CDC Case Definition Research Articles

Determinants of periodontitis among a rural Indian population: A case control study.

Identify the determinants of periodontitis in a rural Indian population aged 35-44 years. Case-control clinical and questionnaire study in a cluster sample of 50 villages. A total of 3000 persons were screened for the presence of periodontitis using the CDC case definition in full mouth examination. Equal numbers of cases (604 persons with periodontitis) and controls (604 without periodontitis) were recruited and interviewed with a piloted questionnaire. Univariate and multivariate analysis estimated crude and adjusted odds ratios (aOR) respectively with 95% confidence limits. Six factors were determined by multivariate analysis to predict periodontitis: education less than or equal to twelve years of schooling (aOR=2.51, 95% CI=1.18-5.34), alcohol consumption (aOR= 1.7, 95% CI=1.16-2.49), consuming a non-vegetarian diet (aOR=1.38, 95% CI=1.08-1.76), not drinking milk (aOR=1.7, 95% CI= 1.29-2.24), not using a toothbrush for cleaning of teeth (aOR=2.98, 95% CI =1.71-5.21) and not cleaning teeth at least once a day (aOR=2.13, 95% CI=1.58-2.87). Risk factors for periodontitis in a rural Indian population were identified. Further studies should validate these findings and appropriate recommendations should be developed to decrease the prevalence and burden of periodontitis in this population.

211. Coxiella burnetii: 7 Years of Experience at a Tertiary-Care Center

BackgroundQ fever is a zoonotic disease caused by Coxiella burnetii. Primary infection can progress to persistent infection irrespective of initial symptomatology. Our aim is to describe the clinical features, treatment, risk of progression, use of prophylaxis, and outcomes of Coxiella burnetii infection at our institution.MethodsWe did a retrospective review of all adult patients with positive Coxiella burnetii serology at Mayo Clinic, Rochester from 1st January 2012 to 31st December 2018. Centers for Disease Control and Prevention (CDC) case definition and classification were used to group the patients into confirmed and probable acute Q fever, and confirmed and probable chronic/persistent Q fever. Data on demographics, clinical presentation, comorbid conditions, exposure history, risk factors associated with progression, serology, treatment and outcomes were collected.ResultsWe found 266 patients with positive titres of Coxiella IgG or IgM greater than 1:16, of which 49 patients met the CDC case definition for Q fever. Median age at presentation was 62 years. 45/49 (91. 8%) were men, while 4/49 (8%) were women. 20/49 (40. 8%) patients presented with acute Q fever of which 5 (25%) patients progressed to persistent infection. 29/49 (59%) patients presented with persistent Q fever of which 4 patients could recall symptoms suggestive of acute Q fever. The most common presentation of acute Q fever was acute febrile illness (65%). Endocarditis (11/29) was the most common presentation of chronic/persistent Q fever. Of the 5 patients with acute Q fever that progressed to persistent infection, 3/5(60%) progressed despite being on doxycycline and hydroxychloroquine. 8/29 patients with persistent Q fever had serological resolution at last follow-up. 2/4(50%) deaths were attributable to Q fever.ConclusionMinority of the patients tested met the case definition. 25% of patients with acute disease progressed to chronic Q fever out of which 60%(3/5) progressed despite prophylaxis. Endocarditis and vascular infections were the most common chronic cases. Interestingly we found 4 cases of MPGN in association with Q fever. Prosthetic valves are the most important risk factors for progression (P = 0.02). Serological cure often lags behind clinical cure (27% vs. 68% in persistent infection)(Table 4). Disclosures All authors: No reported disclosures.

1882. Tuberculosis in the Department of Veterans Affairs: Missed Opportunities for Prevention

BackgroundUS and global elimination of tuberculosis (TB) is an important goal. Despite decreased incidence, CDC predicts elimination of TB in the US will not occur in the 21st century without improved detection and treatment of latent TB infection (LTBI). We describe the current burden of active TB infection and LTBI testing and treatment among patients within the Department of Veterans Affairs (VA).MethodsUsing the 2009 CDC case definition for laboratory-confirmed TB, we queried VA data sources from January 2010 to December 2018 for Mycobacterium tuberculosis detected via culture or nucleic acid amplification test (NAAT) from specimens from all body sites. For all TB patients, we extracted demographic, ICD-9 and ICD-10 risk factor, and LTBI testing and treatment data.ResultsBetween 2010 and 2018, the average annual incidence of TB was 1.7 cases per 100,000 unique users of VA care (ranging from a high of 2.8 in 2010 to low of 0.8 in 2018). For 899 identified cases, demographic factors associated with highest TB rates were age between 45 and 64, Asian race, and residence in District of Columbia (Table 1). The most frequently occurring risk factors were substance abuse, diabetes, and homelessness. Of 90 patients with susceptibility documentation, 14 (15%) had resistance to 1 or more anti-TB drug (1 with multi-drug-resistant TB). Fifteen patients (1.7%) died within 7 days of their TB diagnosis; in all but 2 cases, TB was the primary cause of death (Table 2). Figure 1 depicts screening and treatment for LTBI among patients with TB. Only 228/899 (25.4%) TB patients had LTBI screening ≥ 3 months prior to diagnosis. Of the 347 TB patients never screened for LTBI, 264 (76%) had ≥ 1 documented TB risk factor. Among 228 patients screened for LTBI >3 months prior to active disease, 69 (30%) screened positive; however, only 24 (35%) had LTBI treatment initiated.ConclusionAlthough rates of TB infection are decreasing, VHA providers would benefit from education on recognizing patients with risk factors which place them at high risk for TB who should be screened for LTBI. CDC recommends preventive treatment of patients who screen positive for LTBI, and provider collaboration with local public health departments to provide directly observed therapy in cases where adherence may be in question. Disclosures All Authors: No reported Disclosures.

Sex Differences in Gulf War Illness: A Reanalysis of Data From the CDC Air Force Study Using CDC and Modified Kansas Case Definitions.

Estimate and compare the prevalence of Gulf War Illness (GWI) in male and female Gulf War veterans using Centers for Disease Control and Prevention (CDC) and modified Kansas case definitions. Data from the landmark CDC Air Force Study of GW Air Force veterans is used. Nearly half of the deployed veterans met the GWI CDC case definition compared with 14% of non-deployed veterans. Only 29% met the definition using the modified Kansas criteria compared with 8% of non-deployed veterans. Deployed veterans and female veterans exhibited significantly higher GWI risk. Female GW veterans had higher rates of severe and mild-to-moderate cases of GWI. Results suggest increased GWI rates based on CDC and modified Kansas criteria among deployed and female veterans. Further research is needed to examine the chronic health outcomes of female GW veterans independently.

Validity of hepatitis B and hepatitis C case definitions

BackgroundGlobally, an estimated 257 million people are living with chronic hepatitis B (HBV) infection and an estimated 71 million people with the chronic hepatitis C virus (HCV). The true public health dimensions and impact of hepatitis epidemics are poorly understood. Case definitions are fundamental parts of disease surveillance, representing sets of standardised criteria used to assess whether or not a person has a certain disease. The study evaluated the sensitivity and specificity of hepatitis B and hepatitis C case definitions, current at the time of data collection, recommended by the European Commission (EC) and the Centers for Disease Prevention and Control (CDC). MethodsThe study involved 150 hospital referrals with suspected cases of hepatitis from a Serbian clinic during 2014/2015. Case definitions of hepatitis B and C were tested for their sensitivity, specificity, positive and negative predictive values. ResultsEC 2008 and the CDC 2012 case definitions for acute hepatitis B, and the CDC 2012 case definition for probable case of chronic hepatitis B have low sensitivity. Case definitions which rely on laboratory confirmation only have maximal sensitivity. EC case definitions showed maximal sensitivity and specificity for hepatitis C confirmed cases. The CDC case definition for chronic hepatitis C showed low sensitivity (36.8%) and low negative predictive value (65.6%) for probable cases and maximal sensitivity and specificity for confirmed cases. Hepatitis C case definitions requiring presence of clinical criteria have low sensitivity and high specificity, resulting from presence of infection and absence of any clinical manifestation, but have high positive and negative predictive values. ConclusionSyndromic case definitions show low sensitivity and are of limited use. They highlight the importance of laboratory diagnostics (offering maximal sensitivity and specificity, and high positive and negative predictive values), as well as the need for universal case definitions, for confirmed cases only.

Clinical Subpopulations in a Sample of North American Children Diagnosed With Acute Flaccid Myelitis, 2012-2016

Acute flaccid myelitis (AFM) is an emerging poliolike illness of children whose clinical spectrum and associated pathogens are only partially described. The case definition is intentionally encompassing for epidemiologic surveillance to capture all potential AFM cases. Defining a restrictive, homogenous subpopulation may aid our understanding of this emerging disease. To evaluate the extent to which the US Centers for Disease Control and Prevention (CDC) case definition of AFM incorporates possible alternative diagnoses and to assess the plausibility of a case definition that enriches the biological homogeneity of AFM for inclusion in research studies. Retrospective case analysis of children younger than 18 years diagnosed as having AFM between 2012 and 2016 using the CDC case definition. Group 1 included patients recruited from the United States and Canada based on the CDC case definition of AFM. Group 2 included patients referred to the Johns Hopkins Transverse Myelitis Center for evaluation of suspected AFM. Patients' records and imaging data were critically reviewed by 3 neurologists to identify those cases with definable alternative diagnoses, and the remaining patients were categorized as having restrictively defined AFM (rAFM). Clinical characteristics were compared between patients with rAFM (cases) and those with alternative diagnoses, and a case description distinguishing these AFM groups was identified. Interrater reliability of this description was confirmed for a subset of cases by a fourth neurologist. Data were analyzed between May 2017 and November 2018. Proportion of patients with possible alternative diagnosis. Of the 45 patients who met the CDC AFM case definition and were included, the mean age was 6.1 years; 27 were boys (60%); and 37 were white (82%), 3 were Asian (7%), 1 was Hispanic (2%), and 4 were mixed race/ethnicity (9%). Of the included patients, 34 were classified as having rAFM, and 11 had alternate diagnoses (including transverse myelitis, other demyelinating syndromes, spinal cord stroke, Guillain-Barre syndrome, Chiari I myelopathy, and meningitis). Factors differing between groups were primarily asymmetry of weakness, lower motor neuron signs, preceding viral syndrome, symptoms evolving over hours to days, absence of sensory deficits, and magnetic resonance imaging findings. A case description was able to reliably define the rAFM group. We present an approach for defining a homogeneous research population that may more accurately reflect the pathogenesis of the prototypical poliomyelitis-like subgroup of AFM. The definition of rAFM forms a blueprint for inclusion criteria in future research efforts, but more work is required for refinement and external validation.

Automated Processing of Electronic Data for Disease Surveillance

Automated Processing of Electronic Data for Disease Surveillance

Harmful Algal Bloom–Associated Illnesses in Humans and Dogs Identified Through a Pilot Surveillance System — New York, 2015

Cyanobacteria, also known as blue-green algae, are photosynthetic, aquatic organisms found in fresh, brackish, and marine water around the world (1). Rapid proliferation and accumulation of potentially toxin-producing cyanobacteria characterize one type of harmful algal bloom (HAB). HABs have the potential to cause illness in humans and animals (2,3); however, the epidemiology of these illnesses has not been well characterized. Statewide in 2015, a total of 139 HABs were identified in New York, 97 (70%) of which were confirmed through laboratory analysis; 77 independent beach closures were ordered at 37 beaches on 20 different bodies of water. To better characterize HAB-associated illnesses, during June-September 2015, the New York State Department of Health (NYSDOH) implemented a pilot surveillance system in 16 New York counties. Activities included the collection of data from environmental HAB reports, illness reports, poison control centers, and syndromic surveillance, and increased outreach to the public, health care providers, and veterinarians. During June-September, 51 HAB-associated illnesses were reported, including 35 that met the CDC case definitions*; 32 of the cases occurred in humans and three in dogs. In previous years, New York never had more than 10 HAB-associated illnesses reported statewide. The pilot surveillance results from 16 counties during a 4-month period suggest that HAB-associated illnesses might be more common than previously reported.

A Syndrome Definition Validation Approach for Zika Virus

ObjectiveTo develop and validate a Zika virus disease syndrome definitionwithin the GUARDIAN (Geographic Utilization of ArtificialIntelligence in Real-Time for Disease Identification and AlertNotification) surveillance system.IntroductionIn 2016, the World Health Organization declared Zika virus aglobal public health emergency. Zika infection during pregnancycan cause microcephaly and other fetal brain defects. To facilitateclinicians’ ability to detect Zika, various syndrome definitions havebeen developed.MethodsTo create and validate a detailed syndrome definition for Zika,we utilized the literature based methodology developed anddocumented by GUARDIAN researchers.1,2The syndrome definitionutilized clinical signs and symptoms that were documented inhistorical Zika cases.A testing sample of 1000 randomly selected emergency departmentcases (i.e., true negative cases) and 200 synthetically generated cases(i.e., true positive cases) was created. These 1,200 sample cases wereevaluated by the GUARDIAN surveillance system to determine theprobability of matching the Zika syndrome definition. A probabilityof≥90% was utilized to designate positive Zika cases.We identified the main signs and symptoms contributing to theidentification of Zika cases and conducted statistical performancemetrics. Clinical review of the false positive and false negative casesalong with a sample of true positive and true negative cases wasconducted by a board certified emergency physician.ResultsThe Zika syndrome definition was developed with eleven articles(six used for developing the syndrome definition, and five used fortesting the definition). The sample size for these articles was between1 and 72 positive Zika cases, with a total of 139 cases across the11 articles. The article with the most number of Zika cases wasbased on pregnant women with rash. The publication timeframefor the articles was from 1962 to 2016. Some of the main signsand symptoms from the historical cases that contribute to the Zikasyndrome definition are presented in Table 1. The initial results forthe sample testing data showed accuracy, sensitivity, and specificitywere 94.7%, 93%, and 95% respectively. There were a total of14 false negative and 50 false positive cases.ConclusionsThe initial Zika syndrome definition utilized by the GUARDIANsurveillance system contains similar signs and symptoms to thecurrent CDC case definition, but also includes additional signs andsymptoms such as pruritus/itching, malaise/fatigue/generalizedweakness, headache, retro-orbital pain, myalgia/muscle pain, andlymphadenopathy In addition, the GUARDIAN system provides therelative importance of identified signs and symptoms and allows forproactive surveillance of emergency department patients in real-time.Though we did not include epidemiologic risk factors, such as travel toan infected region or contact with an infected person in the syndromedefinition, GUARDIAN has above 90% sensitivity and specificity.Thus, inclusion of epidemiologic risk factors would further enhancethe early detection of Zika, when used with the appropriate high riskpopulation.Table 1. Main signs and symptoms of Zika syndrome definition*Signs and symptoms included in the Centers for Disease Control andPrevention (CDC)’s Zika clinical case definition

Fatal Abusive Head Trauma Among Children Aged

In the United States, abusive head trauma (AHT) is one of the leading causes of maltreatment fatalities among infants and children, accounting for approximately one third of these deaths (1). Monitoring trends in AHT and evaluating prevention strategies have historically been difficult because of differences in AHT definitions used in research and surveillance. CDC's case definition for AHT and data from the National Vital Statistics System were used to examine the trends in fatal AHT during 1999-2014 using Joinpoint trend analysis software. During this period, AHT resulted in nearly 2,250 deaths among U.S. resident children aged <5 years. Whereas rates were relatively stable during 1999-2009, there was a statistically significant average annual decline of 13.0% in fatal AHT rates during 2009-2014. The fatal AHT rates in 2013 and 2014 (0.41 and 0.43 per 100,000 children aged <5 years, respectively) were the lowest in the 16-year study period. Although this decline in AHT deaths is encouraging, more can be done to prevent AHT, including family-based interventions and policies that create safe, stable, nurturing relationships and environments for children.

Cerebral toxoplasmosis in children and adolescents from “Dr. Victor Babeş” Hospital pediatric HIV-cohort

Cerebral toxoplasmosis (Toxo) is rarely described in children. The Romanian pediatric cohort consists of children that have been infected parenterally in the late ’80s. We aimed to describe the prevalence, clinical findings and outcome of Toxo in children and adolescents from the Romanian Pediatric Cohort, that have been diagnosed in the “Dr. Victor Babes” Hospital, one of the main reference centers for HIV from Romania Cerebral toxoplasmosis was diagnosed based on CDC case definition (presumptive and definitive diagnosis). We reviewed retrospectively the charts of all 29 children diagnosed with Toxo starting 1996, recording the demographic, HIV markers, antiretroviral treatment, clinical and neuroimaging data, treatment and outcome of Toxo. The prevalence of Toxo was 4.8% from 604 patients followed in the Hospital. Out of 29 patients diagnosed with Toxo, 19 were girls and 28 had parenterally and 1 had vertically acquired HIV. The mean age at HIV diagnosis was 11.5±6.5 years, and 15.6±5.3 years at Toxo diagnosis. In 10 patients HIV was diagnosed concomitantly with Toxo. At onset 89.7% patients had focal neurological signs and 62.1% had headache. Median CD4 count was 60 (95% CI for median 27-95) lf/cmm. 28 patients had positive T. gondii IgG antibodies in plasma and/or cerebrospinal fluid. Only 6 patients had treatment with cotrimoxazole, most of them being treated with pyrimethamine/sulphadoxine combination and alternatively with atovaquone. 69% of patients had any adverse reactions to Toxo treatment. Most adverse reactions were cutaneous in 10 patients (5 severe) and anemia in 7 patients. Nine patients had antiretroviral therapy (ART) before Toxo diagnosis, out of them 1 had mono, 1 dual therapy, 6 were failing cART and one patient had immune reconstitution syndrome. Ten patients (34.5%) died. The median survival time was 117 months. In univariate analysis survival was correlated with shorter time from onset to admission (p=0.04) while on multivariate analysis diagnosis in the post-cART period was the only factor associated with longer survival (p=0.03). 14 of 19 patients recovered with sequels, most of them motor deficits. Cerebral toxoplasmosis in this particular pediatric cohort shared common features with that reported in adults pertaining to prevalence in pre-cART period and pathogenic mechanism. Survival was associated with a more rapid diagnosis of cerebral toxoplasmosis and with access to cART.

Prospective surveillance for cardiac adverse events in healthy adults receiving modified vaccinia Ankara vaccines: a systematic review.

BackgroundVaccinia-associated myo/pericarditis was observed during the US smallpox vaccination (DryVax) campaign initiated in 2002. A highly-attenuated vaccinia strain, modified vaccinia Ankara (MVA) has been evaluated in clinical trials as a safer alternative to DryVax and as a vector for recombinant vaccines. Due to the lack of prospectively collected cardiac safety data, the US Food and Drug Administration required cardiac screening and surveillance in all clinical trials of MVA since 2004. Here, we report cardiac safety surveillance from 6 phase I trials of MVA vaccines.MethodsFour clinical research organizations contributed cardiac safety data using common surveillance methods in trials administering MVA or recombinant MVA vaccines to healthy participants. ‘Routine cardiac investigations’ (ECGs and cardiac enzymes obtained 2 weeks after injections of MVA or MVA-HIV recombinants, or placebo-controls), and ‘Symptom-driven cardiac investigations’ are reported. The outcome measure is the number of participants who met the CDC-case definition for vaccinia-related myo/pericarditis or who experienced cardiac adverse events from an MVA vaccine.ResultsFour hundred twenty-five study participants had post-vaccination safety data analyzed, 382 received at least one MVA-containing vaccine and 43 received placebo; 717 routine ECGs and 930 cardiac troponin assays were performed. Forty-five MVA recipients (12%) had additional cardiac testing performed; 22 for cardiac symptoms, 19 for ECG/laboratory changes, and 4 for cardiac symptoms with an ECG/laboratory change. No participant had evidence of symptomatic or asymptomatic myo/pericarditis meeting the CDC-case definition and judged to be related to an MVA vaccine.ConclusionsProspective surveillance of MVA recipients for myo/pericarditis did not detect cardiac adverse reactions in 382 study participants.Trial RegistrationClinicalTrials.gov NCT00082446 NCT003766090 NCT00252148 NCT00083603 NCT00301184 NCT00428337

Analysis of Neutrophil Function in Severe and Moderately Affected Chronic Fatigue Syndrome Subjects.

Event Abstract Back to Event Analysis of Neutrophil Function in Severe and Moderately Affected Chronic Fatigue Syndrome Subjects. Sharni L. Hardcastle1, 2, Ekua W. Brenu1, 2*, Don R. Staines2, 3 and Sonya M. Marshall-Gradisnik1, 2 1 Griffith University, School of Medical Sciences, Australia 2 Griffith University, Griffith Health Institute, Australia 3 Gold Coast Public Health Unit , Queensland Health, Australia Research has commonly shown that people with Chronic Fatigue Syndrome (CFS) have immune system abnormalities. Decreases have been found in neutrophil respiratory burst in a CFS cohort. Reduced ability of neutrophils to eliminate pathogens can contribute to the impaired immune function in CFS subjects. It is unknown whether neutrophil function is more impaired in patients severely affected by CFS. The purpose of this study was to examine neutrophil activity including phagocytosis and respiratory burst in patients with severe CFS in comparison to those with moderate symptoms and non-fatigued controls. CFS subjects were characterised using the CDC Case Definition and the International Consensus Criteria for CFS. CFS subjects were then grouped as either moderate or severely affected based on health and quality of life questionnaires. Blood samples were taken from age and sex matched non-fatigued controls, moderately affected and severely affected CFS subjects. Response to E.coli bacteria was measured in neutrophils by assessing phagocytic activity and respiratory burst, these were then analysed on the flow cytometer. Preliminary data from CFS subjects showed differences in neutrophil function based on respiratory burst and phagocytic activity when compared to the control group. These results suggest that differences in neutrophil function in CFS patients may contribute to CFS related immune dysfunction. Keywords: CFS, Severe, Neutrophil, Respiratory Burst, Phagocyte Conference: 15th International Congress of Immunology (ICI), Milan, Italy, 22 Aug - 27 Aug, 2013. Presentation Type: Abstract Topic: Innate immunity Citation: Hardcastle SL, Brenu EW, Staines DR and Marshall-Gradisnik SM (2013). Analysis of Neutrophil Function in Severe and Moderately Affected Chronic Fatigue Syndrome Subjects.. Front. Immunol. Conference Abstract: 15th International Congress of Immunology (ICI). doi: 10.3389/conf.fimmu.2013.02.01039 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 30 Jun 2013; Published Online: 22 Aug 2013. * Correspondence: Dr. Ekua W Brenu, Griffith University, School of Medical Sciences, Gold Coast, Queensland, 4222, Australia, e.brenu@griffith.edu.au Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Sharni L Hardcastle Ekua W Brenu Don R Staines Sonya M Marshall-Gradisnik Google Sharni L Hardcastle Ekua W Brenu Don R Staines Sonya M Marshall-Gradisnik Google Scholar Sharni L Hardcastle Ekua W Brenu Don R Staines Sonya M Marshall-Gradisnik PubMed Sharni L Hardcastle Ekua W Brenu Don R Staines Sonya M Marshall-Gradisnik Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Two types of fatigue in cancer patients

Sir, The very interesting data presented by Singer et al (2011), on prevalence of fatigue at three time points, that is, the beginning of inpatient treatment, at discharge and half a year after diagnosis, raise some questions and comments. First of all, it is not reported when fatigue present at the beginning of inpatient treatment started; that is, fatigue was present weeks, months or years before the diagnosis of cancer. In other words was fatigue related to the presence of cancer or was it antecedent, and not related to cancer presence? In fact, it could be that some patients had a chronic fatigue present many months or years before the diagnosis of cancer; and therefore, fatigue could not be due to cancer, but was already present for a different reason, for example, a chronic fatigue syndrome (CFS). Moreover, it would be very interesting to know how many of the patients with fatigue half a year after diagnosis were fatigued years after, obviously in case they were alive. These questions are based on the fact that in our opinion there are two types of fatigue in cancer patients needing different symptom monitoring and management: one that could be defined as cancer-related fatigue and is that nicely described by Singer and co-workers, and the other could be defined as CFS-cancer related and it is observed before diagnosis and after therapy, in both cases not obviously related to cancer. In fact, to better understand the different course of fatigue in cancer patients and in survivors, we need different definitions. Cancer-related fatigue, necessarily associated with cancer and its treatments, has to be adopted in patients with active disease, on treatments, and until 1 year from diagnosis. In this population, there are different causes for fatigue, including anaemia, endocrine and metabolic disorders, cardiovascular and renal dysfunctions, and this is the condition nicely reported by Singer and colleagues. Instead, the chronic and persistent fatigue experienced before the diagnosis or by long-term cancer survivors is not necessary related to or caused by cancer and its treatments. These patients show a particular type of fatigue similarly to the fatigue experienced by patients affected by CFS, which accordingly to the CDC case definition (Fukuda et al, 1994) is a severe fatigue usually associated with impairment in short-term memory or concentration (severe enough to cause substantial reduction in previous levels of occupation, educational source or personal activities); post-exertional malaise lasting >24 h; soar throat; tender cervical or axillary lymph nodes; muscle pain; multi-joint pain without joint swelling or redness; headaches of a new type for pattern or severity; and unrefreshed sleep. As we have previously suggested (Simonelli et al, 2008), we believe that, in particular in long-term cancer survivors, fatigue can be a chronic/persistent condition associated with disrupting symptoms similar to CFS (Fukuda et al, 1994). For these reasons, we believe that fatigue in these conditions may be considered a subtype of CFS and could be defined as CFS-cancer related. Further studies could be carried out in these settings to better define these two entities, that is, cancer-related fatigue and CFS-cancer related.

Staphylococcal Toxic Shock Syndrome 2000–2006: Epidemiology, Clinical Features, and Molecular Characteristics

IntroductionCirculating strains of Staphylococcus aureus (SA) have changed in the last 30 years including the emergence of community-associated methicillin-resistant SA (MRSA). A report suggested staphylococcal toxic shock syndrome (TSS) was increasing over 2000–2003. The last population-based assessment of TSS was 1986.MethodsPopulation-based active surveillance for TSS meeting the CDC definition using ICD-9 codes was conducted in the Minneapolis-St. Paul area (population 2,642,056) from 2000–2006. Medical records of potential cases were reviewed for case criteria, antimicrobial susceptibility, risk factors, and outcome. Superantigen PCR testing and PFGE were performed on available isolates from probable and confirmed cases.ResultsOf 7,491 hospitalizations that received one of the ICD-9 study codes, 61 TSS cases (33 menstrual, 28 non-menstrual) were identified. The average annual incidence per 100,000 of all, menstrual, and non-menstrual TSS was 0.52 (95% CI, 0.32–0.77), 0.69 (0.39–1.16), and 0.32 (0.12–0.67), respectively. Women 13–24 years had the highest incidence at 1.41 (0.63–2.61). No increase in incidence was observed from 2000–2006. MRSA was isolated in 1 menstrual and 3 non-menstrual cases (7% of TSS cases); 1 isolate was USA400. The superantigen gene tst-1 was identified in 20 (80%) of isolates and was more common in menstrual compared to non-menstrual isolates (89% vs. 50%, p = 0.07). Superantigen genes sea, seb and sec were found more frequently among non-menstrual compared to menstrual isolates [100% vs 25% (p = 0.4), 60% vs 0% (p<0.01), and 25% vs 13% (p = 0.5), respectively].DiscussionTSS incidence remained stable across our surveillance period of 2000–2006 and compared to past population-based estimates in the 1980s. MRSA accounted for a small percentage of TSS cases. tst-1 continues to be the superantigen associated with the majority of menstrual cases. The CDC case definition identifies the most severe cases and has been consistently used but likely results in a substantial underestimation of the total TSS disease burden.

Frequency and Distribution of Clostridium difficile Testing in an Urban Tertiary Care Medical Center

Methods: VA electronic surveillance (ESSENCE and National Patient Care Database) identified patients with dengue diagnosis codes from VA hospitalizations, plus outpatient and emergency department visits in PR during 2010. The IP provided manual surveillance data from 2010 for comparison. Laboratory and clinical data from EHRs was reviewed for concordance between electronic and manual surveillance and classification based on the 2010 CDC case definition. Sensitivity was calculated as number of confirmed and probable cases identified by each surveillance method divided by the total number of confirmed and probable cases identified.

Survival of AIDS patients using two case definitions, Rio de Janeiro, Brazil, 1986–2003

Recent studies have shown substantial increases in the survival of AIDS patients in developed countries and in Brazil as a result of antiretroviral therapy (ART) and prophylaxis for opportunistic infections. This study compares survival rates using the Brazilian Ministry of Health 2004 and Centers for Disease Control and Prevention (CDC) 1993 case definitions in a large HIV/AIDS referral centre in Rio de Janeiro. Survival after AIDS diagnosis was assessed in a clinic-based cohort of 1415 individuals using the Kaplan-Meier method and Cox proportional hazards models. There were 393 (88%) deaths from AIDS-related causes and 52 (12%) from unrelated or unknown causes. A total of 205 patients (14%) were lost to follow-up and 765 patients (55%) remained alive until the end of the study. Three-quarters of patients (75%) were still alive 22 months [95% confidence interval (CI) 19-26] after the AIDS diagnosis according to the CDC case definition and 31 months (95% CI 26-36) according to the Ministry of Health case definition. Independent predictors of survival included AIDS defined by CD4 cell count and any use of highly active antiretroviral therapy, with either case definition, and initial stage of the case, with the Ministry of Health case definition. Survival observed in this reference centre is comparable or longer than other international studies, although the choice of case definition criterion influenced findings. Adoption of the Ministry of Health case definition may enhance the ability to track the use of and outcomes from ART among AIDS patients.

Racial differences in underlying health problems among persons with Traumatic Brain Injury in South Carolina, 1997–2001

Purpose Underlying health conditions can predispose a person to Traumatic Brain Injury (TBI), and are increasing disparities in TBI-related health outcomes among population groups. Our objectives are to 1) describe the major differences in underlying health problems, causes of injury, and payer status as a function of race, and 2) examine the relationship between sustaining TBI and race in a multivariable log-linear model controlling for other covariates. Methods Persons with TBI were identified from the South Carolina Traumatic Brain Injury Surveillance System using CDC's case definition of TBI. A total of 73,428 persons with TBI were discharged from the hospital or were treated and released from one of the 64 Emergency Departments between 1997 and 2001. We identified underlying chronic health problems using the ICD-9-CM diagnosis codes and classified the comorbid conditions by the Centers for Medicare and Medicaid Services Comorbidity Index. Estimates of the odds of chronic diseases between the two race groups were calculated using multivariable logistic regression techniques. Results African-Americans (AA) were at a higher risk for many comorbid conditions that could predispose them to sustaining a TBI, including seizures (OR = 1.3, CI = 1.1,1.6), drug abuse (OR = 1.3, CI = 1.1,1.5), and alcohol abuse (OR = 1.2, CI = 1.01,1.43). The proportion of AA being injured either by violence or by being a pedestrian were almost double that of Whites. Twenty-eight percent of AA versus 42% of Whites had commercial insurance at time of injury. More AA were covered by Medicaid (21% to 9%) or uninsured (42% to 32%). Conclusion The proportion of TBI associated with underlying chronic health problems is significantly higher among AA. The finding suggests that the higher odds of underlying health problems among AA may be mediated by inadequate health insurance.

Predictive value of clinical diagnostic codes for the CDC case definition of pelvic inflammatory disease (PID): implications for surveillance.

Reporting of pelvic inflammatory disease (PID) from private providers could be incomplete because of time and staff constraints, lack of knowledge of reporting requirements and of case definitions. Reporting burden can be alleviated with the use of administrative data. The goal of this study was to determine the validity of clinical diagnostic codes assigned in electronic medical records (EMR) for identifying PID and their use in enhancing surveillance. A random sample of 296 records with a PID International Classification of Diseases, 9th Revision (ICD-9), code (614.9) were reviewed to assess for the presence of the Centers for Disease Control and Prevention (CDC) criteria for the case definition of PID. We used the records meeting the CDC clinical case definition criteria as the reference standard to determine the sensitivity, specificity, and predictive values of various data elements. Used alone, the positive predictive value (PPV) of ICD-9 code 614.9 for a CDC case definition of PID was 18.1%. The PPV increased to 100% and 56% when the ICD-9 code visit was associated with a positive test for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT), respectively. In this multispecialty group practice, a positive test for GC and CT coupled with ICD-9 code 614.9 could be used to enhance reporting of cases of PID.

An 83-year-old woman with suspected SARS: Implications for emergency nursing

An 83-year-old woman with suspected SARS: Implications for emergency nursing