Impact of nationwide enhanced implementation of best practices in pancreatic cancer care (PACAP-1): a multicenter stepped-wedge cluster randomized controlled trial.

BACKGROUND: Pancreatic cancer has a very poor prognosis. Best practices for the use of chemotherapy, enzyme replacement therapy, and biliary drainage have been identified but their implementation in daily clinical practice is often suboptimal. We hypothesized that a nationwide program to enhance implementation of these best practices in pancreatic cancer care would improve survival and quality of life. METHODS/DESIGN: PACAP-1 is a nationwide multicenter stepped-wedge cluster randomized controlled superiority trial. In a per-center stepwise and randomized manner, best practices in pancreatic cancer care regarding the use of (neo)adjuvant and palliative chemotherapy, pancreatic enzyme replacement therapy, and metal biliary stents are implemented in all 17 Dutch pancreatic centers and their regional referral networks during a 6-week initiation period. Per pancreatic center, one multidisciplinary team functions as reference for the other centers in the network. Key best practices were identified from the literature, 3 years of data from existing nationwide registries within the Dutch Pancreatic Cancer Project (PACAP), and national expert meetings. The best practices follow the Dutch guideline on pancreatic cancer and the current state of the literature, and can be executed within daily clinical practice. The implementation process includes monitoring, return visits, and provider feedback in combination with education and reminders. Patient outcomes and compliance are monitored within the PACAP registries. Primary outcome is 1-year overall survival (for all disease stages). Secondary outcomes include quality of life, 3- and 5-year overall survival, and guideline compliance. An improvement of 10% in 1-year overall survival is considered clinically relevant. A 25-month study duration was chosen, which provides 80% statistical power for a mortality reduction of 10.0% in the 17 pancreatic cancer centers, with a required sample size of 2142 patients, corresponding to a 6.6% mortality reduction and 4769 patients nationwide. DISCUSSION: The PACAP-1 trial is designed to evaluate whether a nationwide program for enhanced implementation of best practices in pancreatic cancer care can improve 1-year overall survival and quality of life. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03513705. Trial opened for accrual on 22th May 2018.

Underutilization of pneumococcal vaccine in nursing home in Washington State: report of a serotype-specific outbreak and a survey.

PURPOSE: To describe an outbreak of pneumococcal disease in a Washington state nursing home and to report a survey of pneumococcal vaccine utilization in Washington nursing homes. PATIENTS AND METHODS: Outbreak. Data were collected from nursing home residents' records. Nasopharyngeal cultures were obtained from residents and staff. Survey. Fifty-four randomly selected Washington nursing homes were surveyed about pneumococcal vaccine utilization and policies. RESULTS: Outbreak. Three confirmed and 4 possible cases of pneumococcal disease occurred over 9 days among 94 residents; 5 patients (71%) died. Cases were identified among 6 of 42 residents on 1 wing, compared with 1 of 52 on the other 2 wings (relative risk 7.4, 95% confidence interval 1.0, 398.5). Streptococcus pneumoniae serotype 9V was cultured from the blood of 3 confirmed case-patients and the nasopharynx of 2 of 73 residents. Only 7% of residents had received pneumococcal vaccine, including one case-patient who had received 14-valent vaccine without serotype 9V. Survey. Only 22% of residents were reported to have received pneumococcal vaccine; vaccination status was unknown for 66%. Physician discretion determined pneumococcal vaccination in 49 (91%) nursing homes; 9 (17%) had a written policy. Two major barriers to pneumococcal vaccination were cited: low priority among physicians (43%) and difficulty in determining residents' vaccine history (37%). CONCLUSIONS: A pneumococcal disease outbreak among undervaccinated nursing home residents probably resulted from person-to-person transmission. Pneumococcal vaccine appears to be underutilized in Washington state nursing homes.

Emergence of nalidixic acid resistant Shigella dysenteriae type 1 in Thailand: an outbreak associated with consumption of a coconut milk dessert.

BACKGROUND: Although Shigella dysenteriae type 1 has been responsible for large outbreaks of severe dysentery in many parts of Asia, relatively few cases of this disease have been reported from Thailand and have generally not involved nalidixic acid resistant strains. METHODS: Beginning March 1991, all patients with diarrhoea seen at the hospital outpatient department (OPD) in Suan Phung, Thailand (a western district near the Burmese border) were cultured for enteric pathogens. Shigella dysenteriae 1 was first recognized in July 1992, and an OPD-based case-control study was conducted to pinpoint the source of the outbreak in the community. For each case of culture confirmed S. dysenteriae 1, one control person without diarrhoea, matched by age and date of visit, was randomly selected from the OPD registry. RESULTS: Of 197 patients treated for diarrhoea at the hospital OPD in July and August 1992, 79 (40%) had bloody diarrhoea, compared with 86/561 (15%) patients seen during 16 months of previous surveillance (P < 0.0001). Shigella dysenteriae 1 was isolated from 33/197 (17%) patients. Compared to matched controls, patients with S. dysenteriae 1 were more likely to attend one of the local elementary schools (odds ratio = 6.74, P = 0.025), or live in the community surrounding this school (odds ratio for non-school age people = 18.0, P = 0.008). A cross-sectional study conducted at the school indicated that 50 (10%) of 485 students had dysentery in July. A coconut milk dessert prepared at the school was identified as the vehicle of transmission (relative risk = 24.9, P < 0.0001). CONCLUSIONS: Nalidixic acid resistant S. dysenteriae 1 emerged in a community in Thailand, and was traced to a point source outbreak at a local school.

PIP: Shigella dysenteriae type 1 has been responsible for large outbreaks of severe dysentery in many parts of Asia, but relatively few cases of the disease have been reported from Thailand and have generally not involved nalidixic acid resistant strains. Nalidixic acid resistant Shigella dysenteriae type 1, however, emerged in a community in Thailand and was traced to a point source outbreak at a local school. Beginning March 1991, as part of prospective surveillance for diarrheal disease in Suan Phung, all patients with diarrhea seen at the hospital outpatient department (OPD) in Suan Phung, Thailand, were cultured for enteric pathogens. 79 of the 197 patients treated for diarrhea at the hospital OPD in July and August 1992 had bloody diarrhea compared with 86/561 patients seen during 16 months of previous surveillance. Shigella dysenteriae type 1 was isolated from 33 of these 197 patients. Compared to matched controls, patients with Shigella dysenteriae type 1 were more likely to attend one of the local elementary schools or live in the community surrounding that school. A cross-sectional study conducted at the school found that 50 of 485 students had dysentery in July. A coconut milk dessert prepared at the school was identified as the vehicle of transmission.

Prospective study of the incidence of diarrheal disease and Helicobacter pylori infection among children in an orphanage in Thailand.

To evaluate the hypothesis that gastric infection with Helicobacter pylori increases risk for diarrheal disease in children, we conducted a yearlong prospective study among 160 orphanage children < 5 years of age in Nonthaburi, Thailand. Serum samples collected at six-month intervals were examined by ELISA for antibodies to H. pylori, and children were followed daily for the development of diarrhea. Seven percent of children were seropositive on enrollment, 59% were seronegative, and 34% were indeterminate. Among the seronegative children, seroconversion occurred at a rate of 7% per six months. Forty-six percent of children developed 214 total episodes of diarrhea. By age group, children < 18 months, 18-24 months and > 24 months of age experienced 2.6, 1.1, and 0.2 mean diarrhea episodes per six months. The incidence of diarrhea was not significantly different between children by H. pylori serostatus. We conclude that H. pylori infection was not associated with an increased risk of diarrheal disease.

Molecular characterization of Vibrio cholerae O139 isolates from Asia.

In 1992, a serologically novel clone of Vibrio cholerae, designated O139, caused large epidemics of diarrhea in India and Bangladesh. To determine the extent of the spread of V. cholerae O139 worldwide, 484 V. cholerae non-O1 strains isolated from different patients with diarrhea in Thailand, Indonesia, the Philippines, and Peru in 1993 were tested for agglutination in O139 antisera. One hundred fifty-one of these 484 isolates were examined for genes encoding cholera toxin, zonula occlulans toxin, the repetitive sequence 1, and the toxin coregulated pilin A (the V. cholerae virulence gene complex). Thirty-three percent (122 of 364) of V. cholerae non-O1 strains isolated from different patients with diarrhea in Thailand agglutinated in O139 antisera. Ninety-eight percent (120 of 122) of V. cholerae O139 contained the V. cholerae virulence gene complex. None of the 104 V. cholerae non-O1 strains isolated from patients with diarrhea in Indonesia or the 14 strains from patients with diarrhea in the Philippines were serotype O139. Four different ribotypes were found in V. cholerae O139 isolated in Asia. Twenty-three (47%) of 49 Thai O139 strains examined were of different ribotypes than isolates from India and Bangladesh; V. cholerae strains that were not O1 or O139 that were isolated from flies and water in Thailand 11 years previously in 1981 contained the same V. cholerae virulence gene complex found in V. cholerae O1 and O139. This suggests that other unidentified virulence determinants are involved in V. cholerae O139 pathogenesis.

Posttraumatic meningococcal meningitis: case report.

A case is described of fulminant meningococcal meningitis occurring 1 day after serious head and facial trauma. Although meningococcus is one of the most common causes of bacterial meningitis in general, it is distinctly rare as a cause of posttraumatic meningitis. A review of the literature is included.

Use of an enzyme immunoassay to detect serum IgG antibodies to Haemophilus ducreyi.

An experimental enzyme immunoassay (EIA) for detecting serum IgG antibody to Haemophilus ducreyi was developed using an ultrasonicated whole-cell antigen. The mean optical densities (OD) for sera from men with proven chancroid from Nairobi (47 patients) and Bangkok (72 patients) were significantly higher than those obtained from Nairobi men with genital ulcers not due to H. ducreyi, from Nairobi men with urethritis, from pregnant women in Nairobi, and from European men with sexually transmitted disease. When an OD of 0.500 was taken as the cutoff value, 89% and 55% of men with proven chancroid in Nairobi and Bangkok, respectively, were positive for H. ducreyi antibody, as compared with 2%-17% in the control groups. A rise in OD was observed in five of 18 patients with clinical chancroid. These results confirm the development of circulating antibodies in chancroid and suggest that this EIA may be useful for the diagnosis and epidemiological study of H. ducreyi infection.

Enterococcal bacteremia: to treat or not to treat, a reappraisal.

The treatment of enterococcal bacteremia not associated with endocarditis has been controversial. We retrospectively reviewed 81 episodes of enterococcal bacteremia and categorized them as to their clinical significance, using a strict case definition. Of the 81 episodes, 41 met our criteria for clinical significance. Mortality was 51% among the 41 patients with clinically significant bacteremia and 50% among the 40 patients with bacteremia of uncertain clinical significance. Despite these equivalent overall mortality figures, antibiotic therapy specific for Enterococcus species was associated with reduced in-hospital mortality among patients with clinically significant infections (relative risk [RR] = 0.46, 95% confidence interval [CI] = 0.27-0.77); mortality was also reduced in the first 7 days after the detection of bacteremia, when death was relatively likely to be directly due to the bacteremic episode (RR = 0.17, CI = 0.04-0.74). The association between appropriate antibiotic therapy and reduced mortality remained statistically significant when adjustments were made for a number of other factors related to mortality, including age, underlying conditions, prior use of antibiotics, nosocomial acquisition, polymicrobial etiology, prior surgery, and source of infection. Thus enterococcal isolates from the blood, even when of doubtful clinical significance, are poor prognostic markers associated with high mortality. However, when the clinical significance of bacteremia is defined by strict criteria, specific therapy against Enterococcus species is associated with improved outcome.

Utility of a polymerase chain reaction diagnostic system in a study of the epidemiology of shigellosis among dysentery patients, family contacts, and well controls living in a shigellosis-endemic area.

Polymerase chain reaction (PCR) diagnostic methods have rarely been used in epidemiologic studies of Shigella and enteroinvasive Escherichia coli (EIEC) infections. In this study, amplification of the invasion plasmid antigen H (ipaH) gene by PCR and standard culture methods was used to identify Shigella species or EIEC among 154 patients with dysentery, 154 age-matched controls, and family contacts in Thailand. The ipaH PCR system increased the detection of Shigella species and EIEC from 58% to 79% among patients with dysentery and from 6% to 22% among 527 family contacts; 75% of infections in family members were asymptomatic. Detection of the ipaH gene was statistically associated with dysentery. Household contacts of patients with shigellosis diagnosed only by PCR had significantly higher rates of shigellosis than household contacts of patients who did not have Shigella or EIEC infections. Detection of the ipaH gene by PCR is far more sensitive than detection by standard culture and is highly correlated with evidence of Shigella transmission among family contacts.

Is Blastocystis hominis a cause of diarrhea in travelers? A prospective controlled study in Nepal.

Although the pathogenicity of Blastocystis hominis has been extensively debated in the medical literature, controlled studies of the association between B. hominis and diarrhea are lacking. We conducted a case-control study among expatriates and tourists in Kathmandu, Nepal, in which we compared the prevalence of the organism among patients with diarrhea to that among a control group without diarrhea. B. hominis was detected in 56 (30%) of 189 patients with diarrhea, compared with 40 (36%) of 112 asymptomatic controls. Patients with diarrhea were significantly more likely to have > or = 10 B. hominis organisms per high-power (400x) field than were controls. However, among the 25 patients with this concentration of organisms, other enteric pathogens were detected in 17 (68%). Only 8 (4%) of 189 patients with diarrhea had > or = 10 B. hominis organisms per high-power field detected in the absence of other pathogens, compared with 5 (5%) of 112 asymptomatic controls. Thus, B. hominis in higher concentrations was not associated with diarrhea. There were no specific symptoms associated with B. hominis infection, and the presence of higher concentrations of the organism in stool was not associated with more-severe symptoms. Despite the high prevalence of the organism among travelers and expatriates in Nepal, the results of this study suggest that B. hominis does not cause diarrhea in this population.

Detection of Shigellae and enteroinvasive Escherichia coli by amplification of the invasion plasmid antigen H DNA sequence in patients with dysentery.

Detection of Shigella organisms and enteroinvasive Escherichia coli (EIEC) by polymerase chain reaction (PCR) was evaluated in 20 patients with dysentery before and in 17 of the 20 after treatment with ciprofloxacin. DNA sequences coding for IpaH antigen, a multiple copy sequence found on the chromosome, and the invasion plasmid locus (ial) was detected after DNA amplification in 13 stools from patients from whom shigellae or EIEC were isolated but not in 21 nondysenteric stools containing other enteric bacteria. Although shigellae or EIEC were not isolated from any patient with dysentery after ciprofloxacin treatment, IpaH and ial sequences were found after PCR amplification in 7 patients after treatment with ciprofloxacin. IpaH sequences alone were detected in 4 patients; DNA augmentation of IpaH in stools in a specific way to identify Shigella or EIEC infection in persons from whom cultures cannot be obtained promptly after the onset of diarrhea or who have received antibiotics.

Detection of Shigella and enteroinvasive Escherichia coli by PCR in the stools of patients with dysentery in Thailand.

The rate of detection of Shigella and enteroinvasive Escherichia coli (EIEC) using a PCR technique was compared with the rate detected by standard microbiological methods (bacteriology plus hybridization of E. coli colonies with a 17 kb EIEC probe) among patients with dysentery before and after antibiotic therapy. The PCR amplified DNA sequences encoding IpaH, a multiple copy sequence located on the chromosome and the invasion plasmid. Shigella or EIEC were detected using the IpaH PCR system among 72 (61%) of 119 patients with dysentery on the first day they were seen at hospital, compared to 50 (42%) using standard microbiological methods (p = 0.006). After three days of antibiotic therapy, IpaH sequences were detected in stools from 38 percent of patients, compared to 10 percent using standard microbiology (p < 0.001). After seven days of therapy, the rates were 26 percent vs. 8 percent respectively (p < 0.001). The IpaH PCR system appeared to be specific for Shigella or EIEC based on low rates of positive reactions among non-diarrhoea controls, and a strong correlation between persistently positive reactions and antibiotic resistance of bacterial isolates. IpaH sequences were detected in 10 (8%) of 119 drinking water samples from homes of patients with disease; none of these specimens were positive for Shigella or EIEC by standard microbiology. In conclusion, PCR amplification of IpaH sequences and detection of target DNA with a non-radioactive probe increased the rates of identification of Shigella and EIEC by 45% in initial clinical specimens and by nearly 300% in specimens obtained from patients receiving antibiotic therapy.

Typing of human group A rotavirus with alkaline phosphatase-labeled oligonucleotide probes or a monoclonal enzyme immunoassay in unfrozen stools of children with diarrhea in Bangkok.

In developed countries, serotypes (or G types) have been identified in > 70% of group A rotavirus using monoclonal enzyme immunoassays (MEIAs); however, these assays have identified < 50% of rotavirus G types from developing countries presumably because the VP7 antigens were damaged by freezing and thawing during transportation of specimens. The VP7 (G) serotypes of rotavirus in unfrozen stool collected from children with acute diarrhea in Bangkok were determined using MEIA and compared to hybridization with alkaline phosphatase-labeled oligonucleotide probes. Reverse transcription of dsRNA coding for VP7 followed by polymerase chain reaction amplification of cDNA was used as an additional step prior to hybridization for 98 specimens that did not hybridize with the oligonucleotide probes. Of 251 rotavirus specimens, 208 (83%; 99% Cl = 76-89%) hybridized with G type specific oligonucleotides compared to 146 (58%; 99% Cl = 50-66%) that were typeable by MEIA. Forty-five (82%) of 55 stools containing G type 1, 80 of 84 (95%) containing G type 2, 0 of 3 containing G type 3, and 2 of 4 (50%) containing G type 4 as identified by MEIA hybridized with G type specific oligonucleotides. Differences in nucleotide sequences coding for VP7, in addition to destruction of the VP7 antigen by freezing and thawing of the specimen, may explain why not all rotavirus hybridized with G type specific probes.

Epidemiologic study of Vibrio cholerae O1 and O139 in Thailand: at the advancing edge of the eighth pandemic.

Vibrio cholerae O139 Bengal emerged on the Indian subcontinent in late 1992 and was first recognized in Thailand in 1993. To characterize the epidemiology of this disease, a hospital-based case-control study was conducted in Samutsakorn, a port city 30 km southwest of Bangkok. Between November 15, 1993, and June 3, 1994, 366 patients were confirmed to have cholera by culture, including 165 (45%) with O139 Bengal, 191 (52%) with O1 Ogawa, and 10 (3%) with both serogroups. During the same time period the previous year, 319 culture-confirmed cholera cases occurred, all serogroup O1. Questionnaires were obtained from 105 patients with O139 Bengal and 103 with O1 infections; for each case patient, two asymptomatic age- and sex-matched control persons were selected. Of the patients with O139 Bengal infections, 93% were adults (> or = 15 years) compared with 92% of patients with O1 infections. Risk factors for cholera identified by case-control comparisons were similar for the two serogroups and included consumption of untreated water, uncooked seafood, and food served at group gatherings. V. cholerae O139 Bengal has emerged in Thailand as a cause of endemic cholera, with epidemiologic features and incidence similar to those of the preexisting O1 strain.

PIP: Vibrio cholera 0139 Bengal emerged on the Indian subcontinent in late 1992 and was first recognized in Thailand in 1993. To characterize the epidemiology of this disease, a hospital-based case-control study was conducted in Samutsakorn, a port city 30 km southwest of Bangkok. Between November 15, 1993, and June 3, 1994, cultures confirmed that 366 patients had cholera, including 165 (45%) with O139 Bengal, 191 (52%) with O1 Ogawa, and 10 (3%) with both serogroups. During the same time period in the previous year, 319 culture-confirmed cholera cases occurred, all serogroup O1. Questionnaires were completed for 217 (59%) of the 366 patients. 105 patients were infected with 0139 Bengal, 103 with V. cholera O1, and 9 with both serogroups. For each case patient, two asymptomatic age- and sex-matched control persons were selected. Of the 105 case patients with 0139 Bengal infections, 98 (93%) were adults (age 15 or older) compared with 95 (92%) of 103 patients with 01 infections. Patient infected with 0139 Bengal were more often male than patients with O1 (58% vs. 42%, p = .018). Cholera cases and matched controls were similar with regard to matching criteria of age and sex. Risk factors for cholera identified by case-control comparisons were similar for the two serogroups and included consumption of untreated water, uncooked seafood, and food served at group gatherings. Raw seafood exhibited a strong trend toward an association with O1 infections, and this variable was a significant risk factor among all cholera cases (matched odds ratio = 2.54). V. cholera 0139 Bengal rapidly displaced existing strains of V. cholera O1 and accounted for over 95% of V. cholera isolates in India and Bangladesh during the first year of its appearance. It has emerged in Thailand as a cause of endemic cholera with epidemiologic features and incidence similar to those of the preexisting O1 strain.

Epidemic of diarrhea caused by Vibrio cholerae non-O1 that produced heat-stable toxin among Khmers in a camp in Thailand.

An epidemic of a cholera-like disease occurred among Khmers in a camp in Aranyaprathet, Thailand, in May 1990. Of 215 patients with diarrhea, Vibrio cholerae O1 was isolated from 25 (12%) and V. cholerae non-O1 was isolated from 15 (7%). Five of 15 (33%) non-O1 V. cholerae isolates hybridized with two different oligonucleotide probes previously used to detect V. cholerae non-O1 that produces a heat-stable toxin. This is the first description of an epidemic of diarrhea caused by V. cholerae non-O1 that produces heat-stable toxin.

Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years.

Antibiotic resistance trends were examined for Shigella species, nontyphoidal Salmonella species, enterotoxigenic Escherichia coli (ETEC), and Campylobacter species isolates from indigenous persons and travelers in Thailand for up to 15 years. Resistance to trimethoprim-sulfamethoxazole was found in >90% of Shigella and 40% of ETEC and nontyphoidal Salmonella isolates. Resistance to nalidixic acid was found in 97%-100% of Shigella dysenteriae 1 strains isolated between 1992 and 1995. Ciprofloxacin resistance was detected in 1% of ETEC isolates in 1994 and 1995 and in one of 349 nontyphoidal Salmonella isolates in 1995. Ciprofloxacin resistance among Campylobacter species increased from zero before 1991 to 84% in 1995 (P < .0001). Azithromycin resistance was found in 7%-15% of Campylobacter isolates in 1994 and 1995, as well as 15% of ETEC and 3% of Salmonella isolates in 1995. Enteric pathogens in Thailand have developed resistance to virtually all antibiotics routinely used in the treatment of diarrhea, as well as the newer fluoroquinolone and macrolide classes of drugs.

Epidemiology and spectrum of Vibrio infections in a Chesapeake Bay community.

The clinical and epidemiologic features of vibrio infections occurring over 15 y in a hospital adjacent to the Chesapeake Bay were examined. Microbiologic techniques included the use of thiosulfate citrate bile salts sucrose (TCBS) medium on all stool specimens. Among 40 vibrio isolates from 32 patients, eight species were identified: V. parahaemolyticus (16), V. vulnificus (10), non-O1 V. cholerae (7), V. mimicus (3), V. hollisae (1), V. fluvialis (1), V. alginolyticus (1), and an unnamed halophilic vibrio. Sources included stool (13), wound (11), sputum (3), ear (3), bone (1), and gallbladder (1). While illnesses were diverse, they were relatively mild and self-limited with no mortality. The mild clinical spectrum and especially lack of mortality are in sharp contrast to the findings of previous reports. Even with the proximity to the bay and use of optimal isolation techniques, the demonstrated incidence of vibrio infections was low (1.6/100,000/y). The routine use of TCBS medium, which has been advocated for high-risk areas, was not cost-effective.

Conducting population behavioral health surveillance by using automated diagnostic and pharmacy data systems.

INTRODUCTION: The Walter Reed Army Institute of Research used the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) to conduct population-based behavioral health surveillance among military-health-system beneficiaries. The study analyzed the effectiveness of using prescribing patterns of psychotropic medications to monitor changes in a community's behavioral health status. OBJECTIVES: The objectives of this study were to 1) determine the feasibility of tracking psychiatric illnesses by monitoring prescriptions for psychiatric medications; 2) assess how often psychiatric medications are prescribed for patients with no record of psychiatric illness; 3) determine at what types of clinics these medications are prescribed most often and what other diagnoses are attributed to these patients; and 4) analyze data for potential changes in the population's mental health after high-stress events. METHODS: Correlation analysis and calculations of sensitivity and specificity were used to determine how well prescription medications correlate with outpatient diagnoses and how well they serve as proxies for outpatient diagnoses. A descriptive analysis was conducted of the types of clinics (e.g., primary care, behavioral health, or other specialty clinics) treating patients and the associated percentage of concurrence between prescriptions and diagnostic codes. RESULTS: In military treatment facilities, a diagnosis of depression or anxiety correlated significantly (r = 0.82) with antidepressant or anxiolytic prescriptions. Sensitivity of prescriptions when compared with outpatient visits was 0.76, and specificity was 0.94. Among those patients who visited a primary care clinic either the day before or the same day as an antidepressant or anxiolytic prescription was filled, 60.1% did not receive a diagnosis of any mental health disorder. Behavioral health clinics had the highest correlation between diagnoses and prescriptions; specialty clinics had the lowest. CONCLUSIONS: Behavioral health trends in a population can be monitored by automated analysis of prescribing patterns alone. This method might be a rapid indicator of needed mental health interventions after acute stress-inducing events and be more sensitive than tracking diagnoses alone.

Etiology of diarrhea in a rural community in western Thailand: importance of enteric viruses and enterovirulent Escherichia coli.

The etiology of gastroenteritis was determined in children and adults with diarrhea seen at a district hospital and three government health clinics in Suan Phung, western Thailand, in 1991. Enteric viruses (rotavirus and astrovirus) were identified in 40%, shigellae in 18%, attaching and effacing Escherichia coli in 13%, Campylobacter jejuni in 9%, and enterotoxigenic E. coli in 7% of children < 5 years old with diarrhea seen at the hospital. Enteric viruses were detected in 15% (24/156) of patients with diarrhea > or = 5 years old and were the only enteric pathogens identified in 12 patients ages 7-79 years (2 astrovirus, 10 rotavirus infections). Attaching and effacing E. coli, rotavirus, and astrovirus were potential causes of diarrhea in children and adults in this population.

Use of a synthetic oligonucleotide probe to detect strains of non-serovar O1 Vibrio cholerae carrying the gene for heat-stable enterotoxin (NAG-ST).

A synthetic oligonucleotide probe was developed to identify the gene for the heat-stable enterotoxin (NAG-ST) of non-serovar O1 Vibrio cholerae. Of 103 non-O1 V. cholerae isolates from Thailand, 31 isolates from Mexico, and 47 isolates from patients in the United States, only 7 (all from Thailand) hybridized with the probe. Probe-positive strains produced significantly higher fluid accumulations in infant mice than probe-negative strains.