Special Considerations for Prophylaxis for and Treatment of Anthrax in Pregnant and Postpartum Women

In August 2012, the Centers for Disease Control and Prevention, in partnership with the Association of Maternal and Child Health Programs, convened a meeting of national subject matter experts to review key clinical elements of anthrax prevention and treatment for pregnant, postpartum, and lactating (P/PP/L) women. National experts in infectious disease, obstetrics, maternal fetal medicine, neonatology, pediatrics, and pharmacy attended the meeting, as did representatives from professional organizations and national, federal, state, and local agencies. The meeting addressed general principles of prevention and treatment for P/PP/L women, vaccines, antimicrobial prophylaxis and treatment, clinical considerations and critical care issues, antitoxin, delivery concerns, infection control measures, and communication. The purpose of this meeting summary is to provide updated clinical information to health care providers and public health professionals caring for P/PP/L women in the setting of a bioterrorist event involving anthrax.     

The psychology of ‘regrettable substitutions’: examining consumer judgements of Bisphenol A and its alternatives

Bisphenol A is a chemical used to make certain types of plastics and is found in numerous consumer products. Because scientific studies have raised concerns about Bisphenol A’s potential impact on human health, it has been removed from some (but not all) products. What many consumers do not know, however, is that Bisphenol A is often replaced with other, less-studied chemicals whose health implications are virtually unknown. This type of situation is known as a potential ‘regrettable substitution’, because the substitute material might actually be worse than the material that it replaces. Regrettable substitutions are a common concern among policymakers, and they are a real-world manifestation of the tension that can exist between the desire to avoid risk (known possible consequences that might or might not occur) and ambiguity (second-order uncertainty), which is itself aversive. In this article, we examine how people make such trade-offs using the example of Bisphenol A. Using data from Study 1, we show that people have inconsistent preferences towards these alternatives and that choice is largely determined by irrelevant contextual factors such as the order in which the alternatives are evaluated. Using data from Study 2, we further demonstrate that when people are informed of the presence of substitute chemicals, labelling the alternative product as ‘free’ of Bisphenol A causes them to be significantly more likely to choose the alternative despite its ambiguity. We discuss the relevance of these findings for extant psychological theories as well as their implications for risk, policy and health communication.     

Assessment of regularization techniques for electrocardiographic imaging

A widely used approach to solving the inverse problem in electrocardiography involves computing potentials on the epicardium from measured electrocardiograms (ECGs) on the torso surface. The main challenge of solving this electrocardiographic imaging (ECGI) problem lies in its intrinsic ill-posedness. While many regularization techniques have been developed to control wild oscillations of the solution, the choice of proper regularization methods for obtaining clinically acceptable solutions is still a subject of ongoing research. However there has been little rigorous comparison across methods proposed by different groups. This study systematically compared various regularization techniques for solving the ECGI problem under a unified simulation framework, consisting of both 1) progressively more complex idealized source models (from single dipole to triplet of dipoles), and 2) an electrolytic human torso tank containing a live canine heart, with the cardiac source being modeled by potentials measured on a cylindrical cage placed around the heart. We tested 13 different regularization techniques to solve the inverse problem of recovering epicardial potentials, and found that non-quadratic methods (total variation algorithms) and first-order and second-order Tikhonov regularizations outperformed other methodologies and resulted in similar average reconstruction errors.     

The accuracy of using last menstrual period to determine gestational age for first trimester medication abortion: a systematic review

Objective

We sought to evaluate the accuracy of assessing gestational age (GA) prior to first trimester medication abortion using last menstrual period (LMP) compared to ultrasound (U/S).

Study Design

We searched Medline, Embase and Cochrane databases through October 2013 for peer-reviewed articles comparing LMP to U/S for GA dating in abortion care. Two teams of investigators independently evaluated data using standard abstraction forms. The US Preventive Services Task Force and Quality Assessment of Diagnostic Accuracy Studies guidelines were used to assess quality.

Results

Of 318 articles identified, 5 met inclusion criteria. Three studies reported that 2.5–11.8% of women were eligible for medication abortion by LMP and ineligible by U/S. The number of women who underestimated GA using LMP compared to U/S ranged from 1.8 to 14.8%, with lower rates found when the sample was limited to a GA < 63 days. Most women (90.5–99.1%) knew their LMP, 70.8–90.5% with certainty.

Conclusion

Our results support that LMP can be used to assess GA prior to medication abortion at GA < 63 days. Further research looking at patient outcomes and identifying women eligible for medication abortion by LMP but ineligible by U/S is needed to confirm the safety and effectiveness of providing medication abortion using LMP alone to determine GA.     

Hospital Costs and Inpatient Mortality among Children Undergoing Surgery for Congenital Heart Disease

Objective

To determine the association between hospital costs and risk-adjusted inpatient mortality among children undergoing surgery for congenital heart disease (CHD) in U.S. acute-care hospitals.

Data Sources/Study Settings

Retrospective cohort study of 35,446 children in 2003, 2006, and 2009 Kids'' Inpatient Database (KID).

Study Design

Cross-sectional logistic regression of risk-adjusted inpatient mortality and hospital costs, adjusting for a variety of patient-, hospital-, and community-level confounders.

Data Collection/Extraction Methods

We identified relevant discharges in the KID using the AHRQ Pediatric Quality Indicator for pediatric heart surgery mortality, and linked these records to hospital characteristics from American Hospital Association Surveys and community characteristics from the Census.

Principal Findings

Children undergoing CHD surgery in higher cost hospitals had lower risk-adjusted inpatient mortality (p = .002). An increase from the 25th percentile of treatment costs to the 75th percentile was associated with a 13.6 percent reduction in risk-adjusted mortality.

Conclusions

Greater hospital costs are associated with lower risk-adjusted inpatient mortality for children undergoing CHD surgery. The specific mechanisms by which greater costs improve mortality merit further exploration.     

Comparing Active and Passive Varicella Surveillance in Philadelphia, 2005–2010: Recommendations for the Transition to Nationwide Passive Varicella Disease Surveillance

Objective

The Philadelphia Department of Public Health (PDPH) conducts active surveillance for varicella in West Philadelphia. For its approximately 300 active surveillance sites, PDPH mandates biweekly reports of varicella (including zero cases) and performs intensive case investigations. Elsewhere in Philadelphia, surveillance sites passively report varicella cases, and abbreviated investigations are conducted. We used active varicella surveillance program data to inform the transition to nationwide passive varicella surveillance.

Methods

We compared classification of reported cases, varicella disease incidence, and reporting completeness for active and passive surveillance areas for 2005–2010. We assessed reporting completeness using capture-recapture analysis of 2- to 18-year-old cases reported by schools/daycare centers and health-care providers.

Results

From 2005 to 2010, PDPH received 3,280 passive and 969 active surveillance varicella case reports. Most passive surveillance reports were classified as probable cases (18% confirmed, 56% probable, and 26% excluded), whereas nearly all of the active surveillance reports were either confirmed or excluded (36% confirmed, 11% probable, and 53% excluded). Overall incidence rates calculated using confirmed/probable cases were similar in the active and passive surveillance areas. Detection of laboratory-confirmed, breakthrough, and moderate-to-severe cases was equivalent for both surveillance areas.

Conclusions

Although active surveillance for varicella results in better classified cases, passive surveillance provides comparable data for monitoring disease trends in breakthrough and moderate-to-severe varicella. To further improve passive surveillance in the two-dose-varicella vaccine era, jurisdictions should consider conducting periodic enhanced surveillance, encouraging laboratory testing, and collecting additional varicella-specific variables for passive surveillance.To monitor the impact of the varicella vaccination program, the Centers for Disease Control and Prevention, in collaboration with the Philadelphia Department of Public Health (PDPH) and Los Angeles County Department of Health Services, conducted varicella surveillance through the Varicella Active Surveillance Project (VASP) from 1996–2011.¹ This new program was essential, because when varicella vaccine was recommended for use in the United States in 1996, varicella was not nationally notifiable; varicella had been removed from the list of notifiable conditions in 1981 because reporting the then-common disease was not feasible in many states.² VASP has supplied vital information for programmatic decision-making, including the 2007 recommendation for a second dose of varicella vaccine.³With the success of the varicella vaccination program in reducing the incidence of disease, relatively small active surveillance areas cannot accurately monitor further declines in varicella incidence, changes in age distribution, and disease severity. Therefore, more widespread passive surveillance is required. In 2003, varicella was again added to the national notifiable diseases list, and the Council of State and Territorial Epidemiologists (CSTE) recommended that all states implement case-based surveillance by 2005.^4–6 To mitigate the burden of varicella surveillance, CSTE recommended that states begin by focusing on the collection of three varicella-specific variables: age at disease onset, number of lesions (as a proxy for disease severity), and vaccination status, adding variables, including rash characteristics, varicella-related complications, and diagnostic laboratory data, when feasible.² As of 2010, 38 states were conducting case-based passive surveillance, but the completeness of information collected is unknown.⁷In this article, we briefly summarize the characteristics of active and passive surveillance in Philadelphia, Pennsylvania, and compare active and passive varicella surveillance data for 2005–2010 as the basis for recommendations to optimize the quality of national passive surveillance. Specifically, we compared (1) the proportions of confirmed, probable, and excluded cases among overall reports; (2) the proportions of cases reported by type of reporting site; (3) the overall reported incidence of varicella; (4) the completeness of reporting assessed by capture-recapture methodology; and (5) the extent of laboratory testing and findings from testing. Our results suggest that optimizing passive surveillance in the U.S. will require efforts to improve the identification and exclusion of non-varicella cases through periodic enhanced surveillance, laboratory testing, or more thorough investigation of rash characteristics.     

Understanding the Burden of Tuberculosis Among American Indians/Alaska Natives in the U.S.: A Validation Study

Objective

We validated cases of active tuberculosis (TB) recorded in the Indian Health Service (IHS) National Patient Information Reporting System (NPIRS) and evaluated the completeness of TB case reporting from IHS facilities to state health departments.

Methods

We reviewed the medical records of American Indian/Alaska Native (AI/AN) patients at IHS health facilities who were classified as having active TB using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes from 2006 to 2009 for clinical and laboratory evidence of TB disease. Individuals were reclassified as having active TB disease; recent latent TB infection (LTBI); past positive tuberculin skin test (TST) only; or as having no evidence of TB, LTBI, or a past positive TST. We compared validated active TB cases with corresponding state records to determine if they were reported.

Results

The study included 596 patients with active TB as per ICD-9-CM codes. Based on chart review, 111 (18.6%) had active TB; 156 (26.2%) had LTBI; 104 (17.4%) had a past positive TST; and 221 (37.1%) had no evidence of TB disease, LTBI, or a past positive TST. Of the 111 confirmed cases of active TB, 89 (80.2%) resided in participating states; 81 of 89 (91.2%) were verified as reported TB cases.

Conclusions

ICD-9-CM codes for active TB disease in the IHS NPIRS do not accurately reflect the burden of TB among AI/ANs. Most confirmed active TB cases in the IHS health system were reported to the state; the national TB surveillance system may accurately represent the burden of TB in the AI/AN population.Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis (M. tuberculosis) complex. Treatment for active TB disease requires months of combination drug therapy. Left untreated, TB can result in substantial morbidity and occasionally death. Although the number of TB cases in the United States has steadily declined during the past two decades, TB remains a major health concern within many subgroups, including American Indians/Alaska Natives (AI/ANs). The TB case rate among AI/ANs is estimated at 5.6 per 100,000 population, notably higher than the national average of 3.4 cases per 100,000 population.¹Surveillance of active TB disease is an important component of monitoring and controlling the spread of TB. Currently, annual rates of TB in the U.S. are calculated by the Centers for Disease Control and Prevention (CDC) National Tuberculosis Surveillance System (NTSS).¹ The NTSS is an electronic database that relies on the collaboration of state and local health departments; each person diagnosed with TB disease is verified as an incident case of TB and reported using a standard TB case form. The criteria for TB disease surveillance are based on a laboratory case definition, clinical case definition, or provider diagnosis.^1,2 The laboratory case definition requires isolation of M. tuberculosis complex in culture or detection of M. tuberculosis complex nucleic acids by amplification testing or demonstration of acid-fast bacilli in a clinical specimen when a culture cannot be obtained. The clinical case definition requires (1) a positive tuberculin skin test (TST), (2) signs and symptoms compatible with TB, (3) treatment with at least two anti-TB medications, and (4) a completed diagnostic evaluation. A provider diagnosis is used when the clinical presentation is consistent with TB but the criteria to meet laboratory or clinical case definitions are not met.The Indian Health Service (IHS), an agency of the U.S. Department of Health and Human Services, provides comprehensive health-care services through IHS, Tribal, and Urban Indian facilities (collectively referred to hereafter as IHS) to eligible AI/AN people who are members of 566 federally recognized Tribes. IHS provides care for approximately 2.1 million (62%) of the nation''s estimated 3.4 million AI/ANs.³ The IHS maintains a national database, the National Patient Information Reporting System (NPIRS).⁴ Within NPIRS, diseases and conditions are coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).⁵ In addition, IHS is in the process of implementing an electronic health record (EHR) system.⁶ Electronic data collected by IHS have the potential to serve as a resource to better understand the burden and monitor trends of TB disease within the AI/AN population; yet, the accuracy of NPIRS for identifying people with TB disease has not been previously established. Several previous studies in other U.S. populations have cited wide variability (0%–77%) in the positive predictive value (PPV) of ICD-9-CM diagnostic codes for active TB disease.^7–13CDC provides guidance for IHS providers to report all nationally notifiable diseases, including TB, to local and state authorites.^1,2 However, there are no explicit mechanisms for IHS to report cases of TB directly to the NTSS, and the extent to which IHS facilities collaborate with local authorities on case reporting is not well understood.We validated active cases of TB disease within the AI/AN population by reviewing the medical charts of individuals assigned an active TB disease ICD-9-CM code in the inpatient and outpatient NPIRS visit data from 2006 to 2009 to determine the completeness of reporting TB disease by examining whether validated TB cases from IHS facilities were reported to state health departments.     

Prenatal and Postnatal Serum PCB Concentrations and Cochlear Function in Children at 45 Months of Age

Background: Some experimental and human data suggest that exposure to polychlorinated biphenyls (PCBs) may induce ototoxicity, though results of previous epidemiologic studies are mixed and generally focus on either prenatal or postnatal PCB concentrations exclusively.Objectives: Our aim was to evaluate the association between pre- and postnatal PCB concentrations in relation to cochlear status, assessed by distortion product otoacoustic emissions (DPOAEs), and to further clarify the critical periods in development where cochlear status may be most susceptible to PCBs.Methods: A total of 351 children from a birth cohort in eastern Slovakia underwent otoacoustic testing at 45 months of age. Maternal pregnancy, cord, and child 6-, 16-, and 45-month blood samples were collected and analyzed for PCB concentrations. At 45 months of age, DPOAEs were assessed at 11 frequencies in both ears. Multivariate, generalized linear models were used to estimate the associations between PCB concentrations at different ages and DPOAEs, adjusting for potential confounders.Results: Maternal and cord PCB-153 concentrations were not associated with DPOAEs at 45 months. Higher postnatal PCB concentrations at 6-, 16-, and 45-months of age were associated with lower (poorer) DPOAE amplitudes. When all postnatal PCB exposures were considered as an area-under-the-curve metric, an increase in PCB-153 concentration from the 25th to the 75th percentile was associated with a 1.6-dB SPL (sound pressure level) decrease in DPOAE amplitude (95% CI: –2.6, –0.5; p = 0.003).Conclusions: In this study, postnatal rather than maternal or cord PCB concentrations were associated with poorer performance on otoacoustic tests at age 45 months.Citation: Jusko TA, Sisto R, Iosif AM, Moleti A, Wimmerová S, Lancz K, Tihányi J, Šovčíková E, Drobná B, Palkovičová L, Jurečková D, Thevenet-Morrison K, Verner MA, Sonneborn D, Hertz-Picciotto I, Trnovec T. 2014. Prenatal and postnatal serum PCB concentrations and cochlear function in children at 45 months of age. Environ Health Perspect 122:1246–1252; http://dx.doi.org/10.1289/ehp.1307473     

Impaired automatization of a cognitive skill in first-degree relatives of patients with schizophrenia

We studied healthy, first-degree relatives of patients with schizophrenia to test the hypothesis that deficits in cognitive skill learning are associated with genetic liability to schizophrenia. Using the Weather Prediction Task (WPT), 23 healthy controls and 10 adult first-degree Relatives Of Schizophrenia (ROS) patients were examined to determine the extent to which cognitive skill learning was automated using a dual-task paradigm to detect subtle impairments in skill learning. Automatization of a skill is the ability to execute a task without the demand for executive control and effortful behavior and is a skill in which schizophrenia patients possess a deficit. ROS patients did not differ from healthy controls in accuracy or reaction time on the WPT either during early or late training on the single-task trials. In contrast, the healthy control and ROS groups were differentially affected during the dual-task trials. Our results demonstrate that the ROS group did not automate the task as well as controls and continued to rely on controlled processing even after extensive practice. This suggests that adult ROS patients may engage in compensatory strategies to achieve normal levels of performance and support the hypothesis that impaired cognitive skill learning is associated with genetic risk for schizophrenia.