Mary M. Ramos

Travel-associated dengue infections in the United States, 1996 to 2005.

BACKGROUND As the incidence of dengue increases globally, US travelers to endemic areas may be at an increased risk of travel-associated dengue. METHODS Data from the US Centers for Disease Control and Preventions laboratory-based Passive Dengue Surveillance System (PDSS) were used to describe trends in travel-associated dengue reported from January 1, 1996 to December 31, 2005. The PDSS relies on provider-initiated requests for diagnostic testing of serum samples via state health departments. A case of travel-associated dengue was defined as a laboratory-positive dengue infection in a resident of the 50 US states and the District of Columbia who had been in a dengue-endemic area within 14 days before symptom onset. Dengue infection was confirmed by serologic and virologic techniques. RESULTS One thousand one hundred and ninety-six suspected travel-associated dengue cases were reported-334 (28%) were laboratory-positive, 597 (50%) were laboratory-negative, and 265 (22%) were laboratory-indeterminate. The incidence of laboratory-positive cases varied from 1996 to 2005, but had an overall increase with no significant trend (53.5 to 121.3 per 10(8) US travelers, p = 0.36). The most commonly visited regions were the Caribbean, Mexico and Central America, and Asia. The median age of laboratory-positive cases was 37 years (range: <1 to 75 y) and 166 (50%) were male. Of the 334 laboratory-positive cases, 41 (12%) were hospitalized, and 2 (1%) died. CONCLUSIONS Residents of the US traveling to dengue-endemic regions are at risk of dengue infection and need to be instructed on appropriate prevention measures prior to travel. Especially in light of the potential transmissibility of dengue virus via blood transfusion, consistent reporting of travel-associated dengue infections is essential.

Attitudes of Physicians in New Mexico Toward Gay Men and Lesbians

Previous studies suggest that negative attitudes held by many physicians toward gay men and lesbians may adversely affect this populations health care. This study examined the attitudes of physicians toward homosexuality through a questionnaire mailed to 1949 physicians in New Mexico. The questionnaire included a validated attitudinal scale. Each respondent was categorized as homophilic, neutral, or homophobic based on their responses. We had a 53.6% response rate. Over 8% of male respondents had homophobic scores versus 1.6% of female respondents. Of those practicing in cities with populations between 25,000 and 50,000, 20.6% had homophobic scores versus 4.5% of those practicing in larger cities and 6.4% of those in more rural areas. Multivariate analysis showed that gender, specialty, community size, and personal experiences help determine whether a physician is likely to hold negative attitudes toward gay men and lesbians. Our study found less homophobia among physicians than reported previously; however, we found that negative attitudes toward homosexuality persist in medicine. This study is the first to measure homophobia among physicians working in smaller cities; this may affect the quality of care available to lesbians and gay men who reside in these areas.

Early clinical features of dengue infection in Puerto Rico

Early diagnosis of dengue is challenging because the initial symptoms are often non-specific, viraemia may be below detectable levels and serological tests confirm dengue late in the course of illness. Identifying dengue early in the clinical course could be useful in reducing dengue virus transmission in a community. This study analyzed data from 145 laboratory-positive and 293 laboratory-negative dengue cases in Puerto Rico to define the early clinical features of dengue infection in children and adults and to identify the clinical features that predict a laboratory-positive dengue infection. Among children, rash and age were independently associated with laboratory-positive dengue infection. Rash in the absence of cough had a positive predictive value of 100% and a negative predictive value of 82.4% as a paediatric dengue screen. Among adults, eye pain, diarrhoea and absence of upper respiratory symptoms were independently associated with laboratory-positive dengue infection. No useful early predictors of dengue infection among adults were found. Using clinical features may promote earlier identification of a subset of paediatric dengue patients in Puerto Rico. Laboratory confirmation is still necessary for the accurate diagnosis of dengue infection.

Physician Survey to Determine How Dengue Is Diagnosed, Treated and Reported in Puerto Rico

Dengue is a major cause of morbidity in Puerto Rico and is well-known to its physicians. Early case identification and timely initiation of treatment for patients with severe dengue can reduce medical complications and mortality. To determine clinical management and reporting practices, and assess knowledge of dengue and its management, a survey was sent to 2,512 physicians with a medical license in Puerto Rico. Of the 2,313 physicians who received the survey, 817 (35%) completed the questionnaire. Of the respondents, 708 were currently practicing medicine; 138 were board certified (Group 1), 282 were board eligible (Group 2), and 288 had not finished residency (Group 3). Although respondents clinically diagnosed, on average, 12 cases of dengue in the preceding three months, 31% did not report any suspected cases to public health officials while about half (56%) reported all cases. Overall, 29% of respondents correctly identified early signs of shock and 48% identified severe abdominal pain and persistent vomiting as warning signs for severe dengue with the proportion of correct respondents highest in Group 1. Reportedly about sixty percent (57%) appropriately never give corticosteroids or prophylactic platelet transfusions to dengue patients. One third (30%) of respondents correctly identified administration of intravenous colloid solution as the best treatment option for dengue patients with refractory shock and elevated hematocrit after an initial trial of intravenous crystalloids, and nearly one half (46%) correctly identified administration of a blood transfusion as the best option for dengue patients with refractory shock and decreased hematocrit after a trial of intravenous crystalloids. Even though dengue has been endemic in Puerto Rico for nearly 4 decades, knowledge of dengue management is still limited, compliance with WHO treatment guidelines is suboptimal, and underreporting is significant. These findings were used to design a post graduate training course to improve the clinical management of dengue.

Measuring Youth Health Engagement: Development of the Youth Engagement With Health Services Survey

PURPOSE The purpose of this study was to create and validate a survey instrument designed to measure Youth Engagement with Health Services (YEHS!). METHODS A 61-item YEHS! survey was created through a multistaged process, which included literature review, subject matter expert opinion, review of existing validated measures, and cognitive interviewing with 41 adolescents in Colorado and New Mexico. The YEHS! was then pilot tested with a diverse group of high school students (n = 354) accessing health services at one of eight school-based health centers in Colorado and New Mexico. We conducted psychometric analyses and examined correlations between the youth health engagement scales and measures of quality of care. RESULTS We created scales to measure two domains of youth health engagement: health access literacy and health self-efficacy. The youth health engagement scales demonstrated strong reliability (Cronbachs α .76 and .82) and construct validity (mean factor loading .71 and .76). Youth health engagement scores predicted higher experiences of care scores (p < .001) and receipt of more anticipatory guidance (p < .01). CONCLUSIONS This study supports the YEHS! as a valid and reliable measure of youth health engagement among adolescents using school-based health centers. We demonstrate an association between youth health engagement and two quality of care measures. Additional testing is needed to ensure the reliability and validity of the instrument in diverse adolescent populations.

An Outbreak of Dengue Fever in St. Croix (US Virgin Islands), 2005

Background Periodic outbreaks of dengue fever occur in the United States Virgin Islands. In June 2005, an outbreak of dengue virus (DENV) serotype-2 with cases of dengue hemorrhagic fever (DHF) was detected in St. Croix, US Virgin Islands. The objective of this report is to describe this outbreak of DENV-2 and the findings of a case-control study examining risk factors for DHF. Methodology/Principal Findings This is the largest dengue outbreak ever recorded in St. Croix, with 331 suspected dengue cases reported island-wide during 2005 (62.2 cases/10,000 population); 54% were hospitalized, 21% had at least one hemorrhagic manifestation, 28% had thrombocytopenia, 5% had DHF and 1 patient died. Eighty-nine laboratory-positive hospitalized patients were identified. Of these, there were 15 (17%) who met the WHO criteria for DHF (cases) and 74 (83%) who did not (controls). The only variable significantly associated with DHF on bivariate or multivariable analysis was age, with an adjusted odds ratio (95% confidence interval) of 1.033 (1.003,1.064). Conclusions/Significance During this outbreak of DENV-2, a high proportion of cases developed DHF and increasing age was significantly associated with DHF.

Sin nombre hantavirus disease in a ten-year-old boy and his mother.

Hantavirus cardiopulmonary syndrome (HCPS) is a rodent-borne zoonotic disease with a characteristic prodrome of fever, myalgias, headache and gastrointestinal distress, with subsequent cardiopulmonary dysfunction leading to death in ;45% of cases. Most cases in the United States are sporadic and have occurred in those older than 16 years of age. Here we report a family cluster with the initial case presenting in a 10-year-old boy with HCPS. Subsequently his 28-year-old mother developed mild hantavirus disease. This HCPS case is unusual for the patient’s young age, the absence of certain laboratory features associated with HCPS (e.g. .10% circulating immunoblasts and hemoconcentration) and a positive Monospot test which led to a misdiagnosis of EpsteinBarr virus (EBV) infection.

Rural‐Urban Disparities in School Nursing: Implications for Continuing Education and Rural School Health

PURPOSE Little is known about the professional and educational challenges experienced by rural school nurses. We conducted this study to describe disparities between the urban and rural professional school nurse workforce in New Mexico and to identify how best to meet the continuing education needs of New Mexicos rural school nurse workforce. METHODS We analyzed state data from a 2009 New Mexico Department of Health school nurse workforce survey (71.7% response rate). We included all survey respondents who indicated working as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311). FINDINGS Rural school nurses were twice as likely as metropolitan nurses to provide clinical services to multiple school campuses (67.3% compared to 30.1%, P < .0001). They were less likely to hold a nursing degree at the baccalaureate level or higher (62.7% compared to 82.3%, P = .0002). Rural school nurses were less likely than metropolitan nurses to have received recent continuing education on anaphylaxis (P < .0001), asthma (P = .027), body mass index (BMI)/healthy weight (P = .0002), diabetes (P < .0001), lesbian, gay, bisexual and transgender (LGBT) health (P = .0004), and suicide risk identification and prevention (P = .015). Online courses and telehealth were identified by rural school nurses as among the preferred means for receiving continuing education. CONCLUSIONS Our findings support the provision of online courses and telehealth content to address urban-rural disparities in school nursing education and support rural school health.

A statewide profile of frequent users of school-based health centers: implications for adolescent health care

BACKGROUND The purpose of this study is to describe patterns of care and service use among adolescent school-based health center (SBHC) users in New Mexico and contrast patterns and services between frequent and infrequent users. METHODS Medical claims/encounter data were analyzed from 59 SBHCs located in secondary schools in New Mexico during the 2011-2012 school year. We used Pearsons chi-square test to examine the differences between frequent (≥ 4 visits/year) and infrequent users in their patterns of SBHC care, and we conducted logistic regression to examine whether frequent use of the SBHC predicted receipt of behavioral, reproductive, and sexual health; checkup; or acute care services. RESULTS Most of the 26,379 adolescent SBHC visits in New Mexico were for behavioral health (42.4%) and reproductive and sexual health (22.9%). Frequent users have greater odds of receiving a behavioral, reproductive, and sexual health; and acute care visit than infrequent users (p < .001). American Indians, in particular, have higher odds of receiving behavioral health and checkup visits, compared with other races/ethnicities (p < .001). CONCLUSIONS SBHCs deliver core health care services to adolescents, including behavioral, reproductive, and checkup services, to high need populations. American-Indian youth, more than their peers, use SBHCs for behavioral health and checkups.

Measuring Unmet Needs for Anticipatory Guidance Among Adolescents at School-Based Health Centers

PURPOSE Our previously validated Youth Engagement with Health Services survey measures adolescent health care quality. The survey response format allows adolescents to indicate whether their needs for anticipatory guidance were met. Here, we describe the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance. METHODS We administered the survey in 2013-2014 to 540 adolescents who used school-based health centers in Colorado and New Mexico. A participant was considered to have unmet needs for anticipatory guidance if they indicated that guidance was needed on a given topic but not received or guidance was received that did not meet their needs. We calculated proportions of students with unmet needs for guidance and examined associations between unmet needs for guidance and participant characteristics using the chi-square test and logistic regression. RESULTS Among participants, 47.4% reported at least one unmet need for guidance from a health care provider in the past year. Topics with the highest proportions of adolescents reporting unmet needs included healthy diet (19.5%), stress (18.0%), and body image (17.0%). In logistic regression modeling, adolescents at risk for depression and those with minority or immigrant status had increased unmet needs for guidance. Adolescents reporting receipt of patient-centered care were less likely to report unmet needs for guidance. CONCLUSIONS The Youth Engagement with Health Services survey provides needs-based measurement of anticipatory guidance received that may support targeted improvements in the delivery of adolescent preventive counseling. Interventions to improve patient-centered care and preventive counseling for vulnerable youth populations may be warranted.