Search

Importance: Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly reported worldwide as a cause of infections with high-mortality rates. Assessment of the US epidemiology of CRE is needed to inform national prevention efforts., Objective: To determine the population-based CRE incidence and describe the characteristics and resistance mechanism associated with isolates from 7 US geographical areas., Design, Setting, and Participants: Population- and laboratory-based active surveillance of CRE conducted among individuals living in 1 of 7 US metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. Cases of CRE were defined as carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, or Klebsiella oxytoca that were recovered from sterile-site or urine cultures during 2012-2013. Case records were reviewed and molecular typing for common carbapenemases was performed., Exposures: Demographics, comorbidities, health care exposures, and culture source and location., Main Outcomes and Measures: Population-based CRE incidence, site-specific standardized incidence ratios (adjusted for age and race), and clinical and microbiological characteristics., Results: Among 599 CRE cases in 481 individuals, 520 (86.8%; 95% CI, 84.1%-89.5%) were isolated from urine and 68 (11.4%; 95% CI, 8.8%-13.9%) from blood. The median age was 66 years (95% CI, 62.1-65.4 years) and 284 (59.0%; 95% CI, 54.6%-63.5%) were female. The overall annual CRE incidence rate per 100<000 population was 2.93 (95% CI, 2.65-3.23). The CRE standardized incidence ratio was significantly higher than predicted for the sites in Georgia (1.65 [95% CI, 1.20-2.25]; P < .001), Maryland (1.44 [95% CI, 1.06-1.96]; P = .001), and New York (1.42 [95% CI, 1.05-1.92]; P = .048), and significantly lower than predicted for the sites in Colorado (0.53 [95% CI, 0.39-0.71]; P < .001), New Mexico (0.41 [95% CI, 0.30-0.55]; P = .01), and Oregon (0.28 [95% CI, 0.21-0.38]; P < .001). Most cases occurred in individuals with prior hospitalizations (399/531 [75.1%; 95% CI, 71.4%-78.8%]) or indwelling devices (382/525 [72.8%; 95% CI, 68.9%-76.6%]); 180 of 322 (55.9%; 95% CI, 50.0%-60.8%) admitted cases resulted in a discharge to a long-term care setting. Death occurred in 51 (9.0%; 95% CI, 6.6%-11.4%) cases, including in 25 of 91 cases (27.5%; 95% CI, 18.1%-36.8%) with CRE isolated from normally sterile sites. Of 188 isolates tested, 90 (47.9%; 95% CI, 40.6%-55.1%) produced a carbapenemase., Conclusions and Relevance: In this population- and laboratory-based active surveillance system in 7 states, the incidence of CRE was 2.93 per 100<000 population. Most CRE cases were isolated from a urine source, and were associated with high prevalence of prior hospitalizations or indwelling devices, and discharge to long-term care settings.

Context: Oculopharyngeal muscular dystrophy (OPMD) is a rare myopathy caused by polyalanine triplet repeat expansion in the gene for poly(A) binding protein 2 (PABP2) and is found in isolated cohorts throughout the world. We have observed numerous cases of OPMD in New Mexico., Objective: To characterize the clinical, genetic, and demographic features of the OPMD population in New Mexico., Design, Setting, and Participants: Cohort study with analysis of outpatient clinic medical records from 1965 to 2001 at the University of New Mexico Hospital and the New Mexico VA Health Care System in Albuquerque, which serve the entire state., Main Outcome Measures: Clinical phenotype, supplemented with genetic confirmation (n = 10 patients) and in-depth clinical evaluations (n = 49 patients)., Results: We identified 216 cases of OPMD (99 women and 117 men) from 39 kindreds of New Mexicans spanning up to 4 generations. All patients were Hispanic, and the majority of probands came from northern New Mexico. In patients who had both ocular and pharyngeal muscle weakness, ptosis was just as likely to occur before or concurrent with dysphagia. Proximal limb muscle weakness and gait abnormalities were common and occurred later than ocular or pharyngeal weakness. The clinical expression of OPMD caused marked debility, although life-table analysis showed no decrease in life expectancy compared with unaffected family members (P =.81). Ten individuals from different kindreds were found to have an identical polyalanine triplet repeat expansion ([GCG](9)) in the PABP2 gene., Conclusions: Individuals in this cohort had clinical and genetic characteristics of classic OPMD. Longevity was not affected, but patients experienced considerable morbidity. The origin of the PABP2 mutation in New Mexican OPMD patients is unclear, although the geographic and genetic isolation of northern New Mexicans with a long ancestry in this region may have contributed to the development of this cohort. This disease cohort represents a large and previously unrecognized health care issue in the state of New Mexico and should serve to raise the awareness of this disorder among clinicians who treat Hispanics in the Southwest and throughout the United States.

Context: Unintentional carbon monoxide (CO) poisoning causes approximately 2100 deaths in the United States per year, but the use of CO detectors could potentially prevent many of these deaths., Objective: To describe the epidemiology of potentially preventable unintentional CO poisoning deaths in New Mexico., Design: Descriptive analysis., Population Studied: A total of 136 deaths from CO poisoning investigated by the New Mexico Office of the Medical Investigator, 1980 through 1995., Main Outcome Measures: Characteristics of deaths from CO poisoning; estimates of the number of deaths potentially preventable with CO detectors., Results: Of 136 people whose deaths were classified as "unintentional carbon monoxide poisoning, not fire related," 49 (36%) most likely were asleep when poisoned. Thirty-nine (49%) of 80 people whose deaths were identified as "residential fatalities" most likely were asleep vs 10 (18%) of 56 of those whose deaths were identified as occurring in or around motor vehicles. A blood-alcohol level greater than 0.01% was present in 56 (42%) of the decedents. Among decedents who had a negative blood-alcohol level (52 in residences and 26 in vehicles), an electronic audible CO detector may have prevented CO poisoning; whereas, among those who had a negative blood-alcohol level and most likely were awake at the time of CO exposure (28 in residences and 23 in vehicles), an electronic detector or a nonaudible, chemical reagent type detector may have prevented CO poisoning., Conclusion: Differences exist between deaths due to unintentional CO poisoning that occur in residences and those that occur in or around motor vehicles. Carbon monoxide detectors, whether the electronic or chemical reagent types, may have prevented approximately half of these deaths. The high proportion of decedents with alcohol in their blood indicates that effective public health campaigns must address the role of alcohol in CO poisoning deaths.

Objective: To determine the nature of excess injury mortality among Native Americans in New Mexico., Design: Retrospective review of death certificates for deaths from unintentional injuries., Setting: The state of New Mexico., Subjects: New Mexico residents who died of unintentional injuries between January 1, 1980, and December 31, 1989., Main Outcome Measure: Cause-specific mortality rates., Results: Over half of the excess mortality from all unintentional injuries among Native Americans resulted from hypothermia and from pedestrian-motor vehicle crashes. New Mexico Native Americans were nearly eight times more likely to die in pedestrian--motor vehicle crashes and were 30 times more likely to die of hypothermia compared with other New Mexico residents. At death, 90% of those Native Americans tested were highly intoxicated (median blood alcohol concentrations of 0.24 and 0.18 g/dL [corrected] for pedestrian and hypothermia deaths, respectively). Despite the fact that most Native Americans in New Mexico live on reservations, most deaths occurred at off-reservation sites in border towns and on roads leading back to the reservation., Conclusions: The possession and sale of alcohol is illegal on many Native American reservations. This policy forces Native Americans who want to drink to travel long distances to obtain alcohol. These data suggest that this policy is also the likely explanation for the markedly increased risk of death from hypothermia and pedestrian-motor vehicle crashes in this population.