An empirical model to estimate the demand for primary care in urban settings

Objective. To measure the demand for primary care and its associated factors by building and estimating a demand model of primary care in urban settings.^ Data source. Secondary data from 2005 California Health Interview Survey (CHIS 2005), a population-based random-digit dial telephone survey, conducted by the UCLA Center for Health Policy Research in collaboration with the California Department of Health Services, and the Public Health Institute between July 2005 and April 2006.^ Study design. A literature review was done to specify the demand model by identifying relevant predictors and indicators. CHIS 2005 data was utilized for demand estimation.^ Analytical methods. The probit regression was used to estimate the use/non-use equation and the negative binomial regression was applied to the utilization equation with the non-negative integer dependent variable.^ Results. The model included two equations in which the use/non-use equation explained the probability of making a doctor visit in the past twelve months, and the utilization equation estimated the demand for primary conditional on at least one visit. Among independent variables, wage rate and income did not affect the primary care demand whereas age had a negative effect on demand. People with college and graduate educational level were associated with 1.03 (p < 0.05) and 1.58 (p < 0.01) more visits, respectively, compared to those with no formal education. Insurance was significantly and positively related to the demand for primary care (p < 0.01). Need for care variables exhibited positive effects on demand (p < 0.01). Existence of chronic disease was associated with 0.63 more visits, disability status was associated with 1.05 more visits, and people with poor health status had 4.24 more visits than those with excellent health status. ^ Conclusions. The average probability of visiting doctors in the past twelve months was 85% and the average number of visits was 3.45. The study emphasized the importance of need variables in explaining healthcare utilization, as well as the impact of insurance, employment and education on demand. The two-equation model of decision-making, and the probit and negative binomial regression methods, was a useful approach to demand estimation for primary care in urban settings.^

Comparison of health behaviors of Mexican American and non -Hispanic White females: Implications for health promotion programs

Hispanics form the second-largest minority group in the United States totaling 22 million people. Health data on this population are sparse and inconsistent. This study seeks to determine use of preventative services and risk factor behaviors of Mexican American and non-Hispanic White females residing in South Texas.^ Baseline data from female respondents in household surveys in six South Texas counties (Ramirez and McAlister, 1988; McAlister et al., 1992) were analyzed to test the following hypotheses: (1) Mexican American and Non-Hispanic White females exhibit different patterns of health behaviors; (2) Mexican American females will exhibit different health behaviors regardless of age; and (3) the differences between Mexican American women and non-Hispanic White females are due to education and acculturation factors.^ Over the past decade, the traditional behaviors of Mexican American females have begun to change due to education, acculturation, and their participation in the labor force. The results from this study identify some of the changes that will require immediate attention from health care providers. Results revealed that regardless of ethnicity, age, education, and language preference, non-Hispanic White females were significantly more likely to participate in preventive screening practices than were Mexican American females. Risk factor analysis revealed a different pattern with Mexican American females significantly more likely to be non-smokers, non-alcoholic drinkers, and to have good fat avoidance practices compared to non-Hispanic White females. However, compared to those who are less-educated or Spanish-speaking, Mexican American females with higher levels of education and preference for speaking English only showed positive and negative health behaviors that were more similar to the non-Hispanic White females. The positive health behaviors that come with acculturation, e.g., more participation in preventive care and more physical activity, are welcome changes. But this study has implications for global health development and reinforces a need for "primordial" prevention strategies to deter the unwanted concomitants of economic development and acculturation. Smoking and drinking behaviors among Mexican American females need to be kept at low levels to prevent increased morbidity and premature deaths in this population. ^

The role of Ski/Sno oncoproteins as negative regulators of the TGF-beta/SMAD signaling pathway in B -cell non -Hodgkin's lymphoma (NHL-B)

Non-Hodgkin's lymphomas are common tumors of the human immune system, primarily of B cell lineage (NHL-B). Negative growth regulation in the B cell lineage is mediated primarily through the TGF-β/SMAD signaling pathway that regulates a variety of tumor suppressor genes. Ski was originally identified as a transforming oncoprotein, whereas SnoN is an isoform of the Sno protein that shares a large region of homology with Ski. In this study, we show that Ski/SnoN are endogenously over-expressed both in patients' lymphoma cells and NHL-B cell lines. Exogenous TGF-β1 treatment induces down-regulation of Ski and SnoN oncoprotein expression in an NHL-B cell line, implying that Ski and SnoN modulate the TGF-β signaling pathway and are involved in cell growth regulation. Furthermore, we have developed an NHL-B cell line (DB) that has a null mutation in TGF-β receptor type II. In this mutant cell line, Ski/SnoN proteins are not down-regulated in response to TGF-β1 treatment, suggesting that downregulation of Ski and SnoN proteins in NHL-B require an intact functional TGF-β signaling pathway Resting normal B cells do not express Ski until activated by antigens and exogenous cytokines, whereas a low level of SnoN is also present in peripheral blood Go B cells. In contrast, autonomously growing NHL-B cells over-express Ski and SnoN, implying that Ski and SnoN are important cell cycle regulators. To further investigate a possible link between reduction of the Ski protein level and growth inhibition, Ski antisense oligodeoxynucleotides were transfected into NHL-B cells. The Ski protein level was found to decrease to less than 40%, resulting in restoring the effect of TGF-β and leading to cell growth inhibition and G1 cell cycle arrest. Co-immunoprecipitation experiments demonstrated that Ski associates with Smad4 in the nucleus, strongly suggesting that over-expression of the nuclear protein Ski and/or SnoN negatively regulates the TGF-β pathway, possibly by modulating Smad-mediated tumor suppressor gene expression. Together, in NHL-B, the TGF-β/SMAD growth inhibitory pathway is usually intact, but over-expression of the Ski and/or SnoN, which binds to Smad4, abrogates the negative regulatory effects of TGF-β/SMAD in lymphoma cell growth and potentiates the growth potential of neoplastic B cells. ^

A NEW TUMOR SUPPRESSOR GENE CANDIDATE REGULATED BY THE NON-CODING RNA PCA3 IN HUMAN PROSTATE CANCER

Prostate cancer is the second leading cause of cancer-related death and the most common non-skin cancer in men in the USA. Considerable advancements in the practice of medicine have allowed a significant improvement in the diagnosis and treatment of this disease and, in recent years, both incidence and mortality rates have been slightly declining. However, it is still estimated that 1 man in 6 will be diagnosed with prostate cancer during his lifetime, and 1 man in 35 will die of the disease. In order to identify novel strategies and effective therapeutic approaches in the fight against prostate cancer, it is imperative to improve our understanding of its complex biology since many aspects of prostate cancer initiation and progression still remain elusive. The study of tumor biomarkers, due to their specific altered expression in tumor versus normal tissue, is a valid tool for elucidating key aspects of cancer biology, and may provide important insights into the molecular mechanisms underlining the tumorigenesis process of prostate cancer. PCA3, is considered the most specific prostate cancer biomarker, however its biological role, until now, remained unknown. PCA3 is a long non-coding RNA (ncRNA) expressed from chromosome 9q21 and its study led us to the discovery of a novel human gene, PC-TSGC, transcribed from the opposite strand and in an antisense orientation to PCA3. With the work presented in this thesis, we demonstrate that PCA3 exerts a negative regulatory role over PC-TSGC, and we propose PC-TSGC to be a new tumor suppressor gene that contrasts the transformation of prostate cells by inhibiting Rho-GTPases signaling pathways. Our findings provide a biological role for PCA3 in prostate cancer and suggest a new mechanism of tumor suppressor gene inactivation mediated by non-coding RNA. Also, the characterization of PCA3 and PC-TSGC led us to propose a new molecular pathway involving both genes in the transformation process of the prostate, thus providing a new piece of the jigsaw puzzle representing the complex biology of prostate cancer.

CIP4 and Src in Promoting the Migration and Invasion of Breast Cancers

Cellular invasion represents a critical early step in the metastatic cascade, and many proteins have been identified as part of an “invasive signature.” The non-receptor tyrosine kinase Src is commonly upregulated in breast cancers, often in conjunction with overexpression of EGFR. Signaling from this pathway stimulates cell proliferation, migration, and invasion and frequently involves proteins that regulate the cytoskeleton. My data demonstrates that inhibition of Src, using the small-molecule inhibitor dasatinib, impairs cellular migration and invasion. Furthermore, Src inhibition sensitizes the cells to the effects of the chemotherapeutic doxorubicin resulting in dramatic, synergistic inhibition of proliferation with combination treatments. The Src-targeted protein CIP4 (Cdc42-interacting protein 4) associates with curved plasma membranes to scaffold complexes of Cdc42 and N-WASp. In these experiments, I show that CIP4 overexpression correlates with triple-negative biomarker status, cellular migration, and invasion of (breast cancer cells. Inhibition of CIP4 expression significantly decreases migration and invasion. Furthermore, I demonstrate the novel finding that CIP4 localizes to invadopodia, which are finger-like projections of the actin cytoskeleton that are associated with matrix degradation and cellular invasion. Depletion of CIP4 in invasive cells impairs the formation of invadopodia and the degradation of gelatin. Therefore, CIP4 is a critical component of the invasive phenotype acquired by human breast cancer cells. In this body of work, I propose a model in which CIP4 promotes actin polymerization by stabilizing the active conformation of N-WASp. CIP4 and N-WASp are both phosphorylated by Src, implicating this pathway in Src-dependent cytoskeletal rearragement. This represents a novel role for F-BAR proteins in migration and invasion.

Ribozyme-mediated reduction of wild-type and mutant cartilage oligomeric matrix protein (COMP) mRNA and protein.

Dominant-negative mutations in the homopentameric extracellular matrix glycoprotein cartilage oligomeric matrix protein (COMP) result in inappropriate intracellular retention of misfolded COMP in the rough endoplasmic reticulum of chondrocytes, causing chondrocyte cell death, which leads to two skeletal dysplasias: pseudoachondroplasia (PSACH) and multiple epiphyseal dysplasia (EDM1). COMP null mice show no adverse effects on normal bone development and growth, suggesting a possible therapy involving removal of COMP mRNA. The goal of this study was to assess the ability of a hammerhead ribozyme (Ribo56, designed against the D469del mutation) to reduce COMP mRNA expression. In COS7 cells transfected with plasmids that overexpress wild-type or mutant COMP mRNA and Ribo56, the ribozyme reduced overexpressed normal COMP mRNA by 46% and mutant COMP mRNA by 56% in a dose-dependent manner. Surprisingly, the use of recombinant adenoviruses to deliver wild-type or mutant COMP mRNA and Ribo56 simultaneously into COS7 cells proved problematic for the activity of the ribozyme to reduce COMP expression. However, in normal human costochondral cells (hCCCs) infected only with adenoviruses expressing Ribo56, expression of endogenous wild-type COMP mRNA was reduced in a dose-dependent manner by 50%. In chondrocytes that contain heterozygous COMP mutations (D469del, G427E and D511Y) that cause PSACH, Ribo56 was more effective at reducing COMP mRNA (up to 70%). These results indicate that Ribo56 is effective at reducing mutant and wild-type COMP levels in cells and suggests a possible mode of therapy to reduce the mutant protein load.

Behavioral and psychosocial factors associated with sexual risk in a population of crack cocaine users

The purpose of this dissertation was to examine the relationship between key psychosocial and behavioral components of the Transtheoretical Model and the Theory of Reasoned Action for sexual risk reduction in a population of crack cocaine smokers and sex workers, not in drug treatment. ^ The first study examined the results of an analysis of the association between two principal constructs in the Transtheoretical Model, the processes of change and the stages of change for condom use, in a high risk population. In the analysis of variance for all respondents, the overall F-test revealed that people in different stages have different levels of experiential process use, F(3,317) = 17.79, p = 0.0001 and different levels of behavioral process use, F(3,317) = 28.59, p = .0001. For the experiential processes, there was a significant difference between the precontemplation/contemplation stage, and both the action, and maintenance, stages.^ The second study explored the relationship between the Theory of Reasoned Action “beliefs” and the stages-of-change in the same population. In the analysis of variance for all participants, the results indicate that people in different stages did value the positive beliefs differently, F(3,502) = 15.38, p = .0001 but did not value the negative beliefs differently, F(3,502) = 2.08, p = .10. ^ The third study explored differences in stage-of-change by gender, partner type drug use, and HIV status. Three discriminant functions emerged, with a combined χ2(12) = 139.57, p = <.0001. The loading matrix of correlations between predictors and discriminant functions demonstrate that the strongest predictor for distinguishing between the precontemplation/contemplation stage and the preparation, action, and maintenance stages (first function) is partner type (.962). The loadings on the second discriminant function suggest that once partner type has been accounted for, ever having HIV/AIDS (.935) was the best predictor for distinguishing between the first three stages and the maintenance stage. ^ These studies demonstrate that behavioral change theories can contribute important insight to researchers and program planners attempting to alter HIV risk behavior in high-risk populations. ^

AN APPROACH TO THE CHARACTERIZATION OF FIBRONECTIN-INTERACTION WITH MAMMALIAN CELLS

Cell adhesion is a fundamentally important process which has been implicated in morphogenesis, metastasis and wound healing. Fibronectin (Fn), a large glycoprotein present in body fluids, the extracellular matrix, and on the cell surface, mediates adhesion of fibroblastic cells. To study the interaction of Fn with Chinese Hamster Cell (CHO) cell membranes, latex beads coated with H('3)-Fn (Fn-beads) were used as surface probes. Binding of Fn-beads was independent of temperature, divalent cations, and metabolic activity. Identification of fibronectin-receptors has been problematical. To study Fn binding components, Fn-beads were pre-incubated with purified glycosaminoglycans (GAGs) and glycolipids. Among the GAGs tested, heparin and heparan sulfate blocked bead binding. Only sialylated glycolipids, GT(,1) and GD(,1) were inhibitory; however, neuraminidase treatment of cells had no effect. It was further shown that Fn-bead binding could be blocked by pre-treating cells with papain. Furthermore, papain digestion releases cellular material which blocks Fn-bead-cell binding. Beads coated with a fragment of Fn which binds to cells but not heparin (F105) were also blocked by soluble papain digests. It was observed that the ability of F105-beads to bind to CHO cells was dependent on surface charge as F105 on uncharged beads did not bind to cells; whereas, F105 on positive or negative beads displayed cell binding activity. The active component in the papain digests was apparently macromolecular (i.e. non-dialysable) and heat stable (i.e. 100(DEGREES)C for 15 min.). This suggested the inhibitory factor is more likely a glycopeptide, rather than a GAG or glycolipid. The findings of this research can be summarized as follows: (1) the expression of cell binding of Fn and Fn fragments can be modulated by the chemical nature of the surface used for adsorption; (2) factors can be released by proteolytic digestion which block Fn and Fn-fragment bead binding; and (3) since bead binding can be done under conditions which reflect initial Fn-cell interaction, it seems likely that the component(s) identified in this way may play a direct role in the recognition phases of cell adhesion to Fn. ^

Non-sexual household transmission of HCV infection: A cohort study

Objective. This study was designed to determine the prevalence and incidence of HCV infection among non-sexual household contacts of HCV-infected women and to describe the association between HCV infection and potential household risk factors in order to examine whether non-sexual household contact is a route of transmission for HCV infection. ^ Methods. A baseline prevalence survey included 409 non-sexual household contacts of 241 HCV-infected index women in the Houston area from 1994 to 1997. A total of 470 non-sexual household contacts with no evidence of HCV infection at baseline investigation were re-assessed approximately three years after baseline enrollment. Information on potential risk factors was collected through face to face interviews and blood samples were tested for anti-HCV with ELISA-2 and Matrix/RIBA-2. The relationships between HCV infection and potential risk factors were examined by using univariate and multivariate logistic regression analyses. ^ Results. The overall prevalence of anti-HCV positivity among 409 non-sexual household contacts was 4.4%. The highest prevalence of anti-HCV was found in parents (19.5%), followed by siblings (8.1%) and other relatives (5.6%); the children had the lowest prevalence of anti-HCV (1.2%). The univariate analysis showed that IDU, blood transfusion, tattoos, sexual contact with injecting drug users, more than 3 sexual partners in a lifetime, history of a STD, incarceration, previous hepatitis, and contact with hepatitis patients were significantly associated with HCV infection, however, sharing razors, nail clippers, toothbrushes, gum, food or beds with HCV-infected women, and history of dialysis, health care job, body piercing, and homosexual activities were not. Multivariate analysis found that IDU (OR = 221.7 with 95% CI of 22.8 to 2155.7) and history of a STD (OR = 11.7 with 95% CI of 1.2 to 113.1) were the only variables significantly associated with HCV infection. No such associations remained for other risk factors. The three-year cumulative incidence of anti-HCV among 352 non-sexual household contacts of HCV-infected women was zero. ^ Conclusion. This study has provided no evidence that non-sexual household contact is a likely route of transmission for HCV infection. The risk of sharing razors, nail clippers, toothbrushes, gum, food and/or beds with HCV-infected women is not evident and has not been shown to be the likely mode for HCV spread among family members. This study does suggest that IDU is the likely route of transmission for most HCV infection. Association also has been shown independently with a history of STD. The prevalence of anti-HCV among non-sexual household contacts was low. Exposure to common parenteral risk factors and sexual transmission between sexual partners may account for HCV spread among household members of HCV-infected persons. ^

Functional and physical associations of beta1 integrins in the activation of human T lymphocytes

Adhesion involves interactions between cells or cells with extracellular matrix components and is a fundamental process for all multicellular organisms as well as many pathogenic microbes. Integrins are heterodimeric transmembrane proteins that function as adhesion molecules and transduce signals between the extracellular environment and the intracellular cytoskeletal machinery. β1 integrin subfamily is highly expressed on T lymphocytes and mediates cell spreading, adhesion and coactivation. T lymphocytes have an important role in the regulation and homeostasis of the immune system therefore, the goals of this study were to first to investigate β1 integrin interaction with fibronectin binding protein A (FnbpA), a surface protein expressed on gram-negative bacteria Staphylococcus aureus. Second, characterize the association and function of a non-integrin surface protein, CD98, with β1 integrins on T lymphocytes. ^ FnbpA binds to fibronectin (FN), also a ligand for α5β1 and α4β1 integrins on T lymphocytes. Since both bacterial proteins FnbpA and T cell integrins utilize FN, it was of interest to determine the effects FnbpA on T cell activation. Results demonstrated that recombinant FnbpA (rFnbpA) coimmobilized with OKT3 mediated T cell coactivation in a soluble FN-dependent manner. Integrin α5β1 was identified as the main integrin utilized by Staphylococcus aureus FnbpA from studies using soluble antibodies to inhibit T cell proliferation and parallel plate flow chamber assays. The mechanism of rFnbpA-mediated coactivation was one that used soluble FN as a bridge between rFnbpA and integrin α5β1 on the T lymphocyte. ^ Since integrins are utilized by T lymphocytes and bacterial proteins, it was of interest to identify proteins involved in integrin regulation. Anti-CD98 mAb 80A10 was identified and characterized from a screen to identify surface proteins involved in integrin signaling and functions. CD98 is a non-integrin protein that was sensitive to integrin inhibition in human T lymphocyte aggregation and activation, thus suggested that CD98 shared a common signaling pathway with integrins. These results led to the question of whether CD98 physically associates with β1 integrins. Fluorescence microscopy and biochemical analysis determined that CD98 is specifically associated with β1 integrin on human T lymphocytes and may be part of a larger multimolecular signaling complex. ^

4HPR-X radiation mechanisms of interactions in non-small cell lung cancer (NSCLC) cells in vitro

Lung cancer is the leading cause of cancer death. However, poor survival using conventional therapies fuel the search for more rational interventions. The objective of this study was to design and implement a 4HPR-radiation interaction model in NSCLC, employing a traditional clinical modality (radiation), a relatively new, therapeutically unexplored agent (4HPR) and rationally combining them based on molecular mechanistic findings pertaining to their interactions. To test the hypothesis that 4HPR sensitizes cells to radiation-induced cell death via G2+M accumulation, we designed a working model consisting of H522 adenocarcinoma cells (p53, K-ras mutated) derived from an NSCLC patient; 4HPR at concentrations up to 10 μM; and X radiation up to 6 Gy generated by a patient-dedicated Phillips RT-250 X ray unit at 250 KV, 15 mA, 1.85 Gy/min. We found that 4HPR produced time- and dose-dependent morphological changes, growth inhibition, and DNA damage-inducing enhancement of reactive oxygen species. A transient G2+M accumulation of cells maximal at 24 h of continuous 4HPR exposure was used for irradiation time scheduling. Our data demonstrated enhanced cell death (both apoptotic and necrotic) in irradiated cells pre-treated with 4HPR versus those with either stressor alone. 4HPR's effect of increased NSCLC cells' radioresponse was confirmed by clonogenic assay. To explore these practical findings from a molecular mechanistic perspective, we further investigated and showed that levels of cyclin B1 and p34cdc2 kinase—both components of the mitosis promoting factor (MPF) regulating the G2/M transition—did not change following 4HPR treatment. Likewise, cdc25C phosphatase was not altered. However, enhanced p34cdc2 phosphorylation on its Thr14Tyr15 residues—indicative of its inactivation and increased expression of MPF negative regulators chk1 and wee1 kinases—were supportive of explaining 4HPR-treated cells' accumulation. Hence, p34cdc2 phosphorylation, chk1, and wee1 warrant further evaluation as potential molecular targets for 4HPR-X radiation combination. In summary, we (1) demonstrated that 4HPR not only induces cell death by itself, but also increases NSCLC cells' subsequent radioresponse, indicative of potential clinical applicability, and (2) for the first time, shed light on deciphering 4HPR-X radiation molecular mechanisms of interaction, including the finding of 4HPR's role as a p34cdc2 inactivator via Thr14Tyr15 phosphorylation. ^

The socioeconomic status of families of hyperglycemic versus non-hyperglycemic children: A descriptive analysis

The proportion of children and adolescents living with type 2 diabetes mellitus (DM) is rising at an alarming rate. Studies have shown that poor dietary choices and sedentary behaviors account for progression of some of the most prevalent diseases in America, including obesity, heart disease and diabetes. Other studies have shown that genetics plays a role in the diabetic determination of an individual, although not very common. What are some of the differentiating factors between elevated and non-elevated fasting capillary glucose (FCG) levels in children of similar ages, knowing they spend a majority of their lives at home or at school? Why are some children acquiring diabetes while others are not? This study utilized an IRB-approved Family Demographic Survey to determine gender, family income, parent education levels, sedentary practices, and household size. Only those families who gave consent to take part in the study received a questionnaire. The statistical results were used to test the hypothesis that children living with elevated FCG levels are more likely to descend from families with lower incomes, and lower levels of education.^ With regard to household income and FCG status of non-hyperglycemic and hyperglycemic children (Table 4b), there are 10.4% more hyperglycemic children in the lower income bracket than non-hyperglycemic children in the same income bracket.^ With regard to maternal education and FCG status (Table 5b), there are 7.0% more hyperglycemic children in the high school or less maternal educational attainment level than non-hyperglycemic children in the same maternal educational level. The Pearson correlation of maternal education and FCG status showed a negative correlation value of -.035 (Table 5d). The higher the occurrence of hyperglycemia in a child, the lower the maternal educational status is. Household size ranges and averages are nearly identical in families of both hyperglycemic and non-hyperglycemic children. ^

Variance of familial dietary intake

Although many family-based genetic studies have collected dietary data, very few have used the dietary information in published findings. No single solution has been presented or discussed in the literature to deal with the problem of using factor analyses for the analyses of dietary data from several related individuals from a given household. The standard statistical approach of factor analysis cannot be applied to the VIVA LA FAMILIA Study diet data to ascertain dietary patterns since this population consists of three children from each family, thus the dietary patterns of the related children may be correlated and non-independent. Addressing this problem in this project will enable us to describe the dietary patterns in Hispanic families and to explore the relationships between dietary patterns and childhood obesity. ^ In the VIVA LA FAMILIA Study, an overweight child was first identified and then his/her siblings and parents were brought in for data collection which included 24 hour recalls and food frequency questionnaire (FFQ). Dietary intake data were collected using FFQ and 24 hour recalls on 1030 Hispanic children from 319 families. ^ The design of the VIVA LA FAMILIA Study has important and unique statistical considerations since its participants are related to each other, the majority form distinct nuclear families. Thus, the standard approach of factor analysis cannot be applied to these diet data to ascertain dietary patterns. In this project we propose to investigate whether the determinants of the correlation matrix of each family unit will allow us to adjust the original correlation matrix of the dietary intake data prior to ascertaining dietary intake patterns. If these methods are appropriate, then in the future the dietary patterns among related individuals could be assessed by standard orthogonal principal component factor analysis.^

Nosocomial infections and their relationship to non-traditional risk factors in a medical intensive care unit

Background. Nosocomial infections are a source of concern for many hospitals in the United States and worldwide. These infections are associated with increased morbidity, mortality and hospital costs. Nosocomial infections occur in ICUs at a rate which is five times greater than those in general wards. Understanding the reasons for the higher rates can ultimately help reduce these infections. The literature has been weak in documenting a direct relationship between nosocomial infections and non-traditional risk factors, such as unit staffing or patient acuity.^ Objective. To examine the relationship, if any, between nosocomial infections and non-traditional risk factors. The potential non-traditional risk factors we studied were the patient acuity (which comprised of the mortality and illness rating of the patient), patient days for patients hospitalized in the ICU, and the patient to nurse ratio.^ Method. We conducted a secondary data analysis on patients hospitalized in the Medical Intensive Care Unit (MICU) of the Memorial Hermann- Texas Medical Center in Houston during the months of March 2008- May 2009. The average monthly values for the patient acuity (mortality and illness Diagnostic Related Group (DRG) scores), patient days for patients hospitalized in the ICU and average patient to nurse ratio were calculated during this time period. Active surveillance of Bloodstream Infections (BSIs), Urinary Tract Infections (UTIs) and Ventilator Associated Pneumonias (VAPs) was performed by Infection Control practitioners, who visited the MICU and performed a personal infection record for each patient. Spearman's rank correlation was performed to determine the relationship between these nosocomial infections and the non-traditional risk factors.^ Results. We found weak negative correlations between BSIs and two measures (illness and mortality DRG). We also found a weak negative correlation between UTI and unit staffing (patient to nurse ratio). The strongest positive correlation was found between illness DRG and mortality DRG, validating our methodology.^ Conclusion. From this analysis, we were able to infer that non-traditional risk factors do not appear to play a significant role in transmission of infection in the units we evaluated.^

Non-staphylococcal infections of cardiac implantable electronic devices

Background. The number of infections of cardiac implantable electronic devices (CIED) continues to escalate out of proportion to the increase rate of device implantation. Staphylococcal organisms account for 70% to 90% of all CIED infections. However, little is known about non-staphylococcal infections, which have been described only in case reports, small case series or combined in larger studies with staphylococcal CIED infections, thereby diluting their individual impact. ^ Methods. A retrospective review of hospital records of patients admitted with a CIED-related infections were identified within four academic hospitals in Houston, Texas between 2002 and 2009. ^ Results. Of the 504 identified patients with CIED-related infection, 80 (16%) had a non-staphylococcal infection and were the focus of this study. Although the demographics and comorbities of subjects were comparable to other reports, our study illustrates many key points: (a) the microbiologic diversity of non-staphylococcal infections was rather extensive, as it included other Gram-positive bacteria like streptococci and enterococci, a variety of Gram-negative bacteria, atypical bacteria including Nocardia and Mycobacteria, and fungi like Candida and Aspergillus; (b) the duration of CIED insertion prior to non-staphylococcal infection was relatively prolong (mean, 109 ± 27 weeks), of these 44% had their device previously manipulated within a mean of 29.5 ± 6 weeks; (c) non-staphylococcal organisms appear to be less virulent, cause prolonged clinical symptoms prior to admission (mean, 48 ± 12.8 days), and are associated with a lower mortality (4%) than staphylococcal organisms; (d) thirteen patients (16%) presented with CIED-related endocarditis; (e) although not described in prior reports, we identified 3 definite and 2 suspected cases of secondary Gram-negative bacteremia seeding of the CIED; and (f) inappropriate antimicrobial coverage was provided in approximately 50% of patients with non-staphylococcal infections for a mean period of 2.1 days. ^ Conclusions. Non-staphylococcal CIED-related infections are prevalent and diverse with a relatively low virulence and mortality rate. Since non-staphylococcal organisms are capable of secondarily seeding the CIED, a high suspicion for CIED-related infection is warranted in patients with bloodstream infection. Additionally, in patients with suspected CIED infection, adequate Gram positive and -negative antibacterial coverage should be administered until microbiologic data become available.^