Incidence, microbiology, and patient characteristics of skin and soft-tissue infections in a U.S. population: a retrospective population-based study.

BACKGROUND: Skin and soft tissue infections (SSTIs) are commonly occurring infections with wide-ranging clinical manifestations, from mild to life-threatening. There are few population-based studies of SSTIs in the period after the rapid increase in community-acquired methicillin-resistant Staphyloccus aureus (MRSA). METHODS: We used electronic databases to describe the incidence, microbiology, and patient characteristics of clinically-diagnosed skin and soft tissue infections (SSTIs) among members of a Northern California integrated health plan. We identified demographic risk factors associated with SSTIs and MRSA infection. RESULTS: During the three-year study period from 2009 to 2011, 376,262 individuals experienced 471,550 SSTI episodes, of which 23% were cultured. Among cultured episodes, 54% were pathogen-positive. Staphylococcus aureus (S. aureus) was isolated in 81% of pathogen-positive specimens, of which nearly half (46%) were MRSA. The rate of clinically-diagnosed SSTIs in this population was 496 per 10,000 person-years. After adjusting for age group, gender, race/ethnicity and diabetes, Asians and Hispanics were at reduced risk of SSTIs compared to whites, while diabetics were at substantially higher risk compared to non-diabetics. There were strong age group by race/ethnicity interactions, with African Americans aged 18 to <50 years being disproportionately at risk for SSTIs compared to persons in that age group belonging to other race/ethnicity groups. Compared to Whites, S. aureus isolates of African-Americans and Hispanics were more likely to be MRSA (Odds Ratio (OR): 1.79, Confidence Interval (CI): 1.67 to 1.92, and, OR: 1.24, CI: 1.18 to 1.31, respectively), while isolates from Asians were less likely to be MRSA (OR: 0.73, CI: 0.68 to 0.78). CONCLUSIONS: SSTIs represent a significant burden to the health care system. The majority of culture-positive SSTIs were caused by S. aureus, and almost half of the S. aureus SSTIs were methicillin-resistant. The reasons for African-Americans having a higher likelihood, and Asians a lower likelihood, for their S. aureus isolates to be methicillin-resistant, should be further investigated.

Fishery resource utilization of a restored estuarine borrow pit: a beneficial use of dredged material case study.

Numerous pits in coastal waters are subject to degraded water quality and benthic habitat conditions, resulting in degraded fish habitat. A pit in Barnegat Bay, New Jersey (USA) was partially filled with dredged sediment to increase flushing, alleviate hypoxia, and enhance benthic assemblages. Restoration objectives were assessed in terms of benthic community parameters and fishery resource occupation. Restoration resulted in increased benthic diversity (bottom samples) and the absence of water column stratification. Fisheries resources occupied the entire water column, unlike pre-restoration conditions where finfish tended to avoid the lower water column. The partial restoration option effectively reproduced an existing borrow pit configuration (Hole #5, control), by decreasing total depth from -11 m to -5.5 m, thereby creating a habitat less susceptible to hypoxic/anoxic conditions, while retaining sufficient vertical relief to maintain associations with juvenile weakfish and other forage fishes. Partially filling pits using dredged material represents a viable restoration alternative.

The epidemiology of herpes zoster in patients with newly diagnosed cancer.

BACKGROUND: Given the limited literature, we conducted a study to examine the epidemiology of herpes zoster (HZ) among newly diagnosed cancer patients. METHODS: We identified adult health plan members of Kaiser Permanente Northern California diagnosed with invasive cancer from 2001 to 2005. Electronic health records with inpatient and outpatient diagnoses, laboratory tests, and antiviral medications were used to identify HZ diagnoses from 2001 to 2006. HZ diagnoses and associated complications were confirmed by medical chart review. Treatment with chemotherapy and corticosteroids was used to classify patients by immunosuppression level. RESULTS: Among 14,670 cancer patients, 424 were diagnosed with HZ during follow-up (median 22 months). The incidence of HZ was 31/1,000 person-year (PY) in patients with hematologic malignancies and 12/1,000 PY in patients with solid tumors. The corresponding 2-year cumulative incidence of HZ was approximately 6% and 2%, respectively. Compared with incidence rates of HZ reported in a general US population, the age- and sex-standardized rates of HZ were 4.8 times higher [95% confidence interval (CI), 4.0-5.6] in patients with hematologic malignancies and 1.9 times higher (95% CI, 1.7-2.1) in those with solid tumors. HZ risk increased with increasing level of immunosuppression. Among HZ cases, 19% with hematologic malignancies and 14% with solid tumors had HZ-associated pain for at least 30 days. The corresponding numbers for nonpain-related complications were 30% and 18%, respectively. CONCLUSIONS: Cancer patients are at substantially increased risk of HZ and among those with HZ, complications are relatively common. IMPACT: Better HZ prevention and treatment options for cancer patients are needed.

Prescription long-term opioid use in HIV-infected patients.

OBJECTIVES: To examine changes the in use of prescription opioids for the management of chronic noncancer pain in human immunodeficiency virus (HIV)-infected patients and to identify patient characteristics associated with long-term use. METHODS: Long-term prescription opioid use (ie, 120+ days supply or 10+ prescriptions during a year) was assessed between 1997 and 2005 among 6939 HIV-infected Kaiser Permanente members and HIV-uninfected persons in the general health plan memberships. RESULTS: In 2005, 8% of HIV individuals had prevalent long-term opioid use, more than double the prevalence among HIV-uninfected individuals. However, the large increases in use from 1997 to 2005 in the general population were not observed for HIV-infected individuals. The strongest associations with prevalent use among HIV-infected individuals were female sex with a prevalence ratio (PR) of 1.8 (95% CI=1.3, 2.5); Charlson comorbidity score of 2 or more (compared with a score of 0) with a PR of 1.9 (95% CI=1.4, 2.8); injection drug use history with a PR of 1.8 (95% CI=1.3, 2.6); and substance use disorders with a PR of 1.8 (95% CI=1.3, 2.5). CD4, HIV viral load, and acquired immunodeficiency syndrome diagnoses were associated with prevalent opioid use early in the antiretroviral therapy era (1997), but not in 2005. CONCLUSIONS: Long-term opioid use for chronic pain has remained stable over time for HIV patients, whereas its use increased in the general population. The prevalence of prescribed opioids in HIV patients was highest for certain subgroups, including women, and those with a comorbidity and substance abuse history.

Lead distributions and risks in New Orleans following Hurricanes Katrina and Rita.

During the last four years, significant effort has been devoted to understanding the effects that Hurricanes Katrina and Rita had on contaminant distribution and redistribution in New Orleans, Louisiana, USA, and the surrounding Gulf Coast area. Elevated concentrations were found for inorganic contaminants (including As, Fe, Pb, and V), several organic pollutants (polycyclic aromatic hydrocarbons, pesticides, and volatiles) and high concentration of bioaerosols, particularly Aeromonas and Vibrio. Data from different research groups confirm that some contaminant concentrations are elevated, that existing concentrations are similar to historical data, and that contaminants such as Pb and As may pose human health risks. Two data sets have been compiled in this article to serve as the foundation for preliminary risk assessments within greater New Orleans. Research from the present study suggests that children in highly contaminated areas of New Orleans may experience Pb exposure from soil ranging from 1.37 microg/d to 102 microg/d. These data are critical in the evaluation of children's health.

Field application of activated carbon amendment for in-situ stabilization of polychlorinated biphenyls in marine sediment.

We report results on the first field-scale application of activated carbon (AC) amendment to contaminated sediment for in-situ stabilization of polychlorinated biphenyls (PCBs). The test was performed on a tidal mud flat at South Basin, adjacent to the former Hunters Point Naval Shipyard, San Francisco Bay, CA. The major goals of the field study were to (1) assess scale up of the AC mixing technology using two available, large-scale devices, (2) validate the effectiveness of the AC amendment at the field scale, and (3) identify possible adverse effects of the remediation technology. Also, the test allowed comparison among monitoring tools, evaluation of longer-term effectiveness of AC amendment, and identification of field-related factors that confound the performance of in-situ biological assessments. Following background pretreatment measurements, we successfully incorporated AC into sediment to a nominal 30 cm depth during a single mixing event, as confirmed by total organic carbon and black carbon contents in the designated test plots. The measured AC dose averaged 2.0-3.2 wt% and varied depending on sampling locations and mixing equipment. AC amendment did not impact sediment resuspension or PCB release into the water column over the treatment plots, nor adversely impactthe existing macro benthic community composition, richness, or diversity. The PCB bioaccumulation in marine clams was reduced when exposed to sediment treated with 2% AC in comparison to the control plot Field-deployed semi permeable membrane devices and polyethylene devices showed about 50% reduction in PCB uptake in AC-treated sediment and similar reduction in estimated pore-water PCB concentration. This reduction was evident even after 13-month post-treatment with then 7 months of continuous exposure, indicating AC treatment efficacy was retained for an extended period. Aqueous equilibrium PCB concentrations and PCB desorption showed an AC-dose response. Field-exposed AC after 18 months retained a strong stabilization capability to reduce aqueous equilibrium PCB concentrations by about 90%, which also supports the long-term effectiveness of AC in the field. Additional mixing during or after AC deployment, increasing AC dose, reducing AC-particle size, and sequential deployment of AC dose will likely improve AC-sediment contact and overall effectiveness. The reductions in PCB availability observed with slow mass transfer under field conditions calls for predictive models to assess the long-term trends in pore-water PCB concentrations and the benefits of alternative in-situ AC application and mixing strategies.

De facto long-term opioid therapy for noncancer pain.

OBJECTIVES: This paper describes characteristics of opioid use episodes for noncancer pain and defines thresholds for de facto long-term opioid therapy. METHODS: CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult members of 2 health plans serving over 1% of the US population. Opioid use episodes beginning in the years 1997 to 2005 were classified as acute, episodic, long-term/lower dose, or long-term/higher dose. RESULTS: On the basis of evaluation of the likelihood of opioid use continuing, long-term opioid therapy was defined by episodes lasting longer than 90 days with 10+ opioid prescriptions or 120+ days supply of opioids dispensed. Long-term/higher dose episodes (<1.5% of all opioid use episodes) were characterized by daily or near daily use, a mean duration of about 1000 days, and an average daily dose of about 55 mg. They accounted for more than half the total morphine equivalents dispensed from the years 1997 to 2006. Short-acting, non-Schedule II opioids (eg, hydrocodone with acetaminophen) were, by far, the most commonly prescribed medications for acute, episodic, and long-term episodes. Long-acting (sustained-release) opioids were the predominately prescribed medication in a minority of long-term episodes (6% to 12%). DISCUSSION: Long-term opioid therapy was characterized by the diversity in medications prescribed, dosage levels, and frequency of use. The proposed threshold for long-term opioid therapy provides a checkpoint for physicians to review whether an explicit decision to sustain opioid therapy has been reached, and to ensure that a documented treatment plan and provisions for monitoring medication use and patient outcomes are in place.

Environmental consequences of water pumped from greater New Orleans following Hurricane Katrina: chemical, toxicological, and infaunal analysis.

The U.S. Army Engineer Research and Development Center Environmental Laboratory, Vicksburg, MS, conducted a study to determine the extent to which Hurricane Katrina floodwaters in the New Orleans, Louisiana area may have had impacts on wildlife habitat and other biological resources in surrounding areas. These studies were conducted as part of the Interagency Performance Evaluation Taskforce, an investigation of environmental impacts originating from the failure of the hurricane protection system during Hurricane Katrina. This paper presents data regarding the effects of pumped floodwaters on sediment chemistry, toxicity, and benthic invertebrate assemblages near pumping stations that discharged floodwaters into marshes near Chalmette and Violet, Louisiana. Chemical contamination of sediments was observed and varied among sample locations (e.g., outfall locations, wastewater treatment plant, canals, and wetlands); however, trends in the chemistry data were not always consistent with bioassay results. A comparison of the sediment chemistry data from this study with three other studies reporting concentrations of chemicals in sediments within the city of New Orleans suggested that sediments and associated contaminants present within the levees were not pumped into the marsh in appreciable quantities.