Neighbourhood influence on the fourth dose of diphtheria-tetanus-pertussis vaccination.

OBJECTIVES: Using 542,159 vaccination records from children born between April 1, 2007, and March 31, 2012, in the Michigan Care Improvement Registry and data from the American Community Survey, we determine if neighbourhood-level characteristics at the Census tract level and block level are associated with low uptake of the fourth dose of diphtheria-tetanus-acellular pertussis vaccine (DTaP4). STUDY DESIGN: This study was a cross-sectional study. METHODS: We used exploratory factor analysis to determine important socio-economic factors at the Census block level and tract level. We then used generalised estimating equations to test the relationship between block- and tract-level socio-economic factors and DTaP4 uptake. RESULTS: DTaP4 coverage was 88.6% (95% confidence interval [CI]: 88.4%-88.7%) in Michigan. At the Census tract level, two factors surfaced as important for DTaP4 vaccination: 'affluence' (Cronbach's alpha = 0.88) and 'socio-economic disadvantage' (Cronbach's alpha = 0.89). At the Census block level, one factor was important: 'affluence' (Cronbach's alpha = 0.90). Affluence may relate to knowledge about medical exemptions and antivaccination sentiment, while socio-economic disadvantage may indicate limited access to healthcare resources. Children in high-affluence tracts had 1.08% lower vaccination coverage (95% CI: -1.62% to -0.55%) than children in low affluence tracts. Children in low socio-economic disadvantage tracts had 2.92% higher coverage than children in high socio-economic disadvantage tracts (95% CI: 2.58%-3.26%). CONCLUSIONS: This study articulates the need to further understand the contribution of neighbourhood-level characteristics, from both affluent and socioeconomically disadvantaged areas to low vaccination rates. Developing a better understanding of these social environmental factors will help determine useful community-level interventions to improve vaccination rates and reduce disease burden.

Risk factors for measles among infants in Tianjin, China.

OBJECTIVES: Infants aged <8 months are ineligible for measles vaccination in China but represent a disproportionate number of cases. We examined the risk factors for measles among infants in Tianjin, China. STUDY DESIGN: Case-control study. METHODS: Cases were enrolled from a surveillance system, and IgG-negative controls were sampled from registries at immunization clinics. A logistic regression model assessed for risk factors. RESULTS: Among 82 cases and 485 controls, exposure to a municipal hospital (OR [odds ratio]: 5.21; 95% confidence interval [CI]: 1.19-22.82) or a specialty hospital (OR: 13.22; 95% CI: 6.13-28.51) was associated with the disease, whereas visiting a township or district hospitals was not associated with increased odds of measles. CONCLUSIONS: Hospitals were an important focal point of measles transmission for infants. Hospitals, particularly higher-level municipal and specialty hospitals, should enforce infection control programs to separate infants with highly communicable diseases to prevent transmission.

The Sustained-Release Dexamethasone Implant: Expanding Indications in Vitreoretinal Disease.

Corticosteroids play an important role in the therapeutic approach to vitreoretinal disease. The Ozurdex implant (DEX Implant 0.7 mg, Ozurdex, Allergan Inc., Irvine, CA, USA) offers sustained release of dexamethasone in the vitreous cavity, and this novel drug delivery system has proven useful both in improving clinical outcomes and in reducing injection burden. While the Food and Drug Administration approves the use of the DEX implant in retinal vein occlusions and non-infectious posterior uveitis, its utilization continues to expand in its breadth of diversity across myriad vitreoretinal conditions. Additionally, modified injection techniques are evolving to improve the safety profile of the DEX implant in eyes that are often considered to have relative contraindications to its use, further extending its application. This review aims to evaluate the evidence supporting the expanding indications and injection techniques of the DEX sustained-release implant in vitreoretinal disease, and explores potential future indications for its use. Arenas for future research are also identified to further elucidate the precise role of the DEX implant in our current treatment model. Increased awareness of effective and safe uses of the DEX implant can refine our therapeutic approach to vitreoretinal disease and ultimately improve patient outcomes.

Autism treatment in the first year of life: a pilot study of infant start, a parent-implemented intervention for symptomatic infants.

The goal of early autism screening is earlier treatment. We pilot-tested a 12-week, low-intensity treatment with seven symptomatic infants ages 7-15 months. Parents mastered the intervention and maintained skills after treatment ended. Four comparison groups were matched from a study of infant siblings. The treated group of infants was significantly more symptomatic than most of the comparison groups at 9 months of age but was significantly less symptomatic than the two most affected groups between 18 and 36 months. At 36 months, the treated group had much lower rates of both ASD and DQs under 70 than a similarly symptomatic group who did not enroll in the treatment study. It appears feasible to identify and enroll symptomatic infants in parent-implemented intervention before 12 months, and the pilot study outcomes are promising, but testing the treatment's efficacy awaits a randomized trial.

Exercise influences circadian gene expression in equine skeletal muscle.

Circadian rhythms are endogenously generated 24-h oscillations that coordinate numerous aspects of mammalian physiology, metabolism and behaviour. The existence of a molecular circadian clock in equine skeletal muscle has previously been demonstrated. This study investigates how the circadian 24-h expression of exercise-relevant genes in skeletal muscle is influenced by a regular exercise regime. Mid-gluteal, percutaneous muscle biopsies were obtained over a 24-h period from six Thoroughbred mares before and after an 8-week exercise programme. Real-time qPCR assays were used to assess the expression patterns of core clock genes ARNTL, PER2, NR1D1, clock-controlled gene DBP, and muscle genes MYF6, UCP3, VEGFA, FOXO1, MYOD1, PPARGC1A, PPARGC1B, FBXO32 and PDK4. Two-way repeated measures ANOVA revealed a significant interaction between circadian time and exercise for muscle genes MYF6, UCP3, MYOD1 and PDK4. A significant effect of time was observed for all genes with the exception of VEGFA, where a main effect of exercise was observed. By cosinor analysis, the core clock genes, ARNTL (P <0.01) and NR1D1 (P <0.05), showed 24-h rhythmicity both pre- and post-exercise, while PER2 expression was rhythmic post-exercise (P <0.05) but not pre-exercise. The expression profiles of muscle genes MYOD1 and MYF6 showed significant fits to a 24-h cosine waveform indicative of circadian rhythmicity post-exercise only (P <0.01). This study suggests that the metabolic capacity of muscle is influenced by scheduled exercise and that optimal athletic performance may be achieved when exercise times and competition times coincide.

Dietary crude protein intake influences rates of whole-body protein synthesis in weanling horses.

The objective of this study was to measure whole-body protein kinetics in weanling horses receiving forage and one of two different concentrates: (1) commercial crude protein (CCP) concentrate, which with the forage provided 4.1 g CP/kg bodyweight (BW)/day (189 mg lysine (Lys)/kg BW/day), and (2) recommended crude protein (RCP) concentrate which, with the same forage, provided 3.1 g CP/kg BW/day (194 mg Lys/kg BW/day). Blood samples were taken to determine the response of plasma amino acid concentrations to half the daily concentrate allocation. The next day, a 2 h-primed, constant infusion of [(13)C]sodium bicarbonate and a 4 h-primed, constant infusion of [1-(13)C]phenylalanine were used with breath and blood sampling to measure breath (13)CO2 and blood [(13)C]phenylalanine enrichment. Horses on the CCP diet showed an increase from baseline in plasma isoleucine, leucine, lysine, threonine, valine, alanine, arginine, asparagine, glutamine, ornithine, proline, serine, and tyrosine at 120 min post-feeding. Baseline plasma amino acid concentrations were greater with the CCP diet for histidine, isoleucine, leucine, threonine, valine, asparagine, proline, and serine. Phenylalanine, lysine, and methionine were greater in the plasma of horses receiving the RCP treatment at 0 and 120 min. Phenylalanine intake was standardized between groups; however, horses receiving the RCP diet had greater rates of phenylalanine oxidation (P = 0.02) and lower rates of non-oxidative phenylalanine disposal (P = 0.04). Lower whole-body protein synthesis indicates a limiting amino acid in the RCP diet.

Refracture with cement extrusion following percutaneous vertebroplasty of a large interbody cleft.

We present a case report of a patient on long-term dialysis who underwent percutaneous vertebroplasty to treat a painful intrabody vertebral cleft and who subsequently experienced a refracture of the posterior portion of the same vertebral body, resulting in anterior displacement of the cement through the anterior cortex. The case raises the question whether, in some patients, the marrow space should be filled with cement in addition to the cleft.

Outcome comparison of patients receiving oral or depot neuroleptic medication.

Three outcome measures of psychiatric treatment were retrospectively compared between two groups of acutely hospitalized psychotic patients who had been prescribed either oral haloperidol (n = 58) or depot haloperidol (n = 95) as the only medication at the time of discharge. There were no significant differences between the groups on demographic variables, including sex, age, and ethnicity. There were no significant differences between the groups on keeping the initial outpatient appointment, in readmission history over a 4-yr. follow-up, or in length of time to subsequent readmission, if any. It appears that there is no benefit in choosing one form of medication over the other from a clinical perspective, as neither appears more clinically efficacious when examined on these outcome variables. However, there is a significant difference in cost of the two forms of the medication in favor of the oral form, making the oral form more favorable if cost is to be minimized.

Isolated stenosis of a persistent hypoglossal artery visualized at 3D CT angiography.

The persistent hypoglossal artery is a rare perseverance of an embryonic vessel connecting the anterior and posterior circulations and is generally considered to be an incidental finding. This is a case of a patient with an atherosclerotic narrowing at the origin of the persistent hypoglossal artery seen at 3D CT angiography. The pertinent findings and clinical implications of this anomalous vessel are discussed.

Relationship of Schmorl's nodes to vertebral body endplate fractures and acute endplate disk extrusions.

BACKGROUND AND PURPOSE: Literature regarding clinical pain syndromes associated with acute, traumatic Schmorl's nodes (SNs) is limited. Our purpose was to determine whether an SN could be related to a previous traumatic event producing either acute SN or a vertebral endplate fracture. METHODS: Two neuroradiologists independently reviewed initial and follow-up MR examinations of 14 patients with a clinical diagnosis of acute, symptomatic thoracolumbar SNs or vertebral body endplate fractures that evolved into SNs to evaluate marrow edema, signal intensity, margin definition, presence of intravertebral extruded disk material, and pattern of contrast enhancement. RESULTS: Edema of the affected vertebral body, adjacent to an endplate without wedging or collapse, was observed on the initial MR images in all cases. The initial MR images of six (43%) of 14 patients exhibited only edema of the marrow immediately adjacent to the endplate without wedging or collapse. The MR images obtained at the time of follow-up showed subsequent formation of a chronic and eventually asymptomatic SN for all six patients. The initial MR images of eight (57%) of the 14 patients showed the typical appearance of acute SNs with marrow edema of the affected vertebra. The contrast-enhanced images of three patients manifested enhancement of the invaginated disk material in three (100%) of three cases and enhancement of the surrounding vertebral body in one case (33%). Six (43%) of 14 patients had acute typical compression fracture of a vertebral body of at least one additional level. CONCLUSION: Most (57%) of the SNs in this series could be traced to episodes of significant, sudden-onset, localized, nonradiating back pain and tenderness for which the MR images showed SNs surrounded by vertebral body marrow edema. The remaining SNs (43%) were not immediately apparent as SNs and manifested only as vertebral body edema representing endplate fracture but did evolve into classical chronic SNs that follow-up imaging revealed.

Radiologic manifestations of round pneumonia in adults.

Round pneumonia, a benign cause of coin lesions seen on chest radiography, can often be difficult to distinguish from bronchogenic carcinoma. Although relatively uncommon in adults, this entity will probably be seen in most radiology practices and may lead to CT and biopsy. Because round pneumonia is easily treated with antibiotics, this diagnosis should be considered in all patients with a coin lesion, keeping in mind that bronchogenic carcinoma is much more frequent. A recent chest radiograph with normal findings or a history of cough and fever can aid in the diagnosis. A trial of antibiotics followed by a second chest radiograph in 2-3 weeks may be indicated in symptomatic or younger patients but should be considered in all patients with a solitary pulmonary nodule, because round pneumonia can occur in patients of any age and may be clinically silent. Any patient with a pulmonary nodule that does not decrease in size or resolution after antibiotic treatment should be further assessed with bronchoscopy, transthoracic needle biopsy, or other diagnostic procedures.

Measurement of the normal optic chiasm on coronal MR images.

PURPOSE: To develop an objective method for measuring the optic chiasm and to document its normal range in size. METHODS: Measurements of the height and area of the optic chiasm, made on coronal T1-weighted MR images with the use of commercially available region-of-interest software, were obtained in 114 healthy subjects who had a total of 123 MR studies. A normal range and standard deviation were calculated, and the information was broken down by age and sex. RESULTS: The mean area of the optic chiasm was 43.7 mm2, with a standard deviation of 5.21. The mean width was 14.0 mm, with a standard deviation of 1.68. CONCLUSION: The area and width of the optic chiasm can be measured with the use of commercially available software, which allows an objective estimate of the chiasm's size. Knowledge of the normal size range of the optic chiasm can be helpful in the early detection of some disorders.

Indocyanine green videoangiography of hemorrhagic retinal arterial macroaneurysms.

We examined 3 patients with isolated retinal macroaneurysms and secondary hemorrhage by standard fluorescein angiography (FA) and indocyanine green (ICG) angiography. In contrast to standard FA, ICG videoangiography clearly demonstrated the lesion to be pulsatile, contiguous with the arterial wall and pathognomonic of an isolated retinal artery macroaneurysm. ICG with its absorption and emission peak in the near-infrared range penetrates hemorrhage to a greater degree than does blue or green light of conventional FA. ICG can be essential in delineating the specific cause of the bleeding and allow the physician to choose the correct specific form of treatment needed.

Can the Yale-Brown Obsessive Compulsive Scale be used to assess trichotillomania? A preliminary report.

Given recent conceptualizations of trichotillomania (TM) as a variant of obsessive compulsive disorder (OCD), clinician-rated measures of obsessive compulsive symptoms have been adapted for use in the assessment of TM. Although the reliability and validity of these instruments have been well-documented in patients with OCD, psychometric properties have not been examined systematically in patients with TM. Here, we evaluate the reliability and validity of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) in a sample of 11 patients with a primary diagnosis of TM. Data addressed the utility of the Y-BOCS for evaluating symptoms of TM, and provided information regarding the proposed overlap between OCD and TM. Initial analyses suggested that interrater reliability, internal consistency, and test-retest reliability for the total score were adequate. However, the range of scores was somewhat restricted, and suggested in particular that interference in daily functioning from TM symptoms is quite low. Both internal consistency and test-retest reliability for the Target Behaviors subscale were inadequate, suggesting that this combined score is inappropriate for use with TM patients. Concurrent validity data using the total score were mixed, although the Y-BOCS did appear to be sensitive to change in TM symptoms over treatment. Implications for the use of the Y-BOCS with TM patients and hypothesized phenomenological differences between TM and OCD are discussed.

Laser excisional conization in an office environment.

Use of the laser as an excisional tool in the treatment of cervical disease is an established technique. A study was constructed to determine whether laser excisional conization could be done safely and effectively in an office environment. The subjects of the study were 104 sequential patients who underwent laser excisional cone in an office environment. The average cone size was 16.5 mm by 12.5 mm. The average operating time was 15 minutes. Margins of the cone specimen were adequate for interpretation in 100 patients (96%). Of patients available for complete posttherapy follow-up, 96/98 (98%) achieved initial cure of their lesion. Complications included bleeding requiring revisit in 7.7%, relocation of the SCJ out of colposcopic view in 7%, and cervical stenosis/occlusion in 2 patients. Four pregnancies have occurred and have either been delivered or are progressing satisfactorily. We believe that laser excisional conization may safely and effectively be moved out of the operating room environment.