Showing papers in "Southern Medical Journal in 2011"

Emergence of Klebsiella pneumoniae carbapenemase-producing bacteria

Abstract: Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria are a group of emerging highly drug-resistant Gram-negative bacilli causing infections associated with significant morbidity and mortality. Once confined to outbreaks in the northeastern United States (US), they have spread throughout the US and most of the world. KPCs are an important mechanism of resistance for an increasingly wide range of Gram-negative bacteria and are no longer limited to K pneumoniae. KPC-producing bacteria are often misidentified by routine microbiological susceptibility testing and incorrectly reported as sensitive to carbapenems; however, resistance to the carbapenem antibiotic ertapenem is common and a better indicator of the presence of KPCs. Carbapenem antibiotics are generally not effective against KPC-producing organisms. The best therapeutic approach to KPC-producing organisms has yet to be defined; however, common treatments based on in vitro susceptibility testing are the polymyxins, tigecycline, and less frequently, aminoglycoside antibiotics. The purpose of this review is to identify the various challenges that KPC-producing bacteria present to clinicians. These include the need for special techniques for microbiological detection, the potential for nosocomial transmission, and therapeutic challenges related to limited, relatively unproven antimicrobial treatment options.

Methemoglobinemia: pathogenesis, diagnosis, and management.

Abstract: The diagnosis of methemoglobinemia should be considered in patients presenting with cyanosis and hypoxia. A variety of frequently used medications are capable of inducing methemoglobinemia, with dapsone and benzocaine being common culprits. Unique features, such as a saturation gap and chocolate-brown-colored blood, can raise suspicion for methemoglobinemia. Typically, symptoms correlate with the methemoglobin level, and treatment with methylene blue is reserved for patients with significantly elevated methemoglobin levels. In the presence of comorbid conditions that impair oxygen transport, however, low-grade methemoglobinemia can become symptomatic and may warrant treatment.

Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm.

Abstract: Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic vomiting and compulsive bathing behaviors in chronic cannabis users. Patients are typically diagnosed with CHS only after multiple and extensive medical evaluations, consequently without a clear etiology of their symptoms or treatment plan leading to symptomatic improvement. Increased healthcare provider awareness of CHS as a cause of nausea, vomiting, and abdominal pain coupled with an attentiveness to focused history taking-especially noting symptomatic improvement with prolonged exposure to hot showers or baths-can lead to effective treatment through cannabis cessation. We propose a diagnosis and treatment algorithm for physicians to follow when evaluating patients presenting with nausea, vomiting, and abdominal pain who are suspected to suffer from CHS.

Risks of transfusion.

Abstract: Each year, more than 4 million patients receive a blood transfusion in the United States to control symptoms associated with anemia, coagulopathy, thrombocytopenia, or some combination thereof. In each of these cases, the physician and the patient must weigh the potential benefits of the transfusion along with the associated risks. To assess accurately the risk:benefit ratio and to discuss this with the patient, the physician must be familiar with the range of adverse transfusion outcomes and the current estimates of their frequency. Most important, during the past decade the risk profile of transfusion has changed significantly. Transfusion-transmitted disease, although still a rare outcome of transfusion, is no longer an overriding concern in transfusion safety considerations; however, risks such as hemolysis, transfusion-related lung injury, and anaphylaxis continue to represent significant concerns and are relatively more common than the transmission of infectious diseases after transfusion. Against this background, the development of a national hemovigilance system, designed to evaluate more accurately transfusion adverse outcomes in the United States, will require greater precision and reliability in the assessment of adverse transfusion outcomes by clinicians if the proposed benefits of this system are to be realized.

Risk factors for the acquisition of nosocomial infection with carbapenem-resistant Klebsiella pneumoniae.

Abstract: Objectives Carbapenem-resistant Klebsiella pneumoniae (CRKP) has been increasingly reported all over the world. In this study, we aimed to investigate the risk factors for the acquisition of nosocomial CRKP infections. Methods We conducted a case-control study with data collected from thirty-nine patients with nosocomially acquired CRKP infection between July 2006 and July 2008. Controls were selected at a ratio of 1:2 from patients with nosocomial carbapenem-susceptible Klebsiella pneumoniae (CSKP) infection and were matched with CRKP cases for site of infection and the date of hospital admission (± within 5 days). T test, chi-square test, and logistic regression were used for statistical analysis. Results Bivariable analysis showed that the age of the patients (P=0.038), days of hospital stay prior to isolation of Klebsiella pneumoniae (K. pneumoniae) (P=0.043), altered consciousness (P=0.007), intensive care unit (ICU) admission within two weeks (P=0.003), tracheal intubation (P=0.027), mechanical ventilation (P=0.009), number of changes in antibiotics≥4 (P=0.001), exposure to carbapenems (P = 0.002), exposure to fourth-generation cephalosporins (P=0.027), and exposure to piperacillin-tazobactams/cefoperazone-sulbactams (P=0.043) and glycopeptides (P=0.042) were related to CRKP infection. The multivariable analysis showed that ICU admission (within two weeks) [odds ratio (OR):4.68, 95% confidence intervals (CI):1.15-19.09, P=0.031], exposure to carbapenems (OR: 12.69, 95% CI: 2.09-77.10, P=0.006) and exposure to glycopeptides (OR: 3.57, 95% CI: 1.11-11.42, P=0.032) were independent risk factors for nosocomial CRKP infections. Conclusion Several factors are related to CRKP infections. ICU admission (within two weeks) or prior exposure to carbapenems or glycopeptides are independent risk factors for the acquisition of nosocomial CRKP infections.

Staphylococcus lugdunensis: an emerging pathogen.

Abstract: Objective: To evaluate the clinical relevance and impact of an emerging bacterial pathogen, Staphylococcus lugdunensis, in a large teaching hospital. Methods: Three-year retrospective microbiological and clinical review of all S. lugdunensis isolates from a single medical center. Results: Seventy-seven isolates were identified; 70 had complete data. Soft tissue, bone, joint, central nervous system, urine and bloodstream infections occurred. Soft tissue infections were primarily abscesses. There were four infections of prosthetic joints and nine cases of osteomyelitis. There were 21 bacteremias, 5 of which were associated with endocarditis; 2 died. Most isolates were penicillin resistant. Conclusion: S. lugdunensis has emerged as a major human pathogen, capable of causing significant infections at many sites. It should never be dismissed as a contaminant without careful review.

Primary Care Practice Addressing Child Overweight and Obesity: A Survey of Primary Care Physicians at Four Clinics in Southern Appalachia

Abstract: Objective: The prevalence of childhood overweight and obesity in southern Appalachia is among the highest in the United States (US). Primary care providers are in a unique position to address the problem ; however, little is known about attitudes and practices in these settings. Methods: A 61-item healthcare provider questionnaire assessing current practices, attitudes, perceived barriers, and skill levels in managing childhood overweight and obesity was distributed to physicians in four primary care clinics. Questionnaires were obtained from 36 physicians. Results: Physicians' practices to address childhood overweight and obesity were limited, despite the fact that most physicians shared the attitude that childhood overweight and obesity need attention. While 71% of physicians reported talking about eating and physical activity habits with parents of overweight or obese children, only 19% reported giving these parents the tools they needed to make changes. Approximately 42% determined the parents' readiness to make small changes for their overweight or obese children. Physicians' self-perceived skill level in managing childhood overweight and obesity was found to be a key factor for childhood overweight- and obesity-related practices. Conclusion: Primary care physicians in southern Appalachia currently play a limited role in the prevention or intervention of child-hood overweight and obesity. Training physicians to improve their skills in managing childhood overweight and obesity may lead to an improvement in practice.

Postpartum Depression: An Essential Overview for the Practitioner

Abstract: Postpartum depression (PPD) is a cross-cultural form of major depressive disorder that affects some 13% of women and can have serious health consequences for both the mother and her child. Easy-to-use, reliable, self-administered screening tools are available. PPD may have a variety of etiologies, which include changing plasma levels of estrogen and progesterone, postpartum hypothyroidism, sleep deprivation, or difficult life circumstances. Standard treatments for PPD include psychotherapy and antidepressants. However, treatment of a thyroid condition or insomnia, or even regular exercise or massage may also be beneficial. PPD is underdiagnosed, therefore more screening is needed. Obstetricians and pediatricians have a unique opportunity to test women for PPD, but general practitioners may encounter patients with undiagnosed PPD, too. These physicians could positively impact the lives of depressed mothers and their children by identifying them, then treating or providing referrals for care as appropriate.

Physical activity benefits and risks on the gastrointestinal system.

Abstract: This review evaluates the current understanding of the benefits and risks of physical activity and exercise on the gastrointestinal system. A significant portion of endurance athletes are affected by gastrointestinal symptoms, but most symptoms are transient and do not have long-term consequences. Conversely, physical activity may have a protective effect on the gastrointestinal system. There is convincing evidence that physical activity reduces the risk of colon cancer. The evidence is less convincing for gastric and pancreatic cancers, gastroesophageal reflux disease, peptic ulcer disease, nonalcoholic fatty liver disease, cholelithiasis, diverticular disease, irritable bowel syndrome, and constipation. Physical activity may reduce the risk of gastrointestinal bleeding and inflammatory bowel disease, although this has not been proven unequivocally. This article provides a critical review of the evidence-based literature concerning exercise and physical activity effects on the gastrointestinal system and provides physicians with a better understanding of the evidence behind exercise prescriptions for patients with gastrointestinal disorders. Well-designed prospective randomized trials evaluating the risks and benefits of exercise and physical activity on gastrointestinal disorders are recommended for future research.

Diffuse alveolar hemorrhage.

Abstract: Diffuse alveolar hemorrhage (DAH) is a life-threatening disorder characterized clinically by the presence of hemoptysis, falling hematocrit, diffuse pulmonary infiltrates and hypoxemic respiratory failure. It refers to bleeding that originates in the pulmonary microvasculature instead of the parenchyma or bronchial circulation. DAH should be considered a medical emergency due to the morbidity and mortality associated with failure to treat the disorder promptly. Pulmonary renal syndromes, connective tissue disorders and drugs make up the majority of the cases of DAH. The treatment of DAH ranges from supportive care and withdrawal of offending drugs to high-dose steroids, immunosuppresents and plasmapharesis. The following review will discuss the clinical, radiographic and pathologic findings in a variety of disorders that cause DAH. Standard treatment options, as well as new treatment options will also be discussed.

Nephrolithiasis: evaluation and management.

Abstract: Nephrolithiasis is a major cause of morbidity involving the urinary tract. The prevalence of this disease in the United States has increased from 3.8% in the 1970s to 5.2% in the 1990s. There were nearly two million physician-office visits for nephrolithiasis in the year 2000, with estimated annual costs totaling $2 billion. New information has become available on the clinical presentation, epidemiologic risk factors, evaluative approach, and outcome of various therapeutic strategies. In this report, we will review the epidemiology and mechanisms of kidney-stone formation and outline management aimed at preventing recurrences. Improved awareness and education in both the general population and among health-care providers about these modifiable risk factors has the potential to improve general health and decrease morbidity and mortality secondary to renal-stone disease.

Multimodality FDG PET/CT appearance of pulmonary tuberculoma mimicking lung cancer and pathologic correlation in a tuberculosis-endemic country.

Abstract: OBJECTIVES Differentiation between pulmonary tuberculoma and malignancy by preoperative diagnostic imaging sometimes proves difficult. The purpose of this study is to investigate variable manifestations of pulmonary tuberculoma mimicking lung cancer on fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) image and pathologic correlation. PATIENTS AND METHODS Twenty-five patients with a high suspicion of malignancy and histopathologically diagnosed as pulmonary tuberculoma were included. Their FDG PET/CT images, clinical data, and pathologic findings were investigated. RESULTS There were 18 men and seven women. The mean age was 52 ± 8.8 years. The maximal diameter of pulmonary tuberculoma ranged from 1.7 to 4.2 cm. CT scan revealed that abnormal signs associated with malignancy such as spicular radiation, notching, and pleural indentation also frequently manifested in tuberculoma. During early imaging, positive FDG uptake was identified in 21 patients (84%), intermediate uptake in 3 patients (12%) and negative uptake in 1 patient (4%). During delayed imaging, 16 patients (64%) showed persistent elevated FDG accumulation and 8 patients (32%) experienced a slight drop of FDG accumulation. Pathologically active tuberculoma showed significantly higher FDG radioactivity during both early and delayed imaging than inactive lesion (P < 0.05). Lymphadenopathy with positive FDG uptake was identified in nine patients (36%). CONCLUSION Pulmonary tuberculomas mimicking lung cancer, most of which were pathologically active lesions, commonly displayed abnormal appearances in CT scan and an increase in FDG uptake, similar to changes seen on malignancy. Coexistent lymphadenopathy made differential diagnosis even more complicated. These results suggested that positive FDG PET/CT findings should be interpreted with caution in tuberculosis-endemic regions.

Association of Helicobacter pylori infection with the development of colorectal polyps and colorectal carcinoma.

Abstract: Background and aims Recent studies have suggested a possible association between Helicobacter pylori (HP) infection and colon neoplasia. HP infection causes hypergastrinemia, and gastrin increases colorectal mucosal proliferation, potentially leading to colorectal cancer. We investigated whether HP infection is associated with colon neoplasia. Methods We conducted a cross-sectional, single-center study in which patients who underwent routine outpatient colonoscopy and were tested for HP infection on esophagogastroduodenoscopy from January 1, 2008 to November 1, 2009 were identified. Patient demographic data (gender and age) and information on colon polyp characteristics (size, number of polyps, location, morphology, and histology) were abstracted from retrospective chart review. Presence of adenoma/carcinoma was compared in the HP-positive cases and HP-negative controls. Results A total of 192 patients were included in the study, with 96 patients each in the HP-positive and -negative groups. The two groups did not differ significantly in gender, age, polyp size, number of polyps, polyp location, morphology, and histology. Adenomatous colon polyps were noted in 31% of the HP-positive cases and in 26% of the HP-negative controls (P = 0.52). Colon carcinoma was found in 6% of HP-positive and 2% of HP-negative patients (P = 0.28). Conclusion The higher prevalence of adenomatous colon polyps/carcinoma in HP-positive patients compared to HP-negative patients was not statistically significant. Larger studies are needed to examine further the potential association between HP infection and colorectal adenoma/carcinoma.

Prevalence, incidence, and recurrence of oral lesions among HIV-infected patients on HAART in Alabama: a two-year longitudinal study

Abstract: Objective Our aim was to quantify prevalence, incidence, and recurrence of oral lesions (OL) among a population in the Southeast. Methods A retrospective study based on chart review was conducted among patients (n = 744) who were ≥19 years of age and initiated highly active antiretroviral therapy (HAART) between January 2000 and June 2006 at the University of Alabama at Birmingham (UAB) 1917 Clinic. Patients' laboratory data and oral conditions were recorded for 2 years after enrollment into the study. Results During 2 years of follow-up, the period prevalence of individuals experienced at least one OL was 35.6% (266/744). Among all of the 374 episodes of OL, 183 were new cases, while 57 were recurrences. The OL person-visit incidence rate was 0.02 per 100 person-visits. Oropharyngeal candidiasis (OPC) was the most frequent manifestation in terms of period prevalence (74.9%) with a person-visit incident rate of 0.01 per 100 person-visits. Conclusions Patients undergoing HAART continue to be affected by HIV-related oral conditions, especially OPC. These results clearly indicate that OL during HIV infection are still highly prevalent in spite of the improvements in medical care and the availability of HAART.

Comparison of two different treatment protocols in Helicobacter pylori eradication.

Abstract: BACKGROUND The prevalence of Helicobacter pylori (H pylori) in Turkey is high and eradication rates are low. As a result, alternative treatment strategies are required. OBJECTIVES To evaluate the status of H pylori eradication in Turkey by comparing the results of this study to other studies reported in the literature. METHODS Two hundred and eighty-two patients diagnosed with H pylori were included in this study. Patients were randomized into two groups. The first group consisted of 138 patients receiving 30 mg lansoprazole bid, amoxicillin 1 g bid, and clarithromycin 500 mg bid for 14 days. The second group consisted of 144 patients who received lansoprazole 30 mg bid and amoxicillin 1 g bid for seven days, followed by metronidazole 500 mg bid, tetracycline 500 mg qid, and lansoprazole 30 mg bid for an additional seven days. RESULTS H pylori eradication rates in the first group were 53.6% according to intention-to-treat analysis, and 52.5% according to per protocol analysis. In the second group, eradication rates were 72.2% per intention-to-treat analysis and 77.6% as per protocol analysis. H pylori eradication rates in the second group were significantly higher than the first group (P=0.001, P<0.05), whereas the incidence of adverse events in the second group was significantly lower (P=0.048, P<0.05). CONCLUSION This study found a significant difference in eradication rates between the traditional triple therapy and modified sequential therapy groups. As a result, modified sequential therapy shows promise as an alternative treatment.

Tetanus: a review.

Abstract: Tetanus is a preventable illness occurring worldwide with a high mortality, mostly affecting neonates in developing countries. Effects are toxin mediated and the diagnosis is clinical. Antibiotics, antitoxin, immunoglobulin and wound care are the mainstays of management.

Protean manifestations of vitamin D deficiency, part 2: deficiency and its association with autoimmune disease, cancer, infection, asthma, dermopathies, insulin resistance, and type 2 diabetes.

Abstract: Vitamin D deficiency is epidemic and its manifestations are protean. Vitamin D deficiency is associated with autoimmune diseases (particularly multiple sclerosis and type 1 diabetes) and has been associated with infection, allergy, asthma, and dermopathies (particularly psoriasis). Asthma may be worsened by vitamin D deficiency and correction of the deficiency has been shown to improve the manifestations of asthma. Vitamin D deficiency has been associated with multiple cancers, including those of the breast, colon, ovary, and prostate. Due mainly to increased insulin resistance but also to an impairment in insulin release, vitamin D deficiency is associated with the development of type 2 diabetes. In addition, the complications of diabetes may be worsened by vitamin D deficiency.

Effect of periodontal treatment on lipoproteins levels in plasma in patients with periodontitis.

Abstract: MDObjectives: Recent epidemiological studies have shown that individ-uals with periodontitis have a significantly increased risk of develop-ing coronary heart disease. In addition to conventional risk factors,dyslipidemia may be associated with this increased risk.Methods: We measured concentration of lipids in patients withmoderate to severe periodontitis before and 3, 6 and 12 months afterlocal periodontal treatment. A total of 50 participants with peri-odontitis and 25 participants without periodontitis were included inthe analyses. Lipoproteins were measured by using serological anal-yses of the Central Biochemical Laboratory in Clinical Center in Nis.Periodontal health indicators included the plaque index, gingivalbleeding index, and periodontal disease status (defined by pocketdepth and attachment loss). Patients were non-surgically treated withmechanical debridement of calculus once a week for 1 month.Results: The results show a significant relation between indicatorsof poor periodontal status and serum level lipoproteins. Periodontaltherapy resulted in a significant reduction of local inflammation andtissue destruction as reflected in reduced pocket depth and reducedbleeding indices. The levels of lipoproteins after therapy seemed tobe lower than those reported before treatment in patients with peri-odontitis compared withhealthyones.Lipoproteinswere significantlydecreased after treatment (P G0.005) except high-density lipoproteincholesterol which was not significantly reduced (P 90.05).Conclusion: This pilot study shows that periodontal disease sig-nificantly affects the serum levels of lipoproteins and suggests thatfollowing successful periodontal treatment decreases serum lipidconcentration. This study suggests also that lipoproteins are possibleintermediate factors that may link periodontal disease to elevatedcardiovascular risk.Key Words: periodontal therapy, periodontitis, lipids, lipoproteins

Transmitted antiretroviral drug resistance in individuals with newly diagnosed HIV infection: South Carolina 2005-2009.

Abstract: OBJECTIVES The transmission of drug-resistant human immunodeficiency virus 1 (HIV-1) has important implications for the antiretroviral management of newly diagnosed individuals, increasing the risk of suboptimal treatment outcomes. The study objective was to characterize rates and factors associated with transmitted drug-resistant HIV-1 infection among newly diagnosed South Carolina (SC) residents. METHODS This study utilized surveillance genotypic data from antiretroviral therapy (ART)-naive individuals newly diagnosed with HIV-1 infection from June 2005 through December 2009. Multivariable negative binomial regression was used to model the association between the presence of major mutations and sociodemographic characteristics. RESULTS Of the 1,277 study participants, 14.4% (184/1,277) had HIV-1 variants with major antiretroviral drug mutations. Of these individuals, 126 had non-nucleoside reverse transcriptase inhibitor-associated mutations (NNRTI), 54 had nucleos(t)ide reverse transcriptase inhibitor-associated mutations (NRTI), 37 had protease inhibitor-associated mutations (PI). Nineteen (10.3%) individuals had dual class-associated mutations (NNRTI and PI in seven, NNRTI and NRTI in seven, and NRTI and PI in five individuals), and seven (3.8%) individuals had triple drug class-associated mutations (PI, NNRTI, and NRTI). The multivariable negative binomial regression models indicated that age at HIV diagnosis had a significant negative association with total number of mutations (rate ratio [RR] 0.88, 95% confidence interval [CI] 0.80-0.96, P value=0.005) and total number of reverse transcriptase (RT) mutations (RR 0.88, 95% CI 0.80-0.97, P value=0.006) present. CONCLUSION Prevalence of transmitted drug resistance is consistently high among newly diagnosed HIV-infected individuals in SC. It is important to continue genotypic surveillance to facilitate effective HIV treatment and empiric post-exposure prophylaxis regimens.

Pressure modes of invasive mechanical ventilation.

Abstract: Pressure modes of invasive mechanical ventilation generate a tidal breath by delivering pressure over time. Pressure control ventilation (PC) is the prototypical pressure mode and is patient- or time-triggered, pressure-limited, and time-cycled. Other pressure modes include pressure support ventilation (PSV), pressure-regulated volume control (PRVC, also known as volume control plus [VC+]), airway pressure release ventilation (APRV), and biphasic ventilation (also known as BiLevel). Despite their complexity, modern ventilators respond to patient effort and respiratory system mechanics in a fairly predictable fashion. No single mode has consistently demonstrated superiority in clinical trials; however, empiric management with a pressure mode may achieve the goals of patient-ventilator synchrony, effective respiratory system support, adequate gas exchange, and limited ventilator-induced lung injury.

Role of sociocultural factors in hepatitis B screening among Asian Americans.

Abstract: Hepatitis B is significantly associated with liver cancer, the fourth most common cause of cancer death among Asian Americans.1 Patients who become infected with HBV earlier in life are at a higher risk of becoming a chronic carrier. 2–4 HBV infection among Asian Americans is estimated to be about 10% and it varies in incidence and prevalence among Asian American subgroups.5 The infection typically occurs through mother-to-child transmission at birth. Babies and young children are more likely to develop chronic infections, which explains, in part, the high number of Asian Americans who are chronic HBV carriers.6 Chinese American males are six times more likely to report HBV-related liver cancer than Caucasians.7, 8 Among Chinese Americans, 46% knew that HBV could cause liver cancer, but only 35% reported that they had been tested for it.9 Forty-eight percent of Chinese immigrants in the United States reported that they had received the HBV blood test.10, 11 Southeast Asians have higher liver cancer rates than any other racial/ethnic group in the U.S. Yet, a survey of Cambodian immigrant women conducted in Seattle, Washington, indicated that only 38% had been serologically tested for HBV.12 Chronic infection rates of HBV among Vietnamese-American adults are between 7% and 14%.13 Our previous study of Vietnamese immigrant adults in Pennsylvania and New Jersey indicated that only 8.8% were screened for HBV.14 Educational level, gender, English fluency, and household income were associated with increased HBV knowledge and previous HBV testing among Asian Americans.15, 16 Study results have indicated that HBV screening may be influenced by Asian cultural factors, such as respect for authority and elders, karma, males as decision makers, saving face, Yin/Yang, and chi.17–21 Family members may not inform each other to protect their members and may believe that talking about illness (karma) manifests it. Male figures, such as a husband or eldest son, often determine decisions about HBV screening and vaccination for the family. Asian Americans may also not want to disagree with a physician; but they may simply not come back to the physician or take their medication as prescribed. The concepts of Yin/Yang may also be important because health entails being in balance; ill health can be restored by bringing back harmony through acupuncture or diet. Asian Americans are likely to use traditional Chinese medicine, Western medicine, or both.22, 23 These concepts have influenced many Asian American subgroups.24–27 These demographic and cultural factors may influence HBV screening rates. Conceptual Model Ma28 developed a Sociocultural Health Behavior Model by incorporating the major constructs of the Health Belief Model,29 Social Cognitive Theory,30,31 the Behavioral Model and access to medical care,32 The Sociocultural Health Behavior Model acknowledges that the complexity and interaction of multiple factors play a major role in many patient’s health-seeking behaviors. It explains health-seeking behavior by describing the relationships among individual, interpersonal, and environmental factors. This model describes relationships between individual health behavior and interaction with the environment. The interactions and multiple levels of influence of individual, interpersonal, and environmental factors underlying the health behavior are emphasized. Since screening behavior is influenced by multiple factors, there is a need to identify the associations among these factors. The role of cultural factors is seldom included in a health behavior analysis. In addition to common theoretical components, this model includes cultural factors as a primary component. The model incorporates the interdependence of predisposing, enabling, need, family/social support, environmental health system, and cultural factors, all of which contribute to a particular health behavior or outcome. A number of variables can be included under cultural factors; these include notions of fatalism, birth in the U.S., years lived in the U.S., English fluency, use of native language at home, native food dietary habits, use of media sources in the native language, and attendance of native-themed social events. The purpose of this community-based study was to apply the proposed Sociocultural Health Behavior Model to determine the relationship of factors proposed in the model to health behaviors related to HBV screening among Asian American adults.

Iron insufficiency and hypovitaminosis D in adolescents with chronic fatigue and orthostatic intolerance.

Abstract: OBJECTIVES: More than 10% of adolescents suffer from severe fatigue and/or orthostatic intolerance. Adult studies show correlations between iron insufficiency and fatigue as well as between hypovitaminosis D and non-specific pain. We sought to determine whether there were correlations between nutritional factors (iron status, and serum vitamin D levels) and chronic ill health. METHODS: We reviewed records of 188 adolescents with symptoms of fatigue and/or orthostatic intolerance and who underwent autonomic reflex screening. RESULTS: Of the 188 patients, 130 patients (69%) had excessive postural tachycardia (PT) with a heart rate (HR) change of ≥30 bpm. 62 patients (47%, n = 131) had iron insufficiency with low iron stores, and 29 patients (22%, n = 131) were iron deficient. HR change did not correlate to ferritin level (P = 0.15). 21 patients (22%, n = 95) had hypovitaminosis D (25-hydroxyvitamin D ≤20 ng/mL). There was a significant association with hypovitaminosis D and orthostatic intolerance (P = 0.024). CONCLUSION: In patients presenting with chronic fatigue and/or orthostatic intolerance, low ferritin levels and hypovitaminosis D are common, especially in patients with PT.

Spirituality and pediatric cancer.

Abstract: Spiritual beliefs are an important source of comfort and support to many cancer patients and their families, but they may play a particularly large role when the patient is a child Parents facing a child's serious illness and possible death, and children themselves trying to make sense of illness, suffering, and death, often look beyond the material world for comfort and explanations

Resolution of statin-induced myalgias by correcting vitamin D deficiency.

Abstract: may report new clinical or laboratory observations and new developments in medical care or may contain comments on recent contents of the Journal. They will be published, if found suitable, as space permits. Like other material submitted for publication, letters must be typewritten, double-spaced, and must not exceed two typewritten pages in length. No more than five references and one figure or table may be used. See ‘‘Information for Authors’’ for format of references, tables, and figures. Editing, possible abridgment, and acceptance remain the prerogative of the Editors.

Effect of hepatitis C virus infection on the left ventricular systolic and diastolic functions.

Abstract: BACKGROUND Hepatitis secondary to infection with the hepatitis C virus (HCV) is one of the most common causes of viral hepatitis worldwide. Multiple extrahepatic manifestations of HCV infection have been recognized. Dilated and hypertrophic cardiomyopathy associated with HCV infection have been recently described in the literature; however, the effect of HCV infection on the left ventricular systolic and diastolic functions is unknown. Therefore, in this study we aimed to examine left ventricular systolic and diastolic functions in HCV patients. METHODS AND RESULTS The study included 50 anti-HCV positive patients and 50 persons for control groups. We performed transthorasic echocardiography and P-wave analysis on all participants. We compared left ventricle diastolic parameters, left ventricle ejection fraction, and P-wave dispersion (Pd) between these two groups. In the group with anti-HCV positivity, the ratio of E/A was found to be lower (1.2 ± 0.7 and 1.37 ± 0.6, P = 0.003); the ratio of E/Em was found to be higher (7.6 ± 1.51 and 6.8 ± 1.72, P = 0.0001). Maximum P-wave duration (Pmax) and Pd were higher in the patient group (99.3 ± 8 and 82.4 ± 7.8, P = 0.004; 44.1 ± 0.9 and 25.3 ± 1.5, P = 0.001). No other statistically significant difference was found between the two groups with regard to the left ventricle systolic and diastolic parameters. CONCLUSION Our findings show that HCV infection may be associated with left ventricular systolic and diastolic dysfunction and cardiac arrhythmias.

Lack of association between chemokine receptor 5 (CCR5) δ32 mutation and pathogenesis of asthma in Iranian patients.

Abstract: Background: Chemokines and their receptors are clinically important mediators, as the chemokine receptors are expressed on almost all immune cells. They play pivotal roles in pathogenesis of almost all clinical situations including asthma. Correspondingly, MIP-1 alpha (CCL3), MIP-1 beta (CCL4), and RANTES (CCL5) are among the important chemokines involved in the pathogenesis of asthma. These chemokines bind to the CCR5 (their related receptor) on the cell surfaces. Attachment of related chemokine ligands to CCR5 plays an important role in the pathogenesis of asthma; hence, this study aimed to analyze delta 32 mutations in CCR5 in asthmatic patients. Material and Methods: This experimental study was undertaken on 162 asthmatic patients and 200 healthy controls during February to June 2008 at Rafsanjan University of Medical Sciences. The Gap-PCR method was applied to analyze the delta 32 mutation in the CCR5 gene, and demographic data (eg, age, sex, occupation, socioeconomic status) were collected using a questionnaire. Results: The findings of this study indicated that none of the asthmatic patients exhibited delta 32 mutation in CCR5 chemokine receptor while only 3 (1.5) of controls had the heterozygotic form of this mutation. Discussion: Several research groups analyzed delta 32 mutations in CCR5 in different diseases, including asthma. Some investigations reported a significant relation between asthma and delta 32 mutations in CCR5, but there are also many reports which failed to find a relation between asthma and this mutation. Based on the results of this study and others, it seems that the delta 32 mutation does not affect the pathogenesis of asthma.

Socioeconomic disparities in prostate cancer mortality and the impact of geographic scale.

Abstract: OBJECTIVE To examine socioeconomic disparities in prostate cancer mortality and to assess the scale effect on the results of the disparity analysis. METHODS Using prostate cancer mortality data (N = 14,036) of Texas from 1996 to 2004, this study examines the variations of socioeconomic disparities in prostate cancer mortality across different geographic scales. Age-adjusted odds ratios are employed to reveal the disparities by single and composite socioeconomic indicators at county, census tract, and block group levels. RESULTS The analysis shows that (1) disparities in prostate cancer mortality are significant for most socioeconomic indicators, (2) area-level socioeconomic indicators tend to reveal a less extent of disparity than individual-level indicators do, and (3) socioeconomic disparities in prostate cancer mortality at the census tract and block group levels are similar to each other but are completely different from those at the county level. CONCLUSION The selection of geographic scale and socioeconomic indicators affects the results of socioeconomic disparity analysis in prostate cancer mortality. Most census tract and block group level socioeconomic indicators are appropriate for analyzing disparities in prostate cancer mortality. County level socioeconomic indicators should be avoided if possible.

Prevalence of colorectal cancer screening among a multimorbid rural Appalachian population.

Abstract: By 2020, more than 1 in 6 people in the United States will be 65 years old or older,1 and 81 million of them likely will be diagnosed as having multiple morbidities (MMs).2 Rates of MMs are especially high in rural areas, such as Appalachian Kentucky, where residents tend to be older, poorer, less educated, and more likely to be uninsured than their urban counterparts.3–6 Moreover, these residents are more likely to have risk factors, such as smoking and obesity, that elevate their mortality rates compared with residents in the rest of the state and the nation.7–11 Scant research exists on how one of the nation’s most vulnerable populations balances MMs and preventive care. Self-care practices for chronic diseases often take extensive time and resources,12,13 involving alterations in diet, exercise, and medications, and extensive interaction with formal health care.14–16 Although most (95%) primary care physicians recommend CRC screening for colorectal cancer (CRC),17 management of MMs may make such recommendations a low priority for both patients and providers.18–20 Patients with MMs must maintain complex, costly, and time-consuming regimens; thus management of MMs may represent a “competing demand” for the provider and the patient.21 Physicians may be disinclined to recommend screening to patients whom they consider physically unable to endure such screening.22 People with MMs, in general, have more contact with healthcare providers than do healthier individuals, and more opportunity to receive a screening recommendation.23–25 Although the preponderance of research confirms that competing demands tend to reduce the likelihood of screening, the jury is still out regarding whether MMs will increase or decrease the likelihood of screening, particularly in the populations that are most likely to experience MMs and inadequate cancer screening. This article describes a cross-sectional study of the association between MMs among older adults in Appalachian Kentucky and the prevalence of CRC screening.26 To our knowledge, this is the first study conducted exclusively in a rural, health-disparities population. In addition, the burgeoning older adult population, the escalating rate of MMs, particularly among vulnerable populations, and the unresolved relation between management of MMs and preventive care enhance the innovation and significance of this focus. The objectives of our study were to determine the relation between MMs and the prevalence of CRC screening by residents of the Appalachian region of Kentucky ages 50 to 76 years and to provide insight about why this relation exists and what it may mean for cancer-control efforts, research, policy, and clinical practice.

Correlation between clinical findings and results of autologous serum skin test in patients with chronic idiopathic urticaria.

Abstract: OBJECTIVES To investigate the correlation between the clinical characteristics of chronic idiopathic urticaria (CIU) and the results of autologous serum skin test (ASST). METHODS This prospective observational study was performed in the Motahari Allergy Clinic and included 69 patients referred to the clinic with a diagnosis of CIU. ASSTs were performed on all patients. We compared the disease characteristics, including duration severity, number of urticaria, and size of urticaria between those with positive and negative results of ASST. RESULTS Of 69 patients with CIU, 39 (56.5%) were female and 30 (43.5%) were male with a mean age of 32.5±12.3 (range 6-62) years. Patients with a positive ASST had a significantly higher number of wheals (P=0.043) with larger sizes (P=0.031). They also had higher frequencies of wheals (63.8% vs. 46.4% daily; P=0.039) and higher disease activity scores (1.57±0.9 vs. 2.01±1.6; P=0.044). The disease activity score was positively correlated with the size of the wheals, duration of the wheals, duration of the disease, and total number of wheals. Patients with positive ASST results had significantly higher frequencies of arthritis (P=0.027). CONCLUSION Positive ASST results are associated with more severe disease determined by the larger wheals' size, longer duration of the disease, and higher frequencies of the disease. As ASST reveals the autoimmune basis of the CIU, it can be concluded that CIU patients with autoimmune basis will suffer from more severe disease.

Vitamin D deficiency in patients with congestive heart failure: mechanisms, manifestations, and management.

Abstract: Recent research suggests that vitamin D may play a role in cardiovascular (CV) health. Although its exact role is still debated and is a matter of controversy, vitamin D deficiency has been linked to increased prevalence of CV risk factors and events. Factors that predispose persons with congestive heart failure (CHF) to hypovitaminosis D include nutritional deficiency, decreased skin production, reduced intestinal absorption, and hepatorenal disease. It is possible that low vitamin D can in turn aggravate CHF. The extent of deficiency can be severe enough to cause hypocalcemia, secondary hyperparathyroidism, osteomalacia, and decreased bone density. No clear data exist showing improvement in CV clinical outcomes with vitamin D replacement. Screening is advocated in most patients, although benefits of replacement are most likely to accrue in those with severe lack or with abnormalities of calcium-parathyroid-bone metabolism. According to current guidelines and research, vitamin D goals of >20 ng/ml in most patients with CHF and >30 ng/ml in those with secondary hyperparathyroidism seem to be appropriate to aim for. Further research is needed to fully unravel the association among CV risk, CHF and hypovitaminosis D, and translate this knowledge into clinically meaningful management recommendations.