COVID-19 impact on screening test volume through the National Breast and Cervical Cancer early detection program, January-June 2020, in the United States.

Women from racial and ethnic minority groups face a disproportionate burden of cervical and breast cancers in the United States. The Coronavirus Disease 2019 (COVID-19) pandemic might exacerbate these disparities as supply and demand for screening services are reduced. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides cancer screening services to women with low income and inadequate health insurance. We examined COVID-19's impact on NBCCEDP screening services during January-June 2020. We found the total number of NBCCEDP-funded breast and cervical cancer screening tests declined by 87% and 84%, respectively, during April 2020 compared with the previous 5-year averages for that month. The extent of declines varied by geography, race/ethnicity, and rurality. In April 2020, screening test volume declined most severely in Health and Human Services Region 2 - New York (96% for breast, 95% for cervical cancer screening) compared to the previous 5-year averages. The greatest declines were among American Indian/Alaskan Native women for breast cancer screening (98%) and Asian Pacific Islander women for cervical cancer screening (92%). Test volume began to recover in May and, by June 2020, NBCCEDP breast and cervical cancer screening test volume was 39% and 40% below the 5-year average for that month, respectively. However, breast cancer screening remained over 50% below the 5-year average among women in rural areas. NBCCEDP programs reported assisting health care providers resume screening.

Foods Implicated in U.S. Outbreaks Differ from the Types Most Commonly Consumed.

ABSTRACT: Foodborne disease outbreak investigations identify foods responsible for illnesses. However, it is not known the degree to which foods implicated in outbreaks reflect the distribution of food consumption in the U.S. population or the risk associated with their consumption. We compared the distribution of 24 categories of foods implicated in outbreaks with the distribution of foods consumed by the U.S. population. Beef, chicken, eggs, fish, herbs, mollusks, pork, sprouts, seeded vegetables, and turkey were implicated in outbreaks significantly more often than expected based on the frequency of their consumption by the general population, suggesting a higher risk of contamination or mishandling from foods in these categories than from foods in other categories. In contrast, pasteurized dairy, fruits, grains and beans, oils and sugars, and root and underground vegetables were less frequently implicated in outbreaks than their frequency of consumption by the general population, suggesting a lower health risk associated with these food categories.

Incubation periods of enteric illnesses in foodborne outbreaks, United States, 1998-2013.

Early in a foodborne disease outbreak investigation, illness incubation periods can help focus case interviews, case definitions, clinical and environmental evaluations and predict an aetiology. Data describing incubation periods are limited. We examined foodborne disease outbreaks from laboratory-confirmed, single aetiology, enteric bacterial and viral pathogens reported to United States foodborne disease outbreak surveillance from 1998-2013. We grouped pathogens by clinical presentation and analysed the reported median incubation period among all illnesses from the implicated pathogen for each outbreak as the outbreak incubation period. Outbreaks from preformed bacterial toxins (Staphylococcus aureus, Bacillus cereus and Clostridium perfringens) had the shortest outbreak incubation periods (4-10 h medians), distinct from that of Vibrio parahaemolyticus (17 h median). Norovirus, salmonella and shigella had longer but similar outbreak incubation periods (32-45 h medians); campylobacter and Shiga toxin-producing Escherichia coli had the longest among bacteria (62-87 h medians); hepatitis A had the longest overall (672 h median). Our results can help guide diagnostic and investigative strategies early in an outbreak investigation to suggest or rule out specific etiologies or, when the pathogen is known, the likely timeframe for exposure. They also point to possible differences in pathogenesis among pathogens causing broadly similar syndromes.

Drug-drug interactions and their harmful effects in hospitalised patients: a systematic review and meta-analysis.

PURPOSE: Drug-drug interactions (DDIs) are often avoidable and, if undetected, can lead to patient harm. This review aimed to determine the prevalence of potential DDIs (pDDIs), clinically relevant DDIs (DDIs that could lead to measurable patient harm, taking into account the patient's individual clinical profile) and DDIs that resulted in actual patient harm during hospitalisation. METHOD: Four databases were scanned for English papers published from 2000 to 2016. Papers that reported prevalence of DDIs in the outpatient setting, at admission or discharge, involving only specific drugs, or in specific disease populations or age groups were excluded. RESULTS: Twenty-seven papers met the inclusion criteria and were graded for quality using the Critical Appraisal Skills Programme (CASP) cohort study checklist. Ten papers were rated as 'poor', 14 as 'fair' and only three papers as 'good'. Overall, the meta-analysis revealed that 33% of general patients and 67% of intensive care patients experienced a pDDI during their hospital stay. It was not possible to determine the prevalence of clinically relevant DDIs or DDIs that resulted in actual patient harm as data on these categories were limited. Of the very few studies that reported on harm, only a small proportion of DDIs were found to have resulted in actual patient harm. CONCLUSIONS: Standardisation of DDI definitions and research methods are required to allow meaningful prevalence rates to be obtained and compared. Studies that go further than measuring pDDIs are critically needed to determine the impact of DDIs on patient safety.

Antimicrobial resistance in Salmonella that caused foodborne disease outbreaks: United States, 2003-2012.

Although most non-typhoidal Salmonella illnesses are self-limiting, antimicrobial treatment is critical for invasive infections. To describe resistance in Salmonella that caused foodborne outbreaks in the United States, we linked outbreaks submitted to the Foodborne Disease Outbreak Surveillance System to isolate susceptibility data in the National Antimicrobial Resistance Monitoring System. Resistant outbreaks were defined as those linked to one or more isolates with resistance to at least one antimicrobial drug. Multidrug resistant (MDR) outbreaks had at least one isolate resistant to three or more antimicrobial classes. Twenty-one per cent (37/176) of linked outbreaks were resistant. In outbreaks attributed to a single food group, 73% (16/22) of resistant outbreaks and 46% (31/68) of non-resistant outbreaks were attributed to foods from land animals (P < 0·05). MDR Salmonella with clinically important resistance caused 29% (14/48) of outbreaks from land animals and 8% (3/40) of outbreaks from plant products (P < 0·01). In our study, resistant Salmonella infections were more common in outbreaks attributed to foods from land animals than outbreaks from foods from plants or aquatic animals. Antimicrobial susceptibility data on isolates from foodborne Salmonella outbreaks can help determine which foods are associated with resistant infections.

A time and motion study of junior doctor work patterns on the weekend: a potential contributor to the weekend effect?

BACKGROUND: Patients admitted to hospital on weekends have a greater risk of mortality compared to patients admitted on weekdays. Junior medical officers (JMO) make up the majority of medical staff on weekends. No previous study has quantified JMO work patterns on weekends. AIM: To describe and quantify JMO work patterns on weekends and compare them with patterns previously observed during the week. METHODS: Observational time and motion study of JMO working weekends using the Work Observation Method by Activity Timing (WOMBAT; Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia) software. Descriptive statistics were used to determine the proportion of total observed time spent in tasks. RESULTS: Weekend JMO predominately spent time in indirect care (32.0%), direct care (23.0%) and professional communication (22.1%). JMO spent 20.9% of time multitasking and were interrupted, on average, every 9 min. Weekend JMO spent significantly more time in direct care compared with weekdays (13.0%; P < 0.001) and nights (14.3%; P < 0.001). Weekend JMO spent significantly less time on breaks (8.5%), with less than 1 h in an 11-h shift, compared with JMO during weekdays (16.4%; P = 0.004) and nights (27.6%; P = <0.001). Weekend JMO were interrupted at a higher rate (6.6/h) than on weekdays (rate ratio (RR) 2.9, 95% confidence intervals (CI) 2.6, 3.3) or nights (RR 5.1, 95% CI 4.2, 6.1). Multitasking on weekends (20.9%) was comparable to weekdays (18.9%; P = 0.19) but significantly higher than nights (6.4%; P = <0.001). CONCLUSION: On weekends, JMO had few breaks, were interrupted frequently and engaged in high levels of multitasking. This pattern of JMO work could be a potential contributing factor to the weekend effect in terms of JMO abilities to respond safely and adequately to care demands.

Follow-up for cervical abnormalities in a managed care plan, 1999-2004.

OBJECTIVE: The objective of this study was to determine the follow-up for women after receiving an abnormal Pap test before and after the updated American Society of Colposcopic and Cervical Pathology (ASCCP) guidelines for management of abnormal cytology. METHODS: In 1999 and 2004, women who had been enrolled in a US health care plan for at least 21 months and were between 18 and 70 years of age were included. We calculated differences in type of follow-up between the time periods before and after ASCCP guideline changes in 2002. RESULTS: Overall, 1.7 million women met study criteria and received at least one Pap test. Overall, 227,802 (14%) women received additional follow-up. Of these women, 73% had a repeat Pap test within 9 months as their first follow-up, 13% received colposcopy, and 7% had other events. The proportion of women receiving a repeat Pap test decreased significantly during the post-guideline time period. The odds of a woman receiving a colposcopy versus a repeat Pap test were 41% higher in the post-guideline period, after controlling for other variables. CONCLUSIONS: Our findings indicate that for the time period after the ASCCP guidelines changed, more colposcopies and fewer repeat Pap tests were performed as a follow-up of abnormal Pap test.

Risk factors for infection with HBV and HCV in a largecohort of hemophiliac males.

BACKGROUND: Before the implementation of donor screening and the development of effective virus-inactivation procedures, persons with hemophilia (PWHs) were at risk of infection with HBV and HCV transmitted through clotting factor concentrates. STUDY DESIGN AND METHODS: Data collected from the medical records of a cohort of 2,772 males with hemophilia who resided in six states of the United States were used to examine relations between demographic and clinical characteristics and laboratory markers of past or present infection with HBV and HCV using logistic regression. RESULTS: Test results were available for 60 percent of the cohort. Among those tested, 30 percent were positive for markers of HBV infection and 64 percent for HCV infection. Factors associated with increased odds of positive HBV markers and HCV infection were greater severity of hemophilia, larger amounts of factor use, and HIV infection. Markers of HBV infection persisted in birth cohorts as late as 1992 and those of HCV infections in birth cohorts through 1991. Compared to same-age US males, PWHs born between 1987 and 1989 were more likely to have markers of HBV and HCV infection. CONCLUSION: PWHs who received clotting factor concentrates before 1990 may be at risk for infection with hepatitis B or hepatitis C and should be tested.

Early-stage breast cancer treatment among medically underserved women diagnosed in a national screening program, 1992-1995.

BACKGROUND: Little research has been conducted on the breast cancer treatment of low income, underserved women. This study was designed to describe initial treatment of breast cancer among low-income women diagnosed through federally funded screening programs in Detroit, Michigan, and the states of New Mexico and California; and to compare the treatment received by program women with early-stage breast cancer with that of all women diagnosed in those regions. METHODS: Data from the three screening programs were linked with cancer registry data from the corresponding geographic areas. All women diagnosed between 1992 and 1995 through the state-based screening programs and all women contemporaneously diagnosed with breast cancer in the three regions were studied. Descriptive analyses were done of the proportion of women with breast cancer receiving treatment; the proportion of early-stage breast cancer (stage I or II) cases treated with breast-conserving surgery, and the proportion treated with mastectomy; and among women with breast-conserving surgery, the proportion receiving radiation therapy. Logistic regression models controlled for age and stage at diagnosis, race or ethnicity and geographic region. RESULTS: Less than 2% of program women diagnosed with breast cancer received no treatment. More than two of five women with early-stage breast cancer underwent breast-conserving surgery, with 72% of these women receiving radiation therapy. Multivariate regression analysis revealed that women with stage IIA or IIB breast cancer had lower odds of undergoing breast-conserving surgery than women with stage I (0.51 [95% CI = 0.30-0.87] and 0.36 [95% CI = 0.19-0.70], respectively). Women over age 65 and those with incompletely staged cancer had the lowest odds for receiving radiation therapy after breast-conserving surgery (0.29 [95% CI = 0.09-0.99] and 0.14 [95% CI = 0.03-0.72], respectively). Women diagnosed through the screening programs had odds of undergoing breast-conserving surgery similar to those of all women in the regions (1.11 [95% CI= 0.89-1.39]). CONCLUSIONS: Treatment patterns for women diagnosed with early-stage breast cancer through three state-based screening programs appear to have been similar to those reported in the literature. In addition, their treatment appears to have been similar to that of other women during the same time period.

Mammography and breast cancer detection by race and Hispanic ethnicity: results from a national program (United States).

OBJECTIVE: Some of the racial and ethnic variation in breast cancer incidence rates may reflect differential use of mammography. We report breast cancer rates using mammography and diagnostic data from five race/ethnicity groups. METHODS: Mammography data were analyzed for 573,751 women who received breast cancer screening between July 1991 and March 1998 from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Abnormal mammography rates, breast cancer detection rates, and cancer stage distribution data are presented by race/ethnicity and screening round (first or subsequent). RESULTS: For the first screening round, percentages of abnormal mammographies ranged from 7.3% among black women to 9.3% among Asian/Pacific Islander women. Cancer detection rates ranged from 4.9 cancers per 1000 mammograms for Hispanic and American Indian/Alaska Native (AI/AN) women to 7.7 per 1000 for white women. Subsequent round rates were lower but varied similarly. AI/AN women had the highest percentage (68%) of first-round cancers detected in the early stage (range for the other groups: 52-63%). CONCLUSIONS: Breast cancer detection rates for racial and ethnic groups in this program varied less than published population-based incidence rates. Differential use of mammography among these groups may account for some of the variation reported for breast cancer incidence.

Mass screening in low-income populations: the challenges of securing diagnostic and treatment services in a national cancer screening program.

Funding for many mass screening programs for low-income and uninsured populations provides resources for screening tests, yet only rarely does it provide coverage for necessary follow-up diagnostic and treatment services. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), a federally funded initiative that provides cancer screening to low-income uninsured and underinsured women, covers some diagnostic follow-up tests and no treatment services. We conducted in-depth case studies of seven state programs participating in the NBCCEDP to investigate the strategies and approaches being used to secure diagnostic and treatment services. The results suggest that the program relies on a patchwork of resources--at state and local levels--to provide diagnostic and treatment services. This includes a number of components of local safety nets, all of which are unstable and have uncertain futures. Public health disease-screening initiatives need to reconsider the feasibility of continued reliance on case-by-case appeals to the local safety net for diagnostic follow-up and treatment services.

Time to diagnosis and treatment of breast cancer: results from the National Breast and Cervical Cancer Early Detection Program, 1991-1995.

OBJECTIVES: This study examined times to diagnosis and treatment for medically underserved women screened for breast cancer. METHODS: Intervals from first positive screening test to diagnosis to initiation of treatment were determined for 1659 women 40 years and older diagnosed with breast cancer. RESULTS: Women with abnormal mammograms had shorter diagnostic intervals than women with abnormal clinical breast examinations and normal mammograms. Women with self-reported breast symptoms had shorter diagnostic intervals than asymptomatic women. Diagnostic intervals were less than 60 days in 78% of cases. Treatment intervals were generally 2 weeks or less. CONCLUSIONS: Most women diagnosed with breast cancer were followed up in a timely manner after screening. Further investigation is needed to identify and then address factors associated with longer diagnostic and treatment intervals to maximize the benefits of early detection.

Strategies for follow-up and treatment services in state breast and cervical cancer screening programs.

This report describes strategies used to provide diagnostic follow-up and treatment services to low-income women screened through the National Breast and Cervical Cancer Early Detection Program.

Effect of oxygen concentration and redox potential on recovery of sublethally heat-damaged cells of Escherichia coli O157:H7, Salmonella enteritidis and Listeria monocytogenes.

The measured heat resistance of cells of Escherichia coli O157:H7, Salmonella enteritidis and Listeria monocytogenes was up to eightfold greater when they were grown, heated and recovered anaerobically rather than aerobically. Measured heat resistance was highest when anaerobic gas mixtures were used (time at 59 degrees C for a 6-decimal (6-D) reduction of E. coli O157:H7, 19-24 min); moderate when low concentrations of oxygen (0.5-1%) were included (time for a 6-D reduction, 5-17 min); and lowest when higher concentrations of oxygen (2-40%) were used (time for a 6-D reduction, 3 min). This effect was principally attributed to the recovery conditions, and a greater effect was noted at lower heating temperatures. The use of reduced oxygen concentration (< 2% O2), e.g. packing under an anaerobic gas mixture or a vacuum, might therefore increase the risk of these pathogens surviving heat treatments applied to food. It is also possible that foods that are packed in air but with a low redox potential might allow the survival of heated cells, and thus the anticipated level of safety might not be achieved.

Predictive models of the effect of temperature, pH and acetic and lactic acids on the growth of Listeria monocytogenes.

The combined effect of temperature (1-20 degrees C), pH (4.5-7.2) and acetic acid (0-10,000 mg/l; model 1) or lactic acid (0-20,000 mg/l; model 2) on growth of Listeria monocytogenes in laboratory media was studied. Growth curves at various combinations of temperature, pH and acid concentration were fitted by the model of Baranyi and Roberts (1994), and specific growth rates derived from the curve fit were modelled. Predictions of growth from the models were compared with data in the literature, and this showed the models to be suitable for use in predicting growth of L. monocytogenes in a range of foods including meat, poultry, fish, egg and milk and dairy products. The two models are compatible, i.e. they give similar predictions for cases when no acid is present.

Acute effects of amiodarone on membrane properties, refractoriness, and conduction in guinea pig papillary muscles.

Amiodarone has potent and complex antiarrhythmic effects associated with a rare incidence of proarrhythmia. For a comprehensive understanding of its antiarrhythmic mechanisms in the same preparations, amiodarone (50 microM) was employed as it would be in the clinical setting and applied to guinea pig papillary muscles impaled by microelectrodes, paced at different rates, and superfused with various concentrations of potassium ([K]e). Amiodarone exerted complex actions, as follows: (1) The maximum rate of rise (Vmax) of the fast action potential (i.e., [K]e = 5.4-9.0 mM) as well as that of the slow action potential (i.e., [K]e = 15.0 mM in the presence of 1.0 microM isoproterenol) was suppressed in a rate-dependent manner. (2) Amiodarone exhibited a rate- and [K]e-dependent increase in the ratio of effective refractory period vs action potential duration at 90% repolarization (ERP/APD90), disclosing post-repolarization refractoriness. (3) Amiodarone had no effect on passive cable factors, such as threshold current and tissue resistance, during propagation. These versatile electrophysiological effects of amiodarone may contribute to its unique antiarrhythmic effects, as well as the low incidence of proarrhythmia with this drug.