Tobacco Research in the Military: Reflections on 20 Years of Research in the United States Air Force.

The U.S. military is one of the world's largest employers. Approximately 30% of active duty military personnel smoke cigarettes and more than 14% use smokeless tobacco. The military has historically supported tobacco use and more recently is attempting to combat its use. Through 20 years of collaborative research with the United States Air Force, we have learned that smoking bans are effective, recruits who have never previously smoked cigarettes initiate tobacco use, smokeless tobacco serves as a gateway for smoking initiation, smoking is associated with discharge, smoking adds significant proximal training costs, tobacco use increases during deployment, and tobacco quitline counseling with a provision of medication is effective. Our findings may provide groundwork for future tobacco control efforts in the U.S. military.

Population-based study of risk factors for coronary heart disease among HIV-infected persons.

Preventing coronary heart disease (CHD) is critical to further extending survival among human immunodeficiency virus (HIV)-infected persons. Previously published findings of CHD risk factors in HIV-infected persons have been derived from facility-based cohort studies, which have limited representativeness for the HIV-infected population. State-specific, population-based surveillance data can assist health care providers and public health agencies in planning and evaluating programs that reduce CHD among HIV-infected persons. We describe CHD risk factors from the 2007-2008 Oregon Medical Monitoring Project, a population-based survey of HIV-infected persons receiving care that included both patient interview and medical record review. Among the 539 HIV-infected patients interviewed, the mean age was 45.5 years. Diagnoses from the medical record associated with CHD risk included preexisting CHD (5%), diabetes (11%), and hypertension (28%). Current smoking was reported by 46%; college graduates were less likely to smoke compared with those with lesser education (21% versus 53%, respectively; P <.0001). Obesity was present among 17%. Among the 65% of the survey group with lipid values available, 55% had high-density lipoprotein cholesterol (HDL) <40 mg/dL and 42% had triglycerides ≥ 200 mg/dL. Among the 15% of the survey group with either preexisting CHD or diabetes, 42% had a non-HDL <130 mg/dL (target goal) and 38% smoked. Risk factors for CHD among HIVinfected persons, particularly smoking and dyslipidemia, should be managed aggressively. Ongoing surveillance is warranted to monitor changes in CHD risk factors in the HIV-infected population.

Acute exertional rhabdomyolysis and triceps compartment syndrome during a high school football cAMP.

BACKGROUND: Acute exertional rhabdomyolysis has been infrequently reported among adolescents. In August 2010, several high school football players from one team developed rhabdomyolysis and triceps compartment syndrome following an upper arm exercise held in a non-air-conditioned wrestling room. PURPOSE: To confirm the diagnoses, characterize the spectrum of illnesses, and determine the factors contributing to rhabdomyolysis and triceps compartment syndromes. STUDY DESIGN: Descriptive epidemiology study. METHODS: The authors reviewed hospital medical records and interviewed players, coaches, school administrators, and hospital staff, using a standardized questionnaire that assessed symptoms, exposures, and activities. RESULTS: Among 43 players, 22 (51%) experienced rhabdomyolysis (peak creatine kinase range, 2434-42 000 U/L): 22 patients had upper arm myalgia; 12 were hospitalized; 3 experienced triceps compartment syndrome; none experienced renal failure. Illnesses started 1 to 3 days after the triceps exercise. Forty players (93%) completed questionnaires. Among 19 players receiving at least 1 vote from a teammate as 1 of the 3 hardest working players, 13 (68%) experienced rhabdomyolysis versus 7 (33%) of 21 not considered hardest working (relative risk, 2.1; 95% confidence interval, 1.04-4.0). Of 40 players, 10 (25%) reported creatine supplement use, which was not associated with rhabdomyolysis. No player acknowledged use of alcohol, illicit drugs, or performance-enhancing drugs; results of performance-enhancing drug tests on the 4 players tested were negative. Environmental investigation did not identify additional factors contributing to illness. CONCLUSIONS: The upper arm exercise, possibly exacerbated by heat, led to rhabdomyolysis and compartment syndrome. Greater awareness of specific exercise hazards and prevention strategies can minimize risk for clinically significant muscle injury.

Guillain-Barre syndrome during the 2009-2010 H1N1 influenza vaccination campaign: population-based surveillance among 45 million Americans.

Because of widespread distribution of the influenza A (H1N1) 2009 monovalent vaccine (pH1N1 vaccine) and the prior association between Guillain-Barré syndrome (GBS) and the 1976 H1N1 influenza vaccine, enhanced surveillance was implemented to estimate the magnitude of any increased GBS risk following administration of pH1N1 vaccine. The authors conducted active, population-based surveillance for incident cases of GBS among 45 million persons residing at 10 Emerging Infections Program sites during October 2009-May 2010; GBS was defined according to published criteria. The authors determined medical and vaccine history for GBS cases through medical record review and patient interviews. The authors used vaccine coverage data to estimate person-time exposed and unexposed to pH1N1 vaccine and calculated age- and sex-adjusted rate ratios comparing GBS incidence in these groups, as well as age- and sex-adjusted numbers of excess GBS cases. The authors received 411 reports of confirmed or probable GBS. The rate of GBS immediately following pH1N1 vaccination was 57% higher than in person-time unexposed to vaccine (adjusted rate ratio = 1.57, 95% confidence interval: 1.02, 2.21), corresponding to 0.74 excess GBS cases per million pH1N1 vaccine doses (95% confidence interval: 0.04, 1.56). This excess risk was much smaller than that observed during the 1976 vaccine campaign and was comparable to some previous seasonal influenza vaccine risk assessments.

Statewide validation of hospital-reported central line-associated bloodstream infections: Oregon, 2009.

BACKGROUND: Mandatory reporting of healthcare-associated infections is common, but underreporting by hospitals limits meaningful interpretation. OBJECTIVE: To validate mandatory intensive care unit (ICU) central line-associated bloodstream infection (CLABSI) reporting by Oregon hospitals. DESIGN: Blinded comparison of ICU CLABSI determination by hospitals and health department-based external reviewers with group adjudication. SETTING: Forty-four Oregon hospitals required by state law to report ICU CLABSIs. PARTICIPANTS: Seventy-six patients with ICU CLABSIs and a systematic sample of 741 other patients with ICU-related bacteremia episodes. METHODS: External reviewers examined medical records and determined CLABSI status. All cases with CLABSI determinations discordant from hospital reporting were adjudicated through formal discussion with hospital staff, a process novel to validation of CLABSI reporting. RESULTS: Hospital representatives and external reviewers agreed on CLABSI status in 782 (96%) of 817 bacteremia episodes (k = 0.77 [95% confidence interval (CI), 0.70-0.84]). Among the 27 episodes identified as CLABSIs by external reviewers but not reported by hospitals, the final status was CLABSI in 16 (59%). The measured sensitivities of hospital ICU CLABSI reporting were 72% (95% CI, 62%-81%) with adjudicated CLABSI determination as the reference standard and 60% (95% CI, 51%-69%) with external review alone as the reference standard (P = .07). Validation increased the statewide ICU CLABSI rate from 1.21 (95% CI, 0.95-1.51) to 1.54 (95% CI, 1.25-1.88) CLABSIs/1,000 central line-days; ICU CLABSI rates increased by more than 1.00 CLABSI/1,000 central line-days in 6 (14%) hospitals. CONCLUSIONS: Validating hospital CLABSI reporting improves accuracy of hospital-based CLABSI surveillance. Discussing discordant findings improves the quality of validation.

Comparison of survey methods in norovirus outbreak investigation, Oregon, USA, 2009.

We compared data from an Internet-based survey and a telephone-based survey during a 2009 norovirus outbreak in Oregon. Survey initiation, timeliness of response, and attack rates were comparable, but participants were less likely to complete Internet questions. Internet-based surveys permit efficient data collection but should be designed to maximize complete responses.