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In 2019, a 42-year-old African man who works as an Ebola virus disease (EVD) researcher traveled from the Democratic Republic of Congo (DRC), near an ongoing EVD epidemic, to Philadelphia and presented to the Hospital of the University of Pennsylvania Emergency Department with altered mental status, vomiting, diarrhea, and fever. He was classified as a “wet” person under investigation for EVD, and his arrival activated our hospital emergency management command center and bioresponse teams. He was found to be in septic shock with multisystem organ dysfunction, including circulatory dysfunction, encephalopathy, metabolic lactic acidosis, acute kidney injury, acute liver injury, and diffuse intravascular coagulation. Critical care was delivered within high-risk pathogen isolation in the ED and in our Special Treatment Unit until a diagnosis of severe cerebral malaria was confirmed and EVD was definitively excluded.
This report discusses our experience activating a longitudinal preparedness program designed for rare, resource-intensive events at hospitals physically remote from any active epidemic but serving a high-volume international air travel port-of-entry.
Birth weight and early growth have been associated with later blood pressure. However, not all studies consistently find a significant reduction in blood pressure with an increase in birth weight. In addition, the relative importance of birth weight and of other lifestyle and environmental factors is often overlooked and the association is rarely studied in adolescents. We investigated early life predictors, including birth weight, of adolescent blood pressure in the Gateshead Millennium Study (GMS). The GMS is a cohort of 1029 individuals born in 1999–2000 in Gateshead in Northern England. Throughout infancy and early childhood, detailed information were collected, including birth weight and measures of height and weight. Assessments of 491 returning participants at age 12 years included measures of body mass and blood pressure. Linear regression and path analysis were used to determine predictors and their relative importance on blood pressure. Birth weight was not directly associated with blood pressure at the age of 12. However, after adjustment for contemporaneous body mass index (BMI), an inverse association of standardized birth weight on systolic blood pressure was significant. The relative importance of birth weight on later systolic blood pressure was smaller than other contemporaneous body measures (height and BMI). There was no independent association of birth weight on blood pressure seen in this adolescent population. Contemporaneous body measures have an important role to play. Lifestyle factors that influence body mass or size, such as diet and physical activity, where interventions are directed at early prevention of hypertension should be targeted.
We explored whether supported (SJE) or coordinated joint engagement (CJE) between mothers recruited from the community and their 24-month-old children who were slow-to-talk at 18 months old were associated with child language scores at ages 24, 36, and 48 months (n = 197). We further explored whether SJE or CJE modified the concurrent positive associations between maternal responsive behaviours and language scores. Previous research has shown that SJE, maternal expansions, imitations, and responsive questions were associated with better language scores. Our main finding was that SJE but not CJE was consistently positively associated with 24- and 36-month-old expressive and receptive language scores, but not with 48-month-old language scores. SJE modified how expansions and imitations, but not responsive questions, were associated with language scores; the associations were evident in all but the highest levels of SJE. Further research is necessary to test these findings in other samples before clinical recommendations can be made.
Schizophrenia (SCZ) and psychotic bipolar disorder (PBD) share considerable overlap in clinical features, genetic risk factors and co-occurrence among relatives. The common and unique functional cerebral deficits in these disorders, and in unaffected relatives, remain to be identified.
A total of 59 healthy controls, 37 SCZ and 57 PBD probands and their unaffected first-degree relatives (38 and 28, respectively) were studied using resting-state functional magnetic resonance imaging (rfMRI). Regional cerebral function was evaluated by measuring the amplitude of low-frequency fluctuations (ALFF). Areas with ALFF alterations were used as seeds in whole-brain functional connectivity analysis. We then tested whether abnormalities identified in probands were present in unaffected relatives.
SCZ and PBD probands both demonstrated regional hypoactivity in the orbital frontal cortex and cingulate gyrus, as well as abnormal connectivity within striatal-thalamo-cortical networks. SCZ probands showed greater and more widely distributed ALFF alterations including the thalamus and bilateral parahippocampal gyri. Increased parahippocampal ALFF was related to positive symptoms and cognitive deficit. PBD patients showed uniquely increased functional connectivity between the thalamus and bilateral insula. Only PBD relatives showed abnormal connectivity within striatal-thalamo-cortical networks seen in both proband groups.
The present findings reveal a common pattern of deficits in frontostriatal circuitry across SCZ and PBD, and unique regional and functional connectivity abnormalities that distinguish them. The abnormal network connectivity in PBD relatives that was present in both proband groups may reflect genetic susceptibility associated with risk for psychosis, but within-family associations of this measure were not high.
Large majorities in nearly every country support democracy, according to studies of cross-national surveys. But many of these reports have treated as missing data persons who did not provide a substantive response when asked to offer an opinion about the suitability of democracy as a regime type for their country, which has led to substantial overestimates of expressed support for democracy in some countries. This article discusses the consequences of excluding such nonsubstantive responses and offers suggestions to improve the study of popular support for democracy.
Between 1972 and 1988 we have serologically confirmed 103 Coxiella burnetii infections: 46 were acute, 5 were chronic, 52 represented past infections. Details of 61 cases are presented.
Of acute cases 80 % had respiratory involvement; at least 63 % had pneumonias. The incidence (22%) of neurological complications was of particular interest; 40% of these patients had prolonged sequelae. One acutely ill patient died of fulminating hepatitis. Patients with pre-existing pathology or immunosuppression were especially susceptible to C. burnetii.
In the absence of acute sera, the complement fixation test alone provided inadequate differentiation between recent and past Q fever: phase II titres persisted at ⋝ 80 for more than 1 year after the acute infection in 15 cases; maximum duration of persistence was 14 years. Three patients acquired high phase I titres.
Only 5% of cases had chronic Q fever, but in view of the diverse sequelae observed in this series, we suggest that long-term serological and clinical follow-up of all cases of Q fever is fully justified.
To describe an outbreak of invasive methicillin-resistant Staphylococcus aureus (MRSA) infection after percutaneous needle procedures (acupuncture and joint injection) performed by a single medical practitioner.
A medical practitioner's office and 4 hospitals in Perth, Western Australia.
Eight individuals who developed invasive MRSA infection after acupuncture or joint injection performed by the medical practitioner.
We performed a prospective and retrospective outbreak investigation, including MRSA colonization surveillance, environmental sampling for MRSA, and detailed molecular typing of MRSA isolates. We performed an infection control audit of the medical practitioner's premises and practices and administered MRSA decolonization therapy to the medical practitioner.
Eight cases of invasive MRSA infection were identified. Seven cases occurred as a cluster in May 2004; another case (identified retrospectively) occurred approximately 15 months earlier in February 2003. The primary sites of infection were the neck, shoulder, lower back, and hip: 5 patients had septic arthritis and bursitis, and 3 had pyomyositis; 3 patients had bacteremia, including 1 patient with possible endocarditis. The medical practitioner was found to be colonized with the same MRSA clone [ST22-MRSA-IV (EMRSA-15)] at 2 time points: shortly after the first case of infection in March 2003 and again in May 2004. After the medical practitioner's premises and practices were audited and he himself received MRSA decolonization therapy, no further cases were identified.
This outbreak most likely resulted from a breakdown in sterile technique during percutaneous needle procedures, resulting in the transmission of MRSA from the medical practitioner to the patients. This report demonstrates the importance of surveillance and molecular typing in the identification and control of outbreaks of MRSA infection.
The Macarthur-Bates Communicative Development Inventories (CDI) have been used widely to document early communicative development. The paper reports on a large community sample of 1,447 children recruited from low, middle and high socioeconomic (SES) areas across metropolitan Melbourne, Australia. Regression analyses were conducted to determine the extent to which communicative behaviours reported at 0 ; 8 and 1 ; 0 predicted vocabulary development at 1 ; 0 and 2 ; 0. In support of previous findings with smaller, often less representative samples, gesture and object use at 1 ; 0 were better predictors of 2 ; 0 vocabulary than were gesture and object use at 0 ; 8. At 1 ; 0, children from the lower SES groups were reported to understand more words than children from the higher SES groups, but there were no SES differences for words produced at 1 ; 0 or 2 ; 0. The findings add to our understanding of the variability in the development of early communicative behaviours.
A prospective controlled study with repeated measures before and after surgery examined the medical, surgical, and health outcomes of gastrostomy for children with disabilities at a tertiary paediatric referral centre in the North Thames area, UK. Anthropometric measures included weight, mid-upper-arm and head circumference. Five-day prospective food diaries were completed and data on physical health and surgical outcomes recorded. Seventy-six children participated and underwent gastrostomy (44 males, 32 females; median age 3y 4mo, range 4mo–17y 5mo), and 35/76 required an anti-reflux procedure. Categories of disability were: cerebral palsy (32/76), syndrome of chromosomal or other genetic origin (25/76), slowly progressive degenerative disease (11/76), and unconfirmed diagnosis (8/76). Most children had gross motor difficulties (99%) and were non-ambulant (83%). Oromotor problems were identified in 78% of children, 69% aspirated, and 65% were fed nasogastrically before surgery. The mean weight before surgery was –2.84 standard deviation score (SDS; SD 2.21, range –9.8 to 3.4). Two-thirds of children achieved catch-up growth postoperatively: weight-for-age (mean difference 0.51 SDS, 95% CI 0.23–0.79, p=0.001) and mid-upper arm circumference (mean difference 1.12cm, 95% confidence interval 0.50–1.75, p=0.001). Health gains included a reduction in drooling, secretions, vomiting, and constipation. Major surgical complications were found in 13/74 children. The study provides evidence that catch-up growth and health gains are possible following gastrostomy.
The moisture content of horse hoof horn is important as it affects its function, quality and mechanical properties. It is believed for horse hoof horn that there is an inverse relationship between the amount of water present and stiffness, or the ability of hoof horn to resist deformation. The majority of studies, until the work of Leach (1980) and Douglas et al. (1996) concentrated on quantitative values for moisture content for the full hoof wall depth (HWD) for horse hoof horn. Douglas et al. (1996) divided the hoof wall into inner and outer wall samples and showed a moisture content of 28% for the outer wall and 35% for the inner wall, confirming a dorsopalmar increase in moisture content. Whether a similar gradient exists for donkey hoof horn is not known. The existence of such a dorso-palmar moisture gradient may have a profound effect on the mechanical properties of the hoof horn and would further contribute towards the understanding of how moisture content affects the function of the hoof.
The moisture content of keratinous materials such as hoof horn is important as the presence of moisture has an inverse relationship on the mechanical properties of hoof horn and may have a subsequent effect on the function of the hoof. Methods previously used to dehydrate samples to calculate the moisture content of hoof horn vary considerably (Hopegood, 2002). Subsequent comparison of results is therefore unreliable. A comparison of different methods of dehydrating hoof horn was therefore carried out to establish a standardised protocol for dehydrating hoof horn to assess its moisture content. The moisture content of donkey hoof horn from normal animals and those with laminitis has not been reported. Maclean (1971) established that the moisture content of cattle suffering from laminitis was significantly higher than normal hooves. The resultant standardised protocol from the first part of this study was then used to compare the moisture content of hoof horn samples taken from horses, donkeys and those donkeys that had suffered from laminitis.
Background. The paper describes a randomized controlled trial of targeting cognitive behavioural therapy (CBT) during prodromal or early signs of relapse in schizophrenia. We hypothesized that CBT would result in reduced admission and relapse, reduced positive and negative symptoms, and improved social functioning.
Method. A total of 144 participants with schizophrenia or a related disorder were randomized to receive either treatment as usual (TAU) (N=72) or CBT+TAU (N=72). Participants were prospectively followed up between entry and 12 months.
Results. At 12 months, 11 (15·3%) participants in the CBT group were admitted to hospital compared to 19 (26·4%) of the TAU group (hazard ratio=0·53, P=0·10, 95% CI 0·25, 1·10). A total of 13 (18·1%) participants in CBT relapsed compared to 25 (34·7%) in TAU (hazard ratio=0·47, P<0·05, 95% CI 0·24, 0·92). In addition, the CBT group showed significantly greater improvement in positive symptoms, negative symptoms, global psychopathology, performance of independent functions and prosocial activities.
Conclusions. The study provides evidence for the feasibility and effectiveness for targeting CBT on the appearance of early signs of relapse in schizophrenia. The results are discussed in context of the study's methodological limitations.
Sudden death has been linked to antipsychotic therapy but the relative risk associated with specific drugs is unknown.
To assess the risk of sudden unexplained death associated with antipsychotic drug therapy and its relation to drug dose and individual agents.
A case-control study of psychiatric in-patients dying suddenly in five hospitals in the north-east of England and surviving controls matched for age, gender and mental disorder. Logistic regression analysis was used to identify significant risk factors, and odds ratios were calculated.
Sixty-nine case-control clusters were identified. Probable sudden unexplained death was significantly associated with hypertension, ischaemic heart disease and current treatment with thioridazine (adjusted odds ratio=5.3, 95% CI 1.7–16.2, P=0.004). There was no significant association with other individual antipsychotic drugs.
Thioridazine alone was associated with sudden unexplained death, the likely mechanism being drug— induced arrythmia.
To determine environmental risk factors for sporadic E. coli O157 infection in Scotland we undertook a prospective, matched case-control study between 1 October 1996 and 31 March 1999. One hundred and eighty-three cases and 545 matched controls were recruited. Contact with animal faeces (OR = 3·65; 95% CI 1·81, 7·34; P < 0·0005) and likely contact with animal faeces (OR = 4·8; 95% CI 2·42, 9·48; P < 0·0005) emerged as strong risk factors for infection. Certain exposures (mainly food-related) were inversely associated with infection i.e. were statistically protective. Most striking was the consumption of bottled water (OR = 0·28; 95% CI 0·15, 0·52; P < 0·0005). Transmission of E. coli O157 does not occur simply through contaminated food. Members of the public need to be aware of the potential for acquiring E. coli O157 through contamination of the environment with animal faeces so that they may take measures to mitigate their risk.