Thursday November 12, 2009




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1112 Mechanical ventilation for patients with lung damage don't always work as planned [Toronto ON]--As more Canadians are diagnosed with H1N1 influenza infection, some will be admitted to hospital. The most severely affected may be treated in the intensive care unit (ICU) and placed on a mechanical ventilator to help them breathe while they recover from the infection.

While mechanical ventilation clearly saves the lives of many people felled by serious illness, in some cases, this supportive measure has been known to damage the lungs, says Dr. Arthur S. Slutsky, a scientist at St. Michael's Hospital in Toronto.

"In clinicians' previous zeal to maintain relatively normal blood gas values, they have ventilated patients using relatively large tidal volumes," Dr. Slutsky explains. "They also tended to ventilate patients in the supine position—that is, while they lay on their backs."

("Tidal volume" refers to the normal volume of air displaced in the lungs between normal inhalation and exhalation when extra effort is not applied. Other studies have found that lowering tidal volumes decreases mortality rates in ventilated patients.)

"Ventilation is what we call a physiological-based treatment," he explains. "We look at the patient's current physiological state, then devise and use treatments aimed at altering this state, hoping the change will translate into recovery."

In the case of severe H1N1 infection of the lungs, patients can develop severe hypoxemia—an abnormally low amount of oxygen in the arterial blood which is the major result of respiratory failure.

In an editorial published this week in the Journal of the American Medical Association (JAMA), Dr. Slutsky comments on new research published by Fabio S. Taccone and colleagues from the University of Milan in Milan, Italy.

The researchers looked at whether patients with Acute Respiratory Distress Syndrome (ARDS) who were mechanically ventilated in the prone position (lying on their stomachs) did better than patients ventilated while they were supine (lying on their backs), as is the standard approach. As in other studies of this physiological-based treatment, blood oxygen levels increased in the prone treatment group. But in the end, the mortality rate among these patients was not statistically different from that of the control group.

In his editorial, Dr. Slutsky asks the following question: "Today, 35 years after prone ventilation was suggested and after hundreds of articles have been published, including more than 150 review articles and more than 10 meta-analyses, why are more definitive conclusions about prone ventilation not available?"

Unfortunately, he says, very few large companies have a commercial interest in this type of intervention—for example, changing a ventilated patient from a supine to a prone position. This explains why funding for such research is hard to obtain and why clear answers about the usefulness of physiological interventions are often lacking.

In this regard, prone ventilation is similar to other physiologically-based interventions for which the effect on important clinical outcomes has not been conclusively proven. In some cases, these physiological "fixes" do not always work as planned—interventions that improve one physiological value may actually worsen another.

In his editorial, Dr. Slutsky says that basing treatments strictly on physiological endpoints—in this case, increasing oxygenation in the blood by mechanically increasing volumes of air in the lungs and changing patients' position during treatment—is "seductive" for several reasons:

* In many ways, the intensive care unit is a physiology laboratory in which patients' vital signs and other functions are monitored and treated around the clock, seven days a week. By explaining why a patient has a physiological abnormality such as a decrease in oxygenation or worsening kidney function, these measurements can suggest therapies to correct the abnormal physiology.

* Many physiological interventions can be quickly instituted and monitored at the bedside. They are usually relatively inexpensive or seen as "free," which makes them attractive and easy to implement.

"But while physiological insights developed at the bedside have led to important, lifesaving therapies, it's been difficult to obtain convincing proof of better clinical outcomes for many such interventions," Dr. Slutsky says.

One solution would be to design large, simple, generalizable trials undertaken by a large global network of investigators. "The time for this may be especially opportune because the world's critical care community is coalescing around an initiative to perform large-scale clinical trials to rapidly address the potential H1N1 pandemic," he says, adding that such trials are necessary to "separate fact from seduction."

Dr. Art Slutsky is a researcher in the Keenan Research Centre at the Li Ka Shing Knowledge Institute of St. Michael's Hospital, and Professor of Medicine, Surgery and Biomedical Engineering at the University of Toronto. He is also Director of the Interdepartmental Division of Critical Care Medicine, University of Toronto.



1112 New polls, reports highlight the need to update the US food safety system [New York NY]--Over the next several weeks, the U. S. Senate has an historic opportunity to take a major step toward improving food safety for all Americans. That is why a coalition of public health professionals, consumer organizations and groups representing victims of foodborne illness is sending the message that it is time to "Make Our Food Safe for the Holidays!"

Every year, millions of Americans are sickened from consuming contaminated food, hundreds of thousands are hospitalized and thousands die. Multiple outbreaks of foodborne illness over the last several years – from spinach to peppers to peanut butter products – have demonstrated that these outbreaks are not random, unpreventable occurrences, but are due to widespread problems with food safety oversight in the United States.

This summer the U.S. House of Representatives passed its version of a sweeping food safety bill, which includes increased inspections of domestic food facilities and greater oversight of imports. The Make Our Food Safe coalition believes the Senate can take a major step forward in protecting public health by passing legislation that gives the U.S. Food and Drug Administration (FDA) enhanced authority to oversee the safety of the nation's food supply by the end of this year.

New polls of voters in selected states – Nevada, New Hampshire, North Carolina and Ohio – show overwhelming support for measures that would give the FDA these new powers. The polls, which were conducted in October by a respected bipartisan team of pollsters at Hart Research (Democratic) and Public Opinion Strategies (Republican), were commissioned by coalition member the Pew Health Group.

"Families across America want the government to do more to ensure their loved ones do not get sick from the food they serve over the holidays," says Sandra Eskin, director of the food safety project for the Pew Health Group. "Congress should enact stronger food safety laws before the end of the year."

Foodborne illness can significantly impact the health of children. According to a new fact sheet released today by the Make Our Food Safe coalition, approximately half of the reported foodborne illnesses occur in children, with the majority of these cases occurring in those under 15 years of age. Data from the Centers for Disease Control & Prevention (CDC) for five major foodborne pathogens —–Salmonella, Listeria monocytogenes, Campylobacter, Shigella, E. coli 0157:H7— clearly show the burden that children are carrying with regard to foodborne disease. The fact sheet also details the health risks associated with Toxoplasma gondii, a common parasite. To obtain a copy of the fact sheet, visit www.MakeOurFoodSafe.org.

In addition, coalition member Center for Foodborne Illness Research & Prevention (CFI) is releasing a report that looks in detail at the long-term impacts of foodborne pathogens. CFI's report, The Long-Term Health Outcomes of Selected Foodborne Pathogens, provides expert descriptions about some of the serious long-term health outcomes ranging from hypertension and diabetes to kidney failure and mental retardation. The report also calls for a new approach to foodborne illness research and surveillance.

"Systematic follow-up of foodborne illness cases will greatly enhance our ability to attribute long-term health problems to acute foodborne illnesses," says Tanya Roberts, Ph.D., an author of the report. "Population-based studies, improved public health surveillance and increased data sharing will improve our knowledge about the sources, trends and health outcomes associated with foodborne disease. Taking this approach will require dedicated funding, but such an investment is necessary to prevent costly economic, health and personal losses."

"The polling and reports released today should show our lawmakers that they need to send food safety legislation to the president's desk as soon as possible," says Elizabeth Armstrong of Fishers, IN, whose young daughter Ashley became seriously ill in 2006 after eating contaminated spinach. "The new legislation may not help my family, but it could save lives and spare others from suffering what we have endured. I want the senators to think about that and heed the coalition's message: Make Our Food Safe for the Holidays!"

To obtain a copy of the CFI report, visit www.foodborneillness.org.

Major public health, consumer and food safety groups have formed the Make Our Food Safe coalition (www.makeourfoodsafe.org), which includes the American Public Health Association, Center for Foodborne Illness Research & Prevention, Center for Science in the Public Interest, the Consumer Federation of America, Consumers Union, Food & Water Watch, National Consumers League, The Pew Charitable Trusts, Safe Tables Our Priority, and Trust for America's Health.



1112 People entering their 60s may have more disabilities today than in prior generations [Los Angeles CA]--In a development that could have significant ramifications for the nation's health care system, Baby Boomers may well be entering their 60s suffering far more disabilities than their counterparts did in previous generations, according to a new UCLA study. The findings, researchers say, may be due in part to changing American demographics.

In the study, which will be published in the January 2010 issue of the American Journal of Public Health, researchers from the division of geriatrics at the David Geffen School of Medicine at UCLA found that the cohort of individuals between the ages of 60 and 69 exhibited increases in several types of disabilities over time. By contrast, those between the ages of 70 and 79 and those aged 80 and over saw no significant increases — and in some cases exhibited fewer disabilities than their previous cohorts.

While the study focused on groups born prior to the post–World War II Baby Boom, the findings hold "significant and sobering implications" for health care because they suggest that people now entering their 60s could have even more disabilities, putting an added burden on an already fragile system and boosting health costs for society as a whole, researchers say.

If this is true, it's something we need to address," said Teresa Seeman, UCLA professor of medicine and epidemiology and the study's principal investigator. "If this trend continues unchecked, it will put increasing pressure on our society to take care of these disabled individuals. This would just put more of a burden on the health care system to address the higher levels of these problems."

The researchers used two sets of data — the National Health and Nutrition Examination Surveys (NHANES) for 1988 and 1999 — to examine how disabilities for the three groups of adults aged 60, 70, and 80 and older had changed over time. They assessed disability trends in four areas: basic activities associated with daily living, such as walking from room to room and getting into and out of bed; instrumental activities, such as performing household chores or preparing meals; mobility, including walking one-quarter mile or climbing 10 steps without stopping for rest; and functional limitations, which include stooping, crouching or kneeling.

The study focused primarily on trends for the more recent 60 age group — those born between 1930 and 1944, just before the start of the Baby Boom, whose data was included in the 1999� NHANES. In particular, researchers felt this group could offer insights into the health of the Boomers following them, who are now entering their 60s.

The researchers found that between the periods 1988 and 1999, disability among those in their 60s increased between 40 and 70 percent in each area studied except functional limitations, independent of sociodemographic characteristics, health status and behaviors, and relative weight. The increases were considerably higher among non-white and overweight subgroups.

By contrast, the researchers found no significant changes among the group aged 70 to 79, while the 80-plus group actually saw a drop in functional limitations.

One reason for this uptick, researchers say, is that disabilities may be linked with the changing racial and ethnic makeup of the group that recently reached or will soon be reaching its 60s, with the most rapid growth projected to be among African Americans and Hispanics — groups with significantly higher rates of obesity and lower socioeconomic status, both of which are associated with higher risk for functional limitations and disabilities.

The researchers note that their controls for differences in sociodemographics, health status (such as chronic conditions and biological risk factors) and health behavior do not completely explain the increase in disability trends among the 60- to 69-year olds. Still, the trends within that group "are disturbing," Seeman said.

"Increases in disability in that group are concerning because it's a big group," she said. "These may be people who have longer histories of being overweight, and we may be seeing the consequences of that. We're not sure why these disabilities are going up. But if this trend continues, it could have a major impact on us, due to the resources that will have to be devoted to those people."

Study co-authors included Arun Karlamangla and Sharon Merkin, of UCLA's geriatrics division, and Eileen Crimmins, of the Andrus Gerontology Center at the University of Southern California.

The National Institute on Aging funded this study.



1112 Researchers mobilizing global resources to test new treatments for severe H1N1 infection [Toronto ON]--An important, ground-breaking initiative is unfolding in the global critical care community in response to the H1N1 pandemic.

While front-line health care workers and infectious disease experts around the world are working round the clock to control, treat and prevent H1N1 infection, those who deal with the most severely ill patients—physicians working in hospital intensive care units (ICUs)—have joined forces to develop a more coordinated, long-term approach to H1N1.

In a commentary published today in the medical journal the Lancet, St. Michael's Hospital's Dr. John Marshall describes this unprecedented initiative, which is called the International Forum for Acute Care Trialists (InFACT) H1N1 Collaboration. While the coalition against H1N1 is led by Canadians, dozens of groups whose members are involved in the care of critically ill influenza patients from every continent on the planet have already signed on.

"A core element of our initiative is to undertake clinical trials of simple, readily available and biologically plausible interventions that can be used to treat patients with severe H1N1 infection," says Dr. Marshall, a senior scientist in the Li Ka Shing Knowledge Institute at St. Michael's Hospital in Toronto who chairs the InFACT collaboration.

Will the clinical trials and the other initiatives planned by InFACT—such as a global registry of influenza victims and a "biobank" of blood samples—benefit people who are already sick or will fall ill over the next few months?

"Probably not," Dr. Marshall says. "But H1N1 isn't going away any time soon. We need to take a coordinated, evidence-based approach to understanding the natural history of the disease, to cataloguing current resources and gaps, and to looking for new and better treatments which may prevent or shorten hospitalization among those most seriously affected."

Proposed clinical trials to test new treatments

Canadian researchers are organizing several clinical trials aimed at finding new and more effective treatments for H1N1 infection.

One of these trials—the Collaborative H1N1 Adjuvant Treatment (CHAT) trial—seeks to enroll 1,400 patients, most of them Canadians, who are being treated in a hospital ICU for severe H1N1 infection and are on a ventilator. The mortality rate for these patients currently ranges from 10󈞔% over the first month. On average, those who survive spend two weeks in the ICU.

Right now H1N1 infection is treated with anti-viral drugs and other supportive measures. But researchers want to evaluate two classes of common, readily available drugs which have shown promise in limiting the severity of H1N1 infection.

"Anecdotal reports and data from animal studies suggest that corticosteroids and statins may dampen the inflammatory response that leads to severe illness and death from H1N1," says Dr. Marshall. "None of these drugs has been adequately studied for efficacy."

Even though no specific data show them to be effective, right now more than half of patients with severe H1N1 infection are treated with corticosteroids—hormones given to reduce swelling and decrease the body's immune response. This is based largely on the observation that corticosteroid drugs have proven useful in treating severe acute lung injury.

A recent study of patients with seasonal influenza found that those who were taking statins when they got sick had a better prognosis than those were not. These drugs are currently taken by millions of people take to help control cholesterol levels and prevent heart disease.

This accelerated "bench-to-bedside" approach is key to success against pandemic influenza and other infectious diseases, says Dr. Marshall. "Research during a pandemic poses unique ethical and logistical challenges. It usually takes years to mount a major clinical trial. But in the case of H1N1 our goal is to drastically shorten this to a period of weeks or a few months without compromising scientific and ethical integrity," he explains.

While funding is needed for the clinical trials to proceed, that time is too short to achieve this through conventional means. "Instead, we've adopted an incremental funding strategy. This means we're seeking money that will allow us to launch the trials and moving ahead with confidence that additional funds can be found," he says.

About the InFACT H1N1 Collaboration

The Canadian-led International Forum for Acute Care Trialists (InFACT) H1N1 Collaboration is a unique and unprecedented attempt to gain control over a new pandemic illness (go to http://www.infactglobal.org).

According to Dr. John Marshall who chairs the group, it is currently organized around three core initiatives:

* A common global registry listing all patients critically ill due to H1N1 infection. The registry, which has been created out of five existing databases around the world, will enable real-time study of the epidemiology, clinical course, and treatment of severe H1N1 disease. In parallel, the group hopes to develop a "biobank"—a repository of samples of blood and other material taken from people infected with H1N1—which will allow for studies of genetic susceptibility and clinical biology. The registry will also help scientists understand how H1N1 infection varies around the world in response to local medical capacity and treatment approaches.

* A program of accelerated randomized clinical trials aimed at quickly identifying, testing and delivering new treatments. The first group of clinical studies will evaluate inexpensive interventions that are available in both the developed and the developing world. The research will use so-called "adaptive designs" which ensures that positive results can be quickly incorporated into practice and that ineffective treatments are quickly dropped.

* The first-ever catalogue of critical care capacity around the world. Any coordinated and effective plan for dealing with H1N1 or another severe pandemic illness requires a host of resources—hospital ICU beds and ventilators, a steady supply of vaccines and medications, and enough health care providers to use them. The group hopes to catalogue international critical care capacity, and also to promote, mentor, and support clinical research activities in resource-poor areas where the human toll is likely to be the greatest.



1112 Health care accounts for 8 percent of US carbon footprint [Chicago IL]--The American health care sector accounts for nearly a tenth of the country's carbon dioxide emissions, according to a first-of-its-kind calculation of health care's carbon footprint.

Published Wednesday in the Journal of the American Medical Association, University of Chicago researchers used expenditures from different parts of the health care sector to measure the industry's potential effect upon global warming through the release of carbon dioxide and other greenhouse gases.

Health care in America, including activities such as hospital care, scientific research and the production and distribution of pharmaceutical drugs, was found to produce 8 percent of the country's total carbon dioxide output despite accounting for 16 percent of the U.S. gross domestic product. Jeanette Chung, PhD, a Research Associate in the Section of Hospital Medicine at the University of Chicago and the study's lead author, said that she hoped the study would draw the attention of the health care industry to its environmental impact.

"In this country, the primary focus is on issues surrounding patient safety, health care quality, and cost containment at this current point in time. The health care sector, in general, may be a bit slower than other sectors to put this on their radar screen," Chung said. "But given the focus on health care policy and environmental policy, it might be interesting - if not wise - to start accounting for environmental externalities in health care."

"The question is, are there large opportunities to improve efficiency in health care that can also have an impact on the environment?" said study co-author David Meltzer, MD, PhD, Chief of the Section of Hospital Medicine, Associate Professor in the Department of Medicine, the Harris School of Public Policy and the Department of Economics. "If one sector is very large, even if it's somewhat less carbon-intensive than others, simply the fact that it's large means it's a big target, and that's the case with health care."

Chung and Meltzer calculated the carbon footprint using 2007 health care spending and a model of environmental impact, called the environmental input-output life cycle assessment (EIOLCA) model, developed by the Green Design Institute at Carnegie-Mellon University.

The study assessed direct environmental effects of health care activities as well as indirect effects capturing emissions generated in the production and distribution of commodities used by the health care sector. The EIOLCA model was then applied to estimate the carbon intensity of each dollar of commodity produced by the health care industry, based on emissions of various greenhouse gases, including carbon dioxide, methane, nitrous oxide and chlorofluorocarbons.

The analysis found that hospitals were by far the largest contributor of carbon emissions in the health care sector, which the authors attributed to the high energy demands needed for temperature control, ventilation and lighting in large hospital buildings. Surprisingly, the second largest health care contributor to the overall carbon footprint was the pharmaceutical industry, a finding Meltzer attributed to the high costs of manufacturing and researching drugs combined with transportation costs associated with distribution.

Chung and Meltzer hoped that their analysis, published as a letter in the prestigious medical journal, would draw the attention of the health care industry to areas where environmental improvements can be made.

"Obviously, health care and health is very highly valued; you're not going to shut down a hospital because of its environmental impact or not produce a drug that you think is going to save lives because of carbon output," Meltzer said. "But this reminds people in health care that we're not a trivial part of the issue."

Some measures hospitals can use to improve energy efficiency include creating recycling programs and purchasing goods and services from environmentally friendly suppliers, Chung suggested.

At the University of Chicago Medical Center, the Sustainability program managed by Mark Lestina has implemented a plastic recycling program that diverts more than 500 pounds of waste each day from landfills to recycling plants and ensured that 90 percent of cleaning supplies used by the hospital have Green Seal certification. Such efforts have reduced waste costs at the Medical Center from $55,000 per month to $35,000 per month, Lestina said, suggesting that reducing environmental impact can go hand in hand with reducing costs in a hospital setting.

"Sustainability does not necessarily just equal garbage and minimalization," Lestina said. "You're incorporating energy efficiencies, saving water, using less, re-using more and so on, and it almost always leads to lower costs."

Lestina is currently working to attain the prestigious LEED Silver certification from the U.S. Green Building Council for the New Hospital Pavilion, scheduled to open in 2012.

The work was funded by grants from the Hospital Medicine and Economics Center for Education and Research in Therapeutics and the National Institute of Aging.



1112 Over 2,200 veterans died in 2008 due to lack of health insurance [Boston MA]--A research team at Harvard Medical School estimates 2,266 U.S. military veterans under the age of 65 died last year because they lacked health insurance and thus had reduced access to care. That figure is more than 14 times the number of deaths (155) suffered by U.S. troops in Afghanistan in 2008, and more than twice as many as have died (911 as of Oct. 31) since the war began in 2001.

The researchers, who released their analysis today [Tuesday], pointedly say the health reform legislation pending in the House and Senate will not significantly affect this grim picture.

The Harvard group analyzed data from the U.S. Census Bureau’s March 2009 Current Population Survey, which surveyed Americans about their insurance coverage and veteran status, and found that 1,461,615 veterans between the ages of 18 and 64 were uninsured in 2008. Veterans were only classified as uninsured if they neither had health insurance nor received ongoing care at Veterans Health Administration (VA) hospitals or clinics.

Using their recently published findings in the American Journal of Public Health that show being uninsured raises an individual’s odds of dying by 40 percent (causing 44,798 deaths in the United States annually among those aged 17 to 64), they arrived at their estimate of 2,266 preventable deaths of non-elderly veterans in 2008. (See table.)

“Like other uninsured Americans, most uninsured vets are working people - too poor to afford private coverage but not poor enough to qualify for Medicaid or means-tested VA care,” said Dr. Steffie Woolhandler, a professor at Harvard Medical School who testified before Congress about uninsured veterans in 2007 and carried out the analysis released today [Tuesday]. “As a result, veterans go without the care they need every day in the U.S., and thousands die each year. It’s a disgrace.”

Dr. David Himmelstein, the co-author of the analysis and associate professor of medicine at Harvard, commented, “On this Veterans Day we should not only honor the nearly 500 soldiers who have died this year in Iraq and Afghanistan, but also the more than 2,200 veterans who were killed by our broken health insurance system. That’s six preventable deaths a day.”

He continued: “These unnecessary deaths will continue under the legislation now before the House and Senate. Those bills would do virtually nothing for the uninsured until 2013, and leave at least 17 million uninsured over the long run. We need a solution that works for all veterans - and for all Americans - single-payer national health insurance.”

While many Americans believe that all veterans can get care from the VA, even combat veterans may not be able to obtain VA care, Woolhandler said. As a rule, VA facilities provide care for any veteran who is disabled by a condition connected to his or her military service and care for specific medical conditions acquired during military service.

Woolhandler said veterans who pass a means test are eligible for care in VA facilities, but have lower priority status (Priority 5 or 7, depending upon income level). Veterans with higher incomes are classified in the lowest priority group and are not eligible for VA enrollment.



1112 Ventilation treatment in prone position for ARDS does not provide significant survival benefit [Milan Italy]--Despite a current suggestion that patients with acute respiratory distress syndrome be positioned lying face down while receiving mechanical ventilation, study results indicate that this positioning does not significantly lower the risk of death compared to similar patients positioned lying face up during ventilation, according to a study in the November 11 issue of JAMA.

Acute respiratory distress syndrome (ARDS) is a serious lung condition with a high mortality rate and may be associated with severe hypoxemia (abnormally low levels of oxygen in the blood, resulting in shortness of breath). Prone positioning is currently suggested for patients with ARDS, for whom various factors makes mechanical ventilation potentially injurious. "Moreover, prone positioning has been advocated as a rescue maneuver for severe hypoxemia, owing to its positive effects on oxygenation, which have been repeatedly documented since its first description in 1976. However, no randomized clinical trial has yet demonstrated a significant reduction in mortality rate associated with prone positioning," the authors write.

Paolo Taccone, M.D., of Fondazione IRCCS–"Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena" di Milano, Milan, Italy, and colleagues conducted a trial to detect the potential survival benefit of prone positioning in patients with moderate and severe hypoxemia who are affected by ARDS. The randomized controlled trial was conducted in 23 centers in Italy and 2 in Spain. The study included 342 adult patients with ARDS receiving mechanical ventilation, enrolled from February 2004 through June 2008 and stratified into subgroups with moderate (n = 192) and severe (n = 150) hypoxemia. Patients were randomized to undergo supine (lying face up; n = 174) or prone (20 hours per day; n = 168) positioning during ventilation.

The researchers found that prone and supine patients from the entire study population had similar 28-day (31.0 percent vs. 32.8 percent) and 6-month (47.0 percent vs. 52.3 percent) mortality rates, despite significantly higher complication rates in the prone group. "Outcomes were also similar for patients with moderate hypoxemia in the prone and supine groups at 28 days (25.5 percent vs. 22.5 percent) and at 6 months (42.6 percent vs. 43.9 percent). The 28-day mortality of patients with severe hypoxemia was 37.8 percent in the prone and 46.1 percent in the supine group, while their 6-month mortality was 52.7 percent and 63.2 percent, respectively."

They authors add that median (midpoint) Sequential Organ Failure Assessment (SOFA) scores, ventilator-free days, and intensive care unit length of stay were also similar between the different groups of patients.

"Do the findings of this trial, together with those of previous studies, represent the end of the prone position technique? Undoubtedly, the data of the present trial together with previous results clearly indicate that prolonged prone positioning, in the unselected ARDS population, is not indicated as a treatment. However, its potential role in patients with the most severe hypoxemia, for whom the possible benefit could outweigh the risk of complications, must be further investigated, considering the strong pathophysiological background, the post hoc result of our previous study, the most recent meta-analysis, and the favorable trend observed prospectively in this study," the authors conclude.

Editorial: Improving Outcomes in Critically Ill Patients

Arthur S. Slutsky, M.D., of St. Michael's Hospital, Toronto, and the University of Toronto, comments on the findings of this study in an accompanying editorial.

"Based on the findings from the trial by Taccone et al combined with data from previous published reports, prone ventilation should not be used routinely in all patients with ARDS. However, for a patient at imminent risk of death from hypoxemia, it makes sense to try prone ventilation, because multiple studies have demonstrated that it can increase oxygenation."



1112 One in four hospitalized heart failure patients with Medicare back in hospital within a month [Dallas TX]--Almost a quarter of heart failure patients with Medicare are back in the hospital within a month after discharge, researchers report in Circulation: Heart Failure, a journal of the American Heart Association.

Each year, from 2004 through 2006, more than a half million Medicare recipients over age 65 went to the hospital for heart failure and were discharged alive. And each year, about 23 percent returned to the hospital within 30 days – signaling a need to improve care, researchers said. Readmission rates for all causes were almost identical all three years.

“I was hoping for improvement and was disappointed to find that was not the case,” said Joseph S. Ross, M.D., M.H.S., the study’s lead author and an assistant professor of geriatrics and palliative medicine at Mount Sinai School of Medicine in New York. “Despite the increased focus on the need to reduce readmissions, about a quarter of patients are back into the hospital within 30 days.”

Heart failure occurs when a heart weakened by disease can no longer pump effectively. Before discharge heart failure patients should receive written information on:

• Eating a proper diet;
• Engaging in appropriate physical activity;
• Taking medicines correctly;
• Monitoring their weight; and
• Knowing what to do if their symptoms worsen.

However, the current fee system in the United States doesn’t encourage a focus on prevention researchers said. In their analysis, they report that doctors and hospitals are financially awarded more for treating and hospitalizing patients, not for preventing hospitalizations through such strategies as disease management.

“Physicians aren’t paid to coordinate care,” Ross said. “That physician is busy seeing patients and that’s what they’re paid to do. If we want to deliver better care, this trend is what we need to address.”

Another barrier to optimal care is a lack of communications between doctors who care for patients in the hospital and the patients’ regular physicians who help patients manage their chronic disease, Ross said. The disruption to the continuum of care can negatively affect the patient.

The average age of patients in the study was 80 years and more than half (57 percent) were women. Most patients had multiple chronic diseases: 60 percent had heart arrhythmias; 73 percent had atherosclerosis or hardening of the arteries; 49 percent had diabetes; and 29 percent had kidney failure.

“Coming back and forth into the hospital isn’t good for patients, and it isn’t good for the healthcare system,” said Ross, who plans to research the reasons heart failure patients are readmitted to the hospital. “This is a tremendous challenge.”

Findings of the study are important for patients and hospitals, Ross said.

“Patients should use this information to vet hospitals, to look at the quality of care delivered there and ask questions about the care they receive,” he said. “Hospitals should consider the rehospitalization rate a grade which, from these findings, needs improvement.”

The Centers for Medicare and Medicaid Services funded the study. In July 2009, the agency began publicly reporting information on readmissions for heart failure patients.

Co-authors are: Jersey Chen, M.D., M.P.H.; Zhen Qiu Lin, Ph.D.; Héctor Bueno, M.D., Ph.D.; Jeptha P. Curtis, M.D.; Patricia S. Keenan, Ph.D.; Sharon-Lise T. Normand, Ph.D.; Geoffrey Schreiner, B.A.; John A. Spertus, M.D., M.P.H.; Maria T. Vidán, M.D., Ph.D.; Yongfei Wang, M.S.; Yun Wang, Ph.D.; and Harlan M. Krumholz, M.D., S.M. Author disclosures are on the manuscript.



1112 Using science to save lives of mothers and children in Africa [Accra Ghana]--The lives of almost 4 million women, newborns, and children in sub-Saharan Africa could be saved every year if well-established, affordable health care interventions reached 90 percent of families, according to a joint report by the national science academies of seven African countries. Many African nations are underutilizing existing scientific knowledge to save lives, says the report, which calls on scientists, health care providers, policymakers, and development agencies to partner on ways to use the latest evidence to fill the gap between the discovery of new interventions and their delivery to families most in need. The report was released today at the annual conference of the African Science Academy Development Initiative, which aims to strengthen effective links between African science academies and national decision makers.

Half of the world's maternal and child deaths each year occur in sub-Saharan Africa, where 265,000 mothers die during pregnancy or childbirth, 1.2 million babies die in their first month of life, and an additional 3.2 million do not reach their fifth birthday. More than 880,000 stillbirths go largely unnoticed by global researchers and policymakers. The U.N.'s Millennium Development Goals call for reducing under-five mortality by two-thirds (MDG4) and maternal mortality by three-fourths (MDG5) by 2015. While acknowledging that most African nations are not on track to meet the goals by then, the report highlights noteworthy exceptions. For example, Eritrea has achieved an annual 4 percent rate of reduction in under-five mortality since 1990, Tanzania and Ghana have experienced up to 30 percent declines since 2000, and Malawi was recently declared itself on track for MDG4.

"Ghana has achieved a reduction in under-five mortality over the past five years as well as an increase in skilled attendance at birth, but to get on track for the Millennium Development Goals by 2015, we [must] value the evidence-based priorities presented in this report," said Professor Reginald Fraser Amonoo, president of the Ghana Academy Arts and Sciences, which is celebrating its 50th anniversary this year and hosting the ASADI conference.

The new report, SCIENCE IN ACTION: SAVING THE LIVES OF AFRICA'S MOTHERS, NEWBORNS, AND CHILDREN, encourages policymakers and other stakeholders to use a scientific approach when setting priorities to improve maternal, newborn, and child health. In particular, local data should be used to identify and prioritize strategic, evidence-based, and essential health interventions that, if scaled up, would have the greatest impact on saving lives.

The report includes a new analysis in which modeling software called the LIVES SAVED TOOL (LIST) was used to estimate the number of lives that would be saved by increasing coverage of a range of essential maternal, newborn, and child health interventions. The analysis suggests that if, by 2015, 90 percent of children under five years old and mothers were covered by already well-known and essential health interventions, about 4 million lives would be saved annually, avoiding an estimated 85 percent of current maternal, newborn, and child deaths; this would exceed the MDGs for maternal and child health. Some of the most effective interventions include increased availability of contraception, skilled attendance at childbirth, neonatal resuscitation and improved newborn care, case management of pneumonia, and promotion of breastfeeding, malaria prevention, and immunization.

The authors of the report also used national data to assess the effect of achievable increases within two years in priority interventions in the seven countries with science academies participating in ASADI -- Cameroon, Ghana, Kenya, Nigeria, Senegal, South Africa, and Uganda -- as well as Ethiopia and Tanzania. Achievable increases are defined as improvements in the quality of care for all births that take place in facilities and a 20 percent increase in selected interventions provided outside of facilities. The analysis showed that such increases in coverage in the nine example countries would save the lives of 770,000 women, newborns, and children each year.

Because the context of health systems varies among countries, interventions have different effects. The report authors therefore showed how many lives could be saved by selected priority interventions in different health system contexts. For example, in settings with few births in facilities, increasing family planning is feasible, saves many lives, and is relatively low cost. The estimated cost of these priority interventions is "extremely affordable" on a per capita basis, the report notes. In fact, the average cost for increasing these selected high-impact interventions to achievable levels in the nine example countries within two years is less than $2 per capita.

Based on the evidence, priorities for maternal, newborn, and child health in sub-Saharan Africa include making childbirth safe, giving newborn babies a healthy start, and preventing and managing infections in newborns and young children, the report says. The evidence also shows that high-impact interventions are most effective and efficient when integrated into existing health delivery systems, yet more research is needed on how to deliver care closer to home and reach populations in remote areas. More study is needed on the use of alternative cadres for certain tasks as well.

The report was authored by representatives of the seven African science academies and a team they assembled of more than 60 experts. One of the report's coordinating authors, Joy Lawn, director of global evidence and policy at Saving Newborn Lives/Save the Children in Cape Town, South Africa, believes that the report will serve as a call to action. "Accelerated action now based on data and science has the potential to saves millions of lives every year and to put many African countries on track to reach the Millennium Development Goals for maternal and children survival," she said. "All of us have a role to play."

The development of the report was supported by the U.S. National Academies; Save the Children; the Academy of Sciences of South Africa; Johns Hopkins Bloomberg School of Public Health; Mars, Inc.; and UNICEF. The report, additional details on the analysis and on assumptions used in the LIST model, a list of contributors, and more information about ASADI are available at http://national-academies.org/asadi. ASADI is a collaboration among the African science academies, the U.S. National Academies, and others to strengthen the ability of the African academies to inform policymaking and public discourse through evidence-based advice. The initiative is funded by a grant from the Bill & Melinda Gates Foundation.



1112 Back pain permanently sidelines soldiers at war [Baltimore MD]--Military personnel evacuated out of Iraq and Afghanistan because of back pain are unlikely to return to the line of duty regardless of the treatment they receive, according to research led by a Johns Hopkins pain management specialist.

In a study published in the Nov. 9 Archives of Internal Medicine, researchers found that just 13 percent of service members who left their units with back pain as their primary diagnosis eventually returned to duty in the field. Women, officers, those deployed in Afghanistan and those with previous back pain had better outcomes, but only marginally. Aside from combat injuries sustained during battle, the return-to-duty rate for spinal pain and other musculoskeletal disorders is lower than for any other disease or non-combat injury category except for psychiatric illness, the researchers said.

"The whole mission of the medical corps for the military is to preserve unit strength, to keep people doing what they're doing," says study leader Steven P. Cohen, M.D., associate professor of anesthesiology at the Johns Hopkins University School of Medicine and a colonel in the U.S. Army Reserves. "If you have only a 13 percent success rate, this is a failure. There's a systemic problem."

Cohen and his team looked at data from 1,410 soldiers who were medically evacuated out of war zones complaining chiefly of back pain from 2004 through 2007. More than 95 percent of the service members were taken to the U.S. military's treatment facility in Landstuhl, Germany. Researchers assessed how many were returned to their stationed units within two weeks and how many were sent to the United States unable to perform their duties.

A previous study done by Cohen showed that when soldiers with back pain were taken to a pain clinic in Iraq, all patients returned to their units. When they were sent to pain clinics in Germany or in Washington, fewer than 2 percent did. Both this previous study and the new research suggest that the further away the evacuee is treated, the less likely they are to return to that unit. Cohen notes that it can be difficult for certain soldiers to return to their jobs, particularly those in physically demanding combat-related roles. "It's the rule in war: People will have back pain because you have to go on these long road marches and carry heavy equipment, wear body armor," he says. "The roads are not paved. Riding in these vehicles while wearing body armor, it hurts your back."

Cohen explains that the reasons why few military personnel return to their units after leaving with back pain may simply be a reflection of the outcomes for back pain in civilian life. "Back pain has notoriously low success rates for treatment," he says. The biggest predictors of a poor outcome, he said, are psychosocial factors. People who are depressed or anxious, who cope poorly with stress, who are unhappy in their jobs, and those with other psychological issues are more likely to remain disabled by back pain. Cohen, who is also director of chronic pain research at Walter Reed Army Medical Center, said those with back pain who remain in the country where they are deployed may be more motivated to stay on the job or are more satisfied with their role in the military.

The military needs to find a way to get soldiers with back pain back to their units wherever possible, Cohen says. He suggests that could be accomplished if there were more pain management options in Iraq or Afghanistan, following the model used for soldiers with symptoms of combat stress. When those symptoms are treated at mental health clinics on base, approximately 95 percent of service members returned to their units. When treated in a transitional unit in nearby Kuwait, the figure was around 50 percent. When sent to Germany, fewer than 10 percent returned.

Other researchers on the study include Shruti G. Kapoor, M.D., M.P.H., a resident in the Department of Anesthesiology at Johns Hopkins University School of Medicine; Maj. Conner Nguyen, M.D., chief of physical medicine and rehabilitation at Landstuhl Regional Medical Center in Germany; and Col. Leslie Foster, D.O., and Maj. Anthony Plunkett, M.D., both of Walter Reed Medical Center.

The research was funded in part by a congressional grant from the John P. Murtha Neuroscience and Pain Institute, Johnstown, Pa., the U.S. Army and the Army Regional Anesthesia & Pain Medicine Initiative, Washington, D.C.



1112 Fewer emergency patients seen within recommended time frame [New Haven CT]--One in four emergency department patients in 2006 waited longer to be evaluated by a clinician than recommended at triage, an increase from one in five in 1997, according to a report in the November 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

"Prolonged emergency department (ED) wait time decreases patient satisfaction, limits access, increases the number of patients who leave before being seen and is associated with clinically significant delays in care for patients with pneumonia, cardiac symptoms and abdominal pain," the authors write as background information in the article. Previous analyses have noted an increase in the amount of time ED patients wait to see a clinician. Between 1997 and 2004, median wait times increased 36 percent, from 22 minutes to 30 minutes. However, wait time alone is an imperfect measure of the timeliness of emergency care because it does not take into account the nature of patients' illnesses or injuries.

Leora I. Horwitz, M.D., M.H.S., of Yale–New Haven Hospital and Yale University School of Medicine, New Haven, Conn., and Elizabeth H. Bradley, Ph.D., also of Yale University School of Medicine, analyzed data from the National Hospital Ambulatory and Medical Care Survey to examine trends in the percentage of patients seen within the target time recommended during triage (initial process of prioritizing patients for treatment according to the seriousness of their condition).


"Emergency departments are increasingly overcrowded, thereby straining resources," the authors write. "Triage assessment is intended to mitigate this strain by ensuring that the most acutely ill patients are prioritized for assessment, regardless of the competing demands on ED physicians' time. Considering wait time within the clinical context of triage assessment therefore allows for a more nuanced understanding of the timeliness of ED care than wait time in aggregate."

A total of 151,999 ED visits between 1997 and 2006 were categorized in the database as emergent (recommended that clinicians see in zero to 14 minutes), urgent (see in 15 minutes to 60 minutes), semi-urgent (see in 61 minutes to two hours) or non-urgent (see in more than two to 24 hours).

For all categories, the percentage of patients seen within the triage target time declined an average of 0.8 percent per year, from 80 percent in 1997 to 75.9 percent in 2006. The decline was greater—2.3 percent per year—for emergent patients, who had 87 percent lower odds than semi-urgent patients of being seen within the triage target time. "Overall, 56.6 percent of emergent patients were seen within the triage target time compared with 100 percent of non-urgent patients," the authors write. Results did not differ for patients with or without insurance, or for those of different racial or ethnic groups.

Many causes likely exist for increased wait times, the authors note. Per capita ED use has increased during the same timeframe, with much of the increase among less acutely ill patients. Moreover, high hospital occupancy rates decrease the number of beds available for patients admitted through the ED.

"The multifactorial nature of prolonged ED wait time lends itself to numerous avenues for improvement," the authors conclude. These include increasing patients' access to alternate sites of care; interventions to improve ED processes; and redesign of the physical environment. "Comparative research into the most effective methods of reducing ED crowding, decreasing ED length of stay and limiting ED wait times is urgently needed to help EDs prioritize their quality improvement activities and maximize their impact."

Editor's Note: This study was supported by Clinical and Translational Science Award grants from the National Center for Research Resources, a component of the National Institutes of Health, and NIH roadmap for Medical Research. Dr. Horwitz is supported by Yale–New Haven Hospital and by the NCRR.

Editorial: Variety of Solutions Needed to Solve ED Problems

"Increasing attention, both in the media and in the academic literature, has been placed on emergency department crowding in the past few decades," write Renee Y. Hsia, M.D., M.Sc., and Jeffrey A. Tabas, M.D., of the University of California, San Francisco, in an accompanying editorial.

"What are the consequences of ED crowding? Crowding in the ED has been associated with poorer process measures, including delays in treatment of pain, delays in antibiotic treatment for community-acquired pneumonia and decreases in the satisfaction of patients with their ED stay and hospitalization. There is also increasing evidence to suggest that ED crowding is associated with poorer clinical outcomes, such as increased in-hospital morbidity and mortality."

"The problem of ED crowding and wait times is certainly not unique to the United States, and no single solution will solve overcrowding," Drs. Hsia and Tabas conclude. "However, the problem is serious and worsening, and we must implement a variety of solutions in the areas of ED input, throughput and output as well as broader health system reform. Otherwise, our patients will remain waiting, waiting, waiting."



1112 Exposure to several common infections over time may be associated with risk of stroke [New York NY]--Cumulative exposure to five common infection-causing pathogens may be associated with an increased risk of stroke, according to a report posted online today that will appear in the January 2010 print issue of Archives of Neurology, one of the JAMA/Archives journals.

Stroke is the third leading cause of death and leading cause of serious disability in the United States, according to background information in the article. Known risk factors include high blood pressure, heart disease, abnormal cholesterol levels and smoking, but many strokes occur in patients with none of these factors. "There is therefore interest in identifying additional modifiable risk factors," the authors write.

Some evidence exists that prior infection with pathogens such as herpes viruses promotes inflammation, contributes to arterial disease and thereby increases stroke risk. Mitchell S. V. Elkind, M.D., M.S., of Columbia University Medical Center, New York, and colleagues studied 1,625 adults (average age 68.4) living in the multi-ethnic urban community of northern Manhattan, New York. Blood was obtained from all participants—none of whom had a stroke—and was tested for antibodies indicating prior exposure to five common pathogens: Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus and herpes simplex virus 1 and 2. A weighted composite index of exposure to all five pathogens was developed.

Participants were followed up annually over a median (midpoint) of 7.6 years. During this time period, 67 had strokes. "Each individual infection was positively, though not significantly, associated with stroke risk after adjusting for other risk factors," the authors write. "The infectious burden index was associated with an increased risk of all strokes after adjusting for demographics and risk factors."

There were several reasons to investigate these five particular pathogens, the authors note. "First, each of these common pathogens may persist after an acute infection and thus contribute to perpetuating a state of chronic, low-level infection," they write. "Second, prior studies demonstrated an association between each of these pathogens and cardiovascular diseases." Studies examining several of these pathogens individually have suggested some may contribute to stroke risk.

"Our study could have potential clinical implications," the authors conclude. "For example, treatment and eradication of these chronic pathogens might mitigate future risk of stroke. Antibiotic therapy directed against C pneumoniae has been tested in randomized controlled trials without evidence of benefit against heart disease. Whether the same holds true for stroke has not yet been established. More studies will be required to further explore infectious burden as a potential modifiable risk factor for stroke."

Editor's Note: This research was supported by National Institutes of Health/National Institute of Neurological Disorders and Stroke grants.



1112 Deep creep means milder, more frequent earthquakes along Southern California's San Jacinto fault [Miami FL]--With an average of four mini-earthquakes per day, Southern California's San Jacinto fault constantly adjusts to make it a less likely candidate for a major earthquake than its quiet neighbor to the east, the Southern San Andreas fault, according to an article in the journal Nature Geoscience.

"Those minor to moderate events along the San Jacinto fault relieve some of the stress built by the constantly moving tectonic plates," said Shimon Wdowinski, research associate professor at the University of Miami's Rosenstiel School of Marine and Atmospheric Science.

Previous estimates may have overstated the likelihood of a major event on the 140-mile long San Jacinto fault, which begins between Palm Springs and Los Angeles and runs south toward the Salton Sea east of San Diego. The US Geological Survey (USGS) is forecasting a 31 percent chance that an earthquake with a magnitude of 6.7 or higher on the Richter Scale will occur on the San Jacinto fault in the next 30 years. Only the San Andreas fault, with a 59 percent chance, is more likely to have a major event during the same period.

"Thirty-one percent is a high probability, when it comes to earthquake forecasting—the second highest in Southern California," said Wdowinski. "Our data show that the next significant event for the San Jacinto fault would probably be between 6.0 and 6.7. It doesn't sound like much, but in earthquake terms it is the difference between a major earthquake and a moderate event."

A magnitude 6.0 earthquake may be felt for dozens of miles from the epicenter, but building damage especially in California, due to strict building codes, would be minimal. As the magnitude approaches and passes 7.0, which is ten times stronger than an earthquake with a magnitude of 6.0, more serious property damage and loss of life may occur.

Wdowinski feels that the San Jacinto fault is not as dangerous as predicted, because "deep creep" releases elastic strain of the moving plates approximately six to ten miles beneath the surface. As a result, the accumulation of strain along the fault occurs in the upper six miles of crust, which may be released by more frequent, moderate earthquakes. However a major event can still occur on the San Jacinto fault, but with lower probability, if two segments of the fault rupture simultaneously.

By contrast, the more famous Southern San Andreas fault to the east is locked some 10 miles down, throughout the entire seizmogenic crust. It has had very few earthquakes to release that strain but promises to release much more energy—a major earthquake—when a rupture occurs.

"It's like bending a stick," said Wdowinski. "You can bend it until it breaks and releases the energy. The San Jacinto fault [on the left in the figure below] is like a stick that has a cut in it. When you begin bending it and it breaks, less energy is released. Deep creep—evidenced by those small, more frequent earthquakes—in effect forms that small cut that reduces the release of energy when the rupture finally occurs. We are less likely to have the big energy release of a major earthquake because the energy is not allowed to build up."

The Southern San Andreas fault to the east is like a thicker stick without any stress-relieving cuts, which will snap with much greater force. USGS predicts that the San Andreas fault has a 59 percent chance of a major earthquake (greater than a magnitude of 6.7) in the next 30 years.

Aside from earthquakes, Wdowinski's primary research interest at the University of Miami is hydrology and water flow in wetlands and the Florida Everglades, in particular. The link between desert earthquakes and swamps is geodesy, the study of the earth's size, shape, orientation, gravitational field, and their variations over time. He uses satellite imaging and the Global Positioning System (GPS) to measure those slight changes.

"These are the new tools of geodesy," said Wdowinski, who co-authored a May 2009 paper in the journal Eos, Transactions, a publication of the American Geophysical Union. The article highlighted "Geodesy in the 21st Century", a look at how technological advances are benefiting the field and are applicable to many important societal issues, such as climate change, natural hazards, and water resources.

After completing his doctoral degree at Harvard, Wdowinski completed a post-doctoral fellowship at Scripps Oceanographic Institute in Southern California, where he studied the San Jacinto fault. A native of Israel, Wdowinski joined the Rosenstiel School faculty in 2005.



1112 Psychiatric impact of torture could be amplified by head injury [Boston MA]--Depression and other emotional symptoms in survivors of torture and other traumatic experiences may be exacerbated by the effects of head injuries, according to a study from the Harvard Program in Refugee Trauma (HPRT), based in the Massachusetts General Hospital (MGH) Department of Psychiatry. In the November 2009 Archives of General Psychiatry, the researchers report finding structural changes in the brains of former South Vietnamese political detainees who had suffered head injuries and clearly link those changes to psychiatric symptoms often seen in survivors of torture.

"This is the first study since the 1950s to demonstrate brain changes in survivors of extreme violence. That work looked at Holocaust survivors, and now we are the first to connect similar brain damage with mental health issues in survivors of political torture," says Richard Mollica, MD, director of the HPRT and leader of the study. "We believe, although it has not yet been proven, that these physical effects may help explain why survivors of both torture and traumatic head injury often don't do well with standard therapies for depression and anxiety."

Studies by Mollica's team and others have documented the fact that head injures are a common form of torture among prisoners of war and political detainees. But no previous work has investigated whether the neurologic effects of head injuries were related to the chronic psychiatric disorders often reported in torture survivors. The current study analyzed information from 42 Vietnamese immigrants, now resettled in the U.S., who had been detained in so-called "re-education camps" and 15 Vietnamese immigrants of similar ages who had not been detained.

All study participants completed questionnaires regarding any history of head injuries and on their exposure to torture or other traumatic experiences before being interviewed by study investigators to assess current symptoms of depression and post-traumatic stress disorder. Comprehensive magnetic resonance imaging studies measured the size and thickness of brain structures that previous reports have associated with depression, anxiety and post-traumatic stress disorder (PTSD) and also have suggested could be affected by traumatic head injuries.

Among the former detainees, 16 reported having experienced head injuries at some time, and 26 did not. Not only were detainees with a history of head injury more likely than those without to report symptoms of depression, the imaging studies showed they had significant reductions in the thickness of the frontal and temporal lobes of the cerebral cortex, reductions not seen in non-head-injured detainees. Participants whose head injuries were more severe had even greater structural changes and more debilitating depression symptoms. These head-injury-associated effects were independent of the effects of other forms of torture or trauma participants had experienced. While head-injured ex-detainees did not have a greater risk of being diagnosed with PTSD, their PTSD symptoms were more severe.

"It's well known in neuropsychology that the frontal and temporal lobes affect executive function – which includes planning, learning, self-monitoring, and flexibility in social interactions," Mollica explains. "It could be that torture survivors who don't do well with standard therapies have head-injury-based cognitive deficits that interfere with standard approaches like behavioral or exposure therapy. It's very rare for patients to relate subsequent health problems to a head injury or to recognize that a head injury is affecting their emotions.

"In some cultures," he adds, "patients and families are relieved to learn that emotional problems are related to a physical injury and may become more committed to working with programs specially designed to treat head injury patients. We hope that our documenting physical effects of brain damage in a group of torture survivors will provide evidence leading to improved diagnostic and treatment approaches. The next steps should be clinical trials comparing the results of head-injury-specific treatment programs with more traditional therapies for emotional disorders in patients with a history of both trauma and head injury."

Mollica also notes the need to improve training for the physicians most likely to treat such patients in the community. "Most primary care physicians are not prepared to identify mild traumatic head injury either in patients who may have experienced trauma or torture – including veterans or refugees – or in survivors of assaults or even auto accidents." He is a professor of Psychiatry at Harvard Medical School.

Co-authors of the study – supported by grants from the U.S. National Institute of Health and the Ministry of Education, Science and Technology of South Korea – are James Lavelle, LICSW, HRTP and MGH Psychiatry; In Kyoon Lyoo, MD, PhD, McLean Hospital; Miriam Chernoff, PhD, Harvard School of Public Health; Hoan Bui, Vietnamese-American Civic Association, Dorchester, Mass.; Sujung Yoon, MD, PhD, Catholic University Medical College, Seoul; Jieun Kim, MD, Seoul National University; and Perry Renshaw, MD, PhD, University of Utah.



1112 Study finds news reports match misperception of civilian deaths [New York NY]--Researchers reporting in BioMed Central's open access journal Conflict and Health found that the discrepancy in media reporting of casualty numbers in the Iraq conflict can potentially misinform the public and contribute to distorted perceptions and gross underestimates of the number of civilians killed in the armed conflict.

In February of 2007 Associated Press conducted a survey of 1,002 adults across the United States about their perceptions of the war in Iraq. Whilst the respondents accurately estimated the death toll of U.S. soldiers (the median estimate was 2,974 while the actual toll at the time was 3,100), they grossly underestimated the number of Iraqi civilian casualties (the median answer was 9,890 at a time when several estimates put the toll at least 10 times that number and some as high as 50 times that number). To assess the potential reasons for this discrepancy, Schuyler W. Henderson and colleagues at Columbia University examined 11 U.S. newspapers and 5 non-U.S. newspapers to collate the number of Coalition and Iraqi fatalities reported in the media between March 2003 and March 2008. They specifically looked at tallies (numbers of death over a period of time) and the descriptions of specific casualty events.

The results of their study showed U.S. newspapers reported more events and tallies related to Coalition deaths than Iraqi civilian deaths, although there were substantially different proportions amongst the different U.S. newspapers. In four of the five non-US newspapers, the pattern was reversed.

The authors of the study suggest that as newspapers reflect the interests of their readers, it is not surprising that U.S. newspapers describe more casualties related to Coalition deaths than Iraqi civilians, however they go on to question whether this is consistent with the goals and tenets of ethical and accurate journalism.

"We feel that this study casts an important light on the role of the media in covering armed conflict and communicating the human costs of war to the public" said Schuyler. "Our paper calls into question the role of the media in providing a tool for civilians to accurately gauge the true effects and outcomes of military action and ongoing warfare."

1. Reporting Iraqi civilian fatalities in a time of war, Schuyler W Henderson, William E Olander and Les Roberts, Conflict and Health (in press)



1107 Poll: Many parents, high-priority adults who tried to get H1N1 vaccine unable to get it [Boston MA]--A new national poll from Harvard School of Public Health (HSPH) researchers found that a majority of adults who tried to get the H1N1 vaccine for themselves or their children have been unable to do so. The poll, which examines the American public's response to the H1N1 vaccine shortage, is the fifth in a series of surveys of public views concerning the H1N1 flu outbreak undertaken by the Harvard Opinion Research Program at HSPH. The polling was done October 30 to November 1, 2009.

Challenges to Getting H1N1 Vaccine

Vaccination: Since the H1N1 flu vaccine became available in October, 17% of American adults, 41% of parents, and 21% of high-priority adults have tried to get it. Among adults who tried to get it for themselves, 30% were able to get the vaccine and 70% were unable to get it. Among parents who tried to get the H1N1 vaccine for their children, 34% were able to get it and 66% were unable to get it. Among high priority adults who tried to get the H1N1 vaccine, 34% were able to get it and 66% were unable to get it.

Parents in this poll include those with children 6 months to less than 18 years. High-priority adults include adults who live with or care for a child less than 6 months of age, pregnant women, health care and emergency health personnel, and adults 25-64 with health conditions associated with higher risk of medical complications from influenza, such as asthma or heart disease.

The poll also shows that some people were not able to find information about the location of available H1N1 flu vaccine. Approximately half who tried to find such information (49%) were unable to find it.

"These findings suggest that the nationwide H1N1 vaccine shortage is presenting a real challenge for those who have tried to get the vaccine," said Robert J. Blendon, Professor of Health Policy and Political Analysis at HSPH, who co-directed the poll.

Personal Reactions to the Experience of Trying to Get H1N1 Vaccination

The poll suggests that nearly a third (29%) of those who have tried and could not get the vaccine (either for themselves or for their children) are very frustrated. That said, most who have tried and not been able to get it yet (91%) say they will try again this year to get the vaccine for themselves, their children or both.

"Public health officials who are encouraging H1N1 vaccination may be relieved to see that most people who have so far been unable to get the vaccine say they will try again," said Blendon.

Response to H1N1 Vaccine Shortage Overall

Looking more broadly at the issue of vaccine shortages, most Americans (82%) believe there is a shortage of H1N1 vaccine in the United States, and approximately 4 in 10 (41%) believe this is a major problem for the country. More than half of adults (60%) believe there is a shortage of H1N1 vaccine in their community.

Forty percent believe there will still not be enough H1N1 flu vaccine by the end of November for everyone in their community who wants it. Nearly a quarter (24%) say it will be a very serious problem for them and their immediate family if the H1N1 vaccine is not available by then.

This is the fifth in a series of surveys of public views concerning the H1N1 flu outbreak undertaken by the Harvard Opinion Research Program (HORP) at HSPH. See below:

"Survey Finds Nearly Half of Americans Concerned They Or Their Family May Get Sick from Swine Flu," May 1, 2009.

"Survey Finds Many Americans Have Taken Steps to Protect Themselves Against H1N1," May 8, 2009

"National Survey Finds Six in Ten Americans Believe Serious Outbreak of Influenza A (H1N1) Likely in Fall/Winter," July 15, 2009

"Survey Finds Just 40% of Adults Absolutely Certain They Will Get H1N1 Vaccine," October 2, 2009

Another survey from HORP looked at business preparedness:

"Four-Fifths of Businesses Foresee Severe Problems Maintaining Operations If Significant H1N1 Flu Outbreak," September 9, 2009


This poll is part of an on-going series of surveys focused on the public and biological security by the Harvard Opinion Research Program (HORP) at Harvard School of Public Health. The study was designed and analyzed by researchers at the Harvard School of Public Health (HSPH). The project director is Robert J. Blendon of the Harvard School of Public Health. The research team also includes Gillian K. SteelFisher, John M. Benson, and Mark M. Bekheit of the Harvard School of Public Health, and Melissa J. Herrmann of SSRS/ICR. Fieldwork was conducted via telephone (including both landline and cell phone) for HORP by SSRS/ICR of Media (PA) October 30-November 1, 2009.

The survey was conducted with a representative national sample of 1,073 adults age 18 and over, including oversamples of non-Hispanic African Americans and Hispanics. Altogether, 107 non-Hispanic African Americans and 141 Hispanics were interviewed. In the overall results, these groups were weighted to their actual proportion of the total adult population.

The margin of error for the total sample is plus or minus 3.8 percentage points. Possible sources of non-sampling error include non-response bias, as well as question wording and ordering effects. Non-response in telephone surveys produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, sample data are weighted to the most recent Census data available from the Current Population Survey for gender, age, race, education, region, and number of adults in the household. Other techniques, including random-digit dialing, replicate subsamples, and systematic respondent selection within households, are used to ensure that the sample is representative.


This Harvard School of Public Health series is funded under a cooperative agreement with the Centers for Disease Control and Prevention (CDC). The award enables HORP to provide technical assistance to the CDC as well as to other national and state government health officials in order to support two critical goals: (1) to better understand the general public's response to public health emergencies, including biological threats and natural disasters; and (2) to improve related public health communications.


1107 NHLBI stops enrollment in study on resuscitation methods for cardiac arrest - Different CPR durations found equally successful; CPR device does not add benefit [Bethesda MD]--Enrollment has ended early in a large, multicenter clinical trial comparing two distinct resuscitation strategies delivered by emergency medical service (EMS) providers to increase blood flow during cardiac arrest.


The study's independent monitoring board and the National Heart, Lung, and Blood Institute (NHLBI), the lead sponsor of the study, stopped enrollment based on preliminary data suggesting that neither strategy significantly improved survival.


One strategy compared different durations of manual cardiopulmonary resuscitation (CPR) by EMS providers before they assessed whether defibrillation was needed, and the other strategy tested the potential benefits and risks of an investigational device to maintain pressure in the chest during CPR.

After reviewing data on approximately 11,500 study participants, the study's Data and Safety Monitoring Board (DSMB) recommended on Oct. 23 that the NHLBI stop enrollment because sufficient data had been gathered, and continuing recruitment was unlikely to change the overall outcomes of the study. The board had no concerns about the safety of any of the interventions tested, and NHLBI accepted the DSMB recommendations on the same day. Researchers will continue to monitor study participants who agree to follow-up visits for up to six months. They will analyze and publish the final data in the coming months. The NHLBI is part of the National Institutes of Health.

"Survival rates for patients who suffer cardiac arrest before reaching a medical facility are tragically low," said Susan Shurin, M.D., deputy director of the NHLBI, who oversees clinical trials supported by NHLBI and accepted the DSMB recommendation.


"This study provides important evidence to help inform first responders and other health care providers on safe and effective life-saving treatment options. We will continue to search for new ways to save lives in the precious few moments after cardiac arrest – and evaluate the benefits and risks of commonly used practices."

The Resuscitation Outcomes Consortium (ROC), the largest clinical research network to study prehospital treatments for cardiac arrest in the United States and Canada, tested both resuscitation strategies as part of the Prehospital Resuscitation using an IMpedance valve and Early versus Delayed (ROC PRIMED) clinical trial. An impedance valve, also called an impedance threshold device (ITD), is a small, hard plastic device about the size of a fist that is attached to the face mask or breathing tube during CPR administered by EMS providers. The device is designed to improve circulation by enhancing changes in pressures within the chest during CPR. Researchers found that ITD use did not significantly improve or worsen survival rates for cardiac arrest patients.

The early versus delayed strategy compared two currently used timing strategies of assessing the heart's rhythm in relation to when CPR is started by EMS providers. The heart rhythm assessment is done to determine whether defibrillation to restore the heart to its normal rhythm is needed. The study compared patient survival rates after EMS providers performed at least 30 seconds of CPR before assessing the need for defibrillation with delivering three minutes of CPR before the assessment. Based on current study data, both timing strategies were equally effective.

EMS providers assess approximately 350,000 people with cardiac arrest in the United States each year. Only 5 to 10 percent of people who have sudden cardiac arrest survive. When administered as soon as possible, CPR and, in some cases, rapid treatment with a defibrillator – a device that sends an electric shock to the heart to try to restore its normal rhythm – can be lifesaving. When delivered by EMS professionals, CPR is a combination of chest compressions, to keep oxygen-rich blood circulating until an effective heartbeat is restored, and rescue breathing. Lay bystanders are encouraged to immediately begin CPR using only chest compressions until professional help arrives, according to the American Heart Association.

ROC PRIMED was designed to test the two promising strategies to increase the chance of survival without functional impairments of patients who suffer cardiac arrest outside of a hospital setting. To test the ITD strategy, patients were randomly assigned to receive standard CPR from participating EMS providers either with an ITD or with a non-working replica (sham) of an ITD.

In animal studies and in small studies in humans, the ITD has been shown to markedly increase blood flow to the heart and to raise blood pressure. Human studies have also showed a tendency toward improved short-term outcomes without adverse effects. A modified version of the ITD is approved by the Food and Drug Administration (FDA) for use in conditions other than cardiac arrest.

However, a large human clinical trial was needed to show whether the device significantly improves survival with preserved neurologic function. Patients with preserved neurologic function are able to carry out activities of daily living. In contrast, patients who suffer neurological damage following cardiac arrest may no longer be able to care for themselves due to injury to parts of the brain.

The study's preliminary results indicate similar survival rates of patients with preserved neurologic function between both groups of patients, suggesting that standard CPR without an ITD is as effective as using an ITD.

"While the ITD is based on a sound physiologic principle, in this study it did not appear to improve survival rates for adults in cardiac arrest outside of the hospital," said Tom Aufderheide, M.D., a professor of emergency medicine at the Medical College of Wisconsin in Milwaukee and a ROC principal investigator. "We will continue to seek out and thoroughly test new devices as well as alternative applications that hold promise for saving the lives of cardiac arrest patients."

The other principal strategy studied in ROC PRIMED was the timing of assessing the heart's rhythm to determine whether defibrillation is needed in relation to when CPR is started. For patients randomly assigned to the Analyze Early group, EMS providers were instructed to perform CPR until they were able to analyze the patient's heart rhythm (approximately 30 to 90 seconds). Patients in the Analyze Later group received CPR for at least three minutes before their heart rhythm was analyzed. When indicated, defibrillation was provided.

Some smaller studies have suggested that longer periods of CPR before defibrillation might increase survival, while other studies have suggested that more immediate defibrillation -- when the patient is treated within two minutes after the start of cardiac arrest -- might be better.

"The ROC PRIMED study answers a long-standing question in the EMS community over whether it is better to defibrillate earlier or later when trying to resuscitate a patient," said Ian Stiell, M.D., professor and chair of the Department of Emergency Medicine at the University of Ottawa, senior scientist at the Ottawa Hospital Research Institute, and a principal investigator for the ROC PRIMED Analyze Early vs. Later protocol. "Both techniques appear to be equally beneficial."

Myron Weisfeldt, M.D., ROC Steering Committee chair and director of the Department of Medicine at the Johns Hopkins University School of Medicine in Baltimore, added, "Questions like this one – which address the relative benefits of current medical practices – are an important example of comparative effectiveness research and, in this case, can help advance emergency medical care."

ROC PRIMED and other ROC clinical trials are conducted under strict U.S. FDA and Canadian guidelines that allow for patients in life-threatening situations to participate in research under an exception to explicit informed consent, according to U.S. and Canadian laws. This is necessary because, among other reasons, participants in cardiac arrest are unconscious and therefore cannot give consent. Before any patients were enrolled, communities were consulted about participation and made aware that informed consent will not be obtained for most study participants, as required by law.

To ensure patient safety during the study, the DSMB that monitors ROC studies reviews the accrued data approximately every six months or more frequently if needed. The ROC DSMB includes experts in trauma, cardiac arrest, statistics, ethics, and the conduct of clinical trials. During its interim data review on Oct. 23, the DSMB recommended stopping enrollment in both ROC PRIMED assessments based on results that suggest that both types of strategies were equally beneficial and that continued enrollment was unlikely to yield different results. The NHLBI accepted the recommendation, and ROC clinical sites stopped enrollment.

The ROC is a large clinical research network of 10 centers in the United States and Canada. Approximately 150 EMS and fire services organizations, involving more than 20,000 EMS providers who serve a combined population of more than 15 million people from diverse urban, suburban, and rural regions participated in ROC PRIMED. ROC research focuses on treatments for patients with life-threatening traumatic injury or cardiac arrest in real-world settings, typically where patients collapse or are critically injured, before they reach the hospital. Participating EMS providers receive intensive training, and give standard emergency care to all patients, with some patients randomly selected to receive the intervention to be tested in addition to usual care.

"The ROC is the largest research network to study real-world, pre-hospital interventions for cardiac arrest," noted George Sopko, M.D., ROC project officer in the NHLBI Division of Cardiovascular Sciences. "Conducting these studies through this robust and experienced network allows us to implement and compare clinical interventions in meaningful ways and to disseminate the results as quickly as possible so they can be applied to improve public health."

Earlier this year, the NHLBI stopped enrollment early for two ROC clinical trials that examined whether concentrated (hypertonic) saline improved survival over standard saline for trauma patients. Patients in the study were either suffering from shock due to significant blood loss or had experienced a traumatic brain injury. In both types of patients, hypertonic saline solution did not improve outcomes over the use of a standard saline solution.

The NHLBI is the lead federal sponsor of the ROC studies. Additional funding is provided by the NIH's National Institute of Neurological Disorders and Stroke, the Institute of Circulatory and Respiratory Health of the Canadian Institutes of Health Research, US Army Medical Research & Materiel Command, American Heart Association, Defence Research and Development Canada, and the Heart and Stroke Foundation of Canada.

Resuscitation Outcomes Consortium:


Sudden Cardiac Arrest:


1107 Less than 1 in 3 Toronto bystanders who witness a cardiac arrest try to help: Study [Toronto ON]--Researchers at St. Michael's Hospital working in conjunction with EMS services, paramedics and fire services across Ontario found that a bystander who attempts cardiopulmonary resuscitation (CPR) can quadruple the survival rate to over 50 per cent. But Dr. Laurie Morrison and the research team at Rescu (www.rescu.ca) have found only 30 per cent of bystanders in Toronto are willing to help, one of the lowest rates of bystanders helping others in the developed world.

"Over the last four years, we have been working hard with paramedics and firefighters in Southern Ontario to increase the survival rate of people who experience cardiac arrest outside of the hospital," says Dr. Morrison. "Since 2004, our efforts have managed to triple the survival rate in the Toronto area but it is still less than 10 per cent."

Compared to other cities during the same time frame, Toronto has much lower rates of bystander CPR and survival. The research team wants to encourage all Canadians to learn the basics of CPR. Home is one of the most common places for cardiac arrests so learning CPR could mean saving a family member's life.

"Even if you perform hands-only CPR, and focus on compressing the chest, you can give a victim of cardiac arrest as much as a 1 in 2 chance of surviving," says Dr. Marco Di Buono, Director of Research at the Heart and Stroke Foundation of Ontario, "on the contrary, doing nothing virtually guarantees the victim will not survive at all."

Dr. Morrison's research group, Rescu www.rescu.ca, is based out of St. Michael's and dedicated to out of hospital resuscitation. It is a collaborative network of EMS and fire services, paramedics and firefighters and over 40 hospitals in Southern Ontario. Rescu is the largest research program of its kind in Canada and the US, and is world renowned for their clinical trials in out of hospital treatment of cardiac arrest and life threatening emergencies.

The trial included Peel EMS, Peel Fire Brampton, Peel Fire Mississauga, Muskoka EMS, Toronto EMS, Toronto Fire, Durham (Ajax Fire, Brock Fire, Clarington Fire, Oshawa Fire, Pickering Fire, Scugog Fire, Uxbridge Fire and Whitby Fire) and Halton.

The study looked at the impact of bystanders using Automated External Defibrillators (AEDs). An AED is a portable electronic device that treats life threatening cardiac rhythms through electrical therapy, allowing the heart to reestablish an effective rhythm. The researchers found that AEDs used in casinos and airports demonstrated an unprecedented survival rate of 50 per cent or greater. The study found that the use of AEDs in Toronto to be very low. Only one per cent of cardiac arrest victims had an AED applied to their chest.

Although more than an estimated 1,800 AEDs are in public places in Toronto and adjacent cities, the study found only 750 of the devices were registered with Toronto EMS. This is problematic when a 911 dispatcher cannot alert a bystander or EMS person that an AED is close by. In times of an emergency the dispatcher can be an effective coach for bystanders to help others.

Even with a 911 dispatcher talking them through the process, many bystanders do not feel comfortable doing CPR or using an AED. Minimal training is required and people can learn CPR or how to use an AED in an emergency by listening to the dispatcher's coaching until paramedics and fire fighters arrive.

"You can learn CPR in 20 minutes with a personal learning kit available through the Heart and Stroke Foundation website www.heartandstroke.ca/restart or by simply watching a video on Youtube," explains Dr. Morrison. "I believe that we should be teaching CPR and AED use in all schools so that helping someone in cardiac arrest is a learned behaviour. You may never need to use your training but if you are a witness, you will be more likely to jump in and help. If you do nothing, very few will survive."

Under Ontario's Good Samaritan Act of 2001, bystanders who assist others with all good intentions are not liable.



1107 Use of N95 masks challenged - Infectious diseases prevention experts say current H1N1 guidance for healthcare workers not supported by science [Arlington VA]--Three leading scientific organizations specializing in infectious diseases prevention issued a letter to President Obama today expressing their significant concern with current federal guidance concerning the use of personal protective equipment (PPE) by healthcare workers in treating suspected or confirmed cases of 2009 H1N1 influenza.


The Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA) and the Association for Professionals in Infection Control and Epidemiology (APIC) urged the administration to modify the guidance and issue an immediate moratorium on Occupational Safety and Health Administration’s (OSHA) enforcement of the current requirements.

Federal PPE guidance and requirements issued recently by the Centers for Disease Control and Prevention (CDC) and OSHA include the use of fit-tested N95 respirators by healthcare workers rather than the use of standard surgical masks.


According to these organizations--representing scientists, infectious disease specialists and healthcare professionals dedicated to healthcare quality, safety and infection control--this guidance does not reflect the best available scientific evidence.


Their letter to the White House cited two recent studies demonstrating that the use of N95 respirators does not offer additional protection over that provided by the use of surgical masks.

Mark Rupp, MD, president of SHEA called the current requirements “deeply flawed” and expressed his concern over the “potential for considerable untoward consequences” that could result from the guidance. Among the consequences, Rupp cited significant confusion among healthcare professionals and administrators and the potential for further limiting the availability of the already scarce respirators in situations where they are truly warranted.

“During a time of a national emergency, healthcare professionals need clear, practical and evidence-based guidance from the government,” said Richard Whitley MD, president of IDSA. “The current guidance is not supported by the best-available science and only serves to create skepticism toward federal public and occupational health decision-making.”

“The supply of N95 respirators is rapidly being depleted in our healthcare facilities,” said APIC 2009 President Christine Nutty, RN, MSN, CIC. “We are concerned that there won’t be an adequate supply to protect healthcare workers when TB patients enter the healthcare system.”

The organizations have provided input to federal agencies including the CDC regarding the handling of 2009 H1N1 influenza in the past and say they stand ready to continue to lend their knowledge and expertise as the pandemic advances.



1107 When should flu trigger a school shutdown? Analysis of data from Japan suggests a protocol for schools to follow [Boston MA]--As flu season approaches, parents around the country are starting to face school closures. But how bad should an influenza outbreak be for a school to shut down? A study led by epidemiologists John Brownstein, PhD, and Anne Gatewood Hoen, PhD of the Children's Hospital Boston Informatics Program, in collaboration Asami Sasaki of the University of Niigata Prefecture (Niigata, Japan), tapped a detailed set of Japanese data to help guide decision making by schools and government agencies. The analysis was published by the Centers for Disease Control and Prevention in the November issue of Emerging Infectious Diseases.

"Currently many U.S. schools don't have specific or consistent algorithms for deciding whether to shut down," says Brownstein. "They don't always use quantitative data, and it may be a political or fear-based decision rather than a data-based one."

Sasaki, Hoen and Brownstein analyzed flu absenteeism data from a Japanese school district with 54 elementary schools. Tracking four consecutive flu seasons (2004-2008), they asked what pattern of flu absenteeism was best for detecting a true school outbreak -- balanced against the practical need to keep schools open if possible.

"You'd want get a school closed before an epidemic peaks, to prevent transmission of the virus, but you also don't want to close a school unnecessarily," explains Brownstein. "We also wanted an algorithm that's not too complex, that could be easily implemented by schools."

A school outbreak was defined as a daily flu absentee rate of more than 10 percent of students. After comparing more than two dozen possible scenarios for closing a school, the analysis suggested three optimal scenarios:

1. A single-day influenza-related absentee rate of 5 percent
2. Absenteeism of 4 percent or more on two consecutive days
3. Absenteeism of 3 percent or more on three consecutive days

The scenarios #2 and #3 performed similarly, with the greatest sensitivity and specificity for predicting a flu outbreak (i.e., the fewest missed predictions and the fewest "false positives.") Both gave better results than the single-day scenario (#1). The researchers suggest that scenario #2 (with a sensitivity of 0.84 and a specificity of 0.77) might be the preferred early warning trigger, balancing the need to prevent transmission with the need to minimize unnecessary closures.

"Our method would give school administrators or government agencies a basis for timely closure decisions, by allowing them to predict the escalation of an outbreak using past absenteeism data," says Hoen. "It could be used with data from schools in other communities to provide predictions. It would leave decision-making in the hands of local officials, but provide them with a data-driven basis for making those decisions."

Japan makes a good model for studying influenza in schools because it closely monitors school absenteeism due to flu, requires testing for the flu virus in students who become ill, and has a track record of instituting partial or complete school closures during outbreaks. However, Brownstein cautions that the scenarios might play out differently in the U.S. than they would in Japan, mainly because students here aren't required to be tested for influenza as they are in Japan, so it's less certain whether they actually have the flu. Also, the vaccination status of students in this study was unknown.

Last spring, during the early days of the H1N1 influenza pandemic, the CDC recommended first a 7-day school closure, then a 14-day closure after appearance of the first suspected case. Later, as more became known about the extent of community spread and disease severity, the CDC changed the recommendation to advise against school closure unless absentee rates interfered with school function. CDC's current guidelines don't provide a specific algorithm, but state that "the decision to selectively dismiss a school should be made locally," in conjunction with local and state health officials, "and should balance the risks of keeping the students in school with the social disruption that school dismissal can cause." When the decision is made to dismiss students, CDC recommends doing so for 5 to 7 calendar days.

Researchers at the Harvard School of Public Health, the Boston University School of Public Health, and Niigata University were coauthors on the study. The study was funded by the Takemi Program, the Japan Foundation for the Promotion of International Medical Research Cooperation, the National Institute of Allergy and Infectious Disease, the National Institutes of Health Research and the Canadian Institutes of Health Research.

Citation: Sasaki A, et al. Evidenced-based tool for triggering school closures during influenza outbreaks, Japan. Emerg Infect Dis 2009 Nov.



1107 Study finds big air pollution impacts on local communities - Traffic corridors in Long Beach and Riverside are a major contributor to illness from childhood asthma [Los Angeles CA]--Heavy traffic corridors in the cities of Long Beach and Riverside are responsible for a significant proportion of preventable childhood asthma, and the true impact of air pollution and ship emissions on the disease has likely been underestimated, according to researchers at the University of Southern California (USC)

The study, which appears in an online edition of the American Journal of Public Health, estimated that nine percent of all childhood asthma cases in Long Beach and six percent in Riverside were attributable to traffic proximity.

The study also found that ship emissions from the Los Angeles-Long Beach port complex contributed to the exacerbation of asthma. For example, approximately 1,400 yearly episodes of asthma-related bronchitis episodes in Long Beach (21 percent of the total) were caused by the contribution of ship emissions to nitrogen dioxide levels in the city.

Although there has been extensive research on the effects of traffic proximity on asthma risk, this study is one of the few that has estimated the number of cases—or "burden of disease"—associated with traffic in specific high risk communities, says principal investigator Rob McConnell, M.D., professor of preventive medicine at the Keck School of Medicine of USC and deputy director of the Children's Environmental Health Center at USC.

"The traditional approach to estimating the burden of air pollution-related disease has markedly underestimated the true effect," McConnell says. "Our results indicate that there is a substantial proportion of childhood asthma that may be caused by living within 75 meters (81 yards) of a major road in Long Beach and Riverside. This results in a much larger impact of air pollution on asthma symptoms and health care use than previously appreciated. This is also one of the first studies to quantify the contribution of ship emissions to the childhood asthma burden."

Such specific data about the local health burden of air pollution is useful for evaluating proposals to expand port facilities or transportation infrastructure in the L.A. area, McConnell noted. Both Long Beach and Riverside already have heavy automobile traffic corridors as well as truck traffic and regional pollution originating in the port complex, which is the largest in the United States.

The study drew upon data from the Children's Health Study (CHS), a longitudinal study of respiratory health among children in 12 Southern California communities, including Riverside and Long Beach. Researchers estimated the number of asthma cases and related complications that occurred because of air pollution, using information from epidemiological studies that they then applied to current exposure to air pollution and traffic in Southern California. The results showed that approximately 1,600 cases of childhood asthma in Long Beach and 690 in Riverside could be linked to living within 81 yards of a major road.

"The impact of roadway proximity on the overall burden of asthma-related illness is remarkable," McConnell says. "Air pollution is a more important contributor to the burden of childhood asthma than is generally recognized, especially to more severe episodes requiring visits to a clinic or emergency room."

Unlike regional air pollutants, the local traffic-related pollutants around homes and their effects are not currently regulated, he notes.

"This is a challenge to communities, to regulatory agencies and to public health," McConnell says. "Traffic-related health effects should have a central role on the transportation planning agenda."

The study, an international collaboration between USC, the Center for Research in Environmental Epidemiology (CREAL) in Spain and the University of Basel in Switzerland, was supported by the National Institute of Environmental Health Sciences, the U.S. Environmental Protection Agency, the South Coast Air Quality Management District, the Hastings Foundation, the Center for Research in Environmental Epidemiology (Switzerland) and the Fundacion Insitut Municipal d'Investigacio Medica (Barcelona). The authors acknowledge the insights of the staff and members of the Long Beach Alliance for Children with Asthma and the Center for Community Action and Environmental Justice.

Laura Perez, Nino Kuenzli, Ed Avol, Andrea M. Hricko, Fred Lurmann, Elise Nicholas, Frank Gilliland, John Peters, Rob McConnell. "Global Goods Movement and the Local Burden of Childhood Asthma in Southern California." American Journal of Public Health. Doi: 10.2105/AJPH.2008.154955



1107 Community education and evacuation planning saved lives in Sept. 29 Samoan tsunami [Atlanta GA]--Community-based education and awareness programs minimized the death toll from the recent Samoan tsunami, though there are still ways to improve the warning and evacuation process, according to a team of researchers that traveled to Samoa last month.

The team, funded by a National Science Foundation (NSF) grant, collected data Oct. 4 through Oct. 11 to document the impacts of the 8.1 earthquake and the ensuing tsunami that occurred on Sept. 29. They examined flow depths, run-up heights, inundation distances, sediment depositions and damage patterns at various scales.

"In addition to timing – the fact that the tsunami struck in the daylight morning hours when most people were on their way to work or school – tsunami education, awareness and evacuation exercises really contained the death toll," noted Hermann Fritz, one of the principal investigators and an associate professor of civil and environmental engineering at the Georgia Institute of Technology. "The technical solution doesn't always work for coastlines near the epicenter with less than 30 minutes between earthquake and onslaught of the tsunami. Earthquakes with durations of more than 30 seconds serve as a natural warning, resulting in a spontaneous self-evacuation."


Nearly 190 people were killed in the tsunami, with the majority of deaths reported in Samoa, a country governing the western part of the Samoan Islands in the South Pacific Ocean. The two main islands of Samoa are Upolu and Savai'i. American Samoa, a territory of the United States southeast of Samoa, is comprised of main island Tutuila, the Manu'a Islands, Rose Atoll and Swains Island. The Samoan government estimates the total damage from the tsunami at $147 million.

The team's survey circled all of the main Samoan islands and spanned 350 kilometers from Ofu in the east to Savai'i in the west. The researchers learned that the tsunami impact peaked at Poloa near Tutuila's western tip and Lepa at Upola's southeast coast. Maximum run-up heights reached 17 meters at Poloa, and inundation distances and damage were recorded at Pago Pago, more than 500 meters inland. The harbor at Pago Pago, well-protected from ordinary storm waves, is vulnerable to long-period tsunami waves.

In addition, researchers noticed a marked difference between the evacuation process in Samoa and American Samoa. While most villagers in Samoa knew to rapidly evacuate after experiencing an earthquake, only a month earlier they had been told that cars help with evacuations, a deadly directive since most roads run parallel to the beach.

"Many perished trapped inside cars waiting in congested small roads or in long lines behind vehicles stopped by landslides or debris on the road," said Costas Synolakis, principal investigator and professor of civil engineering at University of Southern California. "I have been on more than 20 tsunami field surveys, and in many ways this was one of the most surprising in terms of how carnage varied over fairly short distances. This was also the first time we noted what we suspected: misinformation kills."

Emile Okal, a seismologist and professor of earth and planetary sciences at Northwestern University, conducted approximately 120 interviews with tsunami survivors in 70 different locations around Tutuila and Upolu. He found that most people were educated about tsunamis and knew how to react because of community-based educational programs, not ancestral stories.


"The last significant tsunami in Samoa occurred in 1917 and was very similar in seismology to the Sept. 29 tsunami. Surprisingly, no one I interviewed said they knew of family members being in a similar situation," Okal observed. "Since the 2004 Indian Ocean tsunami and the 2007 Solomon Islands tsunami, there has been a concerted effort on the part of the local government in American Samoa to post signs and conduct evacuation drills in some Samoan communities. Many villages were completely destroyed, so I am impressed that the death toll was not larger. The bottom line is education worked."

While Synolakis agreed that the death toll was probably minimized due to educational efforts, he said there is still a lot of progress that can be made. While working in the field on Oct. 7, the team experienced a real tsunami warning and witnessed first-hand the tremendous confusion and disorganization that followed.

"Although there are warning signs along the beaches in American Samoa, there is no information about where the evacuation routes are," he said. "It's also just as important to let people know when it's safe to come back as it is to warn them. We definitely have our work cut out for us."

The collected field data serves as benchmarking and validation of numerical tsunami models with wide-ranging applications including forecasting, warning and sediment transport. The researchers will present their findings at special sessions at the American Geophysical Union Fall Meeting in San Francisco this December. Brief publications summarizing the immediate results will follow in research journals.

This survey was partially supported by the Pacific Earthquake Research Center (PEER).



1107 New insight into predicting cholera epidemics in the Bengal Delta [Medford MA]--Cholera, an acute diarrheal disease caused by the bacterium Vibrio cholerae, has reemerged as a global killer. Outbreaks typically occur once a year in Africa and Latin America. But in Bangladesh the epidemics occur twice a year – in the spring and again in the fall.

Scientists have tried, without much success, to determine the cause of these unique dual outbreaks – and advance early detection and prevention efforts – by analyzing such variables as precipitation, water temperature, fecal contamination and coastal salinity. Now, researchers from Tufts University, led by Professor of Civil and Environmental Engineering Shafiqul Islam, have proposed a link between cholera and fluctuating water levels in the region's three principal rivers – the Ganges, Brahmaputra and Meghna.

"What we are establishing is a way to predict cholera outbreaks two to three months in advance," says Islam, who also holds an appointment as professor of water and diplomacy at The Fletcher School at Tufts. "It's not a microbiological explanation. The key is the river discharge and regional climate."

The Tufts researchers' findings were reported in the latest issue of Geophysical Research Letters, published October 10, 2009.

Understanding cholera's environmental catalysts

Vibrio cholerae lives and thrives among phytoplankton and zooplankton in brackish estuaries where rivers come into contact with the sea. The Bengal Delta, which scientists have considered the native land of cholera, is fed by three rivers.

Almost all of the rainfall in the region occurs during the four-month monsoon season between June and September. Water levels in the river system rise, causing floods that cover 20 percent of the land in an average year. Water levels then fall rapidly, though low-lying, depressed areas remain submerged for weeks.

The Tufts team tracked the month-by-month incidence of cholera using data from the International Center for Diarrhoeal Disease Research, a treatment center that recorded incidences of cholera for the biggest population center of Bangladesh from 1980 to 2000.

The Tufts team correlated these cholera incidence statistics with an analysis of water discharges from the three rivers. Their findings suggested two distinctive epidemic patterns that are associated with the seasonal cycles of low river flows and floods.

A spring outbreak occurs in March, during the period of low river flow in Bangladesh. The low river flow allows seawater from the Bay of Bengal to move inland, transporting bacteria-carrying plankton.

A second epidemic occurs in September and October, after monsoon rains have raised water levels. Here, a different dynamic takes place. Floodwaters have mixed water from sewers, reservoirs and rivers. As the floods recede, contamination is left behind..

Predicting cholera before it happens

Islam and his team linked the incidence of cholera cases to the level of water flow in the rivers. In order to confirm their findings, the researchers looked for a consistent pattern. They analyzed the incidence of cholera in five years of severely low river flow from 1980 to 2000 and compared it with five years of average and below average river flow. The same analysis was done for extreme, average and below average floods to study the fall epidemic.

The researchers found a relationship between the magnitude of cholera outbreaks and the severity of the region's seasonal low river flow and floods. "The more severe the low river flow, the larger the spring epidemic," says Islam. "The same thing is true with flooding during the fall." Islam says that the findings will contribute to the development of systems to anticipate and predict cholera outbreaks based on the hydroclimate of the region.

This research was funded in part by the National Science Foundation and a National Institutes of Health Fellowship. Researchers included engineering doctoral students Ali S. Akanda and Antarpreet S. Jutla.

Akanda, A. S., A. S. Jutla, and S. Islam (2009), "Dual peak cholera transmission in Bengal Delta: A hydroclimatological explanation," Geophys. Res. Lett., 36, L19401, doi: 10.1029/2009GL039312.


1107 Earthquakes actually aftershocks of 19th century quakes - Repercussions of 1811 and 1812 New Madrid quakes continue to be felt [Chicago IL]--When small earthquakes shake the central U.S., citizens often fear the rumbles are signs a big earthquake is coming. Fortunately, new research instead shows that most of these earthquakes are aftershocks of big earthquakes (magnitude 7) in the New Madrid seismic zone that struck the Midwest almost 200 years ago.

The study, conducted by researchers from Northwestern University and the University of Missouri-Columbia, will be published in the Nov. 5 issue of the journal Nature.

"This sounds strange at first," said the study's lead author, Seth Stein, the William Deering Professor of Geological Sciences in the Weinberg College of Arts and Sciences at Northwestern. "On the San Andreas fault in California, aftershocks only continue for about 10 years. But in the middle of a continent, they go on much longer."

There is a good reason, explains co-investigator Mian Liu, professor of geological sciences at Missouri. "Aftershocks happen after a big earthquake because the movement on the fault changed the forces in the earth that act on the fault itself and nearby. Aftershocks go on until the fault recovers, which takes much longer in the middle of a continent."

The difference, Stein explains, is that the two sides of the San Andreas fault move past each other at a speed of about one and a half inches in a year -- which is fast on a geologic time scale. This motion "reloads" the fault by swamping the small changes caused by the last big earthquake, so aftershocks are suppressed after about 10 years. The New Madrid faults, however, move more than 100 times more slowly, so it takes hundreds of years to swamp the effects of a big earthquake.

"A number of us had suspected this," Liu said, "because many of the earthquakes we see today in the Midwest have patterns that look like aftershocks. They happen on the faults we think caused the big earthquakes in 1811 and 1812, and they've been getting smaller with time."

To test this idea, Stein and Liu used results from lab experiments on how faults in rocks work to predict that aftershocks would extend much longer on slower moving faults. They then looked at data from faults around the world and found the expected pattern. For example, aftershocks continue today from the magnitude 7.2 Hebgen Lake earthquake that shook Montana, Idaho and Wyoming 50 years ago.

"This makes sense because the Hebgen Lake fault moves faster than the New Madrid faults but slower than the San Andreas," Stein noted. "The observations and theory came together the way we like but don't always get."

Aftershocks go on for long times in other places inside continents, Stein said. It even looks like we see small earthquakes today in the area along Canada's Saint Lawrence valley where a large earthquake occurred in 1663.

The new results will help investigators in both understanding earthquakes in continents and trying to assess earthquake hazards there. "Until now," Liu observed, "we've mostly tried to tell where large earthquakes will happen by looking at where small ones do." That's why many scientists were surprised by the disastrous May 2008 magnitude 7.9 earthquake in Sichuan, China -- a place where there hadn't been many earthquakes in the past few hundred years.

"Predicting big quakes based on small quakes is like the 'Whack-a-mole' game -- you wait for the mole to come up where it went down," Stein said. "But we now know the big earthquakes can pop up somewhere else. Instead of just focusing on where small earthquakes happen, we need to use methods like GPS satellites and computer modeling to look for places where the earth is storing up energy for a large future earthquake. We don't see that in the Midwest today, but we want to keep looking."

The Nature paper is titled "Long Aftershock Sequences within Continents and Implications for Earthquake Hazard Assessment."



1107 Study suggests rainwater is safe to drink [Adelaide SA]--A world first study by Monash University researchers into the health of families who drink rainwater has found that it is safe to drink.

The research was led by Associate Professor Karin Leder from the Department of Epidemiology and Preventive Medicine in conjunction with Water Quality Research Australia (previously the Cooperative Research Centre for Water Quality and Treatment)

"This is the first study of its kind. Until now, there has been no prospective randomised study to investigate the health effects of rainwater consumption, either in Australia or internationally," Associate Professor Leder said.

The study involved three hundred volunteer households in Adelaide that were given a filter to treat their rainwater. Only half of the filters were real while the rest were 'sham' filters that looked real but did not contain filters.

The householders did not know whether they had a real filter. Families recorded their health over a 12-month period, after which time the health outcomes of the two groups were compared.

"The results showed that rates of gastroenteritis between both groups were very similar. People who drank untreated rainwater displayed no measurable increase in illness compared to those that consumed the filtered rainwater," Associate Professor Leder said.

Adelaide was the location chosen for the study as it the city with the highest use of rainwater tanks in Australia.

Associate Professor Leder said some health authorities had doubts about drinking rainwater due to safety concerns, particularly in cities where good quality mains-water is available.

"This study confirms there is a low risk of illness. The results may not be applicable in all situations; nevertheless these findings about the low risk of illness from drinking rainwater certainly imply that it can be used for activities such as showering/bathing where inadvertent or accidental ingestion of small quantities may occur.

"Expanded use of rainwater for many household purposes can be considered and in current times of drought, we want to encourage people to use rainwater as a resource," she said.

The study was funded by the National Health and Medical Research Council and Water Quality Research Australia.



1107 World Trade Center responders plagued with asthma [New York NY]--Responders to the 2001 World Trade Center (WTC) terrorist attacks, who were exposed to caustic dust and toxic pollutants following the 9/11 disaster, suffer from asthma at a rate more than twice that of the general US population, according to new research presented at CHEST 2009, the 75th annual international scientific assembly of the American College of Chest Physicians (ACCP).

As many as 8 percent of the workers and volunteers who engaged in rescue and recovery, essential service restoration, and cleanup efforts in the wake of 9/11 reported experiencing post-9/11 asthma attacks or episodes, compared with 4 percent of the general population. Furthermore, the lifetime prevalence of asthma in WTC responders was marked by a dramatic increase from 3 percent pre-9/11 to a high of 16 percent in each of the years from 2005 through 2007.

"Although previous WTC studies have shown significant respiratory problems, this is the first study to directly quantify the magnitude of asthma among WTC responders compared with the general US population," said Hyun Kim, ScD, Instructor of Preventive Medicine at Mount Sinai School of Medicine (MSSM), New York, NY, and lead author of the analysis which uses data obtained from the federally-funded World Trade Center Medical Monitoring and Treatment Program. "Six years out from 9/11, the World Trade Center Program was still observing responders affected by asthma episodes and attacks at more than double the percentage of people not exposed to World Trade Center dust."

WTC Study Details

In the multicenter clinical study, researchers from the MSSM-coordinated WTC Program reported on health-related findings of 20,843 WTC responders who received an initial medical screening examination during the program's first 5-1/2 years of existence, from July 2002 through December 2007. Asthma outcomes assessed were the following: (1) prevalence of asthma episodes/attacks reported by responders to have occurred during the previous 12 months, and (2) lifetime asthma prevalence, as measured by participants reporting having ever been told by a physician that they had asthma. Results were compared with the US National Health Survey Interviews (NHIS) adult sample data for the year 2000 (pre-9/11) and years 2002 through 2007.

WTC Study Results

In the general population, the prevalence of asthma episodes and/or attacks in the previous 12 months remained relatively constant at slightly less than 4 percent throughout the period from 2000 to 2007. In contrast, among WTC responders, while fewer than 1 percent recalled asthma episodes or attacks during the year 2000, that percentage increased to 8 percent, and then remained constant, through the period from 2005 to 2007. WTC responders were 2.3 times more likely to report asthma episodes/attacks that had occurred during the previous 12 months when compared with the general population of the United States. Additionally, the increase in lifetime prevalence of asthma among responders undergoing their initial program screening any time during the study period grew from a reported 3 percent for (pre-9/11) diagnoses to 13 percent in 2002. The lifetime prevalence of asthma subsequently rose through the years to plateau at 16 percent from 2005 through 2007.

"It is important to note that this report focused on findings from baseline or initial visit examinations," said Philip J. Landrigan, MD, MSc, Ethel H. Wise Professor and Chair of MSSM's Department of Preventive Medicine, and principal investigator of the WTC Program Data and Coordination Center. "Where the data shows an increasing percentage of responders reporting asthmatic episodes, rising to double that seen in the general population, it is clearly vital that we continue to track responders' health and look further into the medical outcomes of this population."

Of the study's rescue and recovery workers, 86 percent were men; 59 percent were Caucasian; and the average duration of work at WTC sites was 80 days. The study followed uniformed and other law enforcement and protective service workers (42 percent), as well as construction workers and other responders who had engaged in paid and volunteer WTC-related rescue and recovery, essential service restoration, and/or debris removal and cleanup efforts.

"Asthma and other chronic lung conditions remain a significant burden for rescue and recovery workers responding to the attacks on the World Trade Center," said Kalpalatha Guntupalli, MD, FCCP, President of the American College of Chest Physicians. "The significant chronic health problems associated with the World Trade Center attacks only reinforces the need for stronger disaster preparedness plans, as well as long-term medical follow-up for 9/11 responders and individuals who respond to disaster-related events."


1107 Report on H1N1 cases in California shows hospitalization can occur at all ages, with many severe [Richmond CA]--In contrast with some common perceptions regarding 2009 influenza A(H1N1) infections, an examination of cases in California indicates that hospitalization and death can occur at all ages, and about 30 percent of hospitalized cases have been severe enough to require treatment in an intensive care unit, according to a study in the November 4 issue of JAMA.

"Since April 17, 2009, when the first 2 cases of pandemic influenza A(H1N1) virus infection were reported in California, the virus has rapidly spread throughout the world," the authors write. They add that preliminary comparisons with seasonal influenza suggest that this influenza infection disproportionately affects younger ages and causes generally mild disease.

Janice K. Louie, M.D., M.P.H., of the California Department of Public Health, Richmond, Calif., and colleagues examined the clinical and epidemiologic features of the first 1,088 hospitalized and fatal cases due to pandemic 2009 influenza A(H1N1) infection reported in California, between April 23 and August 11, 2009. On April 20 of this year the California Department of Public Health and 61 local health departments initiated enhanced surveillance for hospitalized and fatal cases of this infection.

The researchers found that of the 1,088 A(H1N1) cases, 344 (32 percent) were children younger than 18 years, with infants having the highest rate of hospitalization and persons age 50 years or older having the highest rate of death once hospitalized. The median (midpoint) age of all cases was 27 years. Fever, cough, and shortness of breath were the most common symptoms. Underlying conditions previously associated with severe influenza were reported in 68 percent of cases. Other underlying medical illnesses recorded included obesity, hypertension, hyperlipidemia and gastrointestinal disease. The median length of hospitalization among all cases was 4 days.

Three hundred forty cases (31 percent) were admitted to intensive care units, and of the 297 intensive care cases with available information, 65 percent required mechanical ventilation. Of the 884 cases with available information, 79 percent received antiviral treatment, including 496 patients (71 percent) with established risk factors for severe influenza. Of the 833 patients who had chest radiographs, 66 percent had infiltrates (evidence of infection involving the lungs), suggestive of pneumonia or acute respiratory distress syndrome. Rapid antigen tests were falsely negative in 34 percent of cases evaluated.

"Overall fatality was 11 percent (118/1,088) and was highest (18 percent - 20 percent) in persons aged 50 years or older," the researchers write. "Of the deaths, 8 (7 percent) were children younger than 18 years. Among fatal cases, the median time from onset of symptoms to death was 12 days." The most common causes of death were viral pneumonia and acute respiratory distress syndrome.

"In the first 16 weeks of the current pandemic, 2009 influenza A(H1N1) appears to be notably different from seasonal influenza, with fewer hospitalizations and fatalities occurring in elderly persons. In contrast with the common perception that pandemic 2009 influenza A(H1N1) infection causes only mild disease, hospitalization and death occurred at all ages, and up to 30 percent of hospitalized cases were severely ill. Most hospitalized cases had identifiable established risk factors; obesity may be a newly identified risk factor for fatal pandemic 2009 influenza A(H1N1) infection and merits further study."

"Clinicians should maintain a high level of suspicion for pandemic 2009 influenza A(H1N1) infection in patients presenting currently with influenza-like illness who are older than 50 years or have known risk factors for influenza complications, regardless of rapid test results. Hospitalized infected cases should be carefully monitored and treated promptly with antiviral agents," the authors conclude.



1107 Sneezing in times of a flu pandemic [Ann Arbor MI]--The swine flu (H1N1) pandemic has received extensive media coverage this year. The World Health Organization, in addition to providing frequent updates about cases of infection and death tolls, recommends hyper vigilance in daily hygiene such as frequent hand washing or sneezing into the crook of our arms. News reports at all levels, from local school closures to airport screenings and global disease surveillance, continue to remind us of the high risk.

In times of heightened health concerns, everyday behaviors like sneezing can serve as a reminder to wash our hands or take our vitamins. But, what if we overreact to everyday sneezes and coughs and sniffles? Can these signals transform healthy discretion into an unreasonable fearfulness about germs and more?

New research, forthcoming in Psychological Science, a journal of the Association for Psychological Science, from University of Michigan psychologists, Spike Lee and Norbert Schwarz, tested whether a heightened perception of risk for a flu pandemic might unconsciously trigger fears of other, totally unrelated hazards.

To test this, the researchers stationed an experimenter in a busy campus building and instructed her to sneeze loudly as students passed. The researchers then administered a survey to some of the students asking them to indicate their perceived risk of an "average American" contracting a serious disease, having a heart attack before age 50, or dying from a crime or accident.

The researchers found that those who had just witnessed someone sneezing perceived a greater chance of falling ill. They also indicated an increased fear of dying of a heart attack before age 50, dying in an accident or as a result of a crime. The researchers suggest that the public sneeze triggered a broad fear of all health threats, even ones that couldn't possibly be linked to germs.

The researchers then asked the same people their views on the country's existing health care system. Those within hearing distance of the sneezing actor had far more negative views of health care in America.

This finding was so striking that the psychologists ran another version of the sneezing scenario at a mall. This time, the interviewer himself sneezed and coughed while conducting a survey on federal budget priorities (i.e., should the government spend money on vaccine production or on green jobs?).

Participants were more likely to favor federal spending of $1.3 billion on the production of flu vaccines rather than the creation of green jobs when the experimenter sneezed. Thus, in times of a flu pandemic, "public sneezing has the power to shift policy preferences from other current priorities (i.e., green jobs) to the production of flu vaccines," says Schwarz.



1107 Researchers discover links between city walkability and air pollution exposure [Vancouver BC]--A new study compares neighborhoods' walkability (degree of ease for walking) with local levels of air pollution and finds that some neighborhoods might be good for walking, but have poor air quality. Researchers involved in the study include University of Minnesota faculty member Julian Marshall and University of British Columbia faculty Michael Brauer and Lawrence Frank.

The findings highlight the need for urban design to consider both walkability and air pollution, recognizing that neighborhoods with high levels of one pollutant may have low levels of another pollutant.

The study, done for the city of Vancouver, British Columbia, is the first of its kind to compare the two environmental attributes, and suggests potential environmental health effects of neighborhood location, layout and design for cities around the globe.

The research study is published in the November 2009 issue of Environmental Health Perspectives, the peer-reviewed journal of the United States' National Institute of Environmental Health Sciences, part of the U.S. Department of Health and Human Services.

The research team found that, on average, neighborhoods downtown are more walkable and have high levels of some pollutants, while suburban locations are less walkable and have high levels of different pollutants. Neighborhoods that fare well for pollution and walkability tend to be a few miles away from the downtown area. These "win-win" urban residential neighborhoods--which avoid the downtown and the suburban air pollution plus exhibit good walkability--are rare, containing only about two percent of the population studied. Census data indicate that these neighborhoods are relatively high-income, suggesting that they are desirable places to live. Neighborhoods that fare poorly for both pollution and walkability tend to be in the suburbs and are generally middle-income.

"Research has shown that exposure to air pollution adversely affects human health by triggering or exacerbating a number of health issues such as asthma and heart disease," said Marshall, a civil engineering faculty member in the University of Minnesota's Institute of Technology. "Likewise, physical inactivity is linked to an array of negative health effects including heart disease and diabetes. Neighborhood design can influence air pollution and walkability; more walkable neighborhoods may encourage higher daily activity levels."

In the study, researchers evaluated concentrations of nitric oxide, a marker of motor vehicle exhaust, and ozone, a pollutant formed when vehicle exhaust and other pollutants react, for 49,702 postal codes (89 percent of all postal codes) in Vancouver. The researchers assigned a walkability score by analyzing four common attributes of neighborhood design: land-use mixing, intersection density, population density and for retail areas, the relative amount of land area for shopping versus for parking.

More walkable neighborhoods tend to have mixed land uses, with destinations such as stores and shops within walking distance of people's houses. A conventional street grid and other more walkable road networks tend to have a higher intersection density, while less walkable neighborhoods often have circuitous road networks and low intersection density, thereby increasing average travel distances and reducing the likelihood that people will walk. More walkable areas generally have higher population density. Finally, in less walkable areas, stores devote a greater fraction of their land to parking.

"The finding that nitric oxide concentrations are highest downtown, while ozone concentrations are highest in the suburbs, is not surprising," said Marshall. "Motor vehicle exhaust is most concentrated downtown, leading to the high nitric oxide concentrations downtown. In contrast, ozone takes time to form. Air masses have moved away from downtown--often, to suburban areas--by the time ozone concentrations reach their highest levels. Thus, reductions in vehicle emissions can benefit people who live near high-traffic areas and also people living in less dense areas."

Creating neighborhoods that are more walkable and that allow for alternative travel modes such as walking, biking or public transportation is one approach to reducing motor vehicle emissions, the study suggests. Another approach is reducing emissions per vehicle, for example through mandated emission standards. The research did not study conditions for individual people, but points out that high-rise buildings may allow people to live in walkable neighborhoods while being somewhat removed from street-level vehicle emissions.

The study's new findings indicate that neighborhood design is an important consideration for improving pollution levels and providing opportunities for daily physical activity. The study identified neighborhoods that are walkable yet have low levels of pollution, but those neighborhoods encompass a very small percentage of the population. Researchers hope that future investigation of those "win-win" neighborhoods will suggest urban design features that could usefully be applied elsewhere.

In the future, the researchers hope to investigate changes over time in pollution and walkability, and also study other urban areas to see how spatial patterns may differ elsewhere.


1107 The entwined destinies of mankind and leprosy bacteria [Lausanne Switzerland]--For thousands of years an undesirable and persistent companion has been travelling with man wherever he goes. Mycobacterium leprae, the bacterium that causes leprosy, has only one known natural host – mankind. And because of man's many travels, this bacillus has colonized the entire earth. Its history is therefore intimately tied to our own, and it is this migratory relationship that Stewart Cole, EPFL professor of Microbial Pathogenesis, and his team have analyzed in a study to be published in Nature Genetics. Geneticists, microbiologists, and even archeologists have followed the bacteria's traces from their lab to the Silk Road and the tombs of Egyptian mummies.

The scientists started with the past history of the disease by investigating the remains of English, Croatian, and Bulgarian medieval cemeteries along with an ancient Egyptian burial site to find traces of the bacteria's DNA. "A person infected with the bacteria shows specific signs of bone deformations, like hands gripped closed in the form of a claw," explains Steward Cole, "and these clues helped us determine if we were dealing with the bodies of people who died from the disease."

In the wake of commercial ships

Even though Egypt is geographically close to East Africa, where one of the four strains of leprosy comes from, DNA from a 4th century mommy shows traces of the European strain. Not necessarily surprising, for the Pharaonic Empire was economically and culturally tied to the old continent. With humans being the only possible vessel for the bacteria, it naturally navigated along with man throughout the trade routes of the seas.

The four strains of the leprosy bacilli that the scientific team found are: European, East African, West African and Indian. Their current distribution around the world echoes the history of population movements. Other examples in the study include Madagascar where, in spite of its geographic proximity to the African coast, the Indian strain is found on the island, where the majority of the inhabitants are of Indian origin. In Brazil, the West African strain is dominant, a probable consequence of the slave trade, but we also find the European strain – brought most likely from colonization.

"One of the most interesting surprises is the discovery that the bacteria found in China are of European origin," explains Stewart Cole, "and one would have naturally expected the Indian strain. The most probable explanation is that the strain was carried by traders along the Silk Road."

A stable DNA, more efficient treatments

There is little doubt that the bacillus originated in East Africa – Stewart Cole will examine this hypothesis in a future study – and then mutated into the four different strains. "The results of our analysis are surprising," says Cole, "the difference between the different strains is very small. It is one of the most stable organisms ever observed, even if half of its genome is dead." There are only around a hundred different variations between the DNA of two different strains, whereas with HIV or the flu there may be thousands of difference mutations.

In the case of HIV, mutations are so frequent that it is almost possible to say whether a person was infected in Geneva or in Lausanne," explains Stewart Cole, "but in the case of leprosy, the most we can do is place the infection on a continental scale." But this is not bad news. Frequent mutation by a bacterium often leads to disturbing resistances to antibiotic treatments, such as with tuberculoses. But a more stable bacillus responds more efficiently to treatment regardless of the strain. "Resistant cases are extremely rare for leprosy."

Yet the disease remains a persistent public health issue in certain regions in India and Brazil. Currently, more than 700,000 people are infected world-wide and the length of treatment of at least one year can complicate its application. We have not yet head the last from Mycobacterium leprae, but public health politics, spurred on by work done by the likes of Stewart Cole and his scientific team, could put an end to the common history between leprosy and its unwilling human host.


1107 Cause of common chronic diarrhea revealed in new research [London England]--A common type of chronic diarrhoea may be caused by a hormone deficiency, according to new research published in the November issue of Clinical Gastroenterology and Hepatology. The authors of the paper, from Imperial College London, with collaborators from King's College London and the University of Edinburgh, say their results could help more doctors recognise this type of diarrhoeal illness, and may lead to the development of more effective tests and treatments to help improve the lives of many people suffering with chronic diarrhoea.

Chronic idiopathic bile acid diarrhoea affects an estimated one in 100 people in the UK and it can cause people to have up to ten watery bowel movements a day, often for months at a time. This type of diarrhoea occurs when an overload of bile acid reaches the colon and causes excess water to be secreted into the bowel.

Today's study suggests that bile acid diarrhoea is caused by the body producing too much bile acid, because of a deficiency in a hormone called FGF19, which normally switches off bile acid production. The authors of the study say that new hormone-based treatments could be developed in the future to treat the condition and doctors could potentially test people's hormone levels to diagnose it.

Dr Julian Walters, lead author of the study from the Division of Medicine at Imperial College London, said: "Bile acid diarrhoea is a common condition, likely to affect more people than Crohn's disease or ulcerative colitis, yet until now we did not understand exactly what causes it. People with bile acid diarrhoea need to use the toilet urgently many times during the day and night. This can have a big impact on their lives, at home, at work and while they are travelling, as they always need to be near a toilet.

"If they are diagnosed, we have treatments that can remove bile acid from the colon, alleviate the symptoms and improve their quality of life. However, the current test used to diagnose the condition is not available in many countries and requires patients to attend the hospital twice. This means many people are not diagnosed. Our new findings mean that in the future doctors may be able to diagnose the condition by doing a quick and simple blood test," added Dr Walters.

Bile acid is produced by enzymes in the liver, to help the body digest fats. Its production is controlled by a hormone called Fibroblast Growth Factor 19 (FGF19). Over 90% of the bile acid is absorbed from the intestine back into the blood and is then reused. In healthy people, when bile acid is absorbed by the intestine, the body makes more FGF19 to stop new bile acid from being produced.

However, results of today's study suggest that people with bile acid diarrhoea make less FGF19, so the hormone 'switch' fails to stop the liver from producing more bile acid than the body needs. Because of this, more is produced than the intestine can absorb. This then irritates the colon and the resulting watery secretion causes diarrhoea.

The researchers say that testing the amount of FGF19 in people's blood could lead to a fast, easy and cheap way of diagnosing bile acid diarrhoea. They also hope today's findings will help scientists develop new treatments to increase the production of FGF19 and reduce the amount of bile acid being made in patients.

The researchers tested the amount of bile acid being produced in the livers of 17 patients diagnosed with bile acid diarrhoea and 19 healthy controls. They did this by measuring the amount of a molecule called C4 in the blood, which indicates how much bile acid is being made. The results showed that the people with bile acid diarrhoea were producing an average of nearly three times more bile acid than the controls, with 51 nanograms of C4 per millilitre of blood in the patient group, compared to 18 nanograms per millilitre in the control group.

The researchers then measured the amount of FGF19 in the patients and controls. The results showed that the people with bile acid diarrhoea were producing around half the level of the hormone than the controls, with 120 picograms of FGF19 per millilitre of blood levels in the patient group, compared to 231 picograms per millilitre in the control group.

These results suggest that there is a significant link between bile acid production and decreased levels of FGF19 in people with bile acid diarrhoea. The researchers say that, following this small study, further research is needed to see if these findings can be replicated.



1107 Modified Bluetooth speeds up telemedicine [Coimbatore India]--A telemedicine system based on a modified version of the Bluetooth wireless protocol can transfer patient data, such as medical images from patient to the healthcare provider's mobile device for patient assessment almost four times as fast as conventional Bluetooth and without the intermittent connectivity problems, according to a paper in the forthcoming issue of the International Journal of Medical Engineering and Informatics.

Telemedicine is a rapidly developing technology of clinical medicine where medical information is transferred via telephone, the internet or other networks for the purpose of consulting as a remote medical procedure. However, there are drawbacks to using direct connections between monitoring devices and the healthcare provider, not least the intermittency of standard connections.

Now, T. Kesavamurthy and Subha Rani of the PSG College of Technology Peelamedu, in Coimbatore, India, have devised a dedicated embedded system that uses the short-range Bluetooth wireless networking protocol to connect patient data to the network and then on to the healthcare provider. This avoids the problem of trying to ensure that a viable connection between monitoring devices and the internet or cellular phone network is maintained constantly.

The team has demonstrated a specific application of their technology which involves the transfer of patient medical images (CT scans) to the healthcare provider's personal digital assistant (PDA) device as an example of how Bluetooth might work for telemedicine.

"In medical imaging, picture archiving and communication systems (PACS) are computers in networks dedicated to the storage, retrieval, distribution and presentation of images," the team explains. However, PACS, which replaces hard-copy based means of managing medical images, such as film archives, cannot circumvent the connectivity issues associated with standard internet connections.

The team has developed a system that can handle the digital imaging and communications in medicine (DICOM) standard for medical images and use it to produce compressible images that can be transferred readily using Bluetooth.

The embedded system used in this project is an ARM based processor (AT91SAM9263), which is a 32 bit advanced embedded processor of the type commonly used in mobile data devices. "The design and implementation of an embedded wireless communication platform using Bluetooth serial communication protocol is proposed and problems and limitations are investigated," the team explains.

The team adds that tests with DICOM images of approximately 1.5 megabytes can be transferred using their modified Bluetooth system in just 120 seconds, compared with 400 seconds for standard Bluetooth.

"DICOM medical image transmission using Bluetooth through ARM based processor for telemedicine applications" in Int. J. Medical Engineering and Informatics, 2010, 2, 52-71



1107 PATH Malaria Vaccine Initiative shares strategy for developing 'next-generation' malaria vaccines [Nairobi Kenya]--Marking its tenth anniversary year, the PATH Malaria Vaccine Initiative (MVI) today unveiled a new strategy that sets the stage for an aggressive push targeting the long-term goal of eliminating and eradicating malaria. Malaria is one of the world's deadliest infectious diseases, killing nearly 900,000 people a year, most of them children in sub-Saharan Africa.

Released at the Fifth Multilateral Initiative on Malaria Pan-African Malaria Conference, the MVI strategy represents a multi-pronged approach to developing the next generation of malaria vaccines. The international community in 2006 set a long-term goal of having a malaria vaccine by 2025 that is at least 80 percent effective against clinical disease and lasts longer than four years.

"The malaria community has made impressive strides in reducing deaths in the last ten years, but malaria still incurs a crushing global burden," said Dr. Christian Loucq, Director of MVI. "History has shown us that a vaccine would add a powerful, cost-effective way to save lives and help eliminate this disease."

A key component of MVI's approach will build on the success-to-date of GlaxoSmithKline Biologicals' (GSK Bio) RTS,S malaria vaccine candidate, which has advanced to a further stage of development than ever seen before. In a Phase 2 study reported in 2008 in the New England Journal of Medicine, this vaccine was found to be 53 percent effective against clinical disease in young children. RTS,S is being developed through a partnership among MVI, GSK Bio, and study centers located across Africa.

If successful in Phase 3 testing and licensure, RTS,S could satisfy the intermediate goal set forth in the international community's Malaria Vaccine Technology Roadmap of a "first-generation" malaria vaccine that is at least 50 percent effective against severe disease and death and lasts more than one year. While this would be a landmark achievement, the road to elimination and eradication requires filling the vaccine pipeline with promising new candidates that both build on the success of RTS,S and take different paths toward immunization.

"Our new strategy will build, efficiently and aggressively, on the incredible knowledge generated in MVI's first decade of operation," Loucq added.

Cultivating new approaches

While most malaria vaccine candidates use one or more components of the malaria parasite to elicit an immune response, another approach uses a weakened form of the whole parasite. MVI is working with Sanaria Inc. to develop a novel vaccine candidate that uses this approach with Plasmodium falciparum. Sanaria's vaccine approach is currently being tested in adult volunteers in the United States.

In addition to these vaccine approaches being tested in humans, MVI has numerous feasibility studies underway to develop the vaccine candidates of the future, most focused on developing specific vaccine components. Only the most promising of these will advance to clinical development.

Like RTS,S, many of these studies are focused on the pre-erythrocytic approach. They aim to trigger the immune system to defend against the parasite as soon as it enters a person's bloodstream or infects liver cells. This prevents the parasite from maturing and multiplying in the liver, reentering the bloodstream, and infecting red blood cells.

Another approach targets the malaria parasite when it is most destructive: at the blood stage, when the parasite replicates rapidly in red blood cells. Blood-stage vaccines are not expected to block all infection. Instead, they aim to decrease the number of parasites in the blood, reducing the severity of malaria. MVI will continue to make limited investments in this area, but sees the fruit of this effort as yielding additional components that could be combined with a pre-erythrocytic vaccine, for example, to further boost its effectiveness.

Targeting the mosquito and the most widespread form of malaria

MVI is also looking for vaccine candidates that block the transmission of malaria from mosquitoes to humans. Transmission-blocking vaccines attempt to interrupt the life cycle of the parasite by inducing antibodies that prevent the parasite from maturing in the mosquito after it bites a vaccinated person. Transmission-blocking vaccines would not prevent people from getting malaria, but they could significantly limit the spread of infection.

Another element of MVI's strategy addresses the need to develop vaccines against P. vivax, the less severe but more widespread malaria parasite affecting humans. MVI plans to intensify its support for vivax approaches in hopes of eventually combining them with vaccines targeting P. falciparum, the parasite most deadly to humans and the one targeted by most vaccine research, including MVI's.

Developing tools to measure success

As the number of potential malaria vaccine candidates increases, scientists will need new and better technologies to assess their potential efficacy and decide which should go forward. MVI is supporting the refinement and development of both laboratory tools and methodologies for evaluating vaccine candidates in humans. For example, MVI is supporting development of the Human Challenge Center at the Seattle Biomedical Research Institute that, beginning in 2010, will offer early-stage testing in humans of the safety and efficacy of malaria vaccine candidates.

Continuing need for collaboration

Over the past ten years, MVI has worked with a wide range of partners and the numbers continue to grow.

"We are looking both inside and outside the malaria research community, towards investing aggressively in approaches and technologies that are at an earlier stage of development," Loucq said. "This approach involves many smaller investments in projects that are evaluated as quickly as possible for their feasibility, another way we seek to maximize efficiency and use of scarce resources."

This partnership-based approach has yielded positive results, according to MVI, as seen in the advancement of RTS,S to a Phase 3 trial, the upgrading of clinical trial and research capacity in locations across Africa, and in the decisions by several African countries to put in place mechanisms to facilitate informed decision-making on malaria vaccine use, once one becomes available.

"We see the scientific aspects of our work resulting in a toolbox containing the components for highly effective vaccines against malaria," said Ashley Birkett, MVI's Director of Preclinical Research and Development. "But we are always conscious that our first priority is simply to save the lives of those who need it most—the children of Africa."

MVI stresses, however, that its new strategy is a work in progress and one that will require sustained support.

"Our plan is to maintain sufficient flexibility so that if one or more of our approaches is highly successful, we will be able to realign budget and strategy to accelerate its development," said Loucq. "But what is still as true today as ten years ago is that we cannot achieve our goals without the sustained commitment of partners, including national governments, industry, other researchers, and donors."


1107 Study examines associations between antibiotic use during pregnancy and birth defects [Atlanta GA]--Penicillin and several other antibacterial medications commonly taken by pregnant women do not appear to be associated with many birth defects, according to a report in the November issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals. However, other antibiotics, such as sulfonamides and nitrofurantoins, may be associated with several severe birth defects and require additional scrutiny.

Treating infections is critical to the health of a mother and her baby, according to background information in the article. Therefore, bacteria-fighting medications are among the most commonly used drugs during pregnancy. Although some classes of antibiotics appear to have been used safely during pregnancy, no large-scale studies have examined safety or risks involved with many classes of antibacterial medications.

Krista S. Crider, Ph.D., of the Centers for Disease Control and Prevention, Atlanta, and colleagues analyzed data from 13,155 women whose pregnancies were affected by one of more than 30 birth defects (cases). The information was collected by surveillance programs in 10 states as part of the National Birth Defects Prevention Study. The researchers compared antibacterial use before and during pregnancy between these women and 4,941 randomly selected control women who lived in the same geographical regions but whose babies did not have birth defects.

Antibacterial use among all women increased during pregnancy, peaking during the third month. A total of 3,863 mothers of children with birth defects (29.4 percent) and 1,467 control mothers (29.7 percent) used antibacterials sometime between three months before pregnancy and the end of pregnancy.

"Reassuringly, penicillins, erythromycins and cephalosporins, although used commonly by pregnant women, were not associated with many birth defects," the authors write. Two defects were associated with erythromycins (used by 1.5 percent of the mothers whose children had birth defects and 1.6 percent of controls), one with penicillins (used by 5.5 percent of case mothers and 5.9 percent of controls), one with cephalosporins (used by 1 percent of both cases and controls) and one with quinolones (used by 0.3 percent of both cases and controls).

Two medications—sulfonamides and nitrofurantoins (each used by 1.1 percent of cases and 0.9 percent of controls)—were associated with several birth defects, suggesting that additional study is needed before they can be safely prescribed to pregnant women.

"Determining the causes of birth defects is problematic," the authors write. "A single defect can have multiple causes, or multiple seemingly unrelated defects may have a common cause. This study could not determine the safety of drugs during pregnancy, but the lack of widespread increased risk associated with many classes of antibacterials used during pregnancy should be reassuring."

Editor's Note: The National Birth Defects Prevention Study is funded by a cooperative agreement from the Centers for Disease Control and Prevention.



1107 Ineffective monotherapies common in high-burden malarious countries [Nairobi Kenya]--ACTwatch, a research project led by PSI, in collaboration with the London School of Hygiene and Tropical Medicine, released evidence today that indicates that artemisinin combination therapy, the most effective medicines for treating malaria, continue to have a significantly low presence on the market among populations considered to be most at risk.

Announcing the results at the 5th Multilateral Initiative on Malaria (MIM) Pan-African Malaria Conference in Nairobi, Dr. Kathryn O'Connell presented on the current state of the antimalarial market across 6 sub-Saharan African countries and Cambodia. Data on availability, pricing and volumes for 23,000 antimalarials, sourced from 20,000 outlets, revealed a diverse market structure across countries. The majority of malaria endemic countries changed malaria treatment policies more than three years ago in the face of widespread drug resistance to monotherapies, adopting extremely effective artemisinin combination therapy; however, years later, the availability of these more effective medicines has been shown to be as low as 20% in public sector health facilities. Even in the private sector, where the majority of patients seek treatment, availability is still relatively low compared to cheaper, but less effective, drugs.

"These data confirm that access to ACTs is restricted by their high price. A full course of an adult treatment of ACT can be up to 65 times the minimum daily wage. This provides an overpowering incentive for a consumer to make the wrong antimalarial choice," says Dr. Desmond Chavasse, Vice President of Malaria Control and Child Survival at PSI.

Worryingly, in most countries, ACTs currently make up only 5󈝻% of the total volume of antimalarials on the market, with ineffective monotherapies dominating the market share. More disturbing still, despite a call by the World Health Organisation to ban artemisinin monotherapies, these continue to permeate private sector markets in key countries such as Nigeria and the Democratic Republic of Congo, which together account for 30% of the total malaria-related disease burden in sub-Saharan Africa. In the Nigerian context this is particularly important as approximately 95% of all antimalarials are delivered through the private sector.

With most people accessing antimalarial medication through the private sector, price becomes a critically important barrier affecting demand and utilisation of the more expensive but also most effective treatments. Artemisinin combination therapies can be over twenty times more expensive than ineffective therapies such as chloroquine; for example, some artemisinin combination therapies cost as much as $11 in the private sector, while ineffective antimalarials typically cost a mere $0.30 cents.

ACTwatch data from Cambodia, a country that has implemented a subsidy with the support of PSI, reveals that the most effective antimalarials are sold at around $1.20, which although still expensive compared to ineffective monotherapy sold for $0.20 cents, is a marked improvement compared to other countries. In fact, 60% of all antimalarials provided to patients in Cambodia are now the more effective artemisinin combination therapies.

"The operation of the distribution chain has a major influence on which antimalarials are available to retailers, and their price and quality," says Dr. Kara Hanson of the London School of Hygiene & Tropical Medicine. "Influencing practices of providers near the top of the chain may be the most cost-effective way to change outcomes in this market."

Funded by a $10 million grant to PSI from the Bill & Melinda Gates Foundation, ACTwatch is providing the critical information necessary to make evidence-based policy decisions around the issue of increasing access to ACTs. The project will serve as a thermometer for the success of global interventions aimed at reducing the price and increasing the availability of the most effective antimalarials, including global financing mechanisms such as the Affordable Medicines Facility for malaria (AMFm).



1107 First national zinc campaign for childhood diarrhea increases awareness, but use lags behind [International Center for Diarrhoeal Research]--In a study assessing the impact of the first national campaign to scale up zinc treatment of diarrhea in Bangladesh, researchers found that awareness was high but usage lagged behind.


In this week's open access journal PLoS Medicine, Charles Larson and colleagues from International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) report the results of seven repeated ecologic surveys in four areas in Bangladesh, representing 1.5 million children under the age of 5.

The researchers found that awareness was less than 10% in all communities pre-launch and peaked 10 months later at 90, 74, 66 and 50% in urban non-slum, municipal, urban slum, and rural sites, respectively. After 23 months 25% of urban non-slum, 20% of municipal and urban slum, and 10% of rural children under 5 years were actually receiving zinc for childhood diarrhea.


Use of zinc was found to be safe, with few side-effects, and did not affect the use of traditional treatments for diarrhea. The researchers also found that many children were not given the correct 10-day course of treatment: 50% of parents were sold seven or fewer zinc tablets.

The ''Scaling Up of Zinc for Young Children'' (SUZY) project, funded by the Bill & Melinda Gates Foundation, was established in 2003 to develop a scale-up campaign, produce and distribute zinc tablets, train health professionals to provide zinc treatment, and create media campaigns (such as adverts in TV, radio, and newspapers) to raise awareness and promote the use of zinc for diarrhea.

Diarrheal disease is a significant global health problem causing about 4 billion cases and 2.5 million deaths annually, and disproportionately affecting those in the developing world. Clinical trials show that zinc can help reduce the severity and duration of diarrhea as well as lower the likelihood of a repeat episode in the future. Zinc is now included in the guidelines by the World Health Organization (WHO)/UNICEF for treatment of childhood diarrhea.

Funding: This study was funded by the Bill & Melinda Gates Foundation, grant number 00231. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Citation: Larson CP, Saha UR, Nazrul H (2009) Impact Monitoring of the National Scale Up of Zinc Treatment for Childhood Diarrhea in Bangladesh: Repeat Ecologic Surveys. PLoS Med 6(11): e1000175. doi:10.1371/journal.pmed.1000175



1107 Genes and environment may interact to influence risk for post-traumatic stress disorder [New Haven CT]--Individuals who experience both childhood adversity and traumatic events in adulthood appear more likely to develop post-traumatic stress disorder than those exposed to only one of these types of incidents, according to a report in the November issue of Archives of General Psychiatry, one of the JAMA/Archives journals. In addition, the risk was further increased in individuals with a certain genetic mutation.

Although 40 percent to 70 percent of Americans have experienced traumatic events, only about 8 percent develop PTSD during their lifetimes, according to background information in the article. PTSD is a complex anxiety disorder that involves re-experiencing, avoidance and increased arousal following exposure to a life-threatening event. "In addition to the obvious effect of environmental factors, PTSD has a heritable component," the authors write. Recent studies estimate that genetic factors account for approximately 30 percent of the difference in PTSD symptoms.

Pingxing Xie, B.S., of Yale University School of Medicine, New Haven, Conn., and VA Connecticut Healthcare Center, West Haven, and colleagues studied 1,252 individuals who had experienced childhood adversity (including abuse or neglect), adult trauma (such as combat, sexual assault or a natural disaster) or both. Participants age 17 to 79 (average age 38.9) were interviewed and assessed for a variety of psychiatric and substance use disorders. DNA was extracted and used to differentiate between versions of a particular polymorphism or gene mutation—known as the 5-HTTLPR genotype—previously found to be associated with emotional response after stressful life events.

About one-fifth of the participants (229, or 18.3 percent) met criteria for PTSD. A total of 552 of the 1,252 participants (44.1 percent) experienced both childhood adversity and traumatic events in adulthood. These individuals were more likely to have a lifetime diagnosis of PTSD than were those who experienced trauma in only one life stage (29 percent vs. 9.9 percent).

"Although the 5-HTTLPR genotype alone did not predict the onset of PTSD, it interacted with adult traumatic events and childhood adversity to increase the risk for PTSD, especially for those with high rates of both types of trauma exposure," the authors write. The genotype may influence the way the brain processes the neurotransmitter serotonin, affecting an individual's anxiety levels and changing the way neurons react to fearful stimuli, they note.

"It was only in the group of subjects who could be characterized as having had the highest rates of trauma exposure (i.e., in both childhood and adulthood) that an impact of 5-HTTLPR could be detected," the authors conclude. "This suggests that there may be many neurobiological (including genetically determined) 'buffers' to PTSD; only in instances of extreme and/or repeated trauma exposure (which, it should be pointed out, characterizes those trauma 'types' with the highest conditional risk for PTSD, e.g., domestic violence and military combat), in which these buffers are overwhelmed, can the impact of specific genes such as 5-HTTLPR be detected."

This work was supported by National Institutes of Health grants.



1107 Many US children may live in families receiving food stamps [St Louis MO]--Nearly half of all American children will reside in a household receiving food stamps at some point between the ages of 1 and 20, according to a report in the November issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.

"Research has repeatedly demonstrated that two of the most detrimental economic conditions affecting a child's health are poverty and food insecurity," the authors write as background information in the article. The receipt of food stamps serves as a marker of both, since families receiving them must have low incomes and few assets.


"Understanding the degree to which American children are exposed to the risks of poverty and food insecurity across the length of childhood would appear to be an essential component of pediatric knowledge, particularly in light of the growing emphasis on the importance of community pediatrics."

Mark R. Rank, Ph.D., of the George Warren Brown School of Social Work, Washington University, St. Louis, and Thomas A. Hirschl, Ph.D., of Cornell University, Ithaca, New York, analyzed 30 years of longitudinal data from a nationally representative sample of the U.S. population, the Panel Study of Income Dynamics. During household interviews conducted between 1968 and 1997, demographic and other information was collected regarding children ages 1 through 20, and families reported whether they had received food stamps over the prior year.

By age 1, 12.1 percent of children had lived in households receiving food stamps; 26.1 percent had by age 5, 35.9 percent by age 10, 43.6 percent by age 15, and 49.2 percent by age 20. By age 20, in addition to nearly half receiving food stamps during at least one year of the study period, about one-third of children received them for two or more years, 28.1 percent for three or more years, 26.4 percent for four or more years and almost one-fourth (22.8 percent) for five or more years.

Race, education and marital status all were associated with the receipt of food stamps among children. Black children and those who lived in households headed by adults who were unmarried or had less than 12 years of education were more likely to receive food stamps.

Poverty has been estimated to raise the direct expenditures on children's health care by approximately $22 billion per year. "American children are at a high risk of encountering a spell during which their families are in poverty and food insecure as indicated through their use of food stamps," the authors conclude. "Such events have the potential to seriously jeopardize a child's overall health."

Funding for the analysis in this study was provided by a Joint Center for Poverty Research Development Grant, Northwestern University/University of Chicago.

Editorial: Pediatricians Must Advocate for Children's Interests

"This experience with the Food Stamp Program/Supplementary Nutritional Assistance Program reflects the broader fact that a large portion of American families rely on safety net programs for the necessities of life," writes Paul H. Wise, M.D., M.P.H., of Lucile Packard Children's Hospital and Stanford University, Stanford, Calif., in an accompanying editorial.

"The paradox at the heart of our current safety net system is that the economic conditions generating the growing need for services are, at the same time, also undermining our collective ability to provide them," Dr. Wise writes. "The bottom line is that the current recession is likely to generate for children in the United States the greatest level of material deprivation that we will see in our professional lifetimes. The recession is harming children by both reducing the earning power of their parents and the capacity of the safety net to respond."

"However, it is also essential to recognize that children have been made extremely vulnerable to this recession by a decades-long deterioration in their social position," Dr. Wise continues. "In response, the pediatric community will have to address the enhanced needs of patients, strengthen its capability to take collective action and invigorate its voice in public discourse."



1107 Notorious 'man-eating' lions of Tsavo likely ate about 35 people -- not 135 [Santa Cruz CA]--The legendary "man-eating lions of Tsavo" that terrorized a railroad camp in Kenya more than a century ago likely consumed about 35 people--far fewer than popular estimates of 135 victims, according to a new analysis led by researchers at the University of California, Santa Cruz. The study also yields surprises about the predatory behavior of lions.

Despite the notoriety of the attacks--the harrowing nine-month saga has been the subject of three Hollywood films, and the lions remain a popular exhibit at the Field Museum of Natural History in Chicago--the number of victims has been a matter of dispute. The new study, "Cooperation and Individuality Among Man-Eating Lions," appears in the Nov. 2 issue of the Proceedings of the National Academy of Sciences. The research utilized a sophisticated stable-isotope analysis to investigate this vexing question.

By analyzing samples of the hair and bone of the lions, researchers were able to estimate that one lion likely ate 11 humans and the other consumed 24 people during the animals' final nine months. Both lions were shot and killed in December 1898 by Lt. Col. John H. Patterson, a British officer and engineer hired to restore safety in the region. For years after, Patterson, who gained great notoriety for the feat, claimed the lions had killed 135 people--far more than the Ugandan Railway Company's estimate of 28 victims.

"This has been a historical puzzle for years, and the discrepancy is now finally being addressed," said Nathaniel J. Dominy, an associate professor of anthropology at UCSC. "We can imagine that the railroad company might have had reasons to want to minimize the number of victims, and Patterson might have had reasons to inflate the number. So who do you trust? We're removing all those factors and getting down to data."

Dominy and lead author Justin D. Yeakel, a doctoral candidate in ecology and evolutionary biology at UCSC, collaborated on the project with Bruce D. Patterson, the MacArthur Curator of Mammals at the Field Museum (no relation to John H. Patterson).

To investigate each lion's lifetime dietary patterns, Yeakel analyzed samples of their bone collagen and hair keratin that were provided by the Field Museum. He then compared those data to the isotopic signatures of the lions' presumptive prey, including modern grazing and browsing animals, and humans. Human samples were obtained from the remains of Kenya's Taita population that were gathered by anthropologist Louis Leakey during his famous East African Archaeological Expedition of 1929.

The results suggest that during the final months of what John Patterson described as the lions' "reign of terror," fully half of one lion's diet consisted of humans, with the balance made up of mid-sized grazing animals such as gazelles and impala. Strikingly, the other lion ate very few humans, subsisting instead on herbivores. That dietary disparity leads Dominy and Yeakel to infer that the Tsavo lions worked together to scatter everyone, both humans and wild game, setting the stage for one to gorge on humans and the other to feed on herbivores.

"The idea that the two lions were going in as a team yet exhibiting these dietary preferences has never been seen before or since," said Dominy.

Cooperative hunting is beneficial when lions are stalking large prey like Cape buffalo and zebra, but humans are small enough that lions don't typically need to work together to make a kill. In this case, an array of conditions may have temporarily altered the lions' behavior, including drought and disease that depleted the availability of the lions' conventional prey. In addition, large numbers of people and animals had gathered for the railroad project, and severe dental problems and a jaw injury suffered by one of the lions probably greatly inhibited its ability to hunt.

"These findings underscore the complexity of what lions are capable of doing, and the complex interplay of costs and benefits that determine the size of their coalitions," he said.

The stark dietary differences highlight the importance of considering individuals within populations, said Yeakel. "In ecology, we often think of a population as being the sum of its parts, but there can be really rich things happening among individuals in a population," he said. "It's a new way of thinking about how populations work to consider how individuals affect the whole."

More than a century after the attacks, the Tsavo lions remain notorious; last year, the National Museum of Kenya began an effort to recover the remains of the lions, saying they represent an important part of the country's history and heritage. The grisly chapter finally ended in December 1898, when John Patterson--after nine months spent in pursuit of the animals--shot and killed one lion, then killed the second lion 20 days later. During the final three months of the nine-month siege, lion attacks were a "nightly occurrence," and work on the railroad expansion had ground to a halt as terrified laborers refused to work, said Dominy, noting that the delay prompted the first and only mention of lions in Britain's House of Parliament as members demanded an explanation for the work stoppage.

Ending the terror earned John Patterson widespread and enduring fame, but Dominy wonders if the boastful hunter might have exaggerated his estimate of victims to enhance his own reputation. "The railroad company attributed the deaths of 28 Indian nationals to the lions, and Patterson may have reasonably assumed scores of Africans were also killed," said Dominy. "But based on our statistical analysis, there's an outside chance they ate as many as 75 people. Our evidence attests only to the number of people eaten, not the number of people killed."

In 1924, John Patterson sold the hides of the lions--which he had used as rugs--to the Field Museum, where taxidermists restored and stuffed the pelts and mounted a diorama that continues to fascinate museum visitors today. Patterson's 1907 book, The Man-Eaters of Tsavo, was an international bestseller when it was published, and it remains in print today.

"The fact that we can determine both the diet and the behavior of two animals killed more than a century ago is a testament to the enduring value of museum collections and the science that interprets them," said Field Museum curator Bruce Patterson. "The rather extravagant claims (Colonel) Patterson made in his book can now be pretty much dismissed."

For Dominy, downgrading the number of human victims of the Tsavo lions is the latest chapter in a legend that takes a new turn with the insights about lion predation offered by these animals. The path of human evolution has been shaped by predation, said Dominy, noting that the efficiency benefits of bipedalism are gained at the cost of speed, making humans vulnerable to quick, four-legged predators, including lions.

"In a discussion of bipedalism, Louis Leakey once said, 'People are not cat food,' " said Dominy. "But they are. This study proves that."

In addition to Dominy, Yeakel, and Bruce Patterson, coauthors on the paper are Kena Fox-Dobbs, assistant professor of geology at the University of Puget Sound; Mercedes M. Okumura, research curator in human evolutionary anatomy at the Leverhulme Centre for Human Evolutionary Studies at the University of Cambridge; Thure E. Cerling, distinguished professor of biology and of geology and geophysics at the University of Utah; Jonathan W. Moore, assistant professor of ecology and evolutionary biology at UCSC; and Paul L. Koch, professor of earth and planetary sciences at UCSC.



1103 Mount Sinai assessing health impacts of 1 of the nation's largest environmental disasters [New York NY]--Over nearly a century, thousands of residents and workers in Libby, MT, have been exposed to asbestos-contaminated vermiculite ore, leading to markedly higher rates of lung disease and autoimmune disorders, and causing to Libby in 2002 to be added to the federal Environmental Protection Agency's "National Priorities List."

Researchers at Mount Sinai School of Medicine, leading a team of investigators from four institutions, are now launching three investigations into disease pathology in the town and to determine recommended cleanup efforts.

The Principal Investigator of the project is Stephen Levin, MD, Associate Professor of Preventive Medicine at Mount Sinai School of Medicine and a nationally known expert in occupational medicine and asbestos-related diseases who has also served as PI of the nationwide World Trade Center Medical Monitoring & Treatment Program, coordinated by Mount Sinai since 2002.

"The asbestos-related disease in Libby is far more aggressive and rapidly progressive than what's seen in most asbestos-exposed workers, with high rates of cancers and severe effects on respiratory function," said Dr. Levin. "For that reason alone, the health problems in Libby are important to study and understand."

The first of the three programs will focus on particular risks of exposure to Libby asbestos during childhood, when lungs are still developing and maturing. This research may determine the level of environmental cleanup necessary in Libby to protect children, who are a particularly sensitive target population.

A second study will compare lung scarring among Libby residents who were exposed to asbestos only in their environment (and not at their place of employment) with lung scarring seen in workers with historically long-term, heavy exposure to common commercial forms of asbestos. Researchers hope to discover why Libby residents have advanced rates of lung scarring. They will also investigate the mechanism for asbestos-related scar formation and approaches to preventing scar formation after exposure has already occurred.

The third investigation will examine the relationships between autoimmune disorders, autoimmune antibody abnormalities, and CT-scan evidence of scarring lung disease in the context of exposure to Libby asbestos. Auto-immune disorders such as rheumatoid arthritis and lupus have been found to occur more frequently in Libby, and antibody levels to the body's own tissues are found in Libby residents more frequently and at higher concentrations.

Mount Sinai researchers will collaborate on the research effort, to be known as the Libby Epidemiology Research Program, with Libby's Center for Asbestos Related Disease (CARD), investigators from the University of Montana and Idaho State University, and a national scientific advisory group. The research will be supported by a grant of over $4.8 million from the Agency for Toxic Substances and Disease Registry (ATSDR) of the federal Center for Disease Control and Prevention.

The crisis in Libby, a mining town whose history has been shaped by vermiculite-producing corporations since the 1920s, is the result of community-wide occupational and environmental exposure to Libby's naturally occurring vermiculite, contaminated with asbestos and asbestos-like silicate fibers up to 26% by weight.

Health effects have been detected not just in mine and processing plant workers, area lumber mill workers and loggers (from asbestos dusting of forests) and their families, but also among other Libby residents and their children. Many were exposed through ambient air or to mine tailings and other contaminated materials provided to the town by mining companies for the construction of ball fields, school running tracks, playgrounds, public buildings and facilities, as well as for private gardens and house and business insulation.

There is evidence that even relatively low-level exposures to Libby asbestos can cause serious scarring lung diseases, which markedly impair respiratory function, as well as asbestos-related cancers like lung cancer and mesothelioma, which occur at higher rates among the Libby population than elsewhere in the United States.

The health crisis potentially extends far beyond the borders of Libby, since millions of homes and businesses in North America have used vermiculite from Libby as attic insulation, fireproofing and soil conditioner. The ore from Libby was shipped by rail to 49 plant locations throughout North America and the Caribbean for processing, exposing many more workers and communities to the hazardous dust.

CARD Director Brad Black, MD, said, "The pattern of asbestos disease caused by exposure to Libby amphibole asbestos has led to excessive morbidity and mortality for the Libby population, and has been exceedingly challenging for the medical community. The severity of nonmalignant pulmonary disease in non-occupational exposure has been very unusual, raising question as to the potency of the unique amphibole mixture. We look forward to working with Dr. Levin and Mount Sinai to find some of these answers."



1103 Flu vaccine given to women during pregnancy keeps infants out of the hospital [New Haven CT]--Infants born to women who received influenza vaccine during pregnancy were hospitalized at a lower rate than infants born to unvaccinated mothers, according to preliminary results of an ongoing study by researchers at Yale School of Medicine. The team presented the study October 29 at the 47th annual meeting of the Infectious Diseases Society of America in Philadelphia.

Influenza is a major cause of serious respiratory disease in pregnant women and of hospitalization in infants. Although the flu vaccine is recommended for all pregnant women and children, no vaccine is approved for infants less than six months of age. Preventive strategies for this age group include general infection control and vaccination of those coming in close contact with them. Few studies have examined the effectiveness of the flu vaccine during pregnancy.

Led by Marietta Vázquez, M.D., assistant professor of pediatrics at Yale School of Medicine, this new study is a case-control trial of the effectiveness of vaccinating pregnant women to prevent hospitalization of their infants. During nine flu seasons from 2000 to 2009, Vázquez and colleagues identified and tracked over 350 mothers and infants from 0 to 12 months of age who were hospitalized at Yale-New Haven Hospital. They compared 157 infants hospitalized due to influenza to 230 influenza-negative infants matched by age and date of hospitalization. The team interviewed parents to determine risk factors for influenza and reviewed medical records of both infants and their mothers to determine rates of vaccination with the influenza vaccine.

"We found that vaccinating mothers during pregnancy was 80 percent effective in preventing hospitalization due to influenza in their infants during the first year of life and 89 percent effective in preventing hospitalization in infants under six months of age," said Vázquez.

"These results not only have a positive impact on the health of susceptible infants, but also may be very cost effective, as it involves one vaccine providing protection to two individuals," Vázquez added. "The findings may also help establish public health policy, increase awareness of the importance of influenza vaccination during pregnancy, and even help to overcome barriers to vaccination."

Other authors on the abstract include Isaac Benowitz, Daina Esposito, Kristina DePeau, Richard A. Martinello, M.D. and Eugene D. Shapiro, M.D.



1103 Poorly cleaned public cruise ship restrooms may predict norovirus outbreaks [Boston MA]--A team of researchers from Boston University School (BUSM), Carney Hospital, Cambridge Health Alliance and Tufts University School of Medicine, have found that widespread poor compliance with regular cleaning of public restrooms on cruise ships may predict subsequent norovirus infection outbreaks (NoVOs). This study, which appears in the November 1st issue of Clinical Infectious Diseases, is the first study of environmental hygiene on cruise ships.

Outbreaks of acute gastroenteritis (AGE) often occur in close populations, such as among cruise ship passengers. Recent epidemiologic investigations of outbreaks of AGE confirmed that 95 percent of cruise ship AGE outbreaks are caused by norovirus. Despite biannual sanitation monitoring and hand hygiene interventions among passengers and crew members, 66 ships monitored by the United States Centers for Disease Control and Prevention experienced NoV infection outbreaks (NoVOs) between 2003 and 2008.

Trained health care professionals evaluated the thoroughness of disinfection cleaning of six standardized objects (toilet seat, flush handle or button, toilet stall inner handhold, stall inner door handle, restroom inner door handle, and baby changing table surfaces) with high potential for fecal contamination in cruise ship public restrooms.

The researchers found only 37 percent of the 273 randomly selected public restrooms that were evaluated on 1,546 occasions were cleaned daily. The overall cleanliness of the six standardized surfaces on each ship ranged from four to 100 percent. Although some objects in most restrooms were cleaned at least daily, on 275 occasions no objects in a restroom were cleaned for at least 24 hours.

Overall, the toilet seat was the best-cleaned object and the least thoroughly cleaned object was the baby changing table. Furthermore, 19 objects in 13 ships were not cleaned at all during the entire five-to-seven-day monitoring period. Toilet area handholds were largely neglected, accounting for more than half of the uncleaned objects on 11 ships. Although almost all standardized objects were assessed at the time of each evaluation, baby changing tables were not found in public restrooms on 79 percent of vessels. On three ships, none of the changing tables were cleaned during the study period. The thoroughness of cleaning did not differ by cruise line and did not correlate with Center for Disease Control and Prevention Vessel Sanitation Program inspection scores which averaged 97 out of a possible 100 points for the study vessels.

According to the researchers these findings are of particular note because five of the six evaluated objects could readily be directly contaminated by pathogens during regular use. "Although hand hygiene with soap after toileting may diminish the transmission of enteric pathogens via bathroom door knobs or pulls, hand washing is unlikely to mitigate the potential for any of the other toilet area contact surfaces to serve as a source of transmission of enteric pathogens," said lead author Philip Carling, MD, a professor of clinical medicine at BUSM. "Furthermore, there was a substantial potential for washed hands to become contaminated while the passenger was exiting the restroom, given that only 35 percent of restroom exit knobs or pulls were cleaned daily. Only disinfection cleaning by cruise ship staff can reasonably be expected to mitigate these risks," he added.

Although the thoroughness of disinfection cleaning was 30 percent on more than half of the ships, near-perfect cleaning was documented on several vessels, providing evidence that a high level of environmental hygiene is achievable. "We believe that additional studies on the role of contaminated surfaces in cruise ship NoV transmission are warranted to determine whether improved environmental hygiene will decrease the incidence, duration, or severity of outbreaks," added Carling.

Co-authors include Lou Ann Bruno-Murtha, DO, clinical instructor in medicine of Cambridge Health Alliance, and senior author, Jeffrey K. Griffiths, MD, MPH&TM, an associate professor in the department of public health and community medicine at Tufts University School of Medicine.



1103 Health literacy rates are lower for the disabled and those with lower English proficiency [Columbia MO]--According to the Institute of Medicine, more than 90 million Americans suffer from low health literacy -- a mismatch between patients' abilities to understand healthcare information and providers' abilities to communicate complex medical information in an understandable manner. In two recent studies, researchers at the University of Missouri found that two groups — those with limited English proficiency and those with disabilities — experience significantly lower health literacy than the general population.

"There is already a problem with low health literacy within the general population," said Diane Smith, assistant professor of occupational therapy and occupational science in the University of Missouri School of Health Professions. "When looking at populations with disabilities or limited English proficiency, people need to be more conscious that these particular populations may have more difficulty understanding information, such as treatment options or medication instructions, from their physicians."

In the two studies, researchers found that patients with disabilities or limited English proficiency (LEP) often perceived that their physicians did not listen to them, explain treatment options, treat them with respect, spend enough time with them, or involve them in the treatment decisions. In comparison to the general population, these concerns were much higher among these two groups. Among both groups, a lack of cultural understanding may contribute to poor patient-physician communication, Smith said.

In the LEP population, researchers found, in addition to health literacy issues, those with limited English proficiency had a significantly reduced access to healthcare. Few doctors have multi-lingual backgrounds — especially in rural areas — and it can be difficult to find a provider who can accommodate LEP patients. As a result, these patients make fewer doctor visits and receive less screenings and preventative care. LEP patients also may delay going to the doctor to avoid dealing with the frustrations of the language problems, Smith said.

The researchers found that communication complications also can be a problem among those with disabilities. Individuals who rely on sign language may need an interpreter to communicate with their doctors; interpreters are not always accessible. Assumptions about the disabled community also may contribute to low health literacy.

"Even within the health environment, there is a tendency to assume that if there is a physical disability there is a cognitive one as well," Smith said.

To try and manage the disparities, researchers suggest improving awareness of the problem among doctors. Organizations like Health Literacy Missouri and the University of Missouri Center for Health Policy host training sessions for physicians and other healthcare providers to help them understand health literacy and strategies to better communicate with their patients.

Communicating with medical students is an important strategy identified in the study. Training students about health literacy issues may improve health literacy in the future. To help those with LEP, Smith encourages the use of telehealth communications — a network that uses telecommunications technology to communicate health information and services. Currently, the Missouri Telehealth Interpretation Project provides LEP patients access to interpreters that would otherwise not be available. University of Missouri Health Care provides patients and families spoken and sign-language interpreter services and written translation services for 55 languages.

"Health literacy is being addressed in the healthcare reform debates because it's a safety issue and it's a cost issue," Smith said. "It costs a lot of money when people have to go back to the hospital because they aren't using their medications appropriately."

The researchers used data from the 2006 Medical Expenditure Panel Survey to conduct both studies. Further studies may look at other factors contributing to access to health care to help identify appropriate intervention strategies.

"If people don't understand instructions, they're not going to follow them," Smith said. "All the best treatment plans in the world aren't going to help if patients don't understand what they are supposed to do."

The study "Health Care Disparities for Persons with Limited English Proficiency: Relationships from the 2006 Medical Expenditure Panel Survey" was accepted into the Journal of Healthcare Disparities Research and Practice and will be published later this year. The study, "Disparities in patient-physician communication for persons with a disability from the 2006 Medical Expenditure Panel Survey," was published in Disability and Health Journal in 2009.



1103 Scientists report major advance in human antibody therapy against deadly Nipah virus [Rockville MD]--A collaborative research team from the Uniformed Services University of the Health Sciences (USU), Australian Animal Health Laboratory and National Cancer Institute, a component of the National Institutes of Health, reports a major step forward in the development of an effective therapy against two deadly viruses, Nipah virus and the related Hendra virus.


Nipah and Hendra viruses are found in Pteropid fruit bats (flying foxes) and are characterized by their recent emergence as agents capable of causing illness and death in domestic animals and humans.

In experiments carried out in ferrets at the Australian Animal Health Laboratory in Geelong, Victoria, Australia, where there is a high-level safety and security facility for working with live Nipah and Hendra viruses, the team of researchers demonstrated that giving an anti-virus human monoclonal antibody therapy after exposure to Nipah virus protected the animals from disease.

"These findings are extremely encouraging and clearly suggest the potential that a treatment for Hendra virus infection in a similar manner should be possible, given the very strong cross-reactive activity this antibody has against Hendra virus," said Deborah Middleton, D.V.M., Ph.D., who directed the animal experiments at the Australian Animal Health Laboratory.

Recent earlier work at the National Cancer Institute and USU resulted in the discovery and development of a human monoclonal antibody, m102.4, which could attack a critical component of both the Nipah and Hendra viruses. Antibodies—proteins found in blood or other bodily fluids of vertebrates—are used by the immune system to identify and neutralize viruses and bacteria.

The study's corresponding authors are Christopher C. Broder, Ph.D., professor of microbiology at USU, and Katharine Bossart, Ph.D., a USU alumna, now an assistant professor in the Department of Microbiology, Boston University School of Medicine and an investigator at the National Emerging Infectious Diseases Laboratories Institute in Boston. The pair led a team of researchers to test the effectiveness of the new antibody therapy in animals. The experiments were supported in part by the National Institute of Allergy and Infectious Diseases, NIH. The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. provides research support and management capabilities to the research team.

"We now have good evidence that this antibody could save human lives and the insights offered about how it works also could potentially provide a starting point to developing tools for targeting other diseases," said study co-author Dimiter S. Dimitrov, Ph.D., senior biomedical research scientist at the National Cancer Institute.

Nipah and Hendra viruses, members of the henipavirus family, are highly infectious agents that emerged from flying foxes in the 1990s to cause serious disease outbreaks in humans and livestock in Australia, Bangladesh, India, Malaysia and Singapore. Recent outbreaks have resulted in acute respiratory distress syndrome and encephalitis, person-to-person transmission, and up to 75 percent case fatality rates among humans. Additionally, these properties could allow the viruses to be used as bioterror weapons.

Initial experiments by the researchers using ferrets found that m102.4 was well tolerated, exhibited no adverse effects and retained high neutralizing activity. The findings suggested that m102.4 could potentially be used as a preventive or post-exposure agent, a diagnostic probe or a research reagent.

Hendra virus re-emerged again in August 2009, resulting in the death of several horses and one human. During the outbreak, in a compassionate attempt to save a human life, an available low dose of m102.4 was administered to an individual with advanced encephalitic disease. Although there were no adverse side effects, the patient did not improve as the irreversible damage by the virus had already been done. Like other antimicrobials, the clinical success of this antibody will depend on dose and time of administration. As Hendra and Nipah viruses cause severe disease in humans, a successful application of this antibody as a post-exposure therapy will likely require early intervention.

"In order to make clinical use of this therapeutic antibody against Hendra or Nipah virus, larger amounts will need to be prepared under proper manufacturing guidelines, carefully evaluated again in animal models and safety tested for human use" said Dr. Broder.

Dr. Bossart noted, "We hope this demonstration of anti-viral activity will foster some immediate activities to facilitate further development for future use in humans."

"There are currently no licensed and approved vaccines or therapeutics for prevention and treatment of disease caused by these viruses for humans or livestock," said Dr. Broder. "This fully-human monoclonal antibody is the first antiviral agent against the Nipah and Hendra viruses that has a genuine potential for human therapeutic use."

"The generation of these antibodies as therapeutics could help control outbreaks in geographical regions susceptible to henipaviruses, and could turn information from a deadly pathogen into a benefit for mankind," said Dr. Dimitrov.


The results of this finding appear Oct. 30, 2009, in the open access journal PLoS Pathogens at http://dx.plos.org/10.1371/journal.ppat.1000642.



1103 A look at public policies and motorcycle safety in the US [Coral Gables FL]--One of the joys of riding a motorcycle is the freedom that comes with that form of travel. However the absence of physical barriers to protect riders puts motorcyclists at a higher risk of injury than other motorists.


Motorcycle fatalities have been on the rise for many years, according to the National Highway Transportation Safety Administration. Hence a group of researchers from the University of Miami (UM) and Florida International University (FIU) conducted one of the first longitudinal analyses of the effect of public policies to reduce motorcycle injuries and fatalities.

The researchers believe this study to be the first to use rigorous econometric techniques, to analyze whether traffic and alcohol policies affect non-fatal as well as fatal motorcycle injuries. The findings offer evidence that certain state policies can effectively reduce the morbidity and mortality associated with motorcycle riding. The findings were published in a recent issue of the Journal of Health Economics.

According to the study, the most significant policy in reducing both fatal and non-fatal motorcycle injuries is the universal helmet laws. The findings indicate that about 489 lives could have been saved if universal helmet laws were in effect in all 48 states in 2005. The researchers also found that mandatory rider education programs can reduce non-fatal motorcycle injuries.

"We were not surprised by the consistently significant effect of universal helmet laws on motorcycle fatalities and injuries, but the large magnitude was a bit unexpected," says Michael T. French, director of Health Economic Research Group (HERG), in the UM Department of Sociology and co-author of the study. "In addition, the fact that universal helmet laws dominated all other traffic safety policies further highlights the importance of wearing a helmet to minimize the physical consequences associated with a crash."

On the other hand, two of the policies (speed limits on rural interstates and administrative license revocation) worked in the opposite direction from what was expected in the models for the non-fatal injury rate. Having an administrative license revocation policy was associated with higher rates of non-fatal injuries, while having a higher speed limit was associated with lower rates of non-fatal injuries.

"One possible explanation for these results is that states with these policies have more dangerous road conditions, so that a fatal rather than non-fatal injury is more likely to occur in the event of a crash," says Jenny Homer, senior research associate at HERG, in the UM Department of Sociology. In addition, rural states, which have less traffic congestion, may be more likely to have higher speed limits.

To obtain their results, the researchers first compiled an extensive dataset with fatal and non-fatal motorcycle injuries, state alcohol and traffic policies, and state demographic and environmental characteristics for the period from 1990 to 2005.

The data on fatal injuries were obtained from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System, while non-fatal injury data were collected through personal correspondence with state traffic agencies. The information was analyzed to estimate the effects of the alcohol and traffic policies on fatal and non-fatal injuries. All of the models included state and year fixed effects to account for unobserved characteristics associated with a specific state or year.

"As a result of data limitations, we are not able to account for certain characteristics that vary from state to state, such as policy enforcement and grass-roots efforts by advocacy groups. Nevertheless, the study contains valid information that can significantly impact public policy regarding motorcycle safety," says Gulcin Gumus, assistant professor in the Department of Health Policy and Management, and the Department of Economics at FIU and co-author of the study.

The next stage of the investigation will involve understanding how the universal helmet policies reduce fatalities, and whether their effects change over time.



1103 Cell phones become handheld tools for global development [Seattle WA]--Mobile phones are on the verge of becoming powerful tools to collect data on many issues, ranging from global health to the environment.

Computer scientists at the University of Washington have used Android, the open-source mobile operating system championed by Google, to turn a cell phone into a versatile data-collection device. Organizations that want a fully customizable way to, say, snap pictures of a deforested area, add the location coordinates and instantly submit that information to a global environmental database now have a flexible and free way to do it.

UW computer scientists were already working on mobile tools for the developing world when Android, the first comprehensive open-source platform for mobile devices, was announced two years ago by the Open Handset Alliance, a group of companies of which Google is a member. For the past year UW computer science and engineering doctoral students Carl Hartung, Yaw Anokwa and Waylon Brunette have worked at Google's Seattle office using Android to create a data-collection platform for use in developing regions.

Their free suite of tools, named Open Data Kit, is already used by organizations around the world that need inexpensive ways to gather information in areas with little infrastructure. Seattle's Grameen Foundation Technology Center is using it to evaluate its Ugandan text-messaging information hotline; D-Tree International, a Boston-based nonprofit, is using it in Tanzania to guide health workers treating children under 5 years old; the University of California, Berkeley's Human Rights Center is using it to record human rights violations in the Central African Republic. This fall the Jane Goodall Foundation in Tanzania and the Brazilian Forest Service signed up to use it to monitor deforestation.


"Many organizations need to be able to make evidence-based decisions, and to do that they need data," Anokwa said. "We hope our toolkit enables organizations to gather the data quickly so they can analyze it quickly and make the best decisions for the communities they serve."

They tool is described in an article published this month in the Institute of Electrical and Electronics Engineers' Computer magazine. Gaetano Borriello, UW professor of computer science and engineering, and Adam Lerer, a graduate student at the Massachusetts Institute of Technology, are co-authors.

In the past some researchers have harnessed individual cell phone models to collect data in the field. But when the phone gets outdated, so does the software. Instead of creating a tool for a single phone, or even a single purpose, the UW team built something that would provide a reusable platform to collect all types of mobile data.

"We found a lot of organizations were building a lot of one-off tools that were very similar," Hartung said. "We're trying to make ours as compatible and flexible as possible."

Open Data Kit's versatile suite of tools can collect data; store, view and export data on remote servers; and manage devices in the field from a central office. The output is compatible with emerging data standards such as the Open Medical Records System, which aims to coordinate health records in the developing world.

Many organizations are using Open Data Kit, but the biggest project so far is a major effort to track and treat HIV patients in Kenya. Led by the Academic Model Providing Access to Healthcare, a U.S. Agency for International Development-funded partnership between Indiana University and Kenya's Moi University, it is one of the most comprehensive HIV treatment programs in sub-Saharan Africa. AMPATH trains Kenyan community health workers who conduct door-to-door testing in rural areas for HIV, tuberculosis and malaria, and offer ongoing personalized health counseling.

Hartung and Anokwa traveled to Kenya this summer to meet with AMPATH's community health workers and do a trial run with 10 phones. They spent two weeks working with Kenyan collaborators, then accompanied community health workers on home visits to see the phone being used in the field.

"It's a pretty amazing experience to be sitting in a mud hut seeing someone get counseled, maybe for the first time, on HIV, and the counselor is using your tool to record information," Hartung said. "It gives a whole new perspective on the need for reliable software."

For the past two years AMPATH workers have conducted field visits using a Palm Pilot and separate GPS unit. This required workers to key in a 10-digit identifier for each patient, stand outside and wait up to two minutes to get location coordinates, and at the end of each day return to the main office to upload their information to a central database, which adds travel time and expense.

Phones running Open Data Kit can record location in seconds, scan a barcode rather than requiring the numbers to be entered by hand, and upload the data automatically using a cellular network. AMPATH plans to deploy 100 Google-powered phones by the end of this year. Ultimately, it aims to use 300 phones powered with Open Data Kit to reach 2 million people.


"Adopting this technology was kind of a win-win-win in terms of direction for our organization," said Dr. Burke Mamlin, an assistant professor of medicine at the Indiana University School of Medicine and research scientist with the nonprofit Regenstrief Institute, which supports AMPATH. "This opens doors by allowing us to bring data collected in the field directly into our medical records system. And now we have a phone, all the personal digital assistant capability, the ability to read barcodes, and the ability to capture images or video, all in one unit."

The device also opens up new possibilities for the future. If one family member is absent during a site visit health workers can schedule a follow-up visit and have it automatically appear in their calendars. Health workers could cue up public-health videos if they thought the family could benefit. Program managers in a central office could track data in real time and send updates to field workers without them having to come back to the base.

Building technology for use in the developing world offers new challenges for computer scientists. Power and connectivity may be intermittent, and users may have poor eyesight or literacy.

There are also other issues specific to mobile devices. Web developers in the Western world generally create white text on a dark background, but it turns out dark text on a white background works better in bright sunlight, where most of these devices will be used. And touch-screen phones rely on an electrical signal from users' fingers, but that signal gets blocked by calluses. UW students found some rural users needed to use a softer part of the finger pad, and this meant designing bigger buttons.

The team is now back at the UW, where they are part of a group called Change that studies technology in the developing world. Funding for the project comes from Google.org, the philanthropic arm of the company. The code is freely available and ongoing research will be based at the university. Hartung and Anokwa are co-teaching a new course this fall, Mobile and Cloud Applications for Emerging Regions http://www.cs.washington.edu/education/courses/cse599y/09au/  in which undergraduate computer science and engineering students learn skills and then apply them by creating new features requested by Open Data Kit users.

"We've only seen the tip of the iceberg in terms of the types of applications we can run that are really customized to the person who's holding the device," said Gaetano Borriello. "For places where resources are constrained, where data is unavailable and where large problems exist, this technology is very powerful."


More information on Open Data Kit is at http://change.washington.edu/projects/odk. Watch a demonstration of the tool on YouTube at http://tinyurl.com/lttrqj



1103 New model may help scientists better predict and prevent influenza outbreaks [Athens GA]--Each year, the influenza virus evolves. And each year, public health officials try to predict what the new strain will be and how it will affect the population in order to best combat it.

A new study by an international team of researchers, led by assistant professor Andrew W. Park, who holds a joint appointment in the University of Georgia Odum School of Ecology and in the College of Veterinary Medicine, may make their task a little easier. The study breaks ground by working across scales and linking sub-molecular changes in the influenza virus to the likelihood of influenza outbreaks. The paper, published in the Oct. 30 edition of the journal Science, shows the relationship between the evolution of the virus and immunization rates needed to prevent an outbreak in the population.

Park explained that these findings can help inform efforts to prevent future outbreaks. "Public health officials will be able to assess the usefulness of a vaccine based upon its relationship to the current influenza strain and the population's immunity level," he said.

Through previous vaccinations or infections with earlier strains of the influenza virus, many individuals already have some level of immunity, Park noted. The influenza virus is continually evolving, however. By substituting different amino acids at key molecular points, the virus increases its chances of evading the immune system's defenses, allowing it to reproduce and spread.

As the number of amino acid differences between a new strain and the strain an individual was vaccinated against increases, the likelihood of becoming infected increases, Park said, as does the likelihood of becoming infectious and the length of time the individual will remain infectious. These factors combine to increase the chance of an outbreak in a population.

Working with equine influenza, the research team members looked at the likelihood of an influenza outbreak in a population that had all been vaccinated with the same strain of the virus. They found that outbreaks began occurring when there were two or more amino acid differences and that the size of the outbreak increased with the number of amino acid differences. They also found that large outbreaks were more likely to occur if the virus and the vaccine were from different antigenic clusters—meaning that a host's immune system perceives the two strains as different. Comparing these results with an earlier human influenza study revealed similar trends.

Another key factor in determining the risk of an outbreak in real populations, however, is the individual variation of immunity in the population. Because the virus keeps changing, so do the vaccines used against it. This causes the immunity of the population to be heterogeneous—some individuals have been infected with or vaccinated against last year's influenza strain, some against strains from previous years, and some have no immunity at all. Park and his colleagues found that the degree of variability of immunity in the population plays a crucial role in determining the risk of an outbreak.

Park added that in measuring for the first time how the difference between the population's immunity status and a new virus strain influences the risk of an epidemic, the team has taken a critical step toward linking these relationships with the dynamics of epidemics, not just for influenza but for a wide range of infectious diseases.



1103 Whooping cough immunity lasts longer than previously thought [Ann Arbor MI]--Immunity to whooping cough lasts at least 30 years on average, much longer than previously thought, according to a new study by researchers based at the University of Michigan and the University of New Mexico. Details are published October 30 in the open-access journal PLoS Pathogens.

Once thought to be under control following widespread childhood vaccination, whooping cough (pertussis) has been on the rise since the 1980s in the United States and several other countries. Several explanations have been proposed for the surprising increase in cases, and one leading idea is that the immunity enjoyed by vaccinated or previously exposed people is waning. It has been documented that, in some individuals, immunity has waned over time, but details of how long protection typically lasts and how its waning affects disease transmission have not been clear.

To try to answer these questions, Pejman Rohani (based at the University of Georgia during completion of this study) and Helen Wearing used mathematical models to explore various scenarios and compared the predictions generated by those models to data on whooping cough incidence.

The researchers constructed two different models based on assumptions of the effects of pertussis exposure on a person whose immunity has lapsed and that person's relative contribution to transmission. Then they compared the models' predictions to whooping cough incidence data from England and Wales from both the pre-vaccine era (1945-1957) and the vaccine era (1958-1972).

In particular, Rohani and Wearing looked for matches in two key measures: the number of years between big outbreaks and the frequency of "extinctions"---periods of time when no whooping cough cases were reported in the population. The analysis revealed that, on average, whooping cough immunity lasts at least 30 years and perhaps as long as 70 years after natural infection.

"This is surprising because clinical epidemiologists currently believe the duration of pertussis immunity is somewhere between four and 20 years," said Rohani.

In addition, repeat infections appear to contribute relatively little to the transmission cycle, the researchers found. And when people whose immunity has waned are re-exposed to whooping cough, they rarely become infected. In fact, their immunity to the disease may be boosted by re-exposure, the study suggests. Still, the researchers are cautious about drawing conclusions about current day vaccination practices from their study of historical data.

"It's worth pointing out that in the past 20 years or so, the nature of the vaccines that have been used has changed quite fundamentally," Rohani said. The data we're using are from a time when a whole-cell vaccine was in use; now an acellular vaccine, which stimulates a different part of the immune system, is typically used, especially in North America."

In response, Rohani is doing new work using more recent data from the U.S., such as birth rates, population size, and vaccination coverage, to uncover relevant factors associated with trends in whooping cough incidence.

This work was supported by the National Institutes of Health (R01 GM69111), the National Science Foundation (DEB 0343176) and a New Scholar Award in Global Infectious Disease from the Ellison Medical Foundation to PR. HJW was supported, in part, by start-up funds from the University of New Mexico.



1103 Lack of insurance may have figured in nearly 17,000 childhood deaths [Baltimore MD]--Lack of health insurance might have led or contributed to nearly 17,000 deaths among hospitalized children in the United States in the span of less than two decades, according to research led by the Johns Hopkins Children's Center.

According to the Hopkins researchers, the study, to be published Oct. 30 in the Journal of Public Health, is one of the largest ever to look at the impact of insurance on the number of preventable deaths and the potential for saved lives among sick children in the United States.

Using more than 23 million hospital records from 37 states between 1988 and 2005, the Hopkins investigators compared the risk of death in children with insurance and in those without. Other factors being equal, researchers found that uninsured children in the study were 60 percent more likely to die in the hospital than those with insurance. When comparing death rates by underlying disease, the uninsured appeared to have increased risk of dying independent regardless of their medical condition, the study found. The findings only capture deaths during hospitalization and do not reflect deaths after discharge from the hospital, nor do they count children who died without ever being hospitalized, the researchers say, which means the real death toll of non-insurance could be even higher.

"If you are a child without insurance, if you're seriously ill and end up in the hospital, you are 60 percent more likely to die than the sick child in the next room who has insurance," says lead investigator Fizan Abdullah, M.D., Ph.D., pediatric surgeon at Hopkins Children's.

The researchers caution that the study looked at hospital records after the fact of death so they cannot directly establish cause and effect between health insurance and risk of dying. However because of the volume of records analyzed and because of the researchers' ability to identify and eliminate most factors that typically cloud such research, the analysis shows a powerful link between health insurance and risk of dying, they say.

"Can we say with absolute certainty that 17,000 children would have been saved if they had health insurance? Of course not," says co-investigator David Chang, Ph.D. M.P.H. M.B.A. "The point here is that a substantial number of children may be saved by health coverage."

"From a scientific perspective, we are confident in our finding that thousands of children likely did die because they lacked insurance or because of factors directly related to lack of insurance," he adds.

Given that more than 7 million American children in the United States remain uninsured amidst this nation's struggle with health-care reform, researchers say policymakers and, indeed, society as a whole should pay heed to their findings.

"Thousands of children die needlessly each year because we lack a health system that provides them health insurance. This should not be," says co-investigator Peter Pronovost, M.D., Ph.D., director of Critical Care Medicine at Johns Hopkins and medical director of the Center for Innovations in Quality Patient Care. "In a country as wealthy as ours, the need to provide health insurance to the millions of children who lack it is a moral, not an economic issue," he adds.

In the study, 104,520 patients died (0.47 percent) out of 22.2 million insured hospitalized children, compared to 9, 468 (0.75 percent) who died among the 1.2 million uninsured ones. To find out what portion of these deaths would have been prevented by health insurance, researchers performed a statistical simulation by projecting the expected number of deaths for insured patients based on the severity of their medical conditions among other factors, and then applied this expected number of deaths to the uninsured group. In the uninsured group, there were 3,535 more deaths than expected, not explained by disease severity or other factors. Going a step further and applying the excess number of deaths to the total number of pediatric hospitalizations in the United States (117 million) for the study period, the researchers found an excess of 16,787 deaths among the nearly six million uninsured children who ended up in the hospital during that time.

Other findings from the study:

* More uninsured children were seen in hospitals in the Northeast and Midwest than in the South and West. However, hospitals from the Northeast had lower mortality rates than hospitals from the South, Midwest and West.

* Insured children on average incurred higher hospital charges than uninsured children, most likely explained by the fact that uninsured children tend to present to the hospital at more advanced stages of their disease, which in turn gives doctors less chance for intervention and treatment, especially in terminal cases, investigators say.

* Uninsured patients were more likely to seek treatment though the Emergency Room, rather than through a referral by a doctor, likely markers of more advanced disease stage and/or delays in seeking medical attention.

* Insurance status did not affect how long a child spent overall in the hospital.

The research was funded by the Robert Garrett Fund for the Treatment of Children.

Co-investigators in the study include Yiyi Zhang, M.H.S.; Thomas Lardaro, B.S.; Marissa Black; Paul Colombani, M.D.; Kristin Chrouser, M.D. M.P.H.



1103 PTSD less common than depression and alcohol misuse amongst UK troops [London England]--Common mental disorders, such as depression and alcohol misuse, are the top psychological problems amongst UK troops post-deployment and not post traumatic stress disorder (PTSD) as is widely believed. A study published today in the open access journal, BMC Psychiatry, also finds that reservists remain at special risk of operational stress injury.

Since the beginning of the Iraq conflict, over 100,000 UK Service personnel have been deployed to Iraq and Afghanistan. These personnel are at increased risk of operational stress injury, such as mental health problems. However a detailed clinical picture of their specific health needs has previously been lacking in the UK.

A study conducted by Dr Amy Iversen and colleagues from the King's Centre for Military Health Research and the Academic Centre for Defence Mental Health, Institute of Psychiatry, UK, reports that alcohol abuse is the most common mental health disorder amongst UK Service personnel returning from Iraq and Afghanistan, with disorders such as depression and anxiety being second most common. Dr Iversen said, "Although our perception is that PTSD symptoms are the main source of psychiatric illness in Service personnel, alcohol misuse and depressive disorders are actually much more common. Prevention and intervention in these areas should be high priority."

The London-based team set out to assess the prevalence and risk factors for common mental health disorders and PTSD amongst the UK military, as well as to compare the data with that from US forces. A total of 821 participants undertook a structured telephone interview, which included the Patient Health Questionnaire.

They found that the prevalence of all common mental disorders was 27.2%, and PTSD symptoms, 4.8%. There were no substantial differences in the prevalence of PTSD symptoms between US and UK troops deployed to Iraq, which had been previously found. In UK troops, the most common diagnoses were alcohol abuse (18.0%) and depression/anxiety (13.5%). The data also indicated that reservists who deployed to Iraq are at greater risk of psychiatric injury than regular personnel, thus initiatives in the UK to provide enhanced assistance to reservists are still pertinent.

Dr Iversen concludes: "This research has helped build a detailed picture of the specific heath needs of the UK military. These data should be particularly valuable for health service planners, providers and policy makers."

The prevalence of common mental disorders and PTSD in the UK military: using data from a clinical interview-based study, Amy C Iversen, Lauren van Staden, Jamie Hacker Hughes, Tess Browne, Lisa Hull, John Hall, Neil Greenberg, Roberto J Rona, Matthew Hotopf, Simon Wessely and Nicola T Fear, BMC Psychiatry (in press)



1103 Undocumented foreign-born Latinos face serious financial and language barriers to quality health care [Los Angeles CA]--Where Latinos are born and their immigration status affect the quality of health care they receive in the US, according to Professor Michael Rodríguez and colleagues from the UCLA Department of Family Medicine and the Network for Multicultural Research on Health and Healthcare based in Los Angeles, California.


New information from this just-released study highlights the need for improved health systems for immigrants – documented or undocumented, US-born or foreign-born. Findings are published online this week in the Journal of General Internal Medicine.

Latinos are one of the fastest growing populations in the US. To date, most of the research on quality of health care has focused on the general Latino population. For the first time, Rodríguez and the team's work looks at differences by place of birth and immigration status in this group.

Perceived quality of health care is important because how patients rate the quality of care they receive influences their health outcomes. When patients rate their health care as excellent or good, they are more likely to stick to treatment programs and to be motivated to manage their health problems.

The authors analyzed data from the 2007 Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Survey – a nationally representative telephone survey of more than 4,000 Latino adults in the US. They looked at the differences in perceived quality of care, receipt of preventive care, and usual source of health care among US-born Latinos, foreign-born Latino citizens, Latino permanent residents and undocumented Latinos.

The study found that perceived quality of care is different by place of birth and immigration status. Compared to US-born Latinos, undocumented Latinos were less likely to have health insurance, had the lowest levels of usual source of care, blood pressure and cholesterol checks and were less likely to report excellent or good health care in the past year. Undocumented Latinos were also the most likely group to report receiving no health information from their doctor in the past year. Forty-five percent of undocumented Latinos believed they received poor quality of care because they were unable to pay, 39 percent linked poor care to their ethnic background, and 48 percent thought they received poor care because of their accent.

The authors conclude: "These findings help increase our understanding of the diversity among Latinos and why reporting results by immigration status is important. Policies supporting increased access to affordable, culturally and linguistically competent services could be beneficial to improve quality of health care among Latinos." These findings have direct implications for the health care debate as policies that leave the undocumented out and possibly increase barriers to health care will likely have negative consequences for the health care and health of Latinos.

This research, entitled "Perceived Quality of Care, Receipt of Preventive Care, and Usual Source of Health Care among Undocumented and other Latinos," is one of nine articles published in the special supplement, "Confronting Health Inequities in Latino Health Care."


The research in the supplement resulted from efforts of The Network on Multicultural Research on Health and Healthcare, a consortium of leading researchers from institutions around the country. This team of multidisciplinary senior and junior faculty members conducts health disparities research on the care provided to minority subpopulations.


Guest editors for the supplement, Michael Rodríguez, MD, MPH and his colleague William Vega, PhD also serve as the co-directors of The Network, which is funded by the Robert Wood Johnson Foundation and is located within the UCLA David Geffen School of Medicine, Department of Family Medicine.


Additional information on the articles and relevant background information can be obtained by visiting http://media.multiculturalhealthcare.net/.


1. Rodriguez M et al (2009). Perceived Quality of Care, Receipt of Preventive Care, and Usual Source of Health Care among Undocumented and other Latinos. J Gen Intern Med. DOI 10.1007/s11606-009-1098-2



1103 Member of NFL Hall of Fame diagnosed with degenerative brain disease [Boston MA]--The Center for the Study of Traumatic Encephalopathy (CSTE) at Boston University School of Medicine (BUSM) announced today that a recently deceased member of the NFL Hall of Fame suffered from the degenerative brain disease Chronic Traumatic Encephalopathy (CTE) when he died, becoming the 10th former NFL player diagnosed with the disease.

Last week, CSTE researchers announced CTE had been diagnosed post-mortem in a former college football player who died at 42, the first advanced case in a non-NFL football player. Most concerning, all 11 of the former NFL and college football players studied post-mortem at the CSTE have shown signs of CTE.

Lou Creekmur, former offensive lineman for the Detroit Lions and eight-time Pro Bowl player, was diagnosed with CTE by neuropathologist and CSTE co-director Ann McKee, MD. Creekmur played 10 seasons for the Detroit Lions, and was famous for breaking his nose 13 times while playing without a facemask. He died July 5, 2009 from complications of dementia following a 30-year decline that included cognitive and behavioral issues such as memory loss, lack of attention and organization skills, increasingly intensive angry and aggressive outbursts.

CTE can only be diagnosed by examining brain tissue post-mortem. Creekmur's brain was studied by McKee who determined that he was suffering from CTE and not another cause of dementia such as Alzheimer's disease. McKee said, "This is an important case because we are confident many CTE cases are misdiagnosed as Alzheimer's disease. By examining his brain, I was able to confirm that there was absolutely no sign of Alzheimer's disease or any other type of neurodegenerative disease except for severe CTE. This is the most advanced case of CTE I've seen in a football player; his brain changes were similar to those of profoundly affected professional boxers."

President and CEO of the Alzheimer's Association Mass./N.H. Chapter James Wessler stated, "This is a very important finding that could explain the underlying cause of dementia in countless individuals who have had histories of repetitive head trauma."

The Creekmur case is also important in advancing discussion of what risk factors may play a role in causing CTE other than trauma. One hypothesis that has been put forward is that anabolic steroids could play a role in CTE. However, Creekmur played in the 1950s, a time that predates documented steroid use in the NFL, so the case proves CTE does occur in the absence of steroids.

Robert Stern, PhD, CSTE co-director, added, "The U.S. House Judiciary Committee is holding a hearing on the football head injury crisis on Oct. 28, and we feel that this evidence should be part of the discussion. The long-term consequences of brain trauma in sports are a tremendous public health problem. CTE is the only fully preventable cause of dementia. We need to make changes to the game of football, at all levels of play, which will decrease the risk of CTE to both pro and amateur athletes."

Creekmur was a member the NFL's Plan 88. The Plan was named for former NFL star John Mackey's jersey number. Mackey, a Hall-of-Fame tight end for the Colts in the 1960s and 70s, suffers from severe dementia. The Plan was created by the NFL to provide financial support to families of former players who suffer from some form of dementia. Members of the Plan have been diagnosed with "dementia," which refers to progressive memory and cognitive deficits significant enough to impair daily living. During life, it is not possible to determine the underlying disease that causes dementia. However, now that a Plan 88 member has been examined pathologically, CSTE scientists have proven it is possible to determine the cause of dementia, which in this case was repetitive trauma from football.

Creekmur's wife of 33 years, Caroline Creekmur, had extensive discussions with her husband prior to death about his brain trauma history, and is confident he remembered "16 or 17" concussions, none that caused loss of consciousness or necessitated a hospital visit. He did not have any significant head trauma since retiring from the NFL.

There are approximately 100 former NFL players whose families are receiving support through Plan 88, including Ralph Wenzel, age 66, former lineman for the Pittsburgh Steelers and San Diego Chargers, who now resides in an assisted living facility with advanced dementia. Upon learning of Creekmur's CTE diagnosis, Wenzel's wife, Dr. Eleanor Perfetto, stated, "Sadly, these findings do not come as a surprise. For those of us who have watched our husbands deteriorate and lose their independence from progressive dementia, our hope is that this research will one day lead to changes in the game of football such that other players and their families will not have to experience the pain that we have experienced."

CTE is characterized by the build-up of a toxic protein called tau in the form of neurofibrillary tangles (NFTs) and neuropil threads (NTs) throughout the brain. The abnormal protein initially impairs the normal functioning of the brain and eventually kills brain cells. Early on, CTE sufferers may display clinical symptoms such as memory impairment, emotional instability, erratic behavior, depression and problems with impulse control. However, CTE eventually progresses to full-blown dementia. Although similar to Alzheimer's disease, CTE is an entirely distinct disease.

The CSTE was created in 2008 as a collaborative venture between Boston University School of Medicine (BUSM) and Sports Legacy Institute (SLI). The mission of the CSTE is to conduct state-of-the-art research of Chronic Traumatic Encephalopathy, including its neuropathology and pathogenesis, the clinical presentation and course, the genetics and other risk factors for CTE, and ways of preventing and treating this cause of dementia.

Sports Legacy Institute is a 501(c)(3) nonprofit corporation founded in 2007 to solve the sports concussion crisis. SLI is dedicated to education, prevention, treatment, and research on the effects of concussions and other brain injuries in athletes and the military. SLI partnered with Boston University School of Medicine to form the Center for the Study of Traumatic Encephalopathy in 2008.



1103 Smoking gun: just 1 cigarette has harmful effect on the arteries of young healthy adults [Edmonton AB]--Even one cigarette has serious adverse effects on young adults, according to research presented by Dr. Stella Daskalopoulou at the Canadian Cardiovascular Congress 2009, co-hosted by the Heart and Stroke Foundation and the Canadian Cardiovascular Society.

Her study found that smoking one cigarette increases the stiffness of the arteries in 18 to 30 year olds by a whopping 25 per cent.

Arteries that are stiff or rigid increase resistance in the blood vessels, making the heart work harder. The stiffer the artery, the greater the risk for heart disease or stroke.

"Young adults aged 20-24 years have the highest smoking rate of all age groups in Canada," says Dr. Daskalopoulou, an internal medicine and vascular medicine specialist at McGill University Health Centre. "Our results are significant because they suggest that smoking just a few cigarettes a day impacts the health of the arteries. This was revealed very clearly when these young people were placed under physical stress, such as exercise."

The study compared the arterial stiffness of young smokers (five to six cigarettes a day) to non-smokers. The median age was 21 years. Arterial measurements were taken in the radial artery (in the wrist), the carotid artery (in the neck), and in the femoral artery (in the groin), at rest and after exercise.

Arterial stiffness in both smokers and non-smokers was measured using a new but well established method called applanation tonometry. Dr. Daskalopoulou introduced the 'arterial stress test' which measures the arteries' response to the stress of exercise. The test is comparable to a cardiac stress test, which measures the heart's response to the stress of exercise.

"In effect we were measuring the elasticity of arteries under challenge from tobacco," explains Dr. Daskalopoulou.

An initial arterial stress test was carried out to establish a baseline measurement for both the non-smokers and the smokers, who were asked not to smoke for 12 hours prior to the test. After the first meeting, smokers returned and smoked one cigarette each and then repeated the stress test. During the final meeting, smokers were asked to chew a piece of nicotine gum prior to the stress test.

Dr. Daskalopoulou found that after exercise the arterial stiffness levels in non-smokers dropped by 3.6 per cent. Smokers, however, showed the reverse: after exercise their arterial stiffness increased by 2.2 per cent. After nicotine gum, it increased by 12.6 per cent. After one cigarette, it increased by 24.5 per cent.

Interestingly, there was no difference in the arterial stiffness measurements between smokers and non-smokers at rest.

"In effect, this means that even light smoking in otherwise young healthy people can damage the arteries, compromising the ability of their bodies to cope with physical stress, such as climbing a set of stairs or running to catch a bus," says Dr. Daskalopoulou. "It seems that this compromise to respond to physical stress occurs first, before the damage of the arteries becomes evident at rest."

"More than 47,000 Canadians will die prematurely each year due to tobacco use, which often starts in the teen years," warns Heart and Stroke Foundation spokesperson Dr. Beth Abramson. "We know that over 90 per cent of teenagers who smoke as few as three to four cigarettes a day may be trapped into a lifelong habit of regular smoking, which typically lasts 35 to 40 years."

Smoking contributes to the build up of plaque in the arteries, increases the risk of blood clots, reduces the oxygen in the blood, increases blood pressure, and makes the heart work harder. Smoking also nearly doubles the risk of ischemic stroke.

Dr. Abramson says this study reinforces the importance of education, prevention programs, and legislation such as the recently passed Bill C-32, Cracking Down on Tobacco Marketing Aimed at Youth Act.

If you or someone you know wants to quit smoking, you can order the Heart and Stroke Foundation's free Just Breathe: Becoming and Remaining Smoke-Free brochure by phoning 1-888-HSF-INFO.


Health Canada's Go Smoke Free! website www.gosmokefree.ca also has support resources, tips, and tools to help people become smoke-free.



1103 Significant regional variations exist regarding proximity to burn centers [Seattle WA]--Although nearly 80 percent of the U.S. population lives within 2 hours by ground or helicopter transport to a verified burn center, there is substantial state and regional variation in geographic access to these centers, according to a study in the October 28 issue of JAMA.

More than 500,000 burn injuries occur in the United States each year, causing approximately 4,000 burn-related deaths, according to the American Burn Association. In addition, more than 40,000 patients are admitted to hospitals each year for treatment of burn injury. The authors write that the delivery of optimal burn care to these patients is a resource-intensive endeavor requiring specialized equipment and experienced personnel, and that these resources are typically available only at dedicated burn centers. They add that timely access to a burn center may benefit patients. The current distribution of burn centers relative to geographic area and population is unknown, according to background information in the article.

Matthew B. Klein, M.D., M.S., of the University of Washington, Seattle, and colleagues conducted a study to estimate the proportion of the U.S. population living within 1 and 2 hours by ground or helicopter transport of a burn care facility, evaluating state, regional, and national access. The researchers compiled and analyzed information from the 2000 U.S. census, road and speed limit data, the Atlas and Database of Air Medical Services database, and the 2008 American Burn Association Directory.

The researchers found that in the U.S. in 2008, there were 128 self-reported burn centers, including 51 verified burn centers (verified by the American Burn Association, in which the quality of burn care provided at a center is assessed and confirmed). A total of 782 helipads and 804 helicopters served these centers. Nationally, about 25 percent of the U.S. population lived within 1 hour by ground transport of a verified center; 46.3 percent lived within 2 hours; and 67.7 percent lived within 4 hours by ground transport of a verified burn center.

"By air transport [helicopter], 53.9 percent and 79.0 percent of the population lived within 1 and 2 hours, respectively, of a verified center, and 75.3 percent lived within 1 hour and more than 96.4 percent lived within 2 hours of any self-reported center," the authors write. They add that one-third of the U.S. population must be transported by air to reach a verified burn care center within 2 hours.

The researchers also found that there was significant regional variation in access to verified burn centers by both ground and rotary air transport. "The greatest proportion of the population with access was highest in the northeast region and lowest in the southern United States," they write.

"The variation in baseline geographic access rates found in this study may be an influential predictor of optimal regionalization strategy. For states and regions with a relatively high baseline rate of access, the best strategy for improving access and reducing time to definitive care may involve optimization of air and ground emergency medical service systems. For states and regions with a relatively low baseline rate of access, the best strategy may involve construction or verification of new regional burn care facilities."

"While the optimal distribution of burn centers relative to population and area remains to be determined, these data provide important information about population access that may be used to guide resource allocation in burn care," the authors conclude.



1103 Patients starting dialysis have increased risk of death [Leiden, the Netherlands]--Compared to the general population, patients starting dialysis have an increased risk of death that is not attributable to a higher rate of death from cardiovascular causes, as previously thought, according to a study in the October 28 issue of JAMA.

Several studies have shown that cardiovascular disease accounts for 40 percent to 50 percent of deaths in patients with end-stage kidney disease, according to background information in the article. "It is believed that the life span of patients receiving dialysis is reduced mainly as a consequence of premature cardiovascular death," the authors write.

Dinanda J. de Jager, M.Sc., of the Leiden University Medical Center, Leiden, the Netherlands, and colleagues estimated cardiovascular and noncardiovascular rates of death in a large group of European patients receiving dialysis (n = 123,407) and compared these estimates with mortality data from the general European population, using data from between January 1994 and January 2007.

The researchers found that among the patients receiving dialysis, noncardiovascular death was the most prevalent cause of death (50.8 percent), and 39.1 percent died because of cardiovascular disease. The most common causes of noncardiovascular death were infections and malignancies. In the general population, 10,183,322 persons (58.4 percent) died from noncardiovascular causes, 7,041,747 (40.4 percent) from cardiovascular causes, and 201,050 (1.2 percent) from unknown causes.

Analysis indicated that the overall all-cause mortality rate was higher in patients starting dialysis than in the general population. "In particular, noncardiovascular mortality rates were higher than cardiovascular mortality rates in patients starting dialysis," the authors write. "These results suggest that excess mortality in patients receiving dialysis is not specifically the result of increased cardiovascular deaths."

"In summary, the present study shows that cardiovascular and noncardiovascular mortality are equally increased during the first 3 years of dialysis, compared with the general population. This implies that the importance of noncardiovascular mortality in patients receiving dialysis has generally been underestimated. Therefore, research should focus more on methods to prevent noncardiovascular mortality," the researchers conclude.



1030 Risk of serious flu-related sickness far outpaces risk of injectable vaccine in pregnant women [Baltimore MD]--Pregnant women who catch the flu are at serious risk for flu-related complications, including death, and that risk far outweighs the risk of possible side effects from injectable vaccines containing killed virus, according to an extensive review of published research and data from previous flu seasons.

The review, a collaboration among scientists from the Johns Hopkins Children's Center, Emory University and Cincinnati Children's Hospital, and published online Oct. 22 in the American Journal of Obstetrics & Gynecology, found substantial and persistent evidence of high complication risk among pregnant women -- both healthy ones and those with underlying medical conditions -- infected with the flu virus, while confirming vaccine safety. The findings, researchers say, solidify existing CDC recommendations that make pregnant women the highest-priority group to receive both the H1N1 and seasonal flu vaccines.

"The lessons learned from flu outbreaks in the distant and not-too-distant past are clear and so are the messages," says lead investigator Pranita Tamma, M.D., an infectious disease specialist at the Johns Hopkins Children's Center. "If you are an expectant mother, get vaccinated. If you are a physician caring for pregnant women, urge your patients to get vaccinated."

Because even healthy pregnant women end up in the hospital with preventable flu complications -- some devastating and some fatal -- at a rate far higher than that of other adults, and because of the proven effectiveness and overall safety record of flu vaccines, all pregnant women should consider getting vaccinated to prevent complications in both the expectant mother and her offspring, researchers say.

"Healthcare providers will play a key role in women's decisions about whether or not to be vaccinated against H1N1," says study senior investigator Saad Omer, M.B.B.S., M.P.H. Ph.D., of Emory University. "There is substantial evidence that vaccination is not only safe for pregnant women but that it is critical for protecting women and their infants against serious complications from the flu. Physicians and other providers should talk about risks and benefits with their patients and help alleviate any unfounded fears."

Even though there are still no published data on the safety of the new H1N1 vaccine, experts believe it to be just as safe as the seasonal flu vaccine, Johns Hopkins' Tamma says, because "the H1N1 vaccine is manufactured in the same rigorous way as the seasonal flu vaccines and we expect it to have a very similar safety profile as the other flu vaccines."

In their extensive review of data from three past flu pandemics and 11 published research studies on vaccine safety outcomes over 44 years, the researchers found no increased risk of either maternal complications or bad fetal results from the inactivated (injection) flu vaccine.

Researchers point out that even though study after study has found no link between the vaccine stabilizer thimerosal and autism, thimerosal-free injectable versions of the flu vaccine are available for those who have lingering concerns.

In their review, researchers say four studies have found evidence that antibodies protective against the flu, developed by the mother after vaccination, cross the placenta and transfer some protection to the fetus that lasts up to six months after birth.

Because pregnancy causes a variety of changes in the body, most notably decreased lung capacity, along with increased cardiac output and oxygen consumption, it puts pregnant women at high risk for complications. In addition, parts of the mother's immune system are selectively suppressed, a process that offers essential protection to the fetus, but decreases the mother's ability to fight off infection.

Other findings in the review:

* In the first four months of the H1N1 flu outbreak this spring, pregnant women were hospitalized at four times the rate of other healthy adults infected with the virus, according to the CDC.
* Pregnant women made up 13 percent of all H1N1 deaths during that period, and most of the women who died were previously healthy.
* Pregnant women do not get infected with the flu more often than other adults, but they develop more serious complications and more often. Pregnant women with underlying conditions such as asthma or diabetes are at even higher risk for complications.
* During the 1918 Spanish flu pandemic, of the 1,350 flu-infected pregnant women who were studied, half developed pneumonia, and more than half of those who did so died, with most deaths occurring during the third trimester.
* During the 1957 pandemic, nearly half of all women of childbearing age who died of the flu were pregnant.
* Eleven clinical studies closely followed pregnant women and/or their fetuses after vaccination and found no evidence of harmful side effects in either the mother or the fetus.
* The Vaccine Adverse Event Reporting System database, a national repository of self-reports of adverse vaccine effects, showed 26 reports of adverse effects between 2000 and 2003, a period during which 2 million pregnant women were vaccinated against the flu. Of the 26 reports, six had to do with wrongly administered vaccine without any negative consequences; nine reports described brief injection site tenderness; eight involved systemic symptoms, such as malaise and fever; and three were miscarriages. Investigators point out that these are self-reported events and do not establish any evidence of cause and effect either with respect to either miscarriage or side effects.

The research was funded partially by an NIH fellowship training grant to Pranita Tamma. Co-investigator Neal Halsey, M.D., of Johns Hopkins, receives grant support from NIH, CDC, Berna, Intercel, Merck and Novartis, none of which went toward this particular research.

Other investigators in the study include Kevin Ault, M.D., and Carlos Del Rio, M.D., of Emory University; and Mark Steinhoff, M.D., of Cincinnati Children's Hospital.



1030 Pandemic flu vaccine campaigns may be undermined by coincidental medical events [Cincinnati OH]--The effectiveness of pandemic flu vaccination campaigns – like that now underway for H1N1 – could be undermined by the public incorrectly associating coincidental and unrelated health events with the vaccines.

This is the conclusion of a paper published online Oct. 31 by the Lancet and authored by an international team of investigators led by Cincinnati Children's Hospital Medical Center.

"Regardless of whether someone gets the vaccine, bad things happen to people every day and generally occur at fairly predictable rates," said Steven Black, M.D., lead author and a physician in the Center for Global Health and Division of Infectious Diseases at Cincinnati Children's. "Identifying real safety concerns with new vaccines means we have to untangle actual safety signals from background medical events, which are those that would happen without vaccination."

The team of investigators from 13 global medical institutions and health agencies reviewed medical data from prior studies and from hospital databases to identify background rates of health events that occurred without any vaccine. Their review showed the rates of adverse events varied by year, country, age and sex of the population.

The problem the authors identified is that public concern regarding medical events can interfere with important vaccine programs, even if the vaccine is not the cause. One example they cited is the interruption of a 2006 seasonal influenza campaign in Israel, where four deaths occurred within 24 hours of immunization. The clustering of fatalities and close timing of vaccination resulted in global news coverage, public trepidation and compromised the inoculation campaign.

In actuality, the four patients who died all were in a group already at high risk for sudden death from age and underlying medical conditions. Their deaths were consistent with a cardiac cause of death, and the number of deaths was lower than would be expected normally for such a high risk population. Further analysis of the fatalities in Israel showed death normally occurs in this high risk group at a rate greater than one per 1,000 individuals in the same time period. Based on this, the researchers said 20 coincidental deaths among that group could be expected to occur by chance within 24 hours of an immunization.

The authors also revisited one of the concerns raised during the 1976-77 swine flu vaccination program. The vaccine in that campaign was associated with an increased number of Guillian-Barre Syndrome cases, in which the body's immune system mistakenly attacks part of the nervous system. Guillian-Barre normally affects about one out of every 100,000 people a year. Based on this Guillian-Barre background rate, if 100 million people in the United States are inoculated in a pandemic flu vaccination campaign, the researchers said one would expect 215 new cases of the disease within six weeks of vaccine. These cases would be expected to occur whether or not the vaccine had been given.

"The reporting of even a fraction of such a large number of case as adverse events following immunization, with attendant media coverage, would likely give rise to high levels public concern, even though the occurrence of such cases was completely predictable and would have happened in the absence of a mass campaign," according to the paper.

To help address these concerns, the U.S. Centers for Disease Control and Prevention (CDC) and other health agencies have been creating systems to gather and accurately assess data on background health events when evaluating vaccine safety. The current paper presents some new data but also puts existing data into context for the public, said Dr. Black, who also serves as a pandemic flu vaccine safety consultant to the National Vaccine Program Office at the Department of Health and Human Services.

"In the heat of the moment of a pandemic vaccination campaign, the public isn't good at evaluating comparative risk or realizing that obviously some people die or develop serious illnesses every day," Dr. Black said. "By putting background rate data into proper context, we want to help people make an informed decision about pandemic flu vaccinations."

Also contributing to the research article were: the National Institute of Health and Welfare, Helsinki, Finland; the Center for Vaccinology and Neonatal Immunology, Department of Pediatrics, University of Geneva, Geneva, Switzerland; Institute for Vaccine Safety, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore; Division of Infectious Diseases, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada; Vaccine Safety Section, Centre for Immunization and Respiratory Infectious Diseases, Public Health Agency of Canada; Health Protection Agency, Centre for Infections, United Kingdom; National Vaccine Program Office, U.S. Department of Health and Human Services; Center for Biologics Evaluation and Research, U.S. Food and Drug Administration; Discipline of Paediatrics, School of Paediatrics and Reproductive Health, University of Adelaide, Australia; Department of Pediatrics, Faculty of Medicine University of Sao Paulo, Brazil; Quality, Safety and Standards Team, World Health Organization; Immunization Safety Office (CDC).



1030 Patients in US five times more likely to spend last days in ICU than patients in England [Columbia University]--Patients who die in the hospital in the United States are almost five times as likely to have spent part of their last hospital stay in the ICU than patients in England. What's more, over the age of 85, ICU usage among terminal patients is eight times higher in the U.S. than in England, according to new research from Columbia University that compared the two countries' use of intensive care services during final hospitalizations.

"Evaluating the use of intensive care services is particularly important because it is costly, resource intensive, and often traumatic for patients and families, especially for those at the end of life" said Hannah Wunsch, M.D., M.Sc., assistant professor of anesthesiology and critical care medicine, of Columbia University, lead author of the study. "We found far greater use of intensive care services in the United States during terminal hospitalizations, especially among medical patients and the elderly."

Their findings were published in the November 1 issue of the American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society.

Dr. Wunsch and colleagues wanted to examine the differences in ICU usage in England and the U.S., because the countries' similar life expectancies and population demographics enabled a comparison of fundamentally different healthcare systems.

England has one-sixth the number of intensive care beds available per capita that are available in the U.S. Furthermore, medical decisions in England are generally considered to be the direct responsibility of the physician, rather than that of the patient or the patient's surrogate decision-maker(s) as it is in the U.S.

"In England, there is universal health care through the National Health Service, and there is also much lower per-capita expenditure on intensive care services when compared to the U.S.," said Dr. Wunsch. "The use of intensive care in England is limited by supply to a greater degree than it is in the U.S., and there are consequently implicit and explicit decisions regarding who gets those limited services. We wished to examine what different decisions are made."

Dr. Wunsch and colleagues examined data from the Hospital Episodes Statistics database (in England) and all hospital discharge databases of seven states (FL, MA, NJ, NY, TX, VA, WA) in the U.S. They found that of all hospital discharges, only 2.2 percent in England received intensive care, compared to 19.3 percent in the U.S.

They also found that hospital mortality among those who received intensive care was almost three times higher in England than in the U.S. (19.6 percent vs. 7.4 percent). But when examining deaths overall, only 10.6 of hospital deaths in England involved the ICU, whereas 47.1 in the U.S. did. Of those over 85, only 1.3 percent received ICU care in England vs. 11 percent in the U.S. But young adults and children received ICU services at similar rates in both countries. "These numbers need to be interpreted with caution," explains Dr. Wunsch, "as the differences in mortality for ICU patients likely reflect the higher severity of illness of patients admitted in the first place in England. The data do bring up the interesting question of how much intensive care is beneficial. Doing more may not always be better."

While these findings highlight important differences within the two countries' use of intensive care services, the research was not designed to determine the direct impact of these differences. Past surveys have suggested that the majority of people would prefer not to die in the hospital, but given that so many do, questions about use of intensive interventions remain.

"Whether less intensive care for very elderly patients who are dying is a form of rationing, or is actually better recognition of what constitutes appropriate care at the end of life warrants further research," said Dr. Wunsch. "These findings highlight the urgent need to understand whether there is over-use of intensive care in the U.S., or under-use in England."

Furthermore, future research must further investigate not just the origins, but the implications of these differences. "Faced with a provocative finding of cross-national difference, the scientific community faces a choice between at least two paths," wrote Theodore Iwashyna, M.D., Ph.D., and Julia Lynch, Ph.D., in an editorial in the same issue of the journal. "One path leads to carefully unpacking the origins of this difference and teaching us something generally true about how critical care systems develop. The other path leads into the hospitals, using observational data to imagine new ways to organize care and generate the equipoise necessary for careful interventional studies of such interventions. The first path helps us shape national policy levers. The latter path helps us redesign care organizations to bring change to patients. Both are necessary."



1030 Important new novel 2009 H1N1 flu advisory for cardiopulmonary transplantation [New York NY]--Each year 3-5 million people have severe cases and 250-500,000 die from complications of seasonal influenza world-wide. This year, the novel 2009 H1N1 (nH1N1) influenza, previously called swine flu, has reached pandemic status. Since novel 2009 H1N1 is a viral infection of the respiratory tract, there are additional challenges for cardiopulmonary transplant recipients and donors, as well as for the healthcare workers involved in the transplant process. In an article published online today in the Journal of Heart and Lung Transplantation, physicians representing the International Society for Heart & Lung Transplantation (ISHLT) Infectious Disease Council issue an advisory for all programs in cardiothoracic transplantation.

Mandeep R. Mehra, MBBS, FACC, FACP, Editor-in-Chief, the Journal of Heart and Lung Transplantation observes, "Nowhere is the threat of H1N1 more real than in cardiopulmonary transplantation. The ISHLT's Infectious Disease Council has developed what is assuredly the most comprehensive and clinically relevant direction for prevention and management of H1N1 flu in donors, recipients, care providers and family members."

Recognition of the novel 2009 H1N1 influenza virus, aggressive diagnosis and early treatment need be paired with active preventative measures to stem the impact of infection in the transplant population. This special advisory addresses issues relevant to cardiothoracic transplant candidates, selection of donors, recipient management and patients with mechanical circulatory support devices. Since transplant recipients are treated with anti-rejection drugs, the advisory provides clear directions for specific dosing of antiviral drugs and management of the background immunosuppression. Specific guidelines for evaluation and management of post-surgical transplant patients are also given, as well as recommendations for how and when to administer vaccines. On the donor side, the advisory provides guidelines for how to evaluate and treat donors so that organs can be safely used and not wasted. Finally, it provides specific guidelines for the healthcare teams managing such patients.

Writing in the article, Lara A. Danziger-Isakov MD MPH, Cleveland Clinic Children's Hospital, states, "Interaction with organ procurement organizations for organ selection must take into account emerging data on the use of organs from patients infected and treated for the novel 2009 H1N1 Influenza virus. Improved diagnostic testing with shorter turnaround times is needed in donor evaluation. Individual patient education, prevention measures and treatment strategies will also require attention to the local patterns of infection, availability of the novel 2009 H1N1 Influenza virus vaccination, and emerging patterns of antiviral resistance. Finally, efforts to contain and prevent the novel 2009 H1N1 Influenza virus from spreading within the cardiothoracic transplant setting can be accomplished through infection control measures."

"This article is an initiative of the Infectious Disease (ID) council of ISHLT to provide timely practical guidance for cardiothoracic transplant programs facing a winter pandemic of novel 2009 H1N1 influenza," comments Dr Margaret M Hannan, Mater Misericordiae University Hospital, Dublin, Chairman of ID council for ISHLT. "Evolving diagnostic testing with limitations due to prolonged turnaround time and availability are considered in donor and recipient management. Ensuring that the most accurate diagnostic tests are being carried out in a timely and systematic manner will allow cardiothoracic transplant surgeons to make informed decisions in 'real time' and avoid waste of usable organs." Education of staff and patients in infection control and prevention is fundamental to successful management of this virus in the transplant recipient population.

The article is "The Novel 2009 H1N1 Influenza Virus Pandemic: Unique Considerations for Programs in Cardiothoracic Transplantation" by Lara A. Danziger-Isakov MD MPH, Shahid Husain MD MS , Martha L. Mooney MD FACP, Margaret M. Hannan MD for the ISHLT Infectious Diseases Council. DOI 10.1016/j.healun.2009.10.001. Following advance online publication on October 23, 2009, the article will appear in the Journal of Heart and Lung Transplantation, Volume 28, Issue 12 (December 2009) published by Elsevier.



1030 Boys with urogenital birth defects are 33 percent more common in villages sprayed with DDT [University of Pretoria]--Women who lived in villages sprayed with DDT to reduce malaria gave birth to 33 per cent more baby boys with urogenital birth defects (UGBD) between 2004 and 2006 than women in unsprayed villages, according to research published online by the UK-based urology journal BJUI.

And women who stayed at home in sprayed villages, rather than being a student or working, had 41 per cent more baby boys with UGBDs, such as missing testicles or problems with their urethra or penis.

The authors suggest that this is because they spent more time in homes where domestic DDT-based sprays are still commonly used to kill the mosquitos that cause malaria, even in areas where organised mass spraying no longer takes place.

Researchers led by the University of Pretoria in South Africa studied 3,310 boys born to women from the Limpopo Province, where DDT spraying was carried out in high-risk areas between 1995 and 2003 to control malaria. The study compared boys born to women in the 109 villages that were sprayed, with those born to women from the 97 villages that were not.

This showed that 357 of the boys included in the study – just under 11 per cent – had UGBDs. The incidence of UGBDs was significantly higher if the mother came from a sprayed village.

"If women are exposed to DDT, either through their diet or through the environment they live in, this can cause the chemical to build up in their body" explains lead author Professor Riana Bornman from the University's Department of Urology.

"DDT can cross the placenta and be present in breast milk and studies have shown that the residual concentration in the baby's umbilical cord are very similar to those in maternal blood.

"It has been estimated that if DDT exposure were to cease completely, it would still take ten to 20 years for an individual who had been exposed to the chemical to be clear of it. Our study was carried out on boys born between 2004 and 2006, five to nine years after official records showed that their mothers had been exposed to spraying.

"Records were not kept before 1995 in the Limpopo Province, but it is reasonable to assume that DDT was being used before that date to combat malaria.

"Although most countries have now banned the use of DDT, certain endemic malarial areas still use indoor residual spraying with DDT to decrease the incidence and spread of the disease, which is caused by mosquitoes."

The two-year study included 2,396 boys whose mothers had been exposed to DDT and 914 whose mothers had not.

A number of other factors were taken into account to rule out possible causes of the birth defects. These included smoking and drinking, the mother's age, how long she had lived in her village and her race. These all proved statistically insignificant.

The authors believe that their study highlights the importance of educating people in high-risk malaria areas about the dangers of DDT.

"The use of DDT has contributed to the success in reducing malarial transmission and malarial deaths in South and Southern Africa" says Professor Bornman.

"However, the present findings also strongly suggest that indoor residual spraying with DDT is associated with UGBDs in newborn boys.

"With global concerns about the effect of chemicals on health, and the possibility of malaria resurgence and spread as a result of climate change, all authorities should ensure that the general public, including those living under indoor residual spraying conditions, are aware of the possible health risks.

"Educating people living in the DDT-sprayed communities about ways of protecting themselves from undue DDT exposure needs to be carried out as a matter of extreme urgency.

"There must be long-term monitoring of possible environmental and human health impacts, particularly in those areas where DDT will be introduced as part of the fight against malaria.

"We are now carrying out further research to find out how indoor spraying using DDT-based products affects humans and how this risk can be reduced."

DDT and urogenital malformations in newborn boys in a malarial area. Bornman et al. BJUI. Online publication 23 October 2009. doi: 10.1111/j.1464-410X.2009.09003.x



1030 Despite risk, older African Americans more likely than others to avoid flu vax [Buffalo NY]--A study about why African American seniors do or do not get influenza vaccinations finds that many of them do not have accurate and complete information about the flu itself, the safety and efficacy of the inoculations, and the ease and necessity of getting the shots.

Co-author and health communications specialist Lance Rintamaki, PhD, assistant professor of communication at the University at Buffalo, says that in addition, misinformation about the notorious 1932-72 Tuskegee syphilis studies of African-American men may result in a lingering distrust of some public health inoculation programs.

The study was published in Health Communications.

It notes that, despite the risk of influenza-related medical complications among those 65 years and over, African American seniors are less likely to be vaccinated against flu than are non-Hispanic white seniors.

Rintamaki points out that, although the U.S. Department of Health and Human Services wants to have 90 percent of seniors vaccinated, the vaccination rates for American adults 65 years and over averages 65 percent -- but is only 48 percent among older African Americans.

This is of great concern in the medical community, he says, because 44,000 Americans 65 and older die from influenza and its complications every year, compared to a total of 7,000 flu-related deaths in all other age groups.

According to Rintamaki, the researchers found several reasons for the reluctance of African American seniors to get flu shots.

"One," he says, is that study subjects did not understand how often they need to be vaccinated. Some seniors thought that, like vaccines against common childhood illnesses, the flu vaccine provided lifelong protection against the flu. Many did not know they needed to be re-vaccinated every year.

"The participants knew there are different strains of influenza," he says, "but they didn't realize they needed to be vaccinated against each strain as it turned up.

"Some also thought -- as do many members of the public -- that the vaccines cause the flu. If they became sick with a virus of one kind or other around the time they had a flu shot," he says, "they drew the erroneous conclusion that the shot made them sick.

"This is a common misperception and one that needs to be corrected," Rintamaki adds. "We often tell people the vaccine doesn't 'cause' flu but in failing to address why they might assume that it does, we leave the door open for them to think they are avoiding illness by avoiding the vaccine."

The researchers say better and more targeted messages and interventions are necessary to address concerns specific to older African Americans and to emphasize how important it is for those in this age group to be vaccinated.

The study involved six focus groups of African American seniors in the Chicago area. Their average age was 75 and 85 percent of them were women. They were asked to identify their current perceptions about influenza and influenza vaccination.

Seventy-seven percent of participants said they had received the flu vaccine at some time in their life, but only 50 percent had been vaccinated the previous year.

Despite the group size and the fact that their responses cannot be projected to the community as a whole, the authors say the results of the study confirm those conducted by the Centers for Disease Control and Prevention and others.

Some disturbing news to emerge from the study, says Rintamaki, is that the infamous Tuskegee syphilis experiments continue to affect levels of trust among African Americans toward public health programs.

The Tuskegee experiments, whose original goal was to justify treatment programs for blacks, involved 399 African American sharecroppers infected with syphilis. In 1932, when the study began, the available treatments were highly toxic and of limited effectiveness. The study aimed to determine if patients were better off if they were not treated with those remedies. The researchers also wanted to study the efficacy of specific remedies for individual stages of the disease.

By 1947, penicillin was commonly used as an effective cure for the disease. The researchers, however, failed to treat study participants with the medication. As a result, many men died of syphilis, wives contracted it from husbands and children were born with congenital syphilis. The study was not discontinued until news of this fact emerged, causing a public uproar.

Rintamaki points out that although the some of the seniors interviewed were not familiar with these experiments, those who were thought that the Tuskegee researchers did more than withhold treatment. They thought they actually injected the men with syphilis.

"The Tuskegee experiments have stirred fear and suspicion in the African American community over many health initiatives," he says, "and the suspicion they spawned has a continuing negative effect on the health of that community.

"In fighting the flu by encouraging inoculation, it is imperative that as health communicators we recognize that such fears exist and address such them," he says.

In addition to Rintamaki, the research team included Kenzie A. Cameron, PhD, research assistant professor, Division of General Internal Medicine, Feinberg School of Medicine Northwestern University; Mafo Kamanda-Kosseh, clinical coordinator, Center for Interventional Vascular Therapy, Columbia University Medical Center; Gary A. Noskin, MD, associate professor of medicine, Feinberg School of Medicine, Northwestern University; David W. Baker, MD, professor of medicine and chief of the division of general internal medicine, Feinberg School of Medicine, Northwestern University, and Gregory Makoul, PhD, vice president for academic affairs, St. Francis Hospital and Medical Center.



1029 NIAID scientists propose new explanation for flu virus antigenic drift [Bethesda MD]--Influenza viruses evade infection-fighting antibodies by constantly changing the shape of their major surface protein. This shape-shifting, called antigenic drift, is why influenza vaccines — which are designed to elicit antibodies matched to each year's circulating virus strains — must be reformulated annually. Now, researchers from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, have proposed a new explanation for the evolutionary forces that drive antigenic drift. The findings in mice, using a strain of seasonal influenza virus first isolated in 1934, also suggest that antigenic drift might be slowed by increasing the number of children vaccinated against influenza.

Scott Hensley, Ph.D., Jonathan W. Yewdell, M.D., Ph.D., and Jack R. Bennink, Ph.D., led the research team, whose findings appear in the current issue of Science.

"This research elegantly combines modern genetic techniques with decades-old approaches to give us new insights into the mechanisms of antigenic drift and how influenza viruses elude the immune system," says NIAID Director Anthony S. Fauci, M.D."

"No one is sure exactly how the antigenic drift of flu viruses happens in people," says Dr. Yewdell. According to the prevailing theory, drift occurs as the virus is passed from person to person and is exposed to differing antibody attacks at each stop. With varying success, antibodies recognize one or more of the four antigenic regions in hemagglutinin, the major outer coat protein of the flu virus. Antibodies in person A, for example, may mount an attack in which antibodies focus on a single antigenic region. Mutant viruses that arise in person A can escape antibodies by replacing one critical amino acid in this antigen region. These mutant viruses survive, multiply and are passed to person B, where the process is repeated.

It is not possible to dissect the mechanism of antigenic drift in people directly, notes Dr. Yewdell. So he and his colleagues turned to a classic mouse model system developed in the mid-1950s at the University of Chicago, but used rarely since. The team infected mice with a strain of seasonal influenza virus that had circulated in Puerto Rico in 1934. Some mice were first vaccinated against this virus strain and developed antibodies against it, while others were unvaccinated.

After infecting the vaccinated and unvaccinated mice with the 1934 influenza strain, the scientists isolated virus from the lungs of both sets of mice and passed on these viruses to a new set of mice. They did this nine times. After the final passage, the researchers sequenced the gene encoding the virus hemagglutinin protein. Of course, says Dr. Yewdell, gene sequencing was not possible in the mid-1950s, when the nature of the gene was first elucidated, and until very recently, sequencing was expensive and time-consuming. "Now, with automated gene sequencers, sequencing of dozens of isolates is easily done overnight," he says.

Sequencing revealed that the unvaccinated mice — which lacked vaccine-induced antibodies — had no mutated influenza viruses in their lungs. In contrast, the hemagglutinin gene in virus isolated from vaccinated mice had mutated in a way that increased the ability of the virus to adhere to the receptors it uses to enter lung cells. Essentially, says Dr. Yewdell, the virus can shield its hemagglutinin antigenic sites from antibody attack by binding more tightly to its receptor.

"The virus must strike the right balance, however," Dr. Yewdell says. "Excessively sticky viruses may end up binding to cells lining the nose or throat or to blood cells and may not make it into lung cells. Also, newly formed viruses must detach from infected cells before they can spread to the next uninfected cell. Viruses that have mutated to be highly adherent to the lung cell receptors may have difficulty completing this critical step in the infection cycle."

Next, the researchers infected a new set of unvaccinated mice with the high-affinity mutant virus strain that had emerged in the first series of experiments. In the absence of antibody pressure, the virus reverted to a low-affinity form and was once again able to easily infect cells and spread.

"We propose a model for antigenic drift in which high- and low-affinity influenza virus mutants alternate," says Dr. Yewdell. In adults — who have been exposed to many strains of influenza in their lifetime and, correspondingly, have a wide range of antibody responses — the virus is pressured to increase its receptor affinity to escape antibody neutralization. When such high-affinity mutants are passed to people — such as children — who have not been exposed to many influenza strains or who have not been vaccinated against flu, receptor affinity decreases. People who have not been exposed to multiple influenza virus strains or who have never been vaccinated against influenza are said to be immunologically naïve.

"Our model predicts that decreasing the immunologically naïve population — by increasing the number of children vaccinated against influenza, for example — could slow the rate of antigenic drift and extend the duration of effectiveness of seasonal influenza vaccines," he says.



1027 Older patients with dementia at increased risk for flu mortality [Boston MA]--An epidemiological study on pneumonia and influenza (P&I) in adults age 65 and over reports that patients with dementia are diagnosed with flu less frequently, have shorter hospital stays, and have a fifty percent higher rate of death than those without dementia. The three-pronged study, which analyzed geographic and demographic patterns of P&I and the relationship between P&I and health care accessibility, was published online in advance of print in Journal of the American Geriatrics Society.

“The increased mortality of older patients with dementia hospitalized for flu may be indicative of inadequacies in health care quality and accessibility. It could be beneficial to refine guidelines for the immunization, testing, and treatment of flu in older patients with dementia when planning for the possibility of a flu pandemic,” said first and senior author Elena Naumova, PhD, professor of public health and community medicine at Tufts University School of Medicine.

Dementia, defined by the authors as cognitive impairment to the extent that normal activity is impaired, causes unique obstacles to the early diagnosis and treatment of flu. Patients may have difficulty communicating symptoms and medical complications due to poor oral hygiene or impaired swallowing. Additionally, the authors believe that limited access to health care services and inadequate testing practices may contribute to the higher rates of mortality and lower rates of diagnosis of flu seen in older patients with dementia. A geographic analysis of the data showed that P&I rates were highest among older adults in poor and rural areas, where there is a lower concentration of health care facilities.

“Limited access to specialized health care services can delay diagnosis and treatment of the flu, causing it to progress to pneumonia, the fifth leading cause of death among the elderly. This study has helped us identify this vulnerable population, and now further study is needed to confirm the findings and assess the testing and vaccination policies for older patients with dementia,” said Naumova.

Study data were obtained from the Centers for Medicaid and Medicare Services (CMS), and covered a span of five years, from 1998 to 2002. Of the 36 million hospitalization records for adults aged 65 and older, more than six million records documented a P&I diagnosis. Of these records showing a P&I diagnosis, over 800,000 (13%) also showed dementia. The demographic and geographic patterns of P&I hospitalizations and their links with hospital accessibility were explored. Pneumonia and influenza admissions, length of stay in a hospital, and mortality rates among elderly with dementia were compared to national estimates.

Elena Naumova is the director of the Tufts University Initiative for the Forecasting and Modeling of Infectious Diseases (Tufts InForMID), which works to improve biomedical research by developing computational tools in order to assist life science researchers, public health professionals, and policy makers. The center is focused on developing methodology for analysis of large databases to enhance disease surveillance, exposure assessment, and studies of aging.

Co-authors include Sara M. Parisi and Julia Wenger, now graduates of the Master of Public Health program at Tufts University School of Medicine; Denise Castronovo, MS, Mapping Sustainability, LLC; Manisha Pandita, former research assistant in the department of public health and community medicine at Tufts University School of Medicine; and Paula Minihan, PhD, assistant professor of public health and community medicine, Tufts University School of Medicine.

This study was funded by the National Institute of Allergy and Infectious Diseases and the National Institute of Environmental Health Sciences, both part of the National Institutes of Health.

Naumova EN, Parisi SM, Castronovo D, Pandita M, Wenger J, and Minihan P. Journal of the American Geriatrics Society. “Pneumonia and influenza hospitalizations in elderly people with dementia.” Published online in advance of print, October 26, 2009, doi: 10.1111/j.1532-5415.2009.02565.x.



1026 Latest analysis confirms suboptimal vitamin D levels in millions of US children [Boston MA]--Millions of children in the United States between the ages of 1 and 11 may suffer from suboptimal levels of vitamin D, according to a large nationally representative study published in the November issue of Pediatrics, accompanied by an editorial.

The study, led by Jonathan Mansbach, MD, at Children's Hospital Boston, is the most up-to-date analysis of vitamin D levels in U.S. children. It builds on the growing evidence that levels have fallen below what's considered healthy, and that black and Hispanic children are at particularly high risk.

Both the optimal amount of vitamin D supplementation and the healthy blood level of vitamin D are under heated debate in the medical community. Currently, the American Academy of Pediatrics recommends children should have vitamin D levels of at least 50 nmol/L (20 ng/ml). However, other studies in adults suggest that vitamin D levels should be at least 75 nmol/L (30 ng/ml), and possibly 100 nmol/L (40 ng/ml), to lower the risk of heart disease and specific cancers.

Mansbach and collaborators from the University of Colorado Denver and Massachusetts General Hospital used data from the National Health and Nutrition Examination Survey (NHANES) to look at vitamin D levels in a nationally representative sample of roughly 5,000 children from 2001-2006. Extrapolating to the entire U.S. population, their analysis suggests that roughly 20 percent of all children fell below the recommended 50 nmol/L. Moreover, more than two-thirds of all children had levels below 75 nmol/L, including 80 percent of Hispanic children and 92 percent of non-Hispanic black children.

"If 75 nmol/L or higher is eventually demonstrated to be the healthy normal level of vitamin D, then there is much more vitamin D deficiency in the U.S. than people realize," Mansbach says.

Mansbach and his co-authors suggest that all children take vitamin D supplements, because of the generally low levels that they found and the potential health benefits of boosting vitamin D to normal levels. Vitamin D improves bone health and prevents rickets in children, and recent studies suggest that it also may prevent a host of common childhood illnesses, including respiratory infections, childhood wheezing, and winter-related eczema.

Although sun exposure generates healthy doses of vitamin D, it can also cause skin cancer. Dermatologists and the AAP recommend wearing sunblock, but this actually blocks our skin's ability to make vitamin D. Furthermore, children with more highly pigmented skin require much more sun exposure than fair-skinned children to obtain healthy levels of vitamin D. Vitamin D can also be obtained from certain foods, like liver and fatty fish, but almost all children in the U.S. don't consume these foods in high enough quantities to match the vitamin D that could be provided by summer sunshine or vitamin D supplements.

In the study, children taking multi-vitamins that included vitamin D had higher levels overall, but this accounted for less than half of all children. Mansbach recommends that all children take vitamin D supplements, especially those living in high latitudes, where the sun is scarce in the wintertime.

"We need to perform randomized controlled trials to understand if vitamin D actually improves these wide-ranging health outcomes," Mansbach says. "At present, however, there are a lot of studies demonstrating associations between low levels of vitamin D and poor health. Therefore, we believe many U.S. children would likely benefit from more vitamin D."

This research was funded by the National Institutes of Health.



1026 Vast majority of physicians satisfied with hospital chaplain services [Chicago IL]--A national survey of physicians' experience with hospital chaplains found that the vast majority of doctors were satisfied with the spiritual services provided. Physicians in the Northeast and those with a dim view of religion's effects on patients, however, were less likely to be pleased.

The results of the survey – the largest, most representative survey of physicians' attitudes about religion and spirituality conducted to date – are published in a research letter in the October 26 issue of the Archives of Internal Medicine. George Fitchett, PhD, a chaplain at Rush University Medical Center, is the study's lead author.

"Religion and spirituality are important resources for coping with serious illnesses, but research indicates that patients' needs in this regard often go unmet," Fitchett said. "That's why it is important to understand how physicians view chaplains. Doctors play a crucial role in ensuring that patients get access to this kind of care."

The study was based on data from a random sample of physicians of all specialties selected from the American Medical Association Physician Masterfile. The survey response rate was 63 percent.

Of the 1,102 physicians whose responses were included in the study, 89 percent had some experience with chaplains. Of these physicians, 90 percent were satisfied or very satisfied with chaplains' services.

Those who were satisfied tended to be physicians who worked in teaching hospitals; practiced medical subspecialties, such as cardiology or oncology, or other specialties, such as emergency medicine or neurology; endorsed the notion that religion and spirituality can have a good effect on patients; and believed it was acceptable to pray with a patient whenever the physician sensed it would be appropriate.

Those physicians who believed that religion and spirituality had a negative impact on patients were more likely to be dissatisfied with chaplains' services.

The survey also found that physicians in the Midwest were more likely to be satisfied with chaplains than physicians in the Northeast. The finding was unexplained because of limitations in the data collected.

Other researchers involved in the study were Kenneth Rasinski, PhD, from the University of Chicago; Wendy Cadge, PhD, from Brandeis University; and Dr. Farr Curlin, from the University of Chicago.



1026 Heart attacks become more common but less often fatal in women [USC]--Heart attacks appear to have become more common in middle-aged women over the past two decades, but all women and especially those younger than 55 have recently experienced a greater increase than men in their chances of survival following such a heart event, according to two reports in the October 26 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Middle-aged women have historically had a lower overall risk of heart events and stroke than men of a similar age, according to background information in one of the articles. However, a recent report showing higher stroke rates among women than men in a sample representative of the U.S. population appeared to reveal a new phenomenon and raised the question of whether heart disease or heart attack were also becoming more prevalent among women.

Amytis Towfighi, M.D., of the University of Southern California, Los Angeles, and colleagues analyzed data from U.S. adults age 35 to 54 who participated in the National Health and Nutrition Examination Surveys (nationally representative surveys conducted by the government) during 1988 to 1994 (4,326 participants) and 1999 to 2004 (4,075 participants). The researchers assessed how often men and women had heart attacks and also compared their Framingham coronary risk score, a measurement of heart disease risk over 10 years that includes factors such as age, cholesterol levels, blood pressure and smoking history.

In both study periods, men age 35 to 54 years had more heart attacks than women in the same age group. However, the gap narrowed in more recent years as heart attacks decreased in prevalence among men and increased in prevalence among women (2.5 percent of men and 0.7 percent of women reported a history of heart attack in 1988-1994, whereas 2.2 percent of men and 1 percent of women did so in 1999-2004).

Between the two time periods, the average Framingham coronary risk score showed an improving trend among men but decreased among women. In male participants, total cholesterol levels remained stable, high-density lipoprotein (HDL or "good" cholesterol) levels and systolic (top number) blood pressure levels improved and smoking levels declined. The only risk factor that improved among women was HDL levels. Diabetes prevalence increased among both men and women, likely due to insulin resistance and the obesity epidemic in both sexes.

"Although men in their midlife years continue to have a higher prevalence of myocardial infarction and a higher 10-year risk of hard coronary heart disease than women of similar age, our study suggests that the risk is increasing in women, while decreasing in men," the authors write. "Therefore, intensification of efforts at screening for and treating vascular risk factors in women in their midlife years may be warranted."

In another report, Viola Vaccarino, M.D., Ph.D., of Emory University School of Medicine, Atlanta, and colleagues investigated trends in the rate of in-hospital deaths following heart attack from June 1, 1994, through Dec. 31, 2006. Data were collected from 916,380 patients through the National Registry of Myocardial Infarction.

In-hospital death rates decreased among all patients between 1994 and 2006, but decreased more markedly in women than in men. The reduced risk of death was largest in women younger than 55 years (a 52.9 percent reduction) and lowest in men of the same age (33.3 percent). The absolute decrease in the risk of death among patients younger than 55 was three times larger in women (2.7 percent) than men (0.9 percent).

"A large part (93 percent) of this sharper decrease in mortality of younger women compared with men in recent years was because the risk status of women on admission improved compared with that of men," the authors write. "Such improvement may be due to better recognition and management of coronary heart disease and its risk factors in women before the acute myocardial infarction event, as suggested by the narrowing sex difference in previous revascularization [surgical treatment for heart disease]."

Editorial: Prevention Is Key for Women and Heart Disease

"Cardiovascular illnesses have been long neglected in their role as the primary cause of mortality in women, both by patients and physicians," write Sabine Oertelt-Prigione, M.D., and Vera Regitz-Zagrosek, M.D., Ph.D., of Charité Universitaetsmedizin, Berlin, in an accompanying editorial. "Men are still believed to be at greater risk for myocardial infarction and stroke and are thus more aggressively informed, counseled and treated for these diseases."

"The improvements described by Towfighi et al and Vaccarino et al are encouraging and indicate that we are on the right track. However, much needs to be done, especially in consideration of the increase in prevalence of risk factors as obesity and type 2 diabetes mellitus in the general population."

"As these studies show, increased and continuous vigorous attention to the prevention of cardiovascular risk factors—by healthy diet, regular physical activity and avoidance of smoke and smoking—is necessary for both men and women," they conclude.



1026 Weather patterns help predict dengue fever outbreaks [Hong Kong China]--High temperatures, humidity and low wind speed are associated with high occurrence of dengue fever according to a study published in the open access journal BMC Public Health.

Dengue fever is a viral disease transmitted by mosquitoes in tropical and subtropical regions of the world. It is one of the most significant insect-borne diseases found in humans, with 2.5 billion people living in high-risk areas globally. In recent years, the number of cases occurring has increased dramatically. Being able to predict the trend of dengue fever facilitates early public heath responses to minimise morbidity and mortality.

A research team led by Qiyong Liu of the State Key Laboratory for Infectious Disease Prevention and Control, and China CDC, and Linwei Tian of the Stanley Ho Centre for Emerging Infectious Diseases, School of Public Health and Primary Care, Chinese University of Hong Kong, correlated weather conditions, including minimum and maximum temperature, wind velocity, humidity and rainfall with the number of cases of dengue fever in the city of Guangzhou, capital city of Guangdong Province, China, over a six year period from 2001 until 2006

As dengue fever is a legally notifiable disease in China, the researchers were able to retrieve the monthly incidence of dengue fever from the Notifiable Infectious Disease Report System in the China Centre for Disease Control and Prevention. They correlated this with monthly weather data obtained from the China Meteorological Data Sharing Service System over the same period of time.

Higher minimum temperatures and lower wind speeds were associated with the highest number of cases of dengue fever. If the effects of humidity were factored into the mathematical model, the model fit actual events even better. The effects of minimum temperature and humidity on the incidence of dengue fever were subject to a lag of about one month, whereas the effects of wind velocity were apparent in the same month.

The authors suggest that the effects of humidity and temperature are likely to be related to mosquito survival; low humidity and cooler temperatures decrease mosquito survival. Wind speed affects mosquito flying, so high wind velocities lead to lower density of mosquitoes. But the authors point out "the transmission of dengue fever is more complex, and is influenced by community intervention measures, human behavioural influences on mosquito population and human mosquito interaction," and conclude, "future studies require studying mosquito populations."



1026 Study reveals high death rates and short life expectancy among the homeless and marginally housed [Toronto ON]--Homeless and marginally housed people have much higher mortality and shorter life expectancy than could be expected on the basis of low income alone, concludes a study from Canada published on bmj.com today.

Previous studies have found high levels of excess mortality among the homeless compared with the general population, but little information is available on death rates among homeless and marginally housed people living in low-cost collective dwellings, such as rooming houses and hotels.

So, researchers at St Michael's Hospital in Toronto and Statistics Canada compared death rates and life expectancy among a representative sample of homeless and marginally housed people with rates in the poorest and richest income sectors of the general population.

Using data from the 1991-2001 Canadian census, they tracked 15,000 homeless and marginally housed people across Canada for 11 years.

Mortality rates among homeless and marginally housed people were substantially higher than rates in the poorest income groups, with the highest rates seen at younger ages.

Among those who were homeless and marginally housed, the probability of survival to age 75 was 32% in men and 60% in women. This compared to 51% and 72% among men and women in the lowest income group in the general population.

For men, this equates to about the same chance of surviving to age 75 as men in the general population of Canada in 1921 or men in Laos in 2006. For women, this equates to about the same chance of surviving to age 75 as women in the general population of Canada in 1956 or women in Guatemala in 2006.

Remaining life expectancy at age 25 among homeless and marginally housed men was 42 years - 10 years lower than the general population and six years lower than the poorest income group.

For homeless and marginally housed women, remaining life expectancy at age 25 was 52 years – seven years lower than the general population, and five years lower than the poorest income group.

A large part of this premature mortality is potentially avoidable, say the authors. Many excess deaths were attributable to alcohol and smoking-related diseases and to violence and injuries, much of which might have been related to substance abuse.

There were also many excess deaths related to mental disorders and suicides.

This study shows that homeless and marginally housed people living in shelters, rooming houses, and hotels have much higher mortality and shorter life expectancy than could be expected on the basis of low income alone, they conclude. These findings emphasise the importance of considering housing situation as a marker of socioeconomic disadvantage.



1026 Deadly stomach infection rising in community settings [Rochester MN]--Mayo Clinic researchers have found that a sometimes deadly stomach bug, Clostridium difficile, is on the rise in outpatient settings. Clostridium difficile is a serious bacteria that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. These findings were presented today at the 2009 American College of Gastroenterology (ACG) Annual Meeting in San Diego.

Clostridium difficile, often called C. difficile or "C. diff", is a bacterium that is resistant to some antibiotics and is most often contracted by the elderly in hospitals and nursing homes.

"Recent reports have shown increasing incidence and severity of C. difficile infection — especially in the older population," says Darrell Pardi, M.D., Mayo Clinic gastroenterologist and senior author on the study. "Our study examines why the cases are on the rise and who is getting the infection."

In this population-based study, researchers studied 385 cases of C. difficile bacterial infection from 1991-2005 to determine how many cases were hospital-acquired versus community-acquired infections. Of the cases, 192 were hospital-acquired and 35 were residents of nursing homes. Of these hospital-acquired cases, the median age of infection was 72 years; in contrast, 158 cases were community-acquired and the median age was 50 years. Thirty-five percent of the hospital infections had a severe illness compared to 22 percent of community infections who had a severe illness.

The patients with community-acquired infection were also less likely than the hospital-acquired group to have been exposed to antibiotics before their infection. Thus, many of the community-acquired infections lacked the traditional risk factors for infection, namely recent hospitalization and exposure to antibiotics.

There were no differences between community- and hospital-acquired infections in terms of what patients were treated with (primarily metronidazole), response rates, or recurrence rates after treatment.

"We are seeing more cases of C. difficile in the community, but they tend to be less severe and in a younger population," says Dr. Pardi. "The growing incidence of C. difficile infection in both inpatient and outpatient settings could be linked to the increasing usage of antibiotics and to the possibility that C. difficile may be getting resistant to some of our newer antibiotics."

There are hundreds of kinds of bacteria found normally in the intestines. Many play beneficial roles in the body. When a patient takes an antibiotic to treat an infection, it often destroys beneficial bacteria as well as the bacteria that are causing the illness. Without enough healthy bacteria, dangerous pathogens such as C. difficile can quickly grow out of control. Once it takes hold, C. difficile can produce two virulent toxins that attack the lining of the intestine.

"Doctors have gotten better at spotting C. difficile in hospitals and nursing homes; however, now doctors and patients need to be more aware that you can get this infection as an outpatient and that a case of diarrhea or abdominal cramps at home could become serious," says Dr. Pardi.

According to the Centers for Disease Control and Prevention, each year in the United States, C. difficile is responsible for tens of thousands of diarrhea cases and at least 5,000 deaths.



1026 The pain of torture can make the innocent seem guilty [Cambridge, MA]--The rationale behind torture is that pain will make the guilty confess, but a new study by researchers at Harvard University finds that the pain of torture can make even the innocent seem guilty.

Participants in the study met a woman suspected of cheating to win money. The woman was then "tortured" by having her hand immersed in ice water while study participants listened to the session over an intercom. She never confessed to anything, but the more she suffered during the torture, the guiltier she was perceived to be.

The research, published in the "Journal of Experimental Social Psychology," was conducted by Kurt Gray, graduate student in psychology, and Daniel M. Wegner, professor of psychology, both in Harvard's Faculty of Arts and Sciences.

"Our research suggests that torture may not uncover guilt so much as lead to its perception," says Gray. "It is as though people who know of the victim's pain must somehow convince themselves that it was a good idea—and so come to believe that the person who was tortured deserved it."

Not all torture victims appear guilty, however. When participants in the study only listened to a recording of a previous torture session—rather than taking part as witnesses of ongoing torture—they saw the victim who expressed more pain as less guilty. Gray explains the different results as arising from different levels of complicity.

"Those who feel complicit with the torture have a need to justify the torture, and so link the victim's pain to blame," says Gray. "On the other hand, those distant from torture have no need to justify it and so can sympathize with the suffering of the victim, linking pain to innocence."

The study included 78 participants: half met the woman who was apparently tortured (actually a confederate of the experimenters who was, of course, not harmed at all), and half did not. Participants were told that the study was about moral behavior, and that the woman may have cheated by taking more money than she deserved. The experimenter suggested that a stressful situation might make a guilty person confess, so participants listened for a confession over a hidden intercom as she was subjected to the sham "torture."

The confederate did not admit to cheating but reacted to having her hand submerged in ice water with either indifference or with whimpering and pleading. Participants who had met her rated her as more guilty the more she suffered. Those who did not meet her rated her as more guilty when she felt less pain.

Gray suggests that these results offer an explanation for the debate swirling around torture.

"Seeing others in pain can perpetuate ideological differences about the justifiability of torture," says Gray. "Those who initially advocate torture see those harmed as guilty, unlike those who initially reject torture and its methods."

The findings also shed light on the Abu Ghraib scandal, where prison guards tortured Iraqi detainees. Prison guards, who are close to the suffering of detainees, see detainees as more guilty the more they suffer, unlike the more distant general public.

The case is still open on whether torture actually makes victims more likely to tell the truth. This research suggests instead that the mere fact that someone was tortured leads observers to think that the truth was found.

The research was supported by the Canadian Social Sciences and Humanities Research Council and the Institute for Humane Studies.



1026 Researchers identify dominant chemical that attracts mosquitoes to humans [UC Davis]--Scientists at the University of California, Davis, have identified the dominant odor naturally produced in humans and birds that attracts the blood-feeding Culex mosquitoes, which transmit West Nile virus and other life-threatening diseases.

The groundbreaking research, published this week in the early online edition of the Proceedings of the National Academy of Sciences, explains why mosquitoes shifted hosts from birds to humans and paves the way for key developments in mosquito and disease control.

Entomology professor Walter Leal and postdoctoral researcher Zain Syed found that nonanal (sounds like NAWN-uh-nawl) is the powerful semiochemical that triggers the mosquitoes' keen sense of smell, directing them toward a blood meal. A semiochemical is a chemical substance or mixture that carries a message.

"Nonanal is how they find us," Leal said. "The antennae of the Culex quinquefasciatus are highly developed to detect even extremely low concentrations of nonanal." Mosquitoes detect smells with the olfactory receptor neurons of their antennae.

Birds, the main hosts of mosquitoes, serve as the reservoir for the West Nile virus, Leal said. When infected mosquitoes take a blood meal, they transmit the virus to their hosts, which include birds, humans, horses, dogs, cats, bats, chipmunks, skunks, squirrels and domestic rabbits. Since 1999, the U.S. Centers for Disease Control and Prevention have recorded 29,397 human cases and 1,147 fatalities in the United States alone.

The UC Davis researchers tested hundreds of naturally occurring compounds emitted by people and birds. They collected chemical odors from 16 adult human subjects, representing multiple races and ethnic groups.

"We then determined the specificity and sensitivity of the olfactory receptor neurons to the isolated compounds on the antennae of the mosquitoes," Syed said.

Leal and Syed found that nonanal acts synergistically with carbon dioxide, a known mosquito attractant. "We baited mosquito traps with a combination of nonanal and carbon dioxide and we were drawing in as many as 2,000 a night in Yolo County, near Davis," Syed said. "Nonanal, in combination with carbon dioxide, increased trap captures by more than 50 percent, compared to traps baited with carbon dioxide alone."

The UC Davis research was funded in part by the National Institutes of Health; a cooperative research agreement with Bedoukian Research, a supplier of specialty aroma and flavor ingredients headquartered in Connecticut; and the National Science Foundation.



1021 Researchers can predict hurricane-related power outages [Baltimore MD]--Using data from Hurricane Katrina and four other destructive storms, researchers from Johns Hopkins and Texas A&M universities say they have found a way to accurately predict power outages in advance of a hurricane. Their approach provides estimates of how many outages will occur across a region as a hurricane is approaching.

The information provided by their computer models has the potential to save utilities substantial amounts of money, savings that can then be passed on to customers, the researchers say. In addition, appropriate crew levels and placements can help facilitate rapid restoration of power after the storm.

The study was a collaborative effort involving Seth Guikema, an assistant professor of geography and environmental engineering at Johns Hopkins and formerly of Texas A&M; Steven Quiring, an assistant professor of geography at Texas A&M; and Seung-Ryong Han, who was Guikema's doctoral student at Texas A&M and is now based at Korea University. Their work, which was funded by a Gulf Coast utility company that wishes to remain anonymous, is published in the current issue of the journal Risk Analysis.

The research focused on two common challenges. When a hurricane is approaching, an electric power provider must decide how many repair crews to request from other utilities, a decision that may cost the provider millions of dollars. The utility also must decide where to locate these crews within its service areas to enable fast and efficient restoration of service after the hurricane ends. Having accurate estimates, prior to the storm's arrival, of how many outages will exist and where they will occur will allow utilities to better plan their crew requests and crew locations, the researchers say.

What makes the research team's computational approach unique and increases its accuracy, Guikema and Quiring say, is the combination of more detailed information about the storm, the area it is impacting and the power system of the area, together with more appropriate statistical models.

"If the power company overestimates, it has spent a lot of unnecessary money," Quiring said. "If it underestimates, the time needed to restore power can take several extra days or longer, which is unacceptable to them and the people they serve. So these companies need the best estimates possible, and we think this study can help them make the best possible informed decision."

In addition, more accurate models "provide a much better basis for preparing for restoring power after the storm," Guikema said, adding that "the goal is to restore power faster and save customers money."

In developing their computer model, the researchers looked at damage data from five hurricanes: Dennis (1995), Danny (1997), Georges (1998), Ivan (2004) and Katrina (2005). In the areas studied, Ivan created 13,500 power outages; Katrina, more than 10,000; Dennis, about 4,800; Georges, 1,075; and Danny, 620.

For the worst of these storms, some customers were without power for up to 11 days. The research team collected information about the locations of outages in these past hurricanes, with an outage defined as permanent loss of power to a set of customers due to activation of a protective device in the power system.

The researchers also included information about the power system in each area (poles, transformers, etc.), hurricane wind speeds, wetness of the soil, long-term average precipitation, the land use, local topography and other related factors. This data was then used to train and validate a statistical regression model called a Generalized Additive Model, a particular form of model that can account for nonlinear relationships between the variables.



1021 Major swine flu outbreak at US Air Force Academy provided unique opportunity to study virus behavior [San Diego CA]--With the 2009 influenza season upon us, characterization of the epidemiology and duration of shedding for the nH1N1 virus is critical. Investigators from the U.S. Air Force Academy and the U.S. Air Force School of Aerospace Medicine Epidemiology Consult Service capitalized on a unique opportunity to gain valuable insights about the natural behavior of the nH1N1 virus, including shedding patterns, during a recent large-scale swine flu outbreak at the U.S. Air Force Academy (USAFA). Their results are reported in an article published online on October 20, 2009 by the American Journal of Preventive Medicine. It is the first published study of its kind.

Findings from serial nasal washes indicated the presence of viable virus shedding among about one quarter of confirmed nH1N1 patients sampled on Day 7 from symptom onset. Further, being afebrile and asymptomatic did not guarantee the patient was no longer shedding viable nH1N1 virus; in fact, 19% of those who reported being symptom-free for greater than 24 hours were still found to have viable virus shedding. While viable virus shedding does not necessarily mean the virus can be transmitted, these findings do indicate that the virus may persist even after the individual is feeling well and has returned to work. Furthermore, the results of this study may assist development of appropriate protocols for isolation in high-risk settings or if the scale and/or severity of the current nH1N1 situation increases. The current study also provides groundwork to other investigators for further study of the shedding characteristics of the virus.

In July, this novel H1N1 outbreak represented one of the largest recognized nH1N1 clusters at a U.S. college to date. Lead investigator Catherine Takacs Witkop, MD, MPH, of the U.S. Air Force Academy, comments, "Characterizing virus–host interactions and the epidemiology of nH1N1 is important in both planning assumptions and in defining effective control measures. Studies of seasonal influenza suggest that viral shedding occurs for as long as 7 days after symptom onset. No similar studies on shedding of nH1N1 have been published. In addition, there are no published studies of the epidemiology of nH1N1 infection among military training populations or institutions of higher education."

On June 25, 2009, 1376 new basic cadet trainees (BCTs) arrived at USAFA to begin a 6-week military training program prior to their first academic year. Between July 6 and 7, respiratory complaints increased and two cadets were identified as positive for influenza A. Due to a high level of suspicion that the responsible virus was nH1N1, identification, treatment and containment efforts were initiated immediately.

There were 134 confirmed and 33 suspect cases of nH1N1 infection identified with onset date from June 25 to July 24, 2009. Fever, cough and sore throat were the most commonly reported symptoms. Among the at-risk BCTs, 11% were infected during the outbreak period. Twenty-nine percent (31/106) of samples in patients with temperature <100°F and 19% (11/58) of samples in patients reporting no symptoms for at least 24 hours contained viable nH1N1 virus. Of 29 samples obtained 7 days from illness onset, 7 (24%) contained viable nH1N1 virus.

A total of 228 cadets were placed in separated dorm areas during the outbreak period. There were no confirmed or suspect cases among healthcare personnel.

Investigators determined the outbreak was likely propagated by a social mixing event, which has implications for colleges and universities across the country. Measures undertaken to stem the spread of the virus, quick response and mitigation efforts enacted immediately upon outbreak recognition, good communication and a public health campaign contributed significantly to the subsequent rapid decline of the outbreak.

Writing in the article, Dr. Witkop and co-authors state, "The USAFA outbreak provided a unique opportunity to gain valuable information about the natural behavior of the nH1N1 virus....Novel H1N1 is now endemic in all 50 U.S. states. University- and college-based outbreaks of nH1N1 have occurred and more can be expected this fall as students gather from diverse geographic areas, reside in dorm settings and attend mass gatherings such as football games, pep rallies and student assemblies. The combination of aggressive separation of ill BCTs, public health education and prompt implementation of healthcare infection control practices limited the duration and scope of the nH1N1 infection at USAFA. Comprehensive plans and rapid implementation are critical. Isolation procedures implemented at USAFA may not be practical in other university settings; however, preparedness planning, public health education activities and healthcare infection control practices implemented at USAFA can be adopted in other university settings."

The article is "Novel Influenza A (H1N1) Outbreak at the U.S. Air Force Academy: Epidemiology and Viral Shedding Duration" by Catherine Takacs Witkop, MD, MPH, Mark R. Duffy, DVM, MPH, Elizabeth A. Macias, PhD, Thomas F. Gibbons, PhD, James D. Escobar, MPH, Kristen N. Burwell, MPH and Kenneth K. Knight, MD, MPH. Following advance online publication on October 20, 2009 (DOI 10.1016/j.amepre.2009.10.005), the article will appear in the American Journal of Preventive Medicine, Volume 38, Issue 2 (February 2010) published by Elsevier.


1021 Calling it in: New emergency medical service system may predict caller's fate [Yokohama City, Japan]--Japanese researchers have developed a computer program which may be able tell from an emergency call if you are about to die. Research published in the open access journal BMC Emergency Medicine shows that a computer algorithm is able to predict the patient's risk of dying at the time of the emergency call.

Kenji Ohshige and a team of researchers from the Yokohama City University School of Medicine in Japan assessed the new Yokohama computer-based triage emergency system from its inception on 1st October 2008 until 31st March 2009, collecting information from over 60,000 emergency calls. For each call, triage information was entered into the computer system, which then categorized patients according to the severity of their condition. The researchers then compared the computer-estimated threat of dying at the time of the emergency call with the actual patients' condition upon arrival at the hospital emergency department. They found that the algorithm was effective in assessing the life risk of a patient with over 80% sensitivity.

According to Ohshige, "A patient's life threat risk can be quantitatively expressed at the moment of the emergency call with a moderate level of accuracy. The algorithm for estimating a patient's like threat risk should be improved further as more data are collected."

Ambulance response time has risen rapidly with the increased demand for this service in developed countries such as Japan. This emphasises the need to prioritise ambulance responses according to the severity of the patient's condition. "As delayed response time reduces the number of patients who survive from sudden cardiac arrest priority dispatch of ambulances to patients in critical condition has become a matter of importance", says Ohshige.



1021 Latest diabetes figures paint grim global picture [Montreal QC]--The International Diabetes Federation (IDF) released new data today showing that a staggering 285 million people worldwide have diabetes. The latest figures from the IDF Diabetes Atlas indicate that people in low and middle-income countries (LMCs) are bearing the brunt of the epidemic, and that the disease is affecting far more people of working age than previously believed.

In 1985, the best data available suggested that 30 million people had diabetes worldwide. Fast-forward 15 years and the numbers were revised to just over 150 million. Today, less than 10 years on, the new figures – launched at the 20th World Diabetes Congress in Montreal, Canada – put the number closer to 300 million, with more than half aged between 20 and 60. IDF predicts that, if the current rate of growth continues unchecked, the total number will exceed 435 million in 2030 – many more people than the current population of North America.

Professor Jean Claude Mbanya, President of the International Diabetes Federation, voiced concern: “The data from the latest edition of the IDF Diabetes Atlas show that the epidemic is out of control. We are losing ground in the struggle to contain diabetes. No country is immune and no country is fully equipped to repel this common enemy.”

Type 1 diabetes cannot be prevented. It is an autoimmune disease in which the body destroys its own insulin-producing cells. People with type 1 diabetes require daily injections of insulin to survive. The majority of all diabetes is type 2 diabetes (85%-95%), which in many cases can be prevented. People with type 2 diabetes cannot use the insulin they produce effectively, but can often manage their condition through exercise and diet, although many go on to require medication, including insulin, to properly control blood glucose levels. It is estimated 60% or more of type 2 diabetes could be prevented.

Both type 1 and type 2 diabetes represent a serious health threat. Diabetes claims four million lives every year and is a leading cause of blindness, kidney failure, heart attack, stroke and amputation.

Diabetes explodes worldwide

Diabetes now affects seven percent of the world’s adult population. The regions with the highest comparative prevalence rates are North America, where 10.2 % of the adult population have diabetes, followed by the Middle East and North Africa Region with 9.3%. The regions with the highest number of people living with diabetes are Western Pacific, where some 77 million people have diabetes and South East Asia with 59 million.

India is the country with the most people with diabetes, with a current figure of 50.8 million, followed by China with 43.2 million. Behind them the United States (26.8 million); the Russian Federation (9.6 million); Brazil (7.6 million); Germany (7.5 million); Pakistan (7.1 million); Japan (7.1 million); Indonesia (7 million) and Mexico (6.8 million).

When it comes to the percentage of adult population living with diabetes, the new data reveal the devastating impact of diabetes across the Gulf Region, where five of the Gulf States are among the top ten countries affected. The Pacific island nation of Nauru has the world’s highest rate of diabetes, with almost a third of its adult population (30.9%) living with the disease. It is followed by the United Arab Emirates (18.7%); Saudi Arabia (16.8%); Mauritius (16.2%); Bahrain (15.4%); Reunion (15.3%); Kuwait (14.6%); Oman (13.4%); Tonga (13.4%) and Malaysia (11.6%).

Increasing economic burden

Diabetes has become a development issue. In LMCs, it threatens health and economic prosperity. IDF predicts that diabetes will cost the world economy at least US$376 billion in 2010, or 11.6% of total world healthcare expenditure. By 2030, this number is projected to exceed US$490 billion. More than 80% of diabetes spending is in the world’s richest countries and not in the poorer countries, where over 70 percent of people with diabetes now live.

The United States accounts for $198 billion or 52.7% of total diabetes spending worldwide. India, which has the largest diabetes population, spends US$2.8 billion or 1% of the global total. In most LMCs, people with diabetes must pay for their care out of their own pocket because public medical services and insurance are lacking. The diagnosis of diabetes in a low or middle-income country can often drag entire families into poverty.

“The world needs to invest in integrated health systems that can diagnose, treat, manage and prevent diabetes,” said Professor Nigel Unwin, who leads the team of experts behind the IDF Diabetes Atlas. “Governments also need to invest in actions outside the formal health sector, particularly in promoting healthier diets and physical activity, to reduce obesity and the risk of type 2 diabetes. Without effective prevention diabetes will overwhelm health systems and hinder economic growth.”

Integrating plans for the prevention of diabetes into national health systems and policy frameworks is an important part of the response. IDF warns that many health systems worldwide are not yet equipped to handle the extent of the diabetes threat, and that failure to take action will have serious consequences.

“The epidemic represents nothing short of a global health emergency,” said IDF President Mbanya. “It is alarming that world leaders stand by while the diabetes fuse slowly burns. The serious impact on families, countries and economies continues with little resistance. Governments, aid agencies and the international community must take concerted action to defuse the threat now, before the diabetes time bomb explodes.”



1021 Illness often undiscovered and undertreated among the uninsured [Boston MA]--A new study shows uninsured American adults with chronic illnesses like diabetes or high cholesterol often go undiagnosed and undertreated, leading to an increased risk of costly, disabling and even lethal complications of their disease.

The study, published online today [Tuesday] in Health Affairs, analyzed data from a recent national survey conducted by the Centers for Disease Control and Prevention (CDC). The researchers, based at Harvard Medical School and the affiliated Cambridge Health Alliance, analyzed data on 15,976 U.S. non-elderly adults from the National Health and Nutrition Examination Survey (NHANES), a CDC program, between 1999 and 2006.

Respondents answered detailed questions about their health and economic circumstances. Then doctors examined them and ordered laboratory tests.

The study found that about half of all uninsured people with diabetes (46 percent) or high cholesterol (52 percent) did not know they had these diseases. In contrast, about one-quarter of those with insurance were unaware of their illnesses (23 percent for diabetes, 29.9 percent for high cholesterol).

Undertreatment of disease followed similar patterns, with the uninsured being more likely to be undertreated than their insured counterparts: 58.3 percent vs. 51.4 percent had their high blood pressure poorly controlled, and 77.5 percent vs. 60.4 percent had their high cholesterol inadequately treated.

Surprisingly, being insured was not associated with a widely used measure of diabetes control (a hemoglobin A1c level below 7), a finding the authors attribute to the stringent definition of good diabetes control used in the NHANES survey. Even with excellent medical care, many diabetics fail to achieve such low hemoglobin A1c levels. Using less stringent hemoglobin A1c thresholds of 8 and 9, uninsured adults had significantly worse blood sugar control than their insured counterparts, the researchers found.

Lead author Dr. Andrew Wilper, who worked at Harvard when the study was done and who now teaches at the University of Washington Medical School, said: "Our study should lay to rest the myth that the uninsured can get the care they need. Millions have serious chronic conditions and don't even know it. And they're not getting care that would prevent strokes, heart attacks, amputations and kidney failure."

Referring to a study released in the American Journal of Public Health last month, which has been widely quoted by Sen. Max Baucus and others, he added: "Our previous work demonstrated 45,000 deaths annually are linked to lack of health insurance. Our new findings suggest a mechanism for this increased risk of death among the uninsured. They're not getting life-saving care."

Dr. Steffie Woolhandler, professor of medicine at Harvard and study co-author, said: "The uninsured suffer the most, but even Americans with insurance have shocking rates of undertreatment, in part because high co-payments and deductibles often make care and medications unaffordable. We need to upgrade coverage for the insured, as well as covering the uninsured. Only single-payer national health insurance would make care affordable for the tens of millions of Americans with chronic illnesses."

Dr. David Himmelstein, associate professor of medicine at Harvard and study co-author, said: "The Senate Finance Committee's bill would leave 25 million Americans uninsured and unable to get the ongoing, routine care that could save their lives and prevent disability. No other wealthy nation tolerates this, yet Congress is turning its back on tens of millions of Americans."

"Hypertension, diabetes and elevated cholesterol among insured and uninsured U.S. adults," Andrew P. Wilper, M.D., M.P.H.; Steffie Woolhandler, M.D., M.P.H.; Karen Lasser, M.D., M.P.H.; Danny McCormick, M.D., M.P.H.; David H. Bor, M.D.; David U. Himmelstein, M.D. Health Affairs, Oct. 20, 2009 (online).



1021 Comparison finds considerable differences on estimates of future physician workforce supply [Hanover NH]--Compared with a source of data often used regarding physician workforce supply and projected changes, data from the U.S. Census Bureau suggests that the future physician workforce may be younger but fewer in number than previously projected, according to a study in the October 21 issue of JAMA.

Recent projections have indicated that the supply of physicians may soon decrease below recommended requirements, with some projecting a shortfall as high as 200,000 by 2020. "Although debate over potential shortages has focused largely on the number and type of physicians needed in the future, concerns have also been raised about data used in physician supply estimates and projections," the authors write.

The American Medical Association Physician Masterfile (Masterfile) data, although frequently used by workforce analysts, are believed to overestimate the number of active physicians at older ages, attributed to delays in updating the Masterfile data when a physician retires or experiences a change in status, according to background information in the article.

Douglas O. Staiger, Ph.D., of Dartmouth College, Hanover, N.H., and colleagues conducted an analysis of employment trends of physicians using the Masterfile data and the U.S. Census Bureau Current Population Survey (CPS), a data source used extensively by the U.S. Department of Labor to estimate current trends in employment. The researchers used data from between 1979 and 2008. Physician supply through 2040 was also projected using both data sources.

The researchers found that in an average year, the CPS estimated 67,000 (10 percent ) fewer active physicians than did the Masterfile during the sample period. Estimates from the Masterfile and CPS data were similar for physicians between the ages of 35 and 54 years, but differed markedly at both younger and older ages. Older physicians accounted almost entirely for the lower estimates of active physicians in the CPS. During the sample period, on average, the CPS estimated 22,000 (20 percent) fewer active physicians per year ages 55 to 64 years than did the Masterfile, and estimated 35,000 (51 percent) fewer active physicians per year 65 years or older than the Masterfile. The CPS estimated more young physicians (ages 25-34 years) than did the Masterfile, with the difference increasing to an average of 17,000 (12 percent) during the final 15 years.

"The CPS estimates of more young physicians were consistent with historical growth observed in the number of first-year residents, and the CPS estimates of fewer older physicians were consistent with lower Medicare billing by older physicians," the authors write.

Regarding projections for the future physician workforce supply, both the CPS and the Masterfile data indicate that the number of active physicians will increase by approximately 20 percent between 2005 and 2020. However, projections for 2020 using CPS data estimate nearly 100,000 (9 percent) fewer active physicians than projections using the Masterfile data (957,000 vs. 1,050,000), and estimate that a smaller proportion of active physicians will be 65 years or older.

"The CPS-based projection indicates that 71 percent of active physicians will be younger than 55 years and only 9 percent will be older than 65 years, whereas the Masterfile-based projection indicates that 61 percent of active physicians will be younger than 55 years and 18 percent will be older than 65 years," the researchers note.

"Although this analysis was restricted to physician supply, projections of physician requirements also rely on estimates of the current number of physicians as a starting point for projections. Thus, without more accurate estimates of the size and age distribution of the current workforce, projections of physician supply, requirements, and potential shortages may mislead policymakers as they try to anticipate and prepare for the health care needs of the population," the authors conclude.

Editorial: How Many Physicians? How Much Does It Matter?

In an accompanying editorial, Thomas C. Ricketts, Ph.D., M.P.H., of the University of North Carolina, Cecil G. Sheps Center for Health Services Research, Chapel Hill, N.C., writes on the importance of having accurate projections regarding the physician workforce.

"The physician workforce is one of the most critical factors that must be considered in current health care reform efforts and discussions. Having accurate estimates for determining not only the number of physicians, but also current and future physician workforce requirements and capabilities for delivering primary and specialty care, will be essential for achieving and sustaining effective health care reform."



1021 New immigrants more likely to be homeless due to economic factors rather than health issues [Toronto ON]--New immigrants are more likely to cite economic and housing factors as barriers that keep them homeless compared with native-born individuals, according to a new study on the health of homeless immigrants led by St. Michael's Hospital researcher Dr. Stephen Hwang.

"Homeless people are in much poorer health than the general population, but immigrants who are homeless tend to be healthier than Canadian-born people who are homeless. This is sometimes referred to as the 'healthy immigrant effect'," explains Dr. Hwang. "We also found recent immigrants, non-recent immigrants and Canadian-born individuals gave significantly different responses regarding the single most important thing keeping them homeless."

The study team interviewed 1,189 homeless people in Toronto, Canada to examine the association between immigrant status and current health. Participants were asked to identify the single most important thing keeping them from getting out of homelessness. The categories were: insufficient income, lack of suitable/adequate housing, lack of employment, addiction to alcohol and/or drugs, family or domestic instability, mental health condition and all other reasons. The study was published in the Journal of Epidemiology and Community Health.

Key findings of the study include:

* Recent immigrants who are homeless were found to be physically and mentally healthier and less likely to suffer from chronic conditions and substance abuse problems than native-born homeless individuals.
* 22% of Canadian-born individuals said mental illness, domestic instability and addiction were reasons for their homelessness
* 11 % of recent immigrants named the same factors.

The study also found the length of time since immigration is a critical factor, as the health status of homeless individuals who immigrated more than 10 years ago is not significantly different from that of homeless Canadian-born individuals.

"Previous studies have shown that recent immigrants face an initial disadvantage in the labour market, earning wages well below that of the native-born population," says Hwang. "With economic issues being cited the main factor in recent immigrant homelessness, strategies that focus on job skills, training and employment for this group of individuals could make a difference."



1021 Review: Pneumococcal conjugate vaccines effective at preventing child deaths [Washington DC]--A study published in The Cochrane Review this month concludes that pneumococcal conjugate vaccines (PCV), already known to prevent invasive pneumococcal disease (IPD) and x-ray defined pneumonia, was also effective against child deaths.


The findings were based on a systematic review of the results of 6 randomized and controlled trials conducted in the US, Africa, Philippines, and Finland. Eighty percent of children were less likely to develop vaccine-type IPD, 58% all-serotype IPD, and 27% x-ray defined pneumonia than children who did not receive the vaccine. Eleven percent of child deaths were also prevented. In total, 113,044 children were included in the six trials – 57,015 children in the PCV group and 56,029 in the control group.

"Pneumococcal disease is driving a global health crisis, particularly in the developing world," said Marilla G. Lucero of the Research Institute for Tropical Medicine and primary author of the study. "This study underscores the value of vaccines in preventing this deadly disease and saving children's lives."

Pneumococcal disease, or Streptoccoccus pneumoniae, is a leading cause of pneumonia, meningitis, sepsis and other life-threatening ailments. It takes the lives of 1.6 million people each year, including more than 800,000 children despite the existence of safe and effective vaccines to prevent it. Ninety-five percent of child pneumococcal deaths occur in the developing world, largely unreached by the existing vaccines as yet.

WHO recommends that all countries prioritize introduction of PCV, particularly those with high child mortality rates. In 2000, the United States became the first country to license a 7-valent pneumococcal vaccine (PCV-7), which has virtually eliminated severe pneumococcal disease caused by vaccine serotypes in the U.S. Since then, 37 countries have implemented universal or widespread use of PCV-7, nearly all of which are in the industrialized world. New financial mechanisms, including the GAVI Alliance's Advance Market Commitment, are now in place to help low-income countries prevent pneumococcal deaths in their own countries. Next generation PCVs are expected to shortly become available and will provide expanded serotype coverage of strains common in the developing world.

"While early detection and treatment can save lives, this review highlights the effectiveness of pneumococcal conjugate vaccines for preventing pneumococcal disease before it occurs," said Dr. Orin Levine, executive director of PneumoADIP at the Johns Hopkins Bloomberg School of Public Health. "Low-income countries can now have the opportunity to introduce pneumococcal vaccine on an unprecedented timetable and at prices their governments can afford. We recommend that all countries eligible for GAVI support apply now and take immediate steps to prioritize prevention."



1021 Report examines hidden costs of energy production and use [Washington DC]--A new report from the National Research Council examines and, when possible, estimates "hidden" costs of energy production and use -- such as the damage air pollution imposes on human health -- that are not reflected in market prices of coal, oil, other energy sources, or the electricity and gasoline produced from them.


The report estimates dollar values for several major components of these costs. The damages the committee was able to quantify were an estimated $120 billion in the U.S. in 2005, a number that reflects primarily health damages from air pollution associated with electricity generation and motor vehicle transportation. The figure does not include damages from climate change, harm to ecosystems, effects of some air pollutants such as mercury, and risks to national security, which the report examines but does not monetize.

Requested by Congress, the report assesses what economists call external effects caused by various energy sources over their entire life cycle -- for example, not only the pollution generated when gasoline is used to run a car but also the pollution created by extracting and refining oil and transporting fuel to gas stations. Because these effects are not reflected in energy prices, government, businesses and consumers may not realize the full impact of their choices. When such market failures occur, a case can be made for government interventions -- such as regulations, taxes or tradable permits -- to address these external costs, the report says.

The committee that wrote the report focused on monetizing the damage of major air pollutants -- sulfur dioxide, nitrogen oxides, ozone, and particulate matter – on human health, grain crops and timber yields, buildings, and recreation. When possible, it estimated both what the damages were in 2005 (the latest year for which data were available) and what they are likely to be in 2030, assuming current policies continue and new policies already slated for implementation are put in place.

The committee also separately derived a range of values for damages from climate change; the wide range of possibilities for these damages made it impossible to develop precise estimates of cost. However, all model results available to the committee indicate that climate-related damages caused by each ton of CO2 emissions will be far worse in 2030 than now; even if the total amount of annual emissions remains steady, the damages caused by each ton would increase 50 percent to 80 percent.


Coal accounts for about half the electricity produced in the U.S. In 2005 the total annual external damages from sulfur dioxide, nitrogen oxides, and particulate matter created by burning coal at 406 coal-fired power plants, which produce 95 percent of the nation's coal-generated electricity, were about $62 billion; these nonclimate damages average about 3.2 cents for every kilowatt-hour (kwh) of energy produced. A relatively small number of plants -- 10 percent of the total number -- accounted for 43 percent of the damages. By 2030, nonclimate damages are estimated to fall to 1.7 cents per kwh.

Coal-fired power plants are the single largest source of greenhouse gases in the U.S., emitting on average about a ton of CO2 per megawatt-hour of electricity produced, the report says. Climate-related monetary damages range from 0.1 cents to 10 cents per kilowatt-hour, based on previous modeling studies.

Burning natural gas generated far less damage than coal, both overall and per kilowatt-hour of electricity generated. A sample of 498 natural gas fueled plants, which accounted for 71 percent of gas-generated electricity, produced $740 million in total nonclimate damages in 2005, an average of 0.16 cents per kwh. As with coal, there was a vast difference among plants; half the plants account for only 4 percent of the total nonclimate damages from air pollution, while 10 percent produce 65 percent of the damages. By 2030, nonclimate damages are estimated to fall to 0.11 cents per kwh. Estimated climate damages from natural gas were half that of coal, ranging from 0.05 cents to 5 cents per kilowatt-hour.

The life-cycle damages of wind power, which produces just over 1 percent of U.S. electricity but has large growth potential, are small compared with those from coal and natural gas. So are the damages associated with normal operation of the nation's 104 nuclear reactors, which provide almost 20 percent of the country's electricity. But the life cycle of nuclear power does pose some risks; if uranium mining activities contaminate ground or surface water, for example, people could potentially be exposed to radon or other radionuclides; this risk is borne mostly by other nations, the report says, because the U.S. mines only 5 percent of the world's uranium. The potential risks from a proposed long-term facility for storing high-level radioactive waste need further evaluation before they can be quantified. Life-cycle CO2 emissions from nuclear, wind, biomass, and solar power appear to be negligible when compared with fossil fuels.


The production of heat for buildings or industrial processes accounts for about 30 percent of American energy demand. Most of this heat energy comes from natural gas or, to a lesser extent, the use of electricity; the total damages from burning natural gas for heat were about $1.4 billion in 2005. The median damages in residential and commercial buildings were about 11 cents per thousand cubic feet, and the proportional harm did not vary much across regions. Damages from heat in 2030 are likely to be about the same, assuming the effects of additional sources to meet demand are offset by lower-emitting sources.


Transportation, which today relies almost exclusively on oil, accounts for nearly 30 percent of U.S. energy demand. In 2005 motor vehicles produced $56 billion in health and other nonclimate-related damages, says the report. The committee evaluated damages for a variety of types of vehicles and fuels over their full life cycles, from extracting and transporting the fuel to manufacturing and operating the vehicle. In most cases, operating the vehicle accounted for less than one-third of the quantifiable nonclimate damages, the report found.

Damages per vehicle mile traveled were remarkably similar among various combinations of fuels and technologies -- the range was 1.2 cents to about 1.7 cents per mile traveled -- and it is important to be cautious in interpreting small differences, the report says. Nonclimate-related damages for corn grain ethanol were similar to or slightly worse than gasoline, because of the energy needed to produce the corn and convert it to fuel. In contrast, ethanol made from herbaceous plants or corn stover -- which are not yet commercially available -- had lower damages than most other options.

Electric vehicles and grid-dependent (plug-in) hybrid vehicles showed somewhat higher nonclimate damages than many other technologies for both 2005 and 2030. Operating these vehicles produces few or no emissions, but producing the electricity to power them currently relies heavily on fossil fuels; also, energy used in creating the battery and electric motor adds up to 20 percent to the manufacturing part of life-cycle damages.

Most vehicle and fuel combinations had similar levels of greenhouse gas emissions in 2005. There are not substantial changes estimated for those emissions in 2030; while population and income growth are expected to drive up the damages caused by each ton of emissions, implementation of new fuel efficiency standards of 35.5 miles per gallon will lower emissions and damages for every vehicle mile traveled. Achieving significant reductions in greenhouse gas emissions by 2030 will likely also require breakthrough technologies, such as cost-effective carbon capture and storage or conversion of advanced biofuels, the report says.

Both for 2005 and 2030, vehicles using gasoline made from oil extracted from tar sands and those using diesel derived from the Fischer-Tropsch process -- which converts coal, methane, or biomass to liquid fuel -- had the highest life-cycle greenhouse gas emissions. Vehicles using ethanol made from corn stover or herbaceous feedstock such as switchgrass had some of the lowest greenhouse gas emissions, as did those powered by compressed natural gas.

Fully implementing federal rules on diesel fuel emissions, which require vehicles beginning in the model year 2007 to use low-sulfur diesel, is expected to substantially decrease nonclimate damages from diesel by 2030 -- an indication of how regulatory actions can significantly affect energy-related damages, the committee said. Major initiatives to further lower other emissions, improve energy efficiency, or shift to a cleaner mix of energy sources could reduce other damages as well, such as substantially lowering the damages attributable to electric vehicles.



1021 Tsunami evacuation buildings: another way to save lives in the Pacific Northwest [Boulder CO]--Some time soon, a powerful earthquake will trigger a massive tsunami that will flood the Pacific Northwest, destroying homes and threatening the lives of tens of thousands of people, says Yumei Wang, a geotechnical engineer at the Oregon Department of Geology and Mineral Industries in Portland.

The region's geology makes an earthquake-triggered tsunami inevitable and imminent in geologic time, Wang says, yet coastal towns and cities in the northwest are woefully unprepared for such a large-scale natural disaster. In response, she is working with public officials and stakeholders to develop a series of tsunami evacuation buildings up and down the northwest coast. They would be the first buildings of their kind in the United States. And construction, she urges, can't start soon enough.

"Unless we do this, we will have lots of people dying in a tsunami," Wang says. "That's not how we want our people to die."

Wang will present recommendations in a session titled, Risks and Realities: Current Advances in Understanding Societal Risk and Resilience to Natural Hazards, at this month's Annual Meeting of the Geological Society of America in Portland, Oregon.


A line of volcanoes from northern California to British Columbia marks the eastern edge of a fault system (called the Cascadia subduction zone), where one plate is wedged under another. Those plates shift like geological clockwork every few hundred years, producing earthquakes that shake the region. The last major quake along the Cascadia subduction zone occurred on January 26, 1700. It produced a tsunami that damaged coastal towns as far away as Japan.

The region's next big earthquake could happen any day now, Wang says, or it might not happen for several hundred years. When the day comes, a tsunami—with inundation heights of 50 feet or more—could hit the northwest coast within 10 to 20 minutes.

The standard emergency response in cases like these is to move people inland and uphill, but there are plenty of communities where people simply won't be able to evacuate in time, Wang says. The resort town of Seaside, Ore., for example, is low-lying with inadequate roads and bridges. Kids and the elderly are particularly vulnerable.

In Cannon Beach, Ore., Wang has started meeting with officials to hold serious discussions on constructing the first tsunami evacuation building in the U.S. The building, a proposed rebuilding of the town's existing city hall, would have to be made of reinforced concrete with a deep foundation and strong columns, a post-tensioning structural system to keep it upright, an 18-foot tall first floor, and wave-dissipation structures in front and back, among many other design details.

Tsunami evacuation buildings won't be cheap. Wang estimates that the one in Cannon Beach would have an added cost of between $1 million and $2 million. But the building would provide a safe space that people could reach quickly and be ready for emergency response and long term recovery. Getting just one such building off the ground, Wang said, is a critical first step towards creating a network of buildings that will help save many thousands of lives.



1021 Study finds mercury levels in children with autism and those developing typically are the same [UC Davis]--In a large population-based study published online today, researchers at the UC Davis MIND Institute report that after adjusting for a number of factors, typically developing children and children with autism have similar levels of mercury in their blood streams. Mercury is a heavy metal found in other studies to adversely affect the developing nervous system.

The study, appearing in the journal Environmental Health Perspectives, is the most rigorous examination to date of blood-mercury levels in children with autism. The researchers cautioned, however, that the study is not an examination of whether mercury plays a role in causing the disorder.

"We looked at blood-mercury levels in children who had autism and children who did not have autism," said lead study author Irva Hertz-Picciotto, an internationally known MIND Institute researcher and professor of environmental and occupational health. "The bottom line is that blood-mercury levels in both populations were essentially the same. However, this analysis did not address a causal role, because we measured mercury after the diagnosis was made."

The research was conducted as part of the Northern California-based Childhood Autism Risks from Genetics and the Environment (CHARGE) Study, of which Hertz-Picciotto is the principal investigator. The CHARGE Study is a large, comprehensive, epidemiologic investigation designed to identify factors associated with autism and discover clues to its origins. CHARGE study participants include children between 24 and 60 months who are diagnosed with autism, as well as children with other developmental disorders and typically developing controls.

The study looked at a wide variety of sources of mercury in the participants' environments, including fish consumption, personal-care products (such as nasal sprays or earwax removal products, which may contain mercury) and the types of vaccinations they received. The study also examined whether children who have dental fillings made of the silver-colored mercury-based amalgam and who grind their teeth or chew gum had higher blood-mercury levels. In fact, those children who both chew gum and have amalgams did have higher blood-mercury levels.

But the consumption of fish — such as tuna and other ocean fish and freshwater fish — was far and away the biggest and most significant predictor of blood-mercury levels. Data on most possible sources of mercury — fish consumption and dental amalgams –— were collected by interviews with the study subjects' parents. Information on vaccines was obtained from the child's vaccination and medical records. A few children had recently had a vaccine containing mercury, and their blood-mercury levels were not elevated.

Of the 452 participants included in the research, 249 were diagnosed with autism, 143 were developing typically and 60 had other developmental delays, such as Down syndrome. At the outset, the children with autism appeared to have significantly lower blood-mercury levels than the typically developing children. But children with autism tend to be picky eaters and, in this study, ate less fish. When adjusted for their lower levels of fish consumption, their blood-mercury concentrations were roughly the same as those of children with typical development and very similar to those found in a nationally representative sample of 1- to 5-year-old children.

Hertz-Picciotto said the CHARGE study is casting a wide net, addressing an array of exposures that originate in the home or the broader environment, as well as genes and gene expression. Because so little is known about the causes of autism, the researchers plan to look at everything from household products to medical treatments, diet and supplements, and even infections. Additionally, they will explore interactions among multiple factors.

"Just as autism is complex, with great variation in severity and presentation, it is highly likely that its causes will be found to be equally complex. It's time to abandon the idea that a single 'smoking gun' will emerge to explain why so many children are developing autism. The evidence to date suggests that, without taking account of both genetic susceptibility and environmental factors, the story will remain incomplete. Few studies, however, are taking this kind of multi-faceted approach," Hertz-Picciotto said.

Other study authors include Peter Green, Lora Delwiche, Robin Hansen, Cheryl Walker and Isaac Pessah, all of the University of California, Davis.

The study was funded by the National Institute of Environmental Health Sciences, the U.S. Environmental Protection Agency through the Science to Achieve Results (STAR) program and the UC Davis MIND Institute.



1021 Clots traveling from lower veins may not be the cause of pulmonary embolism in trauma patients [Boston MA]--A report from a team of Massachusetts General Hospital (MGH) physicians calls into question the longstanding belief that pulmonary embolism (PE) – the life-threatening blockage of a major blood vessel in the lungs – is caused in trauma patients by a blood clot traveling from vessels deep within the legs or lower torso. In their study utilizing advanced imaging technologies, which appears in the October Archives of Surgery, the MGH investigators found no evidence of deep venous thrombosis (DVT) in most trauma patients with pulmonary embolism.

"A consistent finding of previous studies – which was often overlooked – was that no lower-extremity vein clots were found in patients suffering pulmonary embolism," says George Velmahos, MD, PhD, chief of the MGH Division of Trauma, Emergency Surgery, and Surgical Critical Care, who led the study. "But our surgical minds were so stuck in the dogma that PE originates from lower-extremity DVT that even though the data was there, we didn't pay attention to it."

Traditional thinking has been that pulmonary embolism results when a deep venous thrombosis in the legs or pelvis breaks off and travels through the bloodstream into the lungs. If that were true, the authors note, pulmonary embolism patients should still have evidence of the DVT, since part of the original clot would remain attached to the location where it formed. The earlier studies that did not find DVTs in trauma patients with PE had utilized ultrasound imaging, which is limited in its ability to locate deep venous thrombosis, possibly missing any remaining clots.

The current investigation analyzed the results of computed-tomography-based tests – CT pulmonary angiograms for the lungs and for the lower extremities CT venography, which is highly accurate in diagnosing clots in major blood vessels. The researchers reviewed the records of 247 trauma patients who had received both CT pulmonary angiograms and CT venograms at MGH from 2004 through 2006. While 46 patients developed pulmonary embolism and 18 had deep venous thrombosis, only 7 of the 46 PE patients also had evidence of DVT. The known accuracy of CT venograms make it highly unlikely, the authors note, that many patients had undetected DVTs.

This report – believed to be the first to express doubts about the accepted origin of pulmonary embolism – needs to be confirmed by other investigators and also cannot be extrapolated to the rare instances when PE develops in otherwise healthy individuals. The authors' hypothesis – yet to be tested – is that clots may form independently in the lungs, and if the study's results hold up, they would imply that current measures to prevent PE – including blood-thinning drugs, mechanical compression of the legs and the insertion of filters into the major vein that carries blood from the lower extremities – are not effective.

"If it turns out that clots are forming primarily in the lungs, it would revolutionize the way we think about PE and they way we prevent and treat it," says Velmahos, who is the John Francis Burke Professor of Surgery at Harvard Medical School.

Additional authors of the Archives of Surgery report are Konstantinos Spaniolas, MD, Malek Tabbara, MD, Marc de Moya, MD, Alice Gervasini, RN, PhD, and Hasan Alam, MD; MGH Trauma, Emergency Surgery, and Surgical Critical Care; and Hani Abujudeh, MD, MGH Radiology.



1021 Violence between couples is usually calculated, and does not result from loss of control [Haifa, Israel]--Violence between couples is usually the result of a calculated decision-making process and the partner inflicting violence will do so only as long as the price to be paid is not too high. This is the conclusion of a new study by Dr. Eila Perkis at the University of Haifa. "The violent partner might conceive his or her behavior as a 'loss of control', but the same individual, unsurprisingly, would not lose control in this way with a boss or friends," she explains.

In this new study, carried out under the supervision of Prof. Zvi Eisikovits and Dr. Zeev Winstok of the University of Haifa's School of Social Work, Dr. Perkis examined intimate violence based on the fact that in most cases the offending partner is a law-abiding individual living a normative life outside of the family unit. Dr. Perkis says that in most cases the couple continues living together and sustaining a shared family unit, so it is important that we learn to understand the dynamics of such partnerships in order to treat them.

First Dr. Perkis divided intimate violence into four levels of severity: verbal aggression; threats of physical aggression; moderate physical aggression; and severe physical aggression. "These four levels follow one another in an escalating sequence; someone who uses verbal violence might well move on over time to threatening physical attack, and from there it is only downhill towards acting on the threat," she explains. Dr. Perkis warns however, that the results of this study should not be correlated to cases of murder, since the dynamics between couples in such cases are different and such offenses are not included in the chain of violent acts being examined.

The researcher found that acting on each type of violence is calculated, such that the violence constitutes a tool for solving conflict between the partners. "Neither of the couple sits down and plans when he or she will swear or lash out at the other, but there is a sort of silent agreement standing between the two on what limits of violent behavior are 'ok', where the red line is drawn, and where behavior beyond that could be dangerous," she explains. She adds that when speaking of one-sided physical violence, most often carried out by men, the violent side understands that for a slap, say, he will not pay a very heavy price, but for harsher violence that is not included in the 'normative' dynamic between them, he might well have to pay a higher price and will therefore keep himself from such behavior.


"A 'heavy price' could be the partner's leaving or reporting the incident to the police or the workplace. As such, it can be said that violent behavior is not the result of loss of control and both sides are aware of where the red line is drawn, even if such an agreement has never been spoken between them," she says.

According to Dr. Perkis, it is important to point out that use of violence is not a normative behavior; it is illegal, and of course, immoral. Therefore, it is only the violent partner who is culpable for the act. Nevertheless, once we understand that violence is being used as a tool for solving conflict between a couple that is interested in staying together, we can help them subdue such behavior by providing them with better tools to cope with the source of tension and conflict in their lives together.

"In couples therapy for partners who express the wish to stay together, therapy must be focused on identifying illegitimate motives, such as nonnormative tactics for solving conflict, and assisting the couple in acknowledging their ability to convert destructive patterns into effective ones and ultimately to run their lives better," the researcher concludes.



1021 Paradigm shift needed to combat drug resistance - international human migration needs to be factored into infectious disease policy [Hamilton ON]--When people travel, bacteria and other infectious agents travel with them. As about a billion people cross international borders each year, many more billions of the bugs come along for the ride.

However, the trend is contributing to substantial domestic and international public health threats and risks, as seen with SARS and more recently with the H1N1 flu virus.

In a paper published today in Emerging Infectious Diseases (EID), a journal of the U.S. Centers for Disease Control and Prevention, a McMaster University infectious disease expert explores the relationship between population mobility, globalization and antimicrobial drug resistance.

In collaboration with a team of international scientists, Douglas MacPherson, an associate professor in the Department of Pathology and Molecular Medicine of the Michael G. DeGroote School of Medicine, assesses the link between human travel and the international movement of drug-resistant infectious diseases around the world.

Citing published data, the authors conclude that population mobility affects the spread and distribution of resistant organisms. But despite this, it has not been considered a primary factor in developing approaches for disease control. The authors propose a paradigm shift is needed to tackle the problem, as well as greater international collaboration and standardization across borders.

"The movement of human beings is introducing many of the greatest risks to our health and health systems today," said MacPherson, a physician and medical microbiology specialist.

"For example, if you go down south on a Florida holiday and break your leg and end up in a Florida hospital, when you come home, you're going to be carrying institutional bugs back to Hamilton and you're going to introduce that variety of antimicrobial resistance into your local environment. Mobile populations are probably the most common way of moving drug-resistant organisms around the world."

Using H1N1 influenza and other infectious diseases as examples, the EID paper concludes that the complexity of human movement exceeds current international disease control policies and practices.

The researchers suggest that an effective response requires engagement at the local level, standardization of practices, partnerships between a variety of sectors and rigorous health information gathering along with threat and risk assessment. They also recommend that mobile populations need to be taken into consideration when modelling drug resistance.

"It's not just about being reactive or responsive to the problem. We now have the ability to be more proactive in decision making, more integrative and more collaborative. That's how we'll get to better solutions," MacPherson said.

The authors recommend a new approach be developed to integrate population factors into health policy and processes, which have traditionally focused on specific diseases.

"A shift in the existing paradigm of pathogen-focused policies and programs to include the 'human factor' in health and disease would contribute to a healthier future for everyone," MacPherson said.

The ideas contained in the Emerging Infectious Diseases paper originated with the work of the Infectious Disease Information Expert Committee of the Council of Experts of the United States Pharmacopeia , an arm's length organization working with the U.S. government that establishes technical and analytic standards for all prescriptions, over-the-counter medicines and dietary supplements manufactured or sold in the United States and many other countries around the world, including Canada. MacPherson is the chair of the infectious disease committee and a member of the Council of Experts.



1021 New mathematical model more accurately diagnoses acute heart failure in emergency rooms [Toronto ON]--Researchers at St. Michael's Hospital have developed the first mathematical model in cardiology and emergency medicine to more quickly and reliably diagnose acute heart failure (AHF) in emergency room patients. Research findings published in the Journal of the American College of Cardiology, have been shown to help physicians diagnose AHF with greater accuracy.

"In Canada, more than 100,000 people are hospitalized each year for acute heart failure while an estimated $1.4 - 2.3 billion is spent to manage the disease," explains Dr. Brian Steinhart, lead researcher and emergency medicine physician at St. Michael's Hospital. "Our model aims to ensure early correct diagnosis and treatment, which allows for shorter emergency department stay for these patients and could lead to improved health outcomes and better access to precious emergency department resources."

According to researchers, the model uses natriuretic-peptide levels (a peptide hormone released from heart muscle to help regulate body fluids and blood pressure) and the clinician's judgement to help diagnose patients whose history, physical or chest X-ray may not clearly indicate AHF. Currently, accurate clinical diagnosis of AHF in the emergency department is less than 80 percent.

"In many cases, when a patient arrives in an emergency department complaining of shortness of breath, physicians are challenged to correctly diagnose patients," says Dr. Steinhart, "Our model does not require extensive clinical information, which makes it relatively simple-to-use. When the result is greater than 80 percent probability for heart failure, it suggests that the physician should treat for AHF and when it is less than 20 percent, the physician should be looking elsewhere for diagnosis."

The study developed the prediction model from the emergency department experience of 534 patients with undifferentiated shortness of breath enrolled in the Canadian Improved Management of Patients with Congestive Heart Failure (IMPROVE-CHF) trial.

Researchers and physicians involved in the trial include: St. Michael's Hospital's Kevin Thorpe, Dr. Ahmed Bayoumi, Dr. Gordon Moe and Dr. David Mazer, and Massachusetts General Hospital and Harvard Medical School's Dr. James Januzzi.



1021 Magnetic leaves reveal most polluted byways [Boulder CO]--Tree leaves may be powerful tools for monitoring air quality and planning biking routes and walking paths, suggests a new study by scientists at Western Washington University in Bellingham. The research will be presented at this month's Annual Meeting of the Geological Society of America in Portland, Oregon.

Leaves along bus routes were up to 10 times more magnetic than leaves on quieter streets, the study found. That magnetism comes from tiny particles of pollution—such as iron oxides from diesel exhaust—that float through the air and either stick to leaves or grow right into them.

Geophysicist Bernie Housen and colleague Luigi Jovane collected several leaves from 15 trees in and around Bellingham. Five of the trees lay next to busy bus routes. Five sat on parallel but much quieter side streets. Five were in a rural area nearby.

Using two measurement techniques, Housen and Jovane found that leaves along bus routes were between two and 8 times more magnetic than leaves from nearby streets and between four and 10 times more magnetic than rural leaves.

Inhaling particulate matter has been linked to a number of negative health consequences, including breathing troubles and even heart problems. Tiny particles bypass the airways and get deep into the lung tissues.

The new study suggests that biking or walking along heavy bus routes might be as bad for your health as you might suspect when choking on exhaust fumes. That’s something cities might want to consider as they plan new routes for cyclists and pedestrians.

“I ride my bike to work every day,” Housen said. “I’ve always wondered what the effects of diesel exhaust are on my health.”

While many details remain to be worked out, the study also suggests that collecting tree leaves can be a simple and effective way to measure the load of particulate matter in the air. European researchers have been exploring the idea for a while, but this is one of the first studies to apply the technique in the United States.

“Using trees is a nice, low-tech way to do these studies and you don’t need to use fancy particle collectors,” Housen said. “If it works, you could easily collect a lot of data from a region. You could even have kids collect leaves. That makes it a powerful tool to see variation of particulate matter on a very detailed level.”



1021 New laryngoscope could make difficult intubations easier [Augusta GA]--A new tool developed by a Medical College of Georgia resident and faculty member may make it easier to place assisted breathing devices under difficult circumstances.

About two percent of patients that undergo the process, called intubation, experience complications – regardless if it's performed in an emergency situation or prior to surgery.

During normal intubation, a physician stands behind a patient's head and uses a metal scope to open the mouth and guide a flexible plastic tube into the trachea. The tube is used to maintain a patient's airway and provide a pathway for mechanical ventilation if necessary.

"In some cases, you can't see the vocal cords, which you have to go through to place the endotracheal tube, because of some obstruction," says Dr. Richard Schwartz, chair of the Department of Emergency Medicine in the MCG School of Medicine.

Some diseases, such as head and neck cancer, can make intubation harder. In other cases, anatomical variations, such as shorter necks and bucked teeth, can make tube placement more challenging, says Dr. Harsha Setty, a third-year anesthesiology resident.

Difficult intubations can be traumatic for patients and lead to problems such as cracked teeth, he says.

To make those intubations easier, Drs. Setty and Schwartz developed the Video Rigid Flexible Laryngoscope.

The Video RIFL is composed of endotracheal tubes surrounding a rigid cylindrical body featuring an illuminated LED camera at one end and a video screen at the other. The light and camera help guide the scope down the airway. The tube is placed and released from the scope.

"Any obstructions are easier to see because of the camera and lighted tip," Dr. Schwartz says. "The flexibility of the tip also makes it easier to navigate. There is also less physical pressure on the patient, so the risk of associated trauma is reduced."

The device is the first of its kind to merge two technologies – video and articulation, he says. It's being used successfully at MCGHealth Medical Center and at other hospitals in California, North Carolina, Washington and Wisconsin.

While the device is being used primarily in operating and emergency rooms right now, the potential range of uses is broader, Dr.Schwartz says.

"It could be used in emergency rescue situations where patients are airlifted by helicopters and intubation is difficult because their heads are typically placed against a wall," he says. "In those cases, rescue workers have to intubate from the front and the camera on the RIFL makes that easier."

Dr. Setty says there are also implications for education. "I could project the camera image on a monitor to teach students how to intubate in difficult situations," he says.



1021 Outfoxing pox: Developing a new class of vaccine candidates [Arizona State University]--In the annals of medicine, Edward Jenner's 1796 vaccination of a young boy against smallpox, using fluid from cowpox blisters, remains a landmark case. In a new study, Kathryn Sykes, a researcher at Arizona State University's Biodesign Institute and her colleagues have taken a fresh look at cowpox. Their findings, appearing in the advanced online issue of Virology, demonstrate that this ancient pathogen still has much to teach us, and may hasten development of novel vaccines against smallpox and other pox-like diseases.

Sykes explains that poxviruses, in addition to their importance for human health, provide an ideal framework for investigating protective antigens—parts of the virus that can be used to develop a vaccine—by means of modern, high-throughput genomic and proteomic screening technologies.

"If you study viruses like ebola or HIV, their genomes contain a small number of genes—maybe just 3-9," she says, noting that this is too small for the purposes of demonstrating a capacity for high-throughput functional screening. Other pathogens like malaria, which boast tens of millions of nucleotides, are too large. "We wanted something in the middle that could demonstrate our high-throughput technologies but not blow us away before we had a few protocols in place," she says. "Poxviruses are the Goldilocks case. At around 220 genes, they are just right."

In the current study, Sykes' team used functional screening of cowpox to identify new vaccine candidates against similar viruses. These were compared with 4-pox—a vaccine comprised of 4 protective genes from a close genetic relative of cowpox called the vaccinia virus. The team found that the identified antigens offered superior protection in a cowpox challenge compared with the 4-pox vaccine. (See figure 1) The 4-pox vaccine was developed by the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) as an alternative to the licensed vaccine against smallpox, known as Dryvax, (which is made from live vaccinia and presents significant risk for those with suppressed immune systems).

By rapidly screening the whole viral genome, Sykes' group attempts to isolate genes necessary for an effective vaccine. This subunit vaccine approach is in contrast to traditional vaccine methods, where scientists use a weakened form of a live, whole-virus strain. "The dogma among old fashioned vaccinologists is that you want to make a vaccine that recreates the immune responses that happens upon natural infection," Sykes explains. But pathogens like poxviruses also contain elements that can help the virus evade or in some cases, subvert the host's immune system. Subunit vaccines make use of only those genomic segments known to be immunogenic, provoking a robust immune response without the danger of initiating disease.

The tricky part is identifying the effective subunits. Using a process known as expression library immunization, the entire cowpox genetic library was separated into pools and tested in comparison with the 4-pox vaccine for protective effect in a mouse model. In all, the team identified 9 new protective components. Sykes stresses that the majority of new candidates would not have been identified through traditional methods, where scientists focus on a viral gene because of its function or surface exposed location. "The power of this technology is that it's assumption-free with respect to what should be a vaccine candidate."

To further boost the immune response, Sykes recommends using a gene gun to deliver the subunit vaccines, a process in which protective antigens are shot directly into the cytoplasm of immunogenic skin cells, (rather than injected by needle into muscle cells, which are not themselves immunogenically active). Such gene gun delivery provides a highly effective mechanism for delivering antigens to the immune system.

Sykes emphasizes that a single viral subunit will likely not offer comprehensive protection. Rather, suites of antigens must work together synergistically. Further high-throughput, rapid vaccine development research will focus on identifying such cooperative antigen groups. "We need to come up with empirical ways of determining which antigens are working together," Sykes says. "There's your highly effective subunit vaccine."

The application of subunit component vaccine strategies for other diseases, including tularemia, African swine fever virus, and even cancer is also under investigation. "If you think of a tumor cell as a pathogen, then you want to take that tumor cell and treat it the same way we treated cowpox—by screening all of its potential antigens and testing them."



1021 News in red and blue: Messages about social factors and health can backfire [Ann Arbor MI]--Here's a health idea that Democrats and Republicans agree on: when given information on the genetic factors that cause diabetes, both parties equally supported public health policies to prevent the disease.

But a study designed by the University of Michigan showed Republicans were less supportive of such policies after reading news reports that people with diabetes got their illness because of social or economic factors in which they live, such as lack of neighborhood grocery stores or safe places to exercise.

The social factors increased Democrats' support.

The study will appear online Thursday ahead of its December publication in the American Journal of Public Health.

"When people are given the same information they can come away with very different opinions," says Sarah E. Gollust, Ph.D., a Robert Wood Johnson Foundation Health and Society Scholar at the University of Pennsylvania who worked on the study during her doctoral work at U-M.

Increasing public awareness of social factors that impact health may not uniformly increase public support for action because some groups simply do not believe they are credible, authors write.

"Policymakers and journalists should be aware that social values influence people's opinions about health policy, and certain messages in the media might trigger these values," she says.

The findings contribute to evidence that Americans' opinions about health policy are polarized by political party lines, according to the study.

Gollust designed the study with Paula Lantz, Ph.D., a social epidemiologist and chair of the Department of Health Management and Policy at the U-M School of Public Health and Peter A. Ubel, M.D., professor of internal medicine at the University of Michigan and director of the U-M Center for Behavioral and Decision Sciences in Medicine.

Study participants viewed news articles about type 2 diabetes on the Internet and then answered questions about their opinions on health policy and their attitudes about people with diabetes.

When each viewed an article on the links between social and neighborhood factors and diabetes, 32 percent of Democrats agreed with social factors' role on health compared to 16 percent of Republicans.

"If you are more liberally minded the 'neighborhood explanation' can be motivating, but for people who are more conservative politically, that message can backfire and make them even less interested," says Ubel. "The same information can polarize people."

Diabetes was merely used as an example of a common health issue.

While type 2 diabetes is associated with health behaviors, such as poor diet, lack of physical activity and obesity, these behavioral factors can be influenced by social and economic factors such as living in an unhealthy neighborhood. Scientists have also identified numerous genetic variants that increase susceptibility to type 2 diabetes.

So why focus on social factors? The goal of framing health matters according to social factors is increasingly used to shift attention to non-medical strategies to improve health. The media also commonly discuss the prevalence of social factors when describing health issues, but few studies have been devoted to whether it shifts public opinion.

"The problem is these messages aren't going to have the same effect on all people," Ubel says.

The authors do not suggest that news media avoid reporting on social factors. Rather, advocates who want to mobilize the public to support public health policies might consider disseminating information to the media about both social factors and individual behavioral causes to avoid triggering resistance.

"Advocacy groups need to be very careful in thinking about who their audience is and what framing will work best for that audience," Ubel says. "Media should do a richer job of helping people understand each of these different causes."

Authors: Sarah E. Gollust, Ph.D., Paula M. Lantz, Ph.D., and Peter A. Ubel, M.D.

Citation: American Journal of Public Health, Vol. 99, No. 12, December 2009

Funding: Robert Wood Johnson Foundation Health and Society Scholars Program at the University of Michigan and at the University of Pennsylvania, the U-M Center for Behavioral and Decision Sciences in Medicine, and the University of Michigan Rackham Predoctoral Fellowship.



1021 Scientists find 'molecular trigger' for sudden death in epilepsy [Houston TX]--The most common gene for a syndrome associated with abnormal heart rhythms and sudden death triggers epileptic seizures and could explain sudden unexplained death in epilepsy, said researchers from Baylor College of Medicine in a report that appears today in the journal Science Translational Medicine.

The identification of this particular potassium channel KvLQT in neurons of the central nervous system gives scientists a clue about which epilepsy patients face the greatest risk of dying unexpectedly, said Dr. Jeffrey Noebels, the study's senior author and director of the Blue Bird Circle Developmental Neurogenetics Laboratory at Baylor College of Medicine. The channel has been identified in heart muscle cells and now for the first time in brain or nerve cells.

"Idiopathic (unexplained) epilepsy is one of neurology's oldest mysteries. While most persons with epilepsy will have a normal lifespan, our finding now points the way to a simple and essential test to identify risk for sudden death in persons with seizures of unknown origin. In these patients, a routine cardiology evaluation consisting of an EKG, and if indicated, a genetic screening test for this family of genes can positively identify this new risk factor," said Noebels.


"If the gene test is positive, there are effective treatments for the heart irregularity, including drugs known as beta blockers, as well as the use of a cardiac pacemaker to prevent lethal arrhythmias."

As many as 18 percent of deaths in epilepsy come suddenly without warning, devastating families.

"Living with epilepsy is difficult enough, but unexpectedly dying from it, as happens in young adults with the disorder, is one of the greatest fears a family must face," said Dr. Alica Goldman, assistant professor in the BCM department of neurology. Noebels is a professor in the departments of neurology, neuroscience and molecular and human genetics at BCM.

No one knew why young people with epilepsy died suddenly, but Goldman built on previous work in Noebels' lab that found that an ion channel gene thought to work only in the heart was active in the brain as well. She examined five ion channel genes linked to long QT syndrome, a disorder associated with heart rhythm disorders and sudden death.

Long QT refers to an interval in electrocardiograms – the QT interval, which is prolonged in this disorder. An ion channel is a tiny pore in a membrane that controls the flow of ions such as calcium and potassium in and out of a cell.

Goldman found that mice with a mutation in the gene that encodes for the KvLQT1 ion channel had frequent epileptic seizes as well as life-threatening heart rhythm irregularities.

'This demonstrates the long-sought molecular link between heart and brain in epilepsy," said Noebels.

Goldman is now screening epilepsy patients to determine whether they have the same gene mutation.

Others who took part in this work include Ed Glasscock, Jong Yoo, Tara Klassen and Tim Chen. Funding for the work came from the Dana Foundation, the National Institutes of Health, the American Heart Association, and Blue Bird Circle Foundation of Houston.



1021 Is the person next to you washing their hands with soap? [London School of Hygiene and Tropical Medicine]--People are more likely to wash their hands when they have been shamed into it, according to a study by the London School of Hygiene & Tropical Medicine.

The study, published in the American Journal of Public Health, looked at responses to electronic hygiene messages displayed in UK service station toilets.

A million people die every year from diarrhoeal disease and respiratory infection. Handwashing with soap is the cheapest and best way of controlling these diseases. It also prevents the spread of flu, and hospital-acquired infections such as Clostridium difficile. However, "it's difficult to know what kind of message is most effective at changing this everyday behaviour, so it's important to experimentally test what works best in a real setting. That way you can save money and make sure your programme will be effective prior to rolling out any public health campaign at great expense" says Robert Aunger, leader of the study.

A quarter of a million people were counted using the toilets and their use of soap was monitored by on-line sensors. Only 32% of men washed their hands with soap whilst women were twice as good, with 64% washing their hands.

A variety of messages, ranging from 'Water doesn't kill germs, soap does' to 'Don't be a dirty soap dodger', were flashed onto LED screens at the entrance of the toilets and the effects of the messages on behaviour were measured. 'Is the person next to you washing with soap?' was best overall, showing how people respond to whether they thought others were watching. There were intriguing differences in behaviour by gender, with women responding to reminders, while men tended to react best to messages that invoked disgust, for example 'soap it off or eat it later'.

Gaby Judah, who ran the study said: "Our findings are particularly important on Global Handwashing Day, when many agencies concerned with improving health worldwide by encouraging people to wash their hands with soap will be looking to use best practice."



1021 Popular antidepressant associated with a dramatic increase in suicidal thoughts amongst men [Kings College, London UK]--Nortriptyline has been found to cause a ten-fold increase in suicidal thoughts in men when compared to its competitor escitalopram. These findings are published in the open access journal BMC Medicine.

The research was carried out by Dr. Nader Perroud from the Institute of Psychiatry, Kings College London, who headed up GENDEP, an international team. Dr Perroud said "Suicidal thoughts and behaviours during antidepressant treatment have prompted warnings by regulatory bodies". He continued "the aim of our study was to investigate the emergence and worsening of suicidal thoughts during treatment with two different types of antidepressant."

Both escitalopram and nortriptyline have their effect through the mood modulating neurotransmitter systems. The former is a selective serotonin reuptake inhibitor (SSRI), preventing serotonin from re-entering the cell and thereby prolonging its effect on nerve synapses. The latter is a tricyclic antidepressant that inhibits the reuptake of noradrenaline, and to a lesser extent, that of serotonin.

The study was carried out on 811 individuals with moderate to severe unipolar depression. Whilst an overall trend in reduction of suicidal thoughts was observed, men who took nortriptyline were found to have a 9.8-fold increase in emerging suicidal thoughts and a 2.4-fold increase in worsening suicidal thoughts compared to those who took escitalopram.

Perroud concludes, "Our findings that treatment-emerging and worsening suicidal thoughts may also be associated with psychomotor activation triggered by antidepressants needs to be investigated in future studies. The study also refutes the idea that newer antidepressants such as the SSRIs are worse than older medications in terms of increasing suicidal thoughts."

1. Suicidal ideation during treatment of depression with escitalopram and nortriptyline in Genome-Based Therapeutic Drugs for Depression (GENDEP): a clinical trial
Nader Perroud, Rudolf Uher, Andrej Marusic, Marcella Rietschel, Ole Mors, Neven Henigsberg, Joanna Hauser, Wolfgang Maier, Daniel Souery, Anna Placentino, Aleksandra Szczepankiewicz, Lisbeth Jorgensen, Jana Strohmaier, Astrid Zobel, Caterina Giovannini, Amanda Elkin, Cerisse Gunasinghe, Joanna Gray, Desmond Campbell, Bhanu Gupta, Anne E Farmer, Peter McGuffin and Katherine J Aitchison
BMC Medicine (in press)



1021 Dying from dementia - far greater access to palliative care required [Indianapolis IN]-- A growing number of older adults are dying from dementia. In an editorial in the October 15, 2009 issue of the New England Journal of Medicine, Greg Sachs, M.D., professor of medicine and director of the Division of General Internal Medicine and Geriatrics at the Indiana University School of Medicine and a Regenstrief Institute investigator, notes that end-of-life care for most older adults with dementia has not changed in decades and urges that these individuals be provided far greater access to palliative care, the management of pain and other symptoms.

Dr. Sachs believes that more research on palliative care for patients with dementia is needed to update public policy and get lawmakers and insurance companies to recognize the need to support and fund care which will improve the overall health of older adults who can no longer speak for themselves.

"Since individuals with advanced dementia cannot report their symptoms, these symptoms often are untreated, leaving them vulnerable to pain, difficulty breathing and various other conditions. We shouldn't allow these people to suffer. We should be providing palliative care to make them more comfortable in the time they have left," said Dr. Sachs, who is a geriatrician and medical ethicist.

While it is not easy, caregivers and medical personnel should attempt to pick up on nonverbal clues of pain, such as the individual holding the body in a certain way to avoid a painful posture, or exhibiting swollen, tender joints, he said. These observations, reported by a caregiver or found on medical examination, may help the physician make the patient more comfortable, and help identify underlying conditions.

Palliative care involves a team-oriented approach to pain management and medical treatment, as well as emotional support tailored to the patient's needs. Palliative care focuses on relieving symptoms such as pain, shortness of breath, fatigue, nausea, loss of appetite and difficulty sleeping. Hospice care provides palliative care but palliative care can be administered regardless of prognosis along with medical treatment and does not hasten death.

Dr. Sachs' editorial accompanies a Harvard University observational study of 323 patients with advanced dementia residing in 22 nursing homes which found that while few suffered a sentinel event such as a stroke or a heart attack, the survival of patients with advanced dementia was usually less than a year, especially following the occurrence of pneumonia, episodes of fever, or eating problems.


Dr. Sachs leads the Indiana Palliative Excellence in Alzheimer Care Efforts (IN-PEACE) Program which is studying the feasibility of incorporating an outpatient palliative care program for patients with dementia into the primary care setting, where most older adults receive their medical care. The program, supported by a grant from the National Palliative Care Research Center, provides improved symptom management, enhanced family support, and assistance with difficult decision making.



1021 Fighting flu: Stricter hand hygiene in schools only a short-term measure [London School of Hygiene and Tropical Medicine]--Increased hand hygiene in primary schools is only a short-term measure in preventing infections such as H1N1 from spreading. Researchers writing in the open access journal, BMC Public Health, found stricter hand hygiene practices are difficult to maintain in a school setting.

School children may be twice as likely to catch H1N1 influenza as adults, as such health policies often stress hand hygiene among school children as one low cost intervention that may prevent influenza from spreading.

A research team led by Wolf-Peter Schmidt at the London School of Hygiene and Tropical Medicine, London, UK used qualitative methods to explore teachers' and students' views on different hand hygiene protocols, as well as interviewing school nurses. Their pilot study in four East London primary schools examined both practical issues and attitudes, and included class exercises in hand washing or lining up to use hand sanitizer.

The researchers found that staff are motivated to contribute to hygiene education over and above what children learn from their parents, provided that expectations are realistic for the school environment. But very frequent and highly monitored hand washing would be hard to keep up over the longer term without the motivation of a major perceived public health threat like the current influenza pandemic. During a busy school day, time was a major factor in deciding what level of hand hygiene could be achieved.

School nurses were more focused on reducing infection, whereas teachers saw hygiene as an important education topic – particularly among the younger age groups. Rinse-free alcohol gel hand sanitizer was the fastest and least messy option. But teachers highlighted to children that this was only for situations where soap and water was in short supply.

"Intensive hand hygiene interventions are feasible and acceptable but only temporarily during a period of a particular health threat like an influenza pandemic and only if rinse-free hand sanitizers are used," according to Schmidt.


"In many settings there may be logistical issues in providing all schools with an adequate supply," he added. "Hand hygiene is important in particular for the prevention of gastro-intestinal infections. The effect of hand hygiene on the spread of influenza is less clear, but may be promoted as a precautionary measure, even in the absence of evidence. Our study highlights the practical issues of bringing improved hand hygiene to scale."



1021 CT scans show patients with severe cases of H1N1 are at risk for developing acute pulmonary emboli [University of Michigan]--Researchers utilizing computed tomography (CT) scans have found that patients with severe cases of the H1N1 virus are at risk for developing severe complications, including pulmonary emboli (PE), according to a study to be published online Oct. 14, 2009, in the American Journal of Roentgenology. The study will be published in the December issue of the AJR.

A pulmonary embolism occurs when one or more arteries in the lungs become blocked. The condition can be life-threatening. However, if treated aggressively, anti-coagulants (blood thinners) can reduce the risk of death.

The study, performed at the University of Michigan Health Service, included 66 patients diagnosed with the H1N1 flu. Two study groups were formed. Group one consisted of 14 patients who were severely ill and required Intensive Care Unit (ICU) admission. Group two consisted of 52 patients who were not severely ill and did not require ICU admission.

All 66 patients underwent chest X-rays for the detection of H1N1 abnormalities. Ten patients from the ICU group and five patients from the largely outpatient group, underwent CT scans. "Pulmonary Emboli were seen on CT in five of 14 ICU patients," said Prachi P. Agarwal, M.D., lead author of the study.

"Our study suggests that patients who are severely ill with H1N1 are also at risk for developing PE, which should be carefully sought for on contrast-enhanced CT scans," she said.

"With the upcoming annual influenza season in the United States, knowledge of the radiologic features of H1N1 is important, as well as the virus's potential complications. The majority of patients undergoing chest X-rays with H1N1 have normal radiographs. CT scans proved valuable in identifying those patients at risk of developing more serious complications as a possible result of the H1N1 virus, and for identifying a greater extent of disease than is appreciated on chest radiographs," said Dr. Agarwal.



1017 Infectious disease experts express concern over N95 recommendations [Society for Healthcare Epidemiology of America]--Last week's announcement by the Centers for Disease Control and Prevention (CDC) that it is modifying its guidance regarding measures that should be taken by healthcare workers who are in contact with either confirmed or suspected cases of H1N1 was met with concern by the scientific community that had submitted its recommendations to CDC.

CDC emphasizes a multipronged approach to protecting healthcare workers from H1N1, including priority use of N95 fit-tested respirators. The Society for Healthcare Epidemiology of America (SHEA) had urged CDC, based on clinical experience and scientific evidence, to remove the use of N95 respirators from its recommendations for routine care in favor of the first-line use of surgical masks, as one component of a cadre of prevention measures. Instead, N95 respirators should be reserved for procedures associated with a higher risk of aerosolization of the virus.

"Our position was and continues to be that N95s are neither necessary nor practical in protecting healthcare workers and patients against H1N1," said Mark Rupp, MD of the University of Nebraska Medical Center and President of SHEA. "The best science available leaves no doubt that the best way to protect people is by vaccinating them."

The scientific community acknowledged that the CDC came under intense pressure from labor unions to recommend the use of N95 fit-tested respirators despite the fact that respirators do not provide any added protection in clinical situations against droplet transmissible diseases such as H1N1. SHEA, whose membership is comprised of doctors and nurses on the front lines caring for patients with the flu, emphasizes the concern that continuing to recommend that respirators be used in routine care has major implications for both patient care and healthcare worker safety. "We could actually put healthcare workers at greater risk by further reducing an already short supply of a device that is needed for high-risk procedures such as bronchoscopy by using it for routine care," said Rupp.

As acknowledged by the CDC guidance, "It is important to remember that protecting against the spread of H1N1, or any type of flu, requires a multi-level approach, and the most effective measure for protection is vaccination," said Rupp, adding that "unfortunately this debate on respirators versus masks has distracted hospitals and clinics from investing in efforts that we know will pay off such as rigorous and consistent application of basic infection control and personal hygiene practices including adherence to cough etiquette and hand hygiene, rapid identification and separation of patients with the virus, and excluding sick workers and visitors from the hospital."

"Along with scientists around the world, we will continue to research H1N1 and its transmissibility," said Rupp. "We understand the role of the CDC in providing reassurance during a period of evolving evidence, and we urge the CDC to continue to revisit its recommendations as new data becomes available."



1014 Earlier flu viruses provided some immunity to current H1N1 influenza [UC Davis]--University of California, Davis, researchers studying the 2009 H1N1 influenza virus, formerly referred to as "swine flu," have identified a group of immunologically important sites on the virus that are also present in seasonal flu viruses that have been circulating for years. These molecular sites appear to result in some level of immunity to the new virus in people who were exposed to the earlier influenza viruses.

More than a dozen structural sites, or epitopes, in the virus may explain why many people over the age of 60, who were likely exposed to similar viruses earlier in life, carry antibodies or other type of immunity against the new virus, immune responses that could be attributed to earlier flu exposure and vaccinations.

Researchers Zheng Xing, a project scientist, and Carol Cardona, a veterinarian and Cooperative Extension specialist, both of the UC Davis School of Veterinary Medicine, report their findings online in the journal of Emerging Infectious Diseases. The report will appear in the November print edition of the journal, published by the Centers for Disease Control and Prevention.

"These findings indicate that human populations may have some level of existing immunity to the pandemic H1N1 influenza and may explain why the 2009 H1N1-related symptoms have been generally mild," Cardona said.

"Our hypothesis, based on the application of data collected by other researchers, suggests that cell-mediated immunity, as opposed to antibody-mediated immunity, may play a key role in lowering the disease-causing ability, or pathogenicity, of the 2009 H1N1 influenza," Xing added.

He noted that immune responses based on production of specific cells, known as cytotoxic T-cells, have been largely neglected in evaluating the efficacy of flu vaccinations. In this type of immune response, the T-cells and the antiviral chemicals that they secrete attack the invading viruses.

About 2009 H1N1 influenza

The 2009 H1N1 virus is a new strain of influenza that first appeared in the United States in April 2009. Early on, it was referred to as "swine flu" because it was genetically similar to influenza viruses that normally occur in pigs in North America. Further study, however, revealed that the virus actually included genes from viruses found in birds and humans, as well as pigs.

At first, this H1N1 influenza virus apparently caused a high number of deaths among patients in Mexico and among people with certain pre-existing medical conditions. But as it has progressed to become a pandemic or geographically widespread virus, H1N1 has caused relatively mild symptoms and few deaths.

One hallmark of this new influenza virus, according to the Centers for Disease Control and Prevention, has been the presence of pre-existing antibodies against the virus in about one third of H1N1 2009 patients over the age of 60, a phenomenon that suggested some levels of immunity may have existed to the new pandemic H1N1 virus. The UC Davis research

To probe this phenomenon, the UC Davis researchers surveyed data from earlier studies of epitopes known to exist on different strains of seasonal influenza A. They found that these epitopes, present in other seasonal H1N1 influenza strains around the world and capable of triggering an immune response, were also present in the strains of H1N1 2009 that were found in California, Texas and New York.

Interestingly, although previous H1N1 viruses seem to have produced a protective antibody response in exposed people, these antibodies largely did not provide cross-protection for individuals infected with the H1N1 2009 strain of influenza. The researchers theorize that, rather than stimulating protective antibodies, the epitopes of the new H1N1 2009 virus produced an immune response by triggering production of cytotoxic T-cells, which boost a person's immune defenses by killing infected cells and attacking the invading viruses.

Humans can mount two types of immune responses. One type is produced when the invading virus triggers production of protective antibodies that circulate in the bloodstream, and the other type, described above, is known as a cell-mediated immune response. It is produced when the invading virus triggers the activation of cytotoxic T-cells, a process that helps clear the virus from the body. Evidence from earlier studies suggests that cytotoxic T-cell immune immunity can be caused by either an active viral infection or by vaccination against such a virus.

Implications for avian influenza

The researchers note that about 80 percent of the epitopes found in seasonal influenza and flu vaccine viruses are also present in the highly pathogenic H5N1, or avian influenza, virus. They suggest that these epitopes may have protected some individuals infected with the highly pathogenic H5N1 virus through cytotoxic T-cell immunity.

However, the H5N1 virus rapidly reproduces itself and spreads so quickly within vital organs that the body may not be able to launch protective immunity, thus accounting for the high fatality rate of avian influenza.

Furthermore, only a fraction of the human population can recognize the specific epitopes necessary to cause the appropriate protective immune response, which may explain why the H1N1 2009 virus, as well as avian influenza, may vary in severity from person to person.

Xing and Cardona propose that immunity acquired from seasonal influenza or flu vaccinations may provide partial protection for patients infected with the avian influenza virus due to the shared epitopes essential for cytotoxic T-cell immunity.

This is supported by statistics from the World Health Organization indicating that there have been fewer avian influenza infections in people 40 years and older than there were in people under that age, and that the fatality rate of avian influenza was just 32 percent in the older age group but 59 percent in the younger group.

The researchers, therefore, suggest that repeated exposure to seasonal influenza viruses or flu vaccinations may have resulted in cytotoxic T-cell immunity to avian influenza, and that the same type of immunity may also have developed in people exposed to the H1N1 virus.

Funding for this study was provided by grants from the Department of Homeland Security's National Center for Foreign Animal and Zoonotic Disease Defense, and by the UC Davis Center for California Food Animal Health.



1014 Flu surveillance boosts control, treatment options [University of Alabama at Birmingham]--Because pandemics unfold in unpredictable ways, surveillance of travel-related illness is among the most powerful tools health officials and doctors can use to detect and respond to new pathogens like the novel H1N1 influenza, says the physician who heads the University of Alabama at Birmingham (UAB) Travelers' Clinic.

"Being able to track disease outbreaks in real time enables you to know, in real-time, what works and what doesn't work in terms of treatment," says David Freedman, M.D., director of the clinic.

Freedman is also co-director of GeoSentinel, a global online network of 48 travel- and tropical-medicine clinics spread across several continents. The network is a partnership between UAB, the International Society of Travel Medicine, the Centers for Disease Control and Prevention (CDC) and other groups – and an important part of that surveillance toolkit.

"GeoSentinel is showing us travelers and mobile populations getting the flu," Freedman says. "We are tracking which countries and places have intense enough transmission that they are then exporting flu and potentially seeding other countries.

"Today, if a GeoSentinel-linked doctor in Singapore has 10 infected patients and treats them a certain way that works well, that information can be disseminated on the same day, as well," he says.

The H1N1 flu virus was first identified in Mexico and quickly spread through human infection to more than 70 countries. H1N1 disease cases began immediately showing up as clickable dots on the GeoSentinel secure Web site in April of this year, Freedman says.

Unlike traditional surveillance maps, the GeoSentinel shows locations where someone got sick during travel, as opposed to where they live or where they may be recuperating.

Tracking and understanding the patterns of H1N1's spread remains crucial as more dots show up on the GeoSentinel map, Freedman says. Member clinics log on to the network and submit disease cases through a standardized Internet form, which links to global positioning. Qualified researchers, doctors and others use those reports for pandemic modeling and monitoring, and to gain a big-picture look at disease transmission.

"The most striking thing is how rapidly the swine flu spread," Freedman says. "Although the H1N1 virus is fairly mild compared to a lot of other novel flu viruses, it is very contagious. Back in 1918 and 1919 when we had the great flu epidemic, it took six months or more to spread across the world.

"The new H1N1 swine flu spread across the world in six weeks."

One important pattern to emerge through GeoSentinel monitoring was naming North America as the early source for spreading H1N1 person-to-person, Freedman says. The initial surveillance data was continuously shared with public-health groups, governmental agencies and doctors who needed to respond swiftly to the pathogen.

"With the speed of modern travel, and the fact that our countries draw visitors from a lot of different nationalities, the ingredients for a pandemic were there. Americans were top of the list for exporting this disease," he says.



1014 H1N1 critical illness can occur rapidly; predominantly affects young patients [JAMA]--Critical illness among Canadian patients with 2009 influenza A(H1N1) occurred rapidly after hospital admission, often in young adults, and was associated with severely low levels of oxygen in the blood, multi-system organ failure, a need for prolonged mechanical ventilation, and frequent use of rescue therapies, according to a study to appear in the November 4 issue of JAMA. This study is being published early online to coincide with its presentation at a meeting of the European Society of Intensive Care Medicine.

Infection with the 2009 influenza A(H1N1) virus has been reported in virtually every country in the world. The World Health Organization declared the first phase six (phase indicating widespread human infection) global influenza pandemic of the century on June 11, 2009. The largest number of confirmed cases occurred in North America between March and July 2009, according to background information in the article.

Anand Kumar, M.D., of the Health Sciences Centre and St. Boniface Hospital, Winnipeg, Manitoba, Canada, and colleagues with the Canadian Critical Care Trials Group H1N1 Collaborative conducted an observational study of critically ill patients with 2009 influenza A(H1N1) in 38 adult and pediatric intensive care units (ICUs) in Canada between April 16 and August 12, 2009. The study focused on the death rate at 28 and 90 days, as well as the frequency and duration of mechanical ventilation and the duration of ICU stay.

The researchers found that a total of 168 patients had confirmed or probable 2009 influenza A(H1N1) infection and became critically ill during this time period, and 24 (14.3 percent) died within the first 28 days from the onset of critical illness. Five more patients died within 90 days. The average age of the patients with confirmed or probable 2009 influenza A(H1N1) was 32.3 years, 113 were female (67.3 percent), and 50 were children (29.8 percent).

"Our data suggest that severe disease and mortality in the current outbreak is concentrated in relatively healthy adolescents and adults between the ages of 10 and 60 years, a pattern reminiscent of the W-shaped curve [rise and fall in the population mortality rate for the disease, corresponding to age at death] previously seen only during the 1918 H1N1 Spanish pandemic," the authors write.

Patients with 2009 influenza A(H1N1) infection-related critical illness experienced symptoms for a median (midpoint) of four days before entering the hospital, but worsened rapidly and required care in the ICU within one or two days. Shock and multi-system organ failure were common, and 136 patients (81 percent) received mechanical ventilation, with the median duration being 12 days. The average ICU stay was 12 days. Lung rescue therapies included neuromuscular blockade, inhaled nitric oxide and high-frequency oscillatory ventilation.

"In conclusion, we have demonstrated that 2009 influenza A(H1N1) infection-related critical illness predominantly affects young patients with few major comorbidities and is associated with severe hypoxemic respiratory failure, often requiring prolonged mechanical ventilation and rescue therapies," the authors write. "With such therapy, we found that most patients can be supported through their critical illness."

Editorial: Preparing for the Sickest Patients With 2009 Influenza A(H1N1)

In an accompanying editorial, Douglas B. White, M.D., M.A.S., and JAMA Contributing Editor Derek C. Angus, M.D., M.P.H., of the University of Pittsburgh School of Medicine, write that many U.S. hospitals may not have adequate numbers of physicians or staffing structures to facilitate timely treatment of the most seriously ill patients with 2009 influenza A(H1N1).

"Hospitals must develop explicit policies to equitably determine who will and will not receive life support should absolute scarcity occur," they write. "Any deaths from 2009 influenza A(H1N1) will be regrettable, but those that result from insufficient planning and inadequate preparation will be especially tragic," they conclude.



1014 Critical illness from 2009 H1N1 in Mexico associated with high fatality rate [JAMA]--Critical illness from 2009 influenza A(H1N1) in Mexico occurred among young patients, was associated with severe acute respiratory distress syndrome and shock, and had a fatality rate of about 40 percent, according to a study to appear in the November 4 issue of JAMA. This study is being published early online to coincide with its presentation at a meeting of the European Society of Intensive Care Medicine.

Novel 2009 influenza A(H1N1) was first reported in the southwestern United States and Mexico in March 2009. Between March 18 and June 1, 2009, 5,029 cases and 97 documented deaths occurred in Mexico. The population and health care system in Mexico City experienced the first and greatest early burden of critical illness, according to background information in the article.

Guillermo Domínguez-Cherit, M.D. of Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán," Mexico City, and colleagues conducted an observational study of critically ill patients at six hospitals in Mexico that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1) between March 24 and June 1, 2009. The study focused on the death rate, rate of critical illness and mechanical ventilation, and length of stay in the hospital and the intensive care unit.

Among 899 patients admitted to hospitals with confirmed, probable, or suspected 2009 influenza A(H1N1), 58 became critically ill. The critically ill patients had a median (midpoint) age of 44 years. Most were treated with antibiotics, and 45 patients were treated with anti-influenza drugs known as neuraminidase inhibitors, including oseltamivir and zanamivir. Fifty-four patients required mechanical ventilation.

"Our analysis of critically ill patients with 2009 influenza A(H1N1) reveals that this disease affected a young patient group," the authors write. "Fever and respiratory symptoms were harbingers of disease in almost all cases. There was a relatively long period of illness prior to presentation to the hospital, followed by a short period of acute and severe respiratory deterioration."

By 60 days, 24 of the critically ill patients (41.4 percent) died. Nineteen patients died within the first two weeks after becoming critically ill.

"Patients who died had greater initial severity of illness, worse hypoxemia [abnormally low levels of oxygen in the blood], higher creatinine kinase levels, higher creatinine levels, and ongoing organ dysfunction," the authors report.

"Early recognition of disease by the consistent symptoms of fever and a respiratory illness during times of outbreak, with prompt medical attention including neuraminidase inhibitors and aggressive support of oxygenation failure and subsequent organ dysfunction, may provide opportunities to mitigate the progression of illness and mortality observed in Mexico," they conclude.



1014 ECMO saves lives: Swine flu study [Monash University]--A research team has warned medical experts in the Northern Hemisphere not to underestimate the serious impact of the H1N1 (Swine flu) virus with a new report showing that many patients who were critically ill with the virus required prolonged life support treatment with heart-lung machines.

The latest report, released today in the Journal of American Medical Association (JAMA) revealed the extent to which doctors in Australia and New Zealand used extracorporeal membrane oxygenation (ECMO) during the height of the pandemic during June to August 2009.

ECMO is the most advanced and invasive form of life support available for lung failure and has previously been used rarely. This winter, 68 patients suffering severe acute respiratory distress syndrome (ARDS) - a major symptom of the H1N1 virus - were treated with ECMO.

At the time of the report, 54 of the 68 patients had survived and 14 (21 per cent) had died. Six patients remained in ICU, including two who were still receiving ECMO. Sixteen patients were still in hospital but had moved out of ICU, and 32 had been discharged from the hospital.

ECMO takes blood from the body through large plastic tubes and circulates it through a system that adds oxygen. ECMO is generally used for a limited time because of the risks of bleeding, clotting, infection and organ failure. ARDS is a very severe condition where the lungs fail due to the rapid accumulation of fluid within the lungs.

The team was led by Monash University researcher Dr Andrew Davies, Senior Research Fellow at the Australian and New Zealand Intensive Care Research Centre, who said the H1N1 patients admitted to ICU's were suffering symptoms of respiratory failure and there seemed no choice but to use ECMO to try and save their lives.

"We had not used ECMO machines to treat swine flu patients before because the disease was new to us – but now we know the treatment works and despite the severity of patients' symptoms, most survived," Dr Davies said.

The average duration of ECMO treatment was ten days and the patients stayed in the hospital for an average of 39 days.

The research team - Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators - conducted the observational study in 15 intensive care units (ICUs) in Australia and New Zealand between June 1 and August 31, 2009.

The researchers looked at a range of factors including degree of lung dysfunction in patients, how many patients were admitted, the duration of treatment and survival.

Dr David Gattas, Intensive Care Specialist at the Royal Prince Alfred Hospital in Sydney said the research information would better prepare ICU's in the Northern Hemisphere for the patients who develop the more severe cases of the virus.

"The findings of the study should be widely read in the Northern Hemisphere and we hope this knowledge will help medical teams who may have to make fast decisions about starting advanced life supports such as ECMO. Many of these severely affected flu victims can survive," Dr Gattas said.



1014 Should noninvasive ventilation be considered a high-risk procedure during an epidemic? [CMAJ]--Contrary to current policies recommending that non-invasive ventilation be avoided during an infectious outbreak, the author of a commentary in CMAJ (Canadian Medical Association Journal) argues that it should be used expeditiously in this setting.

Noninvasive ventilation uses a mask interface to ventilate the lungs of patients in respiratory failure, rather than a tube inserted into the trachea. Because suitable candidates for noninvasive ventilation avoid complications associated with endotracheal intubation, they have better outcomes compared to similar patients who are ventilated invasively.

Prohibitions against noninvasive ventilation were implemented during the SARS (severe acute respiratory syndrome) outbreak in 2003 because it was thought that flow from the mask increased the risk of infectious transmission to staff. Since then, the World Health Organization, the United Kingdom's National Health Agency, the Hong Kong Lung Association, the American Association of Respiratory Care and Ontario's Provincial Infectious Diseases Advisory Committee have published guidelines that treat noninvasive ventilation as a high-risk procedure.

"During the SARS epidemic, the suggestion that noninvasive ventilation may increase the risk of disease transmission was considered sufficient justification to avoid its use. However in the 6 years since then, no convincing evidence has substantiated that theory. On the other hand, noninvasive ventilation has been proven to save the lives of some patients in acute respiratory failure", writes John McCracken, a respiratory therapist at Peterborough Regional Health Centre in Peterborough Ontario Canada.

"It is in no one's best interest for patients to undergo endotracheal intubation in cases where it could be avoided. In light of the available evidence, the precautionary principle would suggest that it is imprudent for policymakers to await scientific certainty. Noninvasive ventilation can be accomplished using simple portable equipment. "If the demand for sophisticated ICU ventilators threatens to exceed supply during an infectious outbreak, the expeditious use of noninvasive ventilation would help conserve the equipment for those who need it most," concludes the author.



1014 Over half of cot deaths occur while co-sleeping [BMJ]--More than half of sudden unexplained infant deaths occur while the infant is sharing a bed or a sofa with a parent (co-sleeping) and may be related to parents drinking alcohol or taking drugs, suggests a study published on bmj.com today.

Although the rate of cot death in the UK has fallen dramatically since the early 1990s, specific advice to avoid dangerous co-sleeping arrangements is needed to help reduce these deaths even further, say the researchers.

The term sudden infant death syndrome (SIDS) was introduced in 1969 as a recognised category of natural death that carried no implication of blame for bereaved parents.

Since then, a lot has been learnt about risk factors, and parents are now advised to reduce the risk of death by placing infants on their back to sleep, placing infants in the "feet to foot" position at the bottom of the cot, and keeping infants in a smoke-free environment.

But it is not clear which risk messages have been taken on board in different social or cultural groups, and little is known about the emergence of new or previously unrecognised risk factors.

So a team of researchers at the Universities of Bristol and Warwick studied all unexpected infant deaths from birth to two years in the southwest region of England from January 2003 to December 2006.

To investigate a possible link between SIDS and socioeconomic deprivation, they compared these deaths with a control group at 'high risk' for SIDS (young, socially deprived mothers who smoked) as well as a randomly selected control group.

Parents were interviewed shortly after the death and information was collected on alcohol and drug use. A detailed investigation of the scene and circumstances of death was also conducted by trained professionals.

Of the 80 SIDS deaths analysed, more than half (54%) occurred whilst co-sleeping compared to 20% co-sleeping rate amongst both control groups.

Much of this risk may be explained by the combination of parental alcohol or drug use prior to co-sleeping (31% compared with 3% random controls), and the high proportion of co-sleeping deaths on a sofa (17% compared with 1% random controls), say the authors.

A fifth of SIDS infants were found with a pillow for the last sleep and a quarter were swaddled, suggesting potentially new risk factors emerging.

The risk factors were similar whichever group the SIDS cases were compared with, suggesting that these risk factors for SIDS apply to all sections of the community and are not just a consequence of social deprivation.

Some of the risk reduction messages seem to be getting across and may have contributed to the continued fall in the SIDS rate, say the authors. However, the majority of the co-sleeping SIDS deaths occurred in a hazardous sleeping environment. The safest place for an infant to sleep is in a cot beside the parental bed in the first six months of life, they write.

Parents need to be advised to never put themselves in a situation where they might fall asleep with a young infant on a sofa. They also need to be reminded that they should never co-sleep with an infant in any environment if they have been drinking or taking drugs.

We have learnt that SIDS is largely preventable, says Edwin Mitchell, Professor of Child Health Research at the University of Auckland, in an accompanying editorial. It is important to monitor parents' knowledge and infant care practices to inform health education and promotion.

Implementing what we already know has the potential to eliminate SIDS, the challenge now is how to change behaviour, he concludes.



1014 Canadian blood supply future uncertain as population ages: Study [McMaster University]--The Canadian blood supply relies heavily on a small number of donors—with young adults donating at higher rates—which may prove problematic as the population ages, according to a new study from McMaster University.

The research, published in open access format in the International Journal of Health Geographics, examined what specific factors had an impact on blood donation in this country.

"Like other countries, Canada's population is aging and the implications of this need to be better understood from the perspective of blood supply," says Antonio Páez, lead researcher and assistant professor in the department of Geography & Earth Sciences at McMaster University. "So while younger people are more likely to donate, they are also a declining share of Canada's population."

Almost every single Canadian will require donor blood at some point in their lifetime, but less than 4% of eligible donors donate, explains Páez.

The team of researchers used records from Canadian Blood Services, the national charitable organization charged with overseeing the safety of the blood supply, which operates 40 permanent collection sites and more than 20,000 donor clinics annually.

The study found those aged 15 to 24 were the most likely to donate, while those who are typically more entrenched in the workforce—aged 25 to 54—were the least likely to donate blood.

Similarly, immigrants and the wealthy were less likely to donate, while English-speaking Canadians, highly educated individuals or those employed in health-related occupations were more likely to give blood. Researchers also found that those living in small cities or towns were far more likely to donate than people who live in larger, metropolitan cities.

"Blood products are an essential component of modern medicine and necessary to support many life-saving and life-prolonging procedures. To achieve sustainable levels of donations, there needs to be targeted campaigns to encourage a greater number of Canadians to consider blood donation," says Páez.

According to researchers, 25% of Canadians believe there are some risks associated with giving blood, but an aggressive education campaign would help expand the donor database, which is estimated at about 12.5 million eligible donors.

The study was funded by Canada's Social Sciences and Humanities Research Council, Canada Blood Services and Environics Analytics. The complete study can be viewed at http://www.ij-healthgeographics.com/content/8/1/56.



1014 H1N1 simulation modeling shows rapid vaccine rollout effective in reducing infection rates [Canadian Medical Association Journal]--Early action, especially rapid rollout of vaccines, is extremely effective in reducing the attack rate of the H1N1 influenza virus, according to a simulation model of a pandemic outbreak reported in a new study in CMAJ (Canadian Medical Association Journal).

The article presents a simulation model that projects how many people will be infected under different disease control strategies. The model simulated a pandemic outbreak based on demographic information from London, a mid-sized city in Ontario, Canada as well as epidemiologic influenza pandemic data. It looked at the impact of vaccination timing, school closures and antiviral drug treatment strategies as well as the effect of pre-existing immunity.

The authors simulated a large range of possible scenarios that may play out in reality, to determine whether any general conclusions could be drawn. The model captures how vaccination not only protects vaccinated individuals but can also help the healthcare system to cope by flattening the peak of the outbreak and delaying the peak. The model provides mathematical predictions for how and when that could happen.

The H1N1 pandemic has required decision-makers to set policy in the face of significant uncertainties, and simulation models can be used to help them decide on the best strategy to mitigate the spread of infection.

"The results of our pandemic influenza simulation model suggest that vaccination can have a disproportionately large impact on reducing the attack rate in a "fall wave," although delays can significantly erode its effectiveness," write Dr. Marija Zivkovic Gojovic and coauthors.

As well, the model predicts that school closures would be effective. However, the authors note there are important social costs of school closures that they did not examine in the analysis. The study did not attempt to predict influenza-related deaths, and did not assess vaccination strategies targeted to high risk groups or specific age groups, such as school age children.

The model was developed by researchers from the University of Toronto, the Ontario Agency for Health Protection and Promotion and the Research Institute of the Hospital for Sick Children in Toronto; and University of Guelph in Guelph, Ontario.



1010 NIH prepares to launch 2009 H1N1 influenza vaccine trial in people with asthma [NIH]--The National Institutes of Health is preparing to launch the first government-sponsored clinical trial to determine what dose of the 2009 H1N1 influenza vaccine is needed to induce a protective immune response in people with asthma, especially those with severe disease. The study is cosponsored by the National Institute of Allergy and Infectious Diseases (NIAID) and the National Heart, Lung, and Blood Institute (NHLBI), both part of NIH.

"People with severe asthma often take high doses of glucocorticoids that can suppress their immune system, placing them at greater risk for infection and possibly serious disease caused by 2009 H1N1 influenza virus," says NIAID Director Anthony S. Fauci, M.D. "We need to determine the optimal dose of 2009 H1N1 influenza vaccine that can be safely administered to this at-risk population and whether one or two doses are needed to produce an immune response that is predictive of protection."

The study plan has been submitted to the Food and Drug Administration for review. With FDA allowing it to proceed, the clinical trial will be conducted at seven sites across the United States that participate in NHLBI's Severe Asthma Research Program.

This program already has a well-characterized group of participants with mild, moderate or severe asthma who may be eligible for this new study. These groups are largely distinguished by the amount and frequency of glucocorticoids needed to control asthma symptoms. People with mild disease may not need glucocorticoids, or may require low doses of inhaled glucocorticoids; those with moderate asthma need low to moderate doses of inhaled glucocorticoids; and those with severe asthma need high doses of inhaled glucocorticoids and frequently use oral glucocorticoids as well.

Individuals who already have been infected with 2009 H1N1 influenza or have received a 2009 H1N1 influenza vaccination will not be eligible for the study.

"The results of this study will have immediate implications for individuals with severe asthma as well as those who have milder asthma," says NHLBI Director Elizabeth G. Nabel, M.D.

Early results from other clinical trials of 2009 H1N1 influenza vaccines in healthy adults have shown that a single 15-microgram dose of 2009 H1N1 influenza vaccine without adjuvant is well tolerated and induces a strong immune response in most participants. The same vaccine also generates an immune response that is expected to be protective in healthy children ages 10 to 17 years. Ongoing trials are comparing the immune response to one and two doses of 15- or 30-micrograms of vaccine given three weeks apart in various populations.

The Centers for Disease Control and Prevention has recommended that certain at-risk populations receive the new H1N1 vaccine as a priority before the general population. These target populations include pregnant women, health care providers and individuals with underlying chronic medical conditions, including asthma.

People who have severe asthma may be particularly at risk for infection with the 2009 H1N1 influenza virus. A report published in 2004 suggested that some people who took high doses of glucocorticoids to treat their asthma may receive less protection from influenza vaccines against some strains of influenza. Early in the 2009 H1N1 flu outbreak a CDC review of hospital records found that people with asthma have a four-fold increased risk of being hospitalized with infection compared to the general population.

The study will enroll approximately 350 people with mild, moderate and severe asthma. Participants will be organized into two groups: those with mild or moderate asthma and those with severe asthma. Half of the participants in each group will receive a 15-microgram dose of vaccine, and the other half a 30-microgram dose. Three weeks later, each participant will receive a second dose of the same amount. The strength of the immune response induced by the vaccine will be determined in blood samples by measuring the level of antibodies against 2009 H1N1 flu virus.

Safety data will be collected and examined throughout the course of the study by trial investigators and by an independent safety monitoring committee. Participants will be monitored for any side effects they may experience because of the vaccine, as well as asthma attacks that occur during the study period.

The vaccine to be used in the trial, manufactured by Novartis, contains inactivated 2009 H1N1 influenza virus and therefore cannot cause anyone to become infected with the virus.

The trial will be conducted at the following locations:

* Cleveland Clinic, Ohio
* Emory University, Atlanta
* University of Pittsburgh Asthma Institute
* University of Virginia, Charlottesville
* University of Wisconsin, Madison
* Wake Forest University, Winston-Salem, N.C.
* Washington University School of Medicine, St. Louis

Detailed information about this study can be found on the ClinicalTrials.gov Web site at http://clinicaltrials.gov/ct2/results?term=H1N1+AND+asthma.



1010 NIH launches 2009 H1N1 influenza vaccine trials in HIV-infected pregnant women [NIH]--The first clinical trials to test whether the 2009 H1N1 influenza vaccine can safely elicit a protective immune response in pregnant women launched yesterday, and a trial to conduct the same test in HIV-infected children and youth will begin next week. The International Maternal Pediatric Adolescent AIDS Clinical Trials Group is conducting the studies, which are sponsored and funded by the National Institute of Allergy and Infectious Diseases (NIAID) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), both part of the National Institutes of Health.

"These studies are important because HIV infection and pregnancy both increase the risk for a poor immune response to the normal 15-microgram dose of seasonal influenza vaccine given to the general population," says NIAID Director Anthony S. Fauci, M.D. "Moreover, children, young people and pregnant women are at higher risk for more severe illness from the 2009 H1N1 influenza virus than other groups, and HIV-infected individuals in these populations may be particularly vulnerable."

"Because of the increased vulnerability of these populations, these trials are testing whether doses of licensed 2009 H1N1 influenza vaccine that are higher than doses being tested in other groups can safely elicit protective immune responses in HIV-infected children, youth and pregnant women," adds Lynne Mofenson, M.D., chief of the Pediatric, Adolescent and Maternal AIDS Branch in NICHD.

One trial will enroll 130 HIV-infected pregnant women ages 18 to 39 years who are in their second or third trimester (14 to 34 weeks) of pregnancy. The other trial will enroll 140 children and youth aged 4 to 24 years who were infected with HIV at birth.

Thirty-five sites and eight sub-sites across the United States and Puerto Rico are eligible to conduct the trials. Each volunteer will receive two 30-microgram doses of 2009 H1N1 influenza vaccine 21 days apart. (In contrast, the NIAID studies of 2009 H1N1 influenza vaccine in HIV-uninfected children, youth and pregnant women are testing doses of 15 and 30 micrograms.)

Safety data will be collected and monitored closely by the study investigators and an independent safety monitoring committee. The strength and longevity of the immune response elicited by the vaccine will be gauged in several ways.

The study team will take blood samples from the pregnant women after each dose and three and six months after delivery to measure the concentration of antibodies the women produce against 2009 H1N1 influenza virus and how strong that antibody response remains over time. After the women give birth, study staff will sample umbilical cord blood to measure the concentration of maternal antibodies against the H1N1 virus that were transferred to the infants through the placenta. The study team also will collect small blood samples from the infants at 3 and 6 months of age to measure their level of maternally derived antibody protection from the virus over time. The infants will not receive vaccine.

Similarly, in children and young people, the strength and longevity of the immune response will be gauged by testing blood samples taken 21 days after the first dose, 10 days after the second dose, and six months after entering the study.

The vaccine, manufactured by Novartis Vaccines and Diagnostics, contains inactivated 2009 H1N1 influenza virus, so it is impossible to become infected with the virus by receiving the vaccine. The vaccine does not contain adjuvant, a substance added to some vaccines to improve the body's response to vaccine.

Research on seasonal influenza vaccine and vaccines for other diseases in HIV-infected and other populations suggest that higher doses of vaccine tend to elicit stronger immune responses. These stronger responses, in turn, increase the concentration of protective antibodies in the bloodstream, which likely is beneficial to both the vaccinated individual and, if pregnant, to her fetus. This is the rationale for testing whether higher doses of licensed 2009 H1N1 influenza vaccine elicit a protective immune response in HIV-infected individuals and whether that protection is transferred to the fetuses of vaccinated pregnant women.

For more information about NIAID-sponsored clinical trials in HIV-infected pregnant women, children and youth, see http://www3.niaid.nih.gov/news/QA/H1N1trialsHIVpedspreg.htm.


1010 Lessons learned from H1N1 virus pandemic - High impact on ICU beds [Monash University]--A comprehensive study has revealed, for the first time, the impact of swine flu on the health of the general public in Australia and New Zealand.

The lessons learned in Intensive Care Units (ICUs) across the two countries on the impact of the H1N1 (swine flu) virus are being shared with countries in the Northern Hemisphere to help them prepare for their upcoming flu season.

The three-month study, conducted at the height of the pandemic between June and August, reveals that 722 patients were admitted to ICUs and that at the peak of the epidemic up to 20 per cent of ICU beds were occupied by patients with swine flu infection.

The study was co-coordinated by the Monash University-based Australian and New Zealand Intensive Care Research Centre (ANZIC-RC). The study involved all ICUs in Australia and New Zealand with the affected patients being treated in 109 of these units. The study was conducted utilising the resources of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG).

Dr Ian Seppelt, a specialist in Intensive Care Medicine and based at Sydney's Nepean Hospital, said the impact of the virus on ICUs across Australia and New Zealand was dramatic.

"Intensive Care Units specialise in the management of patients with life-threatening illness and the surge of patients with H1N1 placed substantial strain on staff and resources. The most severely affected patients had pneumonia affecting both lungs that was caused by the virus. The number of patients admitted to ICUs with this complication represented a 600 per cent increase compared to previous years," Dr Seppelt said.

Clinical Associate Professor Steve Webb, from the Intensive Care Unit at Royal Perth Hospital, was another key researcher on the project and said the information, which surfaced from the study will benefit other countries about to head into their winter flu season.

"Unlike previous 'seasonal' influenza strains, which impact heavily on elderly people and people with severe coexisting medical conditions, the H1N1 virus affected a different profile. Critical illness due to swine flu was most common in infants and middle aged people; with pregnant patients, the overweight, and indigenous patients particularly affected. Overall, about one-third of patients admitted to an ICU because of swine flu had no underlying health problems. " Associate Professor Webb said.

Professor Rinaldo Bellomo, Foundation Chair of the ANZICS CTG and Director of Intensive Care Research at Austin Health, Melbourne said the results of the study would be shared with health authorities in other countries to assist them better prepare for their flu season.

"We have come through our flu season and our assessment of the impact of the H1N1 strain will assist them prepare for any outbreak. The H1N1 virus has taken hold in many countries already, but many countries in the Northern Hemisphere will benefit from the lessons we have learned," Professor Rinaldo Bellomo said.

"Fortunately a vaccine is now available to prevent the complications of swine flu and it is important that all members of the community and especially those with risk factors, consider being vaccinated," he said.



1010 US must focus on protecting critical computer networks from cyber attack [RAND]--Because it will be difficult to prevent cyber attacks on critical civilian and military computer networks by threatening to punish attackers, the United States must focus its efforts on defending these networks from cyber attack, according to a new RAND Corporation study.

The study finds that the United States and other nations that rely on externally accessible computer networks—such as ones used for electric power, telephone service, banking, and military command and control—as a foundation for their military and economic power are subject to cyber attack.

"Adversaries in future wars are likely to go after each other's information systems using computer hacking," said Martin C. Libicki, the report's lead author and senior management scientist at RAND, a nonprofit research organization. "The lessons from traditional warfare cannot be adapted to apply to attacks on computer networks. Cyberspace must be addressed in its own terms."

Working against connected but weakly protected computer systems, hackers can steal information, make the systems malfunction by sending them false commands and corrupt the systems with bogus information.

In most instances, the damage from cyber attacks is temporary and repeated attacks lead the victim to develop systems that are more difficult to penetrate. The RAND study finds that military cyber attacks are most effective when part of a specific combat operation—such as silencing a surface-to-air missile system protecting an important target—rather than as part of a core element in a long, drawn out military or strategic campaign.

Libicki says it is difficult to determine how destructive a cyber attack would be. Damage estimates from recent cyber attacks within the United States range from a few billion dollars to hundreds of billions of dollars a year.

The study indicates that cyber warfare is ambiguous, and that it is rarely clear what attacks can damage deliberately or collaterally, or even determine afterward what damage was done. The identity of the attacker may be little more than guesswork, which makes it hard to know when someone has stopped attacking. The cyber attacker's motivation, especially outside physical combat, may be equally unclear.

The weapons of cyber war are amorphous, which eliminates using traditional approaches to arms control. Because military networks mostly use the same hardware and software as civilian networks, they have similar vulnerabilities.

"This is not an enterprise where means and ends can be calibrated to one another," Libicki said. "As a result, it is ill-suited for strategic warfare."

Because offensive cyber warfare is more useful in bothering, but not disarming, an adversary, Libicki does not recommend the United States make strategic cyber warfare a priority investment. He says similar caution is needed for deterring cyber warfare attacks, as it is difficult to attribute a given attack to a specific adversary, and the lack of an ability to counterattack is a significant barrier.

Instead, Libicki says the United States may first want to pursue diplomatic, economic and prosecutorial efforts against cyber attackers.

The study, "Cyberdeterrence and Cyberwar," was prepared by RAND Project AIR FORCE, a federally funded research and development center for studies and analysis aimed at providing independent policy alternatives for the U.S. Air Force.



1010 Major healthcare challenges persist for DC children despite high rates of health insurance coverage [Children's National Medical Center/ RAND Health]--Despite high rates of health insurance coverage among children in the District of Columbia, children's access to health care is inadequate and poses a significant health problem for the city's young residents, particularly those who are publicly insured, according to a RAND Corporation study issued today.

The study, conducted by RAND Health and funded by Children's National Medical Center, assesses health and health care among the more than 100,000 youth residing in Washington, D.C. Researchers suggest that health promotion efforts must focus on a partnership involving numerous private and public sector organizations that serve children, including schools, community-based organizations and child care centers.

The District of Columbia leads the nation in children with health coverage, with only 3.5 percent estimated to be uninsured in 2007. Nationally, an estimated 9.1 percent of children lack health insurance.

"But having health insurance in the District of Columbia does not automatically translate into access to health care," said Anita Chandra, the report's lead author and a behavioral scientist at RAND.

Access problems appear especially profound for children who have publicly funded insurance. The study finds that rates of well-child care among publicly insured children are substantially below national norms and more than one in four publicly insured children in the District receives care at a hospital emergency department at least once a year.

The study is the first to comprehensively focus on children's health issues and examine not only the health service delivery system, but the communities in which children live in the District of Columbia. Researchers aim to provide a foundation for District policymakers to examine children's health issues, as well as assist the Children's National Medical Center in allocating its community benefit resources.

The study finds that numerous barriers prevent residents from getting primary and specialty health care in non-hospital settings. One major factor is the uneven distribution of primary and specialty care providers across the District. Other barriers cited by District residents in the study include a perceived lack of provider understanding of cultural and neighborhood issues, as well as a limited availability of health care providers who speak languages other than English. The study also finds that particular health conditions and health behaviors require special attention because of their prevalence and potential severity. Although children are generally healthier than adults, researchers identified several chronic health conditions that are prevalent among District youth, including asthma, sickle cell anemia, HIV/AIDS and obesity.

"Children with asthma, in particular, are substantial users of hospital-based care," said Carole Roan Gresenz, a study co-author and senior economist at RAND. "District of Columbia leaders will want to focus on services that will help children manage their asthma and other chronic conditions before they end up in the emergency department or hospital."

Researchers find that socioeconomic, environment and safety conditions also are crucial issues facing District youth.

Though the rate of children in poverty in the District has declined in recent years, the percentage of children who live in poverty in the District remains higher than the national percentage (23 percent versus 18 percent).

Safety and violence are particularly important issues. The rate of dating violence in the District increased from 11 percent to 17 percent from 2005 to 2007, and rates of child abuse and neglect are twice the national average. As a result, far more children are in the District's foster care system than the national average.

The study includes a unique synthesis of information from previous research, including vital statistic reports and studies of school nursing and school mental health programs, along with original data analysis of existing survey and administrative information. The research also included information obtained from focus groups with parents, adolescents and health care providers.

The report's key recommendations include:

* Develop and apply strategies that will increase children's access to primary and specialty care. This includes increasing the network of providers through better and faster reimbursement, and incentives such as support for electronic health record implementation.
* Focus attention on children with the most prevalent chronic illnesses: asthma, sickle cell anemia, HIV/AIDS and obesity. Early preventive care will help children manage their conditions before they need the hospital or emergency department.
* Give more attention to prevention and wellness programs across sectors. This would include violence prevention programs that address school safety issues, emotional wellness programs and sexual health interventions that combine discussions of risky sexual activity with life skills training.

"This report is an unprecedented review of pediatric-specific issues in the District," said Jacqueline D. Bowens, executive vice president at Children's National Medical Center. "Based on these findings, Children's National may take the lead on new issues, collaborate on others, and then play a supporting role on social and infrastructure development factors that ultimately affect children's health."

The study, "Health and Health Care Among District of Columbia Youth," can be found at www.rand.org. Other authors of the report are Janice Blanchard, Alison Evans Cuellar, Teague Ruder, Alex Chen and Emily Gillen.



1010 Injury and hazards in home health care nursing are a growing concern [Columbia University's Mailman School of Public Health]--Patients continue to enter home healthcare ''sicker and quicker," often with complex health problems that may require extensive nursing care. This increases the risk of needlestick injuries in home healthcare nurses. While very few studies have focused on the risks of home healthcare, it is the fastest growing healthcare sector in the U.S.


In a recent study, led by researchers at Columbia University Mailman School of Public Health, the rate of needlestick-type injuries was 7.6 per 100 nurses. At this rate, the scientists estimate that there are nearly 10,000 such injuries each year in home care nurses. The findings, reported in the paper, "The Prevalence and Risk Factors for Percutaneous Injuries in Registered Nurses in the Home Health Care Sector," were published in the September 2009 issue of American Journal of Infection Control.

According to lead author Robyn Gershon, DrPH, professor of clinical Sociomedical Sciences at the Mailman School of Public Health and principal investigator, "although professionally and personally rewarding for many, home care nursing can be both physically and emotionally demanding. Our study findings suggest that home healthcare work may be dangerous for nurses who work in this setting. These types of injuries are serious as they can result in infection with bloodborne pathogens, such as hepatitis and HIV."

A critical finding of this study was the statistical correlation between needlesticks and exposure to stressful conditions in the patients' household. Nurses reporting household stressors, such as cigarette smoke, unsanitary conditions, air pollution, and vermin, were nearly twice as likely to report needlestick injuries. Most significant was the fact that home healthcare nurses exposed to violence in their patients' households were nearly three and a half times more likely to also report needlestick injuries, according to the study.

The home healthcare sector is a very important part of the nation's healthcare infrastructure with over 1.3 million workers in the field, including roughly 125,000 RNs. Many procedures previously performed only in the hospital are now routinely performed in the home.

Over 700 home healthcare RNs from across New York State were recruited for this study, which was funded by the National Institute for Occupational Safety and Health (NIOSH), the Centers for Disease Control and Prevention (CDC).

The provision of a safe work environment in the home healthcare sector is complicated by the fact that worker safety in this setting is largely unregulated. Certain OSHA regulations do not apply to workers employed in individual households. However, home healthcare agencies accredited by the Joint Commission must be in compliance with certain infection control and other standards. Protecting workers from violence in the healthcare setting is an ongoing and well recognized challenge according to Dr. Gershon, "These results indicate that household hazards in general, and home care violence in particular, needs addressing."

"Many of the unsafe conditions identified in this study can also increase risk of harm to patients," said Dr. Gershon. She further noted that as healthcare increasingly moves out from the acute care setting and into the home setting, efforts to improve the health and safety of workers in this sector is critical, with benefits to home health care workers and patients alike.

"Dr. Gershon's research on home healthcare and how it affects elderly patients and caregivers alike is key to helping us evaluate the ways to ensure that both frail older adults and their home health providers remain as safe and healthy in the home setting as possible," says Linda Fried, MD, MPH, dean of the Mailman School of Public Health. "This research is especially important since we know that 20% of the U.S. population will be over 65 years old by the year 2030." Dr. Fried is an epidemiologist and geriatrician whose career has been dedicated to the science of healthy aging.

The study was supported by Centers for Disease Control and Prevention/National Institute of Occupational Safety and Health (5 R01 OH008215-03).



1010 Insured African-Americans more likely to use emergency room than other insured groups [UCLA]--Health insurance, and the access it provides to a primary care physician, should reduce the use of a major driver of health care costs: the emergency room.

Yet in a policy brief released today by the UCLA Center for Health Policy Research, researchers found that in California, privately insured African Americans enrolled in HMOs are far more likely to use the ER and to delay getting needed prescription drugs than HMO-insured members of other racial and ethnic groups. The research was funded by the California Office of the Patient Advocate.

It's not that African Americans fail to see their doctors, researchers say. In fact, of all HMO enrollees, African Americans were the most likely to report seeing a doctor in the past year, according to the authors of the brief, "African-Americans in Commercial HMOs Are More Likely to Delay Prescription Drugs and Use the Emergency Room."

Patient income and illness did not predict ER or prescription drug use either. Researchers found greater ER use and delays in getting prescription drugs even among African American HMO enrollees who were generally healthy and had higher incomes.

While the reasons behind the ER use and drug delays among African Americans are the subject of future research, lead author Dylan Roby, a research scientist with the UCLA Center for Health Policy Research, said the data suggests that the way health maintenance organizations or their contracted physicians provide care — and the way patients respond to that care — may create obstacles to timely primary care, as well as foster excessive use of the emergency room and delays in getting needed medications.

African Americans Depend on HMOs

More than two-thirds of insured African Americans in California are enrolled in HMOs (67.3 percent, or 1.35 million), compared with 64.7 percent (4.5 million) of insured Latinos and 51.6 percent (8 million) of whites.

Using data from the 2007 California Health Interview Survey (CHIS), researchers found that African American patients enrolled in commercial HMO plans were more likely to delay getting needed prescription drugs. Those enrolled in commercial Kaiser Permanente plans were more likely to use the ER, they said.

"It's troubling, because it suggests that even if you are insured and well-off, you still may not be getting the care you need," Roby said. "It also suggests that HMOs that are designed to provide preventive care and to make sure people have their medications are not able to do so."

Kaiser Permanente is the most popular HMO among African Americans, with one-fourth of all insured African Americans enrolled in the Oakland-based insurance carrier. Despite HMO emphasis on preventive care, however, more than a quarter (25.4 percent) of all privately insured African Americans enrolled in a Kaiser Permanente plan used the emergency room in the past year — in contrast to 14 percent of Asian American enrollees and 17.5 percent of Latinos.

The reasons could range from the relative affordability of emergency-room services to the ease of accessing those services, Roby said.

"If it takes days or weeks to get an appointment with your doctor and just hours to be seen in the ER, people might make the easier choice, especially if it is convenient and affordable," he said. "On the other hand, if someone knows their local ER is overcrowded and expensive, they may be more likely to wait and see their own doctor."

Delaying Needed Medicine

Privately insured African American HMO enrollees also were notably more likely to delay getting needed prescription drugs. Prescription drug delays were about 10 percent higher for privately insured African Americans enrolled in non-Kaiser commercial HMO plans than for whites in comparable commercial plans.

Costs, geography and the pharmacy benefits offered by a given HMO may all inhibit the timely purchase of prescription drugs.

"We need to think about how the cost of prescriptions and delays in getting needed medications are compromising health status and quality of life," Roby said.

The research helps health advocates in California identify key health and health care issues for African American HMO members, said Sandra Perez, director of the California Office of the Patient Advocate. "This is the first step in understanding how HMOs can close the gaps in the quality of care and access they provide to their members."

Roby recommended an education campaign for both patient and provider that would address appropriate use of the ER and primary care services, as well as the importance of medication adherence and getting prescribed medications and refills.

"African American HMO members need to be empowered to find a doctor they are comfortable with, while health plans need to make a greater effort to connect patients with that doctor," Roby said.

The policy brief was supported by a grant from the California Office of the Patient Advocate as part of a targeted educational outreach program.



1010 New study finds high rates of childhood exposure to violence and abuse in US [University of New Hampshire]--A new study from the University of New Hampshire finds that U.S. children are routinely exposed to even more violence and abuse than has been previously recognized, with nearly half experiencing a physical assault in the study year.

"Children experience far more violence, abuse and crime than do adults," said David Finkelhor, director of the UNH Crimes against Children Research Center and the study director. "If life were this dangerous for ordinary grown-ups, we'd never tolerate it."

The research was sponsored by the U.S. Department of Justice (DOJ), Office of Juvenile Justice and Delinquency Prevention (OJJDP) and supported by the Centers for Disease Control and Prevention (CDC). The research results are presented in the journal Pediatrics and an Office of Justice Programs/OJJDP bulletin titled "Children's Exposure to Violence: A Comprehensive National Survey."

UNH researchers asked a national sample of U.S. children and their caregivers about a far broader range of exposures than has been done in the past.

According to the research, three out of five children were exposed to violence, abuse or a criminal victimization in the last year, including 46 percent who had been physically assaulted, 10 percent who had been maltreated by a caregiver, 6 percent who had been sexually victimized, and 10 percent who had witnessed an assault within their family.

The authors contend that earlier studies of violence exposure only inquired about individual crimes – looking only at bullying or child maltreatment or sexual abuse. In contrast, this study asked about all such exposures as well as additional ones that are rarely, if ever, covered such as dating violence and witnessing domestic violence.

The study found that more than a third of the children had had two or more different kinds of exposures in the past year and 11 percent had five or more.

"Studies have missed the fact that there are a surprisingly large group of very repeatedly and variously victimized kids whom we should be doing a better job to help and protect," Finkelhor said.

The researchers urge teachers, police, doctors, counselors, and parents to ask children about a broader range of possible victimization experiences, especially children who had been identified as victims already. They also call for new efforts to create safer schools, homes and other youth environments.

The study was conducted in 2008 and involved interviews with caregivers and youth about the experiences of a nationally representative sample of 4,549 children ages 0-17. In addition to Finkelhor, the authors include Heather Turner, professor of sociology at UNH, Richard Ormrod, research professor of geography at UNH, and Sherry Hamby, research associate professor of psychology at Sewanee, the University of the South.



1010 Draft NIST report on Cowboys facility collapse released for comment [National Institute of Standards and Technology]--A fabric-covered, steel frame practice facility owned by the National Football League's Dallas Cowboys collapsed under wind loads significantly less than those required under applicable design standards, according to a report released on October 6 for public comment by the Commerce Department's National Institute of Standards and Technology (NIST).

Located in Irving, Texas, the facility collapsed on May 2, 2009, during a severe thunderstorm. Twelve people were injured, one seriously.

Based on the national standards for determining loads and for designing structural steel buildings, NIST researchers studying the Cowboys facility found that the May 2 wind load demands on the building's framework—a series of identical, rib-like steel frames supporting a tensioned fabric covering—were greater than the capacity of the frame to resist those loads.

Assumptions and approaches used in the design of the Cowboys facility led to the differences between the values originally calculated for the wind load demand and structural frame capacity compared to those derived by the NIST researchers. For instance, the NIST researchers included internal wind pressure due to the presence of vents and multiple doors in their wind load calculations because they classified the building as "partially enclosed" rather than "fully enclosed" as stated in the design documents. The NIST researchers also determined that the building's fabric could not be relied upon to provide lateral bracing (additional perpendicular support) to the frames in contrast to what was stated in the design documents and that the expected wind resistance of the structure did not account for bending effects in some members of the frame.


"Our investigation found that the facility collapsed under a wind load that a building of this type would be expected to withstand," said study leader John Gross. "As a result of our findings, NIST is recommending that fabric-covered steel frame structures be evaluated to ensure the adequate performance of the structural framing system under design wind loads."

The NIST report recommends that such evaluations determine whether or not: (1) the fabric covering provides lateral bracing for structural frames considering its potential for tearing; (2) the building should be considered partially enclosed or fully enclosed based on the openings that may be present around the building's perimeter; and (3) the failure of one or a few frame members may propagate, leading to a partial or total collapse of the structure.

Shortly after the Cowboys facility's collapse, NIST sent a reconnaissance team of three structural engineers to assess the failed structure and wind damage in the surrounding area, and collect relevant data such as plans, specifications and design calculations. Using the data acquired during the reconnaissance, the NIST study team developed a computer model of a typical structural frame used in the practice facility and then studied the frame's ability to resist forces under two wind conditions: the wind loads based on the design standard wind speed of 90 miles per hour and the actual wind loads based on conditions at the time of the collapse.

NIST worked with the National Oceanic and Atmospheric Administration's (NOAA) National Severe Storms Laboratory to estimate the wind conditions at the time of collapse. The researchers determined that, at the time of collapse, the wind was blowing predominantly from west to east, perpendicular to the long side of the building. Maximum wind speed gusts at the time of collapse were estimated to be in the range of 55 to 65 miles per hour—well below the design wind speed of 90 miles per hour in the national standard for wind loads. The center of a microburst (a small, intense downdraft which results in a localized area of strong winds) associated with the May 2 thunderstorm was located about one mile southwest of the structure at the time of collapse.

According to the NIST and NOAA researchers, the wind field in the vicinity of the Cowboys facility at the time of collapse was consistent with design standards and not unusual.

Based on their study of the wind conditions at the time of collapse and the structural response, the NIST researchers determined the following likely collapse sequence:

* Buckling of the inner chord (inner side of the roof truss) of a frame in a section of the roof on the east side resulted in the formation of a kink in the frame.

* Failures of the east and west "knees" (connections between the side walls and the roof) allowed the frame to sway eastward with the wind.

* Compressive failure of the east side at the roof's highest point (ridge) led to fractures of the nearby inner and outer chords in the vicinity of the ridge.

* A progression of frame failures throughout the structure resulted in total structural collapse.

The draft report is available online at www.bfrl.nist.gov/investigations/investigations.htm.

NIST welcomes comments on the draft report and recommendation. Comments must be received by noon Eastern Standard Time on Nov. 6, 2009. Comments may be submitted in writing via e-mail to structuralsafety@nist.gov; fax to (301) 869-6275; or surface mail to the attention of Stephen Cauffman, NIST, 100 Bureau Dr., Stop 8611, Gaithersburg, Md. 20899-8611.

Once the final report is published, NIST will brief and provide technical support on the recommendation to the American Society of Civil Engineers (ASCE) committee currently developing a building standard specifically for tensioned fabric structures. NIST also will brief the appropriate committee of the International Code Council (ICC) on the study's recommendation for use in improving provisions in ICC's model building code.



1010 For safer emergencies, give your power generator some space [National Institute of Standards and Technology]--To subdue the steaming heat of hurricanes or to thaw out during a blizzard, gasoline-powered, portable generators are a lifeline during weather emergencies when homes are cut off without electricity. But these generators emit poisonous carbon monoxide—a single generator can produce a hundred times more of the colorless, odorless gas than a modern car's exhaust.


New research from the National Institute of Standards and Technology (NIST) shows that to prevent potentially dangerous levels of carbon monoxide, users may need to keep generators farther from the house than previously believed—perhaps as much as 25 feet.

Up to half of the incidents of non-fatal carbon monoxide (CO) poisoning reported in the 2004 and 2005 hurricane seasons involved generators run within 7 feet of the home, according to the U.S. Centers for Disease Control and Prevention (CDC).

Carbon monoxide can enter a house through a number of airflow paths, such as a door or window left open to accommodate the extension cord that brings power from the generator into the house. While some guidance recommends 10 feet from open windows as a safe operating distance, NIST researcher Steven Emmerich says the "safe" operating distance depends on the house, the weather conditions and the unit. A generator's carbon monoxide output is usually higher than an automobile's, he says, because most generators do not have the sophisticated emission controls that cars do.

"People need to be aware that generators are potentially deadly and they need to educate themselves on proper use," Emmerich says. With funding from CDC, NIST researchers are gathering reliable data to support future CDC guidance.

NIST building researchers simulated multiple scenarios of a portable generator operating outside of a one-story house, using both a test structure and two different computer models—the NIST-developed CONTAM indoor air quality model and a computational fluid dynamics model.

The simulations included factors that could be controlled by humans, such as generator location, exhaust direction and window-opening size, and environmental factors such as wind, temperature and house dimensions. In the simulations the generator was placed at various distances from the house and tested under different weather conditions.

"We found that for the house modeled in this study," researcher Leon Wang says, "a generator position 15 feet away from open windows was not far enough to prevent carbon monoxide entry into the house."

Winds perpendicular to the open window resulted in more carbon monoxide entry than winds at an angle, and lower wind speeds generally allowed more carbon monoxide in the house. "Slow, stagnant wind seems to be the worst case because it leads to the carbon monoxide lingering by the windows," Wang explains. Researchers determined that placing the generator outside of the airflow recirculation regions near the open windows reduced carbon monoxide entry.

In the next phase of the study NIST will model a two-story house that researchers believe will interact with the wind differently. NIST researchers also have worked with the Consumer Product Safety Commission on related work. (See: "NIST to Study Hazards of Portable Gasoline-Powered Generators," NIST Tech Beat, March 5, 2008.)

The generator study can be downloaded at http://fire.nist.gov/bfrlpubs/build09/PDF/b09009.pdf.

* L. Wang and S.J. Emmerich. Modeling the Effects of Outdoor Gasoline Powered Generator Use on Indoor Carbon Monoxide Exposures. (NIST Technical Note 1637,) 2009.



1010 The high cost of treating alcohol-impaired drivers [Injury Prevention Center at Rhode Island Hospital]--The costs of drinking and driving are all too apparent, with alcohol involved in 41 percent of all motor vehicle crash fatalities in 2006. In addition to the mortality and morbidity associated with drinking and driving, the economic impact of alcohol impaired driving is considerable, estimated at $51 billion, with medical costs accounting for 15 percent of that figure. Now a new study from the Injury Prevention Center at Rhode Island Hospital has found that even minimally injured alcohol-impaired drivers account for higher emergency department (ED) costs than other drivers.

Their study appears in the Volume 54, No. 4 October 2009 edition of Annals of Emergency Medicine and is currently available online in advance of publication. An editorial on the study also appears in the journal.

Treatment of injuries from motor vehicle crashes accounts for four percent of the 120 million ED visits in the United States each year. It is estimated that alcohol is involved in as many as one in eight of these crashes, bringing the total to 600,000 cases each year. Alcohol complicates the clinical assessment of patients within an ED as the patient's perception of pain may be blunted and a period of observation may be warranted until the patient is judged to be coherent enough for an accurate examination.

In the past, research into the cost of treating alcohol impaired drivers focused on the inpatient population. Researchers at the Injury Prevention Center at Rhode Island Hospital led by emergency medicine physician Michael Lee, MD, felt that this was an incomplete representation of the medical costs of drinking and driving as it is estimated that up to 80 percent of alcohol impaired drivers treated in EDs are discharged to home and are not admitted.

The researchers performed a retrospective study of 1,618 patients who had alcohol in their systemand were treated in an urban Level I trauma center and discharged home directly from the ED. The patients ranged in age from 21 to 65.

The study found that the median charges for patients under the influence of alcohol were higher by $4,538. Lee notes, "A large percentage of that cost can be directly correlated to a higher frequency of and costlier diagnostic imaging studies. Imaging itself represents 69 percent of the charge differential." In addition, the median length of stay for alcohol-positive patients was higher by 3.3 hours when compared to alcohol-negative patients.

Lee says, "While an alcohol-impaired driver may be treated for only minor injuries and discharged to home, there is still a considerably higher cost to treat that patient in an ED. Further, the time spent on them with a longer length of stay results in delays for other patients who need care in an ED."

Lee concludes, "The magnitudes are striking for this minimally injured population. This represents a burden of alcohol-impaired driving that was underreported in the past."

Other researchers working with Lee include Michael Mello, MD, director of the Injury Prevention Center at Rhode Island Hospital and Steven Reinert, MS, of Lifespan's information systems department.



1010 Intensive care units poorly equipped to care for the dying [Sahlgrenska Academy]--Almost half of the patients who die in intensive care units die within 24 hours, but the environment is not equipped to provide good end-of-life care. Most relatives are nevertheless happy with the care given, shows a thesis from the Sahlgrenska Academy.

An intensive care unit (ICU) is designed primarily to save lives rather than provide end-of-life care. When a patient dies on an ICU, this often follows a sudden illness or trauma, and neither the patient nor relatives are prepared for death.

"The location and environment in which people die mean a lot not only for the person who is dying but also for those who are to look after them and those who must learn to live without them," says nurse Isabell Fridh, who wrote the thesis.

Her thesis shows that Swedish ICUs are often unable to care for dying patients in separate rooms. The waiting rooms to which relatives are sent are often too few and too small. Most units do not have a care programme for end-of-life care, and many also have no procedures in place for supporting relatives after a death, which is standard practice at hospices. The results also show that almost half of the patients (in the study) died within 24 hours after admittance (to intensive care), and 40% of these did not have any relatives present at the time of death.

"This may seem to paint a bleak picture, but the truth is that most of the relatives I interviewed for my thesis thought that the care given was a positive experience despite their sense of loss," says Fridh. "Many feel that their loved one benefited from all available medical resources and that everything that could be done to save their life was indeed done."

Relatives rarely complain about the physical environment, but they do not like to be separated from the patient against their will, and greatly appreciate being able to spend that last bit of time with their loved one in a private room.

Isabell Fridh also interviewed ICU nurses, who do their utmost to care for dying patients even where the environment is not well suited to it. Nurses use the available medical technology to alleviate patients' suffering and try hard to provide privacy and give relatives a lasting sense that their loved one's death was peaceful and dignified.



1010 Research gives new meaning to 'green' cross code [University of Leeds]--Pedestrians could reduce the amount of traffic pollution they breathe in simply by crossing the street, according to the latest research from the University of Leeds.

The research, led by Professor of Environmental Modelling Alison Tomlin from Leeds' Faculty of Engineering, has shown that air pollution levels change dramatically within small geographical areas dependent on wind patterns, the location of traffic queues and the position and shapes of the surrounding buildings.

The findings showed that pollution hotspots tend to accumulate on the leeward side of the street, (the sheltered side) in relation to the wind's direction at roof-top level.

They also revealed that that carbon monoxide levels were up to four times lower in parallel side streets compared to the main road.

The team monitored traffic flow and carbon monoxide (CO) levels over an eight week period at one of the busiest junctions in the UK - the intersection between Marylebone Road and Gloucester Place in West London.

"CO levels were highly variable over remarkably short distances," says Professor Tomlin. "As you'd expect, the junction itself showed high levels caused by queuing traffic, but with some wind patterns these hotspots moved further down the street. However, the leeward side of the street had consistently higher concentrations of carbon monoxide than the windward side. The same trends would be expected for other traffic related pollutants such as ultrafine particles and nitrogen dioxide."

"Most people would expect pollution levels to be slightly lower away from the main body of traffic, but our figures show a very significant difference," she says.

"Pollution can be trapped within the street where it is emitted by recirculating winds. If it escapes to above roof-top level, it doesn't tend to be mixed back into neighbouring streets very strongly. It would be worth cyclists and pedestrians rethinking their regular routes, as they can massively reduce their pollution exposure by moving just one street away from the main traffic thoroughfares."

The research also has significance for local authorities and other bodies monitoring air quality levels in urban areas. Currently every city has a number of sites monitoring pollution levels to ensure compliance with EU standards, but Professor Tomlin says these may need to be looked at in relation to the other factors identified by the research to ensure an accurate spatial picture.

"Monitoring stations tend to be sited in what are expected to be pollution hotspots, but our research has shown that hotspots move depending on meteorological conditions, particularly wind direction," says Professor Tomlin. "We need to develop models which take these factors into account, so that the data from monitoring sites can be accurately analysed to provide a true reflection of air quality across the whole of an urban area."

The research is published in the latest issue of Atmospheric Environment and has been funded by the Engineering and Physical Sciences Research Council (EPSRC) and the Natural Environment Research Council (NERC).



1010 New technology detects chemical weapons in seconds [Queen's University Belfast]--Scientists at Queen's University Belfast are developing new sensors to detect chemical agents and illegal drugs which will help in the fight against the threat of terrorist attacks.

The devices will use special gel pads to 'swipe' an individual or crime scene to gather a sample which is then analysed by a scanning instrument that can detect the presence of chemicals within seconds. This will allow better, faster decisions to be made in response to terrorist threats.

The scanning instrument will use Raman Spectroscopy which involves shining a laser beam onto the suspected sample and measuring the energy of light that scatters from it to determine what chemical compound is present. It is so sophisticated it can measure particles of a miniscule scale making detection faster and more accurate.

Normally this type of spectroscopy is not sensitive enough to detect low concentrations of chemicals, so here the sample is mixed with nanoscale silver particles which amplify the signals of compounds allowing even the smallest trace to be detected.

Dr Steven Bell from Queen's University Belfast who is leading the research said:

"Although we are still in the middle of the project we have finished much of the preliminary work and are now at the exciting stage where we put the various strands together to produce the integrated sensor device. For the future, we hope to be able to capitalise on this research and expand the range of chemicals and drugs which these sensors are able to detect."

It is hoped the new sensors will also be the basis for developing 'breathalyzer' instruments that could be of particular use for roadside drugs testing in much the same way as the police take breathalyzer samples to detect alcohol.

At present, police officers are only able to use a Field Impairment Test to determine if a person is driving under the influence of drugs. The accuracy of this method has been questioned because of concerns that it is easy to cheat.

To ensure the technology is relevant, senior staff members from FSNI (Forensic Science Northern Ireland) will give significant input into the operational aspects of the technology and give feedback as to how it might be used in practice by the wider user community.

Stan Brown, Chief Executive of FSNI said:

"We consider the work being carried out by researchers at Queen's University extremely important and potentially very useful in driving forward the effectiveness, efficiency and speed of forensic science practice. The combination of leading edge research and hands-on experience of FSNI's practitioners has already proven very fruitful and is likely to lead to significant developments in forensic methodologies across a range of specialisms."

In the future this technology could have a number of important applications and according to Dr Bell: "There are numerous areas, from medical diagnostics to environmental monitoring, where the ability to use simple field tests to detect traces of important indicator compounds would be invaluable."

The research is being led by Dr Steven Bell of the School of Chemistry and Chemical Engineering at Queen's University of Belfast in collaboration with colleagues from the School of Pharmacy at Queen's University and Forensic Science Northern Ireland.

Since 1999 this collaboration has been focused on developing new Raman and SERS methods for analysis of illicit drugs, paints, fibres, materials and other physical evidence. It has already led to routine use of Raman methods within FSNI laboratories for drugs intelligence and a more extensive programme for integrating Raman methods into a broad range of casework is already underway. This new project will take the next step and move this research out of the laboratory and into the field.



1010 Tracing ultra-fine dust [Fraunhofer Institute for Laser Technology ILT in Aachen]--Fine particle emissions have been the subject of heated debate for years. People who live near industrial plants see the smoke being discharged into the atmosphere and wonder how harmful it is. But visible emissions are not always the most harmful. The highest risk is posed by fine dust particles which can easily penetrate the human organism. These ultra-fine particles are difficult to measure, however, because they are less than 100 nanometers in diameter.

Research scientists at the Fraunhofer Institute for Laser Technology ILT in Aachen have developed a technique by which the composition of such particles can be precisely analyzed.


"The statutory limit values for fine particle emissions are based on the total particle weight," explains Dr. Cord Fricke-Begemann, project manager at the ILT.


"Large particles are, however, much heavier than small ones. Weight measurements do not provide any information on the quantity of ultra-fine particles in the fine dust, but they are often more harmful than the larger particles."

The measurement technique developed by the research scientists consists of two steps. A gas stream separates the particles into size classes before they are collected on filters. Their composition is then examined by means of laser emission spectroscopy.


"We are therefore able to identify harmful heavy and transition metals, such as zinc, in the fine dust, and also to ascertain the particle size at which they become particularly enriched," explains Fricke-Begemann.


A key aspect of the method is that it delivers the results in less than 20 minutes. What's more, it can work at a high throughput rate and enables measurements to be taken directly on site – e.g. in steel plants. Emission values can be measured and monitored in real time during production thanks to a further development of the technique in which the particles are continuously drawn off via an air tube and analyzed.

All industrial plants produce fine dust emissions, and every process leaves behind a characteristic "fingerprint" of the particle composition and size distribution. With their measurement method the scientists can test the air in nearby residential areas and identify where the particles are from. They can also help to develop strategies for reducing emissions from the plants concerned.



1010 Air pollution may trigger appendicitis [University of Toronto/ Health Canada]--A new study in CMAJ (Canadian Medical Association Journal) suggests that air pollution may trigger appendicitis in adults.

The study, conducted by researchers at the University of Calgary, University of Toronto and Health Canada, looked at 5191 adults admitted to hospital in Calgary, Alberta, Canada. Fifty-two per cent of admissions occurred between April and September, the warmest months of the year in Canada during which people are more likely to be outside.

The dominant theory of the cause of appendicitis has been obstruction of the appendix opening, but this theory does not explain the trends of appendicitis in developed and developing countries. Appendicitis cases increased dramatically in industrialized countries in the 19th and early 20th centuries, then decreased in the middle and late 20th century, coinciding with legislation to improve air quality. The incidence of appendicitis has been growing in developing countries as they become more industrialized.

Using Environment Canada's air pollution data for Calgary, the researchers determined the levels of ozone, nitrogen dioxide and other air-borne pollutants along with temperature. They found correlations between high levels of ozone and nitrogen dioxide and the incidence of appendicitis between age groups and genders. More men than women were found to have the condition.

"For unexplained reasons, men are more likely than women to have appendicitis," write Dr. Gilaad Kaplan of the University of Calgary and coauthors. "Men may be more susceptible to the effects of outdoor air pollution because they are more likely to be employed in outdoor occupations," although they note that misclassifications of data could explain some of the difference.

While it is not known how air pollution may increase the risk of appendicitis, the authors suggest pollutants may trigger inflammatory responses. They recommend further studies to determine the link.



1010 Keeping children safe: Rethinking design [University of Toronto/ The Hospital for Sick Children]--Injury is the leading cause of death for children over the age of 1 in industrialized countries and improving the safety of the manmade (built) environment will benefit children's health, according to an article in CMAJ (Canadian Medical Association Journal).

Injury accounts for about 40% of childhood deaths in industrialized countries and is even higher in developing countries. It often involves failure to negotiate a manmade environment. Death rates from injury in affluent countries is 15.3 per 100,000 boys and 10 per 100,000 for girls among children 14 and younger. In developing countries, the rates are 50.5 per 100,000 boys and 43.5 per 100,000 girls.

In 2002, 371,000 boys and 289,000 girls worldwide died of injury, with more than 180,000 – mostly pedestrians – killed by traffic.

In addition to causing injury and death, unsafe environments are barriers to physical activity that is important to life long health. Changes such as speed control, traffic light phasing, fencing spaces and enhancing pedestrian visibility can reduce injuries by 50 to 75% in specific locations and 25% in wider areas. By making traffic safer for children, it increases the likelihood they will walk to school and can derive health benefits from physical activity. In fact, 50% of Canadian children never walk to school compared with only 17% who do most of the time.

"By giving priority to automotive over pedestrian transportation we have allowed road traffic to become the leading cause of death among our children," writes Dr. Andrew Howard of the University of Toronto and The Hospital for Sick Children (SickKids). "North American children are increasingly sedentary," and urban sprawl is linked to higher rates of traffic injury and obesity.

Other ways to modify the built environment include appropriate playground equipment that minimizes injuries while encouraging activity. Falls from climbing equipment are 5 times more likely to result in severe fractures than falls from a standing height. Evidence shows that playgrounds that did not comply with standards from the Canadian Standards Association (CSA) had twice the rate of injury of compliant playgrounds, although these standards are voluntary without regulatory authority for most Canadian playgrounds.

Fencing around pools to limit deaths from drowning and modification of homes and apartments to prevent falls from windows are other examples of changes to physical surroundings that can save children's lives.

"Our built environment influences our children's levels of activity, their physical health and their risk for injury," writes Dr. Howard. "Intelligent planning, particularly with consideration for urban design and traffic engineering to emphasize safe walking and cycling, has enormous potential to improve the health and safety of children now and across the lifespan."


1010 Costs of expanding health care coverage partly offset by future Medicare savings [Harvard Medical School]--Expanding health coverage might not cost as much as policymakers assume.

New findings from researchers at Harvard Medical School demonstrate that individuals who were either continuously or intermittently uninsured between the ages of 51 and 64 cost Medicare more than those who had continuous insurance coverage in the years prior to Medicare eligibility.

On average, those who were previously uninsured cost Medicare an additional $1,000 annually per person when compared with those who had been consistently covered. These increased costs were due primarily to complications resulting from cardiovascular disease and diabetes and from apparently delayed surgeries for arthritis.

Had these middle-aged adults been consistently covered, they would have likely cost Medicare less.

"Providing health insurance coverage to older uninsured adults may not cost as much as previously thought," says lead author J. Michael McWilliams, Harvard Medical School assistant professor of health care policy and medicine and a practicing internist at Brigham and Women's Hospital.

The study, published early online in the Annals of Internal Medicine, was funded by the Commonwealth Fund, a private foundation supporting independent research on health policy reform and a high performance health system.

In order to get a comprehensive picture of how coverage before age 65—or a lack thereof—affects Medicare spending after age 65, McWilliams and colleagues, including senior author John Ayanian, professor of healthcare policy and medicine at Harvard Medical School and Brigham and Women's Hospital and professor of health policy and management at the Harvard School of Public Health, looked at two sources of linked national data.

First, they analyzed information from the Health and Retirement Study, a nationally representative longitudinal survey that collected health insurance and other information from a large sample of adults. Starting in 1992, when members of this sample group were between the ages of 51 and 61, survey information was collected every two years until 2006, tracking each person's transition into Medicare. From these data they identified two separate groups, one group of 2951 adults who had been continuously insured before becoming eligible for Medicare at age 65, and another group of 1616 adults who were either intermittently or continuously uninsured before age 65.

Next, they analyzed Medicare claims data for these same individuals from age 65 until age 74, using rigorous statistical methods to ensure that the two groups of adults were evenly balanced for all recorded demographic and health characteristics before age 65.

Not only did they find that the previously uninsured cost the Medicare system substantially more than the previously insured (on average, $5796 versus $4773 per person annually), but they found that nearly two thirds of this increase was due to potentially preventable hospitalizations and delayed elective procedures.

"The bulk of the higher spending was explained by chronic conditions we know how to treat, which makes perfect clinical sense," says McWilliams. "When uninsured adults do not receive adequate care for hypertension, heart disease, and diabetes before age 65, they develop complications that require costlier care after age 65."

For example, after age 65 previously uninsured adults with cardiovascular disease or diabetes had a 48 percent higher risk of hospitalization for complications related to these conditions, complications such as heart attacks, heart failure, and strokes. Those who lacked insurance prior to Medicare and had arthritis were also 86 percent more likely to be hospitalized for hip and knee replacements, suggesting they delayed these surgeries that relieve pain and enhance quality of life until they gained Medicare coverage.

"The debate over health reform has focused on its costs rather than its benefits. This important study shows that closing the gaps in health insurance coverage for older adults can have important benefits in controlling chronic conditions early on—contributing to better health and lower cost once they reach age 65 and qualify for Medicare," said Commonwealth Fund President Karen Davis. "These findings point to the urgent need to act on comprehensive health reform to ensure secure and stable coverage for all Americans, and slow the rise in health care costs for employers, families, and government."

The researchers estimate that filling in the coverage gaps for adults who are uninsured between ages 51 to 64 would cost $197 billion due to greater health care utilization. However, this increase in healthcare for this same group would potentially reduce subsequent Medicare spending by $98 billion. Thus, the overall net cost would be $99 billion.

According to Ayanian, "This study suggests that not only are there substantial health benefits to expanding coverage, but that the economic cost may not be as steep as previously thought. These potential economic benefits to the Medicare program are important to consider when evaluating proposals to expand coverage before age 65."

Written by David Cameron
Full Citation
Annals of Internal Medicine, early online publication Oct 5, 2009
"Medicare Spending for Previously Uninsured Adults"

J. Michael McWilliams, M.D., Ph.D.
Ellen Meara, Ph.D.
Alan M. Zaslavsky, Ph.D.
John Z. Ayanian, M.D., M.P.P.

From the Department of Health Care Policy, Harvard Medical School (J.M.M., E.M., A.M.Z., J.Z.A.), Boston, MA; Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (J.M.M., J.Z.A), Boston, MA; National Bureau of Economic Research (E.M.), Cambridge, MA; and Department of Health Policy and Management, Harvard School of Public Health (J.Z.A.), Boston, MA.



1010 Analyses of flu pandemics project savings from earlier vaccinations [Stanford University Medical Center]--In a city the size of New York, starting a vaccination campaign a few weeks earlier could save almost 600 lives and over $150 million, according to a study by scientists at the Stanford University School of Medicine.

The study, to be published online Oct. 6 in the Annals of Internal Medicine, modeled a pandemic in a hypothetical urban area with a population and demographic characteristics mirroring New York City's.

It concluded that under a very broad range of assumptions, vaccinating this October would save more money and lives than in November, and that vaccinating at either time was better than no campaign at all. An October campaign would avert 2,051 deaths and save $469 million, while a November campaign would prevent 1,468 deaths and save $302 million relative to doing nothing.

"To put it simply, the most cost-saving and life-saving strategy is to vaccinate as many people as possible as soon as possible," said the study's first author, Nayer Khazeni, MD, an instructor of medicine in pulmonary and critical care. She is also an associate at Stanford's Center for Health Policy and Center for Primary Care and Outcomes Research.

Citing New York City's 1976 mass-vaccination program against swine flu, the investigators presumed that a substantial fraction of the city's population could be reached in a 10-day campaign. Their sophisticated mathematical model incorporated numerous alternative assumptions regarding the new viral strain's lethality and transmission rate, the vaccine's effectiveness and side-effect profile and the likelihood that people would limit their social contacts as cases multiplied.

Public health officials have noted that it may not be possible to provide H1N1 vaccine on a mass scale in October. Earlier in the summer, up to 120 million doses of vaccine were expected to be ready in mid-October, enough to inoculate 40 percent of the U.S. population. Although the projected number of doses available by then has been scaled back to 45 million, enough for 15 percent of the U.S population, the study makes a compelling case for the benefits of vaccinating sooner rather than later.

Avoiding hospitalizations, for instance, provides a huge financial payoff, according to the study's senior author Douglas Owens, MD, senior investigator at the Veterans Affairs Palo Alto Health Care System and professor of medicine and of health research and policy at the medical school. "A two-week stay in an intensive care unit could cost well over $50,000," said Owens. "You can vaccinate a lot of people for that much."

To date, H1N1 vaccines appear to have no serious side effects. But even when the researchers programmed their mathematical model with an assumption of substantial vaccine side effects, they found that far more lives and dollars would be saved than lost by a mass-vaccination campaign. For example, under the conservative assumption that the H1N1 vaccine's safety profile would closely resemble that of the one used in the national swine-flu vaccination campaign of 1976, side effects would cause only two deaths in a city the size of New York City if 40 percent of the population were vaccinated.

"That's about 0.1 percent of the lives that would be saved," Khazeni noted. "And even if vaccine side effects occurred far more often, many lives would still be saved by the campaign for every life lost due to side effects."

The Stanford investigators' mathematical model-developed by co-author David Hutton, a graduate student in management science and engineering under Owens' direction-can be used to look at other scenarios that might become relevant in the future. For example, a new vaccination strategy would be needed to cope with a pandemic caused by the H5N1 strain of influenza, commonly referred to as avian flu. That extremely virulent strain was, until the onset of the H1N1 pandemic early this year, the primary concern of public-health authorities anticipating an influenza pandemic. All it would take to ignite a dangerous pandemic is a random mutation that substantially increased H5N1's transmissibility among humans.

A hypothetical vaccination campaign targeting the H5N1 viral strain is the subject of a second study, also undertaken by Khazeni and Owens and their Stanford colleagues, appearing simultaneously in the same journal. This study models the efficacy of an H5N1-directed public-health campaign, once again in a municipality resembling New York City, and examines the extensive stockpiling of vaccines and antiviral drugs (such as Tamiflu and Relenza) and their widespread distribution for preventive use at the onset of a local outbreak.

Unlike the H1N1 vaccine, studies show, a vaccine targeting the H5N1 strain would require two vaccine doses and would need an immune response-boosting substance called an adjuvant in order to induce strong human immune responses. The adjuvant would also lower the required individual dose size by as much as 45-fold, thereby multiplying total available doses by that amount.

Supplies of adjuvant and antivirals in the federal government's Strategic National Stockpile should be expanded, Khazeni said. Those stockpiles would not only be useful against H5N1, but could also be directed toward use against other influenza strains with pandemic potential that may arise at any time.

Added Owens: "Just because we've had H1N1 doesn't mean we won't have something else."

Funding for the study was provided by the Agency for Healthcare Research and Quality, the National Institute on Drug Abuse, the Department of Veterans Affairs and Stanford University. Its other Stanford co-author is Alan Garber, MD, PhD, staff physician at the Veteran's Affairs Palo Alto Health Care System and the Henry J. Kaiser Jr. professor and director of the Center for Health Policy and the Center for Primary Care and Outcomes Research. A researcher at Weill Cornell Medical College in New York was the other co-author.



1010 Child burn injuries down significantly yet alarming number of children still being injured [Nationwide Children's Hospital]--In the next 60 seconds, another child will be on his/her way to the hospital to be treated for serious burns; it happens more than 300 times a day in this country.* Now, one of the largest studies ever done on burn injuries in kids is out from experts at Nationwide Children's Hospital and the results are mixed: while overall injuries are down, there are some kids who are still at serious risk.

Lily McKinney has always loved spending time in the kitchen; whenever anyone is cooking she's willing to do anything to help. But in an instant, Lilly's eagerness to help ended up getting her hurt.

"My husband was checking on the lasagna that was in the oven and she snuck right around him and just put her hands right on the oven door," says Lilly's mother Danette McKinney.

Lilly was left with second-degree burns on both hands. She spent a night in the hospital and weeks in bandages. It's kids like Lilly that are still getting burned at a surprising rate, according to the study.

"We found that kids under age six were actually injured the most, representing about 60 percent of all burn-related injuries," says Lara McKenzie, PhD, a researcher at Nationwide Children's Hospital.

Dr. McKenzie found that while burn injuries have dropped 31 percent overall since 1990, the numbers are still disproportionately high in children under six years of age.

Over the 17-year study period, there were more than 2 million burn-related injuries in this age group, or about 120,000 burns annually.

"For younger children, particularly kids under six, have thinner skin than older children or adults, and they'll actually burn faster, even when exposure time is short," says McKenzie.


Dr. McKenzie, who is also with Ohio State, says many hazards are at eye-level in this age group and in toddlers, their new-found mobility often catches parents off-guard.

"I think we tend to overestimate the reach and ability of children, especially young children and toddlers. They can really reach a lot of surfaces and different hazards," she says.

Experts suggest you sit on the floor in danger zones in your house, like the kitchen, to see your home from your kids' perspective. Seeing the world from their eyes, they say, can help open your eyes to dangers you may not have noticed.


Burns are a common cause of pediatric injury worldwide, typically resulting from hot water, flames, hot surfaces, chemicals and electrical appliances. A recent study conducted by the Center for Injury Research and Policy of The Research Institute at Nationwide Children's Hospital, found that from 1990-2006 more than 2 million children younger than 21 were treated in hospital emergency departments for burn-related injuries. The good news that resulted from the 17-year study period is that researchers saw a 31 percent decrease in the rate of burn-related injuries. The bad news is that children are still being injured from burns – about 120,000 each year.

"The decrease in the burn-related injury rate over the study period is notable," said study author Lara McKenzie, PhD, principal investigator at the Center for Injury Research and Policy at Nationwide Children's Hospital. "However, the disproportionately high number of injuries and the severity of these burns to young children is still cause for concern."

Data from the study, being released online October 5 and appearing in the November issue of Pediatrics, show that children younger than 6 accounted for more than half of all burn-related injuries. Among that age group, most injuries occurred in the home, and the majority (60 percent) resulted from thermal burns. The hands and fingers were the most frequently injured body parts (36 percent), followed by the head and face (21 percent).

Dr. McKenzie, also a faculty member of The Ohio State University College of Medicine, said that reasons why younger children suffered a majority of burn-related injuries during the study period may be due to parents underestimating the reach ability of toddlers, and the fact that younger children have thinner skin.

"Parents should be aware of the capability of reach that their toddler may have," continued Dr. McKenzie. "Items that seem out of reach for young children may not be. That risk should be eliminated. Also, young children, especially those under age 6, have thinner skin, and the severity of a burn can be greater for them even at a reduced exposure time."

Parents can help protect their children from burns by setting the water heater thermostat to no higher than 120 degrees Fahrenheit, keeping kids away from the stove, locking up chemicals and covering unused electrical outlets. Parents should prohibit young children from operating microwaves or other electrical appliances, preparing hot food or drinks, and playing near the kitchen during food preparation.

"Burn-related injuries are potentially preventable with better education, warnings and instructions on consumer products," said Dr. McKenzie. "Increased efforts are needed to improve burn prevention strategies and target households with young children."

Data for this study were collected from the National Electronic Injury Surveillance System (NEISS), which is operated by the U.S. Consumer Product Safety Commission. The NEISS dataset provides information on consumer product-related and sports and recreation-related injuries treated in hospital emergency departments across the country.

Sources: *Pediatric Burn Injuries Treated in Emergency Departments in the United States: 1990-2006; Pediatrics, Vol. 124 No. 5, November 2009.



1010 Battery ingestion not uncommon in children; caregivers and physicians need education [American Academy of Otolaryngology]--Ten years of case studies at a pediatric hospital and a thorough literature review have shown that it is not uncommon for children to ingest small "button" batteries, either through swallowing or inserting the batteries into their noses.

In a paper presented at the 2009 American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Annual Meeting & OTO EXPO in San Diego, researchers revealed that a significant lack of knowledge about the dangers of button batteries exists in the lay population and in healthcare providers.

Button batteries are miniature disc batteries that are typically used to power hearing aids, watches, calculators, and many commonly used items, including small toys and musical greeting cards. Each year, more than 3,000 people of all ages in the U.S. unintentionally swallow these batteries, according to the National Capital Poison Center in Washington, DC. Sixty-two percent of battery ingestions involve children under the age of 5, with a peak incidence in 1- and 2-year-olds.

While many children who ingest button batteries recover with few long-term health issues, some develop long-term complications that significantly deteriorate quality of life, such as tracheostomy-tube or gastrostomy-tube dependence, vocal paralysis, and septal perforation with saddle nose deformity. The authors say expeditious identification and treatment of button battery ingestion is crucial, for which continuing education must be provided to pediatricians, primary care, urgent care, and emergency room care providers, and otolaryngologists.

The authors also concluded that increased public awareness is necessary to diminish the incidence of such ingestions. Industry changes, including improved packaging and button battery markings, will also be fundamental to this process.

Title: Button battery ingestion in the pediatric population
Presenters: Dale Amanda Tylor, MD and Seth Pransky, MD



1010 Global death toll: 1 million premature babies every year [March of Dimes Foundation]--More than one million infants die each year because they are born too early, according to the just released White Paper, The Global and Regional Toll of Preterm Birth.

The new White Paper shows that in 2005, an estimated 13 million babies worldwide were born preterm -- defined as birth at less than 37 full weeks of gestation. That is almost 10 percent of total births worldwide. About one million deaths in the first month of life (or 28 percent of total newborn deaths) are attributable to preterm birth.

According to the White Paper, the highest preterm birth rates in the world are found in Africa, followed by North America (United States and Canada combined).

These data are being presented at the 4th International Conference on Birth Defects and Disabilities in the Developing World to be held in early October in New Delhi, India.

"Premature births are an enormous global problem that is exacting a huge toll emotionally, physically, and financially on families, medical systems and economies," says Dr. Jennifer L. Howse, president of the March of Dimes. "In the United States alone, the annual cost of caring for preterm babies and their associated health problems tops $26 billion annually.

"If world leaders are serious about reaching the United Nation's Millennium Development Goals to reduce child mortality and improve maternal health, then strategies and funding for reducing death and disability related to preterm birth must receive priority," Dr. Howse adds.

An Uneven Global Problem

The new White Paper uses data published recently in The Bulletin of the World Health Organization (WHO). The March of Dimes says the WHO Bulletin figures are conservative –counting only singleton preterm births, for example– and likely underestimates the true magnitude of the worldwide crisis of preterm birth.

Worldwide, the preterm birth rate is estimated at 9.6 percent –representing about 12.9 million babies. Though all countries are affected, the global distribution is uneven: the toll of preterm birth is particularly severe for Africa and Asia, where more than 85 percent of all preterm births occur. Comparison of preterm birth rates across world regions finds the highest rate in Africa -- 11.9 percent or about 4 million babies each year; followed by (in descending order) North America, Asia, Latin America and the Caribbean, Oceania (Australia and New Zealand combined), and Europe. See chart below for more information.

Increase in Preterm Births

Wherever trend data are available, rates of preterm birth are increasing. For example, the rate of preterm birth in the U.S. has increased 36 percent in the past 25 years. Key factors contributing to this increase include a rise in the number of pregnancies in women over age 35; the growing use of assisted reproduction techniques, leading to an increase in the number of twin and higher order multiple births; and the rise in the number of late preterm births (defined as between 34 and 36 weeks gestation).

Babies who survive a preterm birth face the risk of serious lifelong health problems including cerebral palsy, blindness, hearing loss, learning disabilities, and other chronic conditions. Even infants born late preterm have a greater risk of re-hospitalization, breathing problems, feeding difficulties, temperature instability (hypothermia), jaundice and delayed brain development.

Underlying Causes and Risk Factors

There are some known risk factors for preterm birth that can be identified before or during pregnancy. For example, women who have already had one preterm baby are at greater risk. Some preterm births may be preventable by addressing known modifiable risk factors, including:

* Nutrition and body weight;
* Existing medical conditions such as high blood pressure and diabetes;
* Alcohol and tobacco use, and secondhand smoke;
* Early elective inductions and elective Cesarean delivery.

However, at present, there is no reliable way to prevent or delay preterm birth, says Christopher P. Howson, Ph.D., vice president for Global Programs of the March of Dimes. "While much can be done right now to reduce death and disability from preterm birth even in low-resource settings, we need to know more about the underlying causes of premature birth in order to develop effective prevention strategies," he says.

The March of Dimes and the other authors of the white paper call for greater efforts to inform health professionals, policy makers, women of childbearing age, and others about the worldwide toll of preterm birth and opportunities for prevention and for care of women with high-risk pregnancies and their babies.

Preterm Births: Why Don't They Count?

Few countries currently have good health statistics and information systems or birth surveillance registries, the authors of the white paper say, so data on the number of preterm births and related deaths are limited at best.

"This was a first attempt to estimate the worldwide scale of the problem," says Mario Merialdi, M.D., of WHO's Department of Reproductive Health and Research, one of the editors of the White Paper and an author of the study published in The Bulletin of WHO. "As a first step, it is necessary to improve data on the extent of the problem." He says WHO currently is improving its database on preterm birth in order to support decision-making in this area.

Another challenge, the authors of the white paper say, is that there is no internationally accepted classification of preterm birth or glossary of terms. "We need to at least adopt common definitions and agree on what is a preterm baby," says Joy E. Lawn, MRCP, of Saving Newborn Lives/Save the Children USA.

Dr. Lawn says there also is an urgent need for more country and regional data on the prevalence of acute and long-term health problems and impairment caused by preterm birth.

Data gathering and research for the White Paper and the 2010 forthcoming March of Dimes Global Report on Preterm Birth is supported by the March of Dimes, the World Health Organization's Department of Reproductive Health and Research, Save the Children USA, and the Partnership for Maternal, Newborn, and Child Health, a global partnership with 260 members.

Editors of the White Paper were Dr. Howson; Dr. Lawn; Dr. Merialdi; and Jennifer H. Requejo, Ph.D., of the Partnership for Maternal, Newborn and Child Health and the Institute for International Programs at the Johns Hopkins Bloomberg School of Public Health.


Beck S, Wojdyla D, Say L, Betran AP, Merialdi M, Requejo JH, Rubens C, Menon R, Van Look P. 2009. WHO systematic review on maternal mortality and morbidity: The global burden of preterm birth. The Bulletin of the World Health Organization.

* See also Hamilton BE, Martin JA, Ventura SJ. 2007. Births: Preliminary data for 2007. National vital statistics reports, Web release; vol. 57 no. 12. Hyattsville, MD: National Center for Health Statistics.



1003 Survey finds just 40 percent of adults 'absolutely certain' they will get H1N1 vaccine [Harvard School of Public Health]--In a new survey, Harvard School of Public Health (HSPH) researchers found that just 40% of adults are "absolutely certain" they will get the H1N1 vaccine for themselves, and 51% of parents are "absolutely certain" that they will get the vaccine for their children. The survey examined the reasoning among those who said they would not get the vaccine or might not. This is the latest in a series of surveys of public views concerning the H1N1 flu outbreak undertaken by the Harvard Opinion Research Program at HSPH. The polling was done September 14-20, 2009.

Public Mixed on Getting Vaccine, but Interest May Jump If Outbreak Is Severe

About six in ten adults are not "absolutely certain" they will get the H1N1 vaccine for themselves, including 41% who say they will not get it, 6% who say they don't know if they will get it, and 11% who say they are planning to get it but may change their mind. About four in ten parents (44%) are not "absolutely certain" that they will get the vaccine for their children, including 21% who will not get it, 7% who don't know, and 16% who say they are planning to get it but may change their mind.

If there were people in their community who were sick or dying from H1N1, roughly six in ten adults (59%) who say they do not think they'll get the vaccine would change their mind and get it for themselves. About the same percentage of parents (60%) who say they do not think they'll get the vaccine for their children would change their minds if H1N1 was causing sickness or death in their community.

"These findings suggest that public health officials need to be prepared for a surge in demand for the H1N1 vaccine if the H1N1 flu becomes more severe," said Robert J. Blendon, Professor of Health Policy and Political Analysis at HSPH.

Major Reasons for Not Getting Vaccine or Being Unsure

Those who were not "absolutely certain" they will get the H1N1 vaccine cited the following as the top "major" reasons for their thinking: (1) they are concerned about getting side effects from the vaccine (30%); (2) they don't think they are at risk of getting a serious case of the illness (28%); and (3) they think they could get medication to treat H1N1 if they do get sick (26%). The top "major" reasons cited by parents who are not "absolutely sure" they will get the vaccine are that (1) they are concerned about side effects of the vaccine (38%); (2) they are concerned that their children could get other illnesses from the vaccine (33%); and (3) they do not trust public health officials to provide correct information about the safety of the vaccine (31%).

"There's still a lot of uncertainty about what people will ultimately do in terms of getting the vaccine. If public health officials want to encourage a larger number of people to get vaccinated this fall, they will need to address the public's concerns in the coming weeks," said Blendon.

Safety Concerns

At this point in time, only about a third (33%) of the public sees the H1N1 vaccine as very safe "generally for most people to take." By comparison, the figure is 57% for the seasonal flu vaccine. A smaller fraction of the public thinks the H1N1 vaccine is very safe for particular groups to take, including children ages 6 months to 2 years (18%) and pregnant women (13%). The Centers for Disease Control is encouraging these groups, among others, to get the vaccine as early as possible.

Concerns About Outbreak on the Rise

Public concern about a fall or winter outbreak of H1N1 has risen since June. Roughly three-quarters of the public (76%) believe there will be widespread cases of H1N1 this fall or winter with people getting very sick, which is an increase from June when only 59% felt the same way. More people are also now concerned that they or someone in their immediate family will get sick from H1N1 during the next 12 months (52% in later September, as compared to 38% in June). Roughly two-thirds of people (64%) think that public health officials' concerns about a possible outbreak have been justified, while one third (31%) think that they have been overblown.

This poll is part of a series of polls about the way that Americans and their institutions are responding to the H1N1 flu outbreak. The first three focus on the American public, and the fourth focuses on views of businesses across the United States.


This poll is part of an on-going series of surveys focused on the public and biological security by the Harvard Opinion Research Program (HORP) at Harvard School of Public Health. The study was designed and analyzed by researchers at the Harvard School of Public Health (HSPH). The project director is Robert J. Blendon of the Harvard School of Public Health. The research team also includes Gillian K. SteelFisher, John M. Benson, and Kathleen J. Weldon of the Harvard School of Public Health, and Melissa J. Herrmann of SSRS/ICR. Fieldwork was conducted via telephone (including both landline and cell phone) for HORP by SSRS/ICR of Media (PA) September 14-20, 2009.

The survey was conducted with a representative national sample of 1,042 adults age 18 and over, including oversamples of non-Hispanic African Americans and Hispanics. Altogether, 144 non-Hispanic African Americans and 126 Hispanics were interviewed. In the overall results, these groups were weighted to their actual proportion of the total adult population.

The margin of error for the total sample is plus or minus 3.7 percentage points. Possible sources of non-sampling error include non-response bias, as well as question wording and ordering effects. Non-response in telephone surveys produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, sample data are weighted to the most recent Census data available from the Current Population Survey for gender, age, race, education, region, and number of adults in the household. Other techniques, including random-digit dialing, replicate subsamples, and systematic respondent selection within households, are used to ensure that the sample is representative.



1003 How to limit risk of climate catastrophe [MIT]--A new analysis of climate risk, published by researchers at MIT and elsewhere, shows that even moderate carbon-reduction policies now can substantially lower the risk of future climate change. It also shows that quick, global emissions reductions would be required in order to provide a good chance of avoiding a temperature increase of more than 2 degrees Celsius above the pre-industrial level — a widely discussed target. But without prompt action, they found, extreme changes could soon become much more difficult, if not impossible, to control.

Ron Prinn, co-director of MIT's Joint Program on the Science and Policy of Global Change and a co-author of the new study, says that "our results show we still have around a 50-50 chance of stabilizing the climate" at a level of no more than a few tenths above the 2 degree target. However, that will require global emissions, which are now growing, to start downward almost immediately. That result could be achieved if the aggressive emissions targets in current U.S. climate bills were met, and matched by other wealthy countries, and if China and other large developing countries followed suit with only a decade or two delay. That 2 degree C increase is a level that is considered likely to prevent some of the most catastrophic potential effects of climate change, such as major increases in global sea level and disruption of agriculture and natural ecosystems.

"The nature of the problem is one of minimizing risk," explains Mort Webster, assistant professor of engineering systems, who was the lead author of the new report. That's why looking at the probabilities of various outcomes, rather than focusing on the average outcome in a given climate model, "is both more scientifically correct, and a more useful way to think about it."

Too often, he says, the public discussion over climate change policies gets framed as a debate between the most extreme views on each side, as "the world is ending tomorrow, versus it's all a myth," he says. "Neither of those is scientifically correct or socially useful."

"It's a tradeoff between risks," he says. "There's the risk of extreme climate change but there's also a risk of higher costs. As scientists, we don't choose what's the right level of risk for society, but we show what the risks are either way."

The new study, published online by the Joint Program in September, builds on one released earlier this year that looked at the probabilities of various climate outcomes in the event that no emissions-control policies at all were implemented — and found high odds of extreme temperature increases that could devastate human societies. This one examined the difference that would be made to those odds, under four different versions of possible emissions-reduction policies.

Both studies used the MIT Integrated Global Systems Model, a detailed computer simulation of global economic activity and climate processes that has been developed and refined by the Joint Program on the Science and Policy of Global Change since the early 1990s. The new research involved hundreds of runs of the model with each run using slight variations in input parameters, selected so that each run has about an equal probability of being correct based on present observations and knowledge. Other research groups have estimated the probabilities of various outcomes, based on variations in the physical response of the climate system itself. But the MIT model is the only one that interactively includes detailed treatment of possible changes in human activities as well — such as the degree of economic growth, with its associated energy use, in different countries.

Quantifying the odds

By taking a probabilistic approach, using many different runs of the climate model, this approach gives a more realistic assessment of the range of possible outcomes, Webster says. "One of the common mistakes in the [scientific] literature," he says, "is to take several different climate models, each of which gives a 'best guess' of temperature outcomes, and take that as the uncertainty range. But that's not right. The range of uncertainty is actually much wider."

Because this study produced a direct estimate of probabilities by running 400 different probability-weighted simulations for each policy case, looking at the actual range of uncertainty for each of the many factors that go into the model, and how they interact. By doing so, it produced more realistic estimates of the likelihood of various outcomes than other procedures — and the resulting odds are often significantly worse. For example, an earlier study by Tom Wigley of the National Center for Atmospheric Research estimated that the Level 1 emissions control policy — the least-restrictive of the standards studied -would reduce by 50 percent the odds of a temperature increase of more than 2 degrees C, but the more detailed analysis in the new study finds only a 20 percent chance of avoiding such an increase.

One interesting finding the team made is that even relatively modest emissions-control policies can have a big impact on the odds of the most damaging climate outcomes. For any given climate model scenario, there is always a probability distribution of possible outcomes, and it turns out that in all the scenarios, the policy options have a much greater impact in reducing the most extreme outcomes than they do on the most likely outcomes.

For example, under the strongest of the four policy options, the average projected outcome was a 1.7 degrees C reduction of the expected temperature increase in 2100, but for the most extreme projected increase (with 5 percent probability of occurring) there was a 3.2 degree C reduction. And that's especially significant, the authors say, because the most damaging effects of climate change increase drastically with higher temperature, in a very non-linear way.

"These results illustrate that even relatively loose constraints on emissions reduce greatly the chance of an extreme temperature increase, which is associated with the greatest damage," the report concludes.

Webster emphasizes that "this is a problem of risk management," and says that while the technical aspects of the models are complex, the results provide information that's not much different from decisions that people face every day. People understand that by using their seat belts and having a car with airbags they are reducing the risks of driving, but that doesn't mean they can't still be injured or killed. "No, but the risk goes down. That's the return on your decision. It's not something that's so unfamiliar to people. We may make sure to buy a car with airbags, but we don't refuse to leave the house. That's the nature of the kind of tradeoffs we have to make as a society."



1003 Half-million low-income elderly affected by sweeping cuts to state safety net [UCLA]--An 81-year-old San Francisco woman with dementia, little money and an equally aged caregiver sister who is suffering from cancer.

A 72-year-old Riverside woman with Alzheimer's who cannot be left safely on her own, forcing her son to cut back his working hours to care for her.

A 78-year-old Los Angeles man with Alzheimer's whose daughter will have to quit her job to take care of him if day care services are cut.

These are some of the hundreds of thousands of low-income seniors who are likely to lose income — and some of the tens of thousands who will also lose some or all of the in-home and supportive care they rely on — as budget cuts resulting from California's 2009 fiscal crisis go into effect starting Oct. 1, according to a new study by the UCLA Center for Health Policy Research.

Among the most vulnerable: seniors with Alzheimer's disease whose families rely on state-funded Alzheimer's centers that will soon lose all of their state funding. Also impacted are low-income seniors with disabilities, who often rely on a web of safety-net programs that both supplement their incomes and give them access to free or subsidized in-home care, say the authors of the new policy brief, "California Budget Cuts Fray the Long-Term Safety Net."

The research — based on recent data, published research and nearly two-dozen interviews with program and services experts — is the first comprehensive analysis of the likely impact of state budget cuts on California's disabled elderly.

"Our research finds that the state cuts to long-term care services are driven primarily by a quest for saving dollars that disregards the human impact of the results," said Steven P. Wallace, associate director of the UCLA Center for Health Policy Research and a co-author of the study. "These kinds of cuts hit our most vulnerable citizens: seniors with disabilities and low incomes who typically have no resources to fall back on and little in the way of additional family support."

Among the programs particularly affected by the cuts:

* Alzheimer's day care resource centers to lose all state funding
Centers that provide day care for more than 3,200 mostly low-income or socially isolated seniors with Alzheimer's disease will have to curtail hours of service or shut down altogether in response to budget cuts that go into effect Oct. 1.

* Supplemental Security Income (SSI/SSP) cut 8 to 10 percent
SSI is a cash assistance program for more than 500,000 very low-income people who are elderly, blind or permanently disabled. California has always supplemented the federally funded benefit using state funds (SSP). Cuts in the state portion will bring total cuts this year of the combined benefit to 8 percent for individuals (from $907 to $830 maximum benefit) and nearly 11 percent for couples (from $1,579 to $1,407).

* In-Home Supportive Services Program (IHSS) cut 30 percent
This program aids seniors with incomes above what is needed to qualify for SSI but still not high enough to afford in-home supportive services. IHSS provides a subsidy to help defray the costs of in-home personal care and essential household services that seniors are unable to perform without monitoring or assistance. As of Nov. 1, 30 percent of the 445,584 individuals of all ages enrolled in this program will lose some or all of their benefits; about 60 percent are elderly.

"We need lawmakers to rethink these punishing cuts," said Bruce Chernof, president of the SCAN Foundation, which funded the research. "With a rapidly growing older population, we need to make our publicly funded long-term care system more efficient and effective, and this report shows that the cuts do neither."

The state's adult day health care centers, which serve more than 37,000 seniors, were also scheduled for Oct. 1 cuts until a federal judge issued an injunction Sept. 11 preventing California from cutting services until its poor, elderly and disabled clients are provided other Medi-Cal services to prevent their institutionalization. However, many of the seniors who patronize these centers will still endure cuts to their SSI checks.

"It means the meal seniors get at an adult day health care center may be the only meal of the day," Wallace said. "They won't have the income they need to pay for all of their basic necessities."

The cuts to long-term care programs that support the low-income or disabled elderly are expected to shave about $500 million from California's budget. However, Wallace said the cuts may ultimately have the reverse effect, by forcing seniors further into poverty and, ultimately, forcing some into Medi-Cal supported nursing homes.

"As a state, we have two choices," Wallace said. "We can either help seniors live with dignity in their own homes, or we can reduce them to destitution and force them into nursing homes. Either way, the state of California is going to pick up the tab."



1003 Surgical masks vs. N95 respirators for preventing influenza among health-care workers [McMaster University]--Surgical masks appear to be no worse than, and nearly as effective as N95 respirators in preventing influenza in health care workers, according to a study released early online today by JAMA. The study was posted online ahead of print because of its public health implications. It will be published in the November 4 issue of JAMA.

Influenza is the most important cause of medically attended acute respiratory illness worldwide and the authors write there is heightened concern this year because of the influenza pandemic due to the H1N1 virus. "Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse," the authors provide as background information in the article. "Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance."

Mark Loeb, M.D., M.Sc., from McMaster University, Hamilton, Ontario, Canada, and colleagues conducted a randomized controlled trial of 446 nurses in eight Ontario hospitals to compare the surgical mask with the N95 respirator in protecting health care workers against influenza. The nurses were randomized into two groups: 225 were assigned to receive surgical masks and 221 were assigned to receive the fitted N95 respirator which they were to wear when caring for patients with febrile (fever) respiratory illness. The primary outcome of the study was laboratory-confirmed influenza. Effectiveness of the surgical mask was assessed as non-inferiority of the surgical mask compared with the N95 respirator.

Between September 23, 2008 and December 8, 2008, "influenza infection occurred in 50 nurses (23.6 percent) in the surgical mask group and in 48 (22.9 percent) in the N95 respirator group (absolute risk difference -0.73 percent)," indicating non-inferiority of the surgical mask the authors report. Even among those nurses who had an increased level of the circulating pandemic 2009 H1N1 influenza strain, non-inferiority was demonstrated between the surgical mask group and the N95 respirator group for the 2009 influenza A(H1N1).

"Our data show that the incidence of laboratory-confirmed influenza was similar in nurses wearing the surgical mask and those wearing the N95 respirator. Surgical masks had an estimated efficacy within 1 percent of N95 respirators," the authors write. "That is, surgical masks appeared to be no worse, within a prespecified margin, than N95 respirators in preventing influenza."

In conclusion the authors state: "Our findings apply to routine care in the health care setting. They should not be generalized to settings where there is a high risk for aerosolization, such as intubation or bronchoscopy, where use of an N95 respirator would be prudent. In routine health care settings, particularly where the availability of N95 respirators is limited, surgical masks appear to be non-inferior to N95 respirators for protecting health care workers against influenza."

Editor's Note: This study was supported by the Public Health Agency of Canada.

Editorial: Respiratory Protection Against Influenza

In an accompanying editorial, Arjun Srinivasan, M.D., from the Centers for Disease Control and Prevention (CDC), Atlanta, and Trish M. Perl, M.D., M.Sc., from the School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, write: "The 2009 influenza A(H1N1) pandemic has revived debate about the role of respiratory protection in preventing the transmission of influenza to health care personnel." The "N95 particulate respirators protect wearers from small particles when appropriately designed and worn." The World Health Organization and Society for Healthcare Epidemiology of America recommend the use of medical masks for most patient care. The CDC and Institute of Medicine recommend the use of N95 respirators during care of patients infected with the H1N1 influenza.

"That this study is, to our knowledge, the first and only published randomized trial assessing respiratory protection for preventing influenza transmission is a sad commentary on the state of research in this area. Uncovering the truth and identifying the most appropriate way to protect health care personnel will require that other investigators build on this study ...," they write. "Ultimately, accumulating a body of evidence on this topic will provide much-needed answers."


1003 Parasite bacteria may help fight spread of mosquito-borne diseases [Wellcome Trust]--Infecting mosquitoes with a bacterial parasite could help prevent the spread of lymphatic filariasis, one of the major neglected tropical diseases of the developing world, according to research published today in the journal Science.

Lymphatic filariasis affects more than 120 million people worldwide – over 40 million of these are seriously incapacitated and disfigured by the disease. It is caused by infection with the parasitic filarial nematode, a threadlike worm that is spread by mosquitoes and occupies the lymphatic system. In chronic cases, infection leads to a condition known as elephantiasis, which can cause severe swelling in the legs, male scrotum and female breasts.

Previous research has shown that infecting a mosquito with a strain of the bacterial parasite Wolbachia known as wMelPop – nicknamed 'popcorn' – can halve its lifespan. Mosquito-borne parasites such as the filarial nematode or the malaria parasite require an incubation period between ingestion and transmission, so only older mosquitoes can be infective. Skewing the mosquito population towards younger individuals reduces the number of infectious insects.

Now, researchers funded primarily by the Wellcome Trust have shown that as well as reducing the mosquito's lifespan, wMelPop directly inhibits transmission of the filarial nematode by encouraging the mosquito's immune system to attack the worm. They found that significantly reduced numbers of filarial nematodes developed in mosquitoes infected with wMelPop – in some cases, less than 15% of the number in mosquitoes which were not carrying wMelPop.

"Wolbachia infection appears to significantly increase the activity of around two hundred mosquito genes, many of which are involved in the immune response," says Dr Steven Sinkins, a Wellcome Trust Senior Research Fellow at the University of Oxford. "This then primes the mosquito's immune system to fight infection by the filarial nematodes, preventing the worm from developing to a stage where transmission to humans is possible."

Wolbachia infections – including wMelPop – have also been shown to protect against certain viruses. Today's research suggests that this effect could also be a result of the boost to the mosquito's immune system.

Dr Sinkins and colleagues are currently looking at whether infecting other species of mosquito, such as Anopheles gambiae – the mosquito responsible for the majority of malaria infections – with wMelPop will have a similar effect and help inhibit malaria transmission as well as filariasis transmission. Another potential target is the Aedes polynesiensis mosquito, which spreads lymphatic filariasis in the islands of Polynesia, where decades of mass drug administration have failed to eradicate the filarial parasites from the human population.

"The Wolbachia 'popcorn' strain is a naturally-occurring organism found in a particular species of fruit fly which, if successfully introduced into mosquito populations, could potentially help us fight a number of the world's most serious diseases," says Dr Sinkins.

Wolbachia have been shown in previous studies to be capable of spreading rapidly through insect populations. When a male carrying Wolbachia mates with a female that does not, the resulting eggs fail to develop. However, a female that is infected with Wolbachia can breed successfully with any male, and thus produces more offspring on average than Wolbachia-uninfected females.



1003 Gun possession of questionable value in an assault [University of Pennsylvania School of Medicine]--In a first-of its-kind study, epidemiologists at the University of Pennsylvania School of Medicine found that, on average, guns did not protect those who possessed them from being shot in an assault. The study estimated that people with a gun were 4.5 times more likely to be shot in an assault than those not possessing a gun.


The study was released online this month in the American Journal of Public Health, in advance of print publication in November 2009.

“This study helps resolve the long-standing debate about whether guns are protective or perilous,” notes study author Charles C. Branas, PhD, Associate Professor of Epidemiology. “Will possessing a firearm always safeguard against harm or will it promote a false sense of security?”

What Penn researchers found was alarming – almost five Philadelphians were shot every day over the course of the study and about 1 of these 5 people died. The research team concluded that, although successful defensive gun uses are possible and do occur each year, the chances of success are low. People should rethink their possession of guns or, at least, understand that regular possession necessitates careful safety countermeasures, write the authors. Suggestions to the contrary, especially for urban residents who may see gun possession as a defense against a dangerous environment should be discussed and thoughtfully reconsidered.

A 2005 National Academy of Science report concluded that we continue to know very little about the impact of gun possession on homicide or the utility of guns for self-defense. Past studies had explored the relationship between homicides and having a gun in the home, purchasing a gun, or owning a gun. These studies, unlike the Penn study, did not address the risk or protection that having a gun might create for a person at the time of a shooting.

Penn researchers investigated the link between being shot in an assault and a person’s possession of a gun at the time of the shooting. As identified by police and medical examiners, they randomly selected 677 cases of Philadelphia residents who were shot in an assault from 2003 to 2006. Six percent of these cases were in possession of a gun (such as in a holster, pocket, waistband, or vehicle) when they were shot.

These shooting cases were matched to Philadelphia residents who acted as the study’s controls. To identify the controls, trained phone canvassers called random Philadelphians soon after a reported shooting and asked about their possession of a gun at the time of the shooting. These random Philadelphians had not been shot and had nothing to do with the shooting. This is the same approach that epidemiologists have historically used to establish links between such things as smoking and lung cancer or drinking and car crashes.

“The US has at least one gun for every adult,” notes Branas. “Learning how to live healthy lives alongside guns will require more studies such as this one. This study should be the beginning of a better investment in gun injury research through various government and private agencies such as the Centers for Disease Control, which in the past have not been legally permitted to fund research ‘designed to affect the passage of specific Federal, State, or local legislation intended to restrict or control the purchase or use of firearms.’”

This study was funded by the National Institutes of Health. The authors are also indebted to numerous dedicated individuals at the Philadelphia Police, Public Health, Fire, and Revenue Departments as well as DataStat Inc, who collaborated on the study.

Therese S. Richmond, PhD, CRNP, School of Nursing; Dennis P. Culhane, PhD, School of Social Policy; Thomas R. Ten Have, PhD, MPH, and Douglas J. Wiebe, PhD, both from the School of Medicine, are co-authors.



1003 San Andreas affected by 2004 Sumatran quake - Largest quakes can weaken fault zones worldwide [Rice University]--U.S. seismologists have found evidence that the massive 2004 earthquake that triggered killer tsunamis throughout the Indian Ocean weakened at least a portion of California's famed San Andreas Fault. The results, which appear this week in the journal Nature, suggest that the Earth's largest earthquakes can weaken fault zones worldwide and may trigger periods of increased global seismic activity.

"An unusually high number of magnitude 8 earthquakes occurred worldwide in 2005 and 2006," said study co-author Fenglin Niu, associate professor of Earth science at Rice University. "There has been speculation that these were somehow triggered by the Sumatran-Andaman earthquake that occurred on Dec. 26, 2004, but this is the first direct evidence that the quake could change fault strength of a fault remotely."

Earthquakes are caused when a fault fails, either because of the buildup of stress or because of the weakening of the fault. The latter is more difficult to measure.

The magnitude 9 earthquake in 2004 occurred beneath the ocean west of Sumatra and was the second-largest quake ever measured by seismograph. The temblor spawned tsunamis as large as 100 feet that killed an estimated 230,000, mostly in Indonesia, Sri Lanka, India and Thailand.

In the new study, Niu and co-authors Taka'aki Taira and Paul Silver, both of the Carnegie Institution of Science in Washington, D.C., and Robert Nadeau of the University of California, Berkeley, examined more than 20 years of seismic records from Parkfield, Calif., which sits astride the San Andreas Fault.

The team zeroed in on a set of repeating microearthquakes that occurred near Parkfield over two decades. Each of these tiny quakes originated in almost exactly the same location. By closely comparing seismic readings from these quakes, the team was able to determine the "fault strength" -- the shear stress level required to cause the fault to slip -- at Parkfield between 1987 and 2008.

The team found fault strength changed markedly at three times during the 20-year period. The authors surmised that the 1992 Landers earthquake, a magnitude 7 quake north of Palm Springs, Calif. -- about 200 miles from Parkfield -- caused the first of these changes. The study found the Landers quake destabilized the fault near Parkfield, causing a series of magnitude 4 quakes and a notable "aseismic" event -- a movement of the fault that played out over several months -- in 1993.

The second change in fault strength occurred in conjunction with a magnitude 6 earthquake at Parkfield in September 2004. The team found another change at Parkfield later that year that could not be accounted for by the September quake alone. Eventually, they were able to narrow the onset of this third shift to a five-day window in late December during which the Sumatran quake occurred.

"The long-range influence of the 2004 Sumatran-Andaman earthquake on this patch of the San Andreas suggests that the quake may have affected other faults, bringing a significant fraction of them closer to failure," said Taira. "This hypothesis appears to be borne out by the unusually high number of large earthquakes that occurred in the three years after the Sumatran-Andaman quake."

The research was supported by the National Science Foundation, the Carnegie Institution of Washington, the University of California, Berkeley, and the U.S. Geological Survey.



1003 Securing biological select agents and toxins will require developing a culture of trust [National Academy of Sciences]--The most effective way to prevent the deliberate misuse of biological select agents and toxins (BSATs) -- agents housed in laboratories across the U.S. considered to potentially pose a threat to human health -- is to instill a culture of trust and responsibility in the laboratory, says a new report from the National Research Council. Focusing on the laboratory environment will be critical for identifying and reducing concerns about facilities or personnel.

Mechanisms for fostering a safe and secure laboratory environment include engaged management, risk-based security measures, and appropriate monitoring and management of personnel, as well as training for all researchers in scientific ethics and understanding "dual-use" research that could be misused. Other methods of screening and oversight are incomplete without including the laboratory community in minimizing potential security risks, the report says. Policies and procedures that make select agent research more difficult to conduct, as opposed to more secure, diminish overall security rather than strengthen it.

Individuals cleared for access to select agents and toxins are certified for five years. Many changes can occur during this time, however, including those that impact whether an individual poses a security risk. Therefore, efforts to ensure reliable personnel should come from within the laboratories, the report says, through increased engagement and monitoring by managers and staff. The goal should be that individuals watch out for each other and take responsibility for their own performance and that of others. In a laboratory context, some security measures can also improve safety, if there is involvement of researchers in the process.

BSAT research is presently defined by a list of more than 80 select agents and toxins, developed and jointly regulated by the Centers for Disease Control and Prevention (CDC) and the Animal and Plant Health Inspection Service (APHIS). According to the committee that wrote the report, the list should be ordered based on the potential of an agent to be used as a biothreat, and a graded series of security procedures should be applied so that the greatest resources and scrutiny go to securing agents that pose maximum risk.

Personnel issues are often the most controversial and difficult aspects of maintaining security for BSATs. Security programs can be generally divided into two categories: screening individuals to determine whether they are eligible for access, and monitoring the behavior and performance of employees working with these agents. The current Security Risk Assessment screening process, which relies on screening more than 20 criminal, immigration, and terrorist databases to identify disqualifying behavior or activities, is appropriate, the report says. However, a change that should be considered is expanding the appeal process beyond a simple determination of factual errors to include the opportunity to consider circumstances surrounding otherwise disqualifying factors, such as the length of time since an offense occurred. Currently, any discovery of disqualifying factors or behaviors automatically and permanently denies an individual's access.

Improved communication is needed among those funding research on select agents, those administering the Select Agent Program, and those conducting the research, the report says. An advisory committee with members drawn from research institutions and the private sector should be established to provide continued engagement of stakeholders. Representatives from federal agencies would serve in an EX OFFICIO capacity. Rigorous and continuing evaluation of the Select Agent Program is needed to ensure that it is running efficiently and also to consider any intended and unintended consequences of operation.

The committee concludes that, because biological select agents can replicate, an undue reliance on accounting techniques, such as counting vials, to monitor whether a biological agent has been removed from a laboratory offers a false sense of security and is counterproductive. Instead, accountability is best achieved by controlling access to archived stocks and working materials and recording which agents are present, where they are stored, who has access to them, when that access is available, their intended use, and where they are transported, if moved to another off-site location.

Physical security is required of all facilities housing select agents, with broad regulatory guidance provided by CDC and APHIS. The variation in implementing these requirements and regulations can lead to inconsistencies and confusion as facility operators, contractors, and inspectors attempt to determine whether a facility has met the necessary security guidelines. The report calls upon the Select Agent Program to define minimum physical security requirements to assist facilities in meeting their regulatory obligations. The report also recommends laboratory inspectors have scientific and laboratory knowledge and experience, as well as appropriate training specific to BSAT research and that the inspections should be harmonized across agencies. Due to the considerable security and compliance costs involved in working with select agents, a separate category of federal funding should be made available to ensure that facilities always operate with appropriate security measures in place.



1003 Peer pressure builds more latrines than financial assistance [Duke University]--Government subsidies persuade some people to change habits, but social shame works even better, suggests a recent study of efforts to reduce elevated childhood death and disease rates blamed on the microbial pathogens that cause diarrhea in rural India.

"All this started with public health workers there just beating their heads against the reality of how sticky human behavior is and how hard it is to change it," said Subhrendu Pattanayak, an associate professor at Duke University's Sanford School of Public Policy and Nicholas School of the Environment.

According to a report in the August issue of the Bulletin of the World Health Organization, of which Pattanayak was lead author, experts have disagreed "whether improved access to sanitation and other health technologies is better achieved through monetary subsidies or shaming techniques."

Shaming, a strategy first tried in Bangladesh, is an appeal to the emotions during group gatherings of local residents to access the impacts of unhygienic practices, Pattnayak said. Neighbors caught in open defecation, for example, may be taunted.

Pattanayak's evaluation focused on efforts to combine both shaming and reward tactics in the state of Orissa, which has a child mortality rate higher than average for India.

Health workers participating in a Total Sanitation Campaign had previously knocked on doors throughout India, handing out pamphlets designed to persuade individual households to install pit latrines. The poorer households were even offered construction subsidies that would reduce their costs to the U.S. equivalent of $7.50.

But after those initial efforts, followup studies found less than a quarter of the nation's population and less than 10 percent of residents of Orissa had "access to safe water and good sanitation," according to the report.

So Pattanayak worked with frustrated government officials and his collaborators at RTI International in Research Triangle Park, N.C., where he then worked. Collectively they designed a study, funded by the World Bank, to measure the effectiveness of what his report called "a social mobilization strategy."

Twenty Orissa villages were selected at random in 2006 for locally led efforts that included village "walks of shame" and "defecation mapping" that identified sources of contamination and their distances from drinking water supplies. As that study began, about 30 percent of the interviewed households reported a child younger than 5 years had experienced diarrhea within the previous two weeks.

Community based groups were empowered "to establish systems of fines, taunting or social sanctions to punish those who continued to defecate in the open," the report said.

As Total Sanitation Campaign workers organized these additional efforts, Pattanayak's study group remained behind the scenes gathering data through "before and after" health and sanitation surveys.

The results were striking when surveys from those 20 villages were compared with 20 other randomly selected communities where no social mobilization efforts were organized.

Although subsidies for latrine construction were available to residents below India's poverty line in all 40 villages, latrine ownership only rose in those undergoing shaming, according to the surveys.

Within those "shamed" communities, latrine ownership rose from 5 percent to 36 percent among families below the poverty line, and from 7 percent to 26 percent among households above it. Subsequent surveys by Orissa's state government showed that all households had installed latrines by 2007 in 10 of the 20 villages subjected to the shaming.

Statistical analysis suggests that subsidies were responsible for about one third of the improvements in those communities and shame for about two thirds, the report concluded.

Pattanayak, himself a native Indian whose general academic interest is environmental and development economics, thinks his countrymen generally understand how bad hygiene can relate to childhood disease. But they also feel a combination of fatalism and powerlessness.

"Many view the loss of a child every now and then to diarrhea and other stomach ailments as part of normal life," he said. "While some people recognize the connection and do something about it, and the rest also recognize it but find it too abstract compared to life's other problems.

"This is a typical story of why people don't do things that seem beneficial to others," he said. "You feel you are just a small part of the picture: 'If I do this there's some chance that things will improve.' But that is conditional on how many others also do something about it.

"That's the problem with environmental issues, whether they are health or non-health. It's how we end up with so much greenhouse gas in the air and pollution in our water."



1003 Physician-assisted suicide does not increase severity of depression, grief among family members [Oregon Health & Science University]--Unlike other forms of suicide, physician assisted death does not cause substantial regret, or a sense of rejection among surviving family members. In addition, the prevalence and severity of depression and grief among family members whose loved ones received aid in dying is no different than family members whose loved ones did not pursue physician assisted suicide.


These findings are the result of a study conducted by researchers at Oregon Health & Science University and published online this week in the Journal of Pain and Symptom Management.

"Grief following the death of a loved one can be persistent, painful and debilitating," said Linda Ganzini, M.D., a professor of psychiatry and medicine in the OHSU School of Medicine and lead author of the research paper.


"Prior studies on suicides indicate high levels of shame, guilt, stigma and sense of rejection in surviving family members. However, until now, little was known about mental health outcomes in the family members of a patient who receives physician aid in dying. Based on our research, we know that family members of loved ones who pursue physician assisted suicide do not have different prevalence and severity of depression and prolonged grief compared to the general population."

To conduct the study, researchers surveyed 95 family members whose loved ones requested aid in dying through Oregon's Death with Dignity Act. This group included 59 family members whose loved one received a lethal prescription and 36 whose loved one died by lethal ingestion. The researchers compared this information with responses received from 63 family members whose loved one had died from cancer or amyotrophic lateral sclerosis (Lou Gehrig's disease) and had not requested aid in dying.

In comparing survey results, the researchers found that the rate of grief and depression between these two groups was nearly identical. However, family members of loved ones who requested a lethal prescription indicated they felt more prepared for and more accepting of the death.

Among family members whose loved one requested but did not receive a lethal prescription, there was greater likelihood that the family members had regrets about how their loved one died. This group also was less likely to confirm that the patient's preferences for care were honored, and they gave a lower rating for overall quality of care the last week of life.

"One of the other interesting findings in this research was the fact that families often had shared views when it came to the acceptability of physician aid in dying," added Ganzini. "When we communicated with the family members of those who received aid in dying, 98 percent said they would consider physician assisted suicide for themselves."

This research was funded by the Greenwall Foundation.



1003 Using computational models to study fear [University of Missouri]--The brain is a complex system made of billions of neurons and thousands of connections that relate to every human feeling, including one of the strongest emotions, fear. Most neurological fear studies have been rooted in fear-conditioning experiments.


Now, University of Missouri researchers have started using computational models of the brain, making it easier to study the brain’s connections. Guoshi Li, an electrical and computer engineering doctoral student, has discovered new evidence on how the brain reacts to fear, including important findings that could help victims of post-traumatic stress disorder (PTSD).

“Computational models make it much easier to study the brain because they can effectively integrate different types of information related to a problem into a computational framework and analyze possible neural mechanisms from a systems perspective. We simulate activity and test a variety of “what if” scenarios without having to use human subjects in a rapid and inexpensive way,” Li said.

From previous experiments, scientists have found that fear can subside when overcome with fear extinction memory, but it is not permanently lost. Fear extinction is a process in which a conditioned response to a stimulant that produces fear gradually diminishes over time as subjects, such as rats in auditory fear experiments, learn to disassociate a response from a stimulus. One theory has concluded that fear extinction memory deletes fear memory, and another concluded that fear memory is not lost, but is inhibited by extinction memory as fear can recover with the passage of time after extinction.

“Fear extinction memory is not well understood, and our computational model can capture the neuron response well in rat during auditory fear conditioning with a mixture of mathematics and biophysical data,” said Li. “Our main contribution is that our model predicts that fear memory is only partially erased by extinction, and inhibition is necessary for a complete extinction, which is a reconciliation of the erasure and inhibition theories. Furthermore, our model shows that the inhibitory connection from interneurons to pyramidal cells serve as an important site for the storage of extinction memory.”

For PTSD victims, the fear circuit is disrupted and they cannot retrieve the fear extinction memory. However, the fear extinction memory exists, so the fear memory dominates every time victims get a fear cue. Li and his collaborators are targeting the inhibitory connection in the brain that makes it possible to retrieve the extinction memory. Li hopes that his research can contribute to new drugs that can help PTSD victims.

“Treatment for PTSD patients depends on which connection stores the fear extinction memory and which circuit misfires,” Li said. “With our model, we can figure out what specific connections store fear/extinction memory and how such connections are disrupted in the pathology of PTSD, which may lead to the suggestions of new drugs to treat the disease.”

Li, in collaboration with Satish Nair, professor of electrical and computer engineering who just received a three-year National Institute of Health grant for further research in fear modeling, and Gregory Quirk, a neuroscientist in the University of Puerto Rico School of Medicine research, has been published in the Journal of Neurophysiology and Psychiatric Annals.



1003 Protect children first with H1N1 flu vax [University of Alabama at Birmingham]--The optimal way to control swine flu, the new H1N1 virus that emerged as a global threat in 2009, is to vaccinate children with the planned H1N1 flu shot, says the co-director of the University of Alabama at Birmingham (UAB) Division of Pediatric Infectious Diseases.

"Children are the highest-risk group for spreading the virus among themselves, and as a consequence, spreading it around their community," says UAB's David Kimberlin, M.D., one of four U.S. physicians serving on the federal Safety Monitoring Committee reviewing clinical trials of H1N1 vaccines. The committee is a part of the Division of Microbiology and Infectious Diseases at the National Institute of Allergy and Infectious Diseases.

"Like a bull's-eye, the middle of the target is what you vaccinate so you don't see infections in the concentric rings around the center," Kimberlin says. "The center of the protection bull's-eye should be children."

The United States' prospects for developing and distributing a safe and effective vaccine to prevent infection with the current H1N1 virus are excellent, Kimberlin says.

"The National Institutes of Health are conducting a number of studies across the country at special vaccine evaluation sites they've had set up for 40-60 years, and they have enrolled several thousand patients into those studies," he says. "I'm on that federal monitoring board and we look at the vaccine-safety data constantly. These studies are going very well."

The reasoning behind making children the highest priority comes from decades of experience with flu transmission, prevention strategies, infection monitoring and many other factors. Additionally, children younger than age 5 are at higher risk of complications from influenza.

Once the vaccine is available, which is expected to be in October, children 6 months of age and older, teenagers and young adults through age 24 will be among the first groups targeted by the Centers for Disease Control Advisory Committee on Immunization Practices to receive the shots.

Pregnant women, adults who have high-risk medical conditions and health-care workers who are direct care providers are among the others who will be given the earliest shots, says Kimberlin, who is a member of the American Academy of Pediatrics Committee on Infectious Diseases and associate editor of the academy's Red Book, a revered pediatric treatment manual.

Decisions about expanding or establishing priorities for vaccination should be made in accordance with local circumstances based on the judgment of state and county health officials, advises Kimberlin.



1003 New way to monitor faults may help predict earthquakes [Carnegie Institution's Department of Terrestrial Magnetism]--Scientists at the Carnegie Institution have found a way to monitor the strength of geologic faults deep in the Earth. This finding could prove to be a boon for earthquake prediction by pinpointing those faults that are likely to fail and produce earthquakes. Until now, scientists had no method for detecting changes in fault strength, which is not measureable at the Earth's surface.

Paul Silver* and Taka'aki Taira of the Carnegie Institution's Department of Terrestrial Magnetism, with Fenglin Niu of Rice University and Robert Nadeau of the University of California, Berkeley, used highly sensitive seismometers to detect subtle changes in earthquake waves that travel through the San Andreas Fault zone near Parkfield, California, over a period of 20 years. The changes in the waves indicate weakening of the fault and correspond to periods of increased rates of small earthquakes along the fault.

"Fault strength is a fundamental property of seismic zones," says Taira, now at the University of California, Berkeley. "Earthquakes are caused when a fault fails, either because of the build-up of stress or because of a weakening of the fault. Changes in fault strength are much harder to measure than changes in stress, especially for faults deep in the crust. Our result opens up exciting possibilities for monitoring seismic risk and understanding the causes of earthquakes."

The section of the San Andreas Fault near Parkfield, sometimes called the "Earthquake Capital of the World," has been intensively studied by seismologists and is home to a sophisticated array of borehole seismometers called the High-Resolution Seismic Network and other geophysical instruments. Because the area experiences numerous repeated small earthquakes, it is a natural laboratory for studying the physics of earthquakes.

Seismograms from small earthquakes revealed that within the fault zone there were areas of fluid-filled fractures. What caught the researchers' attention was that these areas shifted slightly from time to time. The repeating earthquakes also became smaller and more frequent during these intervals – an indication of a weakened fault.

"Movement of the fluid in these fractures lubricates the fault zone and thereby weakens the fault," says Niu. "The total displacement of the fluids is only about 10 meters at a depth of about three kilometers, so it takes very sensitive seismometers to detect the changes, such as we have at Parkfield."

What caused the fluids to shift? Intriguingly, the researchers noticed that on two occasions the shifts came after the fault zone was disturbed by seismic waves from large, distant earthquakes, such as the 2004 Sumatra-Andaman Earthquake. Pressure from these waves may have been enough to cause the fluids to flow. "So it is possible that the strength of faults and earthquake risk is affected by seismic events on the other side of the world," says Niu.

The paper is published in the October 1 edition of Nature.

*Paul Silver died tragically in an automobile accident in August.



1003 Celebs spawn copycat suicides [Queen Mary Research Centre for Psychology]--Dr Alex Mesoudi, from Queen Mary's newly established Research Centre for Psychology, has found evidence that the increasing reach and influence of the media, combined with a growing number of people assigned celebrity status, could increase the probability of widespread suicide pandemics. The study is published today in the peer reviewed journal PLoS ONE.

Copycat suicides occur when one person's suicide is at least partly caused by exposure to another person's suicide. Sociologists have proposed that clusters of suicides around the same time or geographical area may be caused by this copycat effect.

By studying the behaviour of 1000 computer 'people', pre-programmed with the rules that govern how people learn from one another, Dr Mesoudi has investigated the problem of copycat suicides to see whether suicidal behaviour in the population really does fit with sociologists' assumptions.

Two kinds of suicide clusters have been identified by previous sociological research. Mass clusters are suicides that occur around the same time but across an entire geographic region (eg. a country), and are often associated with media coverage of celebrity suicides, such as that of the musician Kurt Cobain.

Dr Mesoudi said: "The findings of the computer simulations strongly support the proposed link between the mass reporting of a prestigious celebrity's suicide and an increase in national suicide figures. This highlights the need for media guidelines that restrict the dissemination and glorification of suicides, as already introduced in many countries, such as Austria, Switzerland and Australia."

In recent years, satellite television and the internet have increased the global range of the mass media; celebrities such as film actors and pop singers are being assigned increasing importance relative to politicians and intellectuals (whose suicides do not elicit copycat suicide attempts); and reality television programmes are increasing the number of celebrities within society.

Additionally, point clusters are suicides that occur around the same time and physical place, for example a number of suicides occurring in a school or hospital during a few weeks or months. Point clusters have been attributed to direct social learning, where people pick up information in their local social networks or communities. This is the most common theory behind the spate of tragic suicides among young people in Bridgend, South Wales.

The results also showed that direct social learning does generate point clusters, but that this is partially mimicked by homophily; a situation where people who are independently predisposed to committing suicide tend to reside close to one another. These areas therefore have higher suicide risks despite no actual social influence.

Dr Mesoudi added: "These findings suggest that social learning and homophily generate distinct types of clusters. By using this knowledge to distinguish between genuine copycat point clusters and homophilous point clusters, efforts to reduce socially influenced suicides might be more effectively targeted at the former."



1003 Prenatal exposure to flu pandemic increased chances of heart disease [University of Southern California]--People exposed to a H1NI strain of influenza A while in utero were significantly more likely to have cardiovascular disease later in life, reveals a new study published in Journal of Developmental Origins of Health and Disease on Oct. 1.

"Our point is that during pregnancy, even mild sickness from flu could affect development with longer consequences," said senior author Caleb Finch, USC professor of gerontology and biological sciences.

Finch, Eileen Crimmins (USC Davis School of Gerontology), lead author Bhashkar Mazumder (Federal Reserve Bank of Chicago), Douglas Almond (University of Chicago) and Kyung Park (Columbia University) looked at more than 100,000 individuals born during and around the time of the 1918 influenza pandemic in the United States.

After first appearing in the spring and all but disappearing in the summer, the 1918 flu pandemic "resurged to an unprecedentedly virulent October-December peak," the researchers write. The outbreak of influenza A, H1N1 subtype killed two percent of the total population. Most people experienced mild "three-day fever" with full recovery.

"[The] 1918 flu was far more lethal than any since. Nonetheless, there is particular concern for the current swine flu which seems to target pregnant women," said Finch, director of the Gerontology Research Institute at USC. "Prospective moms should reduce risk of influenza by vaccination."

The researchers found that men born in the first few months of 1919 — second or third trimester during the height of the epidemic — had a 23.1 percent greater chance of having heart disease after the age of 60 than the overall population. Heart disease is the leading cause of death in the United States.

For women, those born in the first few months of 1919 were not significantly more likely to have cardiovascular disease than their peers, pointing to possible gender differences in effects of flu exposure. But women born in the second quarter of 1919 — first trimester during the height of the epidemic — were 17 percent more likely to have heart disease than the general population in later life, according to the study.

In addition, the researchers examined height at World War II enrollment for 2.7 million men born between 1915 and 1922 and found that average height increased every successive year except for the period coinciding with in utero exposure to the flu pandemic.

Men who were exposed to the H1N1 flu in the womb were slightly shorter on average than those born just a year later or a year before, according to the study. The researchers controlled for known season-of-birth effects and maternal malnutrition.

"Prenatal exposure to even uncomplicated maternal influenza can have lasting consequences later in life," said Crimmins, professor of gerontology and sociology at USC. "The lingering influences from the 1918-1919 influenza pandemic extend the hypothesized roles of inflammation and infections in cardiovascular disease from our prior Science and PNAS articles to prenatal infection by influenza."

Journal of Developmental Origins of Health and Disease is published and jointly owned by Cambridge University Press in association with the International Society for Developmental Origins of Health and Disease. The research was supported by the National Institute on Aging, the Ellison Medical Foundation and the Ruth Ziegler Fund.

Finch et al., "Lingering Prenatal Effects of the 1918 Influenza Pandemic on Cardiovascular Disease." Journal of Developmental Origins of Health and Disease. DOI: 10.1017/S2040174409990031



1003 Treating even mild gestational diabetes reduces birth complications [NIH/National Institute of Child Health and Human Development]--A National Institutes of Health network study provided the first conclusive evidence that treating pregnant women who have even the mildest form of gestational diabetes can reduce the risk of common birth complications among infants, as well as blood pressure disorders among mothers.

Treatment of severe gestational diabetes is known to benefit mothers and infants. Although treatment is routinely prescribed for all women with gestational diabetes, before the current study, there was no evidence to show whether treating the mild form of the condition benefited, or posed risks for, mothers or their infants.

The researchers found that, compared to the women's untreated counterparts, women treated for mild gestational diabetes had smaller, leaner babies less likely to be overweight or abnormally large, and less likely to experience shoulder dystocia, an emergency condition in which the baby's shoulder becomes lodged inside the mother's body during birth. Treated mothers were also less likely to undergo cesarean delivery, to develop high blood pressure during pregnancy, or to develop preeclampsia, a life-threatening complication of pregnancy that can lead to maternal seizures and death.

The study was conducted by researchers in the Maternal Fetal Medicine Units Network of the NIH's Eunice Kennedy Shriver National Institute of Child Health and Human (NICHD) and appears in the Oct. 1 New England Journal of Medicine. The study's first author was Mark Landon of Ohio State University.

"Whether to treat mild gestational diabetes has never been entirely clear," said study coauthor Catherine Y. Spong, chief of the Pregnancy and Perinatology Branch at the NICHD. "The study results show conclusively that both mothers and infants do better when gestational diabetes is controlled."

In addition to funding from the NICHD, the study was also supported by the NIH's National Center for Research Resources.

Gestational diabetes occurs when pregnant women who did not have any signs or symptoms of diabetes before they were pregnant develop high blood sugar levels. The condition affects from 1 to 14 percent of all U.S. pregnancies. Gestational diabetes is not well understood, but is thought to occur when hormones produced during pregnancy interfere with the body's ability to use insulin to absorb sugar from the blood.

In most cases, treatment for gestational diabetes consists of lowering blood sugar levels through proper diet and exercise. If diet and exercise alone fail to lower blood sugar levels, women may be treated with drugs that increase the body's ability to use insulin, or may be prescribed insulin itself.

The current study is the first to test whether treatment for mild gestational diabetes is beneficial. The researchers defined mild gestational diabetes as having normal blood sugar levels after fasting but abnormally high levels in at least two readings over the course of three hours after an oral glucose tolerance test, in which women consume a sugary drink. Severe diabetes was defined as high blood sugar levels even after fasting.

To conduct the study, the researchers enrolled 958 women with mild gestational diabetes. Roughly half were treated for their diabetes and half were not, receiving only standard pregnancy care.

In their statistical analysis of the study results, the researchers combined several serious potential outcomes into one figure, to represent a single and primary outcome. The primary outcome consisted of all cases of newborn death, stillbirth, newborns with low blood sugar or with high insulin levels, birth-related injuries, and high bilirubin levels (an indicator of newborn jaundice). In terms of the primary outcome, there were no differences between the two groups of women. But the women who received treatment fared significantly better than the untreated women on other measures.

Specifically, compared to women who did not receive treatment, those who did were:

* half as likely to have an unusually large baby,
* half as likely to experience shoulder dystocia during childbirth,
* four-fifths as likely to give birth by cesarean section, and
* three-fifths as likely to develop high blood pressure or preeclampsia.

"Obstetricians are concerned with the immediate risks of birth trauma which may accompany delivery of large infants to women with diabetes," Dr. Landon said.

These risks include fracture of the skull and collar bones, and injury to the nerves that connect the arm, hand and shoulder to the spine.

"Our study demonstrates that treating even mild diabetes can reduce fetal overgrowth and thus could also reduce these birth related risks."

Previous studies suggest that the higher birthweights and greater proportion of body fat seen in the newborns of women with gestational diabetes also pose increased health risks for these children later in life, Dr. Spong said. The children are more likely than other children to be overweight and, as adults, more likely to have impaired glucose tolerance, a prediabetic condition.

"The children would need to be followed long term to be certain, but it's possible that treating women with mild gestational diabetes to reduce birthweight and body fat among their newborns may benefit these children later in life," Dr. Spong said.


1003 Air pollutants from abroad a growing concern [National Research Council]--Plumes of harmful air pollutants can be transported across oceans and continents -- from Asia to the United States and from the United States to Europe -- and have a negative impact on air quality far from their original sources, says a new report by the National Research Council. Although degraded air quality is nearly always dominated by local emissions, the influence of non-domestic pollution sources may grow as emissions from developing countries increase and become relatively more important as a result of tightening environmental protection standards in industrialized countries.

"Air pollution does not recognize national borders; the atmosphere connects distant regions of our planet," said Charles Kolb, chair of the committee that wrote the report and president and chief executive officer of Aerodyne Research Inc. "Emissions within any one country can affect human and ecosystem health in countries far downwind. While it is difficult to quantify these influences, in some cases the impacts are significant from regulatory and public health perspectives."

The report examines four types of air pollutants: ozone; particulate matter such as dust, sulfates, or soot; mercury; and persistent organic pollutants such as DDT. The committee found evidence, including satellite observations, that these four types of pollutants can be transported aloft across the Northern Hemisphere, delivering significant concentrations to downwind continents. Ultimately, most pollutants' impacts depend on how they filter down to the surface.

Current limitations in modeling and observational capabilities make it difficult to determine how global sources of pollution affect air quality and ecosystems in downwind locations and distinguish the domestic and foreign components of observed pollutants. Yet, some pollutant plumes observed in the U.S. can be attributed unambiguously to sources in Asia based on meteorological and chemical analyses, the committee said. For example, one study found that a polluted airmass detected at Mt. Bachelor Observatory in central Oregon took approximately eight days to travel from East Asia.

The health impacts of long-range transport vary by pollutant. For ozone and particulate matter -- which cause respiratory problems and other health effects -- the main concern is direct inhalation. While the amount of ozone and particulate matter transported on international scales is generally quite small compared with domestic sources, neither of these pollutants has a known "threshold," or concentration below which exposure poses no risk for health impacts. Therefore, even small incremental increases in atmospheric concentrations can have negative impacts, the committee said. For instance, modeling studies have estimated that about 500 premature cardiopulmonary deaths could be avoided annually in North America by reducing ozone precursor emissions by 20 percent in the other major industrial regions of the Northern Hemisphere.

For mercury and persistent organic pollutants, the main health concern is that their transport and deposition leads to gradual accumulation on land and in watersheds, creating an increase in human exposure via the food chain. For example, people may consume mercury by eating fish. There is also concern about eventual re-release of "legacy" emissions that have been stored in soils, forests, snowpacks, and other environmental reservoirs.

In addition, the committee said that projected climate change will lead to a warmer climate and shifts in atmospheric circulation, likely affecting the patterns of emission, transport, transformation, and deposition for all types of pollution. However, predicting the net impacts of the potential changes is extremely difficult with present knowledge.

In the coming decades, man-made emissions are expected to rise in East Asia, the report says. These increases could potentially be mitigated by increasingly stringent pollution control efforts and international cooperation in developing and deploying pollution control technology.

To enhance understanding of long-range transport of pollution and its impacts, the committee recommended a variety of research initiatives, such as advancing "fingerprinting" techniques to better identify source-specific pollutant characteristics, and examining how emissions from ships and aircraft affect atmospheric composition and complicate the detection of pollution from land-based sources. The committee emphasized developing an integrated "pollution source-attribution" system that improves capabilities in emissions measurements and estimates; atmospheric chemical and meteorological modeling; long-term, ground-based observations; satellite remote sensing; and process-focused field studies.

Moreover, the committee stressed that the United States, as both a source and receptor of long-range pollution, has an interest in remaining actively engaged in air pollutants that travel abroad, including support of more extensive international cooperation in research, assessment, and emissions control efforts.

The report was sponsored by the U.S. Environmental Protection Agency, National Oceanic and Atmospheric Administration, NASA, and National Science Foundation. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.



1003 Most would refuse emergency use H1N1 vaccine or additive [University of Pittsburgh Schools of the Health Sciences]--A majority of Americans would not take an H1N1 flu vaccine or drug additive authorized for emergency use by the Food and Drug Administration, according to a University of Pittsburgh Graduate School of Public Health and University of Georgia study. The study, available online today in Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, found that fewer than 10 percent of those surveyed said they would be willing to take such a vaccine or drug and nearly 30 percent remained undecided.

The passage of the Project Bioshield Act in 2004 created the emergency use authorization (EUA) giving the FDA the ability to use experimental or "off label" drugs in the event of an actual or potential emergency. To date, four vaccines against H1N1 virus have been approved under the same process used by the FDA for the seasonal flu vaccine. Also, several drug additives, or adjuvants – sometimes added to vaccines to strengthen the immune response and stretch the quantity of available vaccines in the event of a pandemic – have been ordered and stockpiled by the federal government in case they may be needed. But adding them to H1N1 vaccines would trigger an EUA, which is one of the reasons the federal government has chosen not to use them.

"Although the U.S government has held off on including an adjuvant in H1N1 vaccines for now, American officials may need to reconsider this decision as the pandemic unfolds," said study author Sandra Quinn, Ph.D., associate dean for Student Affairs and Education and associate professor at the University of Pittsburgh Graduate School of Public Health. "There also remains a significant shortage of the vaccines in many countries around the world. Given this, our finding that few people would accept a new but not yet fully approved H1N1 vaccine or drug is very worrisome," she said.

The study was based on a survey that focused on attitudes toward H1N1 and willingness to accept flu vaccines and drugs not officially approved by the FDA, but authorized for emergency use. Of the 1,543 adults questioned in June 2009, 46 percent of people surveyed said they were concerned about getting swine flu. However, nearly 86 percent said they thought it was unlikely or very unlikely that they themselves would become ill.

Researchers also report that 63 percent of people surveyed said they would not be willing to take "a new, but not yet approved vaccine", and 50 percent said they would be very or extremely worried about taking it. Of those who reported they would be moderately to extremely worried, 70 percent said they would refuse the vaccine outright. Only 4 percent of the most worried said they would take the vaccine, compared to 23 percent of those who were not at all or slightly worried.

In addition, 65 percent of those who said they would refuse the vaccine reported being confident about their decision, compared to only 46 percent of those who said they would take the vaccine.

Race also was associated with refusal to take the vaccine – 66 percent of whites and 60 percent of blacks reported they would refuse the vaccine, compared to 47 percent of Hispanics. Blacks reported they were the most worried (62 percent), followed by Hispanics (52 percent) and whites (46 percent).

According to Dr. Quinn, these results differ from some current opinion polls on public acceptance of an H1N1 vaccine because the researchers explicitly asked about vaccines approved under the EUA designation.

"Communication about the H1N1 vaccine is enormously challenging," said Dr. Quinn. "The additional issue of emergency use designation would further complicate challenges to clear communication. In the event an emergency-use adjuvant is required to stem the H1N1 pandemic, public health professionals will need to articulate a strong case for the vaccine and aggressively address myths and misinformation to increase understanding and acceptance."

The potential challenge in communicating with the public about emergency use authorization is relevant beyond the question of the H1N1 vaccine, added Dr. Quinn. "EUAs are an important tool for the protection of the public's health in an emergency. It would behoove public health agencies to begin now to think about communication and education of the public on this issue."

Co-authors of the study are Supriya Kumar, Ph.D., Kelley Kidwell, B.S., and Donald Musa, Dr.P.H., University of Pittsburgh; and Vicki S. Freimuth, Ph.D., University of Georgia. The study was funded in part by the Centers for Disease Control and Prevention. Drs. Quinn, Kumar and Musa also were supported by the Research Center of Excellence in Minority Health and Health Disparities at the National Institutes of Health.



1003 Uninterrupted chest-compressions key to survival in cardiac arrest outside hospital setting [UT Southwestern Medical Center]--Maximizing the proportion of time spent performing chest compressions during cardiopulmonary resuscitation (CPR) substantially improves survival in patients who suffer cardiac arrest outside a hospital setting, according to a multicenter clinical study that included UT Southwestern Medical Center.

The findings, available in today’s issue of Circulation, come from the largest clinical investigation to evaluate the association between chest compressions by emergency medical service (EMS) providers before the first attempted defibrillation and survival to hospital discharge. Out-of-hospital cardiac arrest is a leading cause of premature death worldwide, and survival is often less than 5 percent.


One of the most important aspects of quality CPR is the proportion of time spent performing chest compressions, but EMS providers typically perform chest compressions only 50 percent of the total time spent on resuscitative efforts.

“It’s a common problem, because rescuers are involved in so many other tasks — checking for a pulse, starting intravenous therapy and giving ventilation, among other things,” said Dr. Ahamed Idris, professor of emergency medicine at UT Southwestern and a pioneer in resuscitation research and CPR. Dr. Idris also is the principal investigator for the Dallas portion of the new study, conducted at seven clinical centers across North America.

“Compressions are being interrupted half of the time or more, and that has a detrimental effect on the survival of patients,” Dr. Idris said. “This study reinforces that interrupting chest compressions has a bad effect on survival. It also provides a rationale for relatively simple changes to CPR training and practice, that if implemented are likely to improve survival.”

Dallas-area paramedics and firefighters are being trained to begin CPR immediately and to administer uninterrupted chest compressions for two minutes before re-checking the heart rhythm or using a defibrillator to shock the heart. UT Southwestern’s emergency medicine program provides medical oversight for EMS providers in more than a dozen Dallas-area cities.


In this study, researchers studied data from patients in the Resuscitation Outcomes Consortium (ROC) who had suffered from cardiac arrest with a heart rhythm indicating ventricular fibrillation or ventricular tachychardia. The researchers focused on the effect of the number of chest compressions paramedics administered per minute before they shocked the heart.

“People who received chest compressions 60 to 80 percent of the time during CPR did better than those who received fewer chest compressions,” Dr. Idris said.

Previous animal studies have demonstrated that interruptions in chest compressions decrease coronary and cerebral blood flow. Based on further clinical and laboratory observations, the American Heart Association and the European Resuscitation Council Guidelines for Cardiopulmonary Resuscitation in 2005 recommended increasing the proportion of time spent delivering chest compressions.

In 2008 the American Heart Association updated its CPR guidelines and now advocates that bystanders only perform continuous chest compressions for cardiac arrest instead of combining chest compressions with mouth-to-mouth ventilation.

The data for this study was collected from the ROC, which is comprised of 11 regional clinical centers funded by the National Institutes of Health and several U.S. and Canadian agencies to test lifesaving interventions for critical trauma and sudden cardiac arrest.

In addition to UT Southwestern in Dallas, the other U.S. resuscitation centers are in Birmingham, Ala.; Iowa City, Iowa; Milwaukee; Portland, Ore.; Seattle and King County, Wash.; Pittsburgh; and San Diego. Toronto and Ottawa also have resuscitation centers.



1003 Electronic medical records could be used as a predictor of domestic abuse [Children's Hospital Boston Informatics Program and Harvard Medical School]--Doctors could predict a patient's risk of receiving a domestic abuse diagnosis years in advance by using electronic medical records as an early warning system, according to research published on bmj.com today.

Lead author Dr Ben Reis from the Children's Hospital Boston Informatics Program and Harvard Medical School investigated whether the wealth of historical electronic data could be used to flag up high risk patients.

Reis says: "Doctors typically do not have the time to thoroughly review a patient's historical records during the brief clinical encounter. As a result, certain conditions that could otherwise be detected are often missed. One such condition is domestic abuse, which may go unrecognised for years as it is masked by acute complaints that form the basis of clinical encounters."

Domestic abuse is the most common cause of nonfatal injury to women in the United States, accounting for more than half the murders of women every year. It affects both men and women and can result in serious injury and death. Given this, say the researchers, "it is critical that at–risk patients be identified as early as possible".

While evidence demonstrates that screening is a useful tool in detecting domestic abuse, the authors believe that doctors "may not be taking full advantage of the growing amounts of longitudinal data stored in electronic health information systems".

The authors analysed medical records from over 500,000 non-identifiable patients over 18 years of age for whom they had at least four years' data on admissions to hospital and visits to emergency departments. The patients had over 16 million diagnoses among them and cases of abuse were identified according to established record-keeping codes.

The researchers developed a scoring system to predict which patients were likely to receive a domestic abuse diagnosis. The system was successfully able to predict future diagnoses of abuse an average of 10-30 months in advance.

Certain risk factors were strongly associated with a future diagnosis of abuse. For women the risk was highest after being seen in hospital or the emergency department for injuries, poisoning, and alcoholism. For men being seen for mental health conditions such as depression and psychosis conferred the greatest risk of a subsequent diagnosis of domestic abuse.

They also developed a prototype risk-visualisation environment which provides clinicians with instant overviews of longitudinal medical histories and related risk profiles at the point of care. According to the authors: "In conjunction with alerts for high-risk patients, this could enable clinicians to rapidly review and act on all available historical information by identifying important risk factors and long-term trends."

Reis maintains that these risk profiles could help doctors diagnose domestic abuse much earlier, perhaps many years in advance. He points out that: "With increasing amounts of data becoming available, this work has the potential to bring closer the vision of predictive medicine, where vast quantities of information are used to predict individuals' future medical risks in order to improve medical care and diagnosis."



1003 Cold water cyclones may have strong impact on hurricane intensity and activity [LSU]--Complex interactions between the ocean and overlying atmosphere cause hurricanes to form, and also have a tremendous amount of influence on the path, intensity and duration of a hurricane or tropical weather event.


As researchers develop new ways to better understand and predict the nature of individual storms, a largely unstudied phenomenon has caught the attention of scientists at LSU’s Earth Scan Laboratory, or ESL. Cool water upwellings occurring within ocean cyclones following alongside and behind hurricanes are sometimes strong enough to reduce the strength of hurricanes as they cross paths.

“Ocean cyclones are areas of upwelling, meaning that cold water is not far from the surface as compared to the water surrounding it,” said Nan Walker, ESL director. “The Gulf of Mexico is full of ocean cyclones, or cold water eddies, many of which move rapidly around the margin of Gulf’s Loop Current, which is the main source of water for the Gulf Stream.”

While the upwelling is important to Gulf fisheries because it delivers nutrients into the surface waters, causing algal blooms and attracting marine life to the areas, oceanographers have recently begun to realize that these cyclones intensify currents near the surface and along the bottom of the ocean in areas of gas and oil exploration.

“Now,” Walker added, “our research has shown that ocean cyclones also provide temperatures cold enough to reduce the intensity of large Gulf of Mexico hurricanes.”

Walker’s research team has been looking into the upwelling phenomena since 2004, when they were able to use satellite data received at the ESL to view ocean temperatures soon after Hurricane Ivan’s Gulf crossing.

“Clear skies gave us a rare opportunity to really analyze the oceanic conditions surrounding the wake of Ivan,” said Walker. “We saw abnormally low temperatures in two large areas along the storm’s track, where minimum temperatures were well below those required to support a hurricane, about 80 degrees Fahrenheit.” This suggested to Walker that areas of extreme cooling could be providing immediate negative feedback to Gulf hurricanes, decreasing their intensity.

“In Ivan’s case, we found that its wind field increased the counter-clockwise spinning of the ocean cyclones in its path, catapulting cold water to the surface, which in turn reduced the oceanic ‘fuel’ needed for the hurricane to maintain its strength,” said Walker. She observed that Ivan’s intensity decreased as it moved toward the Mississippi/Alabama coast, despite the presence of a large warm eddy, a feature generally known for its potential to increase hurricane strength. Thus, the impact of the cold eddies overwhelmed that of the warm eddy.

“Cool wakes are most beneficial when the storm occurs later in the season because the Gulf doesn’t warm as rapidly in fall and may not have time to warm back up,” said Walker.

The research being conducted at ESL could eventually lead to novel new weather study techniques.

“Our research, in collaboration with Robert Leben at the University of Colorado, is providing an advanced monitoring system so that likely ocean impacts can be assessed in advance of the Gulf crossing,” said Walker. “However, it is important to remember that we don’t predict; we provide valuable information that serves as tools for those in the business of predicting, such as the National Hurricane Center.”

Of course, this is only one facet of the work done at LSU’s ESL. The lab has played a major role in mapping hurricane-related flooding, tracking oil spills and determining causes for the size and location of dead zones in the Gulf of Mexico, along with many other tasks employing satellite imagery.


1003 Universal screening lowers risk of severe jaundice in infants [UCSF]--Screening all newborns for excessive bilirubin in the blood can significantly decrease the incidence of severe jaundice which, in extreme cases, can lead to seizures and brain damage, according to researchers at UCSF Children's Hospital and Kaiser Permanente's Division of Research in Oakland, CA.

The study, one of the first to examine the effectiveness of universal screening for hyperbilirubinemia, appears in the current issue of "Pediatrics," the official journal of the American Academy of Pediatrics. The study is one of six in this issue to explore the topic of bilirubin and hyperbilirubinemia.

Hyperbilirubinemia is caused by an elevation of a bile pigment, called bilirubin, in the blood. Bilirubin is made when the body breaks down old red blood cells, and high levels can cause jaundice, a condition that makes the newborn's skin and the white part of the eyes look yellow.

The researchers explain that most newborns have a rise in bilirubin in the days following birth. However, very high blood levels can be toxic to the nervous system. Monitoring these levels in babies with jaundice is important so that treatment can be started before levels become excessive, explain the researchers. They add that high bilirubin levels can be treated with light therapy, which converts the bilirubin into a form that the body can remove.

"While we know that early identification of bilirubin levels before reaching toxic levels is important, bilirubin screening has not been universal, as physicians have decided which infants to screen based upon their degree of jaundice and clinical risk factors," said Michael Kuzniewicz, MD, MPH, the lead author of the study and a neonatologist at UCSF Children's Hospital.


"This study provides evidence that universal screening during the birth hospitalization is a more effective method for monitoring bilirubin levels in order to prevent them from rising to a point that can damage an infant's brain."

The study evaluated the impact of implementation of the 2004 American Academy of Pediatrics (AAP) guideline on the management of jaundice in the Northern California facilities operated by Kaiser Permanente. The guideline recommends that every newborn be assessed for the risk of developing severe jaundice with a bilirubin level before discharge home and/or an assessment of clinical risk factors.

With universal screening, researchers noted a 62 percent decrease in the number of newborns with very high bilirubin levels. The study also describes an increase in the use of phototherapy to treat infants with elevated bilirubin levels, sometimes even when the AAP guidelines did not call for it.

Researchers in this study evaluated both blood tests and devices that estimate the bilirubin level from the color of the baby's skin as methods of screening. "The method didn't seem to matter as much as changing the standard operating procedure, such that all babies are screened," said study co-author Gabriel Escobar, MD, regional director for hospital operations research and a research scientist with the Kaiser Permanente Division of Research's Perinatal Research Unit in Oakland, CA.


"With additional education to help avoid excessive use of phototherapy, we think universal screening is a very good tool to reduce cases of serious hyperbilirubinemia."

"This research highlights the power of laboratory databases in supporting research and quality improvement," according to senior author Thomas B. Newman, MD, MPH, with the UCSF Department of Epidemiology and Biostatistics and the UCSF Division of General Pediatrics.

The study was funded by a grant from the National Institute of Child Health and Human Development.



1003 Women with diabetes at increased risk for irregular heart rhythm [Kaiser Permanente]--Diabetes increases by 26 percent the likelihood that women will develop atrial fibrillation (AF), a potentially dangerous irregular heart rhythm that can lead to stroke, heart failure, and chronic fatigue.


These are the findings of a new Kaiser Permanente study, published in the October issue of Diabetes Care, a journal of the American Diabetes Association.

While other studies have found that patients with diabetes are more likely to have AF, this is the first large study—involving nearly 35,000 Kaiser Permanente patients over the course of seven years—to isolate the effect of diabetes and determine that it is an independent risk factor for women.

“The most important finding from our study is that women with diabetes have an increased risk of developing this abnormal heart rhythm,” said the study’s lead author, Greg Nichols, PhD, investigator at the Kaiser Permanente Center for Health Research in Portland, Ore.


“Men with diabetes are also at higher risk, but the association between the two conditions is not as strong. For men, obesity and high blood pressure are bigger risk factors from diabetes.”

“AF is the most common arrhythmia in the world, and diabetes is one of the most common and costly health conditions. Our study points out that there is a connection between these two growing epidemics—one we should pay closer attention to, especially among women,” says Sumeet Chugh, MD, co-author and associate director of the Cedars-Sinai Heart Institute in Los Angeles.


“The gender differences need to be looked at more closely because they could have significant implications for how we treat diabetes in men and women.”

Atrial fibrillation occurs when the two upper chambers of the heart beat irregularly and too fast, causing blood to pool and clot. If the clot travels out of the heart and becomes lodged in an artery or in the brain, it can cause a stroke.


About 2.2 million Americans are diagnosed with AF; however, many more people have the condition but don’t know it. Diabetes affects more than 23 million Americans—and, according to the study, nearly 4 percent, or 1 million, have atrial fibrillation.

The study involved 17,372 patients in Kaiser Permanente’s diabetes registry in Oregon and Washington and an equal number of non-diabetic patients, matched for age and sex. Researchers used Kaiser Permanente HealthConnect®, the world’s largest civilian electronic health records system, to identify the non-diabetic patients.


The two groups were followed for an average of 7.2 years until Dec., 31, 2008, or until they died or left the health plan. At the start of the study 3.6 percent of the patients with diabetes had AF, vs. only 2.5 percent of the non-diabetic patients—a difference of 44 percent.


During the study period, diabetics were more likely than non-diabetics to develop AF. But after controlling for other factors like obesity, high blood pressure and age, the increased risk was only significant among women. Women with diabetes were 26 percent more likely than their non-diabetic counterparts to develop AF.

Authors include Gregory A. Nichols, PhD, Kaiser Permanente Center for Health Research; Kyndaron Reinier, PhD, and Sumeet Chugh, MD, co-author and associate director of the Cedars-Sinai Heart Institute in Los Angeles.



1003 Risk of bone fractures associated with use of diabetes drug [London School of Hygiene and Tropical Medicine]--Research published this week in the open access journal, PLoS Medicine, suggests that there is an association between thiazolidinediones – a type of drug introduced in the 1990s to treat type 2 diabetes – and bone fracture.

Ian Douglas of the London School of Hygiene and Tropical Medicine and colleagues searched the UK General Practice Research Database, a computerised record of clinical records from over 6 million patients registered at 400 general practice surgeries in the United Kingdom.


They identified 1,819 individuals aged 40 years or older who had a recorded bone fracture and who had been prescribed a thiazolidinedione at least once and conducted a self-controlled case-series study.


This is a study that compares how often an event (in this case bone fracture) occurs in a population of people during the period when they are taking a particular medication (in this case a thiazolidinedione drug) against the period when they are not taking that medication.


Adjusting for age (as older people are at a higher risk of bone fracture), the researchers found that in the group of people identified nearly one and half times as many fractures occurred when people were taking thiazolidinediones than when they were not taking these drugs.


The increased risk of fracture was observed in both men and women and applied to a wide range of fracture sites on the body. The study also found that the risk of fracture increased as the duration of treatment with the drug increased.

The main advantage of the study design is that it eliminates the possibility that differences between people who do and do not get prescribed a drug contribute to the results. The researchers acknowledge that as with any study there could be other sources of bias because it is observational and not a randomised trial.


Nevertheless, the findings are in keeping with findings from recent trials that suggested a link between thiazolidinediones and bone fracture. The researchers conclude that the results "should be taken into consideration in the wider debate surrounding the possible risks and benefits of treatment with thiazolidinediones.

Funding: This work was funded by a grant from the Wellcome Trust obtained by Professor Smeeth. The Wellcome Trust played no part in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript.

Competing Interests: IJD consults for and holds stock in GlaxoSmithKline. SJE is a co-opted member of the Pharmacovigilance Working Party at the European Medicines Agency (EMEA) and therefore advises on issues of drug safety relevant to Europe. SP consults for GlaxoSmithKline and is on the steering committee of the RECORD rosiglitazone study. LS reports no conflicts of interest.

Citation: Douglas IJ, Evans SJ, Pocock S, Smeeth L (2009) The Risk of Fractures Associated with Thiazolidinediones: A Self-controlled Case-Series Study. PLoSMed 6(9): e1000154. doi:10.1371/journal.pmed.1000154



1003 What proportion of psychotic illness is due to cannabis? [University of New South Wales Sydney]--In this week's PLoS Medicine, a team of researchers from Australia and the US, led by Louisa Degenhardt at the University of New South Wales, Sydney, makes the case for estimating the role that cannabis has worldwide as a risk factor for psychosis.

This estimation, says the team, will give an idea of how much impact cannabis has upon public health globally. The information in turn could be valuable for guiding health policymakers in deciding about health policies, services, and research.

The global impact of different diseases and risk factors upon population health is estimated by a high profile international research initiative called the Global Burden of Disease Project http://www.globalburden.org/. Some of the risk factors that the project assesses are smoking, high blood pressure, obesity, and alcohol use. But in the past the project has not examined cannabis as a risk factor, say Degenhardt and colleagues, because of concerns that the evidence linking cannabis use to psychosis is too weak.

Degenhardt and colleagues examine the studies that have shown a link between using cannabis and developing psychotic illnesses such as schizophrenia. Based on the strength of this evidence, and on the fact that cannabis use is a potentially preventable exposure, they argue that the Global Burden of Disease Project should include cannabis as a risk factor. The authors review lines of evidence which suggest that cannabis may be a particular risk for those vulnerable to developing the illness. They propose to model multiple possible relationships between cannabis and psychosis, including models of poorer outcomes for those who have developed the disorder.

Researchers in Australia, for example, included cannabis in their national study of the impact of risk factors and diseases upon population health. In estimating the impact of cannabis, the researchers assumed that the evidence was good enough to show a link between cannabis use and psychosis, suicide, and car crashes. "Even after assuming that these relationships were causal," say Degenhardt and colleagues, "cannabis was not a major contributor to disease burden in Australia, accounting for 0.2% of all disease burden, which amounted to 10% of the total burden attributable to all illicit drugs."

"These estimates are important for public policy purposes," they say, "because failure to make them allows untested estimates to be offered in public policy debate."

The authors argue that if the international community does not estimate the global impact of cannabis use, there will be important consequences. "There will be a reduced public health, policy, or research imperative, since there will be no estimated burden."
On the other hand, they say that "if we do attempt to estimate burden, future work will examine the accuracy of our estimates and refine them as evidence accumulates. Debates may emerge and (hopefully) improvements made as new evidence supports or challenges the assumptions made.''


Funding: This work was given funding support from the Australian Government Department of Health and Ageing. LD is the recipient of an Australian National Health and Medical Research Council (NHMRC) Senior Research Fellowship. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Citation: Degenhardt L, Hall WD, Lynskey M, McGrath J, McLaren J, et al. (2009) Should Burden of Disease Estimates Include Cannabis Use as a Risk Factor for Psychosis? PLoS Med 6(9): e1000133. doi:10.1371/journal.pmed.1000133








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