Impact of Plans of Safe Care on Prenatally Substance Exposed Infants.

OBJECTIVE: To assess the impact of recent federal statute changes mandating child welfare-based Plan of Safe Care (POSC) supportive programming and community-based linkages to treatment providers, resources, and services for families of infants affected by prenatal substance exposure (IPSE). STUDY DESIGN: Retrospective review of Delaware's statewide child welfare case registry data for IPSE birth notifications and subsequent hotline reports for serious physical injury/fatality concerns from November 1, 2018-October 31, 2020. Abstracted variables included IPSE sex, substance exposure type, family characteristics (maternal personal child welfare history or mental health diagnosis, treatment engagement), and POSC referrals. RESULTS: Of 1436 IPSE, 1347 (93.8%) had POSC support. Most IPSE (67.2%) had exposure to single substance types prenatally. Nearly 90% avoided out-of-home placement. Nearly one-fourth of mothers delivered a prior IPSE; 40% of mothers had personal histories of childhood protective services involvement. Also, 43.5% of mothers and 9.1% of fathers were referred to community-based resources, including substance use, mental health treatment, parenting classes, and home visiting nursing. Nearly 58% of IPSE were referred for pediatric/developmental assessment. Notably, 0.82% (11 out of 1347) of IPSE with POSC sustained serious physical or fatal injury. CONCLUSIONS: POSC promote supportive, potentially protective linkages to community-based programming for IPSE and their families.

Metal and metalloid levels in blood of semipalmated sandpipers (Calidris pusilla) from Brazil, Suriname, and Delaware Bay: Sentinels of exposure to themselves, their prey, and predators that eat them.

Identifying animals as sentinels for humans and other animal species is an excellent method for understanding exposure to environmental contamination at different times and places. Shorebirds are useful sentinels because they have a world-wide distribution, eat a range of prey, and are eaten by a range of other species, including humans. We collected blood from semipalmated sandpipers (Calidris pusilla) wintering in northern (Suriname N = 71) and northeastern (Brazil N = 61) South America to examine levels of heavy metals and metalloids (arsenic, selenium), and compare them to blood levels in sandpipers at a heavily used stopover site in New Jersey (N = 30; Delaware Bay, NJ). Since blood represents relatively recent exposure, it can provide information on where and when the birds were exposed. Levels were highest in Brazil for arsenic and particularly selenium; highest in Suriname for cadmium and lead; and highest in New Jersey for chromium. Samples from Brazil and Suriname presented higher levels of mercury than did those from New Jersey. There were no geographic differences for cobalt. Levels of all metals were generally within an order of magnitude. The significant geographic difference for selenium was interesting because it is regulated in the body. Selenium levels in the NJ sample were directly proportional to levels found in their principle food at this migration stopover site (eggs of horseshoe crab, Limulus polyphemus). Mean selenium level was almost an order of magnitude higher in the semipalmated sandpiper blood samples from Brazil (mean of 27,500 µg/L= ppb) compared to the other sampling locations (mean > 5330 µg/L). This is a toxic level and cause for concern and further investigation, alerting us to look for other evidence of excess selenium exposure. Otherwise the levels of other metals are generally not high enough to cause harm to the sandpipers themselves or to predators that eat them. We discuss the implications for these birds and their exposure to contaminants at different stopover sites.

Development and validation of an instrument to assess imminent risk of homelessness among veterans.

OBJECTIVES: Veterans are overrepresented within the homeless population compared with their non-veteran counterparts, particularly when controlling for poverty. The U.S. Department of Veterans Affairs (VA) aims to prevent new episodes of homelessness by targeting households at greatest risk; however, there are no instruments that systematically assess veterans' risk of homelessness. We developed and tested a brief screening instrument to identify imminent risk of homelessness among veterans accessing VA health care. METHODS: The study team developed initial assessment items, conducted cognitive interviews with veterans experiencing homelessness, refined pilot items based on veterans' and experts' feedback and results of psychometric analyses, and assigned weights to items in the final instrument to indicate a measure of homelessness risk. RESULTS: One-third of veterans who responded to the field instrument reported imminent risk of homelessness (i.e., housing instability in the previous 90 days or expected in the next 90 days). The reliability coefficient for the instrument was 0.85, indicating good internal consistency. Veterans who had a recent change in income, had unpaid housing expenses, were living temporarily with family and friends, needed help to get or keep housing, and had poor rental and credit histories were more likely to report a risk of homelessness than those who did not. CONCLUSION: This study provides the field with an instrument to identify individuals and households at risk of or experiencing homelessness, which is necessary to prevent and end homelessness. In addition, it supports VA's investment in homelessness prevention and rapid rehousing services for veterans who are experiencing or are at risk for homelessness.

Avian paramyxoviruses in shorebirds and gulls.

There are nine serotypes of avian paramyxovirus (APMV), including APMV-1, or Newcastle disease virus. Although free-flying ducks and geese have been extensively monitored for APMV, limited information is available for species in the order Charadriiformes. From 2000 to 2005 we tested cloacal swabs from 9,128 shorebirds and gulls (33 species, five families) captured in 10 states within the USA and in three countries in the Caribbean and South America. Avian paramyxoviruses were isolated from 60 (0.7%) samples by inoculation of embryonating chicken eggs; isolates only included APMV-1 and APMV-2. Two isolates (APMV-2) were made from gulls and 58 isolates (APMV-1 [41 isolates] and APMV-2 [17 isolates]) were made from shorebirds. All of the positive shorebirds were sampled at Delaware Bay (Delaware and New Jersey) and 45 (78%) of these isolates came from Ruddy Turnstones (Arenaria interpres). The APMV-1 infection rate was higher among Ruddy Turnstones compared with other shorebird species and varied by year. Avian paramyxovirus-2 was isolated from two of 394 (0.5%) Ruddy Turnstones at Delaware Bay in 2001 and from 13 of 735 (1.8%) Ruddy Turnstones during 2002. For both APMV-1 and APMV-2, infection rates were higher among Ruddy Turnstones sampled on the south shore of Delaware Bay compared to north shore populations. This spatial variation may be related to local movements of Ruddy Turnstones within this ecosystem. The higher prevalence of APMV in Ruddy Turnstones mirrors results observed for avian influenza viruses in shorebirds and may suggest similar modes of transmission.

Actinorhodopsins: proteorhodopsin-like gene sequences found predominantly in non-marine environments.

Proteorhodopsins are light-energy-harvesting transmembrane proteins encoded by genes recently discovered in the surface waters of the world's oceans. Metagenomic data from the Global Ocean Sampling expedition (GOS) recovered 2674 proteorhodopsin-related sequences from 51 aquatic samples. Four of these samples were from non-marine environments, specifically, Lake Gatun within the Panama Canal, Delaware Bay and Chesapeake Bay and the Punta Cormorant Lagoon in Ecuador. Rhodopsins related to but phylogenetically distinct from most sequences designated proteorhodopsins were present at all four of these non-marine sites and comprised three different clades that were almost completely absent from marine samples. Phylogenomic analyses of genes adjacent to those encoding these novel rhodopsins suggest affiliation to the Actinobacteria, and hence we propose to name these divergent, non-marine rhodopsins 'actinorhodopsins'. Actinorhodopsins conserve the acidic amino acid residues critical for proton pumping and their genes lack genomic association with those encoding photo-sensory transducer proteins, thus supporting a putative ion pumping function. The ratio of recA and radA to rhodopsin genes in the different environment types sampled within the GOS indicates that rhodopsins of one type or another are abundant in microbial communities in freshwater, estuarine and lagoon ecosystems, supporting an important role for these photosystems in all aquatic environments influenced by sunlight.

The relationship of body mass index and blood pressure in primary care pediatric patients.

OBJECTIVE: To determine whether an association of overweight, or risk of overweight, and blood pressure can be detected in children in the pediatric primary care practice setting. STUDY DESIGN: We examined electronic medical record (EMR) data from primary care practices on 18,618 children age 2 to 19 years. Each child was classified on the basis of age- and sex-specific body mass index (BMI) percentile as normal weight (BMI < 85th percentile), at risk for overweight (BMI > or = 85th and < 95th percentile), or overweight (BMI > or = 95th percentile). BMI Z-score and height Z-score were computed. Systolic and diastolic blood pressures were compared among age-sex-BMI groups. RESULTS: Among children in primary care pediatric practices, 16.7% were at risk of overweight and 20.2% were overweight. With increasing BMI status there was a significant increase in both systolic blood pressure (P < .001) and diastolic blood pressure (P < .001). The association of higher blood pressure with increasing BMI status was present in all age groups. CONCLUSIONS: Clinical data from pediatric primary care practices verify the high prevalence of childhood overweight. The effect of overweight on blood pressure is present in childhood and can be detected even in children as young as 2 to 5 years.

Developing local public health capacity in cultural competency: a case study with Haitians in a rural community.

With the increase in cultural diversity in all regions of the United States, public health employees and other health care providers are more challenged than ever before to provide culturally sensitive care to citizens from an increasing range of cultures. Building on their existing experience and skill, health care staff must expand their competencies to address this changing diversity in their communities. This project serves as a case study of how 1 small rural health department in Delaware created a Web site using Purnell's model for cultural competence (Purnell & Paulanka, 2003) as the organizational framework and rose to the challenge of assisting public health staff to provide culturally sensitive health services to a rapidly increasing population of Haitian immigrants.

Rapid population decline in red knots: fitness consequences of decreased refuelling rates and late arrival in Delaware Bay.

Most populations of migrant shorebirds around the world are in serious decline, suggesting that vital condition-dependent rates such as fecundity and annual survival are being affected globally. A striking example is the red knot (Calidris canutus rufa) population wintering in Tierra del Fuego, which undertakes marathon 30,000 km hemispheric migrations annually. In spring, migrant birds forage voraciously on horseshoe crab eggs in Delaware Bay in the eastern USA before departing to breed in Arctic polar deserts. From 1997 to 2002 an increasing proportion of knots failed to reach threshold departure masses of 180-200 g, possibly because of later arrival in the Bay and food shortage from concurrent over-harvesting of crabs. Reduced nutrient storage, especially in late-arriving birds, possibly combined with reduced sizes of intestine and liver during refuelling, had severe fitness consequences for adult survival and recruitment of young in 2000-2002. From 1997 to 2002 known survivors in Delaware Bay were heavier at initial capture than birds never seen again, annual survival of adults decreased by 37% between May 2000 and May 2001, and the number of second-year birds in wintering flocks declined by 47%. Population size in Tierra del Fuego declined alarmingly from 51,000 to 27,000 in 2000-2002, seriously threatening the viability of this subspecies. Demographic modelling predicts imminent endangerment and an increased risk of extinction of the subspecies without urgent risk-averse management.

Pediatric red blood cell transfusions increase resource use.

OBJECTIVE: To test the hypothesis that red blood cell transfusions are associated with increased resource utilization and mortality in critically ill children. METHODS: Five pediatric intensive care units (PICUs) participated in a retrospective, cohort analysis (1996-1999). Children with a hemoglobin value

Pseudo-outbreak of tuberculosis in poultry plant workers, Sussex County, Delaware.

Delaware is a leading US poultry-producing state, and foreign-born workers make up a significant percentage of those employed by Delaware's poultry plants. In Sussex County, Delaware, a high percentage of the poultry workers are from two countries with a high incidence of tuberculosis (TB), Mexico and Guatemala, and thus are at risk for TB infection and disease. Furthermore, their risk of TB may be increased because many of these workers live in crowded conditions and lack access to medical care.

Geographical, seasonal, and sex dynamics of Shipleya inermis (Cestoidea: Dioecocestidae) in Limnodromus griseus Gmelin (Aves: Charadriiformes).

We recovered the cestode Shipleya inermis from 79 of 82 short-billed dowitchers, Limnodromus griseus Gmelin, collected at various locations and times along their migratory route. Previous studies that examined various aspects of the cestode's biology were limited to North America. Data collected from North and South America in the present study provide new information on the geographical and seasonal distribution of this cestode. Although prevalence of infection was high at all times of the year, mean abundance varied from season to season and was significantly higher during the winter months than in the summer, suggesting that most recruitment takes place on the wintering grounds. Sexually mature and gravid cestodes were recovered at all locations, indicating S. inermis is a ubiquitous parasite within the host's range. Shipleya inermis showed a marked tendency to occur in pairs of male and female strobila. Analysis of the patterns of occurrence suggests that S. inermis is a protogynous hermaphrodite that usually becomes regionally dioecious, possibly in response to some form of interaction between individuals.

Himasthla limnodromi n. sp. (Digenea: Echinostomatidae) from the short-billed dowitcher, Limnodromus griseus (Aves: Scolopacidae).

Himasthla limnodromi n. sp. is described from short-billed dowitchers, Limnodromus griseus, from the Araya Peninsula, Venezuela, and Delaware Bay, U.S.A. Himasthla limnodromi was not found in dowitchers on the breeding grounds or on the fall staging grounds in the Bay of Fundy but reappeared in dowitchers on the wintering grounds in the fall. This suggests that H. limnodromi is acquired by the birds on arrival on the wintering grounds and then gradually disappears during the birds' northward migration in the spring. The new species has a reniform collar armed with 31 spines, with 23 in a single uninterrupted row, and 4 corner spines in overlapping pairs at each end. The cirrus sac is up to 10 times longer than the length of the acetabulum and contains a long, smooth cirrus. The vitellaria always commence posterior to the posterior end of the cirrus sac in mature specimens. The testes are found in the posterior eighth of the long, filamentous body. Himasthla limnodromi n. sp. most closely resembles Himasthla alincia, but H. limnodromi is larger in size and has an unspined cirrus and smaller eggs.

Flipping assumptions and revisioning perioperative services.

As we approach a fully capitated healthcare environment, total revisioning and restructuring of hospitals as a whole, and perioperative services in particular, will be necessary to maintain the financial viability of our healthcare institutions. Nurse executives will be in pivotal roles in leading and influencing these hospital initiatives. The authors present a vision of the new hospital and discuss methods of responding to change within the healthcare environment, with an emphasis on perioperative services. An analysis of the findings of an operating room survey conducted with nurse executives is included in the discussion.

Informed consent for blood transfusion: a regional hospital survey.

Ninety-two hospitals in a three-state mid-Atlantic region were surveyed to determine their policy toward obtaining written informed consent for transfusion and to examine the content of written consent documents and the process by which consent is obtained. Of 81 hospitals responding, 50 (62%) required written informed consent. Hospitals with fewer than 200 beds were more likely to require written informed consent. The attending physicians had responsibility for obtaining consent in 28 (57%) of 49 institutions, most often on the day or evening before surgery. Twenty-seven of 48 forms mentioned complications: hepatitis in 80 percent, human immunodeficiency virus infection in 46 percent, nonhemolytic reactions in 32 percent, and hemolysis in 25 percent. Alternatives to allogeneic transfusion were mentioned infrequently; eight hospital forms listed autologous transfusion options and only two mentioned designated donation. The reading level required to comprehend 34 consent forms submitted was grade 14.6, which has been attained by only 23 percent of the adult United States population. Although the majority of respondent institutions require written informed consent, those forms, per se, do not document that the fundamental tenets of informed choice have been applied to the decision to transfuse blood.

Childhood typhoid fever diagnosed in an urban U.S. setting.

The majority of cases of childhood typhoid fever diagnosed in the United States occur in persons recently returned from travel abroad. We report two childhood cases of typhoid fever acquired in Mexico and India and diagnosed in an urban United States setting. This report describes these cases and provides insights into the pitfalls in recognizing this condition in a nonendemic setting as well as information concerning differential diagnosis and treatment.

Evidence for clonal spread of a single strain of beta-lactamase-producing Enterococcus (Streptococcus) faecalis to six hospitals in five states.

Beta-lactamase-producing (Bla+) enterococci have been reported in three state and two countries. Pulsed-field gel electrophoresis was used to compare 14 Bla+ Enterococcus (Streptococcus) faecalis isolated from hospitalized patients in seven states and three continents. The restriction endonuclease digestion patterns of isolates from Connecticut, Massachusetts, Lebanon, and Argentina were all markedly different, indicating that these were different strains. However, isolates from Delaware, Texas, Pennsylvania (Philadelphia and Pittsburgh), Florida, and Virginia were similar, indicating that these isolates were derivatives of a single strain. This conclusion was supported by hybridization using individual fragments as probes. Spread of Bla+ enterococci within the hospital setting was also demonstrated. These findings illustrate the value of pulsed-field gel electrophoresis for epidemiologic analyses and support the importance of identifying and containing organisms with new resistance properties in an effort to decrease their transmission to and from, as well as within, hospitals.

Intestinal parasites in a migrant farmworker population.

Three hundred thirty-nine migrant worker women and children were screened by single stool examination for intestinal parasites. Infection occurred in 34.2%. Giardia lamblia and Trichuris trichiura were the most common pathogens; Entamoeba coli and Endolimax nana were the most common commensals. Infants under 1 year of age were free of infection. Children between 2 and 5 years old and women between 25 and 35 years old had the highest prevalence. Significantly more Haitians were infected than Mexican-Americans or American blacks. Of ten symptoms, only abdominal pain and gas correlated significantly with infection. This migrant population has a greater prevalence of intestinal parasites than the general American public. Screening by stool examination may be beneficial to diminish the reservoir of infection.