Asunto(s)
Infección Hospitalaria/transmisión , Equipo Reutilizado , Hepatitis C/transmisión , Solución Salina/administración & dosificación , Jeringas , Cuidados Críticos , Infección Hospitalaria/epidemiología , Hepatitis C/epidemiología , Hospitales Generales , Humanos , Personal de Enfermería en Hospital , Pautas de la Práctica en Enfermería , Jeringas/virología , Texas/epidemiologíaRESUMEN
OBJECTIVE: On April 17, 2013, a fire and subsequent explosion occurred at the West Fertilizer Company plant in West, Texas, and caused extensive damage to the adjacent neighborhood. This investigation described the fatal and nonfatal injuries caused by the explosion. METHODS: Persons injured by the fertilizer plant explosion were identified through death certificates, medical examination reports, medical records, and survivor interviews. Data on patient characteristics, type of injury, and location of injury were collected. RESULTS: Medical record review indicated that 252 individuals sought medical care for nonfatal injuries directly related to the explosion immediately after the explosion. Fifteen patients died of injuries sustained by the blast. Almost one-quarter of patients were admitted for treatment of injuries. Injuries sustained in the explosion included abrasions/contusions, lacerations/penetrating trauma, traumatic brain injuries/concussions, tinnitus/hearing problems, eye injuries, and inhalational injuries. Patients located closer to the explosion were more likely to be admitted to the hospital for treatment of injuries than were those who were located further away. CONCLUSION: Explosions of this magnitude are rare, but can inflict severe damage to a community and its residents. This investigation could be a useful planning resource for other communities, public health agencies, first responders, and medical facilities. (Disaster Med Public Health Preparedness. 2016;10:583-590).
Asunto(s)
Accidentes de Trabajo/estadística & datos numéricos , Traumatismos por Explosión/epidemiología , Fertilizantes/efectos adversos , Adolescente , Adulto , Traumatismos por Explosión/terapia , Femenino , Incendios/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Texas/epidemiologíaRESUMEN
We examined differences in HIV-infected U.S.-born and foreign-born black mothers who delivered perinatally HIV-exposed and -infected children during 1995-2004 in the Pediatric Spectrum of HIV Disease Project, a longitudinal cohort study. Prevalence ratios were calculated to explain differences in perinatal HIV prevention opportunities comparing U.S.-born to foreign-born and African-born to Caribbean-born black mothers. U.S.-born compared with foreign-born HIV-infected black mothers were significantly more likely to have used cocaine or other non-intravenous illicit drugs, exchanged money or drugs for sex, known their HIV status before giving birth, received intrapartum antiretroviral (ARV) prophylaxis, and delivered a premature infant; and were significantly less likely to have received prenatal care or delivered an HIV-infected infant. African-born compared with Caribbean-born black mothers were more likely to receive intrapartum ARV prophylaxis. These differences by maternal geographical origin have important implications for perinatal HIV transmission prevention, and highlight the validity of disaggregating data by racial/ethnic subgroups.
Asunto(s)
Población Negra/estadística & datos numéricos , Negro o Afroamericano/estadística & datos numéricos , Infecciones por VIH/prevención & control , Infecciones por VIH/epidemiología , Infecciones por VIH/etnología , Humanos , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Transmisión Vertical de Enfermedad Infecciosa/estadística & datos numéricos , Estudios Longitudinales , Atención Prenatal , Estados Unidos/epidemiologíaRESUMEN
PURPOSE: HIV-infected individuals with cancer have worse survival rates compared with their HIV-uninfected counterparts. One explanation may be differing cancer treatment; however, few studies have examined this. PATIENTS AND METHODS: We used HIV and cancer registry data from Connecticut, Michigan, and Texas to study adults diagnosed with non-Hodgkin's lymphoma, Hodgkin's lymphoma, or cervical, lung, anal, prostate, colorectal, or breast cancers from 1996 to 2010. We used logistic regression to examine associations between HIV status and cancer treatment, adjusted for cancer stage and demographic covariates. For a subset of local-stage cancers, we used logistic regression to assess the relationship between HIV status and standard treatment modality. We identified predictors of cancer treatment among individuals with both HIV and cancer. RESULTS: We evaluated 3,045 HIV-infected patients with cancer and 1,087,648 patients with cancer without HIV infection. A significantly higher proportion of HIV-infected individuals did not receive cancer treatment for diffuse large B-cell lymphoma (DLBCL; adjusted odds ratio [aOR], 1.67; 95% CI, 1.41 to 1.99), lung cancer (aOR, 2.18; 95% CI, 1.80 to 2.64), Hodgkin's lymphoma (aOR, 1.77; 95% CI, 1.33 to 2.37), prostate cancer (aOR, 1.79; 95% CI, 1.31 to 2.46), and colorectal cancer (aOR, 2.27; 95% CI, 1.38 to 3.72). HIV infection was associated with a lack of standard treatment modality for local-stage DLBCL (aOR, 2.02; 95% CI, 1.50 to 2.72), non-small-cell lung cancer (aOR, 2.43; 95% CI, 1.46 to 4.03), and colon cancer (aOR, 4.77; 95% CI, 1.76 to 12.96). Among HIV-infected individuals, factors independently associated with lack of cancer treatment included low CD4 count, male sex with injection drug use as mode of HIV exposure, age 45 to 64 years, black race, and distant or unknown cancer stage. CONCLUSION: HIV-infected individuals are less likely to receive treatment for some cancers than uninfected people, which may affect survival rates.
Asunto(s)
Infecciones por VIH/epidemiología , Disparidades en Atención de Salud/estadística & datos numéricos , Neoplasias/epidemiología , Neoplasias/terapia , Anciano , Connecticut/epidemiología , Femenino , Infecciones por VIH/complicaciones , Humanos , Modelos Logísticos , Masculino , Michigan/epidemiología , Persona de Mediana Edad , Neoplasias/virología , Sistema de Registros , Factores de Riesgo , Análisis de Supervivencia , Texas/epidemiologíaRESUMEN
OBJECTIVES: HIV-infected people have elevated risk for lung cancer and higher mortality following cancer diagnosis than HIV-uninfected individuals. It is unclear whether HIV-infected individuals with lung cancer receive similar cancer treatment as HIV-uninfected individuals. DESIGN/METHODS: We studied adults more than 18 years of age with lung cancer reported to the Texas Cancer Registry (N = 156 930) from 1995 to 2009. HIV status was determined by linkage with the Texas enhanced HIV/AIDS Reporting System. For nonsmall cell lung cancer (NSCLC) cases, we identified predictors of cancer treatment using logistic regression. We used Cox regression to evaluate effects of HIV and cancer treatment on mortality. RESULTS: Compared with HIV-uninfected lung cancer patients (N = 156 593), HIV-infected lung cancer patients (N = 337) were more frequently young, non-Hispanic black, men, and with distant stage disease. HIV-infected NSCLC patients less frequently received cancer treatment than HIV-uninfected patients [60.3 vs. 77.5%; odds ratio 0.39, 95% confidence interval (CI) 0.30-0.52, after adjustment for diagnosis year, age, sex, race, stage, and histologic subtype]. HIV infection was associated with higher lung cancer-specific mortality (hazard ratio 1.34, 95% CI 1.15-1.56, adjusted for demographics and tumor characteristics). Inclusion of cancer treatment in adjusted models slightly attenuated the effect of HIV on lung cancer-specific mortality (hazard ratio 1.25; 95% CI 1.06-1.47). Also, there was a suggestion that HIV was more strongly associated with mortality among untreated than among treated patients (adjusted hazard ratio 1.32 vs. 1.16, P-interaction = 0.34). CONCLUSION: HIV-infected NSCLC patients were less frequently treated for lung cancer than HIV-uninfected patients, which may have affected survival.
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Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/terapia , Infecciones por VIH/mortalidad , Disparidades en Atención de Salud/estadística & datos numéricos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/terapia , Adolescente , Adulto , Anciano , Carcinoma de Pulmón de Células no Pequeñas/epidemiología , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Humanos , Incidencia , Neoplasias Pulmonares/epidemiología , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Análisis de Supervivencia , Texas/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
SUMMARY: Performance characteristics of rapid assays for hepatitis C virus antibody were evaluated in 4 National HIV Behavioral Surveillance System injection drug use sites. The highest assay-specific sensitivities achieved for the Chembio, MedMira and OraSure tests were 94.0%, 78.9%, and 97.4%, respectively; the highest specificities were 97.7%, 83.3%, and 100%, respectively. BACKGROUND: The Centers for Disease Control and Prevention (CDC) estimates that 4.1 million Americans have been infected with hepatitis C virus (HCV) and 75%-80% of them are living with chronic HCV infection, many unaware of their infection. Persons who inject drugs (PWID) account for 57.5% of all persons with HCV antibody (anti-HCV) in the United States. Currently no point-of-care tests for HCV infection are approved for use in the United States. METHODS: Surveys and testing for human immunodeficiency virus (HIV) and anti-HCV were conducted among persons who reported injection drug use in the past 12 months as part of the National HIV Behavioral Surveillance System in 2009. The sensitivity and specificity of point-of-care tests (finger-stick and 2 oral fluid rapid assays) from 3 manufacturers (Chembio, MedMira, and OraSure) were evaluated in field settings in 4 US cities. RESULTS: Sensitivity (78.9%-97.4%) and specificity (80.0%-100.0%) were variable across assays and sites. The highest assay-specific sensitivities achieved for the Chembio, MedMira, and OraSure tests were 94.0%, 78.9% and 97.4%, respectively; the highest specificities were 97.7%, 83.3%, and 100%, respectively. In multivariate analysis, false-negative anti-HCV results were associated with HIV positivity for the Chembio oral assay (adjusted odds ratio, 8.4-9.1; P < .01) in 1 site (New York City). CONCLUSIONS: Sensitive rapid anti-HCV assays are appropriate and feasible for high-prevalence, high-risk populations such as PWID, who can be reached through social service settings such as syringe exchange programs and methadone maintenance treatment programs.
Asunto(s)
Técnicas de Laboratorio Clínico/métodos , Infecciones por VIH/diagnóstico , Hepacivirus/inmunología , Anticuerpos contra la Hepatitis C/sangre , Hepatitis C/diagnóstico , Adolescente , Adulto , Anciano , Técnicas de Laboratorio Clínico/normas , Femenino , VIH/inmunología , Infecciones por VIH/inmunología , Infecciones por VIH/virología , Hepatitis C/inmunología , Hepatitis C/virología , Hepatitis C Crónica/diagnóstico , Hepatitis C Crónica/inmunología , Hepatitis C Crónica/virología , Humanos , Masculino , Tamizaje Masivo/métodos , Persona de Mediana Edad , Vigilancia de la Población , Saliva/virología , Sensibilidad y Especificidad , Abuso de Sustancias por Vía Intravenosa/complicaciones , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: The region situated where the borders of Mexico, Texas and New Mexico meet is known as 'Paso del Norte'. The Paso del Norte Collaborative was formed to study the seroprevalence of select pathogens and associated risk behaviors among injection drug users (IDUs) in the region. METHODS: Respondent-driven sampling (RDS) was used: 459 IDU participants included 204 from Mexico; 155 from Texas; and 100 from New Mexico. Each of the three sites used a standardized questionnaire that was verbally administered and testing was performed for select bloodborne infections. RESULTS: Participants were mostly male (87.4%) and Hispanic/Latino (84.7%) whose median age was 38. In Mexico, Texas and New Mexico, respectively: hepatitis B virus (HBV) was seen in 88.3%, 48.6% and 59.6% of participants; hepatitis C virus (HCV) in 98.7%, 76.4% and 80.0%; human immunodeficiency virus (HIV) in 2.1%, 10.0% and 1.0%; and syphilis in 4.0%, 9.9% and 3.0%. Heroin was the drug injected most often. More IDUs in New Mexico were aware of and used needle exchange programs compared with Texas and Mexico. CONCLUSION: There was mixed success using RDS: it was more successfully applied after establishing good working relationships with IDU populations. Study findings included similarities and distinctions between the three sites that will be used to inform prevention interventions.
Asunto(s)
Instituciones de Atención Ambulatoria , Hepatitis C/epidemiología , Hepatitis C/prevención & control , Tamizaje Masivo/métodos , Centros de Tratamiento de Abuso de Sustancias , Adulto , Comorbilidad , Femenino , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Humanos , Masculino , Tamizaje Masivo/organización & administración , Persona de Mediana Edad , Estudios Seroepidemiológicos , Enfermedades de Transmisión Sexual/epidemiología , Enfermedades de Transmisión Sexual/prevención & control , Abuso de Sustancias por Vía Intravenosa/epidemiología , Abuso de Sustancias por Vía Intravenosa/prevención & control , Texas/epidemiologíaRESUMEN
BACKGROUND: Major improvements in disease progression among HIV-infected children have followed the adoption of combination antiretroviral therapy. METHODS: We examined trends in hospitalization rates between 1990-2002 among 3,927 children/youths with perinatal HIV infection, ranging in age from newborn to 21 years. We used Poisson regression to test for trends in hospitalization rates by age and year; binomial regression to test for trends in intensive care unit (ICU) admissions and hospitalization at least once and more than once, by age and year; and multivariate logistic regression to examine factors associated with hospitalization, ICU admission, and hospitalization longer than 10 days. RESULTS: Statistically significant downward trends in hospitalization rates and multiple hospitalizations were observed in all age groups from 1990-2002. The proportion of HIV-infected children/youths who were hospitalized at least once declined from 30.4% in 1990 to 12.9% in 2002, with a steady decline occurring after 1996, when the U.S. Public Health Service issued guidelines recommending triple-drug antiretroviral therapy (triple therapy) for HIV-infected children. ICU admissions declined significantly in all age groups except among children younger than 2 years. Logistic regression results indicated that black and Hispanic children/youths were significantly more likely to be hospitalized than white children/youths and that children/youths receiving triple therapy were significantly more likely to be hospitalized than therapy-naive children; the latter association was not observed among children monitored from 1997-2002. CONCLUSIONS: Substantial reductions in rates of hospitalization, multiple hospitalizations, and ICU admission have occurred among HIV-infected children/youths from 1990-2002, particularly after 1996, with increased use of triple therapy.
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Terapia Antirretroviral Altamente Activa/tendencias , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , VIH , Adolescente , Adulto , Niño , Preescolar , Estudios de Cohortes , Etnicidad , Femenino , Infecciones por VIH/etnología , Hospitalización/estadística & datos numéricos , Hospitalización/tendencias , Humanos , Lactante , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa , Estudios Longitudinales , Masculino , Perinatología , Estudios ProspectivosRESUMEN
BACKGROUND: In the United States, HIV-infected children and adolescents are aging and using antiretroviral (ARV) therapy for extended periods of time. OBJECTIVE: To assess trends in ARV use and long-term survival in an observational cohort of HIV-infected children and adolescents in the United States. METHODS: The Pediatric Spectrum of HIV Disease Study (PSD) is a prospective chart review of more than 2000 HIV-infected children and adolescents. Patients were included in the analysis from enrollment until last follow-up. RESULTS: Triple-ARV therapy use (for 6 months or more) increased from 27% to 66% during 1997 to 2001 (P < 0.0001, chi for trend). The proportion of patients receiving 3 or more sequential triple-therapy regimens also increased from 4% to 17% during 1997 to 2001 (P < 0.0001, chi for trend), however, and the durability of triple-therapy regimens decreased from 13 to 7 months from the first to third regimen. Survival rates for the 1997 to 2001 birth cohorts were significantly better than for the 1989 to 1993 and 1994 to 1996 cohorts (P < 0.0001). CONCLUSIONS: Survival rates in the PSD cohort have increased in association with triple-ARV therapy use. With continued changes in ARV regimens, effective modifications in ARV therapy and the sustainability of gains in survival need to be determined.
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Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/epidemiología , Infecciones por VIH/mortalidad , Adolescente , Edad de Inicio , Niño , Preescolar , Quimioterapia/tendencias , Quimioterapia Combinada , Femenino , Infecciones por VIH/tratamiento farmacológico , Humanos , Lactante , Masculino , Grupos Raciales , Análisis de Supervivencia , Estados Unidos/epidemiologíaAsunto(s)
Antirretrovirales/uso terapéutico , Infecciones por VIH/prevención & control , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Atención Prenatal , África del Sur del Sahara , Lactancia Materna/efectos adversos , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/transmisión , Humanos , Fórmulas Infantiles/economía , Recién Nacido , Embarazo , Complicaciones Infecciosas del Embarazo/diagnósticoRESUMEN
This study describes the sexually transmitted disease (STD) risk assessment practices of a sample of private primary care practitioners in Texas. Elicitation of sexual history was not universal when these clinicians took the health history of their patients. Only 40% of the practices reported conducting a risk assessment for STD with all of their patients. In general, practices in obstetrics and gynecology, physicians providing care for persons infected with human immunodeficiency virus, and female physicians were more likely to indicate that they assess all of their patients for risks of STD. More than 90% of the practitioners conduct risk assessment for STD with all of those patients perceived to be at risk, but the criteria used for determining those patients vary greatly among practitioners. Private physicians in Texas provide care for a large proportion of individuals afflicted with STDs; our findings raise concerns about the lack of uniformity in the process of identifying patients at risk for STD.
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Tamizaje Masivo/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Atención Primaria de Salud/normas , Práctica Privada/normas , Medición de Riesgo/estadística & datos numéricos , Enfermedades de Transmisión Sexual/prevención & control , Adolescente , Adulto , Femenino , Humanos , Masculino , TexasRESUMEN
BACKGROUND: Meta-analysis and randomized clinical trial results reported in June 1998 indicated a significant reduction in perinatal HIV transmission rates among mothers undergoing a cesarean section (C-section). OBJECTIVE: The objective of this study was to examine recent trends in and factors associated with C-section deliveries among HIV-infected women in the United States. DESIGN: A multisite pediatric medical record review of a cohort of HIV-exposed and HIV-infected infants in the Pediatric Spectrum of HIV Disease (PSD) Cohort study (n = 6467) and the national Pediatric HIV/AIDS Reporting System (HARS) (n = 8,306) was conducted. SETTING/PATIENTS: All infants born between 1994 and 2000 to HIV-positive mothers referred to the PSD study or to a Pediatric HARS hospital or clinic site were enrolled. RESULTS: The proportion of deliveries by C-section was steady at about 20% from 1994 through June 1998. From July 1998 through December 2000, this proportion increased to 44% in the PSD study and to nearly 50% in the Pediatric HARS. On analysis by multiple logistic regression, delivery of infants by C-section was associated with the release of study results (OR = 2.83), delivery in four PSD sites in reference to Texas (OR: 2.02-1.43), having private medical care reimbursement (OR = 1.62), and having maternal prenatal care (OR = 1.43). CONCLUSIONS: The PSD and Pediatric HARS data demonstrate a sharp increase in C-section rates mainly among HIV-infected women in the United States after the release of the meta-analysis and randomized clinical trial results in 1998. This finding highlights the rapid impact of study results on obstetric practice. It underscores the critical role of prenatal care in offering perinatal interventions such as scheduled C-section when indicated to reduce the likelihood of HIV transmission.
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Cesárea/tendencias , Infecciones por VIH/transmisión , Vigilancia de la Población , Complicaciones Infecciosas del Embarazo/cirugía , Cesárea/estadística & datos numéricos , Estudios de Cohortes , Femenino , Hospitales Privados , Humanos , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa , Modelos Logísticos , Oportunidad Relativa , Embarazo , Atención Prenatal , Estados UnidosRESUMEN
OBJECTIVE: Despite dramatic reductions in perinatal human immunodeficiency virus (HIV) transmission in the United States, obstacles to perinatal HIV prevention that include lack of prenatal care; failure to test pregnant women for HIV before delivery; and lack of prenatal, intrapartum, or neonatal antiretroviral (ARV) use remain. The objective of this study was to describe trends in perinatal HIV prevention methods, perinatal transmission rates, and the contribution of missed opportunities for perinatal HIV prevention to perinatal HIV infection. METHODS: We analyzed data obtained from infant medical records on 4755 HIV-exposed singleton deliveries in 1996-2000, from 6 US sites that participate in the Centers for Disease Control and Prevention's Pediatric Spectrum of HIV Disease Project. HIV-exposed deliveries refer to deliveries in which the mother was known to have HIV infection during the pregnancy. RESULTS: Of the 4287 women with data on prenatal care, 92% had prenatal care. From 1996 to 2000, among the 3925 women with prenatal care, 92% had an HIV test before delivery; the use of prenatal zidovudine (ZDV) alone decreased from 71% to 9%, and the use of prenatal ZDV with other ARVs increased from 6% to 70%. Complete data on maternal and neonatal ARVs were available for 3284 deliveries. Perinatal HIV transmission was 3% in 1651 deliveries with prenatal ZDV in combination with other ARVs, intrapartum ZDV, and neonatal ZDV; 6% in 1111 deliveries with prenatal, intrapartum, and neonatal ZDV alone; 8% in 152 deliveries with intrapartum and neonatal ZDV alone; 14% of 73 deliveries with neonatal ZDV only started within 24 hours of birth; and 20% in 297 deliveries with no prenatal, intrapartum, and neonatal ARVs. Complete data on prenatal events were available in 328 HIV-infected and 3258 HIV-uninfected infants. A total of 56% of mothers of HIV-infected infants had missed opportunities for perinatal HIV prevention versus 16% of mothers of HIV-uninfected infants. Forty-four percent of the infected infants were born to mothers who had prenatal care, a prenatal HIV diagnosis, and documented prenatal ARV therapy. Seventeen percent of women with reported illicit drug use had no prenatal care versus 3% of women with no reported drug use. In a multivariate analysis, maternal illicit drug use was significantly associated with lack of prenatal care. In a multivariate analysis, year of infant birth and the combination of lack of maternal HIV testing before delivery and lack of prenatal antiretroviral therapies were significantly associated with perinatal HIV transmission. CONCLUSIONS: Missed opportunities for perinatal HIV prevention contributed to more than half of the cases of HIV-infected infants. Prenatal care and HIV testing before delivery are major opportunities for perinatal HIV prevention. Illicit drug use was highly associated with lack of prenatal care, and lack of HIV testing before delivery was highly associated with perinatal HIV transmission.
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Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/prevención & control , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Complicaciones Infecciosas del Embarazo/diagnóstico , Atención Prenatal , Distribución de Chi-Cuadrado , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/transmisión , Humanos , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa/estadística & datos numéricos , Modelos Logísticos , Análisis Multivariante , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Estados Unidos/epidemiologíaRESUMEN
This study evaluates the prenatal human immunodeficiency virus (HIV) testing behaviors of private obstetrics and gynecology practitioners in Texas. A statewide telephone survey of 614 providers of prenatal care determined the level of HIV testing, how testing is offered, and patient acceptance of the test. Ninety-nine percent of the practices offered HIV testing to all their pregnant patients, and 96% of the practices included HIV testing in the routine panel of tests for pregnant patients. More than 95% of the practices reported that 10% or less of the women refused the test when offered it; 73% of the practices reported no refusals. Less than half of the practices, however, discussed HIV prevention topics, and only 29% of the practices referred high-risk pregnant patients for prevention counseling. Although private practices of obstetrics and gynecology report testing almost all their prenatal patients, survey results suggest that providers could improve their prevention and patient education practices.