Understanding COVID-19 Vaccine Hesitancy Among K-12 Staff, Parents, and Students: District of Columbia, February to April, 2022

OBJECTIVE

Despite widespread availability of COVID-19 vaccines, millions of Americans have not received the recommended vaccine doses. In the District of Columbia (DC), COVID-19 vaccination rates are lowest among residents who are Non-Hispanic (NH) Black and among school-aged children. We assessed COVID-19 vaccine hesitancy among staff and parents of students in DC K-12 public and public charter schools.

METHODS

We conducted a telephone-based survey from February 6 to April 16, 2022 to staff, students, and parents of students who participated in school-based COVID-19 screening testing. COVID-19-related survey items included: vaccination status, reasons for not getting vaccinated, perceived vaccine access, and trusted COVID-19 information sources. Utilizing time-to-event analyses, we evaluated differences across demographic groups.

RESULTS

The interview response rate was 25.8% (308/1193). Most unvaccinated participants were NH Black and ages 5 to 11 years. Median time from vaccine eligibility to uptake was 236 days for NH Black participants vs. 10 days for NH White participants. Vaccine safety was the top concern among unvaccinated participants. Government and healthcare providers were the most trusted COVID-19 information sources.

CONCLUSIONS

Differences in timing of vaccine uptake among respondents and greater vaccine hesitancy among NH Black participants compared to other racial/ethnic groups highlight a need for continued tailored outreach and communication using trusted sources to convey the importance, benefits, and safety of COVID-19 vaccination.

Fatigue risk assessment of a Helicopter Emergency Medical Service crew working a 24/7 shift pattern: results of a prospective service evaluation

BACKGROUND

The work of Helicopter Emergency Medical Services (HEMS) teams crosses the boundaries of several high-risk occupations including medicine, aviation, and transport. Working conditions can be challenging and operational demands requires a 24-h rota, resulting in disruption of the normal circadian rhythm. HEMS crews are therefore prone to both mental and physical fatigue. As fatigue in medical providers is linked to poor cognitive performance, degradation of psychomotor skills and error, this study aimed to explore the existence of predictable patterns of crew-fatigue in a HEMS service.

METHODS

HEMS medical crew members working a 3-on 3-off forward rotating rota with a 5-week shift cycle were asked to do psychomotor vigilance tests (PVT) as an objective measure of fatigue. PVT testing was undertaken at the start, mid- and at the end of every shift during a full 5-week shift cycle. In addition, they were asked to score subjective tiredness with the Samn-Perelli Fatigue Scale (SPFS), and to keep a Transport Fatigue Assessment shift log, wherein they noted shift characteristics potentially related to fatigue. Primary outcome of interest was defined as the change in PVT and SPFS scores over time.

RESULTS

Mean baseline resting PVT in milliseconds at the start of the study period was 427 [390-464]. There was an overall trend towards higher PVT-scores with shift progression mean [95% CI] PVT at the start of shifts 447 [433-460]; halfway through the shift 452 [440-463]; end of the shift 459 [444-475], p = 0.10), whereas SPFS scores remained constant. Within a 5 week forward-rotating cycle, an overall trend towards a gradual increase in both average PVT (from 436 [238-454] to 460 [371-527, p = 0.68] ms;) and SPFS (from 2.9 [2.6-3.2] to 3.6 [3.1-4.0], p = 0.38) was observed, although significant interindividual variation was present. Reported SPFS scores ≥ 4 (moderate fatigue) were mainly related to workload (number of jobs) and transport mode (car-based shifts).

CONCLUSION

An overall trend towards a decline in psychomotor vigilance and an increase in self-reported tiredness was found for HEMS crew over a 5-week shift cycle. Using a bespoke predictive fatigue tool on a day-to-day basis could increase fatigue awareness and provide a framework to which relevant mitigating options can be applied.

The Impact of Community-Based Testing Sites and Gift Incentives on COVID-19 Testing Uptake in Maryland, April 29 - May 9, 2021

PURPOSE

Information on incentives for COVID-19 testing is needed to understand effective practices that encourage testing uptake. We describe characteristics of those who received an incentive after performing a rapid antigen test.

DESIGN

Cross-sectional descriptive analysis of survey data.

SETTING

During April 29-May 9, 2021, COVID-19 rapid antigen testing was offered in 2 Maryland cities.

SAMPLE

Convenience sample of 553 adults (≥18 years) who tested and received an incentive; 93% consented to survey.

MEASURES

Survey questions assessed reasons for testing, testing history, barriers, and demographics.

ANALYSIS

Robust Poisson regressions were used to determine characteristic differences based on testing history and between participants who would re-test in the future without an incentive vs participants who would not.

RESULTS

The most common reasons for testing were the desire to be tested (n = 280; 54%) and convenience of location (n = 146; 28%). Those motivated by an incentive to test (n = 110; 21%) were 5.83 times as likely to state they would not test again without an incentive, compared to those with other reasons for testing (95% CI: 2.67-12.72, P < .001).

CRITICAL LIMITATIONS

No comparative study group.

CONCLUSION

Results indicate internal motivation and convenience were prominent factors supporting testing uptake. Incentives may increase community testing participation, particularly among people who have never tested. Keywords COVID-19, pandemic, incentives, health behavior, community testing.

Maternal Periconceptional Folic Acid Supplementation and DNA Methylation Patterns in Adolescent Offspring

BACKGROUND

Folate, including the folic acid form, is a key component of the one-carbon metabolic pathway used for DNA methylation. Changes in DNA methylation patterns during critical development periods are associated with disease outcomes and are associated with changes in nutritional status in pregnancy. The long-term impact of periconceptional folic acid supplementation on DNA methylation patterns is unknown.

OBJECTIVES

To determine the long-term impact of periconceptional folic acid supplementation on DNA methylation patterns, we examined the association of the recommended dosage (400 μg/d) and time period (periconceptional before pregnancy through first trimester) of folic acid supplementation with the DNA methylation patterns in the offspring at age 14-17 y compared with offspring with no supplementation.

METHODS

Two geographic sites in China from the 1993-1995 Community Intervention Program of folic acid supplementation were selected for the follow-up study. DNA methylation at 402,730 CpG sites was assessed using saliva samples from 89 mothers and 179 adolescents (89 male). The mean age at saliva collection was 40 y among mothers (range: 35-54 y) and 15 y among adolescents (range: 14-17 y). Epigenome-wide analyses were conducted to assess the interactions of periconceptional folic acid exposure, the 5,10-methylenetetrahydrofolate reductase (MTHFR)-C677T genotype, and epigenome-wide DNA methylation controlling for offspring sex, geographic region, and background cell composition in the saliva.

RESULTS

In the primary outcome, no significant differences were observed in epigenome-wide methylation patterns between adolescents exposed and those non-exposed to maternal periconceptional folic acid supplementation after adjustment for potential confounders [false discovery rate (FDR) P values < 0.05]. The MTHFR-C677T genotype did not modify this lack of association (FDR P values < 0.05).

CONCLUSIONS

Overall, there were no differences in DNA methylation between adolescents who were exposed during the critical developmental window and those not exposed to the recommended periconceptional/first-trimester dosage of folic acid.

Relationship between cardiovascular symptoms, health status assessment and cardiomyopathy in the obstetric population

Background

Pregnancy related cardiomyopathy is a significant cause of maternal morbidity and mortality globally. A presumed overlap between normal pregnancy-associated symptoms and clinical symptoms of cardiomyopathy contributes to delays in diagnosis and increased risk of maternal mortality.

Purpose

We sought to evaluate the association between patient-reported cardiovascular symptoms and the presence of cardiomyopathy among pregnant and postpartum patients. We hypothesize that individual cardiovascular symptoms are unrelated to the presence of cardiomyopathy. We also evaluated the use of a novel adaptation of a validated health status questionnaire in relation to cardiomyopathy.

Methods

We enrolled 48 pregnant (&gt;13 weeks) and postpartum (up to 12 months) participants in a prospective study between October 2021 and February 2022. All study participants completed a baseline questionnaire, which included current cardiovascular symptoms, an assessment of health status using an adapted version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), followed by a resting transthoracic echocardiogram on the same day. We defined cardiomyopathy as a left ventricular ejection fraction (LVEF) &lt;50% based on 2-D echocardiography. Fisher's exact and Wilcoxon rank-sum tests were employed to evaluate the association between reported cardiovascular symptoms, the adapted KCCQ-12 (KCC-A) score, and cardiomyopathy.

Results

At the time of enrollment, 67% were pregnant and 33% postpartum. Forty-eight percent identified as White, 31% as Black, 10% as Asian, and 10% as other race. The median age was 31 years (Q1: 28, Q3: 35) and 6% had an LVEF &lt;50%. We found no statistically significant association between four reported cardiovascular symptoms (shortness of breath, orthopnea, fast breathing, and episodes of “asthma” that did not improve with inhalers or other treatment) and cardiomyopathy or medial E/e' ratio. KCC-A scores were low in the study population overall (median 52; Q1:40, Q3: 61). We demonstrated a significantly lower KCC-A score among women with LVEF &lt;50% (median 24; Q1: 15, Q3: 44) compared to women with LVEF ≥50% (median 54; Q1: 44, Q3: 61) p=0.02.

Conclusions

We showed no significant association between individual cardiovascular symptoms and cardiomyopathy in an obstetric population. However, we demonstrate for the first time that an adapted KCCQ-12 questionnaire for health status assessment could potentially identify women with a high-likelihood of cardiomyopathy during the peripartum period who may benefit from additional evaluation including echocardiography. Larger studies are needed to validate this finding.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This study was funded by a research grant from the Miami Heart Research Institute, Florida Heart Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

The impact of traumatic experiences, coping mechanisms, and workplace benefits on the mental health of U.S. public health workers during the COVID-19 pandemic

Purpose

To evaluate the association between risk factors, mitigating factors, and adverse mental health outcomes among United States public health workers.

Methods

Cross-sectional online survey data were collected March to April 2021. The survey was distributed to public health workers who worked in a state, tribal, local, or territorial public health department since March 2020.

Results

In total, 26,174 United States state and local public health workers completed the survey. Feeling isolated was a risk factor for anxiety (PR, 1.84; 95% CI, 1.74–1.95), depression (PR, 1.84; 95% CI, 1.75–1.94), post-traumatic stress disorder (PR, 1.50; 95% CI, 1.43–1.57), and suicidal ideation (PR, 3.23; 95% CI, 2.82–3.69). The ability to take time off was linked to fewer reported symptoms of anxiety (PR, 0.87; 95% CI, 0.83–0.90), depression (PR, 0.86; 95% CI, 0.83–0.89), post-traumatic stress disorder (PR, 0.84; 95% CI, 0.81–0.88), and suicidal ideation (PR, 0.84; 95% CI, 0.77–0.92).

Conclusions

Since COVID-19 was declared a pandemic, respondents who felt isolated and alone were at an increased risk for adverse mental health outcomes. Findings from this study call for public health organizations to provide their workforce with services and resources to mitigate adverse mental health outcomes.

Point Prevalence Estimates of Activity-Limiting Long-Term Symptoms among U.S. Adults ≥1 Month After Reported SARS-CoV-2 Infection, November 1, 2021

Background

Although most adults infected with SARS-CoV-2 fully recover, a proportion have ongoing symptoms, or post-COVID conditions (PCC), after infection. The objective of this analysis was to estimate the number of US adults with activity-limiting PCC on November 1, 2021.

Methods

We modeled the prevalence of PCC using reported infections occurring from February 1, 2020 – September 30, 2021, and population-based, household survey data on new activity-limiting symptoms ≥1 month following SARS-CoV-2 infection. From these data sources, we estimated the number and proportion of US adults with activity-limiting PCC on November 1, 2021, as 95% uncertainty intervals, stratified by sex and age. Sensitivity analyses adjusted for under-ascertainment of infections and uncertainty about symptom duration.

Results

On November 1, 2021, at least 3.0–5.0 million US adults were estimated to have activity-limiting PCC of ≥1 month duration, or 1.2%–1.9% of US adults. Population prevalence was higher in females (1.4%–2.2%) than males. The estimated prevalence after adjusting for under-ascertainment of infections was 1.7%–3.8%.

Conclusion

Millions of US adults were estimated to have activity-limiting PCC. These estimates can support future efforts to address the impact of PCC on the U.S. population.

Biomarkers of Choline Metabolism in Women of Reproductive Age in Southern India

Objectives

Inadequate maternal choline intake during pregnancy has been associated with adverse pregnancy and child health outcomes – and has been identified as a potential risk factor for neural tube defects. However, there is limited data on biomarkers of choline metabolism in women of reproductive age (WRA), and few representative population-level data from India. The objective of this analysis was to examine biomarkers of choline metabolism and their correlates in WRA, as part of a population-based biomarker survey in Southern India.

Methods

Participants were WRA (15–40y; n = 980) who were not pregnant or lactating. Free choline, betaine, dimethylglycine, methionine, and trimethylamine N-oxide concentrations were evaluated via liquid chromatography tandem mass spectrometry. Linear regression models were used to examine sociodemographic (e.g., age, parity), dietary (e.g., frequency of animal source food intake), and anthropometric (e.g., body mass index [BMI], waist circumference, waist-hip ratio) correlates of biomarkers of choline metabolism, including betaine concentrations and betaine to choline ratio (B:C).

Results

Betaine concentrations (GM: 44.2 μmol/L [95% CI: 43.4, 45.0]) were 4-fold higher compared to free choline (11.1μmol/L [10.9, 11.2]) levels, with an average B:C of 4.0 [3.9, 4.1]. Increased age (β: −0.01 [SE: 0.002], P < 0.0001), multiparity (multiparous/primiparous vs. nulliparous, P < 0.0001), and increased frequency of animal source food intake (poultry, p = 0.004; red meat, p = 0.01), were associated with lower B:C. Higher BMI (betaine: β: −0.004 [SE: 0.002], p = 0.02; B:C: β: −0.02 [SE: 0.002], P < 0.0001), waist circumference (betaine: −0.002 [0.001], p = 0.02; B:C: −0.01 [0.001], P < 0.0001), and waist-hip ratio (betaine: −0.31 [0.15], p = 0.04; B:C: −1.02 [0.16], P < 0.0001), were also associated with lower betaine concentrations and B:C.

Conclusions

In this population, higher BMI and central adiposity were associated with lower betaine concentrations and B:C. Findings from this biomarker survey will inform prospective research on the role of choline biomarkers in the health and nutritional requirements of WRA.

Funding Sources

Centers for Disease Control and Prevention (5U01DD001007), University of South Carolina Disability Research and Dissemination Center; Cornell DNS; NIH T32DK007158 (HMG); NIH 5T32HD087137 (AF).

Iron Status and Metabolic Health in Women of Reproductive Age in Southern India

Objectives

To examine the associations of iron status with metabolic health outcomes in women of reproductive age (WRA), as part of a population-based biomarker survey in Southern India.

Methods

Participants were WRA (15–40 y; n = 980) who were not pregnant or lactating (2017–2018). Blood samples were analyzed for hemoglobin (Hb; Coulter Counter) and glycated hemoglobin (HbA1c; nephelometry). Serum ferritin (SF) was measured by electrochemiluminescence; soluble transferrin receptor, C-reactive protein, and alpha-1 acid glycoprotein were analyzed via immuno-based assays (Roche). Anthropometric and blood pressure measurements were collected in triplicate. Bioelectrical impedance analysis (BC-418 MA) was used to estimate whole body (WF%) and trunk (TF%) fat in women ≥ 18y. Anemia was defined as Hb < 12.0 g/dL. SF was adjusted for inflammation using Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) methods; iron deficiency (ID) was defined as SF < 15.0 µg/L. Linear and binomial regression were used to examine associations of iron status with metabolic outcomes.

Results

A total of 41.5% of WRA had anemia, and 46.3% had ID (61.5%; BRINDA-adjusted). A total of 23.3% of adults were overweight (BMI: 25.0-<30.0 kg/m²) and 9.6% had obesity (BMI ≥ 30.0 kg/m²). Waist circumference (WC; ≥88.9 cm) and waist-hip ratio (WHR; ≥0.85) were elevated in 13.4% and 20.8% of women, and 25.0% had elevated HbA1c (≥6.5%: 5.0%; ≥5.7-<6.5%: 20.0%). Higher Hb concentrations were associated with increased BMI (β: 0.42 [SE: 0.09]; p < 0.01), WC (0.77 [0.21]; p < 0.01), and WF% (0.89 [0.17]; p < 0.01). Higher SF levels were associated with higher WF% (β: 0.79 [SE: 0.32]; p = 0.01) and TF% (0.92 [0.39]; p = 0.02), and elevated WC (RR: 1.20 [95% CI: 1.02–1.42]). Iron status was not significantly associated with HbA1c or blood pressure.

Conclusions

The burden of adverse metabolic outcomes was substantial in this population. Higher iron status was associated with higher BMI and central adiposity. Evaluating iron status and metabolic outcomes in future studies could help inform screening and interventions to improve the health of WRA.

Funding Sources

Centers for Disease Control and Prevention (5U01DD001007), University of South Carolina Disability Research and Dissemination Center; Consejo Nacional de Ciencia y Tecnología (CEGL); NIH 5T32HD087137 (AF); NIH T32DK007158 (HMG).

Comparison of Anemia Screening Methods Using Paired Venous Samples in Women of Reproductive Age in Southern India

Objectives

To evaluate anemia screening via portable hemoglobinometer (HemoCue 301) compared to automated hematology analyzer (AHA) reference, using paired venous samples from a population-based biomarker survey in Southern India.

Methods

Participants were women of reproductive age (WRA; 15–40 y) who were not pregnant or lactating. Paired venous whole blood samples (n = 896) were analyzed for hemoglobin (Hb) via HemoCue 301 and Coulter Counter AHA, as the gold standard. Serum ferritin (SF) was measured by electrochemiluminescence. Anemia and severe anemia were defined as Hb &lt; 12.0 and &lt; 8.0 g/dL, respectively. SF was adjusted for inflammation using BRINDA methods; iron deficiency (ID) was defined as SF &lt; 15.0 μg/L. Bland-Altman methods were used to assess level of agreement between Hb results (i.e., mean difference, standard deviation of differences, limits of agreement). Diagnostic accuracy parameters (i.e., sensitivity, specificity, positive predictive value, negative predictive value, accuracy) were calculated to evaluate HemoCue performance compared to the AHA reference, overall and by sociodemographic (e.g., age, parity), nutritional (e.g., iron, vitamin B12, folate status), and metabolic (e.g., HbA1c, body mass index (BMI)) characteristics.

Results

The estimated prevalence of anemia (36.3% vs. 41.6%, p &lt; 0.0001) was significantly lower via HemoCue compared to the AHA reference. A total of 84.4% of anemia and 98.8% of severe anemia screening results were concordant. HemoCue had 74.8% sensitivity and 91.2% specificity, compared to AHA. HemoCue sensitivity was higher in women with iron deficiency (SF &lt; 15.0 μg/L: 81.6% vs. ≥15.0 μg/L: 41.3%; p &lt; 0.0001), and lower in WRA who were overweight (BMI ≥ 25.0 kg/m2: 63.9% vs. &lt; 25.0 kg/m2: 78.8%; p = 0.004) or had elevated C-reactive protein (CRP) (CRP &gt; 1.0 mg/L: 67.2% vs. ≤1.0 mg/L: 82.9%; p = 0.001; CRP &gt; 3.0 mg/L: 62.2% vs. ≤3.0 mg/L: 79.3%; p = 0.001).

Conclusions

Findings suggest the estimated prevalence of anemia evaluated via portable hemoglobinometer (HemoCue) was lower compared to the AHA reference. HemoCue sensitivity varied by iron status and metabolic risk factors in this population.

Funding Sources

Centers for Disease Control and Prevention (5U01DD001007), University of South Carolina Disability Research and Dissemination Center; NIH 5T32HD087137 (AF); NIH T32DK007158 (HMG); Cornell DNS.

Assessing Impact of COVID-19 Pandemic on Receipt and Timeliness of Newborn Hearing Screening and Diagnostic Services Among Infants Born in Four States

The study compares receipt and timeliness of newborn hearing screening and follow-up diagnostic services between the pre-pandemic birth cohort and the pandemic birth cohort in four participating states. Findings from this study will help inform state Early Hearing Detection and Intervention (EHDI) programs in the future should a major public health event occur again.

Wound healing and Metabolite Profiling in Collagen-Chitosan Biomaterial-treated Chronic Wounds of Hansen’s Disease Patients

Aims: Impaired wound healing causes chronic ulcers in Hansen’s disease (HD) patients which are an unrecognized clinical manifestation and requires utmost care and attention for wound management. Collagen and chitosan biopolymers when synergistically combined produce a biologically active biomaterial for wound dressings. Hence, the aim was to prepare a collagen/chitosan (COL/CS) composite and characterize for wound healing potential in HD patients. Place and Duration of Study: CSIR-Central Leather Research Institute, Sardar Patel Road, Adyar, Chennai 600021, Southern Railway Headquarters Hospital, Constable Road, Ayanavaram, Chennai 600023, and Gremaltes Hospital, India between June 2013 and July 2020. Methodology: The HD wounds were measured by Planimetry in square cm and were also assessed for morphological structure of epidermis and collagen fiber arrangement by High Resolution- Scanning electron microscopy (HR-SEM).  Proton Nuclear magnetic resonance spectroscopy (1H-NMR) for metabolite identification was studied in blood plasma samples of unwounded, untreated and treated HD patients Results: Size D (wound size on day of discharge) of the wounds were appreciably lower than Size 0 (wound size before biomaterial treatment) demonstrating efficient wound healing by the biomaterial. The morphological structure of the HD wounds showed healthy epidermal layer and thick fibers of collagen matrix in the treated wounds when compared to the controls. Key metabolites of metabolic pathways such as TCA cycle, creatine cycle and protein metabolism were identified by 1H-NMR spectroscopy Conclusion: The COL/CS wound dressing is a promising biomaterial for management of chronic wounds in Hansen’s disease.

Collagen-Chitosan Composite Powder as a Novel Biomaterial for Chronic Wounds in Hansen Disease-A Clinical Study

Aims: Natural biomaterials are more suitable than synthetic biomaterials for in vivo applications for treating damaged tissues. Collagen and chitosan are abundantly available natural biomaterials for wound dressings for tissue/wound repair. In this context, collagen-chitosan composite powder has been used to treat chronic wounds in Hansen disease (HD) patients. Place and Duration of Study: CSIR Central Leather Research Institute, Sardar Patel Road, Adyar, Chennai 600021, Southern Railway Headquarters Hospital, Constable Road, Ayanavaram, Chennai 600023, and Gremaltes Hospital, India between June 2013 and July 2020. Methodology: Collagen extracted from bovine rumen, a waste product of meat industry, and a commercially available chitosan were prepared as a composite powder (COL/CS) and applied to chronic wounds in HD patients after debridement and the wound contours were measured by planimetry. Biochemical parameters in blood samples were periodically assessed. Histopathology of wound tissue with Hematoxylin and Eosin and Masson’s Trichrome staining was studied. Matrix Metalloproteinase-9 (MMP9) levels before and after treatment were estimated. Results: Wound healing of 64.2% was obtained with COL/CS treatment and formation of granulation cells was observed early. Hemogram studies have been reported in a regression model with 95% confidence intervals. Histopathology revealed dense collagen fibres and continuity of sub-epithelial layer on 8th day. MMP-9 levels showed collagen integrity after treatment. Conclusion: The novel biocompatible, biodegradable COL/CS wound dressing is a promising biomaterial for management of chronic wounds in Hansen disease patients.

Prevalence and Disparities in Folate and Vitamin B12 Deficiency Among Preschool Children in Guatemala

BACKGROUND AND OBJECTIVE

Folate and vitamin B12 deficiencies can impair proper growth and brain development in children. Data on the folate and vitamin B12 status of children aged 6-59 months in Guatemala are scarce. Identification of factors associated with higher prevalence of these micronutrient deficiencies within the population is needed for national and regional policymakers.

OBJECTIVE

To describe national and regional post-fortification folate and vitamin B12 status of children aged 6-59 months in Guatemala.

METHODS

A multistage, cluster probability study was carried out with national and regional representation of children aged 6-59 months. Demographic and health information was collected for 1246 preschool children, but blood samples for red blood cell (RBC) folate and vitamin B12 were collected and analyzed for 1,245 and 1143 preschool children, respectively. We used the following deficiency criteria as cutoff points for the analyses: < 305 nmol/L for RBC folate, < 148 pmol/L for vitamin B12 deficiency, and 148-221 pmol/L for marginal vitamin B12 deficiency. Prevalence of RBC folate deficiency and vitamin B12 deficiency and marginal deficiency were estimated. Prevalence risk ratios of RBC folate and vitamin B12 deficiency were estimated comparing subpopulations of interest.

RESULTS

The national prevalence estimates of RBC folate deficiency among children was 33.5% [95% CI 29.1, 38.3]. The prevalence of RBC folate deficiency showed wide variation by age (20.3-46.6%) and was significantly higher among children 6-11 months and 12-23 months (46.6 and 37.0%, respectively), compared to older children aged 48-59 months (20.3%). RBC folate deficiency also varied widely by household wealth index (22.6-42.0%) and geographic region (27.2-46.7%) though the differences were not statistically significant. The national geometric mean for RBC folate concentrations was 354.2 nmol/L. The national prevalences of vitamin B12 deficiency and marginal deficiency among children were 22.5% [95% CI 18.2, 27.5] and 27.5% [95% CI 23.7, 31.7], respectively. The prevalence of vitamin B12 deficiency was significantly higher among indigenous children than among non-indigenous children (34.5% vs. 13.1%, aPRR 2.1 95% CI 1.4, 3.0). The prevalence of vitamin B12 deficiency also significantly varied between the highest and lowest household wealth index (34.3 and 6.0%, respectively). The national geometric mean for vitamin B12 concentrations was 235.1 pmol/L. The geometric means of folate and B12 concentrations were significantly lower among children who were younger, had a lower household wealth index, and were indigenous (for vitamin B12 only). Folate and vitamin B12 concentrations showed wide variation by region (not statistically significant), and the Petén and Norte regions showed the lowest RBC folate and vitamin B12 concentrations, respectively.

CONCLUSIONS

In this study, a third of all children had RBC folate deficiency and half were vitamin B12 deficient. Folate deficiency was more common in younger children and vitamin B12 deficiency was more common in indigenous children and those from the poorest families. These findings suggest gaps in the coverage of fortification and the need for additional implementation strategies to address these gaps in coverage to help safeguard the health of Guatemalan children.

Urodynamic characteristics of neurogenic bladder in newborns with myelomeningocele and refinement of the definition of bladder hostility: Findings from the UMPIRE multi-center study

INTRODUCTION

Infants with myelomeningocele are at risk for chronic kidney disease caused by neurogenic bladder dysfunction. Urodynamic evaluation plays a key role to risk stratify individuals for renal deterioration.

OBJECTIVE

To present baseline urodynamic findings from the Urologic Management to Preserve Initial Renal function for young children with spina bifida (UMPIRE) protocol, to present the process that showed inadequacies of our original classification scheme, and to propose a refined definition of bladder hostility and categorization.

STUDY DESIGN

The UMPIRE protocol follows a cohort of newborns with myelomeningocele at nine children's hospitals in the United States. Infants are started on clean intermittent catheterization shortly after birth. If residual volumes are low and there is no or mild hydronephrosis, catheterization is discontinued. Baseline urodynamics are obtained at or before 3 months of age to determine further management. Based on protocol-specific definitions, urodynamic studies were reviewed by the clinical site in addition to a central review team; and if necessary, by all site urologists to achieve 100% concurrence.

RESULTS

We reviewed 157 newborn urodynamic studies performed between May 2015 and September 2017. Of these 157 infants, 54.8% were boys (86/157). Myelomeningocele closure was performed in-utero in 18.4% (29/157) and postnatally in 81.5% (128/157) of newborns. After primary review, reviewers agreed on overall bladder categorization in 50% (79/157) of studies. Concurrence ultimately reached 100% with further standardization of interpretation. We found that it was not possible to reliably differentiate a bladder contraction due to detrusor overactivity from a volitional voiding contraction in an infant. We revised our categorization system to group the "normal" and "safe" categories together as "low risk". Additionally, diagnosis of detrusor sphincter dyssynergia (DSD) with surface patch electrodes could not be supported by other elements of the urodynamics study. We excluded DSD from our revised high risk category. The final categorizations were high risk in 15% (23/157); intermediate risk in 61% (96/157); and low risk in 24% (38/157).

CONCLUSION

We found pitfalls with our original categorization for bladder hostility. Notably, DSD could not be reliably measured with surface patch of electrodes. The effect of this change on future renal outcomes remains to be defined.

Symptoms of Depression, Anxiety, Post-Traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic - United States, March-April 2021

Increases in mental health conditions have been documented among the general population and health care workers since the start of the COVID-19 pandemic (1-3). Public health workers might be at similar risk for negative mental health consequences because of the prolonged demand for responding to the pandemic and for implementing an unprecedented vaccination campaign. The extent of mental health conditions among public health workers during the COVID-19 pandemic, however, is uncertain. A 2014 survey estimated that there were nearly 250,000 state and local public health workers in the United States (4). To evaluate mental health conditions among these workers, a nonprobability-based online survey was conducted during March 29-April 16, 2021, to assess symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation among public health workers in state, tribal, local, and territorial public health departments. Among 26,174 respondents, 53.0% reported symptoms of at least one mental health condition in the preceding 2 weeks, including depression (32.0%), anxiety (30.3%), PTSD (36.8%), or suicidal ideation (8.4%). The highest prevalence of symptoms of a mental health condition was among respondents aged ≤29 years (range = 13.6%-47.4%) and transgender or nonbinary persons (i.e., those who identified as neither male nor female) of all ages (range = 30.4%-65.5%). Public health workers who reported being unable to take time off from work were more likely to report adverse mental health symptoms. Severity of symptoms increased with increasing weekly work hours and percentage of work time dedicated to COVID-19 response activities. Implementing prevention and control practices that eliminate, reduce, and manage factors that cause or contribute to public health workers' poor mental health might improve mental health outcomes during emergencies.

Dietary Supplement Intake, Folate and Vitamin B12 Status, and Cognitive Impairment Among Older Adults, National Health and Nutrition Examination Survey, 2011–2014

Objectives

Cognitive decline is a major public health issue among older adults. Dietary supplement use is common among older adults, and a concern has been raised about high folic acid intake among those with vitamin B12 (vB12) deficiency and exacerbation of cognitive decline. We evaluated supplement intake and folate and vB12 concentrations among older adults with measured cognitive function.

Methods

We used NHANES 2011–2014 data on adults aged 60 + years (n = 3266) and estimated folic acid and vB12 intake from dietary supplements. We defined vB12 insufficiency as serum vB12 concentration ≤ 258 pmol/L and high folate concentrations as either serum folate ≥ 59 nmol/L or RBC folate ≥ 1609 nmol/L. Cognitive impairment was defined as a test score &lt; 34 (&lt; 25th percentile of the distribution) using the Digit Symbol Substitution Test. We adjusted for age, gender, ethnicity, marital status, education, poverty income ratio (PIR), and creatinine/albumin ratio in our analysis. We performed statistical analyses using weighted procedures in SAS-SUDAAN.

Results

Older adults with cognitive impairment compared to those without were more likely to have less than a high school education; elevated serum methylmalonic acid; lower PIR; or to be non-Hispanic Black or Hispanic. Adults with cognitive decline were also less likely to use folic acid (29.2%) and vB12 (34.3%) supplements compared to those without cognitive decline (43.1% and 46.7%, respectively). Among vB12 insufficient adults, 18.0% were taking a vB12 supplement. After adjustment, compared to persons with normal folate and normal vB12 concentrations, persons with high folate and normal vB12 concentrations had a lower odds of having cognitive (adjusted OR [aOR]: 0.63; 95% confidence interval [CI]: 0.47, 0.85), and persons with high folate and insufficient vB12 concentrations had no significant difference in cognitive decline (aOR: 0.88; 95% CI: 0.36, 2.14). Among those who had cognitive decline with high folate and insufficient vB12 concentrations, 34.3% used a vB12 supplement.

Conclusions

Our findings suggest that contrary to previous reports having concurrent high folate and insufficient vB12 concentrations was not associated with cognitive impairment. Adults who reported taking vB12 supplements orally and continue to have low vB12 concentrations may have vB12 malabsorption issues.

Funding Sources

NA- CDC.

Impact of Voluntary Folic Acid Fortification of Corn Masa Flour on RBC Folate Concentrations in the U.S. (NHANES 2011–2018)

Objectives

Surveillance data have highlighted continued disparities in neural tube defects (NTDs) among infants of Hispanic women of reproductive age (HWRA) in the United States. Starting in 2017, the US Food and Drug Administration implemented voluntary folic acid fortification of corn masa flour to reduce the risk of NTDs. We assessed folate status, using red blood cell (RBC) folate concentrations, in HWRA (aged 12–49 y) before (2011–2016) and after (2017–2018) voluntary fortification of corn masa, stratified by acculturation factors (i.e., primary language spoken at home, length of time residing in the US).

Methods

Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2011–2018 with available RBC folate concentrations for HWRA were analyzed. Additional analyses were conducted among HWRA whose only folic acid source was fortified foods (enriched cereal grain products (ECGP) only), including usual intake and NTD prevalence estimations based on previously published models.

Results

Overall, RBC folate concentrations (adjusted geometric means) among HWRA remained similar from 2011–2016 to 2017–2018, though RBC folate significantly increased in 2017–2018 among lesser acculturated HWRA consuming ECGP only. Concentrations for those who were born outside the US and resided in the US &lt; 15 y increased from 894 nmol/L (95% CI: 844–946) in 2011–2016 to 1018 nmol/L (95% CI: 982–1162; p &lt; 0.001) in 2017–2018. Primarily Spanish speaking HWRA who consumed ECGP only increased from 941 nmol/L (95% CI: 895–990) in 2011–2016 to 1034 nmol/L (95% CI: 966–1107; p = 0.03) in 2017–2018. We observed no significant changes in the proportion at risk of NTD (&lt;748 nmol/L) and no changes in Bayesian model-based estimated NTD rates.

Conclusions

This early analysis following voluntary corn masa fortification found an increase in RBC folate concentrations in lesser acculturated groups relying on fortified foods as their primary folic acid source, though HWRA overall had no significant increase in folate concentrations. These early data suggests that there is remaining risk among Hispanics for folate sensitive NTDs; continued monitoring of folate status with NHANES will help assess the long-term efficacy of voluntary fortification.

Funding Sources

No funding sources outside of salaries.

Vitamin B12 Status and Metabolic Health in Women of Reproductive Age in Southern India

Objectives

To examine the burden of metabolic outcomes and associations of vitamin B12 status with metabolic health in women of reproductive age (WRA), as part of a population-based biomarker survey in Chittoor, India.

Methods

Participants (980 WRA; 15–40y nonpregnant or lactating) were assessed for glycated hemoglobin (HbA1c; nephelometry) and serum vitamin B12 concentrations (chemiluminescence). Anthropometric measurements and systolic (SBP) and diastolic (DBP) blood pressures were collected in triplicate. Bioelectrical impedance analysis was used to evaluate whole body (WF%) and trunk (TF%) fat among women ≤ 18y. We defined elevated HbA1c as ≤ 6.5% and ≤ 5.7-&lt; 6.5%, and hypertension as stage 1 (SBP 130–139 or DBP 80–89 mmHg) and stage 2 (SBP ≤ 140 or DBP ≤ 90 mmHg). Vitamin B12 was natural logarithmically transformed prior to analyses; vitamin B12 deficiency

was defined as &lt; 148 pmol/L. Linear and binomial regression models were used to examine associations of vitamin B12 status with metabolic outcomes.

Results

A total of 23.3% of adult WRA were overweight (body mass index (BMI): 25.0 to &lt; 30.0 kg/m2) and 9.7% had obesity (≤30.0 kg/m2). Waist circumference (WC; ≤88.9 cm) and waist-hip ratio (WHR; ≤0.85) were elevated in 13.4% and 20.1% of adult WRA. One-fourth of WRA had elevated HbA1c (≤6.5%: 5.0%; ≤5.7-&lt; 6.5%: 20.0%), and 18.6% had hypertension (stage 1: 16.4%; stage 2: 2.2%); 48.3% of WRA were vitamin B12 deficient. Higher continuous vitamin B12 concentrations were associated with lower BMI (β [standard error (SE)] -0.65 [0.28]) and WF% (-1.01 [0.50]); lower risk of elevated WC (risk ratio (RR) [95% confidence interval] 0.64 [0.49–0.85]); and higher risk of HbA1c ≤ 5.7% (1.19 [1.00–1.41]). Vitamin B12 deficiency was associated with higher BMI (β [SE] 0.98 [0.34], p = 0.004), WC (1.96 [0.76]), WF% (1.75 [0.59]), and TF% (2.03 [0.73]); and higher risk of having overweight (RR: 1.31 [1.09–1.58]), elevated WC (1.85 [1.32–2.60]), and WHR (1.38 [1.07–1.78]).

Conclusions

The burden of adverse metabolic outcomes was substantial in this population, and vitamin B12 deficiency was associated with central adiposity and overweight. Evaluating the role of vitamin B12 in the development of metabolic outcomes in future studies could inform screening and interventions to improve vitamin B12 status and metabolic health in WRA.

Funding Sources

Centers for Disease Control and Prevention.

Estimating the Serum Folate Concentration Associated With the Red Blood Cell Folate Threshold for Optimal Neural Tube Defects Prevention: A Population Based Biomarker Survey

Objectives

To estimate the serum folate insufficiency threshold (sf-IT) corresponding to the red blood cell (RBC) folate insufficiency threshold for optimal neural tube defect (NTD) prevention.

Methods

Participants were 977 women of reproductive age (WRA; 15–40y; not pregnant or lactating) from a population-based biomarker survey in Southern India. Venous blood samples were collected at enrollment. Plasma, serum, and red blood cells were centrifuged, processed, and stored &lt; -80°C until batch analysis. Total vitamin B12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were measured using the World Health Organization-recommended microbiological assay. Vitamin B12 deficiency was defined as total vitamin B12 &lt; 148 pmol/L. Folate

insufficiency was defined as RBC folate &lt; 748 nmol/L, the recommended calibrator-adjusted equivalent of the threshold for population optimal NTD prevention. A previously developed Bayesian model and the RBC and serum folate distributions in this population were used to estimate the sf-IT corresponding to the RBC folate insufficiency threshold for optimal NTD prevention, overall and by age, body mass index (BMI) category, HbA1c, anemia, and vitamin B12 status.

Results

The overall estimated median sf-IT was 37.8 nmol/L (95% credible interval [33.8–43.3]). This threshold was lower in overweight WRA (BMI: ≥25.0 kg/m2: 32.0 nmol/L [27.3–40.2] vs. BMI &lt; 25.0 kg/m2: 36.2 nmol/L [32.2–43.3]), and varied by age (&lt; 25y: 61.3 nmol/L [44.3–111.8]; 25 to 35y: 35.7 nmol/L [30.8–43.5]; ≥35y: 30.8 nmol/L [26.9–37.2]). The sf-IT was lower in anemic WRA (32.9 nmol/L [28.5–40.1]) compared to non-anemic WRA (42.0 nmol/L [36.1–51.3]), and lower in WRA with elevated HbA1c (≥5.7% to &lt; 6.5: 32.4 nmol/L [27.3–41.6]; ≥6.5%: 20.9 nmol/L [17.8–25.6]) vs. WRA with HbA1c &lt; 5.7% (43.8 nmol/L, [37.5–53.7]). The median sf-IT was higher in WRA with vitamin B12 deficiency (72.1 nmol/L [52.0–126.0]), compared to women who were not vitamin B12 deficient (28.1 nmol/L [25.6–31.5]).

Conclusions

The estimated sf-IT is dependent on anemia, elevated HbA1c, BMI, age, and vitamin B12 status.

Funding Sources

Centers for Disease Control and Prevention; AF was supported by the National Institutes of Health #5 T32 HD087137.

S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV)

INTRODUCTION

Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH.

METHODS

The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF).

RESULTS

The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix).

CONCLUSION

These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.

Differences in rapid increases in county-level COVID-19 incidence by implementation of statewide closures and mask mandates - United States, June 1-September 30, 2020

BACKGROUND AND OBJECTIVE

Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity.

METHODS

We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value< .05); associations were adjusted for county population size.

RESULTS

Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas.

CONCLUSIONS

These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

Faire face au COVID-19, mise en place de novo d’une unité mutualisée « COVID-19 non réanimatoire » : organisation et résultats

Introduction

La pandémie à COVID-19 a touché presque tous les pays du monde, dont la France. Tous les départements français ont ouvert des unités dédiées pour la gestion de la phase aiguë de l’épidémie. Au sein de notre site, notre structure a été la seule à accueillir une unité pour gérer des patients confirmés COVID-19 positifs. En l’absence de soins intensifs sur place, ces patients étaient triés au SAU et ne venaient que les patients sans indication de soins intensifs en raison du bénéfice/risque attendu (âge, comorbidités). Pour activer cette unité, une équipe mutualisée a été mise en place que ce soit au niveau du personnel médical PM (seniors, internes, externes) que personnel non médical (PNM) détachés des services de médecine interne, pédiatrie, médecine du sport, consultation, endocrinologie, hépatologie de notre CHU. Un support psychologique a été proposé aux soignants et aux familles par une équipe mobile de psychiatrie. L’activité quotidienne a été réorganisée après la création de plusieurs binômes junior-senior, en service de 8 h à 19 h, 7 j/7. La continuité des soins a été assurée chaque jour par 3 staffs pour permettre respectivement les transmissions de la nuit entre PM et PNM ; l’état des lieux après la visite du matin ; les projets pour le lendemain. Tous les patients ont été réévalués chaque jour et réorientés selon une échelle de gravité structurée par 5 codes-couleurs. Les externes ont eu pour mission de contacter les familles du fait de la limitation des visites, ainsi que les médecins traitants afin d’améliorer la gestion après le RAD. Les patients ont été traités par oxygénothérapie et protocoles d’antibiothérapie et morphine.

Matériels et méthodes

Analyse descriptive des données personnelles, de la mortalité brute et des issues de l’hospitalisation.

Résultats

Entre le 13 mars et le 19 mai, 147 patients, 56 % d’eux de sexe féminin, ont été hospitalisés dans cette unité d’une capacité maximale de 25 lits. L’âge moyen était de 69 ans [18 ; 97]. La durée moyenne du séjour a été de 5 jours [0 : 29]. La mortalité totale était du 20,4 %, dont 51 % des patients sont rentrés vers leur domicile ou vers des EHPAD. Ensuite, 14,3 % des patients ont été transférés vers un autre service de médecine aiguë, et 12,2 % des patients a poursuit les soins dans un SSR.

Conclusion

L’organisation de ce service montre comme une équipe de PM et PNM avec fonds de travail différentes peut être rapidement mise en place pendant une période de crise. La présence d’un service dédié à la gestion des cas de COVID-19 sans indication à soins intensifs peut soulager des autres services au sein d‘un groupe hospitalier qui travaille en coordination. La mortalité des patients hospitalisés dans ce service reste baisse considérant les comorbidités et l’âge des patients. La durée courte du séjour a permis d’accueillir un grand nombre de patients et de garantir de places en médecine aiguë standard au sein du GH.

Functional Outcomes among a Cohort of Children in Northeastern Brazil Meeting Criteria for Follow-Up of Congenital Zika Virus Infection

Following the large outbreak of Zika virus in the Western Hemisphere, many infants have been born with congenital Zika virus infection. It is important to describe the functional outcomes seen with congenital infections to allow for their recognition and appropriate interventions. We evaluated 120 children conceived during the 2015-2016 Zika virus outbreak in Paraíba, Brazil, who were approximately 24 months old, to assess functional outcomes. All children met either anthropometric criteria or laboratory criteria suggestive of possible congenital Zika virus infection. We collected results of previous medical evaluations, interviewed parents, and performed physical examinations and functional assessments, for example, the Hammersmith Infant Neurological Examination (HINE). We compared patterns of neurologic outcomes and developmental delay at age 24 months by whether children met anthropometric or laboratory criteria, or both. Among children meeting both criteria, 60% (26/43) were multiply affected (had severe motor impairment, severe developmental delay, and suboptimal HINE scores), compared with 5% (3/57) meeting only laboratory criteria and none (0/20) meeting only anthropometric criteria. Of the remaining 91 children, 49% (45) had developmental delay, with more severe delay seen in children meeting both criteria. Although children meeting physical and laboratory criteria for potential congenital Zika virus infection were more severely affected, we did identify several children with notable adverse neurologic outcomes and developmental delay with no physical findings but potential laboratory evidence of Zika virus infection. Given this, all children who were potentially exposed in utero to Zika virus should be monitored in early childhood for deficits to allow for early intervention.

Adapting the Ages and Stages Questionnaire to Identify and Quantify Development Among Children With Evidence of Zika Infection

This article describes novel methods of applying the Ages and Stages Questionnaire-3rd edition (ASQ-3) to assess and quantify developmental delay among children following the 2015-2016 Zika virus outbreak in Brazil. Many of the children with Zika virus infection were expected to have severe developmental delay. However, administering the ASQ-3 to caregivers of these children according to standard protocol would have screened for the overall presence of delay but not the severity of delay. We adopted an amended protocol for administration of the ASQ-3 to quantify the developmental functioning of children severely affected by Zika virus infection in this investigation. Protocols for administering the ASQ-3 among this population were drafted in consultation with developmental measurement experts and are presented here. Specific developmental estimates are discussed, including developmental age equivalents, developmental quotients, and developmental quotient z scores. The calculations of these estimates are presented with examples in the context of the 2015-2016 Zika virus outbreak and associated microcephaly among prenatally infected children from 2 states in northeastern Brazil. Potential applications of these methods for estimating developmental ability among similar pediatric populations are discussed.

Size-dependent influence of NOx on the growth rates of organic aerosol particles

Atmospheric new-particle formation (NPF) affects climate by contributing to a large fraction of the cloud condensation nuclei (CCN). Highly oxygenated organic molecules (HOMs) drive the early particle growth and therefore substantially influence the survival of newly formed particles to CCN. Nitrogen oxide (NOx) is known to suppress the NPF driven by HOMs, but the underlying mechanism remains largely unclear. Here, we examine the response of particle growth to the changes of HOM formation caused by NOx. We show that NOx suppresses particle growth in general, but the suppression is rather nonuniform and size dependent, which can be quantitatively explained by the shifted HOM volatility after adding NOx. By illustrating how NOx affects the early growth of new particles, a critical step of CCN formation, our results help provide a refined assessment of the potential climatic effects caused by the diverse changes of NOx level in forest regions around the globe.

A Bayesian approach to sequential analysis in post-licensure vaccine safety surveillance

With rapid development of computing technology, Bayesian statistics have increasingly gained more attention in various areas of public health. However, the full potential of Bayesian sequential methods applied to vaccine safety surveillance has not yet been realized, despite acknowledged practical benefits and philosophical advantages of Bayesian statistics. In this paper, we describe how sequential analysis can be performed in a Bayesian paradigm in the field of vaccine safety. We compared the performance of the frequentist sequential method, specifically, Maximized Sequential Probability Ratio Test (MaxSPRT), and a Bayesian sequential method using simulations and a real world vaccine safety example. The performance is evaluated using three metrics: false positive rate, false negative rate, and average earliest time to signal. Depending on the background rate of adverse events, the Bayesian sequential method could significantly improve the false negative rate and decrease the earliest time to signal. We consider the proposed Bayesian sequential approach to be a promising alternative for vaccine safety surveillance.

Attenuation of oxidative stress in arthritic rats by ethanolic extract of Albizia procera benth bark through modulation of the expression of inflammatory cytokines

ETHNOPHARMACOLOGICAL RELEVANCE

Albizia procera L. (Leguminosae) commonly known as Konda vagai in Tamil, is used for the treatment of stomach and intestinal disorders. A decoction of the bark is prescribed for rheumatism and haemorrhage. Traditionally, literature claims Albizia procera as a drug to have antirheumatic properties and hence used by Tribal for the management of chronic rheumatism. Consequently, the present study has been undertaken to illustrate the beneficial outcome of Albizia procera in adjuvant induced arthritic rat model with respect to its antioxidant and anti-inflammatory activities.

AIM OF THE STUDY

The present study is aimed to investigate the oxidative stress and the expression of inflammatory markers in arthritic rats treated with ethanolic bark extract of Albizia procera.

MATERIALS AND METHODS

Ethanolic bark extract was characterized by HPTLC analysis. Acute oral toxicity study was performed according to the OECD test guideline 423 - Acute toxic class method. The anti-inflammatory effect of ETBE (100, 200 mg/kg/day/p.o.) was evaluated in complete Freund's adjuvant induced arthritic rats using diclofenac as positive control (0.3 mg/kg/day/p. o.). Plasma levels of interleukins TNF- α, IFN-α, IL-2, IL-6, myeloperoxidase and Cathepsin D levels were measured to assess the inflammatory effect of ETBE extract of Albizia procera. Further, the effect of ETBE on superoxide dismutase (SOD), glutathione peroxidase (GPX), reduced glutathione (GSH) and lipid peroxidation (LPO) were assessed in plasma.

RESULTS

HPTLC analysis showed the presence of 0.57% w/w of biochanin-A in ETBE. ETBE did not show any toxic signs up to 2000 mg/kg body weight. It exhibited the significant anti-inflammatory and antioxidant potential and did not show mortality up to 2000 mg/kg body weight. ETBE treatment significantly reduced the levels of TNF- α, IFN-α, IL-2, IL-6 and myeloperoxidase, and increased cathepsin D levels compared to vehicle treated animals. SOD, GSH and GPX levels were significantly restored to normal levels while LPO was significantly reduced at 200 mg/kg b. wt. Treated animals. Histopathological studies showed complete cartilage regeneration and near normal joint in ETBE treated arthritic rats.

CONCLUSION

ETBE demonstrated potent anti-inflammatory activity by modulating the expression of inflammatory cytokines and restoring the antioxidant enzyme levels.

[Pyogenic granuloma with satellitosis]

A 16-year-old female developed a satellite-like recurrence of a pyogenic granuloma on her thorax 2 weeks after complete excision. Treatment with a pulsed dye laser led to a complete resolution. BRAF and RAS mutations detected in the pyogenic granuloma are considered major driver mutations. Whether these findings are also of importance for the etiopathogenesis of satellitosis is unknown. In our patient, no BRAF or NRAS mutation could be detected.

[Granulomatous reaction pattern of the skin : Interstitial granulomatous dermatitis - lymphoma - vasculitis]

A particular diagnostic situation in the classification of a granulomatous dermatitis results when no circumscribed granulomas but instead a diffuse interstitial histiocytic inflammatory infiltrate, a granulomatous vasculitis or a neoplastic lymphocytic infiltrate is found. Interstitial granulomatous dermatitis was originally described in patients with arthritis. Later, it was recognized that there are also associations with other usually immunological diseases. Differentiating between interstitial granulomatous dermatitis and the interstitial form of granuloma annulare, early morphea and variants of borreliosis or scleromyxedema as well as interstitial granulomatous drug reaction can be very difficult. In long-standing cutaneous granulomatous infiltrates, T‑cell lymphoma should be excluded. Occasionally only a small number of atypical lymphocytes can be found. The detection of a monoclonal T‑cell expansion is then particularly helpful. Only recently, a CD8-positive granulomatous cutaneous T‑cell lymphoma was described which occurred in patients with immunodeficiencies. A granulomatous vasculitis in the skin is extremely rare. According to the Chapel Hill classification from 2012, systemic granulomatous vasculitis is equated with giant cell arteritis. Extracutaneous large arteries are involved. On rare occasions, involvement of the temporal artery can result in skin necrosis. More commonly granulomatous infiltrates in combination with vasculitis can be observed, whereby various infectious diseases, sarcoidosis and nodular vasculitis should be considered. Granulomatosis with polyangiitis (formerly Wegener's granulomatosis), presents in the skin as leukocytoclastic vasculitis. Here granulomas are extremely rare.

Folate and Vitamin B12 Status in Women of Reproductive Age in Rural Areas in Haryana, Northern India (P10-117-19)

Objectives

To conduct a household and biomarker survey to assess the baseline prevalence of folate deficiency and insufficiency and vitamin B12 deficiency in women of reproductive age prior to the start of a wheat flour fortification program in the Ambala District in Haryana, India.

Methods

A multistage cluster probability household and biomarker survey was conducted. Participants were women of reproductive age (18–49 y) who were not pregnant and resided in rural areas of two subdistricts in Ambala District in Haryana. Venous blood samples were collected among 866 women. Plasma, serum, and red blood cells (RBC) were separated by centrifugation, processed, and stored at <-80ºC until analysis. RBC and serum folate concentrations were measured using microbiologic assay and serum vitamin B12 was measured via chemiluminescence. Serum folate deficiency was defined as serum folate <7 nmol/L and RBC folate deficiency and insufficiency were defined as RBC folate <305 nmol/L and <748 nmol/L, respectively. Vitamin B12 deficiency was defined as vitamin B12 <200 pg/mL and vitamin B12 marginal deficiency was defined as vitamin B12 ≥200 and <300 pg/mL.

Results

The geometric mean concentrations for serum folate, RBC folate, and serum vitamin B12 were 12.3 (95% confidence interval [CI]: 11.8, 12.9) nmol/L, 544 (95% CI: 516, 573) nmol/L, and 190 (95% CI: 176, 206) pg/mL, respectively. The prevalence of folate deficiency was 11.3% (95% CI: 9.2, 13.9) for serum folate and 9.7% (95% CI: 7.8, 12.0) for RBC folate, and the prevalence of RBC folate insufficiency was 78.6% (95% CI: 74.8, 82.5). A total of 58.3% (95% CI: 54.2, 62.5) of women were vitamin B12 deficient (<200 pg/mL) and an additional 22.9% (95% CI: 19.7, 26.1) were marginally deficient for vitamin B12.

Conclusions

The magnitude of folate insufficiency and vitamin B12 deficiency in this Northern Indian population is a substantial public health concern. The findings from the survey help establish the baseline for a planned wheat flour fortification program aimed at reducing these micronutrient deficiencies.

Funding Sources

Centers for Disease Control and Prevention.

Lower serum adiponectin level is associated with lipodystrophy among HIV-infected men in the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) study

OBJECTIVES

Adiponectin levels are inversely related to cardiovascular risk and are low in diabetics and obese persons. We examined the association between adiponectin concentration and HIV-associated lipodystrophy, which remains unclear.

METHODS

The Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) was a prospective cohort study of HIV-infected adults conducted in four US cities. Lean body and fat masses were assessed using dual-energy X-ray absorptiometry scans. Using baseline data from 2004 to 2006, we defined lipodystrophy using a sex-specific fat mass ratio and performed cross-sectional analyses of associated risks using multivariable logistic regression.

RESULTS

Among 440 male participants (median age 42 years; 68% non-Hispanic white; 88% prescribed combination antiretroviral therapy; median CD4 lymphocyte count 468 cells/μL; 76% with viral load < 400 HIV-1 RNA copies/mL; 5% diabetic; median body mass index 25 kg/m² ), median concentrations of leptin and adiponectin were 3.04 ng/L [interquartile range (IQR) 1.77-5.43 ng/L] and 8005 μg/mL (IQR 4950-11 935 μg/mL), respectively. The prevalence of lipodystrophy was 14%. Lipodystrophy was significantly associated with increasing age [prevalence ratio (PR) 1.50; 95% confidence interval (CI) 1.10-2.06, per 10 years], adiponectin < 8005 μg/mL (PR 5.02; 95% CI 2.53-9.95), ever stavudine use (PR 2.26; 95% CI 1.36-3.75), CD4 cell count > 500 cells/μL (PR 2.59; 95% CI 1.46-4.61), viral load < 400 copies/mL (PR 3.98; 95% CI 1.25-12.6), highly sensitive C-reactive protein < 1.61 mg/L (PR 1.91; 95% CI 1.11-3.28) and smoking (PR 0.42; 95% CI 0.22-0.78).

CONCLUSIONS

Among men in this HIV-infected cohort, the prevalence of lipodystrophy was similar to previous estimates for persons living with HIV, and was associated with lower adiponectin levels, potentially indicating increased cardiovascular disease risk.

Abstract P2-08-26: High expression of CYP27A1 in breast cancer is associated with poor tumor pathological features and may differentially predict prognosis depending on menopausal status

Background: Pre-clinical and epidemiological data strongly link high cholesterol with breast cancer progression and poor prognosis. It was recently uncovered that the pathogenicity of cholesterol in breast cancer is directly propagated by 27-hydroxycholesterol (27HC), an oxysterol produced when cholesterol is hydroxylated by cytochrome P450, family 27, subfamily A, polypeptide 1 (CYP27A1) during bile acid synthesis. 27HC promotes breast tumor growth and metastasis via interactions with the estrogen receptor (ER) and liver x receptors respectively. Consequently, pharmaceutical approaches that directly interfere with CYP27A1 activity have been proposed to mitigate the adverse impact of 27HC in breast cancer. However, CYP27A1 expression or deregulation in clinical breast cancer is not well characterised. The aim of this study was to comprehensively describe the impact of tumor-specific expression of CYP27A1 protein on clinical breast cancer pathobiology and prognosis.

Methods: CYP27A1 expression in tumor cells was evaluated by immunohistochemistry in two independent population based cohorts including female patients with primary invasive breast cancer diagnosed between 1991 and 2010 (cohort 1) and between 2002 and 2012 (cohort 2). Staining was evaluable in 645 and 813 cases in cohort 1 and cohort 2, respectively. Associations between CYP27A1 expression with tumor pathological factors and survival were assessed by using logistic and Cox regression models respectively. Multivariable models adjusted for age at diagnosis, nodal status, histological grade, tumor size, ER and BMI.

Results: CYP27A1 was overexpressed in 21% and 28% in cohort 1 and cohort 2 respectively. High CYP27A1 expression was significantly associated with adverse tumor pathological features including negative hormone receptor (ER and PgR) status and histological grade 3 in both cohorts and with larger tumors (&gt;20 mm) in cohort two only (p&lt;0.05, for all comparisons). In multivariable Cox regression analyses, overexpression of CYP27A1 was neither independently prognostic for recurrence-free survival (cohort 2: HR=1.3, 95% CI= 0.88 – 1.9) nor overall survival (cohort 1: HR=1.3, 95% CI= 0.88 – 1.9 and Cohort 2: HR=1.3, 95% CI= 0.81 – 2.0, respectively). Upon stratification for menopausal status using age at diagnosis (&lt; 50 years vs ≥ 50 years) as surrogate, the relationship between CYP27A1 expression and prognosis remained non-significant for older (postmenopausal) patients. Interestingly, among younger (premenopausal) women, elevated CYP27A1 expression was independently prognostic for shorter time to recurrence or death (HR=3.3, 95% CI= 1.5 – 7.4; cohort 2).

Conclusions: Collectively, these results indicate that intratumoral CYP27A1 expression supports the notion that 27HC plays an important pathological role in breast cancer progression but tumor cell-specific CYP27A1 expression is not sufficient to independently predict overall survival in postmenopausal patients. Further sufficiently sized studies are needed to clarify the prognostic significance of CYP27A1 in younger and presumably premenopausal patients and evaluate its role as a treatment predictive factor.

Citation Format: Kimbung S, Stålhammar T, Inasu M, Nodin B, Elebro K, Tryggvadottir H, Jirström K, Rose C, Ingvar C, Jernström H, Borgquist S. High expression of CYP27A1 in breast cancer is associated with poor tumor pathological features and may differentially predict prognosis depending on menopausal status [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-26.

"Just too busy living in the moment and surviving": barriers to accessing health care for structurally vulnerable populations at end-of-life

BACKGROUND

Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL.

METHODS

Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently.

RESULTS

Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers.

CONCLUSIONS

Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.

A Dosimetric Comparison of Breast Radiotherapy Techniques to Treat Locoregional Lymph Nodes Including the Internal Mammary Chain

AIMS

Radiotherapy target volumes in early breast cancer treatment increasingly include the internal mammary chain (IMC). In order to maximise survival benefits of IMC radiotherapy, doses to the heart and lung should be minimised. This dosimetry study compared the ability of three-dimensional conformal radiotherapy, arc therapy and proton beam therapy (PBT) techniques with and without breath-hold to achieve target volume constraints while minimising dose to organs at risk (OARs).

MATERIALS AND METHODS

In 14 patients' datasets, seven IMC radiotherapy techniques were compared: wide tangent (WT) three-dimensional conformal radiotherapy, volumetric-modulated arc therapy (VMAT) and PBT, each in voluntary deep inspiratory breath-hold (vDIBH) and free breathing (FB), and tomotherapy in FB only. Target volume coverage and OAR doses were measured for each technique. These were compared using a one-way ANOVA with all pairwise comparisons tested using Bonferroni's multiple comparisons test, with adjusted P-values ≤ 0.05 indicating statistical significance.

RESULTS

One hundred per cent of WT(vDIBH), 43% of WT(FB), 100% of VMAT(vDIBH), 86% of VMAT(FB), 100% of tomotherapy FB and 100% of PBT plans in vDIBH and FB passed all mandatory constraints. However, coverage of the IMC with 90% of the prescribed dose was significantly better than all other techniques using VMAT(vDIBH), PBT(vDIBH) and PBT(FB) (mean IMC coverage ± 1 standard deviation = 96.0% ± 4.3, 99.8% ± 0.3 and 99.0% ± 0.2, respectively). The mean heart dose was significantly reduced in vDIBH compared with FB for both the WT (P < 0.0001) and VMAT (P < 0.0001) techniques. There was no advantage in target volume coverage or OAR doses for PBT(vDIBH) compared with PBT(FB).

CONCLUSIONS

Simple WT radiotherapy delivered in vDIBH achieves satisfactory coverage of the IMC while meeting heart and lung dose constraints. However, where higher isodose coverage is required, VMAT(vDIBH) is the optimal photon technique. The lowest OAR doses are achieved by PBT, in which the use of vDIBH does not improve dose statistics.

Stenosis at the area of Transposition – An Under-Recognized Complication of Transposed Brachiobasilic Fistulas

Background

With an increased focus on native AV fistula creation in hemodialysis patients, a transposed brachiobasilic fistula (tBBF) is becoming an increasingly utilized option. This study describes the outcomes of tBBFs in a chronic hemodialysis population. In particular, we focus on the incidence and location of stenosis, and review the impact of angioplasty on these lesions.

Methods

A retrospective cohort study using all patients with a tBBF created between January 2001 and December 2004.

Results

Of the 543 fistulas created during the study period, 93 were tBBFs. The mean age of patients was 65 years, 56% were male and 55% were diabetic. Stenosis occurred in 54% (46/85) of fistulas; the location of stenosis in the majority (74%) was at or near the area of basilic vein transposition and 50% of fistulas with stenosis in this location required three or more angioplasties. Primary (unassisted) patency was 42% at one year in this cohort. Secondary patency was 68% at 1 year and 58% and 53% at 2 and 3 years respectively.

Conclusion

In a cohort of hemodialysis patients who received a tBBF, we describe a reasonable primary and secondary patency rate and a high rate of stenosis at the point of transposition of the basilic vein. Such stenosis usually requires multiple percutaneous or surgical interventions to ensure or reestablish conduit patency. Further study is required regarding the optimal surgical technique, monitoring, and treatment of stenosis of this fistula type including the utility of repeat angioplasty.