An Emerging Technology: To Model Patient Education for the Dental Hygiene Student

Introduction: Could Livestream Video, an emerging audiovisual media, be used more effectively than the traditional demonstration method of teaching or modeling dental hygiene students on how to provide chairside patient education? [See PDF for complete abstract]

A functional collagen adhesin gene, acm, in clinical isolates of Enterococcus faecium correlates with the recent success of this emerging nosocomial pathogen.

Enterococcus faecium recently evolved from a generally avirulent commensal into a multidrug-resistant health care-associated pathogen causing difficult-to-treat infections, but little is known about the factors responsible for this change. We previously showed that some E. faecium strains express a cell wall-anchored collagen adhesin, Acm. Here we analyzed 90 E. faecium isolates (99% acm(+)) and found that the Acm protein was detected predominantly in clinically derived isolates, while the acm gene was present as a transposon-interrupted pseudogene in 12 of 47 isolates of nonclinical origin. A highly significant association between clinical (versus fecal or food) origin and collagen adherence (P

POLG DNA testing as an emerging standard of care before instituting valproic acid therapy for pediatric seizure disorders.

PURPOSE: To review our clinical experience and determine if there are appropriate signs and symptoms to consider POLG sequencing prior to valproic acid (VPA) dosing in patients with seizures. METHODS: Four patients who developed VPA-induced hepatotoxicity were examined for POLG sequence variations. A subsequent chart review was used to describe clinical course prior to and after VPA dosing. RESULTS: Four patients of multiple different ethnicities, age 3-18 years, developed VPA-induced hepatotoxicity. All were given VPA due to intractable partial seizures. Three of the patients had developed epilepsia partialis continua. The time from VPA exposure to liver failure was between 2 and 3 months. Liver failure was reversible in one patient. Molecular studies revealed homozygous p.R597W or p.A467T mutations in two patients. The other two patients showed compound heterozygous mutations, p.A467T/p.Q68X and p.L83P/p.G888S. Clinical findings and POLG mutations were diagnostic of Alpers-Huttenlocher syndrome. CONCLUSION: Our cases underscore several important findings: POLG mutations have been observed in every ethnic group studied to date; early predominance of epileptiform discharges over the occipital region is common in POLG-induced epilepsy; the EEG and MRI findings varying between patients and stages of the disease; and VPA dosing at any stage of Alpers-Huttenlocher syndrome can precipitate liver failure. Our data support an emerging proposal that POLG gene testing should be considered in any child or adolescent who presents or develops intractable seizures with or without status epilepticus or epilepsia partialis continua, particularly when there is a history of psychomotor regression.

SAMPLING METHODOLOGY FOR AIRBORNE SEMIVOLATILE ORGANIC POLLUTANTS USING POLYURETHANE FOAMS (COLLECTION, PESTICIDES, VOLATILE)

Indoor and ambient air organic pollutants have been gaining attention because they have been measured at levels with possible health effects. Studies have shown that most airborne polychlorinated biphenyls (PCBs), pesticides and many polycyclic aromatic hydrocarbons (PAHs) are present in the free vapor state. The purpose of this research was to extend recent investigative work with polyurethane foam (PUF) as a collection medium for semivolatile compounds. Open-porous flexible PUFs with different chemical makeup and physical properties were evaluated as to their collection affinities/efficiencies for various classes of compounds and the degree of sample recovery. Filtered air samples were pulled through plugs of PUF spiked with various semivolatiles under different simulated environmental conditions (temperature and humidity), and sampling parameters (flow rate and sample volume) in order to measure their effects on sample breakthrough volume (V(,B)). PUF was also evaluated in the passive mode using organo-phosphorus pesticides. Another major goal was to improve the overall analytical methodology; PUF is inexpensive, easy to handle in the field and has excellent airflow characteristics (low pressure drop). It was confirmed that the PUF collection apparatus behaves as if it were a gas-solid chromatographic system, in that, (V(,B)) was related to temperature and sample volume. Breakthrough volumes were essentially the same using both polyether and polyester type PUF. Also, little change was observed in the V(,B)s after coating PUF with common chromatographic liquid phases. Open cell (reticulated) foams gave better recoveries than closed cell foams. There was a slight increase in (V(,B)) with an increase in the number of cells/pores per inch. The high-density polyester PUF was found to be an excellent passive and active collection adsorbent. Good recoveries could be obtained using just solvent elution. A gas chromatograph equipped with a photoionization detector gave excellent sensitivities and selectivities for the various classes of compounds investigated. ^

Emerging arboviruses in Harris County, Texas

Harris County, which includes Houston, Texas, is an endemic and epidemic area for two viruses transmitted by arthropods (arboviruses). These viruses are maintained in cycles involving mosquitoes and wild birds, and transmission to humans is accidental. The majority of human infections is asymptomatic or may result in a flu-like syndrome. However, some infections can result in meningitis or encephalitis. These neuroinvasive infections may cause death, and those who survive may experience serious neurological complications requiring costly and lengthy medical care. The most important arboviruses in terms of morbidity are St. Louis encephalitis (SLEV) and West Nile (WNV) viruses. In fact, Harris County reports more SLEV encephalitis cases than any other county in the U.S. Most arboviral human cases occur from July through September, when mosquitoes are most active. Those at risk for encephalitis and death are the elderly and those with a history of hypertension or immunosuppresion. There is no specific treatment and no human vaccines are commercially available in the U.S. The approach for control of arboviruses in Harris County during epidemics is multidisciplinary and executed by several agencies. It includes surveillance, vector control, and educational messages for the population. Prevention of outbreaks consists of elimination of the vector and its breeding grounds, and practicing personal protective measures to prevent exposure to mosquitoes. ^ Current findings indicate that mosquito-borne viruses other than SLEV and WNV could pose an additional threat for the population. Eastern equine encephalitis virus (EEEV) activity has been detected in dogs and sentinel chickens in Houston and surrounding areas. Several serotypes of dengue virus have caused recent outbreaks in south Texas, and some locally-acquired cases have been detected in Houston. Since the clinical presentation of all arboviruses that cause encephalitis is very similar, and current surveillance is focused on detecting SLEV and WNV, there is a possibility that other arboviruses could be present in the area but are not being detected. Additionally, Harris County's ample annual rainfall and flooding problems, warm weather, multiple mosquito species, local and migrating birds that are susceptible to arboviral infection, and a constant flow of goods and travelers from many parts of the world could favor the emergence or re-emergence of other arboviruses. ^ The aims of this project were to determine if other arboviruses were circulating in the county, to assess the knowledge and attitudes about mosquito-borne viruses in a sample of the population, and to conduct an analysis of the initial WNV epidemic in Harris County. Through the retrospective analysis of clinical specimens collected during the 2002-2005 epidemic seasons, serologic evidence of dengue infection was detected suggesting the possibility that this virus may be co-circulating with SLEV and WNV. A cross-sectional survey revealed high awareness about arboviruses but not a consistent use of protective measures to avoid mosquitoes. The third component for this project included a retrospective review and geographical analysis of the 2002 WNV epidemic. ^ Overall, this study documented valuable information about the dengue virus, a potentially emerging arbovirus in Texas, revealed the need for more educational preventative programs, reinforced the value of mosquito and avian surveillance, and indicated the importance of continuing to investigate the factors that contribute to the development of outbreaks. ^

Lessons for emerging state Children's Health Insurance Premium Assistance programs: Case study of the Massachusetts Masshealth Family Assistance Program (MHFAP)

Providing health insurance coverage for vulnerable populations such as low-income high-risk children with limited access to health care is a challenge for many states. Over the past decade, higher private insurance premiums and unpredictable labor markets have increased the number of uninsured and underinsured children nationwide. Due to recent economic downfalls, many states such as Texas, have expressed interest in using premium assistance programs to increase enrollment of low income children and families in private coverage through employer sponsored health insurance. Massachusetts has been especially successful in reducing the number of uninsured children through the implementation of MassHealth Family Assistance Program (MHFAP), an employer based premium assistance program. The purpose of this study is to identify key implementation factors of a fully established premium assistance program which may provide lessons and facilitate implementation of emerging premium assistance programs. ^ The case study of the fully established MassHealth Family Assistance Program (MHFAP) has illustrated the ability of states to expand their Medicaid and SCHIP programs in order to provide affordable health coverage to uninsured and underinsured low income children and their families. As demonstrated by MHFAP, the success of a premium assistance program depends on four key factors: (1) determination of participant and employer eligibility; (2) determination of employer benefits meeting benchmark equivalency (Medicaid or State Children's Health Insurance Program); (3) the use of appropriate marketing and outreach strategies; and (4) establishment of adequate monitoring and reporting techniques. Successful implementation strategies, revealed by the case study of the Massachusetts MassHealth Family Assistance Program, may be used by emerging premium assistance programs, such as Texas Children's Health Insurance Premium Assistance Program (CHIP-PA) toward establishment of an effective, efficient, and equitable employer sponsored health program.^

Emerging roles for the double strand break repair protein 53BP1 in transcriptional regulation

Disruption of the mechanisms that regulate cell-cycle checkpoints, DNA repair, and apoptosis results in genomic instability and often leads to the development of cancer. In response to double stranded breaks (DSBs) as induced by ionizing radiation (IR), generated during DNA replication, or through immunoglobulin heavy chain (IgH) rearrangements in T and B cells of lymphoid origin, the protein kinases ATM and ATR are central players that activate signaling pathways leading to DSB repair. p53 binding protein 1 (53BP1) participates in the repair of DNA double stranded breaks (DSBs) where it is recruited to or near sites of DNA damage. In addition to its well established role in DSB repair, multiple lines of evidence implicate 53BP1 in transcription which stem from its initial discovery as a p53 binding protein in a yeast two-hybrid screen. However, the mechanisms behind the role of 53BP1 in these processes are not well understood. ^ 53BP1 possesses several motifs that are likely important for its role in DSB repair including two BRCA1 C-terminal repeats, tandem Tudor domains, and a variety of phosphorylation sites. In addition to these motifs, we identified a glycine and arginine rich region (GAR) upstream of the Tudor domains, a sequence that is oftentimes serves as a site for protein arginine methylation. The focus of this project was to characterize the methylation of 53BP1 and to evaluate how methylation influenced the role of 53BP1 as a tumor suppressor. ^ Using a variety of biochemical techniques, we demonstrated that 53BP1 is methylated by the PRMT1 methyltransferase in vivo. Moreover, GAR methylation occurs on arginine residues in an asymmetric manner. We further show that sequences upstream of the Tudor domains that do not include the GAR stretch are sufficient for 53BP1 oligomerization in vivo. While investigating the role of arginine methylation in 53BP1 function, we discovered that 53BP1 associates with proteins of the general transcription apparatus as well as to other factors implicated in coordinating transcription with chromatin function. Collectively, these data support a role for 53BP1 in regulating transcription and provide insight into the possible mechanisms by which this occurs. ^

Hazardous air pollutants and childhood lymphohematopoietic cancer in Southeast Texas, 1995--2004

Southeast Texas, including Houston, has a large presence of industrial facilities and has been documented to have poorer air quality and significantly higher cancer rates than the remainder of Texas. Given citizens’ concerns in this 4th largest city in the U.S., Mayor Bill White recently partnered with the UT School of Public Health to determine methods to evaluate the health risks of hazardous air pollutants (HAPs). Sexton et al. (2007) published a report that strongly encouraged analytic studies linking these pollutants with health outcomes. In response, we set out to complete the following aims: 1. determine the optimal exposure assessment strategy to assess the association between childhood cancer rates and increased ambient levels of benzene and 1,3-butadiene (in an ecologic setting) and 2. evaluate whether census tracts with the highest levels of benzene or 1,3-butadiene have higher incidence of childhood lymphohematopoietic cancer compared with census tracts with the lowest levels of benzene or 1,3-butadiene, using Poisson regression. The first aim was achieved by evaluating the usefulness of four data sources: geographic information systems (GIS) to identify proximity to point sources of industrial air pollution, industrial emission data from the U.S. EPA’s Toxic Release Inventory (TRI), routine monitoring data from the U.S. EPA Air Quality System (AQS) from 1999-2000 and modeled ambient air levels from the U.S. EPA’s 1999 National Air Toxic Assessment Project (NATA) ASPEN model. Further, once these four data sources were evaluated, we narrowed them down to two: the routine monitoring data from the AQS for the years 1998-2000 and the 1999 U.S. EPA NATA ASPEN modeled data. We applied kriging (spatial interpolation) methodology to the monitoring data and compared the kriged values to the ASPEN modeled data. Our results indicated poor agreement between the two methods. Relative to the U.S. EPA ASPEN modeled estimates, relying on kriging to classify census tracts into exposure groups would have caused a great deal of misclassification. To address the second aim, we additionally obtained childhood lymphohematopoietic cancer data for 1995-2004 from the Texas Cancer Registry. The U.S. EPA ASPEN modeled data were used to estimate ambient levels of benzene and 1,3-butadiene in separate Poisson regression analyses. All data were analyzed at the census tract level. We found that census tracts with the highest benzene levels had elevated rates of all leukemia (rate ratio (RR) = 1.37; 95% confidence interval (CI), 1.05-1.78). Among census tracts with the highest 1,3-butadiene levels, we observed RRs of 1.40 (95% CI, 1.07-1.81) for all leukemia. We detected no associations between benzene or 1,3-butadiene levels and childhood lymphoma incidence. This study is the first to examine this association in Harris and surrounding counties in Texas and is among the first to correlate monitored levels of HAPs with childhood lymphohematopoietic cancer incidence, evaluating several analytic methods in an effort to determine the most appropriate approach to test this association. Despite recognized weakness of ecologic analyses, our analysis suggests an association between childhood leukemia and hazardous air pollution.^

Determining associations and assessing methodological issues in a case-control study of hazardous air pollutants and neural tube defects

Recent studies have reported positive associations between maternal exposures to air pollutants and several adverse birth outcomes. However, there have been no assessments of the association between environmental hazardous air pollutants (HAPs) such as benzene, toluene, ethylbenzene, and xylene (BTEX) and neural tube defects (NTDs) a common and serious group of congenital malformations. Before examining this association, two important methodological questions must be addressed: (1) is maternal residential movement likely to result in exposure misclassification and (2) is it appropriate to lump defects of the neural tube, such as anencephaly and spina bifida, into a composite disease endpoint (i.e., NTDs). ^ Data from the National Birth Defects Prevention Study and Texas Birth Defects Registry were used to: (1) assess the extent to which change of residence may result in exposure misclassification when exposure is based on the address at delivery; (2) formally assess heterogeneity of the associations between known risk factors for NTDs, using polytomous logistic regression; and (3) conduct a case-control study assessing the association between ambient air levels of BTEX and the risk of NTDs among offspring. ^ Regarding maternal residential mobility, this study suggests address at delivery was not significantly different from using address at conception when assigning quartile of benzene exposure (OR 1.0, 95% CI 0.9, 1.3). On the question of effect heterogeneity among NTDs, the effect estimates for infant sex P = 0.017), maternal body mass index P = 0.016), and folate supplementation P = 0.050) were significantly different for anencephaly and spina bifida, suggesting it is often more appropriate to assess potential risk factors among subgroups of NTDs. For the main study question on the association between environmental HAPs and NTDs, mothers who have offspring with isolated spina bifida are 2.4 times likely to live in areas with the highest benzene levels (95% CI 1.1, 5.0). However, no other significant associations were observed.^ This project is the first to include not only an assessment of the relationship between environmental levels of BTEX and NTDs, but also two separate studies addressing important methodological issues associated with this question. Our results contribute to the growing body of evidence regarding air pollutant exposure and adverse birth outcomes. ^

Re-emerging Vitamin D deficiency epidemic and its implications on the public health in the US

Vitamin D is essential in maintaining the bone health and Calcium homeostasis in the body. These actions are mediated through the Vitamin D receptors (VDR) present in cells through which the activated vitamin D acts [1]. In the past, it was known that these receptors existed in the intestine and bone cell. However, recent discovery of VDR in other tissues as well, has broadened the action of Vitamin D and increased its adequate intake [1].^ In the past, Vitamin D deficiency was most common among institutionalized, elderly patients and children and thought to be extinct in the healthy population. However, recent evidence has shown that, prevalence of vitamin D deficiency is increasing into an epidemic status in the overall population of the United States, including the healthy individuals [2-3]. The increased daily-recommended requirement and other multiple factors are responsible for the re-emergence of this epidemic [4-5]. Some of these factors could be used to control the epidemic. Studies have also shown the association between vitamin D deficiency and increased risk for developing chronic diseases such as diabetes, hypertension, multiple sclerosis, arthritis, and some fatal cancers like prostate, colon and breast cancers [1, 4, 6-14]. This issue results in increased disease burden, morbidity and mortality in the community [15-20].^ Methods: The literature search was conducted using the University of Texas Health Science Center at Houston (UTHSC) and University of Texas Southwestern Medical Center (UTSW) online library. The key search terms used are “vitamin D deficiency And prevalence Or epidemiology”, “vitamin D deficiency And implication And public health” using PubMed and Mesh database and “vitamin D deficiency” using systematic reviews. The search is limited to Humans and the English language. The articles considered for the review are limited to Healthy US population to avoid health conditions that predispose the population to vitamin D deficiency. Only US population is considered to narrow down the study.^ Results: There is an increased prevalence of low levels of Vitamin D levels below the normal range in the US population regardless of age and health status. Vitamin D deficiency is also associated with increased risk of chronic illnesses and fatal cancers.^ Conclusion: This increased prevalence and the association of the deficiency with increased all-cause mortality has increased the economic burden and compromised the quality of life among the population. This necessitates the health care providers to routinely screen their patients for the Vitamin D status and counsel them to avoid the harmful effects of the Vitamin D deficiency. ^

THE CHLOREX TREATABILITY STUDY: ENVIRONMENTAL FATE IN FACULTATIVE ANAEROBIC AND AEROBIC WASTE STABILIZATION PONDS (BIODEGRADATION, VOLATILIZATION, SORPTION, PRIORITY POLLUTANTS)

The efficacy of waste stabilization lagoons for the treatment of five priority pollutants and two widely used commercial compounds was evaluated in laboratory model ponds. Three ponds were designed to simulate a primary anaerobic lagoon, a secondary facultative lagoon, and a tertiary aerobic lagoon. Biodegradation, volatilization, and sorption losses were quantified for bis(2-chloroethyl) ether, benzene, toluene, naphthalene, phenanthrene, ethylene glycol, and ethylene glycol monoethyl ether. A statistical model using a log normal transformation indicated biodegradation of bis(2-chloroethyl) ether followed first-order kinetics. Additionally, multiple regression analysis indicated biochemical oxygen demand was the water quality variable most highly correlated with bis(2-chloroethyl) ether effluent concentration. ^

A health disparities perspective on developing emerging infectious disease preparedness

A systematic review of the literature yielded 10 articles that explored the interaction between race/ethnicity, citizenship, socioeconomic status, and health literacy domains with respect to preparedness agenda development. Current emerging infectious disease (EID) preparedness plans do not adequately address the needs of vulnerable populations for the events before, during, and after an epidemic. Central to the disadvantage of most vulnerable populations are various health disparity domains that persist as barriers for individuals and communities alike to engage in preparedness efforts. Seven out of the ten articles discussed the importance of including health disparity domains in preparedness policy. Two proposed frameworks for an emerging infectious disease framework that considers health disparities are presented in this study. ^ Framework 1 is beneficial for the evaluation phase after a disaster has struck and preparedness efforts have been initiated. It considers several existing disparities and remediation strategies at the individual, community, and system levels to reach adequate restructuring of preparedness aims. Framework 2 serves as a "how to" carry out preparedness during a disaster event. It is a revision of a framework proposed by Blumenshine et al. (2008) and explores those characteristics central to pandemic preparedness plan development/deployment. Although two frameworks were devised, no one framework will adequately address the needs of vulnerable populations during an epidemic. However, the two frameworks propose to demonstrate the inclusion of important health disparity domains in preparedness plan development. ^ The National Consensus Panel for Emergency Preparedness and Cultural Diversity has released guidelines that are considered the leading strategies necessary to reorient preparedness infrastructure. In order for vulnerable populations to benefit from ample protection during a disaster, inclusion of health disparity domains in the development phases of preparedness must occur prior to full deployment in communities. Although "promising practices" and other methods at the frontier of exploring these multidimensional constraints has entered the research arena, new studies on adequate preparedness merit further investigation and support.^

Associations between ambient levels of combustion pollutants and small for gestational age infants in Texas

There is scant evidence regarding the associations between ambient levels of combustion pollutants and small for gestational age (SGA) infants. No studies of this type have been completed in the Southern United States. The main objective of the project presented was to determine associations between combustion pollutants and SGA infants in Texas using three different exposure assessments. ^ Birth certificate data that contained information on maternal and infant characteristics were obtained from the Texas Department of State Health Services (TX DSHS). Exposure assessment data for the three aims came from: (1) U.S. Environmental Protection Agency (EPA) National Air Toxics Assessment (NATA), (2) U.S. EPA Air Quality System (AQS), and (3) TX Department of Transportation (DOT), respectively. Multiple logistic regression models were used to determine the associations between combustion pollutants and SGA. ^ For the first study looked at annual estimates of four air toxics at the census tract level in the Greater Houston Area. After controlling for maternal race, maternal education, tobacco use, maternal age, number of prenatal visits, marital status, maternal weight gain, and median census tract income level, adjusted ORs and 95% confidence intervals (CI) for exposure to PAHs (per 10 ng/m3), naphthalene (per 10 ng/m3), benzene (per 1 µg/m3), and diesel engine emissions (per 10 µg/m3) were 1.01 (0.97–1.05), 1.00 (0.99–1.01), 1.01 (0.97–1.05), and 1.08 (0.95–1.23) respectively. For the second study looking at Hispanics in El Paso County, AORs and 95% confidence intervals (CI) for increases of 5 ng/m3 for the sum of carcinogenic PAHs (Σ c-PAHs), 1 ng/m3 of benzo[a]pyrene, and 100 ng/m3 in naphthalene during the third trimester of pregnancy were 1.02 (0.97–1.07), 1.03 (0.96–1.11), and 1.01 (0.97–1.06), respectively. For the third study using maternal proximity to major roadways as the exposure metric, there was a negative association with increasing distance from a maternal residence to the nearest major roadway (Odds Ratio (OR) = 0.96; 95% CI = 0.94–0.97) per 1000 m); however, once adjusted for covariates this effect was no longer significant (AOR = 0.98; 95% CI = 0.96–1.00). There was no association with distance weighted traffic density (DWTD). ^ This project is the first to look at SGA and combustion pollutants in the Southern United States with three different exposure metrics. Although there was no evidence of associations found between SGA and the air pollutants mentioned in these studies, the results contribute to the body of literature assessing maternal exposure to ambient air pollution and adverse birth outcomes. ^

Maternal exposure to hazardous air pollutants and oral clefts among offspring: Texas, 1999-2008

Birth defects are a leading cause of infant mortality in the United States. About one in 33 births in the United States is diagnosed with birth defects. Common birth defects include neural tube defects, Down syndrome and oral clefts. The present study focused on oral clefts. ^ Oral clefts refer to the malformation of lip, mouth or both. Birth prevalence of oral clefts in Texas is about 11 per 10,000 births. Etiologically, oral clefts have been classified into two groups, cleft lip with or without cleft palate (CL±P) and isolated cleft palate (CP). In spite of their high prevalence and clinical significance, the etiology of oral clefts in humans has not been well understood. Though a number of risk factors have been identified in epidemiological studies, most of them do not explain the majority of the cases. The need to identify novel risk factors associated with oral clefts provided the motivation for this study. The present study focused on maternal exposure to several hazardous air pollutants. A common subgroup of hazardous air pollutants is the volatile organic compounds found in petroleum derivatives. Four important hydrocarbons in this group are benzene, toluene, ethyl benzene and xylenes (BTEX). ^ The specific aim of this study was to evaluate the association between maternal exposure to environmental levels of BTEX and oral clefts among offspring in Texas for the period 1999-2008. ^ A case-control study design was used to assess if maternal exposure to BTEX increased the risk of oral clefts. The Texas Birth Defects Registry provided data on cases of non-syndromic oral clefts delivered in Texas during the period 1999-2008. Census tract level maternal exposure to BTEX concentrations were obtained from the Hazardous Air Pollutant Exposure Model (HAPEM) developed by the U.S. Environmental Protection Agency. Unconditional logistic regression was used to assess the relationship between maternal exposure to BTEX levels and risk of oral clefts in offspring. ^ In the selected population, mothers who had high estimated exposure to any of the BTEX compounds were not more likely to deliver an offspring with oral clefts. Future research efforts will focus on additional birth defects and thorough assessment of additional potential confounders.^