Kristina W. Kintziger

Dengue outbreak in Key West, Florida, USA, 2009.

After 3 dengue cases were acquired in Key West, Florida, we conducted a serosurvey to determine the scope of the outbreak. Thirteen residents showed recent infection (infection rate 5%; 90% CI 2%–8%), demonstrating the reemergence of dengue in Florida. Increased awareness of dengue among health care providers is needed.

Personal health records and hypertension control: a randomized trial.

PURPOSE To examine the impact of a personal health record (PHR) in patients with hypertension measured by changes in biological outcomes, patient empowerment, patient perception of quality of care, and use of medical services. METHODS A cluster-randomized effectiveness trial with PHR and no PHR groups was conducted in two ambulatory clinics. 453 of 1686 (26.4%) patients approached were included in the analyses. A PHR tethered to the patients electronic medical record (EMR) was the primary intervention and included security measures, patient control of access, limited transmission of EMR data, blood pressure (BP) tracking, and appointment assistance. BP was the main outcome measure. Patient empowerment was assessed using the Patient Activation Measure and Patient Empowerment Scale. Quality of care was assessed using the Clinician and Group Assessment Score (CAHPS) and the Patient Assessment of Chronic Illness Care. Frequency of use of medical services was self-reported. RESULTS No impact of the PHR was observed on BP, patient activation, patient perceived quality, or medical utilization in the intention-to-treat analysis. Sub-analysis of intervention patients self-identified as active PHR users (25.7% of those with available information) showed a 5.25-point reduction in diastolic BP. Younger age, self-reported computer skills, and more positive provider communication ratings were associated with frequency of PHR use. CONCLUSIONS Few patients provided with a PHR actually used the PHR with any frequency. Thus simply providing a PHR may have limited impact on patient BP, empowerment, satisfaction with care, or use of health services without additional education or clinical intervention designed to increase PHR use. CLINICAL TRIAL REGISTRATION NUMBER http://ClinicalTrials.gov Identifier: NCT01317537.

Late Life Depression: A Global Problem with Few Resources

Mental health disorders in terms of an aging population are discussed in this review. Statistics on depression in later life are presented with a discussion of physical health comorbidities. This presentation postulates that the health care infrastructure currently in place is inadequate to meet the present, much less the future, needs of this population. The care of the depressed elder will require the coordinated effort of psychiatrists, psychologists, social workers, nurse practitioners and advanced practice psychiatric nurses, internal medicine gerontologists, internal medicine and family medicine general physicians, community agencies, and volunteers.

Cardiac implantable electronic device infection in patients with end-stage renal disease

INTRODUCTION Cardiac implantable electronic devices (CIED) are increasingly being used in end-stage renal disease (ESRD) patients. These patients have a high risk of device infection. OBJECTIVES To study the optimal management of device infections in patients with ESRD. METHOD We used the United States Renal Data System (USRDS) to assess the presence of a CIED and associated comorbidities, risk factors for infection, and mortality following device extraction or medical management in ESRD patients with CIED infection. Univariable, multivariable, and survival analyses were performed using USRDS data from 2005 to 2009. RESULTS Of 546,769 patients, 6.4% had CIED and 8.0% of those developed CIED infection. The major risk factors for device infection were black race, temporary dialysis catheter, and body mass index >25. Patients with artificial valves were excluded from the analysis. Only 28.4% of infected CIED were removed. CIED removal was more common in those with congestive heart failure. The median time to death following diagnosis of a CIED infection was 15.7 months versus 9.2 months for those treated via device extraction versus medical-only therapy (hazard ratio: 0.75; 95% confidence interval: 0.68-0.82). CONCLUSION Patients with ESRD and infected CIEDs have a poor prognosis. Rates of device extraction are low, but this strategy appears to be associated with modest improvement in survival.

Wild Mushroom Exposures in Florida, 2003-2007

Objective. Exposure to wild mushrooms can lead to serious illness and death. However, there is little information on the epidemiology of mushroom exposures nationwide, as there is no specific surveillance for this outcome. We described mushroom exposures in Florida using available data sources. Methods. We performed a population-based study of mushroom exposure calls to the Florida Poison Information Center Network (FPICN) and cases of mushroom poisoning reported in hospital inpatient and emergency department (ED) data from 2003 through 2007. Results. There were 1,538 unduplicated mushroom exposures reported during this period, including 1,355 exposure calls and 428 poisoning cases. Most exposures reported to FPICN occurred in children ≤6 years of age (45%) and males (64%), and most were unintentional ingestions (60%). Many exposures resulted in no effect (35%), although 21% reported mild symptoms that resolved rapidly, 23% reported prolonged/systemic (moderate) symptoms, and 1% reported life-threatening effects. Most calls occurred when in or en route to a health-care facility (43%). More than 71% of poisonings identified in hospital records were managed in an ED, and most occurred in young adults 16–25 years of age (49%), children ≤6 years of age (21%), adults >25 years of age (21%), and males (70%). No deaths were reported. Conclusions. Combined, these data were useful for describing mushroom exposures. Most exposures occurred in males and in young children (≤6 years of age) and young adults (16–25 years of age), with 78% resulting in contact with a health-care facility. Education should target parents of young children—especially during summer, when mushrooms are more abundant—and young adults who are likely experimenting with mushrooms for their potential hallucinogenic properties.

Severe Leptospirosis Similar to Pandemic (H1N1) 2009, Florida and Missouri, USA

To the Editor: Leptospirosis is caused by pathogenic spirochetes of the genus Leptospira and transmitted through direct contact of skin or mucous membranes with urine or tissues of Leptospira-infected animals or through indirect contact with contaminated freshwater or soil. Leptospirosis shares common clinical signs with influenza, including fever, headache, myalgia, and sometimes cough and gastrointestinal symptoms. During 2009, acute complicated influenza-like illness (ILI) and rapid progressive pneumonia were often attributed to pandemic (H1N1) 2009; however, alternative final diagnoses were reported to be common (1). We report 3 cases of severe leptospirosis in Florida and Missouri with clinical signs similar to those of pandemic (H1N1) 2009. Patient 1 was a 40-year-old Florida man who sought treatment at an emergency department after a 4-day history of fever, myalgia, calf pain, malaise, and headache in July 2009. ILI was diagnosed. Laboratory testing was not performed, and the patient was instructed to take ibuprofen. Three days later, jaundice developed. He was admitted to an intensive-care unit with a diagnosis of hepatitis and acute renal failure. The man raised horses, goats, and chickens on his farm and was frequently employed to control rat infestations at an auto parts store and warehouse. Leptospirosis was suspected. Doxycycline was administered, and the man recovered and was discharged on the eighth day of hospitalization. Leptospira-specific immunoglobulin M antibodies were detected by dot blot (ARUP Laboratories, Salt Lake City, Utah, USA) on the second of paired consecutive blood specimens. Patient 2 was a 17-year-old Missouri woman with a history of obesity. She was hospitalized in August 2009 with a 5-day history of fever, myalgia, calf pain, malaise, headache, nausea, vomiting, dyspnea, and cough, complicated by acute renal failure. The diagnosis on admission was viral infection. On the third day of hospitalization, severe pneumonia and respiratory failure developed, and she was administered vancomycin, piperacillin/tazobactam, levofloxacin, and doxycycline. She died the same day. Ten days before illness onset, she had swum in a creek near her residence. Patient 3 was a 59-year-old Florida man with a history of obesity and diabetes mellitus. He sought treatment at a clinic in September 2009 and reported a 5-day history of fever, myalgia, malaise, nausea, abdominal pain, and dyspnea. He was treated for gastritis. Two days later, he came to an emergency department and was admitted to the hospital with severe pneumonia and multiorgan failure; he died the next day. The man had frequently engaged in activities to control rat infestations on the farm where he raised chickens, pigs, and goats. Although patients 2 and 3 were neither tested nor treated for influenza before they died, their clinical signs and rapidity of death prompted postmortem suspicion of pandemic (H1N1) 2009. Autopsies were performed and formalin-fixed tissues were submitted to the Centers for Disease Control and Prevention (Atlanta, GA, USA). Histopathologic evaluation of both patients demonstrated extensive pulmonary hemorrhage and interstitial nephritis (Figure, panels A and B), features consistent with leptospirosis. Immunohistochemical tests for leptospirosis, spotted fever group rickettsiae, and influenza A were performed on multiple tissues obtained from patients 2 and 3. Immunohistochemical evidence of leptospiral infection was identified in lung, liver, kidney, heart, and spleen tissue in both patients (Figure, panels C and D). Figure Photomicrographs of lung, liver, and kidney sections from patient 2 during study, Missouri and Florida, USA, 2009. Hematoxylin and eosin stain showed pulmonary hemorrhage (A) (original magnification ×10) and interstitial nephritis (B) (original ... These cases of severe leptospirosis were reported during the 2009 influenza pandemic. Although pulmonary hemorrhage (experienced by patients 2 and 3) is increasingly recognized as a severe manifestation of leptospirosis (2), it is also a known complication of influenza (3). ILI was initially diagnosed in patient 1, but symptom progression and clinical complications, combined with a history of animal exposure, prompted the physician to consider leptospirosis and to initiate appropriate antimicrobial drug therapy. Autopsies are critical in determining the reasons for death after undiagnosed illness. Pulmonary involvement in cases of leptospirosis is characterized by congestion and hemorrhage, usually without prominent inflammatory infiltrates (4); pulmonary involvement in cases of severe pandemic (H1N1) 2009 typically manifests as diffuse alveolar damage (5). Postmortem diagnosis of leptospirosis was supported by characteristic histopathologic findings, including pulmonary hemorrhage and interstitial nephritis, and was confirmed by immunohistochemical tests. Our report illustrates the need for autopsies in unexpected deaths, even if the cause appears obvious in a specific clinical and epidemic setting. Leptospirosis ceased being nationally notifiable in the United States in 1994 and is likely underdiagnosed because it is not routinely considered in differential diagnoses. However, outbreaks with exposures similar to the case-patients we studied have been periodically reported in the United States (6–8). Because leptospirosis commonly manifests as acute febrile illness, cases can be underrecognized during infectious-disease epidemics (e.g., dengue) (9). Leptospirosis should be included in the differential diagnosis of acute febrile illness in the United States and other industrialized countries. Epidemiologic clues include recreational or occupational water exposure; animal exposure (including rodents) in the home or the workplace, travel to tropical areas, and water exposure during travel. These risk factors for leptospirosis are increasing in industrialized countries (10). Thorough patient-history reviews and consideration of alternative diagnoses are needed for cases of respiratory illness during an influenza pandemic.

A comprehensive evaluation of the burden of heat-related illness and death within the Florida population

The failure of the human body to thermoregulate can lead to severe outcomes (e.g., death) and lasting physiological damage. However, heat-related illness (HRI) is highly preventable via individual- and community-level modification. A thorough understanding of the burden is necessary for effective intervention. This paper describes the burden of severe HRI morbidity and mortality among residents of a humid subtropical climate. Work-related and non-work-related HRI emergency department (ED) visits, hospitalizations, and deaths among Florida residents during May to October (2005–2012) were examined. Sub-groups susceptible to HRI were identified. The age-adjusted rates/100,000 person-years for non-work-related HRI were 33.1 ED visits, 5.9 hospitalizations, and 0.2 deaths, while for work-related HRI/100,000 worker-years there were 8.5 ED visits, 1.1 hospitalizations, and 0.1 deaths. The rates of HRI varied by county, data source, and work-related status, with the highest rates observed in the panhandle and south central Florida. The sub-groups with the highest relative rates regardless of data source or work-relatedness were males, minorities, and rural residents. Those aged 15–35 years had the highest ED visit rates, while for non-work-related hospitalizations and deaths the rates increased with age. The results of this study can be used for targeted interventions and evaluating changes in the HRI burden over time.

Bacteremia in Hemodialysis Patients With Hepatitis C

Background:Hepatitis C virus (HCV) infection and bacteremia are common comorbidities in hemodialysis patients. A specific relationship between HCV infection and bacteremia has not been defined; however, there is evidence of immune compromise in both HCV-infected and uremic patients, suggesting that this group may be at higher risk for infection. Methods:We investigated risk factors and mortality associated with bacteremia in HCV-infected hemodialysis patients from the United States Renal Data System. Results:During the 4-year study period, HCV was present in 2.1% of 355,084 patients initiating hemodialysis. When compared with the total population, the rate of bacteremia was significantly higher in patients with HCV (38.3% versus 21.8%). The adjusted relative risk (RR) for bacteremia was higher in HCV versus all patients (relative risk, 95% confidence interval [CI]) in the presence of methicillin-resistant Staphylococcus aureus infection (2.64, CI: 2.58–2.70 versus 2.32, CI: 2.27–2.38), HIV (1.93, CI: 1.85–2.02 versus 1.86, CI: 1.77–1.95) urinary tract infection (1.79, CI: 1.77, 1.82 versus 1.64, CI: 1.61–1.67) and cirrhosis (1.49, CI: 1.45–1.54 versus 1.29, CI: 1.25–1.34). The hazard ratio (95% CI) for death was higher in HCV versus all patients at 1.69 (CI: 1.58–1.81) versus 1.54 (CI: 1.53–1.56). Conclusions:These data indicate that several clinical covariates increase the risk of bacteremia in hemodialysis patients, with the magnitude of that risk being further increased by HCV infection. Improving outcomes in HCV-infected hemodialysis patients will likely be dependent on aggressive diagnosis and treatment of both HCV and bacteremia.

Repeat Western Blot Testing After Receiving an HIV Diagnosis and Its Association with Engagement in Care

Objectives: To examine the prevalence of and factors associated with potentially unnecessary repeat confirmatory testing after initial HIV diagnosis and the relationship of repeat testing to medical care engagement. Design: South Carolina HIV/AIDS surveillance data for 12,504 individuals who were newly diagnosed with HIV infection between January 1997 and December 2008 were used for this analysis. State law requires that all positive Western blot [WB] results be reported regardless of frequency. Methods: HIV-infected persons, diagnosed from 1997-2008 and followed through 2009, with repeat positive WB results were compared to those who did not have repeat positive WB results. We defined repeat positive testing as documentation of one or more positive WB obtained ≥90 days following initial WB confirmatory result. HIV care engagement for the period from 2007-2009 was assessed by documentation of CD4+ T-cell/viral load reports to the South Carolina HIV/AIDS surveillance system during each six-month period of a calendar year for those individuals diagnosed prior to the assessment period and still alive at the end. Relative risk [RR] with 95% confidence intervals [CI] and multivariable general linear models were used to assess if any covariates of interest were independently associated with repeat positive confirmatory testing. Results: A total of 4,237 [34%] of 12,504 HIV-infected individuals had results of repeat positive WB testing reported to the surveillance system during 1997-2008. Persons who had repeat positive WB testing were more likely than persons who did not have repeat WB testing to have progressed to AIDS >1 year following diagnosis [RR: 1.70; 95% CI: 1.61, 1.80] and to be consistently in care [RR: 1.35; 95% CI: 1.24, 1.47] or have sporadic care [RR: 1.80; 95% CI: 1.68, 1.94]. Discussion: Having repeat positive WB tests may be a marker of engaging HIV care. However, given the limited resources available for care, it is important that healthcare reform policy and clinical recommendations promote improvements in communications about previous test results.

Comparing the geographic distribution and location characteristics of HIV-seropositive and HIV-seronegative individuals with a diagnosis of cancer living in the southeast US

As HIV-seropositive individuals live longer, they are more likely to acquire conditions seen in the general population. Excluding AIDS-defining malignancies, HIV-seropositive individuals are more likely to develop cancer than individuals in the general population. In order to better inform future screening and prevention efforts in this population, we compared the geographic distribution and location characteristics of HIV-seropositive and HIV-seronegative cancer cases in South Carolina (SC). To do this we obtained linked HIV and cancer data from the SC enhanced HIV/AIDS Reporting System and Central Cancer Registry. Location-related information on SC residents (e.g., employment status, income levels, race of householder, and educational attainment) was obtained from the 2000 US Census. Hotspot analyses were used to analyze the geographic distribution of HIV-seropositive and HIV-seronegative cancer cases using the Getis-Ord Gi* statistic. Poisson regression analyses assessed if county demographic and geographic characteristics were associated with HIV-positive cancer case rates.