Socializing One Health: an innovative strategy to investigate social and behavioral risks of emerging viral threats

In an effort to strengthen global capacity to prevent, detect, and control infectious diseases in animals and people, the United States Agency for International Development’s (USAID) Emerging Pandemic Threats (EPT) PREDICT project funded development of regional, national, and local One Health capacities for early disease detection, rapid response, disease control, and risk reduction. From the outset, the EPT approach was inclusive of social science research methods designed to understand the contexts and behaviors of communities living and working at human-animal-environment interfaces considered high-risk for virus emergence. Using qualitative and quantitative approaches, PREDICT behavioral research aimed to identify and assess a range of socio-cultural behaviors that could be influential in zoonotic disease emergence, amplification, and transmission. This broad approach to behavioral risk characterization enabled us to identify and characterize human activities that could be linked to the transmission dynamics of new and emerging viruses. This paper provides a discussion of implementation of a social science approach within a zoonotic surveillance framework. We conducted in-depth ethnographic interviews and focus groups to better understand the individual- and community-level knowledge, attitudes, and practices that potentially put participants at risk for zoonotic disease transmission from the animals they live and work with, across 6 interface domains. When we asked highly-exposed individuals (ie. bushmeat hunters, wildlife or guano farmers) about the risk they perceived in their occupational activities, most did not perceive it to be risky, whether because it was normalized by years (or generations) of doing such an activity, or due to lack of information about potential risks. Integrating the social sciences allows investigations of the specific human activities that are hypothesized to drive disease emergence, amplification, and transmission, in order to better substantiate behavioral disease drivers, along with the social dimensions of infection and transmission dynamics. Understanding these dynamics is critical to achieving health security--the protection from threats to health-- which requires investments in both collective and individual health security. Involving behavioral sciences into zoonotic disease surveillance allowed us to push toward fuller community integration and engagement and toward dialogue and implementation of recommendations for disease prevention and improved health security

Quantifying changes in size of arrhythmic photoplethysmography waveforms during a Valsalva maneuver for assessing cardiac filling pressure

OBJECTIVE: We previously showed that the change in amplitude of a finger photoplethysmography waveform during the Valsalva maneuver reflects cardiac filling pressure. However, the automated determination of peaks and valleys to calculate amplitude is limited in significant arrhythmias such as atrial fibrillation and premature ventricular complexes, which are common in heart failure. The purpose of this study was to assess the change in size of the waveform by calculating the change in root mean square (RMS) of the signal, thereby utilizing the entire cardiac cycle, and to compare it to change in size of peak-to-valley amplitude. APPROACH: We compared the two approaches in signals obtained from participants of a prior study who were tested prior to a clinically indicated cardiac catheterization. Correlation between the two methods was assessed in cases without, and then with, significant arrhythmias including atrial fibrillation or premature ventricular complexes. MAIN RESULTS: Calculations from the two methods of peak-valley amplitude and RMS were highly correlated with each other in signals without (0.99, p \u3c 0.0001, n = 252) and with significant arrhythmias (0.90, p \u3c 0.0001, n = 34). SIGNIFICANCE: RMS analysis of photoplethysmography signal size during the Valsalva maneuver is highly correlated with the method of analyzing changes in peak-valley amplitude, but does not rely on identifying peaks and valleys. The RMS method may be a more robust automated method of assessing cardiac filling pressure in patients with significant arrhythmias

An Unusual Case of Paraquat-Induced Rhabdomyolysis and Hepatic Injury Presenting With Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TCM) is a syndrome of reversible left ventricular systolic dysfunction that, at presentation, can be easily conflated with acute coronary syndrome. TCM has a clinical preponderance for older, postmenopausal females. We report on a patient's case who presented with complaints of upper and lower extremity weakness with evidence of rhabdomyolysis and hepatic injury. Her occupation as a field worker exposed her to a toxic chemical known as paraquat, which has been banned by multiple countries across the world; a chemical we presume culminated in both. The subsequent clinical cascade and resulting acute physiological illness and emotional distress primed her to develop TCM. However, she neither endorsed chest pain nor dyspnea. Her subtle clinical presentation could have led to a missed diagnosis as she was also not in a fluid overloaded state consistent with the depressed left ventricular function discovered on transthoracic echo. The diagnostic uncertainty until coronary angiography is obtained, and its association with severe and acute emotional and physical stress prompts to a greater reliance on patient history to identify occupational and toxic exposures that can contribute to its development

Rationale and design of a randomized trial of apixaban vs warfarin to evaluate atherosclerotic calcification and vulnerable plaque progression

Vitamin K antagonists (VKAs) are known to increase vascular calcification, suggesting increased cardiovascular disease events. Apixaban is an oral direct factor Xa inhibitor superior to warfarin at preventing stroke or systemic embolism and may stabilize coronary atherosclerosis. The potential benefits of avoiding VKA therapy and the favorable effects of factor Xa inhibitors could contribute to cardiovascular disease event reduction. We hypothesized that apixaban inhibits vascular calcification and coronary atherosclerosis progression compared with warfarin in patients with atrial fibrillation (AF). This study is a single-center, prospective, randomized, open-label study. From May 2014 to December 2015, 66 patients with nonvalvular AF who experienced VKA therapy were enrolled. Patients were randomized into either warfarin or apixaban cohorts and followed for 52 weeks. The primary objective is to compare the rate of change in coronary artery calcification (CAC) from baseline to follow-up in apixaban vs warfarin cohorts. The key secondary objective is to compare the rate of incident plaques and quantitative changes in plaque types between patients randomized to either warfarin or apixaban cohorts using serial coronary computed tomography angiography. Expert readers will blindly assess CAC and coronary artery plaques. It is thought that this trial will result in significant differences in CAC and coronary artery plaque progression between the VKA and apixaban. The results are anticipated to provide a novel insight into treatment selection for AF patients. The study is registered at http://www.clinicaltrials.gov (NCT 02090075)

Embolizing Massive Right Atrial Thrombus in a HIV-Infected Patient

The risk of thromboembolism is increased when associated with the human immunodeficiency viral (HIV) infection. Various factors are involved in promoting thrombosis, and the presence of a patent foramen ovale augments the potential for a paradoxical embolism. We describe the case of a 56-year-old man receiving antiretroviral therapy with features of right heart failure and pulmonary embolism. Due to the high incidence of life-threatening thromboembolism in the HIV-infected group, the need for long-term anticoagulation has to be evaluated

Usefulness of a noninvasive device to identify elevated left ventricular filling pressure using finger photoplethysmography during a Valsalva maneuver.

The high rate of re-hospitalization for heart failure might be reduced by improving noninvasive techniques for identifying elevated left ventricular (LV) filling pressure. We previously showed that changes in a finger photoplethysmography (PPG) waveform during the Valsalva maneuver (VM) reflect invasively measured LV end-diastolic pressure (LVEDP). We have since developed a hand-held device that analyzes PPG while guiding the expiratory effort of a VM. Here we assessed the sensitivity and specificity of this device for identifying elevated LVEDP in patients. We tested 82 participants (28 women), aged 40 to 85 years, before a clinically indicated left heart catheterization. Each performed a VM between 18 and 25 mm Hg for 10 seconds into a pressure transducer. PPG was recorded continuously before and during the VM. LVEDP was measured during the catheterization. An equation for calculating LVEDP was derived using (1) ratio of signal amplitudes: minimum during VM to average at baseline, (2) ratio of peak-to-peak time intervals: minimum during VM to average at baseline, and (3) mean blood pressure. Calculated and measured LVEDP were compared. The range of measured LVEDP was 4 to 35 mm Hg. Calculated LVEDP correlated with measured LVEDP (p20 mm Hg had a 70% sensitivity and 86% specificity for identifying measured LVEDP \u3e20 mm Hg (area under receiver-operating characteristic curve 0.83). In conclusion, a hand-held device for assessing LV filling pressure had high specificity and good sensitivity for identifying LVEDP \u3e20 mm Hg, a clinically meaningful threshold in heart failure