Zoonotic diseases continue to emerge and threaten both human and animal health. Overcrowded shelters and breeding kennels create the perfect environment for amplified infectious disease transmission among dogs and present a critical opportunity for zoonotic pathogens to emerge and threaten people who work in close contact with dogs. The objectives of this study were to determine if people with occupational contact with dogs were more likely to have antibodies against Brucella canis, canine influenza virus (CIV), and canine respiratory coronavirus (CRCoV) compared to persons with no dog exposure. A seroepidemiological cohort study was completed, for which 306 canine-exposed and 101 non-canine exposed study subjects enrolled in the study by providing a serum sample and completing a self-administered questionnaire. Evidence of previous exposure was determined by detecting human antibodies against B. canis, CIV and CRCoV. Potential risk factors for seropositivity were examined. Results suggest the overall seroprevalence for B. canis antibodies among humans was 3.2%, with 13 subjects testing positive for antibodies against B. canis by the rapid slide agglutination test. Several canine-exposed occupations/hobbies not considered in previous studies, including jobs in small breeding kennels and dog show handlers, may be at increased risk for exposure to zoonotic B. canis. Occupational risk factors included exposure to a known B. canis positive dog (adjusted OR=7.6; 95% CI, 1..01-48.7) and not wearing personal protective equipment (PPE) when caring for a whelping dog (adjusted OR=6.0; 95% CI, 1.02-65.0). In addition, survey results indicated 35% of breeders were not performing B. canis /italic> testing in their kennels. Even with indication of antibody cross-reactivity, serological results indicated that the canine-exposed population had higher odds for CIV seropositivity, although the odds were not statistically significant. True human infections with CIV may be occurring at a low level of incidence, for which this sample size was not large enough to detect a significant difference between the exposure groups. An inverse association between elevated antibodies against CIV with the occupational exposures of examining dogs and wearing PPE when working with dogs are counter-intuitive, but nonetheless it suggests contact with dogs is playing some role in the evidence of antibody production against CIV. To determine the seroprevalence of antibodies against CRCoV, a competitive enzyme-linked immunosorbent assay (ELISA) was developed to detect human antibodies against CRCoV but control for cross-reacting antibodies against the human coronavirus OC43. All study subjects were negative for antibodies against CRCoV by this competitive ELISA. Overall, these results suggest that exposure to B. canis and CIV is occurring among this study population. Owners and handlers should first ensure the health and safety of the dogs for which there care. To prevent the zoonotic spread of these pathogens to humans, persons in high-risk occupational settings need to be educated of their potential risks, such that they can take proper precautions, including wearing gloves when exposed to a whelping dog and always washing their hands after caring for a sick dog. Lastly, in order to more accurately identify the cross-species spread of these diseases and associated risk factors, prospective studies employing more sensitive serological assays need to be developed. While serological studies have a number of limitations, they are still a valid first tool for identifying emerging zoonotic diseases.

<p>Background: The life-time prevalence ofHSV-2 is higher in people infected with HIV/AIDS compared to the general population. Little is known about the experiences of women living with these two chronic sexually transmitted viral infections (STVIs), for example, whether HSV-21 HIV co-infection complicates women's experiences and influences their perceived health-related quality of life (HRQoL). The degree to which HSV-2/HIV co-infection changes perceived physical and mental HRQoL ofHIV-positive women when taking into account other factors related to HRQoL including the degree of immunosuppression, demographic characteristics, and co-existent psychological issues is not known. It has not been investigated whether these two chronic STVIs create additional challenges in social and sexual relationships for women. It is also not understood if body image or self-esteem are complicated by HSV-2IHIV co-infection, as well as how women perceive and experience disclosure in relationships and stigma. No quantitative or qualitative studies have explored these phenomena in a Canadian HIVpositive female population.</p> <p>Methods: This mixed methods study explored the association between HIVI HSV-2 coinfection and physical and mental HRQoL of adult HIV -positive women. A sequential exploratory model was utilized, which involved collecting qualitative data after a quantitative phase. In the first quantitative phase, a cross-sectional questionnaire was administered, HSV -2 sero-status was determined and clinical correlates and HRQoL scores were analyzed using multivariable methods. The second qualitative phase was conducted to further explain the quantitative findings; participants' views of the relationship between symptomatic HSV-2 and HIV co-infection and HRQoL were explored. The qualitative phase employed an interpretive phenomenological philosophy and methodology.</p> <p>Quantitative Findings: Although women's HRQoL scores on general and HIV-specific measures differed depending on their HSV-2 sero-status, place of origin, receipt of antiretroviral therapy, etc., HSV-2/HIV co-infected women did not have significantly different HRQoL scores compared to women infected with HIV alone. This conclusion was drawn on the basis of only fair goodness-of-fit of the linear regression models. HSV -2 sero-positivity predicting a better perceived physical and mental HRQoL was also considered biologically implausible and divergent with the literature.</p> <p>Qualitative Findings: The participant narratives highlighted the meaning that women ascribe to living with HIV and HSV-2 in relationship to their perceived HRQoL. HIV was something that affected their global physical and mental HRQoL; it was associated with a social and historical context and was mapped onto their life trajectories. HSV-2, on the other hand, was an immediate concern experienced on an episodic basis, and was more relevant to dimensions of HRQoL such as day-to-day physical and social functioning, as well as intimacy and relationships with partners. HSV-2 infection was a separate, dominant and gendered medical condition that compounded and complicated women's experiences with HIV.</p> <p>Main implication: HRQoL assessments from the perspective of patients will become increasingly important as life-prolonging antiretroviral treatments are refined and clinicians and HIV -positive individuals look to maximize quality oflife and well-being. As people living with HIV I AIDS continue to face complex health-related challenges, it is essential to incorporate HRQoL into treatment and care planning. It is important for service providers to account for HSV -2 as an important medical and psychosocial issue and to discuss with their clients how HSV -2 may affect perceived HRQoL. This study adds to the body of knowledge regarding women's experiences living with HN, but adds an important layer regarding co-infections and co-morbidities, which are relevant to developing an understanding of women's sexual health.</p> / Master of Science (MSc)

No description available.

<p>Context: It is unclear whether the construct of a randomized controlled trial (RCT) itself could confer benefit or harm to trial participants beyond any effect of the experimental treatment under study (trial effect).</p> <p>Objective: To determine whether there is a trial effect appreciated by RCT participants (insiders) compared to similar patients who do not participate (outsiders). Although we are most interested in the pragmatic comparison of insiders to outsiders, we will also conduct the explanatory comparison of insiders to outsiders when the intervention is the same.</p> <p>Data Sources: We searched electronic health research databases, including CENTRAL (1960-2010), MEDLINE (1966-2010), EMBASE(1980-2010) and PsycINFO (1880- 2010).</p> <p>Study Selection: Eligible studies included those that reported the outcomes of insiders and a group of parallel or consecutive outsiders and reported the same health outcome at the same endpoint.</p> <p>Results: We included 147 articles out of the 42493 identified in our initial search. Five out of the 147 studies randomized patients to be insiders or outsiders, the remaining were observational designs. The heterogeneity of our overall result was reduced by grouping studies based on whether the intervention being investigated was effective and whether treatment inside and outside of the RCT was the same or different. There was no significant difference in outcomes between insiders and outsiders when the experimental intervention was ineffective (standard mean difference [95% confidence interval]: -0.03 [-0.1, 0.04]), or when it was effective and received by both insiders and outsiders (0.04 [-0.04,0.13]). If the experimental intervention was effective but was not administered to outsiders, they experienced worse health outcomes (-0.36 [-0.61, -0.12]).</p> <p>Conclusions: There is no evidence to support any benefit or harm associated with trial participation. There is some evidence that better outcomes are experienced by insiders who had access to effective treatments not offered or available to outsiders.</p> / Master of Health Sciences (MSc)

Association between Smoking and Functional Outcome in Acute Ischemic Stroke Population Treated with Tissue Plasminogen Activator Iretioluwa Ajani1, Oluyemi Rotimi1, Olubunmi Kuku1, Ndukwe Kalu1, Olakunle Oni1, Nwabueze Christian1,Thomas Nathaniel2, Shimin Zheng1* 1Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614 2Department of Neurology, Department of Pharmacology, Physiology & Neuroscience, University of South Carolina School of Medicine, Columbia, SC 29208 *Sponsoring faculty Background The effect of smoking on outcome in acute ischemic stroke patients treated with tissue plasminogen activator (TPA) is debatable. Based on the hypothesis that smokers may have more effective thrombolysis with TPA. Some clinical studies have demonstrated a favorable outcome while others have seen worse prognosis or no effect at all. This study seeks to determine the association between smoking and functional improvement in TPA treated and non-treated patients. Methods We analyzed data from the Greenville Health System (GHS) stroke registry on stroke patients between January 2010 and December 2013. Patients were divided into two groups: those treated with TPA and those not treated with TPA but presenting within 4.5 hours. Logistic regression analysis was conducted to assess if smoking was associated with improvement in ambulation. Results Of 1,446 patients, 595 (41.15 %) were treated with TPA (181 smokers (30.42%), 414 non-smokers (69.58 %) and 851 (58.85%) not treated with TPA (198 smokers (23.27 %), 653 non-smokers (76.73 %). In the multiple logistic models, smoking was not independently associated with favorable outcome in patients treated with TPA (OR = 0.84; 95% CI = 0.54 – 1.33; P = 0.46) and those not treated with TPA (OR = 0.96; 95% CI = 0.64 – 1.44; P-value = 0.85) though the bivariate models showed significant association. Conclusion There is no association between smoking and functional outcome in stroke patients regardless of TPA treatment. The effect of smoking on outcome in acute ischemic stroke patients treated with tissue plasminogen activator (TPA) is however stronger than those not treated with TPA.

This thesis explored healthcare quality improvement, considering the general question of why the last decade's worth of quality improvement (QI) had not significantly improved quality and safety. The broad objective of the thesis was to explore how hospitals perform when completing QI projects and whether any organizational characteristics were associated with that performance. First the project evaluated a specific QI collaborative undertaken in the Veterans Affairs (VA) healthcare system. The goal of the collaborative was to improve patient flow throughout the entire care process leading to shorter hospital length of stay (LOS) and an increased percentage of patients discharged before noon. These two goals became the primary outcomes of the analysis, which were balanced by three secondary quality check outcomes: 30-day readmission, in-hospital mortality, and 30-day mortality. The analytic model consisted of a five-year interrupted time-series examining baseline performance (two-years prior to the intervention), the year during the QI collaborative, and then two-years after the intervention to determine how well improvements were maintained post intervention. The results of these models were then used to create a novel 4-level classification model. Overall, the analysis indicated a significant amount of variation in performance; however, sub-group analyses could not identify any patterns among hospitals falling into specific performance categories. Given this potentially meaningful variation, the second half of the thesis worked to understand whether specific organizational characteristics provided support or acted as key barriers to QI efforts. The first step in this process involved developing an analytic model to describe how various categories of organizational characteristics interacted to create an environment that modified a QI collaborative to produce measureable outcomes. This framework was then tested using a collection of variables extracted from two surveys, the categorized hospital performance from part one, and data mining decision trees. Although the results did not identify any strong associations between QI performance and organizational characteristics it generated a number of interesting hypotheses and some mild support for the developed conceptual model. Overall, this thesis generated more questions than it answered. Despite this feature, it made three key contributions to the field of healthcare QI. First, this thesis represents the most thorough comparative analysis of hospital performance on QI and was able to identify four unique hospital performance categories. Second, the developed conceptual model represents a comprehensive approach for considering how organizational characteristics modify a standardized QI initiative. Third, data mining was introduced to the field as a useful tool for analyzing large datasets and developing important hypotheses for future studies.

1. Introduction Injury is the fifth leading cause of mortality and morbidity among adults in Iowa. Work-related, or occupational injuries, constitute a substantial proportion of the injury burden in the US. The Bureau of Labor Statistics reports about 4.9 million occupational injuries annually in the US and over 50,000 injuries in Iowa. The aims of this study were to assess: 1) the burden of work-related injuries using an algorithm based on analysis of the external cause of injury (i.e., E-codes) combined with injury registry variables; 2) the magnitude of disability following an occupational injury by assessing Disability Adjusted Life Years and Discharge to Long Term Care; and 3) the burden of short-term disability one year after discharge from a Level I trauma center. 2. Methods/Approach This research consisted of two observational studies of Iowa cases, ages 18-64, reported to the Iowa State Trauma Registry (STR) from January 1st 2007 to December 31st 2010. A retrospective cohort design was used to assess differences in mortality, length of stays, discharge disposition, disability risk and Disability-Adjusted Life Years (DALYs), and their associated risk factors, such as demographic characteristics, nature and severity of injury, pre-hospital and in hospital trauma care (i.e. transport, resuscitation, vascular and airway access, sedative and paralytic drug usage). A prospective follow-up study a cohort of cases discharged from the University of Iowa Resource Trauma Center was used to assess risk factors associated with short-term disabilities one year after discharge. The EuroQol-5 Dimension Questionnaire (EQ-5D) was mailed to the cohort cases, alive one year after discharge, to assess their overall health status and quality of life. The algorithm classified the study population into occupational, “Work-Likely” (WL), and non-work cases. Work-likely was defined based on work-related activities without pay, informal status or self-employed. The registry cases were matched to 2007-2011 death certificates to identify those who died after discharge and to estimate their survival time. Machine learning methods – logistic regression and 10-fold cross validation were used to validate the algorithm. The survival time from injury to death was assessed using Kaplan Meier and Cox regression modeling. The Generalized Linear Modeling, including multinomial regression, was used to analyze the mean length of stay, the risk of discharge to long term care, DALYs and disability risk. 3. Results From 2007 to 2010, there were individuals (ages 18-64) admitted (average 5,614 per year) as trauma cases to hospitals in Iowa. Based on the algorithm, 3,115 (14.0%) were classified as occupational, 847 (3.8%) as WL, and 18,454 (82.2%) were classified as non-work cases. There were notable differences in demographics, farm exposure, and rural residence. The 10-fold cross validation showed a 20% misclassification rate for occupational and 30% for WL. The area under the curve (AUC) of the receiver-operating characteristics (ROC) was measured at 0.66, which is indicative of poor discriminating effect. Overall, occupational and WL cases had better outcomes than non-work cases; they had lower mean lengths of stay and better survival rates, as detected by Kaplan-Meier and Cox regression models. WL had lower survival rates on the Kaplan Meier estimates but the Cox regression contrast statement didn't find any difference in survival between occupational and WL 30 days and one year after discharge. Multinomial regression showed major differences in the risk of discharge to long-term care (LTC) or acute care compared to discharge home between occupational, WL, and non-work cases WL cases had less risk of being discharged to LTC compared to non-work cases. There were no differences observed between occupational and non-work cases. When stratified by occupational status, the predictors of being discharged to Long term care or acute care were different for occupational, WL and non-work cases. For WL, care in Level I&II , injury type, triage mechanism, first ER systolic blood pressure were no longer good predictors of discharge to LTC compared to occupational or non-work cases. Mean DALYs were lower in the occupational (mean= 4.8; 95% CI: 4.7-4.8) and WL (mean 4.4; 95% CI: 4.4-4.7) cases than the non-work cases (mean= 5.2; 95% CI: 5.1-5.2). However, when all other risk factors were accounted for, the occupational cases had a 10% reduction in mean DALYs, and WL a 20% reduction in DALYs compared to non-work cases. When the disability was assessed separately by occupational status, the risk factors associated with disability were completely different. For WL cases, only injury location and ISS were significantly associated with DALYs. Conversely for occupational and non-work cases, injury type, coma, pre-hospital management (i.e. airway, paralytic drugs), and cause of injury were significantly associated with DALYs. The one-year follow-up questionnaire administered to 156 trauma survivors resulted in 72 (46%) valid responses. Of those who responded, 58 (81%) were occupational and 14 (19%) WL cases. Overall, from the EQ-5Dresults, 46% of the respondents reported a disability. There were no major differences in the prevalence of disability between occupational and WL injury cases. However, occupational injury cases were more likely to receive rehabilitation services. 4. Conclusions This study demonstrated the utility of using trauma registry data in epidemiologic research to study occupational injury using a unique algorithm to include informal or self-employed workers. It identified a neglected group of workers subject to occupational injury and subsequent disability.

While the role of obesity in health outcomes has been well described, the role of low body mass index (BMI), body weight relative to height, has largely been ignored. Those with low BMI are commonly excluded completely or combined with the normal BMI category in BMI studies. However, there have been some studies indicating poorer health outcomes among those with lower BMI, particularly that of increased risk of mortality. The purpose of this study is to explore the role of low BMI throughout the lifespan. Data from the Health and Retirement Study was used to evaluate 1) the association between childhood health and socioeconomic status (SES) exposures and low BMI in midlife adulthood, 2) the association between low BMI and health related outcomes in midlife adulthood (ages 50 to 65), and 3) the association between low BMI in midlife and health related outcomes, including mortality, over a longer follow-up (maximum of 20 years). To increase sample size, two low BMI definitions were used: the traditional Few significant results were found. Low BMI status was consistently associated with older age and female gender as well as current smoking status. Childhood exposure of respiratory disease and greater SES disadvantages was more common among those with low BMI in adulthood. In midlife adulthood, low BMI status was associated with increased difficulties with activities of daily living with either definition of low BMI. Increased risk of fracture was associated with a low BMI definition of <18.5. Increased risk of lung disease and decreased risk of high blood pressure was associated with a low BMI definition of ≤20. An analysis of those 30 years old or older found low BMI to be associated with increased risk of mortality and decreased risk of diabetes regardless of low BMI definition. When low BMI was defined as <18.5, those with low BMI were also more likely to experience difficulty with one or more activities of daily living. When low BMI was defined as ≤20, low BMI status was associated with greater risk of lung disease and decreased risk of high blood pressure. Further research is needed to fully characterize the role of low BMI on health outcomes as well as the role of SES on low BMI. Additionally, there is a need for greater understanding of the potential biological mechanisms of low BMI for health outcomes. Currently, there are few studies evaluating health outcomes and SES of low BMI. Limiting studies to the extreme upper end of the BMI spectrum limits the overall understanding of the role of BMI in health and may overlook unique characteristics and challenges those with low BMI may face.

Three main research topics are reported in this dissertation. This research project focused on estimating the burden of injury on large federal wildland fires and describing the injury characteristics and risk factors for severity of injury in a sample of injured federal wildland firefighters. Chapter 2 "Peak incident management level affects rates of injury on large federal wildland fires" reports estimates of rates of injury for large federal wildland fires and assesses the effect of peak incident management level (PIML) as a predictor of rate of injury. After adjusting for seasonal factors and fire characteristics, PIML was a predictor of both rate of injury and odds of any injury occurrence, but the effect was opposite. Fires with higher PIML demonstrated lower incidence rate ratios, but the odds of injury were increased. Chapter 3 "Wildland fire job assignment and burden of injury" describes the injury characteristics and severity associated with the firefighter's job assignment in fire-related injuries reported to the United States Department of Interior. Job assignment was significantly associated with cause and nature of injury, but not with the severity of injury as defined by days off work or job transfer. Chapter 4 "Cause, characteristics and severity of injuries in wildland firefighters" examines the relationship between the cause of injury and type of injury and the severity of injury. Injuries caused by slips, trips or falls were most frequently reported. Injuries caused by bites or stings and plants were less likely to be severe relative to injuries caused by slips, trips or falls. Together, these studies provide evidence that injuries may significantly impact the wildland fire community, but that better information is needed to fully evaluate risk factors and develop evidence-based interventions.

CHIK is a viral infection transmitted by the Aedes aegypti mosquito which causes an illness with symptoms of severe joint pain, high fever, and rash. The joint pain can continue for months, causing disability and economic strain on families. This study included implementation of a baseline needs assessment, and development, implementation, and evaluation of an experimental community-based educational intervention in rural Tamil Nadu, India. A total of 184 households, across 12 purposively sampled villages (six intervention and six control), participated in the needs assessment between August and December 2010. The experimental community-based educational intervention was implemented between December 2010 and August 2011, in the six intervention villages. A total of 180 households, from the same 12 villages, participated in the post-intervention evaluation. A randomized block design with repetition was used to test whether there was a change in CHIK knowledge scores from baseline to post-intervention in the treatment group. A model including respondent variables, household larval status, household container larval status, recent experience with CHIK, numbers of livestock, socioeconomic position (SEP) variables, and water variables were used to predict CHIK knowledge scores in rural Tamil Nadu. Respondent age, measures of luxury amenities and water source were statistically significant predictors of knowledge in this model. The CHIK knowledge score increased from 9.0 to 9.4 in the intervention group (p=0.6457) and from 8.5 to 9.2 in the control group (p=0.393), showing that the educational intervention did not increase CHIK knowledge in the intervention group. Although this low-cost intervention, utilized in a resource poor area of Tamil Nadu, India did not result in an increase of CHIK knowledge, the process of developing the educational intervention may provide a template for future interventions. Future studies should investigate methods of sustainability in the use of educational messages.