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Flea-borne (murine) typhus is caused by Rickettsia typhi. Infection in pregnant women can lead to adverse outcomes when diagnosis and treatment is delayed. We describe how next-generation sequencing (NGS) using the Karius® test was used to rapidly diagnose murine typhus in two pregnant women admitted to a large tertiary care center in Houston, Texas, when all initial testing was nondiagnostic.

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Introduction: Our purpose was to develop and test a brief, self-report, and scorable survey instrument for measuring population health profiles from the individual respondent's perspective. We defined population health as the state of physical, mental, and social well-being of a group of individuals, including determinants of their well-being. Materials and Methods: Respondents were adult patients in a community health center. Instrument items, an overall scale, and two subscales were developed and evaluated. Reliability was tested by Cronbach's alphas and test-retest correlations; construct validity was tested by correlations between scores and economic and clinical factors; criterion validity was tested by regression analyses for prediction of morbidity and health care utilization by baseline scores; and feasibility was tested by length of administration time. Results: This was a 2-years prospective study of 450 patients, mostly black non-Hispanics (54%) and Hispanics (29%), many with no health insurance (45%), and poor enough to meet the federal poverty level (73%). The Duke Population Health Profile (Duke-PH) was developed with a 14-item PH scale for overall population health profile and two 7-item subscales, one for social determinants and the other for health determinants. Validity of item selection was indicated by item convergent and item discriminant correlations. Scale and subscale reliability were supported for internal consistency by Cronbach's alphas of 0.63-0.73, and for temporal stability by test-retest correlations of 0.65-0.78. Support for construct validity was shown by the more favorable baseline subscale and scale mean scores for patients able to buy private insurance than for patients unable to afford it. Criterion validity was supported by regression analyses showing that baseline scale and subscale scores predicted both baseline morbidity and 6-months utilization. Feasibility was shown by the mean self-administration time of 3.9 min and mean interviewer-administration time of 5.8 min. Discussion: The strength of this study is support for Duke-PH reliability, validity, and feasibility in a community health center patient population. The new instrument is unique because it measures both social and health determinants of population health from the perspective of individuals in the population.

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CASE DESCRIPTION: A 38-year-old man presented with headaches and generalized weakness. He was found to have AIDS; a ring-enhancing central nervous system lesion was found on brain imaging and he had elevated serum Toxoplasma gondii IgG levels. A diagnosis of presumptive toxoplasma encephalitis was made and he received antiretrovirals and antitoxoplasma therapy for 4 years. Intermittent headaches and evidence of disease progression on neuroimaging warranted further evaluation and cerebrospinal fluid analysis revealed amebic forms on hematoxylin and eosin staining and positive polymerase chain reaction testing for Acanthamoeba spp. He was placed on miltefosine, fluconazole, trimethoprim-sulfamethoxazole and flucytosine for 7 months. Five months after therapy discontinuation he remains asymptomatic and is taking only antiretroviral therapy. CONCLUSION: This is the first report of a patient with AIDS and granulomatous amebic encephalitis who survived with medical therapy only.

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OBJECTIVE: The present study analysed the impact of using the 2006 WHO Child Growth Standards ('the WHO standards') compared with the 1977 National Center for Health Statistics (NCHS) international growth reference ('the NCHS reference') on the calculated prevalence of chronic malnutrition in children aged 6·0-59·9 months. DESIGN: Anthropometric data were collected as part of a cross-sectional study exploring the association between household environments and nutritional status of children. Z-scores were computed for height-for-age (HAZ), weight-for-age (WAZ) and weight-for-height (WHZ) using each reference/standard. Results were compared using Bland-Altman plots, percentage agreement, kappa statistics, line graphs and proportion of children in Z-score categories. SETTING: The study was conducted in thirteen rural villages within Honduras's department of Intibucá. SUBJECTS: Children aged 6·0-59·9 months were the focus of the analysis, and households with children in this age range served as the sampling unit for the study. RESULTS: The WHO standards yielded lower means for HAZ and higher means for WAZ and WHZ compared with the NCHS reference. The WHO standards and NCHS reference showed good agreement between Z-score categories, except for HAZ among males aged 24·0-35·9 months and WHZ among males aged >24·0 months. Using the WHO standards resulted in higher proportions of stunting (low HAZ) and overweight (high WHZ) and lower proportions of underweight (low WAZ). The degree of difference among these measures varied by age and gender. CONCLUSIONS: The choice of growth reference/standard employed in nutritional surveys may have important methodological and policy implications. While ostensibly comparable, data on nutritional indicators derived with different growth references/standards must be interpreted cautiously.

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Quality of life (QOL) of adolescents has been scarcely documented in a general population sample. The study was aimed at translating and adapting the Adolescent Duke Health Profile to Vietnamese, validating the questionnaire, determining reference value, and identifying determinants of poor QOL. Following a cross-cultural methodology, the Adolescent Duke Health Profile (ADHP) had content adapted to Vietnamese by alteration of 2 out of 17 items. Test-retest validity was checked in 408 adolescents. Construct validity and internal consistency were assessed in a 1408 probability sample of adolescents in Vietnam, and determinants were analysed by multiple linear regression. The ADHP showed satisfactory internal consistency (Cronbach's alpha=0.87-0.92) and satisfactory construct validity in relation with drug abuse or not, or with parent situation living in couple or alone. Test-retest reliability was acceptable (ICC=0.7-0.8) and major determinants were age, sex, education, chronic disease, alcohol and drug use. This works provide a validated, simple health related QOL scale suited to adolescent population with reference values. Taking into account determinants identified will help program prevention and intervention health policy and to evaluate the effect of these actions.

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BACKGROUND: : Although patient-reported health-related quality of life (HRQOL) is known to predict health services utilization, most risk assessment systems use provider-reported diagnoses as predictors rather than HRQOL. OBJECTIVE: : We sought to classify adult primary care patients prospectively by utilization risk based on age, gender, and HRQOL at a single clinic visit. RESEARCH DESIGN: : Patients completed the Duke Health Profile. Providers completed the Duke Severity of Illness Checklist. Diagnoses were grouped with the Ambulatory Care Groups system. Predictive coefficients for 1-year primary care charges calculated from the age, gender, and HRQOL of 728 reference patients were used to classify 474 test patients into 4 risk classes. Comparisons were made with models that used diagnoses or severity of illness as predictors. RESULTS: : The positive likelihood ratio for predicting highest risk was 2.2 for the HRQOL model, compared with 1.8 for the diagnoses model, 1.6 for the severity model, and 1.5 for age and gender alone. One-year actual primary care visits and charges increased step-wise from lowest to highest risk class. Highest risk patients were older and more likely to be women, black, or Medicaid recipients. Although the highest-risk patients represented only 18.6% of the test group, they accounted for 26.7% of the primary care clinic visits, 31.6% of the clinic charges, 34.6% of the hospital days, 35.1% of hospital charges, and 30.8% of total charges at all healthcare sites. CONCLUSION: : The HRQOL risk classification system can identify primary care patients at risk for high future health services utilization.

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BACKGROUND: Anxiety and depression occur frequently, and recognition of their symptoms can be difficult because of comorbid medical conditions. The purpose of this study was to analyze the relations among symptoms, diagnoses, and severity of illness as indicators of anxiety and depression in primary care. METHODS: This was an observational, cross-sectional study of adult patients in a large, academic family medicine clinic. Patients completed the Duke Health Profile, which measures health-related quality of life and screens for anxiety and depression. Providers recorded patient diagnoses and assessed severity of illness. RESULTS: Patients with higher levels of anxiety and depression symptoms were more likely to have the diagnoses of headache, osteoarthritis, abdominal pain, and diabetes mellitus. These diagnoses, however, were no longer highly associated with anxiety and depression after controlling for age, sex, payer status, perceived health, pain, and disability. The indicators of high anxiety and depression symptom levels that persisted after controlling for all the other variables were female sex, low perceived health, more pain, and greater disability. CONCLUSION: In a primary care setting, female sex, self-reported perceived health, pain, and disability were more predictive of anxiety and depression than any of the most prevalent medical illnesses. Primary care providers need to be knowledgeable about these health measures so they can recognize patients at risk for anxiety and depression regardless of their medical diagnoses.

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