Prevalence and awareness of Hepatitis B virus infection in the United States: January 2017 - March 2020

BACKGROUND

Prevalence and awareness of HBV infection are important national indicators of progress toward hepatitis B elimination.

METHODS

National Health and Nutrition Examination Survey participants were examined for laboratory evidence of HBV infection (positive antibody to HBcAg and HBsAg), and interviewed to determine awareness of HBV infection. Estimates of HBV infection prevalence and awareness were calculated for the US population.

FINDINGS

Among National Health and Nutrition Examination Survey participants aged 6 years and older evaluated from January 2017 through March 2020, an estimated 0.2% had HBV infection; of these 50% were aware of their infection.

Point prevalence and clinical course of proteinuria in dogs with idiopathic non-erosive immune-mediated polyarthritis

Objectives

To describe the point prevalence and clinical course of proteinuria in dogs diagnosed with idiopathic non‐erosive immune‐mediated polyarthritis.

Materials and Methods

Cases presenting to a single referral centre with a diagnosis of idiopathic non‐erosive immune‐mediated polyarthritis were retrospectively recruited from January 2009 to August 2018. Data including signalment, urinalysis, clinicopathological results, cytology from arthrocentesis, treatment and long‐term follow‐up were analysed. Dogs were defined as: non‐proteinuric (UPC <0.2), borderline proteinuric (UPC 0.2‐0.5) or overtly proteinuric (UPC >0.5).

Results

Fifty‐eight dogs met the inclusion criteria. Twenty‐two dogs were overtly proteinuric (38%), eight dogs were borderline proteinuric (14%) and 28 dogs were non‐proteinuric (48%). Repeated urinalysis was performed in nine of 12 dogs with UPC greater than 2.0. The UPC decreased in all nine dogs, with the UPC decreasing to less than 0.5 in 44% of dogs. A greater than 50% decrease in UPC was noted in 44% of dogs, despite seven of nine (77%) receiving prednisolone as either monotherapy or in conjunction with an adjunctive immunosuppressive medication.

Clinical Significance

Proteinuria was common in this cohort of dogs diagnosed with primary idiopathic non‐erosive immune‐mediated polyarthritis. The use of prednisolone does not appear to be contraindicated in proteinuric dogs with idiopathic non‐erosive immune‐mediated polyarthritis.

Systematic review of wastewater surveillance of antimicrobial resistance in human populations

OBJECTIVES

We systematically reviewed studies using wastewater for AMR surveillance in human populations, to determine: (i) evidence of concordance between wastewater-human AMR prevalence estimates, and (ii) methodological approaches which optimised identifying such an association, and which could be recommended as standard. We used Lin's concordance correlation coefficient (CCC) to quantify concordance between AMR prevalence estimates in wastewater and human compartments (where CCC = 1 reflects perfect concordance), and logistic regression to identify study features (e.g. sampling methods) associated with high agreement studies (defined as >70% of within-study wastewater-human AMR prevalence comparisons within ±10%).

RESULTS

Of 8,867 records and 441 full-text methods reviewed, 33 studies were included. AMR prevalence data was extractable from 24 studies conducting phenotypic-only (n = 7), genotypic-only (n = 1) or combined (n = 16) AMR detection. Overall concordance of wastewater-human AMR prevalence estimates was reasonably high for both phenotypic (CCC = 0.85 [95% CI 0.8-0.89]) and genotypic approaches (CCC = 0.88 (95% CI 0.84-0.9)) despite diverse study designs, bacterial species investigated and phenotypic/genotypic targets. No significant relationships between methodological approaches and high agreement studies were identified using logistic regression; however, this was limited by inconsistent reporting of study features, significant heterogeneity in approaches and limited sample size. Based on a secondary, descriptive synthesis, studies conducting composite sampling of wastewater influent, longitudinal sampling >12 months, and time-/location-matched sampling of wastewater and human compartments generally had higher agreement.

CONCLUSION

Wastewater-based surveillance of AMR appears promising, with high overall concordance between wastewater and human AMR prevalence estimates in studies irrespective of heterogenous approaches. However, our review suggests future work would benefit from: time-/location-matched sampling of wastewater and human populations, composite sampling of influent, and sampling >12 months for longitudinal studies. Further research and clear and consistent reporting of study methods is required to identify optimal practice.

Susceptibility to Hepatitis A Virus Infection in the United States, 2007-2016

BACKGROUND

Despite national immunization efforts, including universal childhood hepatitis A (HepA) vaccination recommendations in 2006, hepatitis A virus (HAV)-associated outbreaks have increased in the United States. Unvaccinated or previously uninfected persons are susceptible to HAV infection, yet the susceptibility in the US population is not well known.

METHODS

Using National Health and Nutrition Examination Survey 2007-2016 data, we estimated HAV susceptibility prevalence (total HAV antibody negative) among persons aged ≥2 years. Among US-born adults aged ≥20 years, we examined prevalence, predictors, and age-adjusted trends of HAV susceptibility by sociodemographic characteristics. We assessed HAV susceptibility and self-reported nonvaccination to HepA among risk groups and the "immunization cohort" (those born in or after 2004).

RESULTS

Among US-born adults aged ≥20 years, HAV susceptibility prevalence was 74.1% (95% confidence interval, 72.9-75.3%) during 2007-2016. Predictors of HAV susceptibility were age group 30-49 years, non-Hispanic white/black, 130% above the poverty level, and no health insurance. Prevalences of HAV susceptibility and nonvaccination to HepA, respectively, were 72.9% and 73.1% among persons who reported injection drug use, 67.5% and 65.2% among men who had sex with men, 55.2% and 75.1% among persons with hepatitis B or hepatitis C, and 22.6% and 25.9% among the immunization cohort. Susceptibility and nonvaccination decreased over time among the immunization cohort but remained stable among risk groups.

CONCLUSIONS

During 2007-2016, approximately three-fourths of US-born adults remained HAV susceptible. Enhanced vaccination efforts are critically needed, particularly targeting adults at highest risk for HAV infection, to mitigate the current outbreaks.

Serological markers of gluten sensitivity in Border terriers with gall bladder mucocoeles

OBJECTIVES

To evaluate serological markers of gluten sensitivity in conjunction with cholecystokinin measurement in Border terriers with gall bladder mucocoeles.

MATERIALS AND METHODS

Medical records from two referral hospitals were obtained between 2011 and 2019 to identify Border terriers with gall bladder mucocoeles, non-Border terriers with gall bladder mucocoeles and control Border terriers with non-biliary diseases. Enzyme-linked immunosorbent assays were performed on stored fasted serum samples for anti-gliadin IgG, anti-canine transglutaminase-2-IgA autoantibodies and cholecystokinin. Statistical analysis was performed using the Kruskall-Wallis test to identify differences between the groups.

RESULTS

Fifteen Border terriers with gall bladder mucocoeles, 17 non-Border terriers with gall bladder mucocoeles and 14 control Border terriers with non-biliary diseases were recruited. Median transglutaminase-2-IgA autoantibodies in Border terriers with gall bladder mucocoeles was 0.73 (range: 0.18 to 1.67), which was significantly greater than in control Border terriers at 0.41 (0.07 to 1.14). Median cholecystokinin concentration in Border terriers with gall bladder mucocoeles was 13 pg/mL (6 to 45 pg/mL), which was significantly lower than in control Border terriers at 103 pg/mL (9 to 397 pg/mL). There was no difference in the anti-gliadin IgG between these groups. There was no difference observed in the non-Border terriers with gall bladder mucocoeles with either of the other groups.

CLINICAL SIGNIFICANCE

Reduced cholecystokinin and increased transglutaminase-2-IgA autoantibodies was detected in Border terriers with gall bladder mucocoeles; which is in part homologous to gall bladder disease identified in human coeliac disease. The results suggest an immunological disease with impaired cholecystokinin release may be affecting gall bladder motility and possibly contributing to mucocoele formation in Border terriers.

Identification of a predominant cognitive phenotype in patients with multiple sclerosis

BACKGROUND AND PURPOSE

Cognitive impairment occurs frequently in multiple sclerosis (MS). However, the prevalence and clinical characteristics of cognitive MS phenotype are not well established. The aim of the study was to characterize the clinical course and neurocognitive impairment of patients with MS meeting an Expanded Disability Status Scale (EDSS)-defined cognitive phenotype.

METHODS

A total of 2302 patients from the Comprehensive Longitudinal Investigation of Multiple Sclerosis at Brigham and Women's Hospital (CLIMB) study were studied. Predominant cognitive MS phenotype was defined as EDSS Cerebral Functional System (FS) subscore ≥3 and remaining EDSS FS subscores ≤2 on at least one clinical visit. Demographic/clinical characteristics, phenotype stability and neurocognitive domain impairment of these subjects were assessed.

RESULTS

A total of 60 of 2302 (2.6%) patients (age 52.8 ± 10.8 years, 68% female, 82% relapsing MS) met criteria for phenotype designation. A total of 29 of 60 (48%) were designated within 10 years of their presenting MS symptom. The mean cohort annualized relapse rate was 0.38 and EDSS score at last clinical assessment was 3.2 ± 1.3. Cognitive phenotype status was poorly sustained, with only 27% of subjects maintaining Cerebral FS score ≥2 throughout all follow-up. However, predominant cognitive phenotype subjects with clinical neuropsychiatric testing [n = 39/60 (65%)] frequently had cognitive impairment (1.5 SD below mean) in ≥1 domain [n = 30/39 (77%) of subjects] affecting memory, attention/executive function and processing speed. A total of 11 of 39 (28%) patients had severe-range cognitive impairment (3.0 SD below mean). Cognitive phenotype designation was associated with low rate of employment at last clinical assessment.

CONCLUSION

Predominant cognitive MS phenotype is rare, although an EDSS-based definition identifies patients with multidomain cognitive impairment and may serve as a practical screen for identification of patients who might warrant close monitoring of neurocognitive status.

Rising Trends in Emergency Department Visits Associated With Hepatitis C Virus Infection in the United States, 2006-2014

OBJECTIVE

Emergency departments (EDs) are critical settings for hepatitis C care in the United States. We assessed trends and characteristics of hepatitis C-associated ED visits during 2006-2014.

METHODS

We used data from the 2006-2014 Nationwide Emergency Department Sample to estimate numbers, rates, and costs of hepatitis C-associated ED visits, defined by either first-listed diagnosis of hepatitis C or all-listed diagnosis of hepatitis C. We assessed trends by demographic characteristics, liver disease severity, and patients' disposition by using joinpoint analysis, and we calculated the average annual percentage change (AAPC) from 2006 to 2014.

RESULTS

During 2006-2014, the rate per 100 000 visits of first-listed and all-listed hepatitis C-associated ED visits increased significantly from 10.1 to 25.4 (AAPC = 13.0%; P < .001) and from 484.4 to 631.6 (AAPC = 3.4%; P < .001), respectively. Approximately 70% of these visits were made by persons born during 1945-1965 (baby boomers); 30% of visits were made by Medicare beneficiaries and 40% by Medicaid beneficiaries. Significant rate increases were among visits by baby boomers (first-listed: AAPC = 13.8%; all-listed: AAPC = 2.6%), persons born after 1965 (first-listed: AAPC = 14.3%; all-listed: AAPC = 9.2%), Medicare beneficiaries (first-listed: AAPC = 18.0%; all-listed: AAPC = 3.9%), and persons hospitalized after ED visits (first-listed: AAPC = 20.0%; all-listed: AAPC = 2.3%; all P < .001). Increasing proportions of compensated cirrhosis were among visits by baby boomers (first-listed: AAPC = 11.5%; all-listed: AAPC = 6.3%). Annual hepatitis C-associated total ED costs increased by 400.0% (first-listed) and 192.0% (all-listed) during 2006-2014.

CONCLUSION

Public health efforts are needed to address the growing burden of hepatitis C care in the ED.

Sofosbuvir-Based Regimens for Chronic Hepatitis C in a Well-Insured U.S. Population: Patient Characteristics, Treatment Adherence, Effectiveness, and Health Care Costs, 2013-2015

BACKGROUND

Chronic hepatitis C (CHC) is a leading cause of morbidity and mortality and has imposed a high health care burden in the United States. Direct-acting antiviral (DAA) regimens are well tolerated and highly effective for CHC therapy but were initially marketed at a high price. Studies of their real-world use with a nationwide population are limited.

OBJECTIVE

To examine patient characteristics, treatment adherence, effectiveness, and health care costs in a large U.S. population with commercial and Medicare supplemental insurance plans who received simeprevir (SIM), sofosbuvir (SOF), or ledipasvir/sofosbuvir (LED/SOF) during the years 2013-2015.

METHODS

Patients with at least 1 diagnosis code for CHC and at least 1 claim for SIM, SOF, or LED/SOF prescriptions were selected. The date of the first claim for SIM, SOF, or LED/SOF was defined as the index date. Analyses were stratified by 4 regimens: SOF + SIM ± ribavirin (RBV), SOF + peginterferon alpha-2a or 2b (PEG) + RBV, SOF + RBV, and LED/SOF ± RBV. Adherence was defined by the proportion of days covered (PDC) ≥ 80%. Sustained virologic response (SVR12) was defined as a hepatitis C virus (HCV) RNA load of ≤ 25 IU/mL measured at ≥ 12 weeks following the end of the days supply of the last DAA refill. Health care costs such as DAA drug costs and medical costs (inpatient costs plus outpatient costs) were described.

RESULTS

Of 10,808 CHC patients, approximately two thirds were male, and mean age was 55 years. The proportion of patients with compensated cirrhosis among each regimen ranged from 7.4% in LED/SOF ± RBV to 13.8% in SOF + SIM ± RBV, and the proportion of patients with decompensated cirrhosis ranged from 3.9% in LED/SOF ± RBV to 10.7% in SOF + SIM ± RBV. The majority of patients (89.0%) used the newer regimen LED/SOF ± RBV in 2015. Adherence rates were estimated at 80.5%, 81.5%, 85.7%, and 91.4% for SOF + SIM ± RBV (n = 1,761); SOF + PEG + RBV (n = 1,314); SOF + RBV (n = 1,994); and LED/SOF ± RBV (n = 5,739), respectively. Regimen-specific adherence predictors included sex, age group, payer type, health plan, and treatment option with RBV. Being born during 1945-1965, liver disease severity, and Charlson Comorbidity Index levels did not predict adherence in any regimen. Overall SVR12 was 92.6% in 203 patients with available HCV RNA results: 100% (41/41) in SOF + SIM ± RBV; 83.3% (25/30) in SOF + PEG + RBV; 90.6% (29/32) in SOF + RBV; and 93% (93/100) in LED/SOF ± RBV. While the drug costs for these DAA regimens were initially high, they had decreased 18.9% (P < 0.001) during 2013-2015. Medical costs decreased 9.2% (P < 0.001) 1 year after the index dates.

CONCLUSIONS

These results indicate that DAA drug costs decreased steadily during 2013-2015 and that 89% of patients on SOF-based DAA regimens took newer, lower-cost regimens with adherence rates above 80%. Available data show that SVR12 rates were close to those obtained in clinical studies. Medical costs also significantly decreased 1 year after the index dates.

DISCLOSURES

No outside funding supported this study. All authors are U.S. federal employees of the Centers for Disease Control and Prevention. The authors declare that they have no competing interests. The findings and conclusions in this research are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Prevalence of Hepatitis C Virus Infection in US States and the District of Columbia, 2013 to 2016

IMPORTANCE

Infection with hepatitis C virus (HCV) is a major cause of morbidity and mortality in the United States, and incidence has increased rapidly in recent years, likely owing to increased injection drug use. Current estimates of prevalence at the state level are needed to guide prevention and care efforts but are not available through existing disease surveillance systems.

OBJECTIVE

To estimate the prevalence of current HCV infection among adults in each US state and the District of Columbia during the years 2013 to 2016.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used a statistical model to allocate nationally representative HCV prevalence from the National Health and Nutrition Examination Survey (NHANES) according to the spatial demographics and distributions of HCV mortality and narcotic overdose mortality in all National Vital Statistics System death records from 1999 to 2016. Additional literature review and analyses estimated state-level HCV infections among populations not included in the National Health and Nutrition Examination Survey sampling frame.

EXPOSURES

State, accounting for birth cohort, biological sex, race/ethnicity, federal poverty level, and year.

MAIN OUTCOMES AND MEASURES

State-level prevalence estimates of current HCV RNA.

RESULTS

In this study, the estimated national prevalence of HCV from 2013 to 2016 was 0.84% (95% CI, 0.75%-0.96%) among adults in the noninstitutionalized US population represented in the NHANES sampling frame, corresponding to 2 035 100 (95% CI, 1 803 600-2 318 000) persons with current infection; accounting for populations not included in NHANES, there were 231 600 additional persons with HCV, adjusting prevalence to 0.93%. Nine states contained 51.9% of all persons living with HCV infection (California [318 900], Texas [202 500], Florida [151 000], New York [116 000], Pennsylvania [93 900], Ohio [89 600], Michigan [69 100], Tennessee [69 100], and North Carolina [66 400]); 5 of these states were in Appalachia. Jurisdiction-level median (range) HCV RNA prevalence was 0.88% (0.45%-2.34%). Of 13 states in the western United States, 10 were above this median. Three of 10 states with the highest HCV prevalence were in Appalachia.

CONCLUSIONS AND RELEVANCE

Using extensive national survey and vital statistics data from an 18-year period, this study found higher prevalence of HCV in the West and Appalachian states for 2013 to 2016 compared with other areas. These estimates can guide state prevention and treatment efforts.

Gall bladder mucoceles in Border terriers

Background

Gall bladder mucoceles (GBM) are a leading cause of biliary disease in dogs with several breeds, including the Shetland Sheepdog, American Cocker Spaniel, Chihuahua, Pomeranian, and Miniature Schnauzer apparently predisposed.

Objective

To determine risk factors, clinical features, and response to treatment of GBM in Border terriers (BT).

Animals

Medical records of 99 dogs (including 51 BT) with an ultrasonographic (±histopathologic) diagnosis of GBM from three referral centers in the United Kingdom were collected. A control group of 87 similar‐aged BT with no ultrasonographic evidence of gall bladder disease was selected for comparison.

Method

Retrospective case‐control study. Odds ratios were calculated to establish breed predisposition. Signalment, presence of endocrine disease, clinicopathologic results, and outcome were compared between the BT, other breeds, and control BTs.

Results

The odds of identifying a GBM in a BT in this hospital population was 85 times that of all other breeds (95% confidence interval 56.9‐126.8). BT had similar clinical signs and clinicopathologic changes to other breeds with GBM. There was no evidence that endocrinopathies were associated with GBM in BT.

Clinical Significance

A robust breed predisposition to GBM is established for the BT.

Prevalence of past-year dental visit among US adults, 1999-2010: comparison of trends and estimates between the Behavioral Risk Factor Surveillance System and three national surveys

OBJECTIVES

To compare estimated prevalence of past-year dental visit (PPYDV) among US adults aged ≥18 years from the Behavioral Risk Factor Surveillance System (BRFSS) to estimates from the Medical Expenditure Panel Survey (MEPS), National Health Interview Survey (NHIS), and National Health and Nutrition Examination Survey (NHANES).

METHODS

We estimated PPYDV adjusted for covariates (age, race/ethnicity, education level, poverty status, edentulism) using BRFSS, MEPS, and NHIS 1999-2010, and NHANES 1999-2004. We tested trend in overall PPYDV for BRFSS, MEPS, and NHIS from 1999-2010. For 2002 and 2010, we calculated absolute differences (AD) and 95% confidence intervals (CI) in PPYDV between BRFSS and each of the other surveys overall and among subpopulations defined by covariates. We pooled NHANES 1999-2004 data for comparison with BRFSS 2002.

RESULTS

From 1999 to 2010, BRFSS (68.5% vs. 67.5%), MEPS (43.5% vs. 39.7%), and NHIS (63.3% vs. 59.7%) showed small but significant decreases in overall PPYDV. In 2002, estimates for overall PPYDV were highest for BRFSS (70.0%) and lowest for MEPS (43.9%) with estimates for NHIS (61.5%) and NHANES (1999-2004: 58.1%) in between; the largest AD (26.2%, 95% CI: 25.0%-27.3%) was between BRFSS and MEPS. ADs were consistent in 2002 and 2010, overall and by covariates, except among edentate persons, where PPYDV estimates from BRFSS and NHIS were similar.

CONCLUSIONS

Estimates of PPYDV from BRFSS were notably higher than estimates from MEPS, NHIS, or NHANES except among the edentate. Trends in PPYDV over time, however, were consistent across all surveys.

But who will make the visits? A patient-related information system for management in district nursing

District nurses in Barnsley, UK, have for many years used a patient classification system based on ‘Criteria for Care’, whose value in practical management terms has established itself into the routine of the information system used. This is a descendant of FIP, now known as TCCS (Total Care Community System). ‘Criteria for Care’ was, however, hospital based and an independent validity check was required for community use. This was carried out in Belfast, Northern Ireland, where research produced a system for patient classification, workload analysis and skillmix analysis which was generated by nurses and acted both as a validity check and further development of the system used in Barnsley.

The management information matrix, which is the outcome of this paper, is generated from practitioners using guidelines agreed by them, and yields management information of a directly practical value.

The system presented is now implemented and uses data updated daily, if required, to produce a spreadsheet covering team workload index, a workload profile, and measures of pressure of work on each nurse, patient acuity [1], and a quality of care index. From this it is possible to adjust skillmix and staffing levels to create equity of pressure across teams and to match nursing skillmix to patient classification in the light of a quality index from each team.

From a GP attachment and a team perspective this information can be utilized in conjunction with contract monitoring data in order to review district nursing activity. This will enable workloads to be reviewed and could facilitate integrated team working within the practice.

Water Intake by Outdoor Temperature Among Children Aged 1-10 Years: Implications for Community Water Fluoridation in the U.S

OBJECTIVE

The U.S. water fluoridation recommendations, which have been in place since 1962, were based in part on findings from the 1950s that children's water intake increased with outdoor temperature. We examined whether or not water intake is associated with outdoor temperature.

METHODS

Using linked data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 and the National Oceanic and Atmospheric Administration, we examined reported 24-hour total and plain water intake in milliliters per kilogram of body weight per day of children aged 1-10 years by maximum outdoor temperature on the day of reported water intake, unadjusted and adjusted for age, sex, race/ethnicity, and poverty status. We applied linear regression methods that were used in previously reported analyses of data from NHANES 1988-1994 and from the 1950s.

RESULTS

We found that total water intake was not associated with temperature. Plain water intake was weakly associated with temperature in unadjusted (coefficient 5 0.2, p=0.015) and adjusted (coefficient 5 0.2, p=0.013) linear regression models. However, these models explained little of the individual variation in plain water intake (unadjusted: R(2)=0.005; adjusted: R(2)=0.023).

CONCLUSION

Optimal fluoride concentration in drinking water to prevent caries need not be based on outdoor temperature, given the lack of association between total water intake and outdoor temperature, the weak association between plain water intake and outdoor temperature, and the minimal amount of individual variance in plain water intake explained by outdoor temperature. These findings support the change in the U.S. Public Health Service recommendation for fluoride concentration in drinking water for the prevention of dental caries from temperature-related concentrations to a single concentration that is not related to outdoor temperature.

Association of Socioeconomic Position and Demographic Characteristics with Cardiovascular Disease Risk Factors and Healthcare Access among Adults Living in Pohnpei, Federated States of Micronesia

Background. The burden of cardiovascular disease (CVD) is increasing in low-to-middle income countries. We examined how socioeconomic and demographic characteristics may be associated with CVD risk factors and healthcare access in such countries. Methods. We extracted data from the World Health Organization's STEPwise approach to surveillance 2002 cross-sectional dataset from Pohnpei, Federated States of Micronesia (FSM). We used these data to estimate associations for socioeconomic position (education, income, and employment) and demographics (age, sex, and urban/rural) with CVD risk factors and with healthcare access, among a sample of 1638 adults (25-64 years). Results. In general, we found significantly higher proportions of daily tobacco use among men than women and respondents reporting primary-level education (<9 years) than among those with postsecondary education (>12 years). Results also revealed significant positive associations between paid employment and waist circumference and systolic blood pressure. Healthcare access did not differ significantly by socioeconomic position. Women reported significantly higher mean waist circumference than men. Conclusion. Our results suggest that socioeconomic position and demographic characteristics impact CVD risk factors and healthcare access in FSM. This understanding may help decision-makers tailor population-level policies and programs. The 2002 Pohnpei data provides a baseline; subsequent population health surveillance data might define trends.

Use of Syndromic Data to Determine Oral Health Visit Burden on Emergency Departments

Objective

The objective was to use syndromic surveillance data from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool NCDETECT and from BioSense to quantify the burden on North Carolina (NC) emergency departments of oral health-related visits more appropriate for care in a dental office (ED). Calculations were sought in terms of the Medicaid-covered visit rate relative to the Medicaid-eligible population by age group and by county.

Introduction

Concern over oral health-related ED visits stems from the increasing number of unemployed and uninsured, the cost burden of these visits, and the unavailability of indicated dental care in EDs [1]. Of particular interest to NC state public health planners are Medicaid-covered visits. Syndromic data in biosurveillance systems offer a means to quantify these visits overall and by county and age group.

Methods

Using BioSense data received from NCDETECT, 60.8 million records from 12.9 million ED visits were collected, covering all NC visits for state fiscal years (SFY) 2008–2010. Roughly 4% of visits were dropped because of patient residence zip codes missing or outside NC. A careful multi-step procedure involving both dentist consultants and data analysis was used to derive classification criteria for visits whose main reason was a nontraumatic oral health problem [2]. This procedure yielded 243,970 visits by ∼174,600 patients based on hospital-specific patient identifiers. Nontraumatic oral health-related visits were collected in a study set with added fields for method of payment, patient residence county, and age group. Based on previous studies, consultant preferences, and NC Medicaid eligibility guidelines, selected age groups were 0–14, 15–19, 20–29, 30–49, 50+ years. Stratified counts of Medicaid-eligibles were obtained from the NC Dental Director by study year. Using these tables and the ED visit study set, rates of nontraumatic oral health-related Medicaid visits per 10,000 eligibles were tabulated by county and age group for each study year. Demographics of multiple-visit patients were also studied.

Results

Rates of ED oral health-related visits were substantially higher for young adults than for other age groups. From statewide rates in Table 1, this age factor was consistent across study years.

County-level rates showed the same age pattern to varying degrees. Detailed analysis showed problem areas, with rates in 21 of 100 counties exceeding 60 per 10,000 eligibles for the 20–29 year age group. Plots and tables complemented understanding of the ED oral health visit burden by age and county. The state total ED burden for oral health problems was ∼2% (0.2% – 9.7% by county).

Conclusions

Judicious use of syndromic data with external information, such as the detailed Medicaid denominators and the Method of Payment codes for each visit above, can give quantified estimates for policy-related public health issues. In the current study, the derived oral health visit rates gave numerical detail to concerns about the use of NC EDs for nontraumatic oral health problems by low-income persons affected by the economic recession. Results also show rate variation by county and can be combined with access-to-care data to inform planning of effective local measures to improve access to dental services and thus reduce the ED visit burden.

Nontraumatic Oral Health Classification for Alternative Use of Syndromic Data

Objective

To develop a nontraumatic oral health classification that could estimate the burden of oral health-related visits in North Carolina (NC) Emergency Departments (EDs) using syndromic surveillance system data.

Introduction

Lack of access to regular dental care often results in costly, oral health visits to EDs that could otherwise have been prevented or managed by a dentist (1). Most studies on oral health-related visits to EDs have used a wide range of classifications from different databases, but none have used syndromic surveillance data. The volume, frequency, and included details of syndromic data enabled timely burden estimates of nontraumatic oral health visits for NC EDs.

Methods

Literature review, input by subject matter experts (SMEs), and analysis of syndromic data was used to create the nontraumatic oral health classification. BioSense, a near real-time, national-level, electronic health surveillance system was the source of the NC ED syndromic data. Visits with at least one oral health-related ICD-9-CM code were extracted for NC fiscal years 2008–2010. Univariate analyses of chief complaint (CC) and final diagnosis data along with SME consultation were used to determine the CC substrings and ‘white list’ of ICD-9-CM codes used as inclusion criteria to classify visits as oral health-related. These analyses and consultations also determined the trauma-related codes and substrings used to exclude visits.

Results

Table 1 shows all nontraumatic oral health-related ICD-9-CM codes used for the characterization. Codes likely related to the types of dental emergencies that routine dental care could not have prevented were excluded. Approximately 275,000 patient records were evaluated to determine the CC substrings. The final CC substrings chosen (Table 1) represented over 56% of visits in the candidate record dataset. Over 334,000 BioSense patient records were evaluated, and SMEs reviewed the 32 ICD-9-CM codes that co-occurred most commonly in visits containing oral health-related ICD-9-CM codes to determine which co-occurring ICD-9-CM codes (white list, Table 1) could be present and still maintain the main reason for the visit as an oral health-related problem. Trauma-related visit criteria used for exclusion were derived from a subset of BioSense sub-syndromes (Falls; Fractures and dislocation; Injury, NOS; Sprains and strains; and Motor vehicle traffic accidents) and from selected CC substrings (‘assault’, ‘fight’, and ‘brawl’).

In summary, an ED visit had a nontraumatic oral health classification if it contained 1) an oral health-related CC substring with no trauma-related ICD-9-CM codes or CC substrings or 2) an oral health-related ICD-9 code accompanied by no oral health-related or trauma-related CC substrings and with no other diagnosis codes except for those on the whitelist.

Conclusions

There is increasing demand to determine ways to use syndromic surveillance data in an alternative way for population health surveillance. This use of BioSense data provided a practical classification of patient records for the tracking of nontraumatic oral health-related visits to NC EDs. Visit estimates created using this classification in combination with other pertinent information could prove useful to policymakers when deciding upon resource allocation aimed at reducing this unnecessary burden on the NC ED system. The large volume of records in syndromic surveillance systems offers substantial weight of evidence for alternative use in epidemiological studies; however, accurate classification of records is required to select cases of interest. While data volume precludes validation of every included record, a combination of human expertise and data analysis can provide credible classification criteria.

Comparison of ArcGIS and SAS Geostatistical Analyst to Estimate Population-Weighted Monthly Temperature for US Counties

Temperature changes are known to have significant impacts on human health. Accurate estimates of population-weighted average monthly air temperature for US counties are needed to evaluate temperature's association with health behaviours and disease, which are sampled or reported at the county level and measured on a monthly-or 30-day-basis. Most reported temperature estimates were calculated using ArcGIS, relatively few used SAS. We compared the performance of geostatistical models to estimate population-weighted average temperature in each month for counties in 48 states using ArcGIS v9.3 and SAS v 9.2 on a CITGO platform. Monthly average temperature for Jan-Dec 2007 and elevation from 5435 weather stations were used to estimate the temperature at county population centroids. County estimates were produced with elevation as a covariate. Performance of models was assessed by comparing adjusted R², mean squared error, root mean squared error, and processing time. Prediction accuracy for split validation was above 90% for 11 months in ArcGIS and all 12 months in SAS. Cokriging in SAS achieved higher prediction accuracy and lower estimation bias as compared to cokriging in ArcGIS. County-level estimates produced by both packages were positively correlated (adjusted R² range=0.95 to 0.99); accuracy and precision improved with elevation as a covariate. Both methods from ArcGIS and SAS are reliable for U.S. county-level temperature estimates; However, ArcGIS's merits in spatial data pre-processing and processing time may be important considerations for software selection, especially for multi-year or multi-state projects.

Prevalence and severity of dental fluorosis in the United States, 1999-2004

Dental fluorosis refers to changes in the appearance of tooth enamel that are caused by long-term ingestion of fluoride during the time teeth are forming. Studies conducted in the 1930s showed that the severity of tooth decay was lower and dental fluorosis was higher in areas with more fluoride in the drinking water. In response to these findings, community water fluoridation programs were developed to add fluoride to drinking water to reach an optimal level for preventing tooth decay, while limiting the chance of developing dental fluorosis. By the 1980s, studies in selected U.S. communities reported an increase in dental fluorosis, paralleling the expansion of water fluoridation and the increased availability of other sources of ingested fluoride, such as fluoride toothpaste (if swallowed) and fluoride supplements. This report describes the prevalence of dental fluorosis in the United States and changes in the prevalence and severity of dental fluorosis among adolescents between 1986–1987 and 1999–2004.

Case report: reconstruction of the distal tibia with porous tantalum spacer after resection for giant cell tumor

Treatment options for giant cell tumors of the distal tibia include curettage and cement packing, curettage and bone grafting, or resection and reconstruction for aggressive tumors. Curettage of aggressive tumors often leads to severe bone loss requiring reconstruction. Allograft and autograft may be effective options for reconstruction, but each is associated with drawbacks including the possibility of infection and collapse. We present a case of giant cell tumor of the distal tibia treated with curettage and arthrodesis using a porous tantalum spacer. Complete removal of the tumor and successful arthrodesis of the ankle were accomplished using the spacer. The patient returned to pain-free walking along with eradication of the giant cell tumor. We believe porous tantalum spacers are a reasonable option for reconstructing the distal tibia after curettage of a giant cell tumor with extensive bone loss.

Development and status of the National Oral Health Surveillance System

During the last 2 decades of the 20th century, few national, state, or local oral health programs were able to conduct public health surveillance in a timely fashion. Under the leadership of the Association of State and Territorial Dental Directors and with substantial support from the Division of Oral Health at the Centers for Disease Control and Prevention, the National Oral Health Surveillance System was established as a first step in helping oral health programs routinely document population needs and program impact with standard, feasible methods. In 1999, the Council of State and Territorial Epidemiologists approved 7 oral health indicators for public health surveillance: 3 for adults (most recent dental visit, most recent dental cleaning, total tooth loss) using data from the Behavioral Risk Factor Surveillance System; 3 for third-grade students (presence of treated or untreated dental caries, untreated tooth decay, dental sealants) collected by states using a standard screening protocol; and the percentage of the population served by public water systems that receives optimally fluoridated water, tracked through the Water Fluoridation Reporting System. The Web site that describes the National Oral Health Surveillance System (http://www.cdc.gov/nohss/) and provides access to current indicators was launched in 2001 with adult and water fluoridation data for all states; child indicators were added later. Data are now available electronically for 35 to 51 states (including the District of Columbia), depending on the indicator, indicating progress toward state-specific monitoring of these oral health indicators.

Diabetes and anxiety in US adults: findings from the 2006 Behavioral Risk Factor Surveillance System

AIMS

Anxiety disorders may cause substantial impairment in patient functioning and well-being. Little is known about the relationship between diabetes and anxiety. We estimated the prevalence of lifetime diagnosis of anxiety in adults aged > or = 18 years with and without diabetes in the USA.

METHODS

We analysed data from the 2006 Behavioral Risk Factor Surveillance System (total, N = 201 575; 20 142 with diabetes; 39.4% men, 77.9% non-Hispanic Whites, 8.1% non-Hispanic Blacks and 7.7% Hispanics; mean age 52.4 years). Diabetes and lifetime diagnosis of anxiety were self-reported. A multivariable log-binomial model was used to estimate prevalence ratios (PR) and associated 95% confidence intervals (CI) of anxiety based on diabetes status.

RESULTS

The overall age-adjusted prevalence of lifetime diagnosis of anxiety was 19.5 and 10.9% in people with and without diabetes, respectively. After adjustment for educational level, marital status, employment status, current smoking, leisure-time physical activity and body mass index, people with diabetes had a 20% higher prevalence of lifetime diagnosis of anxiety than those without (PR 1.20; 95% CI 1.12, 1.30). There were no significant differences in the PR by gender (P = 0.06). However, the ratios differed significantly by age (P = 0.04) and by race/ethnicity (P < 0.01), indicating that people aged 18-29 years (PR 1.70; 95% CI 1.19, 2.43) and Hispanics (PR 1.69; 95% CI 1.33, 2.15) had a higher ratio than their counterparts.

CONCLUSION

Diabetes was significantly associated with anxiety in adults in this large population-based sample, particularly in Hispanics and young adults.

The National Violent Death Reporting System: an exciting new tool for public health surveillance

The US does not have a unified system for surveillance of violent deaths. This report describes the National Violent Death Reporting System (NVDRS), a system for collecting data on all violent deaths (homicides, suicides, accidental firearms deaths, deaths of undetermined intent, and deaths from legal intervention, excluding legal executions) in participating states. The NVDRS centralizes data from many sources, providing a more comprehensive picture of violent deaths than would otherwise be available. The NVDRS collects data on victims, suspects, and circumstances related to the violent deaths. Currently, 17 US states participate in the NVDRS; the intention is for the NVDRS to become a truly national system, representing all 50 states, the District of Columbia, and the US territories. This report describes the history of the NVDRS, provides an overview of how the NVDRS functions, and describes future directions.

Race/ethnicity, substance abuse, and mental illness among suicide victims in 13 US states: 2004 data from the National Violent Death Reporting System

OBJECTIVE

To calculate the prevalence of substance abuse and mental illness among suicide victims of different racial/ethnic groups and to identify race/ethnicity trends in mental health and substance abuse that may be used to improve suicide prevention.

METHODS

Data are from the National Violent Death Reporting System (NVDRS), a state-based data integration system that, for 2004, includes data from 13 US states. The NVDRS integrates medical examiner, toxicology, death certificate, and law enforcement data.

RESULTS

Within participating states, for data year 2004, 6865 suicide incidents in which race/ethnicity are known were identified. This included 5797 (84.4%) non-Hispanic whites, 501 (7.3%) non-Hispanic blacks, 257 (3.7%) Hispanics, and 310 (4.5%) persons from other racial/ethnic groups. At the time of the suicide event, non-Hispanic blacks had lower blood alcohol contents than other groups. Non-Hispanic whites had less cocaine but more antidepressants and opiates. There were no differences in the levels of amphetamines or marijuana by race/ethnicity. Hispanics were less likely to have been diagnosed with a mental illness or to have received treatment, although family reports of depression were comparable to non-Hispanic whites and other racial/ethnic groups. Non-Hispanic whites were more likely to be diagnosed with depression or bipolar disorder and non-Hispanic blacks with schizophrenia. Comorbid substance abuse and mental health problems were more likely among non-Hispanic whites and non-Hispanic blacks, while Hispanics were more likely to have a substance abuse problem without comorbid mental health problems.

CONCLUSION

The results support earlier research documenting differences in race/ethnicity, substance abuse, and mental health problems as they relate to completed suicide. The data suggest that suicide prevention efforts must address not only substance abuse and mental health problems in general, but the unique personal, family, and social characteristics of different racial/ethnic groups.

Gorlin's syndrome presenting with myolipoma of tongue base

OBJECTIVE

We report the first case of tongue base myolipoma associated with Gorlin's syndrome.

METHOD

Case report and review of world literature.

RESULTS

A 39-year-old man with known Gorlin's syndrome presented with progressive dysphagia. Subsequent magnetic resonance imaging scan and biopsy confirmed the rare diagnosis of myolipoma arising from the tongue base. In view of the benign nature of this mass, it was debulked rather than completely excised in order to preserve swallowing function.

CONCLUSION

To our knowledge, this is the first report of the coexistence of two rare conditions in an atypical fashion. This case appears to represent a new variant in the broad spectrum of features of Gorlin's syndrome.

Oral transmucosal fentanyl citrate versus placebo for painful dressing changes: a crossover trial

OBJECTIVE

Fentanyl is a potent opioid that is well absorbed via the oral mucosa. It can be given as an oral lozenge. The onset of analgesia is rapid and matches the pain profile observed at dressing changes.

METHOD

Patients experiencing pain during daily dressing changes were given entonox plus either placebo or oral transmucosal fentanyl citrate (OTFC) for two consecutive dressing changes in a randomised double-blind placebo-controlled crossover trial.

RESULTS

Nine patients were recruited. The mean worst pain score during dressing changes was 7/10 with placebo and 4/10 with OTFC; the reduction in pain achieved with OTFC was significant. The mean number of breaths of entonox taken during the dressing change was 27.67 with placebo and 4.67 with OTFC; the reduction in the number of entonox breaths with OTFC was significant. One patient in the OTFC group suffered nausea.

CONCLUSION

Compared with placebo, OTFC improved analgesia during painful dressing changes without an increase in side-effects.

Homicide of children aged 0-4 years, 2003-04: results from the National Violent Death Reporting System

INTRODUCTION

To better understand, and ultimately prevent, infant/child homicide, it is imperative to more thoroughly elucidate the circumstances and conditions related to such instances. Data were obtained from the US National Violent Death Reporting System (NVDRS) to illuminate circumstances related to homicide among children aged 4 years or less, and to identify demographic groups which may be at increased risk.

METHODS

The NVDRS is an active surveillance system that provides comprehensive information on all violent deaths that occur within participating states within the US. Standard statistical tests were conducted to determine homicide rates among children ages 0-4 across states that provided data for both 2003 and 2004 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, and Virginia). These data were further used to investigate infant/child homicides by race, gender, and other relevant circumstances (for example, victim-suspect relationship, weapon type, and location of homicide). A Poisson regression model was fitted to the sample data to investigate the multivariate relationship between the infant/child homicide rate and available demographic information.

RESULTS

The 2003 homicide rate for children ages 0-4 was 3.0 per 100,000 population. The 2004 homicide rate was 2.5 per 100,000 population. African Americans were 4.2 times as likely as whites to be victims of homicide. Suspects were commonly parents/caregivers. The vast majority of infant/child homicides occurred in houses or apartments, using weapons that include household objects.

CONCLUSION

Homicides of infants and young children are most often committed in the home, by parents/caregivers, using "weapons of opportunity". This suggests that the risk of infant/child homicide is greatest within the primary care giving environment. Moreover, the use of "weapons of opportunity" may be indicative of maladaptive stress responses. Prevention and intervention strategies to reduce infant/child homicide should target the home environment and attend to maladaptive stress responses.

Characteristics of homicide followed by suicide incidents in multiple states, 2003-04

OBJECTIVE

To calculate the prevalence of homicide followed by suicide (homicide/suicide) and provide contextual information on the incidents and demographic information about the individuals involved using data from a surveillance system that is uniquely equipped to study homicide/suicide.

METHODS

Data are from the National Violent Death Reporting System (NVDRS). This active state-based surveillance system includes data from seven states for 2003 and 13 states for 2004. The incident-level structure facilitates identification of homicide/suicide incidents.

RESULTS

Within participating states, 65 homicide/suicide incidents (homicide rate = 0.230/100,000) occurred in 2003 and 144 incidents (homicide rate = 0.238/100,000) occurred in 2004. Most victims (58%) were a current or former intimate partner of the perpetrator. Among all male perpetrators of intimate partner homicide 30.6% were also suicides. A substantial proportion of the victims (13.7%) were the children of the perpetrator. Overall, most victims (74.6%) were female and most perpetrators were male (91.9%). A recent history of legal problems (25.3%), or financial problems (9.3%) was common among the perpetrators.

CONCLUSIONS

The results support earlier research documenting the importance of intimate partner violence (IPV) and situational stressors on homicide/suicide. These results suggest that efforts to provide assistance to families in crisis and enhance the safety of IPV victims are needed to reduce risk for homicide/suicide. The consistency of the results from the NVDRS with those from past studies and the comprehensive information available in the NVDRS highlight the promise of this system for studying homicide/suicide incidents and for evaluating the impact of prevention policies and programs.

Longitudinal farm study of extended-spectrum beta-lactamase-mediated resistance

Extended-spectrum beta-lactamase (ESBL)-mediated resistance is of considerable importance in human medicine. Recently, such enzymes have been reported in bacteria from animals. We describe a longitudinal study of a dairy farm suffering calf scour with high mortality rates. In November 2004, two Escherichia coli isolates with resistance to a wide range of beta-lactams (including amoxicillin-clavulanate and cefotaxime) were isolated from scouring calves. Testing by PCR and sequence analysis confirmed the isolates as being both bla(CTX-M14/17) and bla(TEM-35) ((IRT-4)) positive. They had indistinguishable plasmid and pulsed-field gel electrophoresis (PFGE) profiles. Transferability studies demonstrated that bla(CTX-M) was located on a conjugative 65-MDa IncK plasmid. Following a farm visit in December 2004, 31/48 calves and 2/60 cows were positive for E. coli with bla(CTX-M). Also, 5/48 calf and 28/60 cow samples yielded bla(CTX)- and bla(TEM)-negative E. coli isolates that were resistant to cefotaxime, and sequence analysis confirmed that these presented mutations in the promoter region of the chromosomal ampC gene. Fingerprinting showed 11 different PFGE types (seven in bla(CTX-M)-positive isolates). Six different PFGE clones conjugated the same bla(CTX-M)-positive IncK plasmid. One clone carried a different-sized, bla(CTX-M)-positive, transformable plasmid. This is the first report of bla(CTX-M) from livestock in the United Kingdom, and this report demonstrates the complexity of ESBL epidemiology. Results indicate that horizontal plasmid transfer between strains as well as horizontal gene transfer between plasmids have contributed to the spread of resistance. We have also shown that some clones can persist for months, suggesting that clonal spread also contributes to the perpetuation of resistance.

Use of HIV postexposure prophylaxis by dental health care personnel: an overview and updated recommendations

BACKGROUND

The authors conducted a study on the use of postexposure prophylaxis, or PEP, for exposure to human immunodeficiency virus, or HIV, among dental health care personnel, or DHCP, enrolled in a surveillance system established by the Centers for Disease Control and Prevention, or CDC. They also discuss updated U.S. Public Health Service, or USPHS, recommendations for managing occupational exposures to HIV, as well as considerations for dentistry.

METHODS

The authors analyzed occupational exposures reported by DHCP to the CDC to describe characteristics of the exposure (for example, type and severity), the source patient's HIV status and use of PEP.

RESULTS

From June 1995 through August 2001, DHCP reported 208 exposures--199 percutaneous injuries, six mucous membrane exposures and three skin exposures--to the CDC. One-third of these percutaneous injuries were caused by small-bore hollow syringe needles, and most (66 percent) were moderate in depth. Nearly half the devices involved (46 percent) were visibly bloody at the time of injury. Per the criteria described in USPHS guidelines, one-half of the injuries were categorized as "less severe." Twenty-four (13 percent) known source patients were HIV-positive; 14 had symptomatic HIV infection or a high viral load. In this study, three in four DHCP exposed to an HIV-positive source warranted a three-drug PEP regimen. Twenty-nine (24 percent) DHCP exposed to a source patient who subsequently was found to be HIV-negative took PEP; six took PEP for five to 29 days. No exposures resulted in HIV infection.

CONCLUSIONS

Findings of this study are consistent with earlier reports indicating that the risk of HIV transmission in dental settings is low. Strategies such as rapid HIV testing of source patients and follow-up counseling may reduce unnecessary use of PEP.

CLINICAL IMPLICATIONS

Dental practices should develop comprehensive, written programs for preventing and managing occupational exposures to blood.