Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority,Liberia, Mid-2014

Over the span of a few weeks during July and August 2014, events in West Africa changed perceptions of Ebola virus disease (EVD) from an exotic tropical disease to a priority for global health security. We describe observations during that time of a field team from the Centers for Disease Control and Prevention and personnel of the Liberian Ministry of Health and Social Welfare. We outline the early epidemiology of EVD within Liberia, including the practical limitations on surveillance and the effect on the country’s health care system, such as infections among health care workers. During this time, priorities included strengthening EVD surveillance; establishing safe settings for EVD patient care (and considering alternative isolation and care models when Ebola Treatment Units were overwhelmed); improving infection control practices; establishing an incident management system; and working with Liberian airport authorities to implement EVD screening of departing passengers.     

A Randomized Study of Extended Dosing Regimens for Initiation of Epoetin Alfa Treatment for Anemia of Chronic Kidney Disease

Background and objectives: Although epoetin alfa is commonly initiated weekly (QW) in anemic chronic kidney disease (CKD) patients, recent evidence indicates that it can be initiated every 2 wk (Q2W) and used in maintenance therapy every 4 wk (Q4W). This study examined the feasibility of initiating epoetin alfa Q4W in anemic CKD patients not receiving dialysis.Design, setting, participants, & measurements: This open-label study randomized subjects (1:2:2:2) to treatment with epoetin alfa 10,000 IU QW, 20,000 IU Q2W, 20,000 IU Q4W, or 40,000 IU Q4W for 16 wk. Subjects were ≥18 yr, had hemoglobin <11 g/dl, a glomerular filtration rate of 15 to 90 ml/min per 1.73 m², and had not received erythropoietic therapy within 8 wk. The primary analysis was a noninferiority comparison of the 40,000 IU Q4W to the 20,000 IU Q2W group in the per-protocol population with respect to hemoglobin change from baseline to the end of study.Results: Of 262 subjects randomized, 229 comprised the per-protocol population. Mean hemoglobin change from baseline for the 40,000 IU Q4W group (1.24 g/dl) was not inferior to the 20,000 IU Q2W group (1.11 g/dl) with the lower limit of 95% CI, −0.21 g/dl. In the QW, 20,000 IU Q2W, 20,000 IU Q4W, and 40,000 IU Q4W groups, 90%, 87%, 75%, and 86% of subjects, respectively, achieved a hemoglobin increase ≥1 g/dl. Serious adverse events were similar across all groups.Conclusions: Epoetin alfa can be initiated Q4W in anemic CKD subjects.Epoetin alfa, the first commercially available erythropoietic-stimulating agent (ESA), was initially administered three times per week to patients with chronic kidney disease (CKD) and anemia. Today physicians commonly initiate the drug weekly. This may be inconvenient for patients with chronic anemia. In clinical practice, extended dosing regimens may offer advantages for patients and healthcare practitioners in terms of flexibility, improved compliance, and reduced costs (1). To allow for longer dosing intervals, newer ESAs have been developed with longer serum half-lives. There is now increasing evidence that epoetin alfa, despite its relatively short serum half-life, can be administered at extended dosing intervals. Epoetin alfa regimens of up to every 4 wk (Q4W) have been shown to be effective in maintaining hemoglobin (Hb) concentrations ≥11 g/dl in patients with CKD (2–4). Recently, a study demonstrated that epoetin alfa could be effectively initiated every 2 wk (Q2W) (5). The primary objective of this study was to explore the feasibility of initiating therapy with epoetin alfa at dosing intervals of up to Q4W in subjects with anemia of CKD not receiving dialysis.     

Intraaortic balloon counterpulsation with and without reperfusion for myocardial infarction shock

Forty patients were treated for cardiogenic shock secondary to acute myocardial infarction. Twenty-one (group 1) were treated with intraaortic balloon counterpulsation and 19 (group 2) were treated with counterpulsation and coronary artery bypass grafting. The groups were similar in age, incidence of previous infarction, initial hemodynamics and coronary anatomy. The in-hospital mortality between group 1 (52.4%) and group 2 (42.1%) was not significantly different. The difference in long-term mortality between group 1 and group 2 was substantially different (71.4% vs 47.3%). The subset of group 2 (n = 12) that underwent reperfusion and counterpulsation within 16 hours from the onset of symptoms of infarction had a lower mortality (25.0%) than the subset (n = 7) that underwent operation more than 18 hours after the onset of symptoms (71.4%). The long-term mortality in the subset of group 2 patients operated on within 16 hours after the onset of infarction was significantly different from that in group 1 (25.0% vs 71.4%, p less than 0.03). The data suggest that reperfusion with counterpulsation is more effective when carried out early. Patients who develop shock more than 18 hours after the onset of symptoms of infarction appear to benefit most if treated with counterpulsation alone.     

Acute and chronic effects of alcohol on iron absorption

Digestive Diseases and Sciences - The absorption of nonheme59ferric chloride from a test meal was measured, using a whole-body counter, in 34 alcoholics with liver disease of varying severity, 30...     

Risk Factors for Campylobacteriosis in Two Washington State Counties with High Numbers of Dairy Farms

Campylobacteriosis is a frequently reported, food-borne, human bacterial disease that can be associated with ruminant reservoirs, although public health messages primarily focus on poultry. In Washington State, the two counties with the highest concentrations of dairy cattle also report the highest incidences of campylobacteriosis. Conditional logistic regression analysis of case-control data from both counties found living or working on a dairy farm (odds ratio [OR], 6.7 [95% confidence interval [CI], 1.7 to 26.4]) and Hispanic ethnicity (OR, 6.4 [95% CI, 3.1 to 13.1]) to have the strongest significant positive associations with campylobacteriosis. When the analysis was restricted to residents of one county, Hispanic ethnicity (OR, 9.3 [95% CI, 3.9 to 22.2]), contact with cattle (OR, 5.0 [95% CI, 1.3 to 19.5]), and pet ownership (OR, 2.6 [95% CI, 1.1 to 6.3]) were found to be independent risk factors for disease. Campylobacter jejuni isolates from human (n = 65), bovine (n = 28), and retail poultry (n = 27) sources from the same counties were compared using multilocus sequence typing. These results indicated that sequence types commonly found in human isolates were also commonly found in bovine isolates. These findings suggest that, in areas with high concentrations of dairy cattle, exposure to dairy cattle may be more important than food-borne exposure to poultry products as a risk for campylobacteriosis.     

Demonstrated health care cost savings for women: findings from a community health worker intervention designed to address depression and unmet social needs

To evaluate the impact of a community health worker intervention (CHW) (referred to as Personalized Support for Progress (PSP)) on all-cause health care utilization and cost of care compared with Enhanced Screening and Referral (ESR) among women with depression. A total of 223 patients (111 in PSP and 112 in ESR randomly assigned) from three women’s health clinics with elevated depressive symptoms were enrolled in the study. Their electronic health records were queried to extract all-cause health care encounters along with the corresponding billing information 12 months before and after the intervention, as well as during the first 4-month intervention period. The health care encounters were then grouped into three mutually exclusive categories: high-cost (> US$1000 per encounter), medium-cost (US$201–$999), and low-cost (≤ US$200). A difference-in-difference analysis of mean total charge per patient between PSP and ESR was used to assess cost differences between treatment groups. The results suggest the PSP group was associated with a higher total cost of care at the baseline; taking this baseline difference into account, the PSP group was associated with lower mean total charge amounts (p = 0.008) as well as a reduction in the frequency of high-cost encounters (p < 0.001) relative to the ESR group during the post-intervention period. Patient-centered interventions that address unmet social needs in a high-cost population via CHW may be a cost-effective approach to improve quality of care and patient outcomes.