Seroepidemiology of pertussis in senior adults.
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Adolescent↗
Biomedical subjects
G W Reed
Publications and source records attributed to G W Reed.
Self-assessment in clinical health psychology: a model for ethical expansion of practice.
Society expects autonomous professions to ensure the competency of it practitioners, and professions should facilitate the continuing education and training of its members. Given the shift from psychology as a mental health profession to that of a health profession, the authors propose a self-assessment model for the individual practitioner to gauge his or her readiness to provide professional service in expanded areas of practice. This model could also be useful to the American Psychological Association, state psychological associations, and other purveyors of continuing education programs in systematically developing postgraduate experiences. A template for self-assessment that reflects well-accepted core domains of knowledge and skills is presented.
Education, Continuing↗
Role of weight loss and polyunsaturated fatty acids in improving metabolic fitness in moderately obese, moderately hypertensive subjects.
OBJECTIVE: While the exact regulatory interactions between blood pressure (BP) and obesity are not completely understood, weight loss provides an alternative to pharmacological treatment of hypertension. The intent of this repeated measures study of mild-moderate hypertensive, moderately obese subjects (34 females/18 males) was to determine if the reduction in BP following weight loss could be further affected by modifying the fatty acid (FA) composition of the hypocaloric diet. METHODS: BP, insulin sensitivity (Si), and lipid parameters were assessed before and after a 10-week calorie-restricted period. Subjects were randomized to one of three dietary groups differing in FA composition. Reduced body weight was maintained for a further 4 weeks and body composition assessment, BP and heart rate measurements were repeated. RESULTS: Weight loss (10%) in obese hypertensive subjects resulted in substantial improvements in BP, Si and lipid profile. There was no additional effect on the reduction in BP by the type of FA consumed in the diet. Following weight loss, there was a trend for omega-3 FAs to have a protective effect on fat-free mass loss (compared to omega-6 FA Group and saturated FA Group) and a trend to further enhance Si. There were significant improvements in circulating lipid profiles independent of the dietary FA intervention following the weight loss. The improvements in BP and body composition were maintained during the weight-loss maintenance period. The type of fat consumed had minor differential effects on some of the measured metabolic outcomes. CONCLUSION: These results provide strong support for modest weight loss as a treatment for hypertension.
Aldosterone↗
Can diet in conjunction with stress reduction affect the rate of increase in prostate specific antigen after biochemical recurrence of prostate cancer?
PURPOSE: Epidemiological and laboratory evidence indicates that a Western diet is associated with an increased incidence of prostate cancer. Specific components of the diet, such as high saturated fat, low fiber and high meat content, may have greatest clinical significance in the later stages of tumor promotion and progression. However, departure from the conventional diet is difficult to initiate and maintain. Therefore, we combined the well-known Mindfulness-Based Stress Reduction (MBSR) program with a low saturated fat, high-fiber, plant-based diet to determine the effect on the rate of change in prostate specific antigen (PSA) in patients with biochemical recurrence after prostatectomy. MATERIALS AND METHODS: We enrolled 10 men and their partners in a 4-month group-based diet and MBSR intervention. A pre-study post-study design in which each subject served as his own control was used to compare the rate of increase in and doubling time of PSA before and after intervention. RESULTS: The rate of PSA increase decreased in 8 of 10 men, while 3 had a decrease in absolute PSA. Results of the signed rank test indicated a significant decrease in the rate of increase in the intervention period (p = 0.01). Estimated median doubling time increased from 6.5 months (95% confidence interval 3.7 to 10.1) before to 17.7 months (95% confidence interval 7.8 to infinity) after the intervention. CONCLUSIONS: Our small study provides evidence that a plant-based diet delivered in the context of MBSR decreases the rate of PSA increase and may slow the rate of tumor progression in cases of biochemically recurrent prostate cancer. Larger-scale randomized studies are warranted to explore further the preventive and therapeutic potential of diet and lifestyle modification in men with prostate cancer.
Adenocarcinoma↗
Evaluation of a live, cold-passaged, temperature-sensitive, respiratory syncytial virus vaccine candidate in infancy.
A live-attenuated, intranasal respiratory syncytial virus (RSV) candidate vaccine, cpts-248/404, was tested in phase 1 trials in 114 children, including 37 1-2-month-old infants-a target age for RSV vaccines. The cpts-248/404 vaccine was infectious at 104 and 105 plaque-forming units in RSV-naive children and was broadly immunogenic in children >6 months old. Serum and nasal antibody responses in 1-2 month olds were restricted to IgA, had a dominant response to RSV G protein, and had no increase in neutralizing activity. Nevertheless, there was restricted virus shedding on challenge with a second vaccine dose and preliminary evidence for protection from symptomatic disease on natural reexposure. The cpts-248/404 vaccine candidate did not cause fever or lower respiratory tract illness. In the youngest infants, however, cpts-248/404 was unacceptable because of upper respiratory tract congestion associated with peak virus recovery. A live attenuated RSV vaccine for the youngest infant will use cpts-248/404 modified by additional attenuating mutations.
Antibodies, Viral↗
Management of shoulder dystocia.
OBJECTIVE: We sought to determine the management of shoulder dystocia currently practiced by physicians in the Middle Tennessee region and the frequency of use of the all-fours (Gaskin) maneuver in clinical practice. METHODS: A questionnaire was developed and sent to physicians in the Middle Tennessee area, asking how they would manage shoulder dystocia in specific practice scenarios. RESULTS: The methods most commonly used to manage shoulder dystocia are episiotomy, the McRoberts maneuver, and suprapubic pressure. Twenty-four percent of practitioners listed more than four options for the management of shoulder dystocia. Only 8% of those surveyed claimed knowledge of and use of the all-fours maneuver. CONCLUSION: Educational programs should be developed to inform practitioners of additional options for the management of shoulder dystocia.
Algorithms↗
Fetal surgery for myelomeningocele and the incidence of shunt-dependent hydrocephalus.
CONTEXT: Intrauterine closure of exposed spinal cord tissue prevents secondary neurologic injury in animals with a surgically created spinal defect; however, whether in utero repair of myelomeningocele improves neurologic outcome in infants with spina bifida is not known. OBJECTIVE: To determine whether intrauterine repair of myelomeningocele improves patient outcomes compared with standard care. DESIGN: Single-institution, nonrandomized observational study conducted between January 1990 and February 1999. SETTING: Tertiary care medical center. PARTICIPANTS: A sample of 29 study patients with isolated fetal myelomeningocele referred for intrauterine repair that was performed between 24 and 30 gestational weeks and 23 controls matched to cases for diagnosis, level of lesion, practice parameters, and calendar time. All infants were followed up for a minimum of 6 months after delivery. MAIN OUTCOME MEASURES: Requirement for ventriculoperitoneal shunt placement, obstetrical complications, gestational age at delivery, and birth weight for study vs control subjects. RESULTS: The requirement for ventriculoperitoneal shunt placement for decompression of hydrocephalus was significantly decreased among study infants (59% vs 91%; P = .01). The median age at shunt placement was also older among study infants (50 vs 5 days; P = .006). This may be explained by the reduced incidence of hindbrain herniation among study infants (38% vs 95%; P<.001). Following hysterotomy, study patients had an increased risk of oligohydramnios (48% vs 4%; P = .001) and admission to the hospital for preterm uterine contractions (50% vs 9%; P = .002). The estimated gestational age at delivery was earlier for study patients (33.2 vs 37.0 weeks; P<.001), and the birth weight of study neonates was less (2171 vs 3075 g; P<.001). CONCLUSIONS: Our study suggests that intrauterine repair of myelomeningocele decreases the incidence of hindbrain herniation and shunt-dependent hydrocephalus in infants with spina bifida, but increases the incidence of premature delivery.
Female↗
Mucosal immune response to trivalent live attenuated intranasal influenza vaccine in children.
Intranasal trivalent, cold-adapted, live attenuated influenza vaccine (CAIV-T) is a promising alternative to inactivated vaccine for protection against influenza in children. However, correlates of immunity are not well defined. To determine the mucosal immune response to CAIV-T, 19 children ages 15-55 months were randomized to receive two doses of CAIV-T or placebo. Influenza-specific IgA to the haemagglutinin of each of three contemporary strains was measured in nasal washes collected pre- and postvaccination using a kinetic enzyme-linked immunosorbent assay. After two doses of study drug, 62, 69 and 85% of CAIV-T recipients demonstrated a mucosal IgA response to influenza A/H1N1, A/H3N2, and B strains respectively; in comparison, 33, 0 and 17% of placebo recipients demonstrated an IgA response to the same strains (p = 0.35, 0.01 and 0.01). Overall, seropositive vaccinees were 4.5 times more likely to develop a mucosal immune response than an HAI response (p = 0.015). Two doses of CAIV-T induce a mucosal IgA response to all three influenza vaccine antigens in the majority of children. In addition, a mucosal antibody response may be the only indication of a vaccine take in a seropositive child.
Administration, Intranasal↗
Influenza-associated morbidity and mortality in young and middle-aged women.
CONTEXT: Data are limited on rates of influenza-associated hospitalizations and deaths among adults younger than 65 years. OBJECTIVE: To quantify serious morbidity and mortality from influenza for women younger than 65 years with and without certain chronic medical conditions, including human immunodeficiency virus infection. DESIGN: Retrospective cohort study. SETTING AND POPULATION: Women aged 15 to 64 years enrolled in the Tennessee Medicaid program from 1974 to 1993. MAIN OUTCOME MEASURE: All hospitalizations for and deaths from pneumonia, influenza, and other selected acute cardiopulmonary conditions for women with and without selected chronic medical conditions during 19 consecutive years. Influenza-attributable risk was calculated by subtracting event rates during peri-influenza season (November through April of each year when influenza virus was not circulating) from adjusted rates during influenza season (November through April when influenza virus was circulating). RESULTS: During the 19 years of the study, we identified 53607 acute cardiopulmonary hospitalizations and deaths. Rates of such events were consistently higher during influenza seasons than peri-influenza seasons. Among high-risk women, the estimated annual excess was 23 hospitalizations and deaths per 10000 women aged 15 to 44 years and 58 such events per 10000 women aged 45 to 64 years. The estimated annual excess mortality due to influenza was 2 deaths per 10000 high-risk women for both age groups combined. Among women with no identified high-risk conditions, estimated annual excess hospitalizations and deaths were 4 and 6 per 10000 women aged 15 to 44 and 45 to 64 years, respectively. CONCLUSIONS: Women younger than 65 years with certain chronic medical conditions experience substantial morbidity and mortality from acute cardiopulmonary events during influenza season. More effective targeting of these populations for annual influenza immunization is warranted.
Adolescent↗
Epidemiology of rotavirus in infants and protection against symptomatic illness afforded by primary infection and vaccination.
This study assessed the frequency of symptomatic and asymptomatic primary and secondary infections with rotavirus in children under 24 months and determined protection against symptomatic illness afforded by rhesus and human-rhesus rotavirus reassortant vaccines. Successive cohorts of children (n 236) were followed through five winter rotavirus seasons with cultures of each reported episode of diarrheal disease and serologic determination of rotavirus exposure on paired sera bracketing the winter. An average of 46% of children experienced rotavirus infection in each season with almost all infected by two years of age. The relative risk of rotavirus associated gastroenteritis in naive children versus naturally immune children was 2.4 (1.1, 5.3). The relative risk of rotavirus associated gastroenteritis in naive children versus vaccinees was 4.1 (1.6, 10.7). In a community with predominantly serotype G1 rotavirus rhesus rotavirus-based vaccines are as protective against rotavirus gastroenteritis as prior natural infection.
Antibodies, Viral↗
Effects of weight cycling induced by diet cycling in rats differing in susceptibility to dietary obesity.
OBJECTIVE: Although the majority of evidence in rodents does not support the view that weight cycling (consisting of bouts of food restriction and refeeding) promotes obesity, the effects of weight cycling on body weight regulation remain controversial. We have previously demonstrated that some rats within a strain are more susceptible to develop obesity than others when given free access to a high-fat diet. In this study, we tested the hypothesis that rats most susceptible to weight gain on a high-fat diet would also be most susceptible to weight gain as a consequence of weight cycling. RESEARCH METHODS AND PROCEDURES: Rats were provided a low-fat diet (12% corn oil) for 2 weeks, then given a high-fat diet (45% corn oil) for 2 weeks to identify those most (obesity prone) and least (obesity resistant) susceptible to weight gain. Half of each group was then subjected to three 30-day cycles of food restriction (10 days) and refeeding (20 days) [weight cycler (WC) rats]. The other half were allowed free access to the high-fat diet [control (CO) rats]. All rats were then followed for an additional 10 weeks, with free access to the high-fat diet. RESULTS: When considering the entire 160 days of the study, we found no evidence that WC rats relative to CO rats had increased body weight, increased body fat content, or elevated energy efficiency. We found no evidence that rats most prone to dietary obesity were also prone to weight gain after weight cycling. During the weight cycling phase (days 1 to 90), weight cycled groups consumed less energy and gained less weight than controls. During the follow-up phase, WC and CO rats did not differ significantly in weight gain or energy intake. DISCUSSION: In this study, weight cycling did not exacerbate the obesity produced by high-fat diet feeding.
Animals↗
The natural history of human immunodeficiency virus 1 infection in Haitian infants.
OBJECTIVES: The current study followed HIV-infected women through pregnancy and their infants through the first 2 years of life to determine the rate of vertical transmission of HIV infection from Haitian women, factors in maternal health and obstetrical history that might influence such transmission and the natural history of HIV infection in their affected offspring. STUDY DESIGN: The medical histories of 81 infants born of HIV-infected women and of a control group of 88 infants born to uninfected women were documented with close clinical and serologic follow-up. In addition to standard tests for persistence of HIV antibodies, the use of acid-dissociated p24 assays enabled us to assign some additional infants to the HIV-infected cohort. RESULTS: Transmission could be documented in 27% of infants born to HIV-infected women. Excess early deaths occurred in infants of HIV-infected women in Port-au-Prince with 60% of infected infants dead by 6 months of age. This is a more accelerated mortality than that in a group of 42 HIV-infected infants born of Haitian mothers living in Miami where 10% were dead at 6 months. Clinically, in 6 of 19 deaths in HIV-infected children in Haiti, failure to thrive and gastroenteritis lead to a systemic infection manifested as meningitis, sepsis or pneumonia as the immediate cause of death. CONCLUSIONS: Early mortality attributable to perinatally acquired AIDS was identified in Haiti. The comparison of data from Miami and Port-au-Prince suggests that environmental exposures in developing countries may be more operative in this early mortality than viral strain or maternal host factors, both of which might be expected to be similar between the two groups of Haitian ethnicity.
Adult↗
A negative arterial-portal venous glucose gradient increases net hepatic glucose uptake in euglycemic dogs.
We investigated whether a negative arterial-portal venous (a-pv) glucose gradient, or "portal signal," can increase net hepatic glucose uptake (NHGU) and decrease muscle glucose uptake at euglycemia as it does at hyperglycemia. Twenty 42-h fasted dogs were studied during a basal and two 120-min euglycemic periods (period I and period II). Glucagon was maintained at basal levels, and insulin was raised 3-fold (3xIns, n = 10) or 15-fold (15xIns, n = 10). During period I, dogs received glucose only peripherally. During period II, one-half of the dogs continued the peripheral infusion; the other one-half received glucose intraportally (4 mg. kg(-1). min(-1) and reduced peripheral glucose infusion). A negative a-pv glucose gradient was present during intraportal glucose infusion. All 3xIns and 15xIns dogs had similar NHGU in period I. In period II, it was 2.1 +/- 0.3 (3xIns) and 2.5 (15xIns) mg. kg(-1). min(-1) greater in the presence than in the absence of the portal signal (P < 0.001). The net glucose fractional extraction data paralleled NHGU. In 3xIns, but not in 15xIns, whole body nonhepatic glucose uptake was lower in the presence of the portal signal than in its absence. In conclusion, in hyperinsulinemic, but not hyperglycemic conditions, the portal signal is effective in activating NHGU. The inhibition of nonhepatic glucose uptake, on the other hand, is minimal under euglycemic as opposed to hyperglycemic conditions.
Animals↗
Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women.
This study sought to quantify influenza-related serious morbidity in pregnant women, as measured by hospitalizations for or death from selected acute cardiopulmonary conditions during predefined influenza seasons. The study population included women aged 15-44 years who were enrolled in the Tennessee Medicaid program for at least 180 days between 1974 and 1993. In a nested case-control study, 4,369 women with a first study event during influenza season were compared with 21,845 population controls. The odds ratios associated with study events increased from 1.44 (95% confidence interval (CI) 0.97-2.15) for women at 14-20 weeks' gestation to 4.67 (95% CI 3.42-6.39) for those at 37-42 weeks in comparison with postpartum women. A retrospective cohort analysis, which controlled for risk factors identified in the case-control study, identified 22,824 study events during 1,393,166 women-years of follow-up. Women in their third trimester without other identified risk factors for influenza morbidity had an event rate of 21.7 per 10,000 women-months during influenza season. Approximately half of this morbidity, 10.5 (95% CI 6.7-14.3) events per 10,000 women-months, was attributable to influenza. Influenza-attributable risks in comparable nonpregnant and postpartum women were 1.91 (95% CI 1.51-2.31) and 1.16 (95% CI -0.09 to 2.42) per 10,000 women-months, respectively. The data suggest that, out of every 10,000 women in their third trimester without other identified risk factors who experience an average influenza season of 2.5 months, 25 will be hospitalized with influenza-related morbidity.
Adolescent↗
Effects of 14 d of covert substitution of olestra for conventional fat on spontaneous food intake.
We conducted a double-blind, placebo-controlled, within-subject crossover study to investigate the effects of covert substitution of olestra, a non-energy-containing fat replacer, for conventional fat on food selection and energy intake in lean and obese men and women. Fifty-one subjects [BMI (kg/m2): 19-36; age: 25-63 y] were studied during two 14-d treatment periods (olestra and placebo), with a 7-d washout between feeding periods. During the intervention periods all foods were provided to the subjects. The aim was to produce a 10% dilution of total energy intake by replacing conventional triacylglycerol with olestra. To accomplish this, subjects were required to consume core foods providing 20-35 g olestra (depending on estimated energy needs) or the same foods containing placebo triacylglycerol. Additional items could be selected from foods that varied in macronutrient composition. When the two treatment periods were compared, total energy intake was 8% lower and fat intake 11% lower during the olestra period than during the placebo treatment period (P < 0.0001). Overall, subjects compensated for 15% of the fat and 20% of the total energy replaced by olestra. In absolute terms, subjects consumed 32% of total energy from fat during the placebo period and 27% of total energy from fat during the olestra period. Neither carbohydrate nor protein intake (g/d) differed between periods. The results did not differ as a function of BMI (lean compared with obese) or sex. Over a 2-wk period, covert substitution of olestra for conventional fat led to reductions in dietary fat intake and total energy intake in all subjects.
Adult↗
Clinical manifestations of human immunodeficiency virus infection in Haitian children.
OBJECTIVE: This study was designed to describe the characteristics of HIV-1 infection in children in Haiti and to assess its impact on morbidity and mortality. BACKGROUND: Throughout the developing world the female-to-male ratio of HIV-1 infection approaches 1:1, leading to a tremendous burden of vertically transmitted HIV-1 infection. The frequency of transmission, progression of disease and AIDS-defining clinical illnesses are not as well-described in this setting as in the industrial world. METHODS: Children were identified as being HIV-1-seropositive from case findings among family members of individuals presenting for screening at the GHESKIO Centers in Port-au-Prince, Haiti. Children who were seronegative from the same population were also enrolled and both groups were followed at regular intervals. The clinical course and illnesses associated with HIV infection were documented. RESULTS: Rapid progression to symptomatic disease and death was seen and a battery of physical findings enabled a clinician over time to assign with high sensitivity and specificity the diagnosis of AIDS to a child. Although many findings are similar, the presentation of HIV-1 infection in Haiti differed in significant ways from observations in the industrial world. In particular signs of malnutrition, failure to thrive and tuberculosis were more common in the Haitian population. CONCLUSION: Pediatric HIV-1 infection in Haiti differs significantly from the illness in the industrial world. Early mortality poses a particular difficulty in diagnosing and ascribing mortality to HIV-1 infection.
Acquired Immunodeficiency Syndrome↗
Neonatal tetanus in the United States: a sentinel event in the foreign-born.
BACKGROUND: Neonatal tetanus occurred in a 7-day-old infant born to Mexican immigrant parents in Tennessee in February, 1995. This was the first patient with neonatal tetanus reported in the United States since 1989. METHODS: We interviewed the infant's mother and physicians and reviewed the medical record. We conducted a telephone survey of 103 (17%) of the 609 licensed obstetrician/gynecologists practicing in Tennessee to assess vaccination history-taking practices during prenatal care. RESULTS: The mother was a 30-year-old gravida 4 para 3 woman who grew up in rural Mexico. After moving to the United States in 1987, she had delivered two children before this delivery. The hospital-based delivery and nursery stay in February, 1995, were uncomplicated. On the sixth day of life the infant became irritable and developed muscle stiffness. The next day he was examined by a pediatrician who diagnosed neonatal tetanus. The infant recovered fully after a 2-month hospitalization. The survey of obstetrical practices revealed that 61 (59%) of 103 respondents asked about the patient's vaccination status during prenatal care. However, of all respondents, only 14 (14%) confirmed that they specifically asked about prior tetanus vaccinations. Tetanus toxoid was available in 47% of offices on the day of the survey. CONCLUSIONS: Neonatal tetanus can still occur in the United States. This infant's immigrant mother had multiple missed opportunities to be vaccinated against tetanus during her three pregnancies in this country. Health care providers should ask patients about their vaccination status, particularly those patients who are foreign-born or who grew up outside the United States.
Emigration and Immigration↗
Twenty years of outpatient respiratory syncytial virus infection: a framework for vaccine efficacy trials.
BACKGROUND: Respiratory syncytial virus (RSV) is the most important viral respiratory pathogen of infancy and childhood. Much has been written about inpatients with severe disease. Inpatients, however, represent only a minority of RSV-infected children. We studied the characteristics of symptomatic outpatient RSV infection in healthy children to gain a better understanding of RSV disease and to provide a background for the testing of intervention strategies in children without high-risk conditions. METHODS: A total of 1113 children were followed during 20 consecutive RSV seasons. Signs and symptoms of respiratory infection were monitored. Cultures were obtained for febrile upper respiratory infection, acute otitis media, and lower respiratory infection (LRI). Rates of febrile upper respiratory infection, acute otitis media, LRI, and hospitalization were calculated. Given those rates, numbers of children needed to demonstrate efficacy of a vaccine product were calculated. RESULTS: Mild disease from RSV infection lacked some of the classic features of RSV infection seen in hospitalized children. Involvement of the lower respiratory tract was, however, noted to be much higher in RSV infection than it was in infection with other viral respiratory pathogens. LRI was, therefore, considered the best candidate endpoint for vaccine trials. A product with 60% efficacy could be proven, with a power of 0.8, to be efficacious with as few as 1500 infants. CONCLUSIONS: RSV infection is common and often involves the lower respiratory tract, even in outpatients. Our 20-year study of RSV infection provides a basis for calculation of sample sizes to be used in trials of vaccine candidates.
Ambulatory Care Facilities↗