Iowa Surveillance of Notifiable and Other Diseases Annual Report, 2014

Promoting and protecting the health of Iowans is the mission of the Iowa Department of Public Health (IDPH). Surveillance of notifiable health conditions is essential in establishing what, how, and when events impact the public’s health. Once this information is gathered, public health and health care providers around the state are able to use this data to take steps to prevent illnesses from occurring. Multiple divisions and bureaus are dedicated to accomplishing the goals of surveillance. In 2014, there were more than 86,000 laboratory results of infectious diseases and conditions submitted to IDPH disease surveillance programs. IDPH also investigates non-infectious conditions related to lead, occupational, and environmental hazards like carbon monoxide. In 2014, approximately 71,000 children’s and more than 7,000 adults’ blood tests results were reported to IDPH. ********Amended Annual Report 2014************ Amended May 2, 2016

IDSS Iowa Diseases Surveillance System: Security and Confidentiality Policy, May 2010

The Iowa Disease Surveillance System (IDSS) was developed by the Iowa Department of Public Health (IDPH) to streamline and enhance communication and collaboration between laboratory, hospital, and public health (local and state) personnel related to infectious disease surveillance and reporting (as required by Iowa Code 139A) throughout Iowa. IDSS is a tool that speeds communication regarding cases of reportable infectious disease to allow public health to respond sooner and reduce costs associated with disease reporting and surveillance.

Extreme self-monitoring, fear of hypoglycemia and obsessive-compulsive disorder in type 1 diabetes mellitus: when less is better

Background: Pre-existing psychological factors can strongly influence coping with type 1 diabetes mellitus and interfere with self-monitoring. Psychiatric disorders seem to be positively associated with poor metabolic control. We present a case of extreme compulsive blood testing due to obsessive fear of hypoglycemia in an adolescent with type 1 diabetes mellitus. Case report: Type 1 diabetes mellitus (anti GAD-antibodies 2624 U/l, norm < 9.5) was diagnosed in a boy aged 14.3 years [170 cm (+ 0.93 SDS), weight 50.5 kg (+ 0.05 SDS)]. Laboratory work-up showed no evidence for other autoimmune disease. Family and past medical history were unremarkable. Growth and developmental milestones were normal. Insulin-analog based basal-bolus regime was initiated, associated to standard diabetic education. Routine psychological evaluation performed at the onset of diabetes revealed intermittent anxiety and obsessivecompulsive traits. Accordingly, a close psychiatric follow-up was initiated for the patient and his family. An adequate metabolic control (HbA1c drop from >14 to 8%) was achieved within 3 months, attributed to residual 1538;-cell function. In the following 6 months, HbA1c rose unexpectedly despite seemingly adequate adaptations of insulin doses. Obsessive fear of hypoglycemia leading to a severe compulsive behavior developed progressively with as many as 68 glycemia measurements per day (mean over 1 week). The patient reported that he could not bear leaving home with glycemia < 15 mmol/l, ending up with school eviction and severe intra-familial conflict. Despite intensive psychiatric outpatient support, HbA1c rose rapidly to >14% with glycemia-testing reaching peaks of 120 tests/day. The situation could only be discontinued through psychiatric hospitalization with intensive behavioral training. As a result, adequate metabolic balance was restored (HbA1c value: 7.1 %) with acceptable 10-15 daily glycemia measurements. Discussion: The association of overt psychiatric disorders to type 1 diabetes mellitus is very rare in the pediatric age group. It can lead to a pathological behavior with uncontrolled diabetes. Such exceptional situations require long-term admissions with specialized psychiatric care. Slow acceptation of a "less is better" principle in glycemia testing and amelioration of metabolic control are difficult to achieve.

Potential Role of TRAIL in the Management of Autoimmune Diabetes Mellitus.

Type 1 diabetes mellitus (T1DM) is an autoimmune disease, due to the immune-mediated destruction of pancreatic β-cells, whose incidence has been steadily increasing during the last decades. Insulin replacement therapy can treat T1DM, which, however, is still associated with substantial morbidity and mortality. For this reason, great effort is being put into developing strategies that could eventually prevent and/or cure this disease. These strategies are mainly focused on blocking the immune system from attacking β-cells together with functional islet restoration either by regeneration or transplantation. Recent experimental evidences suggest that TNFrelated apoptosis-inducing ligand (TRAIL), which is an immune system modulator protein, could represent an interesting candidate for the cure for T1DM and/or its complications. Here we review the evidences on the potential role of TRAIL in the management of T1DM.

2011 Diabetes in Iowa Supplement to the 2009 Iowa Chronic Disease Report, October 1, 2012

The Iowa Behavioral Risk Factor Surveillance System (BRFSS), a household interview survey of adults that began to include a core question covering diagnosed diabetes prevalence in 1988, is the primary source of data in this Iowa Chronic Disease Report supplemental update on diabetes. Most rates in this supplement are age-adjusted, rather than crude rates. Age-adjusting eliminates differences in rates that are attributable to populations being compared having difference age distributions.

Prévalence des maladies infectieuses au Centre hospitalier universitaire vaudois [Prevalence of infectious diseases at the Vaud University Hospital Center].

The prevalence of infectious diseases at our hospital (Centre hospitalier universitaire vaudois, Lausanne [CHUV], 900 beds) was studied retrospectively over a two years period (1980-1981). The medical diagnosis of 30203 patients recorded in the computerized medical archives, representing 93% of the patients admitted during the period of observation, was reviewed. To assess the reliability of the computerized data, quality control was carried out through detailed analysis of all the histologically proven appendicitis recorded during 1981. 88% of the histologically proven appendicitis were registered in the computer and the diagnosis was specific in 87% of cases. An infectious disease was the primary reason for admission in 12.8% of the patients (3873) during the study period. Altogether, 20.2% of patients presented with an infection during their hospital stay. Because of the retrospective nature of the study it was not possible to determine whether these additional infections were nosocomially acquired. The organ systems most frequently infected were the respiratory tract (28.5% of all infections), the digestive tract (20.5%), the skin and osteoarticular system (16%) and the urogenital tract (11.6%). An infection was the primary reason for admission of 40.2% of the patients hospitalized in the dermatology service, of 19.7% of patients admitted in internal medicine, of 15-17% of the patients admitted in pediatrics, ENT and general surgery, and of 1-2% of the patients admitted in neurosurgery and radiotherapy. These observations highlight the continuing importance of infectious diseases in a modern hospital, in spite of high socio-economic levels, stringent hygiene and epidemiologic measures, and modern antibiotic availability.

Cytokines in parasitic diseases: the example of cutaneous leishmaniasis.

The essential role of cytokines in parasitic diseases has been emphasised since the in vivo description of the importance of T helper 1 (Th1) and T helper 2 (Th2) CD4+ T cell responses in resistance and susceptibility to infection with L. major in mice. Th1 cells produced IL-2, IFN-gamma and Lymphotoxin T (LT) and Th2 cells produce IL-4, IL-5 and IL-13. In this model of infection the correlation between on the one hand resistance to infection and the development of a Th1 response and on the other hand susceptibility and Th2 cell development allowed the identification of the mechanisms directing the differentiation of CD4+ T cell precursors towards either Th1 type or Th2 type responses. Cytokines are the crucial inducer of functional CD4+ T cell subset differentiation during infection with L. major. IL-12 and IFN-gamma direct the differentiation of Th1 response and IL-4 of a Th2 response. In susceptible mice, careful analysis of IL-4 production during the first days of infection has shown that the IL-4 produced as a result of a very early burst of IL-4 mRNA expression (16 hours) plays a essential role in the maturation of a Th2 CD4+ T cell response by rendering the CD4+ T cell precursors unresponsive to IL-12. Activation of a restricted population of CD4+ T cells expressing the V beta 4 V alpha 8 TCR heterodimer after recognition of a single antigen, the LACK (Leishmania Activated c Kinase) antigen, resulted in this rapid production of IL-4 required for the subsequent CD4+ T cell differentiation. Thus, tolerization of these cells might contribute a strategy for preventing infection with L. major.

TL1A-DR3 interaction regulates Th17 cell function and Th17-mediated autoimmune disease.

T helper type 17 (Th17) cells play an important pathogenic function in autoimmune diseases; their regulation, however, is not well understood. We show that the expression of a tumor necrosis factor receptor family member, death receptor 3 (DR3; also known as TNFRSF25), is selectively elevated in Th17 cells, and that TL1A, its cognate ligand, can promote the proliferation of effector Th17 cells. To further investigate the role of the TL1A-DR3 pathway in Th17 regulation, we generated a TL1A-deficient mouse and found that TL1A(-/-) dendritic cells exhibited a reduced capacity in supporting Th17 differentiation and proliferation. Consistent with these data, TL1A(-/-) animals displayed decreased clinical severity in experimental autoimmune encephalomyelitis (EAE). Finally, we demonstrated that during EAE disease progression, TL1A was required for the optimal differentiation as well as effector function of Th17 cells. These observations thus establish an important role of the TL1A-DR3 pathway in promoting Th17 cell function and Th17-mediated autoimmune disease.

Subclinical coronary and aortic atherosclerosis detected by magnetic resonance imaging in type 1 diabetes with and without diabetic nephropathy.

BACKGROUND: Patients with type 1 diabetes and nephropathy maintain an excess cardiovascular mortality compared with diabetic patients with normoalbuminuria. We sought to evaluate coronary and aortic atherosclerosis in a cohort of asymptomatic type 1 diabetic patients with and without diabetic nephropathy using cardiovascular magnetic resonance imaging. METHODS AND RESULTS: In a cross-sectional study, 136 subjects with long-standing type 1 diabetes without symptoms or history of cardiovascular disease, including 63 patients (46%) with nephropathy and 73 patients with normoalbuminuria, underwent cardiovascular magnetic resonance imaging. All subjects underwent cardiac exercise testing and noninvasive tests for peripheral artery disease and autonomic neuropathy. Coronary artery stenoses were identified in 10% of subjects with nephropathy (versus 0% with normoalbuminuria; P=0.007). Coronary plaque burden, expressed as right coronary artery mean wall thickness (1.7+/-0.3 versus 1.3+/-0.2 mm; P<0.001) and maximum right coronary artery wall thickness (2.2+/-0.5 versus 1.6+/-0.3 mm; P<0.001), was greater in subjects with nephropathy. The prevalence of thoracic (3% versus 0%; P=0.28) and abdominal aortic plaque (22% versus 16%; P=0.7) was similar in both groups. Subjects with and without abdominal aortic plaques had similar coronary plaque burden. CONCLUSIONS: In asymptomatic type 1 diabetes, cardiovascular magnetic resonance imaging reveals greater coronary plaque burden in subjects with nephropathy compared with those with normoalbuminuria.

Length variation in HIV-1 gp120 as the product of DNA misalignment mechanism

Background: To determine whether misalignment structures such as duplications, repeats, and palindromes are associated to insertions/deletions (indels) in gp120, indicating that indels are indeed frameshift mutations generated by DNA misalignment mechanism. Methods: Cloning and sequencing of a fragment of HIV-1 gp120 spanning C2-C4 derived from plasma RNA in 12 patients with early chronic disease and naïve to antiretroviral therapy. Results: Indels in V4 involved always insertion and deletion of duplicated nucleotide segments, and AAT repeats, and were associated to the presence of palindromic sequences. No duplications were detected in V3 and C3. Palindromic sequences occurred with similar frequencies in V3, C3 and V4; the frequency of palindromes in individual genes was found to be significantly higher in structural (gp120, p ≤ 3.00E-7) and significantly lower in regulatory (Tat, p ≤ 9.00E-7) genes, as compared to the average frequency calculated over the full genome. Discussion: Indels in V4 are associated to misalignment structures (i.e. duplications repeat and palindromes) indicating DNA misalignment as the mechanism underlying length variation in V4. The finding that indels in V4 are caused by DNA misalignment has some very important implications: 1) indels in V4 are likely to occur in proviral DNA (and not in RNA), after integration of HIV into the host genome; 2) they are likely to occur as progressive modifications of the early founder virus during chronic infection, as more and more cells get infected; 3) frameshift mutations involving any number of base pairs are likely to occur evenly across gp120; however, only those mutants carrying a functional gp120 (indels as multiples of three base pairs) will be able to perpetuate the virus cycle and to keep spreading through the population.

The role of MIC-1/GDF15 cytokine in glioblastoma

AbstractDespite advances in diagnosis and treatment made over the past two decades, high-gradeprimary brain tumors remain incurable neoplasms. Glioblastoma (GBM) represents the mostmalignant stage of astrocytic brain tumors. Identification of diagnostic and prognostic markers ineasily accessible biological material, such as plasma or cerebro-spinal fluid (CSF), would greatlyfacilitate the management of GBM patients. Elucidation of the molecular mechanisms that underlie thefunction of the factors implicated in GBM development would pave the way towards their potentialutility in cancer-targeting therapy.MIC-1/GDF15 (Macrophage Inhibitory Cytokine-1/ Growth Differentiation Factor 15), asecreted protein of the TGF-β superfamily, emerged as a candidate marker exhibiting increasingmRNA expression during astrocytoma malignant progression. However, injection of MIC-1/GDF15over-expressing GBM cell lines into nude mice has been previously shown to completely abolish theinherent tumorigenicity.In this study, determination of MIC-1/GDF15 protein levels in the CSF of a cohort of 94patients with intracranial tumors including astrocytomas (grades II, III and IV), meningioma, andmetastasis revealed significantly increased concentrations in GBM patients as compared to controlcohort of patients treated for non-neoplastic diseases. However, MIC-1/GDF15 levels were notelevated in the matching plasma samples from these patients. Most interestingly, GBM patients withthe increased concentrations of MIC-1/GDF15 in the CSF had worse outcome.In GBM tissue, it was found that the expression of MIC-1/GDF15 gene is low. Promotermethylation of the gene may partially explain the overall low expression levels. Investigation of thecellular origin of MIC-1/GDF15 expression in GBM tissue led to the MIC-1/GDF15 protein detectionin a subpopulation of the tumor infiltrating macrophages. These findings substantiated the workinghypothesis of MIC-1/GDF15 as harboring tumor-suppressive properties in GBM. Analysis of thesignaling pathway mediated by MIC-1/GDF15 in GBM highlighted the potential role of TGF-β signaltransduction. However, the lack of the functional response to the presence of MIC-1/GDF15 in-vitrosuggested operation of a paracrine loop for suppression of tumor formation which is evident solely invivo.In conclusion, MIC-1/GDF15 protein measured in the CSF may have diagnostic andprognostic values in patients with intracranial tumors. Molecular studies collectively proposeimplication of the tumor-host interactions in mediating the MIC-1/GDF15 tumor-suppressing activityduring GBM development.RésuméMalgré les progrès durant ces deux dernières décennies dans le diagnostique et le traitementdes tumeurs du cerveau primaires, ces néoplasmes restent incurables. Le glioblastome représente laforme la plus maligne des tumeurs astrocytiques du cerveau (astrocytomes). Pour le diagnostic et lepronostic, l'identification de marqueurs présents dans des substances facilement accessibles comme leplasma où le liquide céphalorachidien (LCR) faciliterait beaucoup la prise en charge des patients. Lacompréhension des mécanismes moléculaires de facteurs impliqués dans le développement du GBMpourrait ouvrir la voie vers l'utilisation de ces mécanismes dans des thérapies ciblées.MIC-1/GDF15 (Macrophage Inhibitory Cytokine-1/ Growth Differentiation Factor 15), uneprotéine secrétée qui appartient à la superfamille TGF-β, s'est révélé être un marqueur candidat, dontl'expression d'ARN messager augmente pendant la progression des astrocytomes malins. Cependant,une précedente étude montre que l'injection des lignées cellulaires de GBM fortement productrices deMIC-1/GDF15 dans des souris immunodéprimées abolit la tumorigénicité.Dans cette étude, les mesures dans une cohorte de 94 patients atteints de tumeursintracrâniennes comprenant des astrocytomes (grades II, III et IV), méningiomes et métastases,présentent des augmentations significatives des niveaux protéiques de MIC-1/GDF15 dans le LCRdes patients atteints de GBM par rapport aux patients traités pour des maladies non cancéreuses.Cependant, les niveaux de MIC-1/GDF15 n'étaient pas spécialement élevés dans le plasma. De plus,les patients atteints d'un GBM avec des niveaux élevés de MIC-1/GDF15 dans le LCR ont survécumoins longtemps. Dans les tissus de glioblastome, on observe que le gène MIC-1/GDF15 est peuexprimé. La méthylation du promoteur explique partiellement le faible niveau d'expression du gène.La recherche l'origine cellulaire de l'expression de MIC-1/GDF15, a permis de découvrir la présencede protéines MIC-1/GDF15 dans une sous-population de macrophages qui infiltrent les tumeurs. Cetteobservation supporte l'hypothèse que MIC-1/GDF15 présentait des propriétés de suppression destumeurs de type GBM. Des études sur les voies de signalisation régulées par MIC-1/GDF15 dans lesGBMs ont souligné l'importance de la voie de transduction du signal TGF-β. Cependant, l'absence deréponse fonctionnelle à MIC-1/GDF15 in vitro suggère fortement l'activité d'une boucle paracrinepour la répression de la formation de tumeur, qui n'est observé que in vivo.En conclusion, la protéine MIC-1/GDF15 mesurée dans le LCR pourrait avoir une valeur pourle diagnostic et le pronostic chez les patients atteints de GBM. Les études moléculaires suggèrent unepossible implication de l'interaction hôte-tumeur dans l'activité anti-tumorale de MIC-1/GDF15 sur leGBM.

Ambiguous nucleotide calls from population-based sequencing of HIV-1 are a marker for viral diversity and the age of infection.

Background. The time passed since the infection of a human immunodeficiency virus (HIV)-infected individual (the age of infection) is an important but often only poorly known quantity. We assessed whether the fraction of ambiguous nucleotides obtained from bulk sequencing as done for genotypic resistance testing can serve as a proxy of this parameter. Methods. We correlated the age of infection and the fraction of ambiguous nucleotides in partial pol sequences of HIV-1 sampled before initiation of antiretroviral therapy (ART). Three groups of Swiss HIV Cohort Study participants were analyzed, for whom the age of infection was estimated on the basis of Bayesian back calculation (n = 3,307), seroconversion (n = 366), or diagnoses of primary HIV infection (n = 130). In addition, we studied 124 patients for whom longitudinal genotypic resistance testing was performed while they were still ART-naive. Results. We found that the fraction of ambiguous nucleotides increased with the age of infection with a rate of .2% per year within the first 8 years but thereafter with a decreasing rate. We show that this pattern is consistent with population-genetic models for realistic parameters. Finally, we show that, in this highly representative population, a fraction of ambiguous nucleotides of >.5% provides strong evidence against a recent infection event < 1 year prior to sampling (negative predictive value, 98.7%). Conclusions. These findings show that the fraction of ambiguous nucleotides is a useful marker for the age of infection.

Comparison of molecular signatures from multiple skin diseases identifies mechanisms of immunopathogenesis.

The ability to obtain gene expression profiles from human disease specimens provides an opportunity to identify relevant gene pathways, but is limited by the absence of data sets spanning a broad range of conditions. Here, we analyzed publicly available microarray data from 16 diverse skin conditions in order to gain insight into disease pathogenesis. Unsupervised hierarchical clustering separated samples by disease as well as common cellular and molecular pathways. Disease-specific signatures were leveraged to build a multi-disease classifier, which predicted the diagnosis of publicly and prospectively collected expression profiles with 93% accuracy. In one sample, the molecular classifier differed from the initial clinical diagnosis and correctly predicted the eventual diagnosis as the clinical presentation evolved. Finally, integration of IFN-regulated gene programs with the skin database revealed a significant inverse correlation between IFN-β and IFN-γ programs across all conditions. Our study provides an integrative approach to the study of gene signatures from multiple skin conditions, elucidating mechanisms of disease pathogenesis. In addition, these studies provide a framework for developing tools for personalized medicine toward the precise prediction, prevention, and treatment of disease on an individual level.

Immunopathogenesis of Asthma and Atopic Diseases – The specific Role of a selected Panel of Genes in human T helper Cell Differentiation

T helper cell (Th) functions are crucial for proper immune defence against various intra- and extracellular pathogens. According to the specific immune responses, Th cells can be classified into subtypes, Th1 and Th2 cells being the most frequently characterized classes. Th1 and Th2 cells interact with other immune cells by regulating their functions with specific cytokine production. IFN, IL-2 and TNF- are the cytokines predominantly produced by Th1 cells whereas Th2 cells produce Th2-type cytokines, such as IL-4, IL-5 and IL-13. Upon TCR activation and in the presence of polarizing cytokines, Th cells differentiate into effector subtypes from a common precursor cell. IFN and IL-12 are the predominant Th1 polarizing cytokines whereas IL-4 directs Th2 polarization. The cytokines mediate their effects through specific receptor signalling. The differentiation process is complex, involving various signalling molecules and routes, as well as functions of the specific transcription factors. The functions of the Th1/Th2 cells are tightly regulated; however, knowledge on human Th cell differentiation is, as yet, fairly poor. The susceptibility for many immune-mediated disorders often originates from disturbed Th cell responses. Thus, research is needed for defining the molecular mechanisms involved in the differentiation and balanced functions of the Th cells. Importantly, the new information obtained will be crucial for a better understanding of the pathogenesis of immune-mediated disorders, such as asthma or autoimmune diseases. In the first subproject of this thesis, the role of genetic polymorphisms in the human STAT6, GATA3 and STAT4 genes were investigated for asthma or atopy susceptibility in Finnish asthma families by association analysis. These genes code for key transcription factors regulating Th cell differentiation. The study resulted in the identification of a GATA3 haplotype that associated with asthma and related traits (high serum IgE level). In the second subproject, an optimized method for human primary T cell transfection and enrichment was established. The method can be utilized for functional studies for the selected genes of interest. The method was also utilized in the third subproject, which aimed at the identification of novel genes involved in early human Th cell polarization (0-48h) using genome-wide oligonucleotide arrays. As a result, numerous genes and ESTs with known or unknown functions were identified in the study. Using an shRNA knockdown approach, a panel of novel IL-4/STAT6 regulated genes were identified in the functional studies of the genes. Moreover, one of the genes, NDFIP2, with a previously uncharacterized role in the human Th differentiation, was observed to promote IFN production of the differentiated Th1 cells. Taken together, the results obtained have revealed potential new relevant candidate genes serving as a basis for further studies characterizing the detailed networks involved in the human Th cell differentiation as well as in the genetic susceptibility of Th-mediated immune disorders.