Occurrence and Practices for Pain, Agitation, and Delirium in Intensive Care Unit Patients.

P R Health Sci J. 2019 Sep;38(3):156-162

Authors: Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA

Abstract
OBJECTIVE: Our study described the occurrence, assessment, prevention, and management practices of pain, agitation, and delirium (PAD) in four intensive care units (ICUs) from the Puerto Rico Medical Center and compared findings with the 2013 PAD guidelines.
METHODS: A descriptive study, with repeated bedside measures (two times a day/two times a week) of PAD and review of patient clinical records.
RESULTS: Eighty ICU patients (20 per ICU) were evaluated, (median 3 times [IQR, 2-7]). At least once during the assessment period, 57% percent of patients had significant pain and 34% had delirium. Moreover, 46% were deeply sedated, 17.5% had agitation, and 52.5% of patients were within the recommended Richmond Agitation-Sedation Scale (RASS) scores. The Numeric Rating Scale and RASS were the most common tools used by clinicians to evaluate pain and agitation/sedation levels, respectively. Clinicians did not assess pain in patients unable to self-report with any guideline-recommended tools, as was the case for delirium. Fentanyl and morphine were the most commonly used analgesics, while benzodiazepines were used for sedation.
CONCLUSION: Although pain, agitation, and delirium occurrence were similar to other studies, patients continue to suffer. A gap exists between clinical practices in these ICUs and current guidelines. Strategies that contribute to integrating guidelines into these ICUs should be developed, studied, and implemented.

PMID: 31536628 [PubMed - in process]

Pancreatic Cancer Incidence, Mortality, and Survival in Puerto Rico, 2001-2015.

P R Health Sci J. 2019 Sep;38(3):148-155

Authors: Castañeda-Avila M, Torres-Cintrón CR, Cruz-Benítez A, Fuentes-Payán W, Maldonado-Albertorio A, Nieves-Ferrer L, Padró-Juarbe P, Soto-Abreu R, Perez-Ríos N, Ortiz-Ortiz KJ, Magno P, Ortiz AP

Abstract
OBJECTIVE: To perform an epidemiologic profile of pancreatic cancer (PC) in Puerto Rico (PR) with data gathered from 2001 to 2015.
METHODS: Using data from the PR Central Cancer Registry we estimated incidence and mortality rates and trends of PC in PR, and performed survival analyses. We also compared the age-standardized incidence and mortality rates of PC in people in PR with those of Hispanics, non-Hispanic whites, and non Hispanic blacks in the United States (US).
RESULTS: From 2011 to 2015, 7.8 per 100,000 persons were diagnosed with PC in PR; higher rates were observed in men than in women (9.2 vs. 6.7 per 100,000, respectively) and in persons 65 years old and older (42.7 per 100,000 persons). For the same period, 6.7 per 100,000 persons died from PC; men and persons 65 years and older had higher mortality rates. Incidence and mortality trends of PC in PR increased from 2001-2015 (annual percent change [APC] = 3.8% and 1.9%, respectively (p<0.05). Lower risk of being diagnosed with and dying from PC was seen in PR than in members of several racial/ethnic groups in the US. The median survival time for PC cases diagnosed in PR during the period of 2008 to 2012 was 5.3 months.
CONCLUSION: We observed increasing mortality rates and low survival in PC patients in PR. Research on access and response to treatment is needed to elucidate the reasons for the observed results and have a positive impact on PC burden and survival.

PMID: 31536627 [PubMed - in process]

Historical Migration revealed through a Case of Autosomal Dominant Alzheimer's Disease.

P R Health Sci J. 2019 Sep;38(3):144-147

Authors: Poblete J, Dokuru D, Coppola G, Ortiz F, Medina LD, Vinters HV, Ringman JM

Abstract
With the increasing geopolitical instability and environmental devastation occurring across the globe, human migration is increasing. We report a case that illustrates a migration pattern seen a century ago that is currently in the process of repeating itself. Using information from a neuropathological examination, genetic analyses, and historical sources, we linked a patient with autosomal dominant Alzheimer's disease in Hawai'i with her ancestors in Puerto Rico. In this patient we identified the G206A PSEN1 mutation, previously identified as being linked to a founder effect from Puerto Rico. At the turn of the twentieth century, due to devastating hurricanes in Puerto Rico and the island's new status as a possession of the United States, over 5,000 Puerto Ricans, including the grandparents of our patient, migrated to Hawai'i. This short-term but historic migration has resulted in a significant population of Puerto Ricans in Hawai'i, today. As physicians we sometimes have the opportunity and privilege, through the patients who come to us for help, to be indirect witnesses to such historical events and movements. These occurrences can inform the present and also portend future developments in this rapidly changing world.

PMID: 31536626 [PubMed - in process]

Scientific Representations at the UPR School of Tropical Medicine. I: Images of Science.

P R Health Sci J. 2019 Sep;38(3):127-143

Authors: Mayo-Santana R

Abstract
The essay examines the scientific representations that prevailed at the University of Puerto Rico School of Tropical Medicine (STM) under the auspices of Columbia University (1926-1949). This article on the STM's scientific endeavors is the first in a historical serial collection about the images and evolution of sciences at the institution. It reviews faculty's principal investigations (by disciplines and research problems), development of research programs, and concomitant scientific productivity and research outcomes. The essay focuses on the emerged scientific representations and the nature of sciences, and has been divided into four sections: 1) images of science, 2) the evolution of science in the first two eras (1926-40), 3) the third and last era unfolding (1941-49), and 4) special studies. This first paper focuses on the scientific images that emerged from an examination of communities' interactions, networks, and academic and foundational documents. The scientific representations have been brought about through the analyses of different sources: academic and research reports, and publications in external and local venues. The most significant findings of this representational inquiry are: the idea of an academic tropical center in the tropics had a shared colonial-metropolis image; the community of common, but unequal, scientific citizens became an integrated epistemological community; interdisciplinary cooperation was the School's research dictum; and an image of a mature science and school of tropical medicine emerged. The richness and varieties of the practices and outcomes of science at the STM are analytically viewed as research schemas, exemplars of knowledge (paradigms), and epistemological fields (epistemes).

PMID: 31536625 [PubMed - in process]

Parenteral Nutrition Drug Shortages: A Single-Center Experience With Rapid Process Change.

JPEN J Parenter Enteral Nutr. 2019 Jul;43(5):583-590

Authors: Nystrom EM, Bergquist WJ, Wieruszewski PM, McMahon MM, Barreto EF

Abstract
Disruptions in the medication supply chain and consequent drug product shortages, including shortages of parenteral products used for parenteral nutrition (PN) compounding, have become an increasingly common occurrence. The amino acid solution shortage that resulted from the devastating impact of Hurricanes Maria and Irma on manufacturing facilities in Puerto Rico in 2017 necessitated a rapid, coordinated shift from use of compounded PN to commercial multichamber-bag PN (MCB-PN) at our hospitals. We describe our experience operationalizing this intervention via a framework that may be adapted for addressing other drug product shortages to promote rapid yet safe use of therapeutic alternatives.

PMID: 31531869 [PubMed - in process]

Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults.

JAMA Psychiatry. 2019 Sep 11;:1-9

Authors: Turban JL, Beckwith N, Reisner SL, Keuroghlian AS

Abstract
Importance: Gender identity conversion efforts (GICE) have been widely debated as potentially damaging treatment approaches for transgender persons. The association of GICE with mental health outcomes, however, remains largely unknown.
Objective: To evaluate associations between recalled exposure to GICE (by a secular or religious professional) and adult mental health outcomes.
Design, Setting, and Participants: In this cross-sectional study, a survey was distributed through community-based outreach to transgender adults residing in the United States, with representation from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and US military bases overseas. Data collection occurred during 34 days between August 19 and September 21, 2015. Data analysis was performed from June 8, 2018, to January 2, 2019.
Exposure: Recalled exposure to GICE.
Main Outcomes and Measures: Severe psychological distress during the previous month, measured by the Kessler Psychological Distress Scale (defined as a score ≥13). Measures of suicidality during the previous year and lifetime, including ideation, attempts, and attempts requiring inpatient hospitalization.
Results: Of 27 715 transgender survey respondents (mean [SD] age, 31.2 [13.5] years), 11 857 (42.8%) were assigned male sex at birth. Among the 19 741 (71.3%) who had ever spoken to a professional about their gender identity, 3869 (19.6%; 95% CI, 18.7%-20.5%) reported exposure to GICE in their lifetime. Recalled lifetime exposure was associated with severe psychological distress during the previous month (adjusted odds ratio [aOR], 1.56; 95% CI, 1.09-2.24; P < .001) compared with non-GICE therapy. Associations were found between recalled lifetime exposure and higher odds of lifetime suicide attempts (aOR, 2.27; 95% CI, 1.60-3.24; P < .001) and recalled exposure before the age of 10 years and increased odds of lifetime suicide attempts (aOR, 4.15; 95% CI, 2.44-7.69; P < .001). No significant differences were found when comparing exposure to GICE by secular professionals vs religious advisors.
Conclusions and Relevance: The findings suggest that lifetime and childhood exposure to GICE are associated with adverse mental health outcomes in adulthood. These results support policy statements from several professional organizations that have discouraged this practice.

PMID: 31509158 [PubMed - as supplied by publisher]

Consideration of Aggressive and Strategic Approaches to Address Declining Enrollment in US Pharmacy Schools.

Am J Pharm Educ. 2019 Aug;83(6):6959

Authors: Pavuluri N, Aparasu RR, Boje KMK, Danielson J, El-Ibiary SY, Iyer AKV, Ochs LA, Robinson JD, Shah S, Williams CC, Moore TM, Wargo KA

Abstract
Members from Cohort 13 of the Academic Leadership Fellows Program (ALFP) 2016-2017 were challenged to present a debate on the topic: "In Turbulent Times, Pharmacy Education Leaders Must Take Aggressive Action to Prevent Further Declines in Enrollment" at the American Association of Colleges of Pharmacy INfluence 2017 meeting in Rio Grande, Puerto Rico. This paper is the result of thoughtful insights emerging from this debate. We present a discussion of the question of whether pharmacy education leaders must take aggressive action or strategic approaches to prevent further declines in enrollment. There are many thoughts regarding current declines in enrollment. Some educators contend that a more aggressive approach is needed while others argue that, while aggressive actions might lead to short-term gains, a more viable approach involves strategic actions targeting the underlying causes for decreasing enrollment. This paper explores themes of enrollment challenges, current and future workforce needs, and financial issues for both pharmacy programs and students. In summation, both aggressive actions and a strategic, sustainable approach are urgently needed to address declining enrollment.

PMID: 31507290 [PubMed - in process]

Reconsidering culture, attachment, and inequality in the treatment of a Puerto Rican migrant: Toward structural competence in psychotherapy.

J Clin Psychol. 2019 Sep 11;:

Authors: Gaztambide DJ

Abstract
Cultural competence refers to our ability to understand, engage, and treat patients from diverse backgrounds or belief systems different from our own. Although addressing culture and cultural difference as part of diversity is important, it is also critical to consider how systemic and economic forces influence the patient's presenting problem and clinical interactions. Summarizing research on cultural competence, attachment, and inequality, this paper reconsiders diversity considerations by discussing how structural inequities disrupt one's ability to trust others interpersonally and across cultural difference. Psychotherapy from this point of view is a relationship that attempts to address the effects of inequality at an individual level by repairing trust and using that trust to work toward change. To illustrate this perspective, the author presents a case of a Puerto Rican migrant whose developmental and family history was impacted by colonial, racial, cultural, and socioeconomic inequality.

PMID: 31506935 [PubMed - as supplied by publisher]

Luciferase gene of a Caribbean fireworm (Syllidae) from Puerto Rico.

Sci Rep. 2019 Sep 10;9(1):13015

Authors: Mitani Y, Yasuno R, Futahashi R, Oakley TH, Ohmiya Y

Abstract
The fireworms Odontosyllis spp. are globally distributed and well-known for their characteristic and fascinating mating behavior, with secreted mucus emitting bluish-green light. However, knowledge about the molecules involved in the light emission are still scarce. The fireworms are believed to emit light with a luciferin-luciferase reaction, but biochemical evidence of the luciferase is established for only one species living in Japan and no information is available for its luciferin structure. In this study, we identified a luciferase gene from a related Puerto Rican fireworm. We identified eight luciferase-like genes in this Puerto Rican fireworm, finding amino acid identities between Japanese and Puerto Rican luciferase-like genes to be less than 60%. We confirmed cross reactivity of extracts of the Japanese fireworm luciferin with a recombinant Puerto Rican luciferase (PR1). The emission spectrum of recombinant PR1 was similar to the crude extract of the native luciferase, suggesting that PR1 is a functional luciferase of this Puerto Rican fireworm. Our results indicate that the molecular mechanism of luminescence is widely conserved among fireworms.

PMID: 31506523 [PubMed - in process]

Lessons Learned from Dengue Surveillance and Research, Puerto Rico, 1899-2013.

Emerg Infect Dis. 2019 Aug;25(8):1522-1530

Authors: Sharp TM, Ryff KR, Santiago GA, Margolis HS, Waterman SH

Abstract
Dengue was first reported in Puerto Rico in 1899 and sporadically thereafter. Following outbreaks in 1963 and 1969, the Centers for Disease Control and Prevention has worked closely with the Puerto Rico Department of Health to monitor and reduce the public health burden of dengue. During that time, evolving epidemiologic scenarios have provided opportunities to establish, improve, and expand disease surveillance and interventional research projects. These initiatives have enriched the tools available to the global public health community to understand and combat dengue, including diagnostic tests, methods for disease and vector surveillance, and vector control techniques. Our review serves as a guide to organizations seeking to establish dengue surveillance and research programs by highlighting accomplishments, challenges, and lessons learned during more than a century of dengue surveillance and research conducted in Puerto Rico.

PMID: 31503540 [PubMed - in process]

The effect of minority status and social context on the development of depression and anxiety: a longitudinal study of Puerto Rican descent youth.

World Psychiatry. 2019 Oct;18(3):298-307

Authors: Alegria M, Shrout PE, Canino G, Alvarez K, Wang Y, Bird H, Markle SL, Ramos-Olazagasti M, Rivera DV, Cook BL, Musa GJ, Falgas-Bague I, NeMoyer A, Dominique G, Duarte C

Abstract
Few longitudinal studies have explored to date whether minority status in disadvantaged neighborhoods conveys risk for negative mental health outcomes, and the mechanisms possibly leading to such risk. We investigated how minority status influences four developmental mental health outcomes in an ethnically homogeneous sample of Puerto Rican youth. We tested models of risk for major depressive disorder (MDD) and generalized anxiety disorder (GAD), depressive and anxiety symptoms (DAS), and psychological distress, as Puerto Rican youth (aged 5-13 years) transitioned to early adulthood (15-29 years) in two sites, one where they grew up as a majority (the island of Puerto Rico), and another where they were part of a minority group (South Bronx, New York). At baseline, a stratified sample of 2,491 Puerto Rican youth participated from the two sites. After baseline assessment (Wave 1), each youth participant and one caregiver were assessed annually for two years, for a total of three time points (Waves 1-3). From April 2013 to August 2017, participants were contacted for a Wave 4 interview, and a total of 2,004 young people aged 15 to 29 years participated in the assessment (response rate adjusted for eligibility = 82.8%). Using a quasi-experimental design, we assessed impacts of minority status on MDD, GAD, DAS and psychological distress. Via mediation analyses, we explored potential mechanisms underlying the observed relationships. Data from 1,863 Puerto Rican youth (after exclusion of those with MDD or GAD during Waves 1-3) indicated links between minority status and higher rates of lifetime and past-year GAD, DAS and past 30-day psychological distress at Wave 4, and a marginal trend for MDD, even after adjustments. Childhood social support and peer relationships partially explained the differences, as did intercultural conflict, neighborhood discrimination, and unfair treatment in young adulthood. The experience of growing up as a minority, as defined by context, seemingly elevates psychiatric risks, with differences in social relationships and increased social stress as mediators of this relationship. Our findings suggest that interventions at the neighborhood context rather than at the individual level might be important levers to reduce risks for the development of mood disorders in minority youth.

PMID: 31496076 [PubMed]

Lactobacillus delbrueckii ssp. bulgaricus OLL1073R-1 feeding enhances humoral immune responses, which are suppressed by the antiviral neuraminidase inhibitor oseltamivir in influenza A virus-infected mice.

J Dairy Sci. 2019 Sep 05;:

Authors: Takahashi E, Sawabuchi T, Kimoto T, Sakai S, Kido H

Abstract
Antiviral neuraminidase inhibitors, such as oseltamivir, zanamivir, and peramivir, are widely used for treatment of influenza virus infection. We reported previously that oseltamivir inhibits the viral growth cycle, ameliorates symptoms, and reduces viral antigen quantities. Suppressed viral antigen production, however, induces a reduction of acquired antiviral humoral immunity, and increases the incidence of re-infection rate in the following year. To achieve effective treatment of influenza virus infection, it is necessary to overcome these adverse effects of antiviral neuraminidase inhibitors. Feeding of yogurt fermented with Lactobacillus delbrueckii ssp. bulgaricus (L. bulgaricus) OLL1073R-1 is reported to have immune-stimulatory effects on influenza virus infection in mice and humans. In the present study, we assessed the effect of feeding L. bulgaricus OLL1073R-1 yogurt cultures (YC) on local and systemic humoral immune responses, which were suppressed by oseltamivir treatment, in mice infected with influenza A virus. Yogurt culture (1.14 × 108 cfu/0.4 mL per mouse per day) or sterile water (vehicle) was administered by intragastric gavage for 35 d. At d 22, influenza A virus/Puerto Rico/8/34 (H1N1) (PR8; 0.5 pfu/15 μL per mouse) was instilled intranasally, followed immediately by oral administration of oseltamivir (50 μg/100 μL per mouse, twice daily) or 5% methylcellulose (100 μL/mouse) as a vehicle for 13 d. Titers of anti-PR8-specific IgG and IgA in serum and mucosal secretory IgA (S-IgA) and IgG in bronchoalveolar lavage fluid (BALF) were analyzed by ELISA at 14 d after infection. Oseltamivir significantly suppressed the induction of anti-PR8-specific IgG and IgA in serum and S-IgA and IgG in BALF after infection. Feeding YC mildly but significantly stimulated production of PR8-specific IgA in serum, S-IgA in BALF, and IgG in serum without changing the IgG2a:IgG1 ratio. We analyzed the neutralizing activities against PR8 in serum and BALF and found that oseltamivir also reduced protective immunity, and YC feeding abrogated this effect. The immune-stimulatory tendency of YC on anti-PR8-specific IgA and IgG titers in serum and BALF was also detected in mice re-infected with PR8, but the effect was insignificant, unlike the effect of YC in the initial infection.

PMID: 31495632 [PubMed - as supplied by publisher]

Effectiveness of a Disability Preventive Intervention for Minority and Immigrant Elders: The Positive Minds-Strong Bodies Randomized Clinical Trial.

Am J Geriatr Psychiatry. 2019 Aug 13;:

Authors: Alegría M, Frontera W, Cruz-Gonzalez M, Markle SL, Trinh-Shevrin C, Wang Y, Herrera L, Ishikawa RZ, Velazquez E, Fuentes L, Guo Y, Pan J, Cheung M, Wong J, Genatios U, Jimenez A, Ramos Z, Perez G, Wong JY, Chieng CK, Bartels SJ, Duan N, Shrout PE

Abstract
OBJECTIVE: To test the acceptability and effectiveness of a disability prevention intervention, Positive Minds-Strong Bodies (PMSB), offered by paraprofessionals to mostly immigrant elders in four languages.
DESIGN: Randomized trial of 307 participants, equally randomized into intervention or enhanced usual care.
SETTING: Community-based organizations in Massachusetts, New York, Florida, and Puerto Rico serving minority elders. Data collected at baseline, 2, 6, and 12 months, between May 2015 and March 2019.
PARTICIPANTS: English-, Spanish-, Mandarin-, or Cantonese-speaking adults, age 60+, not seeking disability prevention services, but eligible per elevated mood symptoms and minor to moderate physical dysfunction.
INTERVENTIONS: Ten individual sessions of cognitive behavioral therapy (PM) concurrently offered with 36 group sessions of strengthening exercise training (SB) over 6 months compared to enhanced usual care.
MEASUREMENTS: Acceptability defined as satisfaction and attendance to >50% of sessions. Effectiveness determined by changes in mood symptoms (HSCL-25 and GAD-7), functional performance (SPPB), self-reported disability (LLFDI), and disability days (WHODAS 2.0).
RESULTS: Around 77.6% of intervention participants attended over half of PM Sessions; 53.4% attended over half of SB sessions. Intent-to-treat analyses at 6 months showed significant intervention effects: improved functioning per SPPB and LLFDI, and lowered mood symptoms per HSCL-25. Intent-to-treat analyses at 12 months showed that effects remained significant for LLFDI and HSCL-25, and disability days (per WHODAS 2.0) significantly decreased 6-month after the intervention.
CONCLUSIONS: PMSB offered by paraprofessionals in community-based organizations demonstrates good acceptability and seems to improve functioning, with a compliance-benefit effect showing compliance as an important determinant of the intervention response.

PMID: 31494015 [PubMed - as supplied by publisher]

Burkholderia pseudomallei, the causative agent of melioidosis, is rare but ecologically established and widely dispersed in the environment in Puerto Rico.

PLoS Negl Trop Dis. 2019 Sep 05;13(9):e0007727

Authors: Hall CM, Jaramillo S, Jimenez R, Stone NE, Centner H, Busch JD, Bratsch N, Roe CC, Gee JE, Hoffmaster AR, Rivera-Garcia S, Soltero F, Ryff K, Perez-Padilla J, Keim P, Sahl JW, Wagner DM

Abstract
BACKGROUND: Burkholderia pseudomallei is a soil-dwelling bacterium and the causative agent of melioidosis. The global burden and distribution of melioidosis is poorly understood, including in the Caribbean. B. pseudomallei was previously isolated from humans and soil in eastern Puerto Rico but the abundance and distribution of B. pseudomallei in Puerto Rico as a whole has not been thoroughly investigated.
METHODOLOGY/PRINCIPAL FINDINGS: We collected 600 environmental samples (500 soil and 100 water) from 60 sites around Puerto Rico. We identified B. pseudomallei by isolating it via culturing and/or using PCR to detect its DNA within complex DNA extracts. Only three adjacent soil samples from one site were positive for B. pseudomallei with PCR; we obtained 55 isolates from two of these samples. The 55 B. pseudomallei isolates exhibited fine-scale variation in the core genome and contained four novel genomic islands. Phylogenetic analyses grouped Puerto Rico B. pseudomallei isolates into a monophyletic clade containing other Caribbean isolates, which was nested inside a larger clade containing all isolates from Central/South America. Other Burkholderia species were commonly observed in Puerto Rico; we cultured 129 isolates from multiple soil and water samples collected at numerous sites around Puerto Rico, including representatives of B. anthina, B. cenocepacia, B. cepacia, B. contaminans, B. glumae, B. seminalis, B. stagnalis, B. ubonensis, and several unidentified novel Burkholderia spp.
CONCLUSIONS/SIGNIFICANCE: B. pseudomallei was only detected in three soil samples collected at one site in north central Puerto Rico with only two of those samples yielding isolates. All previous human and environmental B. pseudomallei isolates were obtained from eastern Puerto Rico. These findings suggest B. pseudomallei is ecologically established and widely dispersed in the environment in Puerto Rico but rare. Phylogeographic patterns suggest the source of B. pseudomallei populations in Puerto Rico and elsewhere in the Caribbean may have been Central or South America.

PMID: 31487287 [PubMed - as supplied by publisher]

Visitors to a Tropical Marine Beach Show Evidence of Immunoconversions to Multiple Waterborne Pathogens.

Front Public Health. 2019;7:231

Authors: Simmons KJ, Eason TN, Curioso CL, Griffin SM, Ramudit MKD, Oshima KH, Sams EA, Wade TJ, Grimm A, Dufour A, Augustine SAJ

Abstract
Determining infections from environmental exposures, particularly from waterborne pathogens is a challenging proposition. The study design must be rigorous and account for numerous factors including study population selection, sample collection, storage, and processing, as well as data processing and analysis. These challenges are magnified when it is suspected that individuals may potentially be infected by multiple pathogens at the same time. Previous work demonstrated the effectiveness of a salivary antibody multiplex immunoassay in detecting the prevalence of immunoglobulin G (IgG) antibodies to multiple waterborne pathogens and helped identify asymptomatic norovirus infections in visitors to Boquerón Beach, Puerto Rico. In this study, we applied the immunoassay to three serially collected samples from study participants within the same population to assess immunoconversions (incident infections) to six waterborne pathogens: Helicobacter pylori, Campylobacter jejuni, Toxoplasma gondii, hepatitis A virus, and noroviruses GI. I and GII.4. Further, we examined the impact of sampling on the detection of immunoconversions by comparing the traditional immunoconversion definition based on two samples to criteria developed to capture trends in three sequential samples collected from study participants. The expansion to three samples makes it possible to capture the IgG antibody responses within the survey population to more accurately assess the frequency of immunoconversions to target pathogens. Based on the criteria developed, results showed that when only two samples from each participant were used in the analysis, 25.9% of the beachgoers immunoconverted to at least one pathogen; however, the addition of the third sample reduced immunoconversions to 6.5%. Of these incident infections, the highest levels were to noroviruses followed by T. gondii. Moreover, many individuals displayed evidence of immunoconversions to multiple pathogens. This study suggests that detection of simultaneous infections is possible, with far reaching consequences for the population. The results may lead to further studies to understand the complex interactions that occur within the body as the immune system attempts to ward off these infections. Such an approach is critical to our understanding of medically important synergistic or antagonistic interactions and may provide valuable and critical information to public health officials, water treatment personnel, and environmental managers.

PMID: 31482082 [PubMed]

Determinants and characterization of exposure to phthalates, DEHTP and DINCH among pregnant women in the PROTECT birth cohort in Puerto Rico.

J Expo Sci Environ Epidemiol. 2019 Sep 03;:

Authors: Rodríguez-Carmona Y, Ashrap P, Calafat AM, Ye X, Rosario Z, Bedrosian LD, Huerta-Montanez G, Vélez-Vega CM, Alshawabkeh A, Cordero JF, Meeker JD, Watkins D

Abstract
BACKGROUND: As a result of evidence suggesting phthalate toxicity, their use has decreased in recent years. However, new phthalates and non-phthalate replacements have emerged in their place, with unknown potential impacts on health.
METHODS: We measured 15 phthalate, two di(2-ethylhexyl)terephthalate (DEHTP), and two di(isononyl)cyclohexane-1,2-dicarboxylate (DINCH) urinary metabolites, collected up to three times during pregnancy from 994 women in Northern Puerto Rico (2011-2017). We used tests of linear trend to assess changes in concentrations over time and linear mixed models to identify predictors of exposure (sociodemographic characteristics, drinking water sources, diet, product use).
RESULTS: Several phthalate metabolites decreased over the study period indicating decreased exposure, while the geometric mean of DEHTP metabolites (molecular sum) increased threefold between 2014 and 2017. Intraclass correlations revealed low to moderate reproducibility of these biomarkers across pregnancy. Several metabolites were associated with maternal age, income, education, pre-pregnancy BMI, drinking public water, use of cleaning and personal care products, and ice cream consumption. DINCH metabolite concentrations remained low throughout the study period.
CONCLUSION: Although exposure to some phthalates may be decreasing, exposure to replacements, such as DEHTP, is increasing. Additional studies are needed to further characterize sources of phthalate replacement chemicals and potential exposure-related health effects among vulnerable populations.

PMID: 31481681 [PubMed - as supplied by publisher]

A Luciferase-fluorescent Reporter Influenza Virus for Live Imaging and Quantification of Viral Infection.

J Vis Exp. 2019 Aug 14;(150):

Authors: Chiem K, Rangel-Moreno J, Nogales A, Martinez-Sobrido L

Abstract
Influenza A viruses (IAVs) cause human respiratory disease that is associated with significant health and economic consequences. As with other viruses, studying IAV requires the use of laborious secondary approaches to detect the presence of the virus in infected cells and/or in animal models of infection. This limitation has been recently circumvented with the generation of recombinant IAVs expressing easily traceable fluorescent or bioluminescent (luciferase) reporter proteins. However, researchers have been forced to select fluorescent or luciferase reporter genes due to the restricted capacity of the IAV genome for including foreign sequences. To overcome this limitation, we have generated a recombinant replication-competent bi-reporter IAV (BIRFLU) stably expressing both a fluorescent and a luciferase reporter gene to easily track IAV infections in vitro and in vivo. To this end, the viral non-structural (NS) and hemagglutinin (HA) viral segments of influenza A/Puerto Rico/8/34 H1N1 (PR8) were modified to encode the fluorescent Venus and the bioluminescent Nanoluc luciferase proteins, respectively. Here, we describe the use of BIRFLU in a mouse model of IAV infection and the detection of both reporter genes using an in vivo imaging system. Notably, we have observed a good correlation between the expressions of both reporters and viral replication. The combination of cutting-edge techniques in molecular biology, animal research and imaging technologies, provides researchers the unique opportunity to use this tool for influenza research, including the study of virus-host interactions and dynamics of viral infections. Importantly, the feasibility to genetically alter the viral genome to express two foreign genes from different viral segments opens up opportunities to use this approach for: (i) the development of novel IAV vaccines, (ii) the generation of recombinant IAVs that can be used as vaccine vectors for the treatment of other human pathogen infections.

PMID: 31475986 [PubMed - in process]

Evaluation of Emergency Department-Based Surveillance Systems at 2 Healthcare Facilities After Hurricane Maria: Puerto Rico, 2017-2018.

Disaster Med Public Health Prep. 2019 Sep 02;:1-9

Authors: Adams LE, Vargas L, Frasqueri-Quintana VM, Torres-Figueroa X, Ryff K, Sanchez-Gonzalez L, Little E, Ciampaglio K, Reyes Claudio JM, Ponton-Cruz E, Santiago W, Paz-Bailey G, Alvarado LI

Abstract
OBJECTIVES: Hurricane Maria caused catastrophic damage in Puerto Rico, increasing the risk for morbidity and mortality in the post-impact period. We aimed to establish a syndromic surveillance system to describe the number and type of visits at 2 emergency health-care settings in the same hospital system in Ponce, Puerto Rico.
METHODS: We implemented a hurricane surveillance system by interviewing patients with a short questionnaire about the reason for visit at a hospital emergency department and associated urgent care clinic in the 6 mo after Hurricane Maria. We then evaluated the system by comparing findings with data from the electronic medical record (EMR) system for the same time period.
RESULTS: The hurricane surveillance system captured information from 5116 participants across the 2 sites, representing 17% of all visits captured in the EMR for the same period. Most visits were associated with acute illness/symptoms (79%), followed by injury (11%). The hurricane surveillance and EMR data were similar, proportionally, by sex, age, and visit category.
CONCLUSIONS: The hurricane surveillance system provided timely and representative data about the number and type of visits at 2 sites. This system, or an adapted version using available electronic data, should be considered in future disaster settings.

PMID: 31475668 [PubMed - as supplied by publisher]

Re: Excess death estimates in Puerto Rico have been consistent all along.

Epidemiology. 2019 Aug 12;:

Authors: Santos-Lozada AR, Howard JT

PMID: 31469697 [PubMed - as supplied by publisher]

Use of extracorporeal membranous oxygenation in the management of refractory trauma-related severe acute respiratory distress syndrome: a national survey of the Eastern Association for the Surgery of Trauma.

Trauma Surg Acute Care Open. 2019;4(1):e000341

Authors: Raff L, Kerby JD, Reiff D, Jansen J, Schinnerer E, McGwin G, Bosarge P

Abstract
Objective: To report results of a national survey of provider attitudes, observations, and opinions regarding the use of extracorporeal membranous oxygenation (ECMO) to manage severe acute respiratory distress syndrome (ARDS) in trauma patients.
Design: A survey was created to query providers on the use of ECMO in trauma, as well as general management principals related to care of the patient with refractory hypoxic respiratory failure. The survey was sent to all members of Eastern Association for the Surgery of Trauma (EAST). Once completed, the survey was returned to the University of Alabama at Birmingham and results were analyzed.
Setting/patients: Trauma patients with refractory ARDS.
Interventions: None.
Measurements and main results: Respondents were from 37 states, the District of Columbia, and Puerto Rico. 56.9% reported institutional ECMO capabilities, but only 45.2% reported using ECMO for trauma patients. Most respondents (90.2%) reported ECMO use in less than or equal to five trauma patients per year. 20.9% think there is not enough data to support its use in trauma but only 4.7% would absolutely not consider ECMO use for trauma patients. Ranking the preferred modality of treatments for refractory ARDS from most to least preferable is as follows: airway pressure release ventilation, bilevel ventilation, paralysis, prone positioning, inhaled nitric oxide, epoprostenol, high-frequency oscillatory ventilation, corticosteroids, surfactant.
Conclusions: ARDS has a high mortality among trauma patients. Despite its utility in treating severe ARDS and other pulmonary disease processes, ECMO has not been universally embraced by the trauma community. There are an increasing number of studies that suggest that ECMO is a safe and viable treatment option for trauma patients with ARDS. Based on the results of this survey, ECMO use remains limited by trauma providers that care for patients with refractory hypoxic respiratory failure and ARDS, likely due to a combination of knowledge gaps and lack of access to ECMO.
Level of evidence: Level V.

PMID: 31467986 [PubMed]