/caregiver responses were conducted. Correlation and agreement between caregiver and child responses were assessed. RESULTS: Of the 217 caregiver/child pairs eligible for this study, 181 pairs agreed to participate (83.4%). The mean age of children was 13.9 ± 1.9 years, and 56.4% were males. Cronbach's alpha was 0.892 and 0.886 for the caregiver and child versions of CFM respectively, showing good internal consistency in both. There was a significant overall agreement between mean score of caregiver (5.36 ± 5.63 out of 39) and child (5.45 ± 5.34) pairs. Spearman's rank correlation between the pairs was 0.806 (strong positive correlation). Bland-Altman plots for CFM scores showed greater agreement between caregiver and child at lower scores. Percentage agreement between the pairs for overall disability was greater for mild (83.53%) and moderate (79.37%) categories as compared to the severe (66.67%) category. There was substantial agreement (kappa 0.623) for overall disability between the pairs. CONCLUSION: This study indicates that there is significant correlation and agreement between self-reported caregiver-child pair responses, opening the way for considering children as CFM respondents, when possible.

The use of personal protective equipment during common industrial hog operation work activities and acute lung function changes in a prospective worker cohort, North Carolina, USA.

INTRODUCTION: As occupational activities related to acute industrial hog operation (IHO) worker lung function are not well defined, we aimed to identify IHO work activities associated with diminished respiratory function and the effectiveness, if any, of personal protective equipment (PPE) on IHOs. METHODS: From 2014-2015, 103 IHO workers were enrolled and followed for 16 weeks. At each bi-weekly visit, lung function measurements were collected via spirometry and work activities and PPE use were self-reported via questionnaire. Generalized linear and linear fixed-effects models were fitted to cross-sectional and longitudinal data. RESULTS: At baseline, increasing years worked on an IHO were associated with diminished lung function, but other activities were less consistent in direction and magnitude. In longitudinal models, only reports of working in feeding/finisher barns, showed a consistent association. However, a -0.3 L (95% confidence interval: -0.6, -0.04) difference in FEV 1 was estimated when workers wore PPE consistently versus those weeks they did not. In post-hoc analyses, we found that coveralls and facemasks were worn less consistently when workers experienced worse barn conditions and had more contact with pigs, but coveralls were worn more consistently as cleaning activities increased. CONCLUSIONS: Similar to past studies, baseline estimates were likely obscured by healthy worker bias. Also making it challenging to disentangle the effect of work activities on lung function was the discovery that IHO workers used PPE differently according to work task. These data suggest that interventions may be targeted toward improving barn conditions so that workers can consistently utilize IHO-provided PPE. KEY MESSAGES: What is already known about this subject?: Working on industrial hog operations may be deleterious to long- and short-term respiratory health due to airborne bacteria, endotoxin, hazardous gases, dust, and dander in barns. In efficacy studies PPE has been shown to be protective, but studies have shown that PPE utilization among hog workers has historically been sub-optimal.What are the new findings?: As barn conditions worsened and contact with pigs increased, workers in this cohort reported wearing coveralls and face masks less often; however, they reported increased PPE use as they conducted more cleaning activities at work. During weeks when workers wore PPE their lung function declined, a possible cause being the improper use of the equipment leading to a false sense of protection or re-exposure to hazardous contaminants.How might this impact on policy or clinical practice in the foreseeable future?: Given COVID-19, the H1N1 "swine flu" pandemic, our knowledge of antimicrobial resistant pathogens, and increasing awareness about how food systems are linked to the spread of emerging infectious diseases, occupational health intervention research and workplace policies may focus on creating barn environments that are more conducive to PPE use which could help protect workers and consequently the community.

Adaptation and validation of UNICEF/Washington group child functioning module at the Iganga-Mayuge health and demographic surveillance site in Uganda.

BACKGROUND: The UNICEF/Washington Group Child Functioning Module (CFM) assesses child functioning among children between 5 and 17 years of age. This study adapted and validated the CFM at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Uganda. METHODS: This cross-sectional study was conducted between September 2018-January 2019 at the IM-HDSS. Respondents were caregivers of children between 5 and 17 years of age who were administered modified Washington Group short set (mWG-SS) and CFM. The responses were recorded on a 4-point Likert scale. Descriptive analysis was conducted on child and caregiver demographic characteristics. Exploratory factor analysis (EFA) assessed underlying factor structure, dimensionality and factor loadings. Cronbach's alpha was reported as an assessment of internal consistency. Face validity was assessed during the translation process, and concurrent validity of CFM was assessed through comparison with disability short form. RESULTS: Out of 1842 caregivers approached, 1439 (78.1%) participated in the study. Mean age of children was 11.06 ± 3.59 years, 51.4% were males, and 86.1% had a primary caregiver. Based on EFA, vision, hearing, walking, self-care, communication, learning, remembering, concentrating, accepting change, behavior control, and making friends loaded on factor 1 - "Motor and Cognition," while anxiety and depression loaded on factor 2 - "Mood". Cronbach's alpha for the overall CFM was 0.899 (good internal consistency). Cronbach's alpha for each extracted factor was excellent, motor and cognition (0.904), and mood (0.902). CFM had acceptable face validity. Spearman's rank correlation between scores of CFM and modified WG short set was 0.51 (p-value < 0.001). The overall mean CFM score was 2.47 ± 3.82 out of 39. The mean score for Mood (1.35 ± 1.42 out of 6) was higher compared to Motor and Cognition (1.12 ± 3.06 out of 33). Comparing modified WG short set and CFM Likert responses, the percent agreement was greatest for "cannot do at all." CONCLUSION: CFM is a two-factor, valid and reliable scale for assessing disability in Uganda and can be applied to other similar settings to contribute towards disability data from the region. It is an easy-to-administer tool that can help in deeper understanding of context-specific burden and extent of disability in children between 5 and 17 years of age.

Interventions Made to Preserve Cognitive Function Trial (IMPCT) study protocol: a multi-dialysis center 2x2 factorial randomized controlled trial of intradialytic cognitive and exercise training to preserve cognitive function.

BACKGROUND: Kidney disease and dialysis significantly impact cognitive function across the age spectrum. Cognitive training (CT) and/or exercise training (ET) are promising approaches to preserve cognitive function among community-dwelling older adults, but have not been tested for cognition preservation in hemodialysis patients of all ages. In this manuscript, we summarize the protocol for the Interventions Made to Preserve Cognitive Function Trial (IMPCT). METHODS: We will perform a 2 × 2 factorial randomized controlled trial (RCT) of eligible adult (≥18 years) hemodialysis initiates (n = 200) to test whether intradialytic CT (brain games on a tablet PC), ET (foot peddlers) and combined CT + ET while undergoing hemodialysis preserves executive function compared to standard of care (SC). Participants will engage in the interventions to which they are randomized for 6 months. The primary objective is to compare, among interventions, the 3-month change in executive function measured using the Trail Making Test A (TMTA) and B (TMTB); specifically, executive function is calculated as TMTB-TMTA to account for psychomotor speed. This primary outcome was selected based on findings from our pilot study. The secondary objectives are to compare the risk of secondary cognitive outcomes, ESKD-specific clinical outcomes, and patient-centered outcomes at 3-months and 6-months. All data collection and interventions are conducted in the dialysis center. DISCUSSION: We hypothesize that receiving intradialytic CT or ET will better preserve executive function than SC but receiving combined CT + ET, will be the most effective intervention. The current trial will be an important step in understanding how intradialytic interventions might preserve cognitive health. TRIAL REGISTRATION: Clinicaltrials.Gov (Date: 8/6/18): # NCT03616535 . Protocol Version: 10 (April 2020). FUNDING: NIDDK R01DK114074.

Eradication of persistent methicillin-resistant Staphylococcus aureus infection in cystic fibrosis.

BACKGROUND: The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in individuals with cystic fibrosis (CF) has increased significantly. While studies demonstrate that persistent MRSA infection in CF is associated with poor clinical outcomes, there are no randomized controlled studies informing management. METHODS: The Persistent MRSA Eradication Protocol was a double-blind, randomized, placebo-controlled study investigating a comprehensive 28-day treatment regimen with or without inhaled vancomycin for eradication of MRSA. Eligible participants had CF and documented persistent MRSA infection. All participants received oral antibiotics, topical decontamination, and environmental cleaning and were randomized to receive inhaled vancomycin or inhaled placebo. The primary outcome was the difference in MRSA eradication rates one month after completion of the treatment protocol. RESULTS: 29 participants were randomized. Four subjects in the inhaled vancomycin group required withdrawal from the study for bronchospasm before outcome data were collected and were excluded from analysis. There was no difference in the primary outcome: 2/10 (20%) of subjects in the intervention group and 3/15 (20%) in the placebo group had a MRSA negative sputum culture one month after treatment. There were no statistically significant differences in the rates of MRSA eradication at the end of treatment or three months after treatment completion. CONCLUSIONS: This study suggests that persistent MRSA infection is difficult to eradicate, even with multimodal antibiotics. The use of a single course of inhaled vancomycin may not lead to higher rates of MRSA eradication in individuals with CF and may be associated with bronchospasm. FUND: This trial was financially supported by the Cystic Fibrosis Foundation.

Towards diaspora-driven research capacity strengthening in low- and middle-income countries: results from India and Nepal.

BACKGROUND: Biomedical research from high-income countries often informs practice and policy in low- and middle-income countries (LMICs) with vastly different socioeconomic and health systems. Engagement of LMIC-based researchers is integral to setting research priorities in the local context. METHODS: A program, comprising a research seminar and workshop, and utilizing diaspora health professionals to understand research needs and build research capacity in LMICs, was created and pilot-tested at two institutions in India (65 participants) and Nepal (30 participants). Pre- and post-program surveys were instituted to assess participants' attitudes towards research. RESULTS: In the pre-program survey, most participants (India: 76%, Nepal: 100%) perceived research as 'very/extremely important' in their careers. However, a majority felt that finding time (India: 75%, Nepal: 81%) and funding (India: 82%, Nepal: 100%) for research was 'difficult/very difficult'. After the program, 86-91% and 86-100% of participants from India and Nepal, respectively, felt that the various courses were very useful/useful for their research careers. CONCLUSIONS: Research is seen as an integral part of educational training and career advancement in LMICs. However, inadequate training, funding and mentorship remain a challenge. Engagement of diaspora health workers may serve as an important avenue for collaborative biomedical research capacity strengthening in LMICs.

Intrahost Dynamics of Human Cytomegalovirus Variants Acquired by Seronegative Glycoprotein B Vaccinees.

Human cytomegalovirus (HCMV) is the most common congenital infection worldwide and a frequent cause of hearing loss and debilitating neurologic disease in newborn infants. Thus, a vaccine to prevent HCMV-associated congenital disease is a public health priority. One potential strategy is vaccination of women of child bearing age to prevent maternal HCMV acquisition during pregnancy. The glycoprotein B (gB) plus MF59 adjuvant subunit vaccine is the most efficacious tested clinically to date, demonstrating 50% protection against primary HCMV infection in a phase 2 clinical trial. Yet, the impact of gB/MF59-elicited immune responses on the population of viruses acquired by trial participants has not been assessed. In this analysis, we employed quantitative PCR as well as multiple sequencing methodologies to interrogate the magnitude and genetic composition of HCMV populations infecting gB/MF59 vaccinees and placebo recipients. We identified several differences between the viral dynamics in acutely infected vaccinees and placebo recipients. First, viral load was reduced in the saliva of gB vaccinees, though not in whole blood, vaginal fluid, or urine. Additionally, we observed possible anatomic compartmentalization of gB variants in the majority of vaccinees compared to only a single placebo recipient. Finally, we observed reduced acquisition of genetically related gB1, gB2, and gB4 genotype "supergroup" HCMV variants among vaccine recipients, suggesting that the gB1 genotype vaccine construct may have elicited partial protection against HCMV viruses with antigenically similar gB sequences. These findings suggest that gB immunization had a measurable impact on viral intrahost population dynamics and support future analysis of a larger cohort.IMPORTANCE Though not a household name like Zika virus, human cytomegalovirus (HCMV) causes permanent neurologic disability in one newborn child every hour in the United States, which is more than that for Down syndrome, fetal alcohol syndrome, and neural tube defects combined. There are currently no established effective measures to prevent viral transmission to the infant following HCMV infection of a pregnant mother. However, the glycoprotein B (gB)/MF59 vaccine, which aims to prevent pregnant women from acquiring HCMV, is the most successful HCMV vaccine tested clinically to date. Here, we used viral DNA isolated from patients enrolled in a gB vaccine trial who acquired HCMV and identified several impacts that this vaccine had on the size, distribution, and composition of the in vivo viral population. These results have increased our understanding of why the gB/MF59 vaccine was partially efficacious, and such investigations will inform future rational design of a vaccine to prevent congenital HCMV.

Mortality after deferral of treatment or no treatment for choroidal melanoma.

PURPOSE: To report mortality of patients who were eligible for enrollment in the Collaborative Ocular Melanoma Study (COMS) clinical trials of medium-sized choroidal melanoma or large-sized choroidal melanoma but chose to defer treatment or receive no melanoma treatment. DESIGN: Prospective nonrandomized multicenter cohort study as an adjunct to COMS randomized clinical trials. METHODS: Patient follow-up procedures included examinations, correspondence, telephone contacts, and National Death Index searches. Primary outcome was patient death measured by all-cause mortality. Secondary outcomes were melanoma treatment and melanoma metastasis. RESULTS: Of 77 patients eligible for COMS clinical trials who chose to defer or receive no melanoma treatment, 61 were appropriate candidates and 45 (74%) enrolled in the natural history study (NHS). In all, 42 patients (42 eyes) had medium melanoma, and the median follow-up was 5.3 years (range, 4-10.7 years). In all, 22 patients (52%) had subsequent melanoma treatment, and 20 (48%) had no melanoma treatment. For the 42 patients, Kaplan-Meier estimate of 5-year mortality was approximately 30% [95% confidence interval (CI), 18%-47%]. For COMS medium melanoma trial, 5-year mortality was 18% (95% CI, 16%-20%), not statistically significantly different from the NHS patients. After adjusting for differences in age and longest basal diameter, the 5-year risk of death for NHS patients versus COMS trial patients was 1.54 (95% CI, 0.93-2.56). Three patients had large melanoma. Melanoma metastasis was confirmed or suspected in 8 (42%) of 19 deaths. CONCLUSION: Greater mortality and higher risk of death for NHS patients are probative but not conclusive evidence of a beneficial, life-extending effect of medium melanoma treatment.

Design and Deployment of a Pediatric Cardiac Arrest Surveillance System.

OBJECTIVE: We aimed to increase detection of pediatric cardiopulmonary resuscitation (CPR) events and collection of physiologic and performance data for use in quality improvement (QI) efforts. MATERIALS AND METHODS: We developed a workflow-driven surveillance system that leveraged organizational information technology systems to trigger CPR detection and analysis processes. We characterized detection by notification source, type, location, and year, and compared it to previous methods of detection. RESULTS: From 1/1/2013 through 12/31/2015, there were 2,986 unique notifications associated with 2,145 events, 317 requiring CPR. PICU and PEDS-ED accounted for 65% of CPR events, whereas floor care areas were responsible for only 3% of events. 100% of PEDS-OR and >70% of PICU CPR events would not have been included in QI efforts. Performance data from both defibrillator and bedside monitor increased annually. (2013: 1%; 2014: 18%; 2015: 27%). DISCUSSION: After deployment of this system, detection has increased ∼9-fold and performance data collection increased annually. Had the system not been deployed, 100% of PEDS-OR and 50-70% of PICU, NICU, and PEDS-ED events would have been missed. CONCLUSION: By leveraging hospital information technology and medical device data, identification of pediatric cardiac arrest with an associated increased capture in the proportion of objective performance data is possible.

Relation of Resting Heart Rate to Incident Atrial Fibrillation (From ARIC [Atherosclerosis Risk in Communities] Study).

The evidence on the association between resting heart rate (HR) and incident atrial fibrillation (AF) is conflicting. Whether change in resting HR is associated with incident AF is unknown. We evaluated 11,545 participants (mean [±standard deviation] age: 57 ± 5.7 years) free of AF at baseline (1990 to 1992). Resting HR was obtained from 10-second electrocardiograms at baseline and 3 years later. AF diagnosis was ascertained from visit electrocardiograms, hospital discharge records, and death certificates through 2013. High and low resting HR were defined as ≥80 and <55 beats/min, respectively. Increase and decrease in HR were defined as a 3-year HR difference >15 and <-15 beats/min, respectively. Over a median follow-up of 22.5 years, 1,746 (15%) participants developed AF. Both baseline high resting HR and increase in HR were independently associated with incident AF (hazard ratio = 1.2, 95% confidence interval = 1.0 to 1.5 and hazard ratio = 1.4, 95% confidence interval = 1.1 to 1.9). Increase in HR was no longer associated with incident AF after additional adjustment for incident heart failure. In stratified analyses, increase in HR was associated only with AF in participants <60 years, with bachelor's degree or above, without diabetes, and without hypertension (p values for interaction ≤0.05). In conclusion, in a middle-aged population, high resting HR is associated with higher AF risk. Increase in resting HR is also associated with higher AF risk, especially in individuals without traditional AF risk factors. Whether interventions to decrease HR can prevent AF remain to be examined.

Cytomegalovirus Kinetics Following Primary Infection in Healthy Women.

The kinetics of cytomegalovirus (CMV) DNA in infected asymptomatic hosts are largely unknown. We measured viral load (VL) in 124 fluid samples (oral, urine, vaginal, blood) collected from 21 women who acquired CMV. A quantitative real-time polymerase chain reaction assay of US17, which correlated with clinical assays, was used. VL decreased following primary infection in all fluids. The geometric mean VL of vaginal fluid was significantly higher than that of other sources: oral (3.89; 95% confidence interval [CI], 1.43-10.57), urine (6.36; 95% CI, 2.48-16.32), and whole blood (11.88; 95% CI, 4.12-34.20). Vaginal CMV shedding may provide a route for sexual and possibly perinatal transmission.

Associations Between Khat Use and HIV Risk and Status Among Voluntary Counseling and Testing Center Clients in Addis Ababa, Ethiopia.

OBJECTIVES: Ethiopia is 1 of 15 countries that account for nearly 75% of all people living with HIV. Khat use, a common practice in Ethiopia and sub-Saharan Africa, has gained attention as a potential risk factor for HIV. Our objective was to evaluate associations between khat use and demographic and risk-taking characteristics (alcohol use, sexual behavior), and also associations between HIV status and these characteristics among voluntary counseling and testing clients in Addis Ababa, Ethiopia. METHODS: This cross-sectional study was conducted among Pro Pride voluntary counseling and testing center clients, aged 18 to 49 years, from November 2009 to March 2010. All clients were approached, and 98.8% of these (684) completed a self-administered questionnaire. Associations between khat use, alcohol use, multiple sexual partners, and HIV status were assessed using logistic regression models. RESULTS: Using khat in the past 90 days (current khat use) was significantly associated with being Muslim, being male, alcohol use, and having a greater number of sex partners in one's lifetime. The adjusted odds of current khat use was almost 7-fold higher in those having 4 or more sexual partners in their lifetime (adjusted odds ratio 6.89, 95% confidence interval 3.87, 12.25) as compared with those with 1 or none. HIV-positive status was significantly associated with age, employment, marital status, number of sex partners in one's lifetime, and khat use. Having used khat in one's lifetime, but not currently, past khat use, was associated with over a 2-fold increased adjusted odds (adjusted odds ratio 2.64, 95% confidence interval 1.13, 6.19) of being HIV-infected. CONCLUSIONS: Our findings highlight associations between current khat use and the modifiable factors of number of lifetime sexual partners and alcohol use. In addition, we observed the association between HIV status and past khat use after adjusting for age, marital status, and number of sex partners in one's lifetime.

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial.

BACKGROUND: Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome. METHODS: In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134. FINDINGS: Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar. INTERPRETATION: In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status. FUNDING: National Institute of Neurological Disorders and Stroke.