An evaluation of the global network of field epidemiology and laboratory training programmes: a resource for improving public health capacity and increasing the number of public health professionals worldwide.

BACKGROUND: Given that many infectious diseases spread rapidly, across borders and species, there is a growing worldwide need to increase the number of public health professionals skilled in controlling infectious epidemics. Needed also are more public health professionals skilled in non-communicable disease surveillance and interventions. As a result, we surveyed all 57 field epidemiology training programmes (FETPs) that are members of the Training Program in Epidemiology and Public Health Interventions Network (TEPHINET), to evaluate the progress of the FETPs, the only global applied epidemiology network, toward increasing public health capacity globally. METHODS: Data on the FETP programmes and the training they provide were abstracted from TEPHINET membership surveys and verified with FETP directors for all FETPs that were members of TEPHINET in 2012. Data on abstracts submitted to the recent TEPHINET Global Scientific Conference, on recent accomplishments by each FETP, and on quality improvement were also compiled to provide a worldwide view of the public health human resource capacity produced by these programmes. RESULTS: A total of 6980 public health professionals worldwide have graduated from an FETP or from the Center for Disease Control and Prevention's Epidemiology Intelligence Service (EIS). FETP residents and graduates participate in key public health prevention, control, and response activities. Each FETP has adapted its curriculum and objectives over time to align with its country's public health priorities. FETPs are well integrated into their national public health infrastructures, and they have many partners at the national, regional and global levels. CONCLUSION: FETPs are a competent and diverse source of highly skilled public health professionals who contribute significantly to public health's global human resource needs. This finding is evidenced by 1) the training curricula that were adapted over time to meet public health's human resource needs, 2) the FETPs' continued support from internal and external partners, 3) the increasing number of FETP residents and graduates and their increasing contribution to effective public health work, and 4) the increased quality improvement initiatives facilitated through the FETPs membership in one global network, TEPHINET.

[Gastroenteritis outbreak in tourists: limitations of information and response]. / Brote de gastroenteritis en turistas: limitaciones de información y respuesta.

BACKGROUND: We present the results of different studies performed in the investigation of a gastroenteritis outbreak and we describe the difficulties and limitations encountered during its study. METHODS: Several analytical studies were designed: one cohort study and one case-control study with different samples sizes. RESULTS: Of the 189 trip participants, 43% answered the questionnaire. Forty-five cases were identified. The factors significantly associated with the disease were: dinner in one of the restaurants of the resort on December 11 in all analytical studies and the excursion to a nearby island in the cohort study. DISCUSSION: The outbreak was confirmed however due to the low response rate and the problems encountered to interview the participants in the trip, it was not possible to identify the route of transmission.

[Investigation of a foodborne intoxication in a high-density penitentiary center]. / Investigación de una toxiinfección alimentaria en un centro penitenciario de alta ocupación.

BACKGROUND: On September 25 2005, more than 100 inmates (almost 5% of the 1,800 prison population) experienced sudden onset gastroenteritis. This outbreak was the largest foodborne outbreak described in a prison population in Spain. Our objective was to confirm the outbreak, identify risk factors, implement control measures, and provide recommendations. METHODS: We conducted a cohort analysis of a stratified random sample of all the inmates, a cohort analysis of the one of the prison blocks, and an environmental investigation. RESULTS: A total of 221 inmates were selected, of which 196 were interviewed. Twenty-eight percent had gastroenteritis and the main symptoms were abdominal pain (85%) and diarrhea (71%). All foods consumed caused similar attack rates. Factors associated with the risk of illness were eating the entire portion of seafood cocktail at lunch or all of the fried shrimp at dinner on September 24 (RR = 2; 95% CI, 1.1-3.8, and RR = 1.8; 95% CI, 1.1-3.1). Analysis of one of the prison blocks yielded results similar to those of the random sample. Clostridium perfringens, Bacillus cereus and Escherichia coli were isolated from a sample of the seafood cocktail. CONCLUSION: A gastroenteritis outbreak caused by several pa-thogens was confirmed. Both the reported symptoms and the calculated incubation periods corresponded to the pathogens isolated. Preparation of food in prison facilities should meet minimum safety standards, including refrigeration and training of food handlers.

[Descriptive epidemiology of non-meningococcal bacterial meningitis in the province of Saragossa [Spain] from 1999 to 2004. Evaluation of the Epidemiological Surveillance System]. / Epidemiología descriptiva de meningitis no meningocócicas bacterianas de la provincia de Zaragoza (1999-2004). Evaluación de su sistema de vigilancia.

OBJECTIVES: To describe non-meningococcal bacterial meningitis (nMM) and to evaluate the Epidemiological Surveillance System (ESS) in the province of Saragossa (Spain) between 1999 and 2004. METHODS: Information was obtained from the register of diseases subject to mandatory reporting and the Minimum Basic Data Set (MBDS). The ESS was evaluated by using the Centers for Disease Control and Prevention (CDC) criteria and by estimating the completeness of the system through the capture-recapture technique. RESULTS: 111 cases of nMM were notified (62.2% in males) and the mean age was 40.7 years. The largest proportion of cases (16.5%) occurred in children under 2 years of age. The clinical presentation was meningitis in 81.1%. Diagnosis was through bacterial culture in 70.3%. Streptococcus sp. was found in 54% (82% due to S. pneumoniae), enterobacteria in 5.4%, Listeria and Staphylococcus in 4.5%, Pseudomonas aeruginosa in 1.8%, and Haemophilus influenzae in 0.9%. The incidence rate per 100,000 inhabitants was 1.6 in 2004 and 2.6 in 2001. The case fatality was 7.3%. The completeness of the mandatory reporting system reached a peak in 2004 at 84.4%. The combined completeness of the MBDS and the mandatory reporting system was above 85% and timeliness of reporting was 2 days. The acceptability of the system was high since 75% of all variables were complete in 97% of the questionnaires. CONCLUSION: We highlight the importance of evaluation of the ESS, based on its results. nMM due to S. pneumoniae represent an important group of diseases and their case fatality is high. The completeness of the ESS in Saragossa was over 80% when the mandatory reporting system and the MBDS were combined. Incorporating the MBDS into surveillance would facilitate the estimation of the real incidence of various diseases subject to mandatory reporting.

[Associated factors to increased sensitivity in the transthoracic echocardiogram for the diagnosis of infective endocarditis]. / Factores asociados a aumento de la sensibilidad del ecocardiograma transtorácico en el diagnóstico de la endocarditis infecciosa.

INTRODUCTION AND OBJECTIVES: Echocardiography is considered a basic tool in the diagnosis and management of infective endocarditis. Transesophageal echocardiography is more sensitive than transthoracic echocardiography. Our aim was to describe which factors are related to the ability of transthoracic echocardiography to establish the diagnosis of infective endocarditis. The presence of this factors in a patient with a normal transthoracic echocardiography would make unnecessary to perform a transesophageal echocardiography and would suggest to seek for other diagnostic possibilities. METHODS: 127 consecutive patients admitted to our hospital with the diagnosis of infective endocarditis and a complete transthoracic echocardiography and transesophageal echocardiography comprised our study group. Predisposing factors and clinical, echocardiographic and microbiological variables were studied. RESULTS: The presence of a cardiac murmur, the presence of an optimal acoustic window, degenerative valvular disease as the predisposing factor for infective endocarditis and positive blood cultures were related to the ability of transthoracic echocardiography to diagnose the existence of signs of infective endocarditis on its own. Nevertheless, only the presence of a cardiac murmur (RR 2.724; 95% CI 1.071-6.926; p 0,035) and the presence of an optimal acoustic window (RR 5.538; 95% IC 2.75-11.15; p < 0.001) were found as independent factors to detect those patients in which transthoracic echocardiography is able to diagnose signs of infective endocarditis on its own. CONCLUSIONS: The diagnostic accuracy of transthoracic echocardiography to detect echocardiographic signs of infective endocarditis is high in those patients with cardiac murmur and optimal acoustic window. In those patients with these characteristics, without prosthetic heart valves and a negative transthoracic echocardiography for infective endocarditis other diagnostic possibilities should be ruled out before performing of a transesophageal echocardiography.

Evaluation of myocardial perfusion with grey-scale ultra-harmonic and multiple-frame triggering. The need for quantification.

BACKGROUND AND OBJECTIVE: Contrast echocardiography has been recently introduced as a new technique for evaluating myocardial perfusion in a qualitative basis. The objective of this study was to test whether a visual subjective evaluation of myocardial perfusion by myocardial contrast echocardiography adequately matches the data obtained with an off-line quantification of myocardial perfusion. METHODS: Sixty-one myocardial segments were evaluated by myocardial contrast echocardiography with Ultra-harmonic and Multiframe Triggering in 11 patients 3-7 days after an anterior myocardial infarction, using SH-U 563A (Levovistâ, Schering AG, Berlin, Germany) as contrast agent. Myocardial perfusion was classified as grade 1 (absent), 2 (patchy or incomplete) and 3 (complete) in each segment. The quantitative analysis was performed off-line by a different investigator blinded to the qualitative evaluation, using a commercially available software. The quantitative data on grey-scale obtained were compared between grade 1, 2 and 3 segments. RESULTS: Of the 61 segments, 45 (73.8%) were classified as grade 3, whereas the remaining 16 (26.2%) were considered to be abnormally perfused (grade 2: n=12, 19.6%; grade 1: n=4, 6.6%). Segments with grade 1 perfusion had a significantly higher grey-scale value (123.6 +/- 41.3 vs. 70.1 +/- 34.3, p=0.004). However, there were no significant differences between segments with perfusion grade 2 and 3 (76.8 +/- 33.2 vs. 68.3 +/- 34.8, p=0.452). CONCLUSION: Qualitative assessment of myocardial perfusion by Ultra-harmonic and Multiframe Triggering is of limited value, since only myocardial segments with absent perfusion may be reliably identified. This findings support the need of quantification in the evaluation of myocardial perfusion by contrast echocardiography.

Myocardial perfusion in real-time using power modulation. In vivo evidence for microcirculatory damage after acute myocardial infarction.

BACKGROUND AND OBJECTIVES: In addition to the myocardium, the microvasculature may be also damaged in acute myocardial infarction. The aim was to evaluate the capability of myocardial contrast echocardiography in the detection of microvasculature damage after myocardial infarction. PATIENTS AND METHODS: Twelve patients with recent acute myocardial infarction and five control subjects with normal coronary arteries and without history of myocardial infarction were studied. Myocardial contrast echocardiography with power modulation was performed, and quantitative data were measured off-line. Power modulation uses a combination of low (0.1) and high (1.7) mechanical indexes, allowing a real-time evaluation of myocardial perfusion. Contrast agent was administered as a 3-min bolus. The quantitative analysis was performed off-line by a different blinded investigator. The refilling velocity was calculated as the difference between the peak myocardial refilling value and the value at 1 s after the impulse divided by the time from the first second after the impulse to the peak refilling value. RESULTS: Eighty-one myocardial segments (75%) were analysed qualitatively and quantitatively in AMI patients, and 18 (60%) in control subjects (P=NS). The peak refilling intensity was not significantly different in patients and control subjects (6.62+/-5.85 vs. 7.53+/-4.06 dB, respectively). However, time to peak refilling intensity was significantly longer (5.25+/-1.57 vs. 4.00+/-0.53, P=0.004) and the velocity of refilling was significantly lower (2.74+/-5.34 vs. 6.58+/-8.02, P=0.028) in patients with myocardial infarction. CONCLUSION: There is microvasculature damage after myocardial infarction that is reflected as a delayed velocity of refilling in myocardial contrast echocardiography.

Value of automated segmental motion analysis in the assessment of aortic stenosis severity.

BACKGROUND AND AIMS OF THE STUDY: Left ventricular (LV) contraction is slowed in patients with aortic stenosis (AS). Although the possible role of LV systolic function abnormalities in the assessment of AS severity has been evaluated, current echocardiographic techniques cannot offer precise quantification of LV motion velocity. The study aim was to evaluate an automated segmental motion analysis (ASMA) system to assess AS severity. METHODS: Twenty-two patients with AS, sinus rhythm and preserved LV ejection fraction were studied prospectively. Patients underwent both conventional Doppler echocardiography to measure transaortic gradient and aortic valve area by the continuity equation, and ASMA of the interventricular septum. The ASMA line graph mode displays changes in area through the cardiac cycle. The RR interval and time from the R-wave to peak maximum area shortening were measured, and an ASMA index was calculated. RESULTS: A significant and strong inverse correlation was found between aortic valve area and ASMA index (r = -0.78; 95% CI -0.90 to -0.55; p <0.001). The area under the ROC curve in the diagnosis of severe AS (aortic valve area < or =0.8 cm2) was 0.97 (95% CI 0.90-1.0). Sensitivity, specificity, positive and negative predictive values and overall accuracy for an ASMA index >0.40 were 100, 91.7, 92.3, 100 and 95.8%, respectively. CONCLUSION: The ASMA system may be valuable in evaluating AS, as it offers a strong correlation with aortic valve area calculated by the continuity equation, and very high sensitivity and specificity in the diagnosis of severe AS.

Influence of diabetes mellitus on short- and long-term outcome in patients with active infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: The incidence and severity of certain infections appear to be increased in patients with diabetes mellitus (DM). The study aim was to evaluate the effect of DM on short- and long-term outcome in patients with active infective endocarditis (IE). METHODS: A total of 151 patients with IE was included and followed up for a mean of 3.1 years. Of these patients, 13 (9%) were diabetics. The outcome of patients with or without DM was compared at short-term (in-hospital) and long-term follow up. RESULTS: Patients with DM were older (66 +/- 11 versus 50 +/- 19 years, p < 0.01) and had a lower frequency of intravenous drug abuse (0 versus 30%, p <0.01) and tricuspid valve involvement (0 versus 20%, p = 0.02) than non-DM patients. Mortality was higher in DM patients both in hospital (31% versus 15%, p = NS) and at a mean follow up of 3.1 years (54% versus 31%, p = 0.002). DM patients also had a significantly higher rate of cardiac failure (69% versus 38%, p = 0.03) and renal failure (62% versus 20%, p <0.01) during hospitalization. Incidences of anatomic complications (abscess, pseudoaneurysm) (15.4% versus 20.3%), valve rupture or perforation (7.7% versus 16.7%) and need for surgical repair (46.2% versus 45.7%) were similar in both DM and non-DM patients. DM, without secondary pathology like renal failure, did not appear to be an independent risk factor for mortality at either short- or long-term follow up. CONCLUSION: Although mortality and morbidity in IE were greater in DM than in non-DM patients, diabetes itself does not constitute an independent risk factor.

[Infective endocarditis in patients with chronic liver disease: clinical and prognostic assessment]. / Endocarditis infecciosa en pacientes con hepatopatía crónica: valoración clínica y pronóstica.

INTRODUCTION AND OBJECTIVES: Chronic liver disease increases the susceptibility to bacterial infections and infective endocarditis. Our aim was to determine the clinical and microbiological features and the prognosis in patients with chronic liver disease who also had infective endocarditis. PATIENTS AND METHOD: One hundred and seventy-four consecutive inpatients at our institution were recruited and followed. Thirty of them had chronic liver disease. Clinical, microbiological and echocardiographic variables were analyzed and, in some cases, histological variables were also recorded. RESULTS: Patients with chronic liver disease were younger (36 11 vs 54 18 years; p < 0.01) and had a larger proportion of intravenous drug users (73 vs 16%; p < 0.01), HIV infection (47 vs 10%; p < 0.01), right valve involvement and spleen enlargement, but heart failure appeared less often (7 vs 34%; p = 0.003). Thirty percent of the patients with and 51% of patients without chronic liver disease underwent surgery for infective endocarditis. Total mortality among patients with and without chronic liver disease was 40% and 31%, respectively. After adjustment for age and for the incidence of congestive heart failure, chronic liver disease doubled mid-term mortality with a RR = 2.45 (p = 0.015). CONCLUSIONS: Chronic liver disease has a significant impact on the prognosis in patients with infective endocarditis, and these patients should therefore be considered a high risk group.

Evaluating Application of Knowledge and Skills: The Use of Consensus Expert Review to Assess Conference Abstracts of Field Epidemiology Training Participants.

BACKGROUND: Often evaluations of training programs are limited - with many focusing on the aspects that are easy to measure (e.g., reaction of trainees) without addressing the important outcomes of training, such as how trainees applied their new knowledge, skills, and attitudes. Numerous evaluations fail to measure training's effect on job performance because few effective methods are available to do so. Particularly difficult is the problem of evaluating multisite training programs that vary considerably in structure and implementation from one site to another. PURPOSE: NA. SETTING: NA. INTERVENTION: NA. RESEARCH DESIGN: We devised a method of a consensus expert review to evaluate the quality of conference abstracts submitted by participants in Field Epidemiology Training Programs - an approach that can provide useful information on how well trainees apply knowledge and skills gained in training, complementing data obtained from other sources and methods. This method is practical, minimally intrusive, and resource-efficient, and it may prove useful for evaluation practice in diverse fields that require training. DATA COLLECTION AND ANALYSIS: NA. FINDINGS: NA.

[Evaluation of tuberculosis control in an area of the autonomous region of Madrid, Spain (1999-2004)]. / Evaluación del control de la tuberculosis en un área de la Comunidad de Madrid, España (1999-2004).

OBJECTIVE: Area 7 of the autonomous region of Madrid has one of the highest incidences of tuberculosis (23/100,000 population per year 2004). This study aimed to identify tuberculosis control in this area. METHODS: A descriptive study of tuberculosis cases diagnosed in area 7 from January 1, 1999 to December 31, 2004 was carried out by analyzing the incidence of tuberculosis and the management of cases and their contacts. We also analyzed the microepidemics that occurred during this period. RESULTS: The incidence of tuberculosis in area 7 during this period was 30.9/100,000 inhabitants. Respiratory tuberculosis accounted for 80.9% of all tuberculosis cases; of these, contact investigation was only undertaken in 38%. Thirty-five percent of cases were lost to follow-up. In the 24 microepidemics detected during the study period, 29 secondary cases were diagnosed; of these, the protocol for contact investigation was not correctly followed in 48%. CONCLUSION: The lack of information and/or errors in the management of cases and their contacts should be corrected by establishing a new program to ensure proper treatment and follow-up of cases, contact investigations and correct reporting.

[Incidence and risk factors for acute gastroenteritis among pilgrims following the French way to Santiago de Compostela (Spain) in 2008]. / Incidencia y factores de riesgo de gastroenteritis en los peregrinos del Camino de Santiago durante el verano de 2008 en el camino francés.

OBJECTIVES: To determine the incidence of acute gastroenteritis in pilgrims on St. James' Way, as well as associated risk factors and microbiological characteristics. METHODS: Two studies were designed simultaneously: a cross-sectional study through self-completed questionnaires among pilgrims reaching Santiago, and a case-control study of pilgrims traveling along the Way. Multivariate analysis was performed using logistic regression. RESULTS: In the cross-sectional study, the incidence rate was 23.5 episodes of acute gastroenteritis/10³ pilgrims-day (95% CI: 18.9-2.4/10³. In the case-control study, the major risk factors were age <20 years (OR=4.72; 95% CI: 2.16-10.28), traveling in groups (three or more) (OR=1.49; 95% CI: 0.98-2.28), and drinking unbottled water (OR=2.09; 95% CI: 0.91-4.82). The most frequent etiologic agent was norovirus (56%). CONCLUSIONS: Age less than 20 years, traveling in groups and drinking unbottled water were important risk factors for acute gastroenteritis.

Assessment of myocardial deformation: Predicting medium-term left ventricular dysfunction after surgery in patients with chronic mitral regurgitation.

INTRODUCTION AND OBJECTIVES: The development of left ventricular dysfunction after mitral valve replacement is a common problem in patients with chronic severe mitral regurgitation. Assessment of myocardial deformation enables myocardial contractility to be accurately estimated. Our aim was to compare the value of the preoperative strain and strain rate derived by either speckle-tracking echocardiography or tissue Doppler imaging (TDI) for predicting the medium-term decrease in left ventricular ejection fraction (LVEF) following surgery. METHODS: This prospective study involved 38 consecutive patients with chronic severe mitral regurgitation who were scheduled for mitral valve replacement. The longitudinal strain and strain rate in the interventricular septum were measured preoperatively using speckle-tracking echocardiography and TDI. The LVEF was determined preoperatively and postoperatively using 3-dimensional echocardiography. Echocardiographic assessments were performed in the 48 hours prior to surgery and 6 months postoperatively. RESULTS: The patients' mean age was 59.9+/-11.3 years and 10 (29.4%) were male. Both speckle-tracking echocardiography and TDI were found to be predictors of a >10% decrease in LVEF at 6 months. However, the predictive value of speckle-tracking echocardiography was greater than that of TDI. The longitudinal strain at baseline in the interventricular septum as measured by speckle-tracking echocardiography was the most powerful predictor; the area under the curve was 0.85 and the optimal cut-off value was -0.11. CONCLUSIONS: Speckle-tracking echocardiography can be used to predict a decrease in LVEF over the medium term after mitral valve replacement. Moreover, the predictive accuracy of speckle-tracking echocardiography was greater than that of TDI.

Diastolic heart failure in the elderly: in-hospital and long-term outcome after the first episode.

Our aim was to describe the incidence and predictors of in-hospital mortality and long-term mortality and morbidity in elderly patients after a first admission due to diastolic HF (DHF). Six hundred and seventy nine consecutive elderly patients with a first admission to hospital due to DHF comprised our study group. Mean age was 83.3+/-6.7 (464 women--68.3%). A history of dilated cardiomyopathy was associated to increased in-hospital mortality and age and pulmonary artery systolic pressure were identified as independent markers of bad long-term outcome. Thus, patients with DHF have high mortality during and after the first admission.

[Quantification of aortic valve area using three-dimensional echocardiography]. / Utilidad de la ecocardiografía tridimensional en la cuantificación del área valvular aórtica.

INTRODUCTION AND OBJECTIVES: To determine whether the reproducibility of left ventricular outflow tract (LVOT) area measurement is greater with three-dimensional echocardiographic (3D-echo) planimetry than with conventional 2D-echo. To determine the LVOT circularity index by means of 3D-echo. To determine the usefulness of measuring the LVOT area by 3D-echo for quantifying the severity of valvular aortic stenosis. METHODS: The study included 40 patients, of whom 22 had an aortic stenosis. The LVOT area was measured using both 2D-echo and 3D-echo, and the circularity index, using 3D-echo alone. In addition, the severity of valvular aortic stenosis was categorized using both 2D-echo and 3D-echo. RESULTS: The levels of inter- and intra-observer agreement on LVOT area measurements were better with 3D-echo. The circularity index was 1.50 (0.25), and there was a very poor linear correlation with LVOT area (r=-0.34; P=.47). Patients with valvular aortic stenosis were categorized according to the severity of their stenoses using both 2D-echo and 3D-echo. The level of agreement between the two techniques was poor (kappa=0.36). CONCLUSIONS: Measurements of the LVOT area made using 3D-echo were more reproducible than those made using 2D-echo. Consequently, 3D-echo may be a better technique for assessing the LVOT area. In addition, 3D-echo showed that the LVOT is elliptical in form and that its size is not related to its circularity. Moreover, 3D-echo could also be helpful in classifying the severity of valvular aortic stenosis.

Effect of antithrombotic therapy in patients with mitral stenosis and atrial fibrillation: a sub-analysis of NASPEAF randomized trial.

AIMS: The randomized NASPEAF study included non-valvular with prior embolism and mitral stenosis patients in the same group. This is a sub-study to specially focus on the antithrombotic therapy in mitral stenosis. METHODS AND RESULTS: We analysed 311 patients with mitral stenosis, compared with 175 non-valvular atrial fibrillation patients with prior embolism, stratified by a history of previous embolism and assigned to anticoagulant therapy [target international normalized ratio (INR) = 2.0-3.0] or combined antiplatelet plus moderate intensity anticoagulant therapy. Median follow-up was 2.9 years. Outcomes were fatal and non-fatal embolism, stroke and myocardial infarction, sudden death, and death from bleeding. Combined therapy in mitral stenosis patients, compared with anticoagulant alone therapy, reduced the risk of vascular events by 58.3%. During equal therapy, the outcome annual rates were essentially the same in non-valvular and valvular patients [hazard ratio 0.90 (95% confidence interval 0.37-2.16), P = 0.81]. During anticoagulant alone therapy, the annual event rate in mitral stenosis patients without prior embolism was low (2.5%) and it was very high in patients with prior embolism (6.6%). CONCLUSION: Combined therapy was effective in mitral stenosis patients. Prior embolism patients are not efficiently protected with anticoagulant alone therapy for an INR of 2.0-3.0.