Official position of the Brazilian Association of Bone Assessment and Metabolism (ABRASSO) on the evaluation of body composition by densitometry: part I (technical aspects)-general concepts, indications, acquisition, and analysis.

OBJECTIVE: To review the technical aspects of body composition assessment by dual-energy X-ray absorptiometry (DXA) and other methods based on the most recent scientific evidence. MATERIALS AND METHODS: This Official Position is a result of efforts by the Scientific Committee of the Brazilian Association of Bone Assessment and Metabolism (Associação Brasileira de Avaliação Óssea e Osteometabolismo, ABRASSO) and health care professionals with expertise in body composition assessment who were invited to contribute to the preparation of this document. The authors searched current databases for relevant publications. In this first part of the Official Position, the authors discuss the different methods and parameters used for body composition assessment, general principles of DXA, and aspects of the acquisition and analysis of DXA scans. CONCLUSION: Considering aspects of accuracy, precision, cost, duration, and ability to evaluate all three compartments, DXA is considered the gold-standard method for body composition assessment, particularly for the evaluation of fat mass. In order to ensure reliable, adequate, and reproducible DXA reports, great attention is required regarding quality control procedures, preparation, removal of external artifacts, imaging acquisition, and data analysis and interpretation.

Gene signature of children with severe respiratory syncytial virus infection.

BACKGROUND: The limited treatment options for children with severe respiratory syncytial virus (RSV) infection highlights the need for a comprehensive understanding of the host cellular response during infection. We aimed to identify host genes that are associated with severe RSV disease and to identify drugs that can be repurposed for the treatment of severe RSV infection. METHODS: We examined clinical data and blood samples from 37 hospitalized children (29 mild and 8 severe) with RSV infection. We tested RNA from blood samples using next-generation sequencing to profile global mRNA expression and identify cellular processes. RESULTS: Retractions, decreased breath sounds, and tachypnea were associated with disease severity. We observed upregulation of genes related to neutrophil, inflammatory response, blood coagulation, and downregulation of genes related to T cell response in children with severe RSV. Using network-based approach, 43 drugs were identified that are predicted to interact with the gene products of these differentially expressed genes. CONCLUSIONS: These results suggest that the changes in the expression pattern in the innate and adaptive immune responses may be associated with RSV clinical severity. Compounds that target these cellular processes can be repositioned as candidate drugs in the treatment of severe RSV. IMPACT: Neutrophil, inflammation, and blood coagulation genes are upregulated in children with severe RSV infection. Expression of T cell response genes are suppressed in cases of severe RSV. Genes identified in this study can contribute in understanding the pathogenesis of RSV disease severity. Drugs that target cellular processes associated with severe RSV can be repositioned as potential therapeutic options.

Norovirus-specific immunoglobulin A in breast milk for protection against norovirus-associated diarrhea among infants.

BACKGROUND: Norovirus (NV) causes acute gastroenteritis in infants. Humoral and fecal immunoglobulin A (IgA) responses have been correlated with protection against NV; however, the role of breast milk IgA against NV infection and associated diarrhea is still unknown. This study aimed to evaluate the protective role of NV-specific IgA (NV-IgA) in breast milk. METHODS: Ninety-five breast milk samples collected from mothers enrolled in a 2016-2017 Peruvian birth cohort study were tested for total IgA and NV-IgA by ELISA using GII·4 variants and non-GII·4 genotype virus-like particles (VLPs). Breast milk samples were grouped according to the NV infection and diarrheal status of infants: NV positive with diarrhea (NV+D+, n=18); NV positive without diarrhea (NV+D-, n=37); and NV negative without diarrhea (NV-D-, n=40). The percent positivity and titer of NV-IgA were compared among groups. The cross-reactivity was estimated based on the correlation of ratio between NV-IgA against GII·4 variants and non-GII·4 genotype VLPs. FINDINGS: NV-IgA had high positivity rates against different VLPs, especially against GII (89-100%). The NV+D- group had higher percent positivity (89% vs. 61%, p=0·03) and median titer (1:100 vs 1:50, p=0·03) of NV-IgA than the NV+D+ group against GI·1 VLPs. A relatively high correlation between different GII·4 variants (0·87) and low correlation between genogroups (0·23-0·37) were observed. INTERPRETATION: Mothers with high positivity rates and titers of NV-IgA in breast milk had NV infected infants with reduced diarrheal symptoms. Antigenic relatedness to the genetic diversity of human norovirus was suggested.Funding National Institute of Allergy and Infectious Diseases, National Institute of Health: 1R01AI108695-01A1 and the Japan Society for the Promotion of Science (Fostering Joint International Research B):19KK0241.

Secretion of Galectin-9 as a DAMP during Dengue Virus Infection in THP-1 Cells.

Damage-associated molecular patterns (DAMPs) are endogenous cellular molecules released to the extracellular environment in response to stress conditions such as virus infection. Galectins are ß-galactoside-binding proteins that are widely expressed in cells and tissues of the immune system, are localized in the cell cytoplasm, and have roles in inflammatory responses and immune responses against infection. Elevated levels of galectin-9 (Gal-9) in natural human infections have been documented in numerous reports. To investigate the effect of dengue virus (DENV) infection on expression of endogenous Gal-9, monocytic THP-1 cells were infected with varying doses of DENV-3 (multiplicity of infection (MOI) 0.01, 0.03 and 0.1) and incubated at varying time points (Day 1, Day 2, Day 3). Results showed augmentation of Gal-9 levels in the supernatant, reduction of Gal-9 levels in the cells and decreased expression of LGALS9 mRNA, while DENV-3 mRNA copies for all three doses remained stable through time. Dengue virus induced the secretion of Gal-9 as a danger response; in turn, Gal-9 and other inflammatory factors, and stimulated effector responses may have limited further viral replication. The results in this pilot experiment add to the evidence of Gal-9 as a potential DAMP.

Complete genome sequence of chikungunya virus isolated in the Philippines.

Chikungunya virus is an alphavirus of the Togaviridae family, which causes a febrile illness with arthralgia in humans. We report here on the complete genome sequence of chikungunya virus strain CHIKV-13-112A isolated from a patient in the Philippines who was suspected to have dengue virus. Phylogenetic analysis revealed that the strain is of the Asian genotype.

Exploratory analysis of the relationship between home health agency engagement in a national campaign and reduction in acute care hospitalization in US home care patients.

RATIONALE, AIMS AND OBJECTIVES: To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies. METHOD: We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March-November 2009 and 2010, respectively). RESULTS: Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. CONCLUSION: We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures.

Bringing all the players to the table: the West Virginia Controlled Substance Advisory Board.

Abuse and diversion of controlled substances are well-known problems in West Virginia and nationally. The costs to our society in both dollars and human capital are substantial. These problems touch groups as diverse as law enforcement, medical professionals, government leaders, addiction specialists, pain specialists, social workers, educators and regulatory boards, among others. The issues these groups face are varied and often unique to each profession, often resulting in a lack of communication and collaboration. This problem has been compounded by the fact that each group often makes decisions based on independent data related to substance abuse and diversion, which historically have not been shared due to privacy and other concerns. The West Virginia Controlled Substance Advisory Board was created to address these and other issues involved in drug diversion and substance abuse in West Virginia.

Understanding the cultures of prescription drug abuse, misuse, addiction, and diversion.

Prescription drug abuse, misuse, addiction, and diversion have reached epidemic proportions in the United States. The elimination of the burden of these activities on the healthcare system, the criminal justice system and society as a whole requires a multifaceted approach. Before resolution of these issues around prescription drugs can occur, a clear understanding of the cultures leading to these activities is required.

Quality of ambulatory care for diabetes and lower-extremity amputation.

Lower extremity amputation (LEA) is a serious complication of diabetes. We sought to determine whether quality of ambulatory care affects risk of LEA. We conducted a claims-based case-control study of 409 Medicare beneficiaries younger than age 75 with diabetes and LEA between January 1, 2003, and December 31, 2005. They were matched with controls with diabetes without LEA, on age, gender, number of diabetes outpatient visits, and (for those with hospital admissions between January 1, 2000, and December 31, 2002) number of comorbid conditions, diabetes complications, and peripheral vascular disease. Quality-of-care measures for cases and controls covered the period April 1, 1999, through March 31, 2001. LEA patients were less likely to have had lipid screening than controls (odds ratio = 0.73; 95% confidence interval = 0.53-0.99), and controls were more likely to use physicians with high performance in lipid screening (chi(2) = 6.631, P = .012) and hemoglobin A1c testing (chi(2) = 6.079, P = .014).

Impact of the 2004 influenza vaccine shortage on repeat immunization rates.

PURPOSE: We assessed the impact of the severe influenza vaccine shortage of 2004 on individual physicians' immunization performance. METHODS: Using 1998-2004 Medicare claims data, we monitored the physician continuity rate (proportion of patients receiving influenza immunization from a physician in 1 year who received a subsequent immunization from the same physician the subsequent year) and other clinician rate (proportion of patients with claims from 1 physician in 1 year with a claim from another clinician the subsequent year) in West Virginia Medicare beneficiaries from 2000-2004. We examined vaccine claim trends by clinician and surveys of self-reported immunization to determine whether patients received vaccine from nonphysician clinicians or went without immunization each year. RESULTS: Claims-based influenza vaccination rates increased from 35.5% to 41.3% from 2000-2003, reflecting historical trends, before declining 14.1% in 2004. Median continuity rates among the 723 to 849 physicians claiming 25 or more influenza immunizations from 2000-2003 increased from 47% in 2000-2001 to 54% in 2002-2003; then fell to 3% in 2003-2004. The number of physicians filing 100 or more claims declined from 337 in 2003 to 130 in 2004. More than 25% of physicians had no repeat vaccinations of the same beneficiaries in 2004. Trends in clinician type and survey data indicated a shift of many beneficiaries to mass vaccinators and institutional providers; however, compared with previous years, there was an estimated 8% increase in 2004 in the number of West Virginia beneficiaries who did not receive vaccine. CONCLUSIONS: The 2004 vaccine shortage had a severe impact on influenza immunization rates in private physician's offices, disrupting continuity of care.

Improving self-reporting of adverse drug events in a West Virginia hospital.

Adverse drug events significantly increase length of stay and costs of hospitalization but are underreported in health care institutions. We hypothesized that hospitals could improve the accuracy of adverse drug event self-reporting by comparing adverse drug events recorded in an occurrence reporting tool with those detected by surveillance of "rescue" drugs administered to treat adverse drug events. We conducted a prospective cohort study of all adult inpatient discharges from a 200-bed rural acute care hospital in West Virginia during a 6-month period. We performed 3572 chart audits, of which 1011 included rescue drug administration. Our outcome measure was the proportion of adverse drug events in the rescue drug surveillance that were found in the occurrence reporting tool. We found that less than 4% of all adverse drug events involving use of rescue drugs were reported. We concluded that underreporting of preventable adverse drug events in this hospital is comparable to published rates and that surveillance of adverse drug events to detect underreporting is feasible.

ACE inhibitor use and mortality reduction: do controlled trial results equal clinical practice?

Randomized trials have shown that angiotensin converting enzyme inhibitors (ACEIs) reduce mortality and morbidity and improve symptoms in many patients with heart failure. However, recent data show that the rate of ACEI prescriptions in West Virginia Medicare beneficiaries diagnosed with heart failure is not increasing. Data from the charts of patients who were discharged from 44 acute care hospitals during 2000 and 2001 were obtained, and these data were matched with current beneficiary data to determine if and when the patient died subsequent to the hospitalization of record. We examined data from 5,144 patients with heart failure for whom we had information on ACEI use, comorbidities, and contraindications, in addition to basic demographics. Patients who received angiotensin receptor blockers (ARBs) were excluded. Of these patients, 863 were eligible for ACEls, and 716 (83%) were discharged on an ACEI. Logistic regression showed that being discharged on an ACEI had a significant negative association with mortality one year later (P = .0009), reducing mortality in patients with heart failure by about one third.

Promoting influenza and pneumococcal immunization in older adults.

BACKGROUND: Reducing the risk of influenza and pneumococcal disease in older adults is a long-standing goal of Medicare's Quality Improvement Organization (QIO) program and parallels the Joint Commission's National Patient Safety Goal 10. ADDRESSING THE GOAL: Since 1999 the West Virginia Medical Institute has worked with a statewide partnership of health organizations on a program to improve influenza and pneumonia vaccination rates in hospitalized Medicare beneficiaries. Methods included education, audit and feedback, toolkits, and training meetings. RESULTS: During the first three years (1999-2001) of the effort, the rate of assessment for pneumococcal immunization at discharge increased from < 10% to 74.1% statewide and for influenza immunization from near zero to 63.4% statewide. Since 2002 pneumococcal immunization administration has increased from 16.1% to 41.1%, with similar improvement in influenza measures. LESSONS LEARNED/NEXT STEPS: Hospitals--and, by extension, long term care facilities--can make dramatic improvements in quality performance in a relatively short time when key staff receive feedback about the need to improve and the tools to assist in improving.

Physician supply in key medical specialties in West Virginia hospitals, 2001-2004.

This article describes the development, implementation and analysis of an ongoing prospective physician supply survey of the largest acute care hospitals in West Virginia. This survey was designed to assess changes in availability of physicians in key specialties from 2001-2004, a period of years that included a "malpractice insurance crisis." The malpractice crisis in this article describes the period of time in 2001-2002 when medical malpractice insurance rates increased abruptly in West Virginia and a number of physicians publicized their departure from practice in the state. We calculated the absolute and relative percentage change in the median number of physicians in each specialty between 2001-2004, calculated percentage change for each specialty by year, and performed univariate analysis on the percentage changes among all hospitals. We also calculated univariate analysis on the percentage changes among all hospitals. The median number of staff physicians in these hospitals declined steadily from 2001-2004. Declines in the number of specialists (some statistically significant) occurred, especially early in the three-year period, notably among surgical specialties. The availability of nephrologists increased significantly from 2003-2004. Decreases in staff physician numbers may have leveled off, but there is no evidence of sustained growth.