World Trade Center exposure, post-traumatic stress disorder, and subjective cognitive concerns in a cohort of rescue/recovery workers.

OBJECTIVE: To determine whether World Trade Center (WTC)-exposure intensity and post-traumatic stress disorder (PTSD) are associated with subjective cognitive change in rescue/recovery workers. METHOD: The population included 7875 rescue/recovery workers who completed a subjective cognition measure, the Cognitive Function Instrument (CFI), between 3/1/2018 and 2/28/2019 during routine monitoring, indicating whether they had experienced cognitive and functional difficulties in the past year. Higher scores indicated greater self-perceived cognitive change. Probable PTSD, depression, and alcohol abuse were evaluated by validated mental health screeners. Logistic regression assessed the associations of WTC exposure and current PTSD with top-quartile (≥2) CFI score, and of early post-9/11 PTSD with top-quartile CFI in a subpopulation (N = 6440). Models included demographics, smoking, depression, and alcohol abuse as covariates. RESULTS: Mean age at CFI completion was 56.7 ± 7.7 (range: 36-81). Participants with high-intensity WTC exposure had an increased likelihood of top-quartile CFI score (odds ratio[OR] vs. low exposure: 1.32, 95%CI: 1.07-1.64), controlling for covariates. Current and early PTSD were both associated with top-quartile CFI (OR: 3.25, 95%CI: 2.53-4.19 and OR: 1.56, 95%CI: 1.26-1.93) respectively. CONCLUSIONS: High-intensity WTC exposure was associated with self-reported cognitive change 17 years later in rescue/recovery workers, as was PTSD. Highly WTC-exposed subgroups may benefit from additional cognitive evaluation and monitoring of cognition over time.

Centrally Acting ACE Inhibitor Use and Physical Performance in Older Adults.

BACKGROUND: There is conflicting evidence regarding the role of angiotensin-converting enzyme inhibitors and physical function. While some studies show improvements in muscle strength and physical function, others show no significant difference or decreased performance. This ambiguity could be due to differential effects of angiotensin-converting enzyme inhibitor subtypes which can be categorized as centrally or peripherally-acting based upon their ability to cross the blood-brain barrier. OBJECTIVE: The objective of this study is to compare physical performance measures among angiotensin-converting enzyme inhibitor subtype users. METHODS: Design: Cross-sectional Setting: Ambulatory Participants: Performed in 364 participants in the Health and Retirement Study cohort who were ≥ 65 years (median age (IQR) 74.00 (69-80) years. MEASUREMENTS: Average difference in hand grip (kg), gait speed(m/s) and peak expiratory flow (L/min). RESULTS: Compared to participants on a peripherally-acting angiotensin-converting enzyme inhibitor (113 (31%)), those on a centrally-acting agent (251(69%)) had stronger grip strength 28.9 ±1.0 vs 26.3±1.0, p=.011 and higher peak expiratory flow rates 316.8±130.4 vs. 280.0±118.5, p= .011 in unadjusted analysis. After multiple adjustments the difference in PEF remained statistically significant (Estimate(CI) 26.5, 95% CI 2.24, 50.5, p = 0.032). CONCLUSION: Our results suggest that in older adults the use of centrally-acting angiotensin-converting enzyme inhibitors compared to a peripherally acting angiotensin-converting enzyme inhibitors was associated with better lung function in older individuals.

A mucosal antibody response following systemic Haemophilus influenzae type B infection in children.

The possibility that mucosal antibody is produced as a host response to Haemophilus influenzae type b (Hib) infection was examined in this study. 17 of 18 prospectively evaluated children ranging in age from 2 mo to 7 yr developed a detectable level of anticapsular antibody in their nasopharyngeal secretions after systemic Hib infection. The mean concentration of nasal anti-capsular antibody of the 18 children was 554 ng/mg IgA (SD = 35-8,863) during the acute phase of illness and declined to 224 ng/mg IgA (SD = 19-2,688) in convalescence. Some children had mucosal antibody detectable at least 10 mo after infection. The mucosal antibody levels were not affected by the length of illness before diagnosis, type of disease, age of the patient, sex, or presence of detectable capsular antigen or viable bacteria in the nasopharynx. The mucosal antibody was predominantly of the IgA class and occurred independent of the serum antibody. Six of the children aged less than 1 yr who did not produce and/or sustain a serum antibody level correlated with protection demonstrated a persistent mucosal antibody response. These findings suggest that the mucosal immune system may have the ability to respond at an earlier age than the serum immune system and lead us to postulate that protective secretory antibodies to prevent systemic Hib disease may be inducible in young infants in spite of the poor serum antibody response occurring at this age.

Total body water in pregnancy: assessment by using bioelectrical impedance.

Determinations of total body water (TBW) calculated from deuterium dilution spaces and bioelectrical-impedance measurements were made serially in a group of 15 women before, during, and after pregnancy. Similar measurements were made once in a group of 50 nonpregnant women and intermittently in another group of 10 women during pregnancy and postpartum. TBW increased significantly during pregnancy, then decreased postpartum. Estimates of TBW in pregnancy and postpartum calculated with models derived from nonpregnant and pregnant women were similar to measured values. Changes in reactance and resistance explained more of the variance in predicting changes in TBW than did body weight, abdominal circumference, or hematocrit (50-75% vs 4-50%, respectively). Changes in TBW estimated with the nonpregnancy impedance model were significantly different than either the measured changes or changes predicted with the pregnancy impedance model. These findings indicate that the impedance method is a practical and valid method for determining longitudinal changes in TBW.

White matter abnormalities in mobility-impaired older persons.

OBJECTIVE: To investigate the relationship between white matter abnormalities and impairment of gait and balance in older persons. METHODS: Quantitative MRI was used to evaluate the brain tissue compartments of 28 older individuals separated into normal and impaired groups on the basis of mobility performance testing using the Short Physical Performance Battery. In addition, individuals were tested on six indices of gait and balance. For imaging data, segmentation of intracranial volume into four tissue classes was performed using template-driven segmentation, in which signal-intensity-based statistical tissue classification is refined using a digital brain atlas as anatomic template. RESULTS: Both decreased white matter volume, which was age-related, and increased white matter signal abnormalities, which were not age-related, were observed in the mobility-impaired group compared with the control subjects. The average volume of white matter signal abnormalities for impaired individuals was nearly double that of control subjects. CONCLUSIONS: This cross-sectional study suggests that decreased white matter volume is age-related, whereas increased white matter signal abnormalities are most likely to occur as a result of disease. Both of these changes are independently associated with impaired mobility in older persons and therefore likely to be additive factors of motor disability.

Nosocomial viral respiratory infections: perennial weeds on pediatric wards.

The frequency and importance of nosocomial infections of the respiratory tract in pediatrics have generally been underestimated. In part this has resulted from the emphasis on bacterial infections which occur primarily in select at-risk populations. Most respiratory infections in pediatric patients, hospital- and community-acquired, are viral and all patients are potentially susceptible The epidemiologic patterns of these viral respiratory agents on the ward mirror those seen in the community in terms of frequency, season, age affected and severity of illness. Hence, the most frequent nosocomial agents are the viruses that occur in outbreaks or epidemics and cause respiratory illness, epidemic respiratory viruses--respiratory syncytial virus, which causes the greatest morbidity and mortality; influenza, and the parainfluenza viruses. Their import, as exemplified by respiratory syncytial virus, results from (1) the severity of disease produced in young children, which is magnified in those hospitalized with certain underlying conditions; (2) the abundant and prolonged viral shedding, allowing easy spread; (3) the potential susceptibility of all patients and staff, since infections recur throughout life; and (4) the difficulty in controlling nosocomial spread.

Nosocomial influenza infection as a cause of intercurrent fevers in infants.

All patients on an infants' ward manifesting intercurrent fevers were studied for viral and bacterial etiology during a community outbreak of influenza A. During a one-month period, of 29 infants admitted to the ward, 17 were hospitalized for seven or more days. Intercurrent fever complicated the course of 13 (76%) of these 17 infants. Nosocomially acquired influenza A infection was found in 13 infants. Two of these also contracted a dual infection with influenza B. The fever lasted an average of 2.7 days with a peak of 38.2 to 39.8 C. Initial white blood cell counts tended to by high and shifted to the left. These infants appeared to be at high risk for developing lower respiratory tract disease. Seven of the 12 had infiltrates on chest X-ray, and five subsequently developed a secondary bacterial pneumonia. These infants tended to be young, five were under 6 months, and all but one had underlying cardiorespiratory disease. They also appeared to have prolonge shedding of influenza virus from their nasal secretions. Six of seven shed the virus for 7 or 21 days.

Atypical bacterial infections explained by a concomitant virus infection.

Because both viral and bacterial infections are common during early childhood, dual infections are not unexpected. However, the clinical manifestation of such combined infections may be, difficult to interpret, and they are often misdiagnosed as "atypical bacterial infection." Five patients with concomitant viral-bacterial infections are described. In all five cases, virus detection enabled the physicians to better understand an otherwise puzzling clinical presentation. In view of the recent progress in rapid viral diagnoses and the potential of antiviral drugs, the possibility of dual infection should be investigated more often.

Live attenuated influenza virus vaccine trial in children.

Thirty-four children received intranasally a live attenuated influenza A virus vaccine, and were then followed for six months to evaluate the vaccine safety, immunogenicity, and efficacy. All but one of the 31 children with hemagglutination inhibition (HI) titers less than 64 before inoculation responded with at least a four-fold rise in antibody titer to a single dose of vaccine. One child required two doses. Seven (21%) of the vaccinees also responded with production of nasal neutralizing antibody. The vaccine was well tolerated with few clinical reactions. Two vaccinees developed fever possibly attributable to the vaccine. No transmission of the vaccine virus to any of the 25 unvaccinated contact children was demonstrable. Five months after this vaccine trial an influenza epidemic due to a heterologous influenza A strain occurred in the community. During this outbreak acute febrile and/or respiratory illness occurred in 12 or 52% of the contact controls, and in six or 19% of the vaccinees. In two of these six vaccinees, influenza A infection was confirmed by at least a four-fold increase in HI titer. This study suggests this study suggests that this vaccine is safe, easily administered, highly immunogenic in children, and is protective against a heterologous strain epidemic in the community.

Control of nosocomial respiratory syncytial viral infections.

We evaluated methods to control the spread of respiratory syncytial virus (RSV) on our infants' ward during a community outbreak of RSV infection. Methods included isolation and cohorting of infected infants, strict handwashing, use of gowns, and the cohorting of staff to the ill infants. Of 123 infants studied, 36 were admitted with RSV infections. Of the remaining 87 contact infants, eight (19%) acquired nosocomial RSV disease. Three of the eight developed pneumonia and one died. Of the 43 staff members, 24 (56%) became infected and 82% were symptomatic. Four acquired repeated infections within weeks of the initial infection. Studies a year previously had revealed that 45% of contact infants and 42% of the staff had acquired nosocomial RSV infections. Thus, the employed procedures appeared to have decreased the transmission of RSV to infants but not to the staff. Staff may continue to be infected by large droplets from close contact with ill infants or by self-inoculation of contaminated secretions.

Predicting deterioration in previously healthy infants hospitalized with respiratory syncytial virus infection.

OBJECTIVE: To estimate the incidence of clinical deterioration leading to intensive care unit transfer in previously healthy infants with respiratory syncytial virus (RSV) infection hospitalized on a general pediatric unit and, to assess the hypothesis that history, physical examination, oximetry, and chest radiographic findings at time of presentation can accurately identify these infants. STUDY DESIGN: A virology database was used to identify and determine the disposition of all children 80 and an O(2) saturation <85% at time of presentation each had a specificity >97% for predicting subsequent deterioration. Each parameter, however, had a sensitivity

Immunization practices of pediatricians and family physicians in the United States.

OBJECTIVE: To assess current practices and attitudes among pediatricians and family physicians across the United States regarding immunizations. DESIGN: Survey of a random sample of pediatricians and family physicians. SUBJECTS: Fellows of the American Academy of Pediatrics (N = 746) and American Academy of Family Medicine (N = 429). SURVEY TOPICS: General immunization practices (eg, types of visits during which vaccinations are provided, mechanisms to identify undervaccinated children); and opinions about perceived barriers to immunizations, acceptance of alternative sites for immunizations, and possible immunization requirements for Medicaid and The Special Supplemental Food Program for Women, Infants, and Children (WIC). RESULTS: Pediatricians and family physicians (combined) reported the following: immunizing children during acute illness visits (28%), follow-up visits (90%), and chronic illness visits (77%); using computer or reminder files to identify undervaccinated children (13%); and simultaneously administering four vaccines (diphtheria-tetanus-pertussis, oral poliovaccine, measles, mumps, and rubella and Haemophilus influenzae type b) to an eligible 18-month-old child (66%). Physicians perceived the following as barriers to immunizations: missed preventive visits (40%), vaccine costs (24%), lack of insurance coverage (24%), inability to track undervaccinated patients (22%), incomplete immunization records (12%), and missed vaccination opportunities (12%). Physicians agreed with offering vaccinations during hospitalizations (51%) or emergency department visits (30%), and with immunization requirements for continued eligibility for Medicaid (66%) or WIC (64%). Pediatricians were more likely to vaccinate during chronic illness and follow-up visits, and were more likely to use systems to track undervaccinated children (P < .05); however, most immunization practices and attitudes of pediatricians and family physicians were similar. Physicians who graduated from medical school more recently and those in high-risk urban practices were more likely to vaccinate during acute illness visits, provide simultaneous vaccinations, and favor vaccinations in hospital settings. CONCLUSIONS: Vaccination rates might be improved by closer adherence to current immunization guidelines regarding vaccinations during all encounters and simultaneous vaccinations, by developing systems to identify undervaccinated children, and by reducing patient costs for vaccinations. Current immunization practices fall short of the immunization guidelines; changes in individual practice styles will be required to conform with these standards.

Is an emergency department visit a marker for undervaccination and missed vaccination opportunities among children who have access to primary care?

The purpose of this study was to determine: (1) whether preschool-age patients who utilize the emergency department (ED) are undervaccinated compared with patients having the same primary care provider and (2) whether reducing missed vaccination opportunities in the primary care office can potentially reduce the differences in undervaccination between the groups. This retrospective cohort study involved two groups: 583 ED patients, aged 4 to 48 months, who had primary care providers; and 583 control subjects randomly selected from primary care sites and matched according to date of birth and primary care site. The major outcome variable was the point prevalence of undervaccination, defined as more than 60 days past due for a vaccine at the time of the ED visit, and for control subjects, at the time of their matched patient's ED visit. Demographic variables, vaccination history, presence of chronic illness, and office utilization history were abstracted from office charts. The mean age of all patients was 20.0 months. Emergency department patients were more likely to be boys (61% vs 50%) and had more chronic illness, but did not differ racially from those in the control group. Primary care sites included a hospital-based clinic (n = 137), neighborhood health centers (n = 172), and private practices (n = 274). The undervaccination rates by primary provider type were for (1) hospital clinic ED patients 21.1%, control subjects 19.7%; (2) neighborhood health center ED patients 29.1%, control subjects 22.7%; and (3) private practice ED patients 26.6%, control subjects 14.9%. Overall, the odds ratio of ED patients' being undervaccinated compared with control subjects was 1.8 (95% confidence interval 1.3 to 2.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Children with influenza A infection: treatment with rimantadine.

Treatment with rimantadine of influenza in children and the potential development of resistance in clinical isolates associated with therapy have not been previously studied. We compared rimantadine to acetaminophen therapy in a controlled, double-blind study of 91 children with influenza-like illness. Of 69 children with proven influenza A/H3N2 infection, 37 received rimantadine and 32 received acetaminophen for five days. Children receiving rimantadine showed significantly greater reduction in fever and improvement in daily scores for symptoms and severity of illness during the first three days. Viral shedding also diminished significantly during the first two days but subsequently increased such that by days 6 and 7 the proportion of children shedding virus, as well as the quantity of virus shed, was significantly greater in the rimantadine group. During the seven-day study, of the 22 children in the rimantadine group with serial isolates tested, ten (45.5%) had resistant isolates compared with two (12.5%) of those with serial isolates in the acetaminophen group (P less than .03). Thus, of the total 37 children in the rimantadine group, 27% were found to have resistant isolated compared with 6% in the total group receiving acetaminophen (P less than .04). Furthermore, the mean inhibitory concentration of rimantadine increased with time in the rimantadine group (r = .4, P = .002) but not in the acetaminophen group. Rimantadine therapy, thus, appears to be significantly more effective than acetaminophen in ameliorating the clinical signs and symptoms of influenza in children. Treatment with rimantadine was also associated with increased viral shedding after the medication was discontinued and with the development of resistance in the clinical isolates, the significance of which is unknown.

Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status.

To determine the rate of childhood under-vaccination, rate and types of missed opportunities (MOs) for vaccinations, and the contribution of MOs to the undervaccination of preschool-age children, the authors conducted a retrospective medical chart review in seven primary care settings in the Rochester, NY, area: a hospital clinic, a neighborhood health center, a group-model health maintenance organization, an urban group practice, a suburban group practice, a rural health center, and a rural private practice. The random sample included 1124 children having birth dates between March 15, 1988, and September 15, 1989. The main outcome measures were cumulative undervaccination rate, defined as the proportion of patients from each practice who were ever > 60 days past-due for a vaccination by 12, 18, or 24 months of age; undervaccination time, defined as the median number of months during which children were undervaccinated; number of MOs; visit types and conditions associated with the MOs; and the duration of undervaccination time attributable to MOs. The cumulative undervaccination rate by 12 months was at least 20% in each practice except for the suburban practice, where it was 4%. The frequency of MOs varied from a high of 1.8 MO per patient per year at the rural private practice to a low of 0.3 MO per patient per year at the suburban practice. More than one quarter of MOs occurred during either health supervision or follow-up visits in all practices. In 28% of visits during which an MO occurred, patients had no fever or acute illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical significance of pulmonary function tests. Alterations in pulmonary function following respiratory viral infection.

Respiratory viral illness is a major cause of morbidity in both adults and children. This report focuses on both the acute and chronic effects on respiratory function of these ubiquitous infections. Infant airways are particularly vulnerable due to the relatively low conductance in immature peripheral airways. Bronchiolitis, caused predominantly by respiratory syncytial virus, is the most important of these viral illnesses and is emerging as a major risk factor for the subsequent development of obstructive airway diseases in adults, possibly by interference with normal alveolar proliferation. The basic pathogenic mechanism involved in adult respiratory viral infection is bronchial hyperreactivity, presumably secondary to epithelial damage and resultant sensitization of rapidly adapting airway receptors. In addition, there may be virus-related alterations in the autonomic and humoral regulation of airway tone. Viral infections may alter the effects of common air pollutants on respiratory function.

Parainfluenza viral infections in pediatric outpatients: seasonal patterns and clinical characteristics.

Parainfluenza types 1, 2 and 3 were studied in a pediatric outpatient population from 1976 to 1992 to compare seasonal patterns over time and to define better the spectrum of illness in all ages of children caused by these viruses. Parainfluenza type 1 occurred in the fall of odd numbered years; parainfluenza type 2 was less predictable; and parainfluenza type 3 appeared yearly with peak activity in spring or summer. The parainfluenza viruses were the major cause of croup and also accounted for one-half of the cases of laryngitis and over one-third of all lower respiratory tract illness in children from whom a virus was isolated. The major clinical manifestations of infection with parainfluenza types 1 and 2 were croup, upper respiratory infections and pharyngitis; for parainfluenza type 3 upper respiratory tract infection was predominant in all age groups. The parainfluenza viruses cause appreciable respiratory morbidity each year among infants and young children. They are the major cause of croup but also produce a spectrum of diseases ranging from mild upper respiratory tract infection to bronchiolitis and pneumonia. Most studies have focused on the morbidity of parainfluenza viruses in infants and young children who are hospitalized. Less appreciated is the impact of parainfluenza viral infections in outpatients and in older children. The parainfluenza viruses have a striking epidemiologic pattern which has evolved over the past 30 years. In the early 1960s parainfluenza types 1, 2 and 3 were all reported to be endemic.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for the early acquisition of human herpesvirus 6 and human herpesvirus 7 infections in children.

OBJECTIVE: Human herpesviruses 6 and 7 (HHV-6 and HHV-7) are common infections in children, but risk factors for their early acquisition have not been described. METHODS: Excess sera from children 12 to 31 months of age enrolled in a cross-sectional, random survey were tested for human herpesviruses 6 and 7 infection, as measured by using immuno-blot and immunofluorescence assays. RESULTS: Of 164 children 131 (80%) had antibody to HHV-6, and 79 (47%) of 167 had antibody to HHV-7. In logistic regression analysis low income [odds ratio (OR), 2.9; 95% confidence intervals (CI), 1.02 to 8.7] and having more than 1 sibling (OR=2.1, 95% CI=0.9 to 5.1) were risk factors for HHV-6 infection after adjusting for age, whereas month of test (OR=2.7, 95% CI=1.3 to 5.9) and Black race (OR=2.0, 95% CI=0.9, 4.6) were associated with a higher prevalence of HHV-7 infection. In contrast having ever been breast-fed appeared to protect against HHV-7 infection (OR=0.5, 95% CI=0.3 to 1.1). CONCLUSIONS: Despite studies linking both HHV-6 and HHV-7 with exanthem subitum, risk factors for the early acquisition of HHV-6 and HHV-7 are distinct. Subsequent studies investigating the transmission of HHV-6 should explore family size and other factors associated with poverty, whereas breast-feeding should be examined as a protective factor for HHV-7 infection.

Long term follow-up of children hospitalized with respiratory syncytial virus lower respiratory tract infection and randomly treated with ribavirin or placebo.

PURPOSE: To determine the long term effects of ribavirin therapy in children hospitalized for respiratory syncytial virus (RSV) lower respiratory tract infection. METHODS: Fifty-four of 60 children in randomized trials of ribavirin therapy were enrolled in a prospective follow-up study. Subjects were examined annually and had age-appropriate pulmonary function tests; interim histories were obtained from families and personal physicians. RESULTS: Recurrent lower respiratory tract illness was reported at least once for 79% of the ribavirin and 73% of placebo group. In the first 5 years after RSV, 54% of the ribavirin group and 50% of the placebo group reported wheezing. There were no significant differences between the groups in annual rates, timing, or severity of recurrent lower respiratory tract illness. No significant differences in pulmonary function were detected by tests of oxygen saturation, peak expiratory flow and spirometry. CONCLUSIONS: Children in the ribavirin treatment group did not have exacerbated respiratory symptoms compared with those in the control group, and their pulmonary function measurements were equal to those of the placebo-treated group, suggesting no long term adverse effect or benefit of ribavirin therapy.

Risk of recurrent seizures after a primary human herpesvirus 6-induced febrile seizure.

OBJECTIVE: To test the hypothesis that children experiencing first febrile seizures caused by human herpesvirus 6 (HHV-6) have an increased risk for recurrent seizures when compared with children experiencing first febrile seizures attributed to other illnesses. DESIGN AND PARTICIPANTS: Descriptive prospective study of 36 HHV-6 culture-positive children and a matched subgroup of 86 HHV-6 culture-negative children, all of whom had their first febrile seizures evaluated in a tertiary care emergency department and were followed for at least 12 months, with an average follow-up of 35.7 months. PRIMARY OUTCOME MEASURE: The recurrence of seizures among HHV-6 culture-positive and HHV-6 culture-negative children with no known previous neurologic deficits. RESULTS: A decreased incidence of recurrent seizures occurred in children whose first febrile seizures were caused by HHV-6. Twenty percent of HHV-6 culture-positive children and 40% of HHV-6 culture-negative children (P < 0.038) experienced a recurrent seizure within 1 year of their first febrile seizure. The mean time to recurrence within 12 months was 8.6 months for children with HHV-6 infection and 3.8 months (P < 0.001) for children without HHV-6 infection. Most recurrent seizures occurred within 12 months of a first febrile seizure for both HHV-6-positive and HHV-6-negative children (88 and 91%). CONCLUSIONS: Children who had their first febrile seizures caused by primary HHV-6 infection did not demonstrate an increased risk for recurrent seizures when compared with children whose first febrile seizures were from other etiologies.