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St Clair NE, Sharahil NB, Umphrey L, Merry S, Koueik J, Beshish A, Acheampong B, Kloster H, Conway JH. Health Care Providers Working Cross-Culturally: Pitfalls, Pearls, and Preparation Resources for Culture Shock. Pediatr Ann 2023; 52:e335-e343. [PMID: 37695280 DOI: 10.3928/19382359-20230720-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Health care providers engaging in cross-cultural work will likely experience culture shock, a psychological, behavioral, and physiologic response to new cultural environments that can significantly affect travelers. Culture shock has the potential for both negative and positive outcomes. Well-being, health, and professionalism can be negatively influenced during the peak of culture shock, but the experience may also positively promote transformative learning and professional identity formation. Culture shock has been carefully researched for different types of sojourners, such as undergraduate students and business personnel, but minimally for health care providers. This article defines culture shock, describes different health care-related cross-cultural opportunities, identifies factors contributing to culture shock, describes complexities related to measuring culture shock, depicts common cross-cultural challenges encountered by traveling health care providers, and offers tangible guidance to help prepare for culture shock. We conclude with a call for further research and resource development to support the well-being of an increasingly global health care workforce. [Pediatr Ann. 2023;52(9):e335-e343.].
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Marshall GS, Abbing-Karahagopian V, Marshall HS, Cenci S, Conway JH, Occhipinti E, Bekkat-Berkani R, Banzhoff A, Sohn WY. A comprehensive review of clinical and real-world safety data for the four-component serogroup B meningococcal vaccine (4CMenB). Expert Rev Vaccines 2023. [PMID: 37278390 DOI: 10.1080/14760584.2023.2222015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Gary S Marshall
- Norton Children's and University of Louisville School of Medicine, Louisville, KY, USA
| | - Victoria Abbing-Karahagopian
- Women's and Children's Health Network and Adelaide Medical School and Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | | | | | - James H Conway
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health Clinical Sciences Center, Madison, WI, USA
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Aufhauser DD, Condit P, Schmit KM, Conway JH, Cook S, D’Alessandro AM, Furuya KN. Liver Transplantation for Refractory Congenital Cytomegaloviral Hepatitis. JPGN Rep 2023; 4:e275. [PMID: 38293317 PMCID: PMC10754569 DOI: 10.1097/pg9.0000000000000275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 10/10/2022] [Indexed: 02/01/2024]
Abstract
Congenital cytomegalovirus (cCMV) is the most common congenital infection. Here, we report on a case of severe, refractory cCMV hepatitis resulting in end-stage liver disease. A male infant born at 37 weeks gestational age presented with petechiae, splenomegaly, and jaundice associated with a direct hyperbilirubinemia, elevated transaminases, and thrombocytopenia. Urine screen was positive for CMV, and he was treated with valganciclovir. He progressed to decompensated cirrhosis with ascites, hypoglycemia, and coagulopathy and was listed for liver transplant at 4 months of age. At 5 months of age, he developed massive hematemesis with hemorrhagic shock and underwent emergent portocaval shunt followed by living donor liver transplant with a left lateral segment graft. Postoperatively, he received CMV immune globulin and intravenous ganciclovir and cleared his viremia by 2 months post-transplant. This case illustrates the diagnostic and management challenges of severe cCMV hepatitis and reports a successful liver transplantation despite active CMV viremia.
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Affiliation(s)
- David D. Aufhauser
- From the Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Paige Condit
- Department of Pediatrics, University of Wisconsin- Madison School of Medicine and Public Health, Madison, WI
| | - Kathryn M. Schmit
- Department of Pediatrics, University of Wisconsin- Madison School of Medicine and Public Health, Madison, WI
| | - James H. Conway
- Department of Pediatrics, University of Wisconsin- Madison School of Medicine and Public Health, Madison, WI
| | - Shelly Cook
- Department of Pediatrics, University of Wisconsin- Madison School of Medicine and Public Health, Madison, WI
| | - Anthony M. D’Alessandro
- From the Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Katryn N. Furuya
- Department of Pediatrics, University of Wisconsin- Madison School of Medicine and Public Health, Madison, WI
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Chongsuwat T, Ibrahim AO, Evensen AE, Conway JH, Zwick M, Oloya W. Health facility assessments of cervical cancer prevention, early diagnosis, and treatment services in Gulu, Uganda. PLOS Glob Public Health 2023; 3:e0000785. [PMID: 36962762 PMCID: PMC10021907 DOI: 10.1371/journal.pgph.0000785] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 01/13/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Cervical cancer is ranked globally in the top three cancers for women younger than 45 years, with the average age of death at 59 years of age. The highest burden of disease is in low-to-middle income countries (LMICs), responsible for 90% of the 311,000 cervical cancer deaths in 2018. This growing health disparity is due to the lack of quality screening and treatment programs, low human papillomavirus (HPV) vaccination rates, and high human immunodeficiency virus (HIV) co-infection rates. To address these gaps in care, we need to develop a clear understanding of the resources and capabilities of LMICs' health care facilities to provide prevention, early diagnosis through screening, and treatment for cervical cancer. OBJECTIVES This project aimed to assess baseline available cervical cancer prevention, early diagnosis, and treatment resources, at facilities designated as Health Center III or above, in Gulu, Uganda. METHODS We adapted the World Health Organization's Harmonized Health Facility Assessment for our own HFA and grading scale, deploying it in October 2021 for a cross-sectional analysis of 21 health facilities in Gulu. RESULTS Grading of Health Center IIIs (n = 16) concluded that 37% had "excellent" or "good" resources available, and 63% of facilities had "poor" or "fair" resources available. Grading of Health Center IVs and above (n = 5) concluded that 60% of facilities had "excellent" or "good" resources, and 40% had "fair" resources available. DISCUSSION The analysis of health facilities in Gulu demonstrated subpar resources available for cervical cancer prevention, early diagnosis, and treatment. Focused efforts are needed to expand health centers' resources and capability to address rising cervical cancer rates and related health disparities in LMICs. The development process for this project's HFA can be applied to global cervical cancer programming to determine gaps in resources and indicate areas to target improved health equity.
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Affiliation(s)
- Tana Chongsuwat
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, United States of America
| | - Aaliyah O Ibrahim
- Gulu Women's Economic Development & Globalization (GWED-G), Gulu, Uganda
| | - Ann E Evensen
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, United States of America
| | - James H Conway
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, United States of America
| | - Margaret Zwick
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, United States of America
| | - William Oloya
- Gulu Women's Economic Development & Globalization (GWED-G), Gulu, Uganda
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Fergie J, Pawaskar M, Veeranki P, Samant S, Harley C, MacEwan J, Schwartz TT, Surati S, Conway JH. Recognition & management of varicella infections and accuracy of antimicrobial recommendations: Case vignettes study in the US. PLoS One 2022; 17:e0269596. [PMID: 35749342 PMCID: PMC9231738 DOI: 10.1371/journal.pone.0269596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background
In 1995, the CDC recommended one-dose routine varicella immunization for children <12 years of age, expanding its recommendation to two doses in 2006. Today, with widespread varicella vaccination coverage, an estimated 3.5 million cases of varicella, 9,000 hospitalizations, and 100 deaths are prevented annually in the United States. Since varicella infections are now uncommon, health care providers (HCPs) may not recognize varicella infections and may prescribe inappropriate treatment.
Methods
An online survey of HCPs was conducted to assess recognition and management of varicella infections. Responses to eight varicella vignettes describing patients with varying varicella symptoms were analyzed and descriptive analyses performed. Stratified analysis comparing responses of those licensed before and in/after 1996 was also performed.
Results
153 HCPs (50 nurse practitioners, 103 doctors) completed the survey. Mean age of respondents was 44 years. 62% were female, and 82% were licensed before 1996. Varicella infection was correctly diagnosed 79% of the time. HCPs correctly recognized uncomplicated varicella vignettes 85% of the time versus 61% of the time for complicated varicella vignettes. Antibiotics were recommended 17% of the time and antivirals 18% of the time, of which 25% and 69% (respectively) were not appropriate per guidelines. HCPs licensed before 1996 were better able to recognize varicella compared to those licensed later, but prescribed more antimicrobials medications to treat varicella.
Conclusions
Although most HCPs recognized varicella infection, a sizable proportion could not recognize cases with complications, and some of the varicella cases were inappropriately treated with antibiotics and/or antivirals. Additional HCP training and high vaccination coverage are important strategies to avoid inaccurate diagnoses and minimize unnecessary exposure to antimicrobial/antiviral therapies.
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Affiliation(s)
- Jaime Fergie
- Driscoll Children’s Hospital, Corpus Christi, Texas, United States of America
| | - Manjiri Pawaskar
- Merck & Co. Inc., Rahway, New Jersey, United States of America
- * E-mail:
| | - Phani Veeranki
- PRECISIONheor, Los Angeles, California, United States of America
| | - Salome Samant
- Merck & Co. Inc., Rahway, New Jersey, United States of America
| | - Carolyn Harley
- PRECISIONheor, Los Angeles, California, United States of America
| | - Joanna MacEwan
- PRECISIONheor, Los Angeles, California, United States of America
| | - Taylor T. Schwartz
- Avalere Health, Washington DC, District of Columbia, United States of America
| | - Shikha Surati
- Merck & Co. Inc., Rahway, New Jersey, United States of America
| | - James H. Conway
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
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Pawaskar M, Fergie J, Harley C, Samant S, Veeranki P, Diaz O, Conway JH. Impact of universal varicella vaccination on the use and cost of antibiotics and antivirals for varicella management in the United States. PLoS One 2022; 17:e0269916. [PMID: 35687559 PMCID: PMC9187103 DOI: 10.1371/journal.pone.0269916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/31/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Our objective was to estimate the impact of universal varicella vaccination (UVV) on the use and costs of antibiotics and antivirals for the management of varicella among children in the United States (US).
Methods
A decision tree model of varicella vaccination, infections and treatment decisions was developed. Results were extrapolated to the 2017 population of 73.5 million US children. Model parameters were populated from published sources. Treatment decisions were derived from a survey of health care professionals’ recommendations. The base case modelled current vaccination coverage rates in the US with additional scenarios analyses conducted for 0%, 20%, and 80% coverage and did not account for herd immunity benefits.
Results
Our model estimated that 551,434 varicella cases occurred annually among children ≤ 18 years in 2017. Antivirals or antibiotics were prescribed in 23.9% of cases, with unvaccinated children receiving the majority for base case. The annual cost for varicella antiviral and antibiotic treatment was approximately $14 million ($26 per case), with cases with no complications accounting for $12 million. Compared with the no vaccination scenario, the current vaccination rates resulted in savings of $181 million (94.7%) for antivirals and $78 million (95.0%) for antibiotics annually. Scenario analyses showed that higher vaccination coverage (from 0% to 80%) resulted in reduced annual expenditures for antivirals (from $191 million to $41 million), and antibiotics ($82 million to $17 million).
Conclusions
UVV was associated with significant reductions in the use of antibiotics and antivirals and their associated costs in the US. Higher vaccination coverage was associated with lower use and costs of antibiotics and antivirals for varicella management.
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Affiliation(s)
- Manjiri Pawaskar
- Merck & Co. Inc., Rahway, New Jersey, United States of America
- * E-mail:
| | - Jaime Fergie
- Driscoll Children’s Hospital, Corpus Christi, Texas, United States of America
| | - Carolyn Harley
- PRECISIONheor, Los Angeles, California, United States of America
| | - Salome Samant
- Merck & Co. Inc., Rahway, New Jersey, United States of America
| | - Phani Veeranki
- PRECISIONheor, Los Angeles, California, United States of America
| | - Oliver Diaz
- PRECISIONheor, Los Angeles, California, United States of America
| | - James H. Conway
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
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Temte JL, Barlow S, Goss M, Temte E, Schemmel A, Bell C, Reisdorf E, Shult P, Wedig M, Haupt T, Conway JH, Gangnon R, Uzicanin A. Cause-specific student absenteeism monitoring in K-12 schools for detection of increased influenza activity in the surrounding community—Dane County, Wisconsin, 2014–2020. PLoS One 2022; 17:e0267111. [PMID: 35439269 PMCID: PMC9017898 DOI: 10.1371/journal.pone.0267111] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/04/2022] [Indexed: 11/19/2022] Open
Abstract
Background Schools are primary venues of influenza amplification with secondary spread to communities. We assessed K-12 student absenteeism monitoring as a means for early detection of influenza activity in the community. Materials and methods Between September 2014 and March 2020, we conducted a prospective observational study of all-cause (a-TOT), illness-associated (a-I), and influenza-like illness–associated (a-ILI) absenteeism within the Oregon School District (OSD), Dane County, Wisconsin. Absenteeism was reported through the electronic student information system. Students were visited at home where pharyngeal specimens were collected for influenza RT-PCR testing. Surveillance of medically-attended laboratory-confirmed influenza (MAI) occurred in five primary care clinics in and adjoining the OSD. Poisson general additive log linear regression models of daily counts of absenteeism and MAI were compared using correlation analysis. Findings Influenza was detected in 723 of 2,378 visited students, and in 1,327 of 4,903 MAI patients. Over six influenza seasons, a-ILI was significantly correlated with MAI in the community (r = 0.57; 95% CI: 0.53–0.63) with a one-day lead time and a-I was significantly correlated with MAI in the community (r = 0.49; 0.44–0.54) with a 10-day lead time, while a-TOT performed poorly (r = 0.27; 0.21–0.33), following MAI by six days. Discussion Surveillance using cause-specific absenteeism was feasible and performed well over a study period marked by diverse presentations of seasonal influenza. Monitoring a-I and a-ILI can provide early warning of seasonal influenza in time for community mitigation efforts.
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Affiliation(s)
- Jonathan L. Temte
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Shari Barlow
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Maureen Goss
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Emily Temte
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Amber Schemmel
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Cristalyne Bell
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
- * E-mail:
| | - Erik Reisdorf
- Wisconsin State Laboratory of Hygiene, Madison, Wisconsin, United States of America
| | - Peter Shult
- Wisconsin State Laboratory of Hygiene, Madison, Wisconsin, United States of America
| | - Mary Wedig
- Wisconsin State Laboratory of Hygiene, Madison, Wisconsin, United States of America
| | - Thomas Haupt
- Wisconsin Division of Public Health, Wisconsin Department of Health Services, Madison, Wisconsin, United States of America
| | - James H. Conway
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Ronald Gangnon
- Department of Biostatistics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Amra Uzicanin
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Russ RK, Schultz TJ, Kalscheur N, Conway JH, Safdar N, Caldera F, Hayney MS. Cross-sectional study of coronavirus disease 2019 (COVID-19) vaccine uptake among healthcare workers. Antimicrob Steward Healthc Epidemiol 2022; 2:e61. [PMID: 36483423 PMCID: PMC9726565 DOI: 10.1017/ash.2022.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 06/17/2023]
Affiliation(s)
- Rachel K. Russ
- School of Pharmacy, University of Wisconsin–Madison, Madison, Wisconsin
| | | | | | - James H. Conway
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Freddy Caldera
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine & Public Health, 800 University Bay Drive, Madison, Wisconsin
| | - Mary S. Hayney
- School of Pharmacy, University of Wisconsin–Madison, Madison, Wisconsin
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9
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Kujawski S, Ru B, Das AK, Afanador NL, baumgartner R, Liu Z, Lu S, Pillsbury M, Lewnard J, Conway JH, Pawaskar MD. 1344. Predicting Measles Outbreaks in the United States: Application of Different Modeling Approaches. Open Forum Infect Dis 2021. [DOI: 10.1093/ofid/ofab466.1536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Although measles is still rare in the United States (U.S.), there have been recent resurgent outbreaks in the U.S. To improve the accuracy of prediction given the rarity of measles events, we used machine learning (ML) algorithms to model measles case predictions at the U.S. county level.
Methods
The main outcome was occurrence of ≥1 measles case at the U.S. county level. Two ML prediction models were developed (HDBSCAN, a clustering algorithm, and XGBoost, a gradient boosting algorithm) and compared with traditional logistic regression. We included 28 predictors in the following categories: sociodemographics, population statistics, measles vaccination coverage, healthcare access, and exposure to measles via international air travel. The models were trained on 2014 case data and validated on 2018 case data. Models were compared using area under the receiver operating curve (AUC), sensitivity, specificity, positive predictive value (PPV), and F2 score (combined measure of sensitivity and PPV).
Results
There were 667 measles cases in 2014 and 375 in 2018 in the U.S. We identified U.S. counties for 635 (95.2%) cases in 2014 and 366 (97.6%) cases in 2018 through published sources, corresponding to 81/3143 (2.6%) counties in 2014 and 64/3143 (2.0%) counties in 2018 with ≥1 measles case. HDBSCAN had the highest sensitivity (0.92), but lowest AUC (0.68) and PPV (0.04) (Table). XGBoost had the highest F2 score (0.49), best balance of sensitivity (0.72) and specificity (0.94), and AUC = 0.92. Logistic regression had high AUC (0.91) and specificity (1.00) but the lowest sensitivity (0.16).
Conclusion
Machine learning approaches outperformed logistic regression by maximizing sensitivity to predict counties with measles cases, an important criterion to consider to prevent or prepare for future outbreaks. XGBoost or logistic regression could be considered to maximize specificity. Prioritizing sensitivity versus specificity may depend on county resources, priorities, and measles risk. Different modeling approaches could be considered to optimize surveillance efforts and develop effective interventions for timely response.
Disclosures
Stephanie Kujawski, PhD MPH, Merck & Co., Inc. (Employee, Shareholder) Boshu Ru, Ph.D., Merck & Co. Kenilworth, NJ (NYSE: MRK) (Employee, Shareholder) Amar K. Das, MD, PhD, Merck (Employee) richard baumgartner, PhD, Merck (Employee) Shuang Lu, MBA, MS, Merck (Employee) Matthew Pillsbury, PhD, Merck & CO. (Employee, Shareholder) Joseph Lewnard, PhD, Merck (Consultant, Grant/Research Support) James H. Conway, MD, FAAP, GSK (Advisor or Review Panel member)Merck (Advisor or Review Panel member)Moderna (Advisor or Review Panel member)Pfizer (Advisor or Review Panel member)Sanofi Pasteur (Research Grant or Support) Manjiri D. Pawaskar, PhD, Merck & Co., Inc. (Employee, Shareholder)
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Affiliation(s)
| | - Boshu Ru
- Merck Sharp & Dohme, West Point, Pennsylvania
| | | | | | | | | | - Shuang Lu
- Merck & Co., Inc., New York, New York
| | | | | | - James H Conway
- University of Wisconsin -- Madison, School of Medicine and Public Health, Madison, Wisconsin
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Svenson EL, Tun R, Conway JH, Legenza L, Svenson JM, Duffy S, Svenson JE. A One Health Approach to Compare Self-Prescribed Antibiotic Use across Rural and Semi-urban Populations in San Lucas Tolimán, Guatemala. J Health Care Poor Underserved 2021; 32:1798-1817. [PMID: 34803044 DOI: 10.1353/hpu.2021.0167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Antimicrobial resistance resulting from antibiotic overuse represents an increasing public health challenge. The purpose of this study was to investigate antibiotic self-medication practices in a rural, indigenous Guatemalan population, and to compare self-prescribing patterns in rural and semi-urban populations using a One Health integrated approach, a framework acknowledging that health arises at the interface of humans, animals, and the environment. We conducted a mixed methods study using semi-structured interviews in and around San Lucas Tolimán, Guatemala. Antibiotic self-medication was common in both rural and semi-urban populations, regardless of demographic characteristics. Antibiotic usage in animals, while less common, almost always occurred without a veterinary consult. Although subjects recognized that self-medication could be harmful to health, they face significant barriers to accessing appropriate care. These patterns of use have impacts on the rise of antimicrobial resistance locally, and have the potential to contribute to the spread of such resistance globally.
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11
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Garcia-Prats AJ, Salazar-Austin N, Conway JH, Radtke K, LaCourse SM, Maleche-Obimbo E, Hesseling AC, Savic RM, Nachman S. Coronavirus Disease 2019 (COVID-19) Pharmacologic Treatments for Children: Research Priorities and Approach to Pediatric Studies. Clin Infect Dis 2021; 72:1067-1073. [PMID: 32594142 PMCID: PMC7337679 DOI: 10.1093/cid/ciaa885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/23/2020] [Indexed: 02/06/2023] Open
Abstract
Clinical trials of pharmacologic treatments of coronavirus disease 2019 (COVID-19) are being rapidly designed and implemented in adults. Children are often not considered during development of novel treatments for infectious diseases until very late. Although children appear to have a lower risk compared with adults of severe COVID-19 disease, a substantial number of children globally will benefit from pharmacologic treatments. It will be reasonable to extrapolate efficacy of most treatments from adult trials to children. Pediatric trials should focus on characterizing a treatment's pharmacokinetics, optimal dose, and safety across the age spectrum. These trials should use an adaptive design to efficiently add or remove arms in what will be a rapidly evolving treatment landscape, and should involve a large number of sites across the globe in a collaborative effort to facilitate efficient implementation. All stakeholders must commit to equitable access to any effective, safe treatment for children everywhere.
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Affiliation(s)
- Anthony J Garcia-Prats
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Nicole Salazar-Austin
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - James H Conway
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kendra Radtke
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Sylvia M LaCourse
- Departments of Medicine and Global Health, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | | | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Rada M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Sharon Nachman
- Department of Pediatrics, Stony Brook Children’s, Stony Brook, New York, USA
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Koning SM, Scott K, Conway JH, Palta M. Reproductive health at conflict borders: a cross-sectional survey of human rights violations and perinatal outcomes at the Thai-Myanmar border. Confl Health 2021; 15:15. [PMID: 33691764 PMCID: PMC7945312 DOI: 10.1186/s13031-021-00347-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 02/17/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Human rights violations (HRVs) are common in conflict and displacement contexts. Women are especially vulnerable to HRVs in these contexts, and perinatal health is acutely sensitive to related stressors and health care barriers. However, how HRVs affect immediate and long-term perinatal health in chronic displacement settings has not been closely investigated. Furthermore, it remains unclear whether and how HRVs in these contexts are tied directly to displacement circumstances or other marginalizing factors affecting local migrant and minority populations generally. METHODS We investigated these questions using novel survey data from 577 women at the northern Thai-Myanmar border, where thousands of people have fled conflict in Shan State, Myanmar, for refuge in a range of precarious settings in Thailand, including unofficial refugee camps, villages, and worksites. We compared HRV exposures by ethnicity, country of birth, legal documentation, and residential setting. We then analyzed perinatal outcomes associated with HRV frequency, timing, and type. RESULTS Birth in Myanmar, and ethnic minority and precarious legal status more broadly, predicted higher HRV prevalence. HRV frequency significantly predicted unmet antenatal care and lower birth weight, along with HRVs related to labor exploitation and violence or conflict. HRVs timed closer to pregnancies were more adversely associated with perinatal outcomes. Resource/property deprivation was the strongest predictor of pregnancy complications. CONCLUSIONS Human rights must be urgently attended to, through expanded HRV screenings and responsive care, and policy changes to further protect migrant workers, displaced persons, and others in precarious legal status situations.
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Affiliation(s)
- Stephanie M Koning
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
- Present address: Institute for Policy Research, Northwestern University, 2040 Sheridan Road, Evanston, IL, 60208, USA.
| | - Kaylee Scott
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - James H Conway
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mari Palta
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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13
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Fergie J, Pawaskar MD, Veerkani P, Samant S, Harley C, MacEwan J, Schwartz TT, Surati S, Conway JH. 1387. Current practices in the diagnosis and treatment of varicella infections in the United States. Open Forum Infect Dis 2020. [PMCID: PMC7777010 DOI: 10.1093/ofid/ofaa439.1569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The Advisory Committee on Immunization Practices recommended a 1 dose varicella immunization program in 1996, expanding this to include 2 doses in 2006. As a result, more than 3.5 million cases of varicella, 9,000 hospitalizations, and 100 deaths are prevented annually in the United States. Since varicella infections have become uncommon, the response of health care providers (HCPs) to patients presenting with varicella symptoms may result in misdiagnosis and/ mistreatment. This study investigated the diagnostic and treatment strategies used by HCPs for managing varicella infections in US children. Methods An online cross-sectional survey of licensed HCPs was conducted, after an Institution review board approval and HCP consent. 8 clinical vignettes with information on patients with varying varicella symptoms (representing uncomplicated and complicated cases) were presented. For each vignette, HCPs selected a diagnosis and appropriate intervention(s) from pre-determined lists. Descriptive analyses were performed. Results A total of 153 HCPs (50 nurses, 103 doctors) completed the survey. Mean age was 44 years, 62% were female, and 82% were licensed after 1995. Varicella infection was correctly diagnosed 79% of the time. HCPs were able to recognize uncomplicated cases of varicella 85% of the time and complicated cases 61% of the time. HCPs recommended the correct intervention 43% of the time for uncomplicated cases and 25% of the time for complicated cases. For example, HCPs recommended antibiotics 17% of the time and/or antivirals 18% of the time (Table 1), of which 25% and 69% (respectively) were not appropriate per the American Academy of Pediatrics guidelines respectively. Antibiotics were incorrectly recommended 6% of the time for uncomplicated cases of varicella. Table 1. Additional Diagnosis & Treatment Results ![]()
Conclusion Given the low incidence of varicella infections in the US, complicated cases of varicella may be under-recognized or inappropriately treated by some HCPs. Additional training may help HCPs better recognize/ treat cases of varicella. Further, ensuring high rates of varicella vaccination is important to avoid vaccine preventable conditions and to minimize unnecessary exposure to antimicrobial and antiviral therapies. Disclosures Jaime Fergie, MD, AstraZeneca (Speaker’s Bureau)Sobi, Inc. (Speaker’s Bureau) Manjiri D. Pawaskar, PhD, Merck & Co., Inc (Employee, Shareholder) Phani Veerkani, MD, DrPH, Merck (Research Grant or Support) Salome Samant, MBBS, MPH, Merck & Co., Inc., Kenilworth, NJ, USA (Employee, Shareholder) Carolyn Harley, PhD, Merck (Consultant) Joanna MacEwan, PhD, PRECISIONheor (Employee) Taylor T. Schwartz, MPH, Merck (Consultant, Grant/Research Support, Scientific Research Study Investigator, Research Grant or Support) Shikha Surati, MPH, Merck & Co., Inc. (Employee, Shareholder)
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Affiliation(s)
- Jaime Fergie
- Infectious Disease, Driscoll Children’s Hospital, Corpus Christi, TX
| | | | | | | | | | | | | | | | - James H Conway
- University of Wisconsin -- Madison, School of Medicine and Public Health, Madison, Wisconsin
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Carias C, Pawaskar M, Nyaku M, Conway JH, Roberts CS, Finelli L, Chen YT. Potential impact of COVID-19 pandemic on vaccination coverage in children: A case study of measles-containing vaccine administration in the United States (US). Vaccine 2020; 39:1201-1204. [PMID: 33334618 PMCID: PMC7723783 DOI: 10.1016/j.vaccine.2020.11.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/24/2022]
Abstract
Background The COVID-19 pandemic and stay-at-home orders have caused an unprecedented decrease in the administration of routinely recommended vaccines. However, the impact of this decrease on overall vaccination coverage in a specific birth cohort is not known. Methods We projected measles vaccination coverage for the cohort of children becoming one year old in 2020 in the United States, for different durations of stay-at-home orders, along with varying catch-up vaccination efforts. Results A 15% sustained catch-up rate outside stay-at-home orders (compared to what would be expected via natality information) may be necessary to achieve projected vaccination coverage similar to previous years. Permanent decreases in vaccine administration could lead to projected vaccination coverage levels below 80%. Conclusion Modeling measles vaccination coverage under a range of scenarios provides useful information about the potential magnitude and impact of under-immunization. Sustained catch-up efforts are needed to assure that measles vaccination coverage remains high.
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Affiliation(s)
| | | | | | - James H Conway
- University of Wisconsin-Madison, School of Medicine & Public Health, Dept. of Pediatrics, USA
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Conway JH, Davis JP, Eickhoff JC, Pool V, Greenberg DP, Decker MD. Brand-specific rates of pertussis disease among Wisconsin children given 1-4 doses of pertussis Vaccine, 2010-2014. Vaccine 2020; 38:7063-7069. [PMID: 32921507 DOI: 10.1016/j.vaccine.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acellular pertussis vaccines were initially licensed based on placebo-controlled efficacy trials, but such trials are no longer ethical. The effectiveness of current pertussis vaccines among properly vaccinated children <5 years is so high that a randomized trial is infeasible. Fluctuations in pertussis incidence and characteristics of the US vaccine marketplace make selection of suitable controls for a case-control study problematic. To satisfy an FDA requirement to evaluate rates of pertussis following licensure of Pentacel® vaccine, we used a case-cohort study design with a novel method for characterizing the cohort population. METHODS This prospective, observational study was conducted in Wisconsin from 2010 to 2014 among Wisconsin residents <60 months of age who received ≤four doses of pertussis vaccine (surveillance population). Cases were identified by the Wisconsin Division of Public Health. Characteristics and pertussis vaccinations of the surveillance population were estimated by ongoing random telephonic survey. The primary objective was to determine rates of pertussis disease among those who received only Pentacel vaccine (Group 1) vs those who received a single brand of vaccine other than Pentacel vaccine (Group 2). RESULTS 1195 pertussis cases were identified. It was estimated that the surveillance population accrued a total of 1,133,403 person-years (Group 1, 39%; Group 2, 41%; Group 3 [those not in Group 1 or Group 2], 20%). Pertussis rates were similar in Group 1 (98.9/100,000) and Group 2 (96.2/100,000); rate ratios were 1.03 (unadjusted; 90% CI, 0.92-1.15) and 0.99 (adjusted; 90% CI, 0.89-1.12). Persons with one or more delayed vaccinations had a 66% higher risk of pertussis (90% CI, 39-96%). DISCUSSION Pertussis protection was not found to differ for recipients of the newly licensed vs other available pertussis vaccines. Delayed vaccination substantially increased risk of pertussis. Sample survey methodology was able to characterize the study cohort and enable an otherwise-infeasible study. Clinical Trial Registry number: ClinicalTrials.gov, NCT01129362.
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Affiliation(s)
- James H Conway
- Department of Pediatrics, Division of Infectious Diseases, University of Wisconsin, School of Medicine and Public Health, Madison, WI, United States
| | - Jeffrey P Davis
- Formerly State Epidemiologist, Wisconsin Division of Public Health, Madison, WI, United States
| | - Jens C Eickhoff
- Department of Biostatistics and Medical Informatics, University of Wisconsin, School of Medicine and Public Health, Madison, WI, United States
| | - Vitali Pool
- US Medical Affairs, Sanofi Pasteur, Swiftwater, PA, United States
| | | | - Michael D Decker
- US Medical Affairs, Sanofi Pasteur, Swiftwater, PA, United States; Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States.
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16
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Schmuhl NB, Mooney KE, Zhang X, Cooney LG, Conway JH, LoConte NK. No association between HPV vaccination and infertility in U.S. females 18-33 years old. Vaccine 2020; 38:4038-4043. [PMID: 32253100 DOI: 10.1016/j.vaccine.2020.03.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Human papillomavirus (HPV) vaccines have been recommended as primary prevention of HPV-related cancers for over 10 years in the United States, and evidence reveals decreased incidence of HPV infections following vaccination. However, concerns have been raised that HPV vaccines could decrease fertility. This study examined the relationship between HPV immunization and self-reported infertility in a nationally representative sample. METHODS Data from the 2013-2016 National Health and Nutrition Examination Survey were analyzed to assess likelihood of self-reported infertility among women aged 20 to 33, who were young enough to have been offered HPV vaccines and old enough to have been queried about infertility (n = 1114). Two logistic regression models, stratified by marital history, examined potential associations between HPV vaccination and infertility. Model 1 assessed the likelihood of infertility among women who had never been pregnant or whose pregnancies occurred prior to HPV vaccination. Model 2 accounted for the possibility of latent and/or non-permanent post-vaccine infertility by including all women 20-33 years old who reported any 12-month period of infertility. RESULTS 8.1% reported any infertility. Neither model revealed any association between HPV vaccination at any age and self-reported infertility, regardless of marital status. CONCLUSION There was no evidence of increased infertility among women who received the HPV vaccine. These results provide further evidence of HPV vaccine safety and should give providers confidence in recommending HPV vaccination. Further research should explore protective effects of HPV vaccines on female and male fertility.
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Affiliation(s)
- Nicholas B Schmuhl
- Department of Obstetrics and Gynecology, University of Wisconsin, School of Medicine and Public Health, 4th Floor, McConnel Hall, 1010 Mound St, Madison, WI 53715, USA.
| | - Katherine E Mooney
- University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI 53726, USA.
| | - Xiao Zhang
- University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792, USA.
| | - Laura G Cooney
- Department of Obstetrics and Gynecology, University of Wisconsin, School of Medicine and Public Health, 4th Floor, McConnel Hall, 1010 Mound St, Madison, WI 53715, USA.
| | - James H Conway
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792, USA.
| | - Noelle K LoConte
- University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792, USA.
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17
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Affiliation(s)
- Jessica L Walker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - James H Conway
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - James E Svenson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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18
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Arkader A, Brusalis CM, Warner WC, Conway JH, Noonan K. Update in Pediatric Musculoskeletal Infections: When It Is, When It Isn't, and What to Do. Instr Course Lect 2017; 66:495-504. [PMID: 28594525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Musculoskeletal infections, including osteomyelitis, septic arthritis, and pyomyositis, are a substantial cause of morbidity in children and adolescents. The increased virulence of infectious agents and the increased prevalence of antimicrobial-resistant pathogens, particularly methicillin-resistant Staphylococcus aureus, have resulted in a more complicated clinical course for diagnosis and management, which is evidenced by an increased length of hospital stays, incidence of complications, and number of surgical interventions. Musculoskeletal infections are a challenge for surgeons because they vary substantially in their presentation and in their required treatment, which is based on the causative organism, the location of the infection, and the age of the patient. The necessity for a prompt diagnosis is complicated by several diseases that may mimic musculoskeletal infection, including transient synovitis, autoimmune arthritis, and tumors. Recent innovations in diagnosis and management have provided surgeons with new options to differentiate musculoskeletal infections from these rapidly evolving disease pathologies. As diagnostic and treatment modalities improve, collaboration among surgeons from multiple disciplines is required to develop evidence-based clinical practice guidelines that minimize the effect of musculoskeletal infection and optimize clinical outcomes for patients.
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Affiliation(s)
- Alexandre Arkader
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Associate Professor of Orthopaedic Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Vonasek BJ, Bajunirwe F, Jacobson LE, Twesigye L, Dahm J, Grant MJ, Sethi AK, Conway JH. Do Maternal Knowledge and Attitudes towards Childhood Immunizations in Rural Uganda Correlate with Complete Childhood Vaccination? PLoS One 2016; 11:e0150131. [PMID: 26918890 PMCID: PMC4769080 DOI: 10.1371/journal.pone.0150131] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 02/09/2016] [Indexed: 11/19/2022] Open
Abstract
Improving childhood vaccination coverage and timeliness is a key health policy objective in many developing countries such as Uganda. Of the many factors known to influence uptake of childhood immunizations in under resourced settings, parents' understanding and perception of childhood immunizations has largely been overlooked. The aims of this study were to survey mothers' knowledge and attitudes towards childhood immunizations and then determine if these variables correlate with the timely vaccination coverage of their children. From September to December 2013, we conducted a cross-sectional survey of 1,000 parous women in rural Sheema district in southwest Uganda. The survey collected socio-demographic data and knowledge and attitudes towards childhood immunizations. For the women with at least one child between the age of one month and five years who also had a vaccination card available for the child (N = 302), the vaccination status of this child was assessed. 88% of these children received age-appropriate, on-time immunizations. 93.5% of the women were able to state that childhood immunizations protect children from diseases. The women not able to point this out were significantly more likely to have an under-vaccinated child (PR 1.354: 95% CI 1.018-1.802). When asked why vaccination rates may be low in their community, the two most common responses were "fearful of side effects" and "ignorance/disinterest/laziness" (44% each). The factors influencing caregivers' demand for childhood immunizations vary widely between, and also within, developing countries. Research that elucidates local knowledge and attitudes, like this study, allows for decisions and policy pertaining to vaccination programs to be more effective at improving child vaccination rates.
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Affiliation(s)
- Bryan J. Vonasek
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Francis Bajunirwe
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Laura E. Jacobson
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Leonidas Twesigye
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - James Dahm
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Monica J. Grant
- Department of Sociology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Ajay K. Sethi
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - James H. Conway
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
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20
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Abstract
Vaccines are one of the greatest public health achievements, preventing both mortality and morbidity. However, overall immunization rates are still below the 90% target for Healthy People 2020. There remain significant disparities in immunization rates between children of different racial/ethnic groups, as well as among economically disadvantaged populations. There are systemic issues and challenges in providing access to immunization opportunities. In addition, vaccine hesitancy contributes to underimmunization. Multiple strategies are needed to improve immunization rates, including improving access to vaccines and minimizing financial barriers to families. Vaccine status should be assessed and vaccines given at all possible opportunities.
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Affiliation(s)
- Svapna S Sabnis
- Department of Pediatrics, Downtown Health Center, Medical College of Wisconsin, 1020 North 12th Street, Milwaukee, WI 53233, USA.
| | - James H Conway
- Division of Pediatric Infectious Diseases, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, H4/450 CSC, Madison, WI 53792, USA
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21
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Koepke R, Kahn D, Petit AB, Schauer SL, Hopfensperger DJ, Conway JH, Davis JP. Pertussis and Influenza Vaccination Among Insured Pregnant Women — Wisconsin, 2013-2014. MMWR Morb Mortal Wkly Rep 2015; 64:746-50. [PMID: 26182193 PMCID: PMC4584586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
On February 22, 2013, the Advisory Committee on Immunization Practices (ACIP) revised recommendations for vaccination of pregnant women to recommend tetanus-diphtheria-acellular pertussis vaccine (Tdap) during every pregnancy, optimally at 27-36 weeks of gestation, to prevent pertussis among their newborns. Since 2004, influenza vaccination has been recommended for pregnant women in any trimester to prevent influenza and associated complications for mother and newborn. To evaluate vaccination of pregnant women in Wisconsin after the 2013 Tdap recommendation, health insurance claims data for approximately 49% of Wisconsin births were analyzed. The percentage of women who received Tdap during pregnancy increased from 13.8% of women delivering during January 2013 (63.1% of whom received Tdap 2-13 weeks before delivery) to 51.0% of women delivering during March 2014 (90.9% of whom received Tdap 2-13 weeks before delivery). Among women delivering during November 2013-March 2014, 49.4% had received influenza vaccine during pregnancy. After the 2013 recommendation, Tdap vaccination among pregnant women increased but plateaued at rates similar to influenza vaccination rates. Prenatal care providers should implement, evaluate, and improve Tdap and influenza vaccination programs, and strongly recommend that pregnant patients receive these vaccines to prevent severe illness and complications among mothers and infants.
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Affiliation(s)
- Ruth Koepke
- Wisconsin Division of Public Health,Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison,Corresponding author: Ruth Koepke, , 608-266-9783
| | | | | | | | | | - James H. Conway
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison
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22
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Koepke R, Bartholomew ML, Eickhoff JC, Ayele RA, Rodd D, Kuennen J, Rosekrans J, Warshauer DM, Conway JH, Davis JP. Widespread Bordetella parapertussis Infections-Wisconsin, 2011-2012: Clinical and Epidemiologic Features and Antibiotic Use for Treatment and Prevention. Clin Infect Dis 2015; 61:1421-31. [PMID: 26113655 DOI: 10.1093/cid/civ514] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 06/13/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND During October 2011-December 2012, concurrent with a statewide pertussis outbreak, 443 Bordetella parapertussis infections were reported among Wisconsin residents. We examined clinical features of patients with parapertussis and the effect of antibiotic use for treatment and prevention. METHODS Patients with polymerase chain reaction results positive for B. parapertussis reported during October 2011-May 2012 were interviewed regarding presence and durations of pertussis-like symptoms and receipt of azithromycin treatment. Data regarding acute cough illnesses and receipt of azithromycin prophylaxis among parapertussis patient household members (HHMs) were also collected. Using multivariate repeated measures log-binomial regression analysis, we examined associations of treatment receipt by the HHM with the earliest illness onset and prophylaxis receipt among other HHMs with the presence of any secondary cough illnesses in the household. RESULTS Among 218 patients with parapertussis, pertussis-like symptoms were frequently reported. Illness durations were significantly shorter among patients with treatment initiated 0-6 days after cough onset, compared with nonrecipients (median durations: 10 vs 19 days, P = .002). Among 361 HHMs from 120 households, compared with nonrecipients, prompt prophylaxis of HHMs was associated with no secondary cough illnesses (relative risk: 0.16; 95% confidence interval, .04-.69). CONCLUSIONS Bordetella parapertussis infection causes pertussis-like illness that might be misclassified as pertussis if B. parapertussis testing is not performed. Prompt treatment might shorten illness duration, and prompt HHM prophylaxis might prevent secondary illnesses. Further study is needed to evaluate antibiotic effectiveness for preventing parapertussis and to determine risks and benefits of antibiotic use.
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Affiliation(s)
- Ruth Koepke
- Division of Public Health, Wisconsin Department of Health Services Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison
| | - Michael L Bartholomew
- Division of Public Health, Wisconsin Department of Health Services Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jens C Eickhoff
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison
| | - Roman A Ayele
- Division of Public Health, Wisconsin Department of Health Services Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison
| | - Diane Rodd
- Wood County Health Department, Wisconsin Rapids
| | | | | | | | - James H Conway
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison
| | - Jeffrey P Davis
- Division of Public Health, Wisconsin Department of Health Services
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23
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Koepke R, Eickhoff JC, Ayele RA, Petit AB, Schauer SL, Hopfensperger DJ, Conway JH, Davis JP. Reply to Decker et al. J Infect Dis 2015; 211:498-9. [PMID: 25156559 DOI: 10.1093/infdis/jiu478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ruth Koepke
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health Department of Pediatrics
| | - Jens C Eickhoff
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison
| | - Roman A Ayele
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health Department of Pediatrics
| | - Ashley B Petit
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health Department of Pediatrics
| | - Stephanie L Schauer
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health
| | - Daniel J Hopfensperger
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health
| | | | - Jeffrey P Davis
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health
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Poulsen KP, Pillers DM, Conway JH, Faith NG, Czuprynski CJ. Post-parturient shedding of Listeria monocytogenes in breast milk of infected mice. [corrected]. J Neonatal Perinatal Med 2014; 6:145-51. [PMID: 24246517 DOI: 10.3233/npm-1366312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objectives of this study were to develop an animal model to study Listeria monocytogenes infection during the peri-parturient period and identify sources of maternal shedding of the pathogen. Peri-parturient mice were infected intragastrically with L. monocytogenes that expressed bacterial luciferase. Mice were then imaged in vivo over time. Secreted breast milk samples from mice infected after parturition were enriched and plated for culture and imaging. Bioluminescence imaging technology was able to detect luciferase emitting L. monocytogenes in vaginal secretions and maternal and fetal organs at 72 and 96 h post infection in mice infected prior to, or just after, parturition. The results from this study clearly show that L. monocytogenes is shed in vaginal secretions and disseminates to the mammary chain, from which it can be shed in the milk of peri-parturient mice.
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Affiliation(s)
- K P Poulsen
- Department of Clinical Sciences, Oregon State University College of Veterinary Medicine, Corvallis, OR, USA
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Koepke R, Eickhoff JC, Ayele RA, Petit AB, Schauer SL, Hopfensperger DJ, Conway JH, Davis JP. Estimating the effectiveness of tetanus-diphtheria-acellular pertussis vaccine (Tdap) for preventing pertussis: evidence of rapidly waning immunity and difference in effectiveness by Tdap brand. J Infect Dis 2014; 210:942-53. [PMID: 24903664 DOI: 10.1093/infdis/jiu322] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We estimated the vaccine effectiveness (VE) of tetanus-diphtheria-acellular pertussis vaccine (Tdap) for preventing pertussis among adolescents during a statewide outbreak of pertussis in Wisconsin during 2012. METHODS We used the population-based Wisconsin Immunization Registry (WIR) to construct a cohort of Wisconsin residents born during 1998-2000 and collect Tdap vaccination histories. Reports of laboratory-confirmed pertussis with onset during 2012 were matched to WIR clients. Incidence rate ratios (IRRs) of pertussis and Tdap VE estimates [(1 - IRR)*100%], by year of Tdap vaccine receipt and brand (Boostrix/Adacel), were estimated using Poisson regression. RESULTS Tdap VE decreased with increasing time since receipt, with VEs of 75.3% (95% confidence interval [CI], 55.2%-86.5%) for receipt during 2012, 68.2% (95% CI, 60.9%-74.1%) for receipt during 2011, 34.5% (95% CI, 19.9%-46.4%) for receipt during 2010, and 11.9% (95% CI, -11.1% to 30.1%) for receipt during 2009/2008; point estimates were higher among Boostrix recipients than among Adacel recipients. Among Tdap recipients, increasing time since receipt was associated with increased risk, and receipt of Boostrix (vs Adacel) was associated with decreased risk of pertussis (adjusted IRR, 0.62 [95% CI, .52-.74]). CONCLUSIONS Our results demonstrate waning immunity following vaccination with either Tdap brand. Boostrix was more effective than Adacel in preventing pertussis in our cohort, but these findings may not be generalizable to adolescent cohorts that received different diphtheria-tetanus-acellular pertussis vaccines (DTaP) during childhood and should be further examined in studies that include childhood DTaP history.
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Affiliation(s)
- Ruth Koepke
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health Department of Pediatrics
| | - Jens C Eickhoff
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison
| | - Roman A Ayele
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health Department of Pediatrics
| | - Ashley B Petit
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health Department of Pediatrics
| | - Stephanie L Schauer
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health
| | - Daniel J Hopfensperger
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health
| | | | - Jeffrey P Davis
- Bureau of Communicable Diseases and Emergency Response, Wisconsin Division of Public Health
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Yaeger JP, Conway JH, Butteris SM, Howard CR, Moreno MA. Pediatric global health education: correlation of website information and curriculum. J Pediatr 2013; 163:1764-8. [PMID: 23968746 DOI: 10.1016/j.jpeds.2013.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 06/10/2013] [Accepted: 07/02/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Web sites describing residency programs are initial sources of information for applicants. The correlation of global health content on pediatric residency program Web sites with reported curricula is unknown. To determine the accuracy of global health education, information on program Web sites was compared with queried program content responses. STUDY DESIGN The Fellowship and Residency Electronic Interactive Database was used to assess pediatric residency programs' Web sites for global health education, applying American Academy of Pediatrics consensus guidelines. The authors developed a questionnaire using these consensus guidelines and contacted each program to assess Web site findings, and χ(2) tests were used to compare data from these 2 sources. RESULTS Of 194 programs, 177 had operational Web sites, of which 98 participated in the questionnaire (55%). Ninety-three of 177 programs (53%) reported global health education on Web sites, whereas 80 of 98 programs (82%) reported global health education through direct questioning (P < .001). Results include provision of resident salaries during global health elective (Web site 5% vs questionnaire 98%, P < .001), mandatory training before global health elective (8% vs 20%, P = .02), presence of global health elective curriculum (24% vs 75%, P < .001), postexperience debriefing (16% vs 29%, P = .05), and bidirectional resident exchange (2% vs 13%, P = .01). CONCLUSIONS Results indicate continued expansion of pediatric global health education, but significant differences exist between information on Web sites and data obtained through direct questioning. Accurate representation of global health opportunities would allow for more informed decision-making among prospective applicants. Findings also suggest substantial variability in global health curricula that needs to be addressed through improved planning and cooperation among training programs.
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Affiliation(s)
- Jeffrey P Yaeger
- Department of International Health, Center for American Indian Health, Johns Hopkins University, Baltimore, MD.
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Tarr GAM, Eickhoff JC, Koepke R, Hopfensperger DJ, Davis JP, Conway JH. Using a bayesian latent class model to evaluate the utility of investigating persons with negative polymerase chain reaction results for pertussis. Am J Epidemiol 2013; 178:309-18. [PMID: 23735308 DOI: 10.1093/aje/kws465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pertussis remains difficult to control. Imperfect sensitivity of diagnostic tests and lack of specific guidance regarding interpretation of negative test results among patients with compatible symptoms may contribute to its spread. In this study, we examined whether additional pertussis cases could be identified if persons with negative pertussis test results were routinely investigated. We conducted interviews among 250 subjects aged ≤18 years with pertussis polymerase chain reaction (PCR) results reported from 2 reference laboratories in Wisconsin during July-September 2010 to determine whether their illnesses met the Centers for Disease Control and Prevention's clinical case definition (CCD) for pertussis. PCR validity measures were calculated using the CCD as the standard for pertussis disease. Two Bayesian latent class models were used to adjust the validity measures for pertussis detectable by 1) culture alone and 2) culture and/or more sensitive measures such as serology. Among 190 PCR-negative subjects, 54 (28%) had illnesses meeting the CCD. In adjusted analyses, PCR sensitivity and the negative predictive value were 1) 94% and 99% and 2) 43% and 87% in the 2 types of models, respectively. The models suggested that public health follow-up of reported pertussis patients with PCR-negative results leads to the detection of more true pertussis cases than follow-up of PCR-positive persons alone. The results also suggest a need for a more specific pertussis CCD.
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Affiliation(s)
- Gillian A M Tarr
- Department of Pediatrics, School ofMedicine and Public Health, University of Wisconsin–Madison, Madison,WI 53792, USA
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Kawai K, O'Brien MA, Conway JH, Marshall GS, Kuter BJ. Factors associated with receipt of two doses of varicella vaccine among adolescents in the United States. Pediatr Infect Dis J 2013. [PMID: 23190788 DOI: 10.1097/inf.0b013e31827f4c3c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2006, routine two-dose varicella vaccination for all children was recommended, including a second dose catch-up program for older children and adolescents. Recent studies have shown that a second dose of the vaccine provides incremental protection against varicella disease. METHODS This study is a cross-sectional analysis of data collected in the National Immunization Survey-Teen 2010 combined with publicly available data related to state immunization requirements. Bivariate and multivariable logistic regression analyses were performed to examine individual-level and state-level factors associated with receipt of two doses of varicella vaccine among 10,542 adolescents 13 to 17 years of age with no history of varicella. RESULTS Overall, 58.1% of adolescents without any history of varicella had received two doses of varicella vaccine. Coverage varied widely among states, ranging from 19.7% in South Dakota to 85.3% in Rhode Island. In the multivariable model, receipt of two doses of varicella vaccine was significantly associated with younger age, higher maternal education level, private health insurance, more frequent health care visits, receipt of both quadrivalent meningococcal conjugate and tetanus, diphtheria, and acellular pertussis vaccinations, and residing in a state with two-dose policies for middle school entry. Vaccines for Children program-eligible adolescents were less likely to have received two doses. CONCLUSION Two-dose varicella vaccination coverage remained low among adolescents in 2010, despite the universal recommendation. Programs that are aimed specifically at Vaccines for Children program-eligible adolescents, state policies requiring two doses for middle school entry, and broad education and implementation of the adolescent vaccination platform may help to improve varicella vaccination coverage.
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Affiliation(s)
- Kosuke Kawai
- School of Pharmacy, Temple University, Philadelphia 19140, USA.
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Conway JH, Green T. Childhood immunization policies and the prevention of communicable disease. Pediatr Ann 2011; 40:136-43. [PMID: 21417204 PMCID: PMC6267946 DOI: 10.3928/00904481-20110217-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CME Educational Objectives
1.
Review the process through which vaccines are licensed and recommendations are developed for routine use.
2.
Discuss immunization coverage rates.
3.
Review possible strategies to improve immunization coverage rates.
The drastic reduction in the incidence of vaccine-preventable diseases through childhood immunization represents one of public health’s greatest achievements. The social and economic benefits gained through the prevention of mortality and morbidity caused by infectious diseases have dramatically improved the lives of people around the world. The most impressive gains have been in developed countries, where abundant economic resources and extensive healthcare systems have supported the development and implementation of increasingly sophisticated and expensive vaccines.
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Affiliation(s)
- James H Conway
- University of Wisconsin School of Medicine and Public Health, Department of Population Health Sciences, Madison, WI 53792, USA.
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Abstract
OBJECTIVES To determine the current status of immunisation coverage in Western Kenya before intervention, to identify strengths and weaknesses of the existing programme in order to design educational interventions that could improve the services provided and find out the training needs of the mid-level managers of Kenya Expanded Programme of Immunisation. DESIGN Cross-sectional descriptive study. SETTING All thirty nine districts in Rift Valley, Western and Nyanza provinces. SUBJECTS Mid-level managers of Kenya Expanded Programme on Immunisation in the 39 districts and the provinces. These included Provincial Logisticians, Provincial Medical Officers of Health, District Medical Officers of Health, District Public Health Nurses, District Records and Health Information Officers, District Disease Surveillance Officers, and District Public Health Officers. MAIN OUTCOME MEASURES Number of staff trained on EPI, coverage rates and perceived training needs of the mid-level managers. RESULTS A total of eighty eight mid-level managers participated in the interviews. Most of these were District Public Health Nurses (40.9%) and District Health Information and Records Officers (23.9%). Only 49 (25%) of the District Health Management Team members had undergone training at the supervisory level. Eighteen districts (43.6%) had no member of the District Health Management Team that had ever been trained at the supervisory level. Using rates of Pentavalent 1 and measles coverage, Nyanza Province had the highest immunisation dropout rate (Pentavalent 1--measles) whereas Rift Valley Province had the lowest. The annual cumulative coverage for all the provinces by antigen was 80% for Pentavalent 1 and 2 and 60% for measles. The most requested need for inclusion in the training curriculum was maintenance of the cold chain equipment. CONCLUSIONS Most of the members in the study area have not been trained on Expanded Programme on Immunisation and may be ill-equipped to manage the complicated programmes needed to maximise delivery of services. The immunisation coverage in this area is low while the dropout rates are high. We therefore recommend that all the mid-level managers of Expanded Programme on Immunisation in this area be trained comprehensively through the Merck Vaccine Network--Africa programme using the World Health Organisation approved mid-level managers course.
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Affiliation(s)
- S O Ayaya
- Department of Child Health and Paediatrics, Faculty of Health Sciences, Moi University, Eldoret, Kenya
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Goebel WS, Conway JH, Faught P, Vakili ST, Haut PR. Disseminated toxoplasmosis resulting in graft failure in a cord blood stem cell transplant recipient. Pediatr Blood Cancer 2007; 48:222-6. [PMID: 16333839 DOI: 10.1002/pbc.20537] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Toxoplasmosis is an infrequent infection with a high mortality rate in hematopoietic stem cell transplant recipients, and is usually caused by reactivation of prior, latent infection upon intensive immunosuppression. We report a case of fatal disseminated toxoplasmosis, diagnosed at autopsy, in a 7-year-old boy who received a cord blood graft for recurrent acute lymphoblastic leukemia. This case represents both the first reported case of toxoplasmosis in an engrafted cord blood recipient, and also of graft failure due to toxoplasmosis. Recommendations for toxoplasmosis diagnosis, treatment, and prophylaxis in stem cell transplant recipients are reviewed.
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Affiliation(s)
- W Scott Goebel
- Department of Pediatrics, Pediatric Stem Cell Transplantation Program, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Abstract
An adolescent with recently removed ureteral stents and exposure to toilet water contaminated with sink flies developed urinary myiasis after stent removal. Poor hygiene, urinary obstruction and retention and decreased general health are known risk factors for developing urinary myiasis. Good hygiene and sanitation practices should be emphasized to patients with indwelling urogenital foreign bodies such as ureteral stents.
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Affiliation(s)
- David Y Hyun
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
Knowledge of human lung morphology is of paramount importance in calculating deposition patterns of inhaled particulate matter (PM) to be used in the definition of ambient air quality standards. Due to the inherently complex nature of the branching structure of the airway network, practical assumptions must be made for modeling purposes. The most commonly used mathematical models reported in the literature that describe PM deposition use Weibel's model A morphology. This assumes the airways of the lung to be a symmetric, dichotomously branching system. However, computer simulations of this model, when compared to scintigraphy images, have shown it to lack physiological realism (Martonen et al., 1994a). Therefore, a more physiologically realistic model of the lung is needed to improve the current PM dosimetry models. Herein, a morphological model is presented that is based on laboratory data from planar gamma camera and single-photon emission computed tomography (SPECT) images. Key elements of this model include: The parenchymal wall of the lung is defined in mathematical terms, the whole lung is divided into distinct left and right components, a set of branching angles is derived from experimental measurements, and the branching network is confined within the discrete left and right components (i.e., there is no overlapping of airways). In future work, this new, more physiologically realistic morphological model can be used to calculate PM deposition patterns for risk assessment protocols.
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Affiliation(s)
- T B Martonen
- Experimental Toxicology Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, 86 T. W. Alexander Drive, Research Triangle Park, NC 27711, USA.
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Babu KS, Woodcock DA, Smith SE, Staniforth JN, Holgate ST, Conway JH. Inhaled synthetic surfactant abolishes the early allergen-induced response in asthma. Eur Respir J 2003; 21:1046-9. [PMID: 12797502 DOI: 10.1183/09031936.03.00069202] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Allergen-induced inhibition of pulmonary surfactant in asthma may promote airway oedema and consequently potentiate the severity of the asthmatic response. A randomised, single-blind, cross-over study of an inhaled synthetic phospholipid dry-powder surfactant (Pumactant) was conducted in atopic, asthmatic subjects with previously documented early and late asthmatic responses (EAR and LAR) to an inhaled allergen. This was conducted to evaluate the role of exogenous surfactant administration on EAR and LAR. A total of seven subjects had complete evaluable data and received the full dose of Pumactant. Asthmatic subjects inhaled two separate doses of 400 mg Pumactant prior to an allergen exposure. The first dose was administered 8 h in advance and the second dose 30 min in advance. The dosage occurred through a purpose-built administration device. This was followed by a standard bronchial-provocation test, and forced expiratory volume in one second (FEV1) was measured at regular intervals over a 10-h period. Pumactant was well tolerated and, surprisingly, abolished the EAR but not the LAR in all seven subjects. The mean area under the curve between 0-2 h (EAR) following bronchial provocation test was 0.08 for the Pumactant treatment group (PT) and 13.29 for the no treatment (NT) group. The maximum drop in FEV1 for EAR was 4.19% and 23.98% in the PT and the NT group, respectively. The demonstration of inhibition of the early asthmatic response by exogenous surfactant, provides the first evidence that pulmonary surfactant dysfunction may also contribute to the very early asthmatic response to allergen. Exogenous surfactant administration could serve as a useful adjunct in controlling the early allergen-induced symptoms in patients with allergic asthma.
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Affiliation(s)
- K S Babu
- Division of Infection, Inflammation and Repair, School of Medicine, Southampton General Hospital, Southampton, UK.
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Fleming JS, Conway JH, Bolt L, Holgate ST. A comparison of planar scintigraphy and SPECT measurement of total lung deposition of inhaled aerosol. J Aerosol Med 2003; 16:9-19. [PMID: 12737680 DOI: 10.1089/089426803764928310] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Planar gamma camera imaging of inhaled aerosol deposition is extensively used to assess the total deposition in the lung. However, validation of the measurements is not straightforward, as gold standard measurements of lung activity against which to compare are not readily available. Quantitative SPECT imaging provides an alternative method for comparison. Four different methods for planar image quantification are compared. Two attenuation correction techniques, thickness measurement and transmission measurement, have been combined with two scatter correction techniques, reduced attenuation coefficient and line-source scatter function convolution subtraction. Each technique has been applied to 10 studies of aerosol deposition of a fine aerosol (mass median aerodynamic diameter 1.8 microm) and 10 studies using a coarse aerosol (mass median aerodynamic diameter 6.5 microm). The total activity in the right lung for each measurement has been compared to the value determined from SPECT imaging on the same subjects. When the thickness measurement and transmission techniques were applied with scatter compensation using a reduced attenuation coefficient, activity was systematically overestimated by 5% in both cases. The corresponding random errors (coefficient of variation) were 8.6% and 6.6%. Separate scatter correction reduced these systemic errors significantly to -1.5% and 2.7%, respectively. The random errors were not affected. All techniques provided assessment of total lung activity with an accuracy and precision that differed by less than 10% compared to the SPECT values. Planar gamma camera imaging provides a good method of assessing total lung deposition of inhaled aerosol.
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Affiliation(s)
- J S Fleming
- Department of Medical Physics and Bioengineering, Southampton University Hospitals NHS Trust, Southampton, United Kingdom.
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Affiliation(s)
- Jason M Kane
- Riley Hospital for Children, Section of Pediatric Infectious Diseases, 702 Barnhill Dr, Room 1740X, Indianapolis, IN 46202-5225, USA
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38
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Kane JM, Jackson K, Conway JH. Maternal postpartum group B beta-hemolytic streptococcus ventriculoperitoneal shunt infection. Arch Gynecol Obstet 2003; 269:139-41. [PMID: 14648181 DOI: 10.1007/s00404-002-0464-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2002] [Accepted: 02/25/2002] [Indexed: 11/30/2022]
Abstract
BACKGROUND Women with cerebrospinal fluid shunts require special management during the course of pregnancy. CASE REPORT We describe a case of delayed postpartum ventriculoperitoneal shunt infection by Group B streptococcus in a 19-year-old who presented complaining of headache and a fever. The CSF culture from the shunt tap and the distal shunt tip both grew Group B beta-hemolytic streptococcus. CONCLUSION Women who are colonized with Group B streptococcus and who have cerebrospinal fluid shunts should receive perinatal antibiotic prophylaxis, and may require more extended prophylactic antibiotics with cesarean section deliveries to prevent catheter tip colonization and subsequent shunt infection.
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Affiliation(s)
- Jason M Kane
- Department of Pediatrics, Indiana University School of Medicine, 702 Barnhill Drive 1740X, Indianapolis, Indiana 46202-5225, USA
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Walker PS, Conway JH, Fleming JS, Bondesson E, Borgström L. Pulmonary clearance rate of two chemically different forms of inhaled pertechnetate. J Aerosol Med 2002; 14:209-15. [PMID: 11681652 DOI: 10.1089/08942680152484135] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Attempts to image the pulmonary deposition site of radiolabeled aerosols delivered by dry powder inhalers (DPIs) and pressurized metered-dose inhalers (pMDIs) using single photon emission computed tomography (SPECT) have been limited by the rapid pulmonary clearance of radiolabel. To determine whether aqueous solubility of the radiolabel is a significant factor, the pulmonary clearance rates of two chemically different forms of 99mTc were calculated. A dry powder formulation of terbutaline sulphate was radiolabeled for inhalation by Turbuhaler (AstraZeneca) using the water-soluble salt sodium pertechnetate and the water-insoluble salt tetraphenylarsonium pertechnetate. A pilot study was conducted during which two control subjects each inhaled the two radiolabeled aerosols on separate days. Intrasubject clearance rates for the two species were very similar. It was therefore concluded that water insolubility of the pertechnetate salt alone was not enough to extend the lung residency time of the radiolabel.
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Affiliation(s)
- P S Walker
- Department of Nuclear Medicine, Southampton General Hospital, England.
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40
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Walker PS, Petterson GL, Bondesson E, Conway JH. An advanced and detailed in vitro validation procedure for the radiolabeling of carrier-free terbutaline sulphate dry powder. J Aerosol Med 2002; 14:227-36. [PMID: 11681654 DOI: 10.1089/08942680152484153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aerodynamic properties of 99mTc radiolabeled carrier-free terbutaline sulphate (TBS) have been thoroughly investigated following delivery by Turbuhaler (AstraZeneca Lund, Sweden). A full and detailed radiolabeling procedure is also reported. The in vitro radiolabel validation was performed to determine whether TBS radiolabeled in this way would be representative of the commercially available product Bricanyl Turbuhaler during clinical trials. The results indicated that variations in aerodynamic properties had been introduced and that the radiolabel would slightly underestimate the fine particle fraction of Bricanyl, but would nonetheless act as a suitable marker in vivo. Assumptions regarding the aerodynamic properties of doses likely to be received by clinical trial subjects were also examined. This has been achieved by extending the validation procedures beyond those usually reported to include dose number, time, and homogeneity dependent studies. It was found that doses extracted for testing purposes and simulated patient doses extracted shortly afterward had similar properties. Doses extracted 2 h after initial testing also had similar properties to the test doses. These results suggested that data from the test doses could be used for quality control purposes, would be representative of the doses to be received by clinical trial subjects, and that a short delay between initial testing and trial subject inhalation would be acceptable.
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Affiliation(s)
- P S Walker
- Department of Nuclear Medicine, Southampton General Hospital, England.
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MESH Headings
- Administration, Inhalation
- Aerosols/pharmacokinetics
- Humans
- Imaging, Three-Dimensional/instrumentation
- Imaging, Three-Dimensional/methods
- Imaging, Three-Dimensional/standards
- Imaging, Three-Dimensional/trends
- Lung/drug effects
- Mucociliary Clearance
- Reproducibility of Results
- Sensitivity and Specificity
- Tissue Distribution
- Tomography, Emission-Computed/instrumentation
- Tomography, Emission-Computed/methods
- Tomography, Emission-Computed/standards
- Tomography, Emission-Computed/trends
- Tomography, Emission-Computed, Single-Photon/instrumentation
- Tomography, Emission-Computed, Single-Photon/methods
- Tomography, Emission-Computed, Single-Photon/standards
- Tomography, Emission-Computed, Single-Photon/trends
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Fleming JS, Sauret V, Conway JH, Holgate ST, Bailey AG, Martonen TB. Evaluation of the accuracy and precision of lung aerosol deposition measurements from single-photon emission computed tomography using simulation. J Aerosol Med 2001; 13:187-98. [PMID: 11066022 DOI: 10.1089/jam.2000.13.187] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Single-photon emission computed tomography (SPECT) imaging is being increasingly used to assess inhaled aerosol deposition. This study uses simulation to evaluate the errors involved in such measurements and to compare them with those from conventional planar imaging. SPECT images of known theoretical distributions of radioaerosol in the lung have been simulated using lung models derived from magnetic resonance studies in human subjects. Total lung activity was evaluated from the simulated images. A spherical transform of the lung distributions was performed, and the absolute penetration index (PI) and a relative value expressed as a fraction of that in a simulated ventilation image were calculated. All parameters were compared with the true value used in the simulation, and the errors were assessed. An iterative method was used to correct for the partial volume effect, and its effectiveness in improving errors was evaluated. The errors were compared with those of planar imaging. The precision of measurements was significantly better for SPECT than planar imaging (2.8 vs 6.3% for total lung activity, 6 vs 20% for PI, and 3 vs 6% for relative PI). The method of correcting for the influence of the partial volume effect significantly improved the accuracy of PI evaluation without affecting precision. SPECT is capable of accurate and precise measurements of aerosol distribution in the lung, which are improved compared with those measured by conventional planar imaging. A technique for correcting the SPECT data for the influence of the partial volume effect has been described. Simulation is demonstrated as a valuable method of technique evaluation and comparison.
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Affiliation(s)
- J S Fleming
- Department of Medical Physics and Bioengineering, Southampton University Hospitals, NHS Trust, Southampton, United Kingdom.
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Affiliation(s)
- N F Fiore
- Department of Surgery, Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, USA
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Fleming JS, Conway JH, Holgate ST, Moore EA, Hashish AH, Bailey AG, Martonen TB. Evaluation of the accuracy and precision of lung aerosol deposition measurements from planar radionuclide imaging using simulation. Phys Med Biol 1998; 43:2423-9. [PMID: 9725617 DOI: 10.1088/0031-9155/43/8/033] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Planar images of known, theoretical distributions of radioaerosol in the lung have been simulated using lung models derived from magnetic resonance studies on human subjects. Total lung activity was evaluated from the simulated images together with the absolute penetration index (PI) and a relative value expressed as a fraction of that in a simulated ventilation image. The accuracy and precision of these measurements were calculated by comparison with the true values used in the simulation. Total activity was assessed with systematic errors within 5% and precision within 6.5%. Measured PIs varied only slowly with true PI and inter-model variation masked changes between measurements on the different distributions. The relative PI reduced inter-model variation and provided significant differences between all the distributions. PI was significantly affected by misalignment of the lung region of interest. The conducting airways deposition fraction (CADF) used in the simulation correlated linearly with the fractional activity in a central lung region, allowing CADF to be estimated with a precision of 21%.
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Affiliation(s)
- J S Fleming
- Department of Medical Physics, and University Medicine, Southampton General Hospital, UK
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Affiliation(s)
- J H Conway
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital, Denver, USA
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Affiliation(s)
- J H Conway
- Section of Infectious Diseases, Children's Hospital, Denver, CO, USA.
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Fleming JS, Hashish AH, Conway JH, Nassim MA, Holgate ST, Halson P, Moore E, Bailey AG, Martonen TB. Assessment of deposition of inhaled aerosol in the respiratory tract of man using three-dimensional multimodality imaging and mathematical modeling. J Aerosol Med 1995; 9:317-27. [PMID: 10163661 DOI: 10.1089/jam.1996.9.317] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Multimodality medical imaging enables measurement of the three-dimensional spatial distribution of a radiolabeled aerosol within the lung. Using a conceptual spatial morphological model these data may be transformed to provide information on deposition per airway generation. This methodology has been used to study the intrapulmonary deposition patterns of two formulations of a metered dose inhaler and two nebulizers in control subjects. The nebulizer study has also been stimulated using a computer model of deposition. The comparison between derived experimental results and those from computer modeling shows areas of agreement, although there are also areas of discrepancy. The new methodology has considerable potential value in the fields of inhalation therapy and deposition modeling, although more detailed validation is still required.
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Affiliation(s)
- J S Fleming
- Department of Medical Physics, Southampton General Hospital, U.K
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Leaver H, Conway JH, Holgate ST. The Incidence of Post-operative Hypoxaemia Following Lobectomy and Pneumonectomy: A pilot study. Physiotherapy 1994. [DOI: 10.1016/s0031-9406(10)60843-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
OBJECTIVE To examine the manner of presentation and time elapsed before diagnosis in a current population of pediatric patients with coagulopathies compared with a historically similar group presented by Baehner and Strauss in 1966. DESIGN Comparative retrospective patient series. SETTING A large pediatric (hemophilia) referral center in New York, NY. POPULATION Sixty-five male patients presented for evaluation of a presumed coagulopathy between 1974 and 1989. Nine patients were excluded for inadequate data or follow-up. Of the 56 patients included, 47 were were factor VIII deficient (32 severely affected, 15 not severely affected) and nine were factor IX deficient (six severely affected, three not severely affected). INTERVENTIONS None. RESULTS Severely affected neonates were diagnosed younger than 1 month significantly more often in this patient population compared with the 1966 population (68.4% vs < 10%, P < .001). Patients not severely affected were also diagnosed younger than 1 month significantly more often than in 1966 (50% vs 2.5%, P < .001). Workup in these groups was initiated because of either bleeding events or family history with similar frequency (48.6% vs 51.4%); historically, diagnosis had ensued primarily after bleeding events. By 1 year of age, all severely affected infants had been diagnosed in our population, a statistically significant improvement compared with the historical group (100% vs < 40%, P < .001); patients not severely affected were also diagnosed more frequently (72.2% vs 15%, P < .001). Eighty-five percent of diagnoses made after 1 month of age were based on bleeding events, despite a positive family history of 28.6%. Overall, 35.7% of diagnoses resulted after a positive family history was elicited. CONCLUSIONS In this population, diagnoses were made earlier than in the comparison group. Attention to family history and early bleeding events continues to contribute to the early diagnosis of factor deficiencies.
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Affiliation(s)
- J H Conway
- Department of Pediatrics, Northwestern University-McGaw Medical Center, Chicago, Ill
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Conway JH, Hitchcock RA, Godfrey RC, Carroll MP. Nasal intermittent positive pressure ventilation in acute exacerbations of chronic obstructive pulmonary disease--a preliminary study. Respir Med 1993; 87:387-94. [PMID: 8209060 DOI: 10.1016/0954-6111(93)90054-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Ten patients (two male) suffering from acute exacerbations of long-standing chronic obstructive pulmonary disease and admitted in hypoxic, hypercapnic respiratory failure were treated with Nasal Intermittent Positive Pressure Ventilation (NIPPV) plus supplemental oxygen, on a general medical ward. The median (range) pH on admission was 7.30 (7.20-7.35), the median age was 67 years (47-77) with an FEV1 (percent of predicted) of 30 (17-39). On admission the median arterial oxygen tension (PaO2) was 4.71 kPa (3.45-6.26) on air, and the carbon dioxide tension (PaCO2) was 7.68 kPa (6.85-9.83). With controlled oxygen therapy there was no significant improvement in PaO2, but the median PaCO2 increased significantly to 9.75 kPa (7.04-11.70) (P < 0.05). By using NIPPV with supplemental oxygen it was possible to significantly improve the median PaO2 to 11.25 kPa (6.70-26.90) (P < 0.01) without worsening PaCO2 levels (8.96 kPa; 6.85-13.10). NIPPV was applied by a senior, respiratory physiotherapist and used intermittently depending on patient tolerance and clinical response. The median total time on NIPPV was 27 h, delivered over 1-5 days. One patient found the mask difficult to tolerate beyond a short period of time. NIPPV was well accepted on a general ward by nursing staff. Three patients later died with progressive hypercapnia, despite an initial response; with one of these patients also receiving intubation and mechanical ventilation. A further patient also received intubation and mechanical ventilation and was eventually discharged. NIPPV plus supplemental oxygen offers a method to correct hypoxaemia on a general medical ward without worsening hypercapnia for acute on chronic, hypoxic, hypercapnic respiratory failure, and warrants further investigation.
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Affiliation(s)
- J H Conway
- Respiratory Support Unit, Southampton General Hospital, U.K
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