Tuberculosis control in the 21st century.

In response to tuberculosis (TB) outbreaks in the United States in the late 1980s and early 1990s, U.S. hospitals spent tremendous resources to ensure a safer workplace. A remarkable decrease in nosocomial transmission resulted, along with a decrease in TB cases nationally. Federal standards have been promulgated to ensure a safer work environment for all U.S. workers potentially exposed to TB. However, these measures may prove costly and burdensome and thus may compromise the ability to deliver care

Occupational Deaths among Healthcare Workers

Recent experiences with severe acute respiratory syndrome and the US smallpox vaccination program have demonstrated the vulnerability of healthcare workers to occupationally acquired infectious diseases. However, despite acknowledgment of risk, the occupational death rate for healthcare workers is unknown. In contrast, the death rate for other professions with occupational risk, such as police officer or firefighter, has been well defined. With available information from federal sources and calculating the additional number of deaths from infection by using data on prevalence and natural history, we estimate the annual death rate for healthcare workers from occupational events, including infection, is 17–57 per 1 million workers. However, a much more accurate estimate of risk is needed. Such information could inform future interventions, as was seen with the introduction of safer needle products. This information would also heighten public awareness of this often minimized but essential aspect of patient care

The myth of the medical breakthrough: Smallpox, vaccination, and Jenner reconsidered

AbstractA discussion of the particulars leading to the eradication of smallpox is pertinent to both investigators and the public as the clamor for more “breakthroughs” intensifies. The rational allocation of biomedical research funds is increasingly threatened by disease-advocacy groups and congressional earmarking. An overly simplistic view of how advances truly occur promises only to stunt the growth of researchers and research areas not capable of immediate great breakthroughs. The authors review the contributions of Jenner and his countless predecessors to give a more accurate account of how “overnight medical breakthroughs” truly occur—through years of work conducted by many people, often across several continents.In the public eye, few achievements are regarded with such excitement and awe as the medical breakthrough. Developments such as the discovery of penicillin and the eradication of polio and smallpox have each become a great story built around a singular hero. Edward Jenner, for example, is credited with discovering a means of safely conferring immunity to smallpox. The success of vaccination and subsequent eradication of this disease elevated Jenner to a status in medical history that is rivaled by few.However, the story of the eradication of smallpox does not start or end with the work of Jenner. Men such as Benjamin Jesty and Reverend Cotton Mather as well as unnamed physicians from tenth century China to eighteenth century Turkey also made critical contributions to the crowning achievement. Inoculation to prevent smallpox was commonplace in Europe for generations prior to Jenner's work. Jenner himself was inoculated as a child. In fact, vaccination with cowpox matter was documented in England over 20 years prior to Jenner's work.The authors' review of primary and secondary sources indicates that although Jenner's contribution was significant, it was only one of many. It is extremely rare that a single individual or experiment generates a quantum leap in understanding; this “lone genius” paradigm is potentially injurious to the research process. Wildly unrealistic expectations can only yield unsuccessful scientific investigation, but small steps by investigators supported by an informed public can build toward a giant leap, as the story of smallpox eradication clearly demonstrates

The Great Retail Metamorphosis: How Americans Shop is How Americans Live (Metro Atlanta Case Study)

This paper will address factors to guide decision makers in anticipating future retail space demand and how this shift will affect the networks of cities and their associated suburbs. By focusing on Metro Atlanta and examining retail through a social, business, economic development lens, a literature review of retail location theory will be discussed. Then, a brief history of malls in the United States will and e-commerce behavior be overviewed. After that, the paper will then focus on Metro Atlanta to understand the current supply and market trends of malls and changing retail market, in terms of e-commerce businesses growth in Metro Atlanta. From there, the current supply and market and consumer data sources, specifically sales volume and employment data from 2012-2017, will be analyzed and applied to metro Atlanta to understand the health of regional malls and shopping centers. Lastly, the data limitations and implications for further research will be highlighte

Estimating risk of C. difficile transmission from PCR positive but cytotoxin negative cases

Background: The use of molecular methods to diagnose Clostridium difficile infection (CDI) has improved diagnostic yield compared to conventional methods. However, PCR testing can detect colonization and has introduced several practical challenges pertaining to need for treatment and isolation of cases. Methods: For all new cases detected by real-time PCR, concurrent cytotoxin assay was performed and genetic characterization with MLVA (multi-locus variable number tandem repeat analysis) was done to determine relatedness. We used PCR cycle threshold (Ct) of detection as surrogate marker for bacterial burden in stool. Results: Overall, 54 cases of CDI were detected during the study period. 42 were concurrently tested by CYT and characterized by MLVA. MLVA analysis revealed marked genetic diversity with no ongoing outbreaks; four cases were due to NAP1 strain. CYT-/PCR + cases had a higher median Ct value of detection compared to CYT+/PCR + cases (28.2 vs 22.5; p = 0.01). Among 25 strains that were genetically related, 9/11 isolates in this dominant cluster were positive by CYT compared to 4/14 in non-dominant clusters (p = 0.02). Conclusion: CYT-/PCR+ cases contribute to hospital based transmission. However, the risk of transmission of C. difficile from CYT +/PCR+ cases may be higher than those that are CYT-/PCR+. © 2014 Kamboj et al

Clinicians' Knowledge, Attitudes, and Concerns Regarding Bioterrorism After a Brief Educational Program

We conducted this study to determine the knowledge, attitudes, and intended behaviors of New York City clinicians regarding bioterrorism-related diseases after a brief educational program. Data on clinicians’ knowledge and attitudes toward bioterrorism and related diseases were collected using a self-administered questionnaire following a 3.5-hour educational program. Participants (n = 310, 82% response rate) reported increased confidence in recognizing symptoms of bioterrorism-related diseases (89%), in addressing patients’ bioterrorism concerns (83%), and ability to treat bioterrorism victims (75%). Despite a high level of confidence in the efficacy of infection control precautions, participants’ knowledge scores regarding safe work practices suggest that additional education is warranted. Educational programs are useful in enhancing the public health response to bioterrorism and its consequences

An analysis of the utilisation of chemoprophylaxis against Pneumocystis jirovecii pneumonia in patients with malignancy receiving corticosteroid therapy at a cancer hospital

Pneumocystis jirovecii pneumonia (PCP) is associated with high mortality in immunocompromised patients without human immunodeficiency virus infection. However, chemoprophylaxis is highly effective. In patients with solid tumours or haematologic malignancy, several risk factors for developing PCP have been identified, predominantly corticosteroid therapy. The aims of this study were to identify the potentially preventable cases of PCP in patients receiving corticosteroid therapy at a tertiary care cancer centre and to estimate the frequency of utilisation of chemoprophylaxis in these patients. Two retrospective reviews were performed. Over a 10-year period, 14 cases of PCP were identified: no cases were attributable to failed chemoprophylaxis, drug allergy or intolerance. During a 6-month period, 73 patients received high-dose corticosteroid therapy (⩾25 mg prednisolone or ⩾4 mg dexamethasone daily) for ⩾4 weeks. Of these, 22 (30%) had haematologic malignancy, and 51 (70%) had solid tumours. Fewer patients with solid tumours received prophylaxis compared to patients with haematologic malignancy (3.9 vs 63.6%, P<0.0001). Guidelines for PCP chemoprophylaxis in patients with haematologic malignancy or solid tumours who receive corticosteroid therapy are proposed. Successful primary prevention of PCP in this population will require a multifaceted approach targeting the suboptimal prescribing patterns for chemoprophylaxis