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The article summarizes the results of an investigation concerning the outbreak of pandemic influenza A (H1N1) at a school in Hawaii in May 2009. The Hawaii Department of Health, the Hawaii Department of Education, and the school established an education program urging employees and students to stay home if ill. The first two cases of H1N1 were discovered in an 8th-grade student and a 3rd-grade teacher on May 12. The investigation found infections among residents of various communities with no travel history.

The purpose of our study was to correlate radiographic characteristics with rotator cuff tendon injury on magnetic resonance imaging after fractures of the proximal humerus. We prospectively obtained magnetic resonance imaging on 30 patients with proximal humerus fractures after classifying each fracture radiographically using Neer and AO systems and determining the displacement of the greater tuberosity. Twelve patients (40.0%) had either complete ruptures or avulsions of at least one of the rotator cuff muscles. No abnormality was identified in the rotator cuff musculature in nine patients (29%). Severity of injury to the rotator cuff tendons increased substantially with respect to increasing AO and Neer classes and 5 mm or greater displacement of the greater tuberosity fragment. Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures. [ABSTRACT FROM AUTHOR]

Background: Traumatic hip dislocation results from the dissipation of a large amount of energy about the hip joint. Clinically, these forces often are first transmitted through the knee en route to the hip. It is therefore logical to look for coexistent ipsilateral knee injury in patients with a traumatic hip dislocation.Methods: Over a one-year period, we prospectively evaluated the ipsilateral knee of all patients who had a traumatic hip dislocation on the basis of a standardized history, physical examination, and magnetic resonance imaging.Results: Twenty-one (75%) of the twenty-eight knees were painful. Twenty-five (89%) of the twenty-eight knees had visible evidence of soft-tissue injury on inspection. Magnetic resonance imaging revealed evidence of some abnormality in twenty-five (93%) of twenty-seven knees, with effusion (37%), bone bruise (33%), and meniscal tear (30%) being the most common findings.Conclusions: The present study provides evidence of a high rate of associated ipsilateral knee injuries in patients with a traumatic hip dislocation. Bone bruises may provide a plausible explanation for persistent knee pain following a traumatic hip dislocation. The liberal use of magnetic resonance imaging is recommended for the evaluation of these patients in order to detect injuries that may not be discoverable on the basis of a history and physical examination alone. [ABSTRACT FROM AUTHOR]

Objective: To compare four imaging methods in the evaluation of the postoperative meniscus: conventional arthrography, conventional MR imaging, MR arthrography with iodinated contrast material, and MR arthrography with gadolinium-based contrast material.Design and Patients: Thirty-three patients referred for knee MR examinations with a history of meniscal surgery were studied prospectively. At the first patient visit, conventional MR examination was followed by an MR arthrogram with gadolinium-based contrast material. At the second visit, a conventional arthrogram with iodinated contrast material was followed immediately by an MR examination. Imaging examinations were interpreted by a masked reader, and then compared with the results of repeat arthroscopic surgery in 12 patients.Results: The correct evaluation of the status of postoperative menisci was allowed in 12 of 13 patients (92%) by MR arthrography using gadolinium-based contrast agent, 10 of 13 patients (77%) by conventional MR examination, 9 of 12 patients (75%) by MR arthrography, and 7 of 12 patients (58%) by conventional arthrography.Conclusion: Intra-articular fluid is advantageous in the evaluation of patients with a suspected meniscal retear. MR arthrography with gadolinium-based contrast material is the most accurate imaging method for the diagnosis of meniscal retears. [ABSTRACT FROM AUTHOR]

The U.S. territory of American Samoa has experienced recent outbreaks of illnesses caused by viruses transmitted by Aedes species mosquitoes, including dengue, chikungunya, and Zika virus. In November 2016, a traveler from the Solomon Islands tested positive for infection with dengue virus type 2 (DENV-2). Additional dengue cases were identified in the subsequent weeks through passive and active surveillance. Suspected dengue cases were tested locally with a dengue rapid diagnostic test (RDT) for DENV nonstructural protein 1 (NS1). Specimens from RDT-positive cases and patients meeting the dengue case definition were tested by real-time reverse transcription-polymerase chain reaction (real-time RT-PCR) at Hawaii State Laboratories. During November 2016-October 2018, a total of 3,240 patients were tested for evidence of DENV infection (118 by RDT-NS1 alone, 1,089 by real-time RT-PCR alone, and 2,033 by both methods), 1,081 (33.4%) of whom tested positive for dengue (19.5 per 1,000 population). All 941 real-time RT-PCR-positive specimens were positive for DENV-2. The monthly number of laboratory-confirmed cases peaked at 120 during December 2017. Among laboratory-confirmed dengue cases, 380 (35.2%) patients were hospitalized; one patient, who was transferred to American Samoa for care late in his illness, died. The public health response to this outbreak included disposal of solid waste to remove mosquito breeding sites, indoor residual spraying of pesticides in schools, reinforcement of dengue patient management education, and public education on mosquito avoidance and seeking medical care for symptoms of dengue., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Cross-reactivity within flavivirus antibody assays, produced by shared epitopes in the envelope proteins, can complicate the serological diagnosis of Zika virus (ZIKAV) infection. We assessed the utility of the plaque reduction neutralization test (PRNT) to confirm recent ZIKAV infections and rule out misleading positive immunoglobulin M (IgM) results in areas with various levels of past dengue virus (DENV) infection incidence. We reviewed PRNT results of sera collected for diagnosis of ZIKAV infection from 1 January through 31 August 2016 with positive ZIKAV IgM results, and ZIKAV and DENV PRNTs were performed. PRNT result interpretations included ZIKAV, unspecified flavivirus, DENV infection, or negative. For this analysis, ZIKAV IgM was considered false positive for samples interpreted as a DENV infection or negative. In U.S. states, 208 (27%) of 759 IgM-positive results were confirmed to be ZIKAV compared to 11 (21%) of 52 in the U.S. Virgin Islands (USVI), 15 (15%) of 103 in American Samoa, and 13 (11%) of 123 in Puerto Rico. In American Samoa and Puerto Rico, more than 80% of IgM-positive results were unspecified flavivirus infections. The false-positivity rate was 27% in U.S. states, 18% in the USVI, 2% in American Samoa, and 6% in Puerto Rico. In U.S. states, the PRNT provided a virus-specific diagnosis or ruled out infection in the majority of IgM-positive samples. Almost a third of ZIKAV IgM-positive results were not confirmed; therefore, providers and patients must understand that IgM results are preliminary. In territories with historically higher rates of DENV transmission, the PRNT usually could not differentiate between ZIKAV and DENV infections., (This is a work of the U.S. Government and is not subject to copyright protection in the United States. Foreign copyrights may apply.)

During December 2015-January 2016, the American Samoa Department of Health (ASDoH) detected through surveillance an increase in the number of cases of acute febrile rash illness. Concurrently, a case of laboratory-confirmed Zika virus infection, a mosquito-borne flavivirus infection documented to cause microcephaly and other severe brain defects in some infants born to women infected during pregnancy (1,2) was reported in a traveler returning to New Zealand from American Samoa. In the absence of local laboratory capacity to test for Zika virus, ASDoH initiated arboviral disease control measures, including public education and vector source reduction campaigns. On February 1, CDC staff members were deployed to American Samoa to assist ASDoH with testing and surveillance efforts.

In this study, a multicenter evaluation of the Life Technologies TaqMan(®) Array Card (TAC) with 21 custom viral and bacterial respiratory assays was performed on the Applied Biosystems ViiA™ 7 Real-Time PCR System. The goal of the study was to demonstrate the analytical performance of this platform when compared to identical individual pathogen specific laboratory developed tests (LDTs) designed at the Centers for Disease Control and Prevention (CDC), equivalent LDTs provided by state public health laboratories, or to three different commercial multi-respiratory panels. CDC and Association of Public Health Laboratories (APHL) LDTs had similar analytical sensitivities for viral pathogens, while several of the bacterial pathogen APHL LDTs demonstrated sensitivities one log higher than the corresponding CDC LDT. When compared to CDC LDTs, TAC assays were generally one to two logs less sensitive depending on the site performing the analysis. Finally, TAC assays were generally more sensitive than their counterparts in three different commercial multi-respiratory panels. TAC technology allows users to spot customized assays and design TAC layout, simplify assay setup, conserve specimen, dramatically reduce contamination potential, and as demonstrated in this study, analyze multiple samples in parallel with good reproducibility between instruments and operators., (Copyright © 2015 Elsevier B.V. All rights reserved.)

On October 21, 2015, the Hawaii Department of Health (HDOH) was notified of a positive dengue immunoglobulin M (IgM) antibody result in a woman residing on Hawaii Island (also known as the Big Island). The patient had no history of travel off the island, and other family members reported having similar signs and symptoms, which consisted of fever, headache, myalgias and arthralgias, and a generalized erythematous rash. HDOH initiated an investigation to identify any additional cases and potential exposure sources. On October 24, HDOH received report of a group of mainland U.S. visitors who had traveled together on Hawaii Island, including several who had developed a febrile illness. Additionally, on October 27, HDOH was notified of an unrelated person, also on Hawaii Island, with a positive dengue IgM result. As of November 26, 2015, HDOH had identified 107 laboratory-confirmed cases of dengue fever, with dates of onset ranging from September 11 to November 18, 2015.

Objective: To examine the role of radiography in screening trauma patients with suspected injury to the cervical spine., Subjects and Methods: Over a period of 2 years, 5172 people were admitted to our trauma service and 297 (5.4%) were found to have cervical fractures. The radiographic and CT films and reports of 245 of these 297 patients were reviewed., Results: The 245 subjects had sustained 309 distinct individual injuries. Radiography detected injuries in 108 cases (44.1%) and CT detected injuries in 243 cases (99.2%). The two fractures missed by CT occurred at C2; one fracture was obscured by dental artefacts and the other was in the horizontal plane of the scan. Both fractures were detected on lateral radiographs of the region., Conclusion: CT is superior to radiography for identification of cervical spine fractures. The fractures most likely to be missed by CT occur at C2. We recommend that CT be used as the primary screening method for people with suspected cervical injury, together with a single lateral view of the cervical spine to include the C2 region.

In a West Nile virus (WNV) -free ecosystem, it is essential to verify the integrity of RNA before concluding that RNA extracted from mosquito specimens is negative for WNV gene sequences. The primary objective of our study was to develop a rapid molecular assay to rapidly screen mosquitoes for the presence of 18S RNA and WNV gene sequences. Mosquitoes, collected from multiple sites on the island of O'ahu, were pooled into groups of 1-50 mosquitoes according to capture site, date, and species. Using primer design software and the GenBank database, generic oligonucleotide primer pairs were designed to amplify mosquito18S rRNA gene sequences from different species. RNA was extracted from mosquito pools, and reverse transcriptase-polymerase chain reaction (RT-PCR) was performed for the presence of mosquito18S rRNA and WNV gene sequences. Three of the seven primer pairs successfully detected 18S rRNA sequences for both Aedes and Culex by RT-PCR, and one primer pair successfully amplified 18S rRNA sequences for 15 different mosquito species. All 64 mosquito pools from 10 different sites on the island of Oahu, Hawaii, were negative for WNV nonstructural protein-5 gene sequences. This simple, one-step RT-PCR method for screening mosquito pools for arboviruses will become an increasingly valuable tool as WNV becomes endemic throughout the Americas.

Rationale and Objectives: We performed a multipoint rank-order experiment to evaluate variability in observers' sensitivity to small differences in image presentation and to assess observers' performance as a function of the type and number of tasks included., Methods: Five experienced observers were presented with four sets of chest images that had been compressed at five different levels. Each set contained six images ranging from noncompressed to approximately 60:1-compressed images. Observers were asked to review all images of each case side by side and rank-order the "quality" of each to enable determination of the presence or absence of interstitial disease and/or pneumothoraces., Results: Observers varied significantly in their ability to detect very small differences among the images (P < 0.001). Those who performed well did so regardless of whether they ranked a specific abnormality in a multidisease or a single-disease setting., Conclusions: Selected observers can reliably detect very small differences among similar images. These readers could be used to confirm or rule out the need for objective observer-performance-type studies.

Rationale and Objectives: To evaluate the effect of the transverse ligament on translation of the menisci., Methods: Six cadaveric knees were examined by MR imaging inside a positioning device before and after transecting the transverse ligament. The knees were examined at various positions: extension, 30 degrees of flexion, 60 degrees of flexion, and full flexion. Sagittal T1-weighted spin-echo images were generated at each knee position and evaluated for statistical differences with regard to anterior-posterior meniscal excursion., Results: Statistically significant differences in meniscal excursion were found before and after transsecting the transverse ligament for anterior-posterior meniscal motion of the anterior horn of the medial meniscus at 30 degrees of knee flexion. No such significant differences were found, however, at 60 degrees of flexion and full flexion in anterior-posterior meniscal excursion of the anterior or posterior horn of either meniscus before and after transsecting the transverse ligament., Conclusions: The transverse ligament has a restricting effect on anterior-posterior excursion of the anterior horn of the medial meniscus at lower degrees of knee flexion.

Two patients with open complex dislocation of a metacarpophalangeal joint were treated by cleansing of the wound, open reduction, primary wound closure, and early motion. One dislocation occurred in the index finger, the other in the long finger which is only the second such case to be described. Antibiotics were given before and continued for 5 days after operation. There were no infections, and both patients regained an excellent range of motion without pain.