Santa Clara County Behavioral Health Services

The Fifth International Workshop-Conference on Gestational Diabetes Mellitus (GDM) was held in Chicago, IL, 11–13 November 2005 under the sponsorship of the American Diabetes Association. The meeting provided a forum for review of new information concerning GDM in the areas of pathophysiology, epidemiology, perinatal outcome, long-range implications for mother and her offspring, and management strategies. New information and recommendations related to each of these major topics are summarized in the report that follows. The issues regarding strategies and criteria for the detection and diagnosis of GDM were not reviewed or discussed in detail, since it is anticipated that the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study will provide data in mid-2007 that will foster the development of criteria for the diagnosis of GDM that are based on perinatal outcomes. Thus, for the interim, the participants of the Fifth International Workshop-Conference on GDM endorsed a motion to continue use of the definition, classification criteria, and strategies for detection and diagnosis of GDM that were recommended at the Fourth Workshop-Conference. Those guidelines are reproduced (with minor modifications) in this article in appendix Tables 1 and 2. The invited lectures, topical discussions, and posters presented at the conference and the invited manuscripts that appear in this issue of Diabetes Care served as the basis for the following summary and recommendations. ### Pathophysiology #### General considerations. Current diagnostic criteria assign the diagnosis of GDM to women with glucose levels in the upper ∼5–10% of the population distribution. The hyperglycemia varies in severity from glucose concentrations that would be diagnostic of diabetes outside of pregnancy to concentrations that are asymptomatic and only slightly above normal, but associated with some increased risk of fetal morbidity. Like all forms of hyperglycemia, GDM is characterized by insulin levels that are insufficient to meet insulin demands. The causes of pancreatic β-cell dysfunction that …

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging cause of infections outside of health care settings. We investigated an outbreak of abscesses due to MRSA among members of a professional football team and examined the transmission and microbiologic characteristics of the outbreak strain. METHODS: We conducted a retrospective cohort study and nasal-swab survey of 84 St. Louis Rams football players and staff members. S. aureus recovered from wound, nasal, and environmental cultures was analyzed by means of pulsed-field gel electrophoresis (PFGE) and typing for resistance and toxin genes. MRSA from the team was compared with other community isolates and hospital isolates. RESULTS: During the 2003 football season, eight MRSA infections occurred among 5 of the 58 Rams players (9 percent); all of the infections developed at turf-abrasion sites. MRSA infection was significantly associated with the lineman or linebacker position and a higher body-mass index. No MRSA was found in nasal or environmental samples; however, methicillin-susceptible S. aureus was recovered from whirlpools and taping gel and from 35 of the 84 nasal swabs from players and staff members (42 percent). MRSA from a competing football team and from other community clusters and sporadic cases had PFGE patterns that were indistinguishable from those of the Rams' MRSA; all carried the gene for Panton-Valentine leukocidin and the gene complex for staphylococcal-cassette-chromosome mec type IVa resistance (clone USA300-0114). CONCLUSIONS: We describe a highly conserved, community-associated MRSA clone that caused abscesses among professional football players and that was indistinguishable from isolates from various other regions of the United States.

with patients with confirmed COVID-19 (2). The aims of these efforts were to ensure rapid evaluation and care of patients, limit further transmission, and better understand risk factors for transmission.

does not appear. First page follows. The utility of a given variety of grapes for wine making depends upon several factors. These include production factors such as scion-stock interrelationship, susceptibility to disease, inherent vigor of the vine, resistance to frost (which depends on the time of leafing out, the vine’s ability to produce crops after frost injury, and the like), and the yield and composition of the grapes under various soil and climatic conditions. One must also carefully evaluate: (1) the influence of environmental conditions (rainfall, wind, fogs, humidity, exposure, mean daily temperature, and time of maturity); (2) the adaptability of the must to various vinification and amelioration practices (temperature, type of yeast, aeration, and other variations); (3) the suitability of the wine for aging in the wood and in the bottle (rate of clarification, bouquet development, and resistance to disease); and (4) the basic quality of the wine produced by the variety. The production of wine may be considered as the complex interrelation, interaction, and mutual influence of all these factors with and upon each other. In order to study wine-grape-variety adaptation in California, one must consider each of these critically and separately. The primary problem in enology is to determine the influences which affect the utility of a wine. Since grapes are the raw material, a study of the various varieties is the starting point. Because of the numerous variations in environmental conditions in California, the experiments must be repeated with each variety in as many different localities as possible.

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread globally, with >365,000 cases in California as of 17 July 2020. We investigated the genomic epidemiology of SARS-CoV-2 in Northern California from late January to mid-March 2020, using samples from 36 patients spanning nine counties and the Grand Princess cruise ship. Phylogenetic analyses revealed the cryptic introduction of at least seven different SARS-CoV-2 lineages into California, including epidemic WA1 strains associated with Washington state, with lack of a predominant lineage and limited transmission among communities. Lineages associated with outbreak clusters in two counties were defined by a single base substitution in the viral genome. These findings support contact tracing, social distancing, and travel restrictions to contain the spread of SARS-CoV-2 in California and other states.

THE administration of the pyrazolone derivatives, phenylbutazone and oxyphenbutazone, to a patient already being treated with coumarin anticoagulant drugs can lead to serious hemorrhagic complications.1 2 3 4 5 6 The means whereby these drugs potentiate the prothrombinopenic effect of the coumarins is not clear. It is not caused by impaired liver function or defective vitamin K metabolism since these drugs do not alter blood coagulation when given alone.7 , 8 In 1956 Sigg et al.1 reported a decrease in the disappearance rate of ethylbiscoumacetate in 1 of their patients when phenylbutazone was given. They attributed this to delayed renal excretion of the coumarin drug. Weiner and . . .

SETTING: Tuberculosis (TB) related stigma is associated with lack of treatment adherence. Individual perceptions of stigma differ by societal context. Limited data are available on variations of TB stigma worldwide. OBJECTIVE: To describe the influence of TB stigma on knowledge, attitudes and responses to TB and to identify similarities and differences across countries. DESIGN: Systematic review of international descriptive studies. RESULTS: A total of 1268 studies were identified from PubMed/Medline, Web of Science, Cochrane, PsycINFO and Cumulative Index to Nursing and Allied Health Literature database searches. Eighty-three studies from 35 countries met the inclusion criteria for English, peer-reviewed, original and non-interventional studies. Variation and similarities in the influence of TB stigma on knowledge, attitudes and responses to TB across countries were identified. Stigma antecedents included negative attitudes and misperceptions regarding the causes of TB and the association with the human immunodeficiency virus. Decisions about illness disclosure and choices between traditional healers and public or private providers were influenced by TB stigma. Sex-influenced perceptions and management of TB and public health responses contributed to TB stigma. CONCLUSION: Our findings confirm cultural variations with respect to TB and the potential for stigma. Cultural variations should be considered in the development of interventions aimed at reducing stigma and improving treatment adherence.

The optieal enantiomorphs of warfarin were studied in 10 normal sub;ects. Eaeh sub;ect was given in separate experiments a single oral dose of R(+) warfarin, S(‐) warfarin, and the racemate, R,S(±) warfarin, in the amount of 1.5 mg of drug per kilogram of body weight. The biologie half‐life for (+) warfarin, (‐) warfarin, and raeemie warfarin was 58 ± 5, 33 ± 4, and 42 ± 2 hours, respeetively, a highly significant differenee (p < 0.01) between the enantiomorphs. The blood level of drug for (+) warfarin was 94% greater than that tor (‐) warfarin. The area under the pro thrombin time curve plotted logarithmically showed a 76% greater effect for (‐) warfarin than for (+) warfarin. Thus, the intrinsic activity of (‐) warfarin was 3.4 times as great as thot of (+) warfarin in the induction of hypoprothrombinemia. A high degree of direct correlation was found between the area for the blood level of drug and the hypoprothrombinemic effect for both the (+) and (‐) warfarin enantiomorphs. It is concluded that the greater intrinsic activity of (‐) warfarin than (+) warfarin does not result primarily from the blood level of the enantiomorphs but may result from a difference in permeability or affinity for the receptor site.

Ticks are the vectors of many zoonotic diseases in the United States, including Lyme disease, human monocytic and granulocytic ehrlichioses, and Rocky Mountain spotted fever. Most known Bartonella species are arthropod borne. Therefore, it is important to determine if some Bartonella species, which are emerging pathogens, could be carried or transmitted by ticks. In this study, adult Ixodes pacificus ticks were collected by flagging vegetation in three sites in Santa Clara County, Calif. PCR-restriction fragment length polymorphism and partial sequencing of 273 bp of the gltA gene were applied for Bartonella identification. Twenty-nine (19.2%) of 151 individually tested ticks were PCR positive for Bartonella. Male ticks were more likely to be infected with Bartonella than female ticks (26 versus 12%, P = 0.05). None of the nine ticks collected at Baird Ranch was PCR positive for Bartonella. However, 7 (50%) of 14 ticks from Red Fern Ranch and 22 (17%) of 128 ticks from the Windy Hill Open Space Reserve were infected with Bartonella. In these infected ticks, molecular analysis showed a variety of Bartonella strains, which were closely related to a cattle Bartonella strain and to several known human-pathogenic Bartonella species and subspecies: Bartonella henselae, B. quintana, B. washoensis, and B. vinsonii subsp. berkhoffii. These findings indicate that I. pacificus ticks may play an important role in Bartonella transmission among animals and humans.

After the intensified treatment often required for treating gestational diabetes mellitus (GDM), clinicians may be tempted to relax after delivery of the baby. If it is assumed that no further management is needed, an excellent opportunity to improve the future health status of these high-risk women may be lost. There are special concerns for the early postpartum care of women with GDM. Encouragement and facilitation of exclusive breastfeeding is very important because of the profound short-term as well as long-term health benefits to the infant and the reduced risks for subsequent obesity and glucose intolerance demonstrated in many breastfeeding women. A method of contraception should be chosen that does not increase the risk of glucose intolerance in the mother. Some women with GDM will have persisting hyperglycemia in the days after delivery that will justify medical management for diabetes and perhaps for hypertension, microalbuminuria, and dyslipidemia. Treatment should be maintained according to the guidelines of the American Diabetes Association and other relevant organizations and adjusted for the needs of lactation. Treatment should be continued in adequate fashion to minimize risks to the early conceptus if there is a subsequent planned or unplanned pregnancy. Most women with GDM will not have severe hyperglycemia after delivery. This group should be followed for at least 6–12 weeks to determine their glucose status. Many studies over 3 decades on all continents of the globe demonstrate the high risk of subsequent diabetes in this female population. The degree of this risk is best assessed by glucose tolerance testing. Randomized controlled trials have proven that several interventions (diet and planned exercise 30–60 min daily at least 5 days per week and antidiabetic medications) can significantly delay or prevent the appearance of type 2 diabetes in the women with impaired glucose tolerance (IGT). The high-risk women can …

For more than 50 years, methamphetamine has been a widely used stimulant drug taken to maintain wakefulness and performance and, in high doses, to cause intense euphoria. Animal studies show that methamphetamine can cause short-term and even persistent depletion of brain levels of the neurotransmitter dopamine. However, the clinical features of Parkinson's disease, a dopamine deficiency disorder of the brain, do not appear to be characteristic of human methamphetamine users. We compared dopamine levels in autopsied brain tissue of chronic methamphetamine users with those in patients with Parkinson's disease and in a control group. Mean dopamine levels in the methamphetamine users were reduced more in the caudate (-61%) than in the putamen (-50%), a pattern opposite to that of Parkinson's disease. Some methamphetamine users had severely decreased dopamine levels, within the parkinsonian range, in the caudate (up to 97% dopamine loss) but not in the putamen. As the putamen and caudate subserve aspects of motor and cognitive function, respectively, our data suggest that methamphetamine users are not parkinsonian because dopamine levels are not sufficiently decreased in the motor component of the striatum. However, the near-total reduction in the caudate could explain reports of cognitive disturbances, sometimes disabling, in some drug users, and suggests that treatment with dopamine substitution medication (e.g. levodopa) during drug rehabilitation might be helpful.

THE variability of response of human beings to many drugs is usually continuous and gives a unimodal frequency-distribution curve for the drug action measured. These unimodal distribution curves are consistent with multifactorial inheritance and are difficult to analyze for the genetic influences involved. The few drugs that have a discontinuous variation in action show a bimodal or trimodal distribution. This probably indicates a single gene system with each mode representing a phenotype1 from which the genotype may be inferred. This multimodal distribution curve of drug response is usually the result of an alteration in drug metabolism and causes increased sensitivity . . .

Abstract Rationale Although amphetamines are recognized as “likely” agents to cause drug- and toxin-associated pulmonary arterial hypertension (PAH), (meth)amphetamine-associated PAH (Meth-APAH) has not been well described. Objectives To prospectively characterize the clinical presentation, histopathology, and outcomes of Meth-APAH compared with those of idiopathic PAH (iPAH). Methods We performed a prospective cohort study of patients with Meth-APAH and iPAH presenting to the Stanford University Pulmonary Hypertension Program between 2003 and 2015. Clinical, pulmonary angiography, histopathology, and outcomes data were compared. We used data from the Healthcare Cost and Utilization Project to estimate the epidemiology of PAH in (meth)amphetamine users hospitalized in California. Measurements and Main Results The study sample included 90 patients with Meth-APAH and 97 patients with iPAH. Patients with Meth-APAH were less likely to be female, but similar in age, body mass index, and 6-minute-walk distance to patients with iPAH. Patients with Meth-APAH reported more advanced heart failure symptoms, had significantly higher right atrial pressure (12.7 ± 6.8 vs. 9.8 ± 5.1 mm Hg; P = 0.001), and had lower stroke volume index (22.2 ± 7.1 vs. 25.5 ± 8.7 ml/m2; P = 0.01). Event-free survival in Meth-APAH was 64.2%, 47.2%, and 25% at 2.5, 5, and 10 years, respectively, representing more than double the risk of clinical worsening or death compared with iPAH (hazard ratio, 2.04; 95% confidence interval, 1.28–3.25; P = 0.003) independent of confounders. California data demonstrated a 2.6-fold increase in risk of PAH diagnosis in hospitalized (meth)amphetamine users. Conclusions Meth-APAH is a severe and progressive form of PAH with poor outcomes. Future studies should focus on mechanisms of disease and potential therapeutic considerations.

Abstract Introduction More than 93,000 cases of coronavirus disease (COVID-19) have been reported worldwide. We describe the epidemiology, clinical course, and virologic characteristics of the first 12 U.S. patients with COVID-19. Methods We collected demographic, exposure, and clinical information from 12 patients confirmed by CDC during January 20–February 5, 2020 to have COVID-19. Respiratory, stool, serum, and urine specimens were submitted for SARS-CoV-2 rRT-PCR testing, virus culture, and whole genome sequencing. Results Among the 12 patients, median age was 53 years (range: 21–68); 8 were male, 10 had traveled to China, and two were contacts of patients in this series. Commonly reported signs and symptoms at illness onset were fever (n=7) and cough (n=8). Seven patients were hospitalized with radiographic evidence of pneumonia and demonstrated clinical or laboratory signs of worsening during the second week of illness. Three were treated with the investigational antiviral remdesivir. All patients had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2–3 weeks after illness onset, with lowest rRT-PCR Ct values often detected in the first week. SARS-CoV-2 RNA was detected after reported symptom resolution in seven patients. SARS-CoV-2 was cultured from respiratory specimens, and SARS-CoV-2 RNA was detected in stool from 7/10 patients. Conclusions In 12 patients with mild to moderately severe illness, SARS-CoV-2 RNA and viable virus were detected early, and prolonged RNA detection suggests the window for diagnosis is long. Hospitalized patients showed signs of worsening in the second week after illness onset.

Wastewater surveillance for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA can be integrated with COVID-19 case data to inform timely pandemic response. However, more research is needed to apply and develop systematic methods to interpret the true SARS-CoV-2 signal from noise introduced in wastewater samples (e.g., from sewer conditions, sampling and extraction methods, etc.). In this study, raw wastewater was collected weekly from five sewersheds and one residential facility. The concentrations of SARS-CoV-2 in wastewater samples were compared to geocoded COVID-19 clinical testing data. SARS-CoV-2 was reliably detected (95% positivity) in frozen wastewater samples when reported daily new COVID-19 cases were 2.4 or more per 100,000 people. To adjust for variation in sample fecal content, four normalization biomarkers were evaluated: crAssphage, pepper mild mottle virus, Bacteroides ribosomal RNA (rRNA), and human 18S rRNA. Of these, crAssphage displayed the least spatial and temporal variability. Both unnormalized SARS-CoV-2 RNA signal and signal normalized to crAssphage had positive and significant correlation with clinical testing data (Kendall's Tau-b (τ)=0.43 and 0.38, respectively), but no normalization biomarker strengthened the correlation with clinical testing data. Locational dependencies and the date associated with testing data impacted the lead time of wastewater for clinical trends, and no lead time was observed when the sample collection date (versus the result date) was used for both wastewater and clinical testing data. This study supports that trends in wastewater surveillance data reflect trends in COVID-19 disease occurrence and presents tools that could be applied to make wastewater signal more interpretable and comparable across studies.

The strategies that Japanese and American mothers use to gain compliance from young children were compared. Six hypothetical compliance-relevant situations were described to 58 Japanese and 67 American mothers. Their responses were scored for the rationale or cognitive structure they offered as a basis for compliance and the flexibility or psychological space evident in their negotiations with the child. Japanese mothers were more likely to utilize feeling-oriented appeals and demonstrated greater flexibility than their American counterparts. American mothers relied more extensively on appeals to their authority as mothers. The cultural contexts that contribute to these different responses are discussed.

Autism is a developmental disability increasing in incidence over the past decade. Parents of children with autism experience prolonged levels of stress and isolation. Using qualitative research design, nine parents of children with autism participated in this study that focused on the effect of autism on the family, coping styles, and support systems. The target population was first-generation Southeast Asian American parents. Results revealed nine coping style patterns: (a) denial/passive coping, (b) empowerment, (c) redirecting energy, (d) shifting of focus, (e) rearranging life and relationships, (f) changed expectations, (g) social withdrawal, (h) spiritual coping, and (i) acceptance. The school was considered the primary supportive entity. Although findings may not be unique to the Southeast Asian group, the research provides an in-depth perspective on their lived experience, their struggles, and strengths. Insight gained from this investigation can help school nurses better understand the affect of autism on families, identify specific needs, and address these needs by advocating for appropriate supportive programs.

Bartonella vinsonii subsp. berkhoffii was originally isolated from a dog suffering infectious endocarditis and was recently identified as a zoonotic agent causing human endocarditis. Following the coyote bite of a child who developed clinical signs compatible with Bartonella infection in Santa Clara County, Calif., this epidemiological study was conducted. Among 109 coyotes (Canis latrans) from central coastal California, 31 animals (28%) were found to be bacteremic with B. vinsonii subsp. berkhoffii and 83 animals (76%) had B. vinsonii subsp. berkhoffii antibodies. These findings suggest these animals could be the wildlife reservoir of B. vinsonii subsp. berkhoffii. PCR-restriction fragment length polymorphism (PCR-RFLP) analysis of the gltA and 16S rRNA genes for these 31 isolates yielded similar profiles that were identical to those of B. vinsonii subsp. berkhoffii. Partial sequencing of the gltA and 16S rRNA genes, respectively, indicated 99.5 and 100% homology between the coyote isolate and B. vinsonii subsp. berkhoffii (ATCC 51672). PCR-RFLP analysis of the 16S-23S intergenic spacer region showed the existence of two different strain profiles, as has been reported in dogs. Six (19%) of 31 Bartonella bacteremic coyotes exhibited the strain profile that was identified in the type strain of a canine endocarditis case (B. vinsonii subsp. berkhoffii ATCC 51672). The other 25 bacteremic coyotes were infected with a strain that was similar to the strains isolated from healthy dogs. Based on whole bacterial genome analysis by pulsed-field gel electrophoresis (PFGE) with SmaI restriction endonuclease, there was more diversity in fingerprints for the coyote isolates, which had at least 10 major variants compared to the two variants described for domestic dog isolates from the eastern United States. By PFGE analysis, three Bartonella bacteremic coyotes were infected by a strain identical to the one isolated from three healthy dog carriers. Further studies are necessary to elucidate the mode of transmission of B. vinsonii subsp. berkhoffii, especially to identify potential vectors, and to determine how humans become infected.

OBJECTIVE: To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting. METHODS: Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval. RESULTS: All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria. DISCUSSION: The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment. CONCLUSION: The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.

The study reports epidemiologic field survey data on the distribution of depressive symptoms among Anglos (n = 637) and two Mexican-American subsamples (n = 551) living in Santa Clara County, California. One of the Mexican-American subsamples was interviewed in English (n = 330) and the other in Spanish (n = 221). Analysis of variance indicated that those with low educational achievement, females, those in disrupted marital statuses, and those under 30 years of age had significantly higher levels of depressive symptoms than their counterparts. The prevalence of depressive symptoms for the Anglo and Mexican-American English-speaking samples was very similar and much lower than that reported by the Spanish-speaking Mexican-American subsample. Differences in educational levels appear to be accounting for many of the variations in depressive symptoms between the Anglo and English-speaking subsamples and the Spanish-speaking one. The authors suggest that the lack of language skills along with low educational achievement may be indicating a relative lack of acculturation and societal integration which in turn may be accounting for some of the increased symptoms among the Spanish-speaking subsample. The results of multiple stepwise regression analyses indicate that age, sex, marital status, and educational attainment explain relatively low and fluctuating amounts of the total variance. These analyses also indicate that social and demographic factors are differentially related to depressive symptoms for each of the subsamples. The variables education, female, and separated were significant in all of the equations, but their order of entrance and the amount of variance explained by them varied.