The tattooing paradox: are studies of acute hepatitis adequate to identify routes of transmission of subclinical hepatitis C infection?

BACKGROUND: The Hepatitis Branch of the Centers for Disease Control and Prevention does not recommend routine regulation and inspection of tattoo parlors because surveillance of hepatitis C virus (HCV)-positive acute hepatitis cases rarely identifies tattooing in the incubation period. However, the majority of seroepidemiological studies agree that tattooing is a strong, independent risk factor for subclinical HCV seropositivity. We postulated that this paradox might be explained if transmission of HCV by tattooing generally caused subclinical HCV seropositivity without the acute hepatitis syndrome. METHODS: We reanalyzed data from a prior seroepidemiological study of 626 consecutive patients who were unaware of their HCV serologic status and whose risk factors were ascertained by interview of an internist. Separate multiple logistic regression models were developed to predict a history of the acute hepatitis syndrome and HCV seropositivity. RESULTS: A history of injection-drug use was strongly associated with both HCV seropositivity (adjusted odds ratio [AOR], 7.2; 95% confidence interval [CI], 3.1-16.5) and a history of acute hepatitis (AOR, 5.9; 95% CI, 2.5-13.8), whereas having a commercially applied tattoo was strongly associated with HCV seropositivity (AOR, 6.5; 95% CI, 2.9-14.4) but not with a history of acute hepatitis (AOR, 1.2; 95% CI, 0.5-3.3). CONCLUSIONS: Intravenous injection of relatively large quantities of innocula of HCV may be more likely to result in the relatively rare acute HCV hepatitis syndrome, whereas intradermal exposure to small quantities of innocula may cause only subclinical HCV infections. If so, public policy on regulation and inspection of tattoo parlors should be determined by seroepidemiological studies rather than by the Sentinel Counties Study of acute hepatitis cases.     

Twenty-four hour ambulatory blood pressure in the Hypertension Optimal Treatment (HOT) study

BACKGROUND AND AIMS: The Hypertension Optimal Treatment (HOT) study showed that when antihypertensive treatment reduces diastolic blood pressure well below 90 mmHg, there can be a further reduction of cardiovascular events, particularly myocardial infarction, with no evidence of a J-shaped curve at lower pressures. Office measurement, however, gives no information about blood pressure outside the office. This paper describes a HOT substudy in which patients underwent both office measurement and 24 h ambulatory blood pressure monitoring. METHODS: The mean age of the substudy population was 62 +/- 7 years. Substudy patients were treated for a median period of 2 years. All received the dihydropyridine calcium antagonist felodipine, while some also received an ACE-inhibitor, a beta-blocker or a diuretic. Average 24 h, day and night ambulatory blood pressure values were computed at baseline (n = 277) and during treatment (n = 347): 112 patients had been randomized to a target office diastolic blood pressure 相似文献   

HER-2 gene amplification can be acquired as breast cancer progresses

Amplification and overexpression of the HER-2 oncogene in breast cancer is felt to be stable over the course of disease and concordant between primary tumor and metastases. Therefore, patients with HER-2-negative primary tumors rarely will receive anti-Her-2 antibody (trastuzumab, Herceptin) therapy. A very sensitive blood test was used to capture circulating tumor cells (CTCs) and evaluate their HER-2 gene status by fluorescence in situ hybridization. The HER-2 status of the primary tumor and corresponding CTCs in 31 patients showed 97% agreement, with no false positives. In 10 patients with HER-2-positive tumors, the HER-2/chromosome enumerator probe 17 ratio in each tumor was about twice that of the corresponding CTCs (mean 6.64 +/- 2.72 vs. 2.8 +/- 0.6). Hence, the ratio of the CTCs is a reliable surrogate marker for the expected high ratio in the primary tumor. Her-2 protein expression of 10 CTCs was sufficient to make a definitive diagnosis of the HER-2 gene status of the whole population of CTCs in 19 patients with recurrent breast cancer. Nine of 24 breast cancer patients whose primary tumor was HER-2-negative each acquired HER-2 gene amplification in their CTCs during cancer progression, i.e., 37.5% (95% confidence interval of 18.8-59.4%). Four of the 9 patients were treated with Herceptin-containing therapy. One had a complete response and 2 had a partial response.     

Related umbilical cord blood transplantation in patients with thalassemia and sickle cell disease

Allogeneic bone marrow transplantation (BMT) from HLA-identical siblings is an accepted treatment for both thalassemia and sickle cell disease (SCD). However, it is associated with decided risk of both transplant-related mortality (TRM) and chronic graft-versus-host disease (GVHD). We analyzed 44 patients (median age, 5 years; range, 1-20 years) given an allogeneic related cord blood transplant for either thalassemia (n = 33) or SCD (n = 11). Thirty children were given cyclosporin A (CsA) alone as GVHD prophylaxis, 10 received CsA and methotrexate (MTX), and 4 patients received other combinations of immunosuppressive drugs. The median number of nucleated cells infused was 4.0 x 10(7)/kg (range, 1.2-10 x 10(7)/kg). No patient died and 36 of 44 children remain free of disease, with a median follow-up of 24 months (range, 4-76 months). Only one patient with SCD did not have sustained donor engraftment as compared with 7 of the 33 patients with thalassemia. Three of these 8 patients had sustained donor engraftment after BMT from the same donor. Four patients experienced grade 2 acute GVHD; only 2 of the 36 patients at risk developed limited chronic GVHD. The 2-year probability of event-free survival is 79% and 90% for patients with thalassemia and SCD, respectively. Use of MTX for GVHD prophylaxis was associated with a greater risk of treatment failure. Related CBT for hemoglobinopathies offers a good probability of success and is associated with a low risk of GVHD. Optimization of transplantation strategies could further improve these results.     

Measuring Accreditation Activity and Progress: Findings from a Survey of Indiana Local Health Departments, 2013

A 2013 survey of Indiana local health departments (LHDs) measured accreditation activity and progress. Reported activities were categorized using the Public Health Accreditation Board''s (PHAB''s) accreditation steps as a guiding framework and matched with selected sociodemographic, organizational, and technical assistance variables. Findings indicated that 42 (59.2%) of responding Indiana LHDs reported pursuing accreditation. Of LHDs pursuing accreditation, 21 were at the initial introductory step, 18 were at the prerequisite step, one reported submitting an application to PHAB, and two reported no activity, yet intent to pursue accreditation. Reported receipt of technical assistance was associated with accreditation progress (p=0.01) and, specifically, with being at the prerequisite step. Facilitating the pursuit of LHD accreditation in states with low public health investment is possible with targeted accreditation resources. Finding meaningful measures of accreditation progress will help advance the study of factors associated with LHD accreditation on a broad scale and for the long term.As public health accreditation emerges, recognition of its structural and policy importance is growing.^1,2 As of April 25, 2015, 320 health departments were actively engaged in the process of accreditation. Twenty-six states had accredited health departments, most of which were local (52 local health departments [LHDs] vs. eight state health departments).³ These accredited health departments varied considerably in terms of geography, politics, and public health investment; however, many were early participants in the various learning collaboratives and communities with targeted accreditation funding through initiatives such as the Robert Wood Johnson Foundation''s Community of Practice and Public Health Improvement and the Centers for Disease Control and Prevention''s (CDC''s) National Public Health Improvement Initiative.^4–6Several reported studies of accreditation have focused on states that have relatively strong public health systems and have made targeted accreditation-related investments.^7–10 Understanding the progress of accreditation nationally will require not only the development of solid measures, but also studies conducted in states that have minimal public health investment so that a more comprehensive national picture can emerge for policy and evaluation discourse.Indiana is an example of a low public health investment state. The state per capita public health investment is $13.08 (ranked 44th in the nation), and Indiana is last among states for federal per capita investments from CDC (ranked 50th) and the Health Resources and Services Administration (ranked 47th).¹¹ This investment picture has not changed appreciably in the last five years. Indiana received a small amount of targeted technical assistance funding for accreditation about 5–7 years ago as one of the early learning collaborative states.^4,12 This funding supported assessment, quality improvement, and technical assistance to LHDs.The objectives of this study were to (1) identify accreditation pursuit and progress among Indiana health departments, (2) explore a framework for measuring accreditation progress, and (3) associate reported accreditation progress with sociodemographic, organizational, and technical assistance variables.     

A Window of Opportunity: Maximizing the Effectiveness of New HCV Regimens in the United States With the Expansion of the Affordable Care Act

Patients with chronic HCV have predictable overlapping comorbidities that reduce access to care. The Affordable Care Act (ACA) presents an opportunity to focus on the benefits of the medical home model for integrated chronic disease management.New, highly effective HCV treatment regimens in combination with the medical home model could reduce disease prevalence. We sought to address challenges posed by comorbidities in patients with chronic HCV infection and limitations within our health care system, and recommend solutions to maximize the public benefit from ACA and the new drug regimen.Over 180 million people worldwide have HCV-related chronic liver disease, with an estimated yearly incidence of 17 000 and prevalence of 3.2 million people in the United States alone.1,2 Years of undetected infection and untreated disease might culminate in hepatic fibrosis, cirrhosis, hepatocellular carcinoma, and liver transplantation, accompanied by increased morbidity and mortality. Approximately 20% of chronically infected adults develop cirrhosis within 20 years.3,4Each stage of disease incurs increasing human and economic costs, with medical treatment of infected patients in the United States estimated as high as $9 billion in 2012.5–7 Curing HCV infection, measured by a sustained virological response (negative HCV-RNA PCR) 24 weeks after the end of therapy (SVR 24), reduces mortality and the risk of hepatocellular carcinoma.8,9 Regrettably, the reach of curative therapy has been limited by the efficacy and tolerability of past regimens.A radical shift in standard therapy for HCV infection is occurring in which new regimens exceed 90% cure rates, eliminate injectable interferon and its attendant adverse effects, reduce dosing frequency and pill burden potentially to 1 pill daily, and reduce treatment duration to as short as 3 months. Currently, an interferon-free regimen exists for the treatment of genotype 1. It combines sofosbuvir with simeprevir. Because the efficacy trial combined drugs from separate manufacturers, the regimen is not explicitly supported by either drug label.10 There are multiple regimens with high efficacy in genotype 1 without interferon that are expected to be approved by fall 2014.11For the past decade, treatment has consisted of peginterferon (pegINF) α-2a/2b plus ribavirin, administered up to 12 months, which has clinical trial efficacy rates among genotype 1 treatment-naive patients that range from 41% to 55%.12–14 In 2012, the efficacy of regimens for genotype 1, estimated to comprise more than 70% of HCV-infected patients in the United States, modestly improved when 2 new protease inhibitors, boceprevir15 and telaprevir15 were approved. However, both of these medications must be administered in addition to the standard regimen of interferon and ribavirin, add significant toxicity, and are unlikely to continue to play a significant role in future treatment regimens.In 2013, the US Food and Drug Administration approved 2 novel HCV drugs: simeprevir,16 an NS3/4A protease inhibitor, and sofosbuvir,17 an oral nucleotide inhibitor of HCV polymerase. Sofosbuvir enables the first all-oral, interferon-free regimen approved for the cure of chronic HCV infection, though an indication for an interferon-free regimen for genotype 1 is not yet available. Treatment with sofosbuvir plus pegylated interferon plus ribavirin yields cure in an unprecedented 89% of genotype 1 patients in only 3 months.17 In the near-term, other novel antiviral agents are expected to become available that will enable interferon-free regimens for genotype 1. Already, phase 2 trials have shown that sofosbuvir in combination with ledipasvir and ribavirin, without interferon, achieves 100% cure rates in genotype 1 patients without cirrhosis, with an excellent safety profile.18This dramatic improvement in HCV treatment has the potential to substantially reduce the public health burden of chronic liver disease as earlier therapy yielded low efficacy, was long in duration, and had burdensome side effects that deterred both physicians and patients. Better treatment regimens could lead to more screening, more diagnoses, stronger adherence, more cures, and ultimately reduce HCV-associated cirrhosis and liver cancer, liver transplantation, mortality, and lower health care system costs associated with chronic HCV infection.Maximizing the public health benefit from this therapeutic innovation will require addressing the barriers that US patients with chronic HCV face when attempting to access treatment. Most people in the United States with chronic HCV live in areas of high poverty, lack health insurance or rely on public insurance19 and have a history of injection drug use.20 With multiple medical and behavioral health co-morbidities, patients with HCV face a fragmented health care delivery system.Historically, the chasm between clinical trial HCV cure rates (efficacy) and cure rates in the community (effectiveness) has been considerable.21,22 The specific efficacy-effectiveness gap in curative HCV therapy has been modeled to suggest that even a substantial improvement in the efficacy of a curative regimen alone is unlikely to move the effectiveness bar very far.23 One model suggests that if the new antiviral treatments consistently resulted in an 80% response rate and half of all HCV-infected patients were treated, then incidence of cirrhosis would decline by 15%.24 Consequently, to move beyond treatment efficacy to improved cure rate, greater attention must be given to the social determinants of health, consistent access to care, as well as patient and provider acceptance of treatment therapy.25,26A key component of the efficacy-effectiveness gap is the readiness of the health care system to identify patients, address comorbidities, safely and effectively administer a curative regimen, reduce the risk of reinfection, and measure population-level progress. Fortunately, the Affordable Care Act (ACA)27 represents a timely opportunity to engage HCV infected patients in care and achieve a higher community-level cure rate.     

Distance Learning Teaching Strategies in Registered Nurse to Baccalaureate Nurse Programs: Advancing Cultural Competence of Registered Nurses in Providing End-of-Life Care

In order to prepare nurses to effectively provide holistic nursing care to an increasingly diverse patient population, nurse educators must incorporate cultural care practices into the nursing curricula. Specifically, teaching culturally competent end-of-life care is essential but can pose challenges for distance education programs. The purpose of this article is to identify multiple learning strategies utilized in an online nursing program to teach students how to provide culturally competent end-of-life care.