Tick-transmitted rickettsial diseases, such as ehrlichiosis and spotted fever rickettsiosis, are significant sources of morbidity and mortality in the southern United States. Because of their exposure in tick-infested woodlands, outdoor workers experience an increased risk of infection with tick-borne pathogens. As part of a double blind randomized-controlled field trial of the effectiveness of permethrin-treated clothing in preventing tick bites, we identified tick species removed from the skin of outdoor workers in North Carolina and tested the ticks for Rickettsiales pathogens. Ticks submitted by study participants from April-September 2011 and 2012 were identified to species and life stage, and preliminarily screened for the genus Rickettsia by nested PCR targeting the 17-kDa protein gene. Rickettsia were further identified to species by PCR amplification of 23S-5S intergenic spacer (IGS) fragments combined with reverse line blot hybridization with species-specific probes and through cloning and nucleotide sequence analysis of 23S-5S amplicons. Ticks were examined for Ehrlichia and Anaplasma by nested PCR directed at the gltA, antigen-expressing gene containing a variable number of tandem repeats, 16S rRNA, and groESL genes. The lone star tick (Amblyomma americanum) accounted for 95.0 and 92.9% of ticks submitted in 2011 (n = 423) and 2012 (n = 451), respectively. Specimens of American dog tick (Dermacentor variabilis), Gulf Coast tick (Amblyomma maculatum) and black-legged tick (Ixodes scapularis) were also identified. In both years of our study, 60.9% of ticks tested positive for 17-kDa. "Candidatus Rickettsia amblyommii", identified in all four tick species, accounted for 90.2% (416/461) of the 23S-5S-positive samples and 52.9% (416/787) of all samples tested. Nucleotide sequence analysis of Rickettsia-specific 23S-5S IGS, ompA and gltA gene fragments indicated that ticks, principally A. americanum, contained novel species of Rickettsia. Other Rickettsiales, including Ehrlichia ewingii, E. chaffeensis, Ehrlichia sp. (Panola Mountain), and Anaplasma phagocytophilum, were infrequently identified, principally in A. americanum. We conclude that in North Carolina, the most common rickettsial exposure is to R. amblyommii carried by A. americanum. Other Rickettsiales bacteria, including novel species of Rickettsia, were less frequently detected in A. americanum but are relevant to public health nevertheless.
Deaths related to the recreational use of cocaine in the United States have increased to epidemic proportions within the last decade. Frequently, persons with cocaine toxicity present to the emergency room, require critical care nursing, and are admitted to the intensive care unit. This article outlines the cardiovascular effects of recreational cocaine abuse. Initially, the historical perspective of the drug is outlined. The mechanism of action, administration, absorption, and excretion are discussed. Details regarding the cardiovascular effects of cocaine are described. Although no uniform treatment plan has been developed for every complication of cocaine overdose, the current therapeutic modalities are outlined. Finally, the clinical implications for clinical practice are addressed. The recreational abuse of cocaine presents new patient care challenges for the critical care nurse. With increased knowledge, the health care provider may assist in meeting the clinical needs of this emerging patient population.
Many health care inequalities seem to be racially based. Racism and racial conflict in America can be explained in the context of three historical time periods and the prevailing economic systems of those times. The problem of access to basic health care for the black underclass is enormous. Traditional solutions of health education, health promotion, and low-cost health care have done very little to change the outcomes of increased morbidity and mortality. Health care professionals need to confront the real problem of inadequate life chances and limited economic resources for the underclass through research and the restructuring of our health care delivery system.
Abstract Objective. The purpose of this study was to determine whether a T cell receptor (TCR) polymorphism, either by itself or in combination with particular HLA polymorphism, leads to susceptibility to rheumatoid arthritis (RA). Methods. Eight restriction fragment length polymorphisms (RFLPs) detected with TCR gene segments were investigated in 46 individuals with RA and were compared with data from normal control subjects. Results. A statistically significant difference in the genotype frequencies of a Taq I RFLP detected with the TCRα constant region (C α ) gene was noted. In addition, when the DR4+ subpopulations were examined, the allelic frequency of a 2‐kb Bam HI fragment detected with a V β 8 gene was increased in the samples from RA patients ( P < 0.0086). Conclusion. The results of this study suggest that germline differences in the TCR repertoire may be associated with RA, and that there is a contributory effect of DR4+ haplotypes with certain TCR haplotypes in susceptibility to RA.
Abstract Long lasting permethrin-impregnated (LLPI) clothing can retain permethrin and repel ticks for up to three months and without exceeding EPA-approved safe levels; however, little is known about longer term effects of wearing LLPI clothing. Here, permethrin content was measured in new forester pants soon after initial impregnation (Insect Shield) and again one year later after being repeatedly worn by foresters in the field. Urine samples were collected from foresters for biomonitoring of permethrin metabolites at multiple time intervals (pre-use, one-month, three-to-four-months, and one-year post-use). Lethality against nymphal Ixodes scapularis Say was measured in clothing after one year of wear by foresters. Furthermore, to test potential variability in permethrin impregnation of different batches of clothing, separate sets of clothing were anonymously sent to Insect Shield for permethrin treatment over a period of three months and permethrin was quantified. Results demonstrated 33% of participants’ pants had no measurable permethrin after one year of wear and permethrin content and tick mortality varied significantly between clothing. Only two of the participants’ clothing resulted in ≥ 30% tick mortality after one year of wear. Significant differences were observed in 3-PBA and trans-DCCA, but not cis-DCCA metabolites in participants over the four measured time points and were higher than general United States population levels. This study provides practical information on the safety (measured by urinary metabolites) over time of LLPI clothing. It also provides snapshots (pre-washing and after one year of wear) of effectiveness of LLPI clothing as personal protective equipment against ticks for outdoor workers.
Tick-borne diseases cause substantial morbidity throughout the United States, and North Carolina has a high incidence of spotted fever rickettsioses and ehrlichiosis, with sporadic cases of Lyme disease. The occupational risk of tick-borne infections among outdoor workers is high, particularly those working on publicly managed lands. This study identified incident tick-borne infections and examined seroconversion risk factors among a cohort of North Carolina outdoor workers. Workers from the North Carolina State Divisions of Forestry, Parks and Recreation, and Wildlife (n = 159) were followed for 2 years in a randomized controlled trial evaluating the effectiveness of long-lasting permethrin-impregnated clothing. Antibody titers against Rickettsia parkeri, Rickettsia rickettsii, "Rickettsia amblyommii," and Ehrlichia chaffeensis were measured at baseline (n = 130), after 1 year (n = 82), and after 2 years (n = 73). Titers against Borrelia burgdorferi were measured at baseline and after 2 years (n = 90). Baseline seroprevalence, defined as indirect immunofluorescence antibody titers of 1/128 or greater, was R. parkeri (24%), R. rickettsii (19%), "R. amblyommii" (12%), and E. chaffeensis (4%). Incident infection was defined as a fourfold increase in titer over a 1-year period. There were 40 total seroconversions to at least one pathogen, including R. parkeri (n = 19), "R. amblyommii" (n = 14), R. rickettsii (n = 9), and E. chaffeensis (n = 8). There were no subjects whose sera were reactive to B. burgdorferi C6 antigen. Thirty-eight of the 40 incident infections were subclinical. The overall risk of infection by any pathogen during the study period was 0.26, and the risk among the NC Division of Forest Resources workers was 1.73 times that of workers in other divisions (95% confidence interval [CI]: 1.02, 2.92). The risk of infection was lower in subjects wearing permethrin-impregnated clothing, but not significantly (risk ratio = 0.81; 95% CI: 0.47, 1.39). In summary, outdoor workers in North Carolina are at high risk of incident tick-borne infections, most of which appear to be asymptomatic.
Vector-borne diseases are an important cause of morbidity and mortality in the USA. Effective, convenient prevention methods are needed. Long-lasting permethrin-impregnated (LLPI) clothing can prevent tick bites, however, additional information is needed on the real-world effectiveness and safety of this preventative measure. In this pilot study, we recruited state and county park employees from North Carolina to wear LLPI uniforms for three months during the summer of 2016. We collected spot urine samples for biomonitoring of permethrin metabolites at one week, one month and three months after first use of the LLPI uniform. Following three months of wear, we collected pants and socks and analyzed them for permethrin content and mortality to ticks and mosquitoes. Thirteen park employees were included in the analysis. Bioactive amounts of permethrin remained in all clothing swatches tested, although there was great variability. Tick mortality was high, with 78% of pant and 88% of sock swatches having mean knockdown percentages ≥ 85%. In contrast, mosquito mortality was low. Over the study period, the absorbed dosage of permethrin averaged < 4 μg/kg/d of body weight based on measurements of three metabolites. LLPI clothing retained permethrin and bioactivity against ticks after three months of use in real-world conditions. The estimated absorbed dosage of permethrin was well below the U.S. EPA level of concern, suggesting that LLPI clothing can be used safely by outdoor workers for tick bite prevention.
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