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1.  Antibodies to Leptospira among blood donors in higher-risk areas of Australia: possible implications for transfusion safety 
Blood Transfusion  2015;13(1):32-36.
Background
Leptospirosis is one of the most common bacterial zoonoses worldwide, and clinical manifestations range from asymptomatic infection to acute febrile illness, multi-organ failure and death. Asymptomatic, acute bacteraemia in a blood donor provides a potential for transfusion-transmission, although only a single such case from India has been recorded. Human leptospirosis is uncommon in developed countries; however, the state of Queensland in Australia has one of the highest rates among developed countries, especially after increased rainfall. This study examined the prevalence of antibodies to Leptospira spp. in blood donors residing in higher-risk areas of Australia, to evaluate the appropriateness of current blood safety guidelines.
Materials and methods
Plasma samples collected from blood donors residing in higher-risk areas of Australia during 2009 and 2011 were included in the study. All samples were tested for the presence of antibodies to 22 leptospiral serovars using the microscopic agglutination test.
Result
No sample had antibody titres suggestive of a current or recent infection, however, seven samples (1.44%, 95% CI: 0.38–2.50%) had titres suggestive of a past infection.
Discussion
This study provides data that may support the appropriateness of current relevant donor selection policies in Australia. Given that the risk profile for leptospirosis is expanding and that the infection is likely to become more prevalent with climate change, this disease may become more of a concern for transfusion safety in the future.
doi:10.2450/2014.0012-14
PMCID: PMC4317087  PMID: 24960651
emerging pathogen; climate; rainfall
2.  Are the Dietary Guidelines for Meat, Fat, Fruit and Vegetable Consumption Appropriate for Environmental Sustainability? A Review of the Literature 
Nutrients  2014;6(6):2251-2265.
This paper reviews the current literature around the environmental impacts of dietary recommendations. The focus of the review is on collating evidence relating to environmental impacts of the dietary advice found in the World Health Organisation guidelines, and environmental impact literature: reducing the consumption of fat, reducing the consumption of meat-based protein and animal-based foods, and increasing the consumption of fruit and vegetables. The environmental impact of reducing dietary fat intake is unclear, although reducing consumption of the food category of edible fats and oils appears to have little impact. However most, but not all, studies support environmental benefits of a reduced consumption of animal-based foods and increased consumption of fruit and vegetables. In general, it appears that adhering to dietary guidelines reduces impact on the environment, but further study is required to examine the environmental impacts of animal-based foods, and fruit and vegetable intake in depth.
doi:10.3390/nu6062251
PMCID: PMC4073148  PMID: 24926526
environmental impact; diet; food; red meat; animal protein; fat; fruit; vegetables
3.  Using Mathematical Transmission Modelling to Investigate Drivers of Respiratory Syncytial Virus Seasonality in Children in the Philippines 
PLoS ONE  2014;9(2):e90094.
We used a mathematical transmission model to estimate when ecological drivers of respiratory syncytial virus (RSV) transmissibility would need to act in order to produce the observed seasonality of RSV in the Philippines. We estimated that a seasonal peak in transmissibility would need to occur approximately 51 days prior to the observed peak in RSV cases (range 49 to 67 days). We then compared this estimated seasonal pattern of transmissibility to the seasonal patterns of possible ecological drivers of transmissibility: rainfall, humidity and temperature patterns, nutritional status, and school holidays. The timing of the seasonal patterns of nutritional status and rainfall were both consistent with the estimated seasonal pattern of transmissibility and these are both plausible drivers of the seasonality of RSV in this setting.
doi:10.1371/journal.pone.0090094
PMCID: PMC3937436  PMID: 24587222
4.  An evidence-based framework to measure quality of allied health care 
Background
There is no standard way of describing the complexities of allied health (AH) care, or its quality. AH is an umbrella term which excludes medicine and nursing, and variably includes disciplines which provide therapy, diagnostic, or scientific services. This paper outlines a framework for a standard approach to evaluate the quality of AH therapy services.
Methods
A realist synthesis framework describing what AH does, how it does it, and what is achieved, was developed. This was populated by the findings of a systematic review of literature published since 1980 reporting concepts of quality relevant to AH. Articles were included on quality measurement concepts, theories, debates, and/or hypothetical frameworks.
Results
Of 139 included articles, 21 reported on descriptions of quality potentially relevant to AH. From these, 24 measures of quality were identified, with 15 potentially relating to what AH does, 17 to how AH delivers care, 8 relating to short term functional outcomes, and 9 relating to longer term functional and health system outcomes.
Conclusions
A novel evidence-based quality framework was proposed to address the complexity of AH therapies. This should assist in better evaluation of AH processes and outcomes, costs, and evidence-based engagement of AH providers in healthcare teams.
doi:10.1186/1478-4505-12-10
PMCID: PMC4015500  PMID: 24571857
Allied health; Therapy; Quality constructs
5.  Treatment fidelity of brief motivational interviewing and health education in a randomized clinical trial to promote dental attendance of low-income mothers and children: Community-Based Intergenerational Oral Health Study “Baby Smiles” 
BMC Oral Health  2014;14:15.
Background
Fidelity assessments are integral to intervention research but few published trials report these processes in detail. We included plans for fidelity monitoring in the design of a community-based intervention trial.
Methods
The study design was a randomized clinical trial of an intervention provided to low-income women to increase utilization of dental care during pregnancy (mother) or the postpartum (child) period. Group assignment followed a 2 × 2 factorial design in which participants were randomly assigned to receive either brief Motivational Interviewing (MI) or Health Education (HE) during pregnancy (prenatal) and then randomly reassigned to one of these groups for the postpartum intervention. The study setting was four county health departments in rural Oregon State, USA. Counseling was standardized using a step-by-step manual. Counselors were trained to criteria prior to delivering the intervention and fidelity monitoring continued throughout the implementation period based on audio recordings of counselor-participant sessions. The Yale Adherence and Competence Scale (YACS), modified for this study, was used to code the audio recordings of the counselors’ delivery of both the MI and HE interventions. Using Interclass Correlation Coefficients totaling the occurrences of specific MI counseling behaviors, ICC for prenatal was .93, for postpartum the ICC was .75. Participants provided a second source of fidelity data. As a second source of fidelity data, the participants completed the Feedback Questionnaire that included ratings of their satisfaction with the counselors at the completion of the prenatal and post-partum interventions.
Results
Coding indicated counselor adherence to MI protocol and variation among counselors in the use of MI skills in the MI condition. Almost no MI behaviors were found in the HE condition. Differences in the length of time to deliver intervention were found; as expected, the HE intervention took less time. There were no differences between the overall participants’ satisfaction ratings of the HE and MI sessions by individual counselor or overall (p > .05).
Conclusions
Trial design, protocol specification, training, and continuous supervision led to a high degree of treatment fidelity for the counseling interventions in this randomized clinical trial and will increase confidence in the interpretation of the trial findings.
Trial registration
ClinicalTrials.gov: NCT01120041
doi:10.1186/1472-6831-14-15
PMCID: PMC3996055  PMID: 24559035
Dental health; Motivational interviewing; Clinical competence; Postpartum care; Prenatal care
6.  Design of a community-based intergenerational oral health study: “Baby Smiles” 
BMC Oral Health  2013;13:38.
Background
Rural, low-income pregnant women and their children are at high risk for poor oral health and have low utilization rates of dental care. The Baby Smiles study was designed to increase low-income pregnant women’s utilization of dental care, increase young children’s dental care utilization, and improve home oral health care practices.
Methods/design
Baby Smiles was a five-year, four-site randomized intervention trial with a 2 × 2 factorial design. Four hundred participants were randomly assigned to one of four treatment arms in which they received either brief Motivational Interviewing (MI) or health education (HE) delivered during pregnancy and after the baby was born. In the prenatal study phase, the interventions were designed to encourage dental utilization during pregnancy. After childbirth, the focus was to utilize dental care for the infant by age one. The two primary outcome measures were dental utilization during pregnancy or up to two months postpartum for the mother, and preventive dental utilization by 18 months of age for the child. Medicaid claims data will be used to assess the primary outcomes. Questionnaires were administered at enrollment and 3, 9 and 18 months postpartum (study end) to assess mediating and moderating factors.
Discussion
This trial can help define the most effective way to provide one-on-one counseling to pregnant women and new mothers regarding visits to the dentist during pregnancy and after the child is born. It supports previous work demonstrating the potential of reducing mother-to-child transmission of Streptococcus mutans and the initiation of dental caries prevention in early childhood.
Trial registration
ClinicalTrials.gov Identifier NCT01120041
doi:10.1186/1472-6831-13-38
PMCID: PMC3751087  PMID: 23914908
Counseling; Motivation; Dental caries; Early childhood caries; Health Education; Dental; Mothers; Infant
7.  Poor Growth and Pneumonia Seasonality in Infants in the Philippines: Cohort and Time Series Studies 
PLoS ONE  2013;8(6):e67528.
Children with poor nutrition are at increased risk of pneumonia. In many tropical settings seasonal pneumonia epidemics occur during the rainy season, which is often a period of poor nutrition. We have investigated whether seasonal hunger may be a driver of seasonal pneumonia epidemics in children in the tropical setting of the Philippines. In individual level cohort analysis, infant size and growth were both associated with increased pneumonia admissions, consistent with findings from previous studies. A low weight for age z-score in early infancy was associated with an increased risk of pneumonia admission over the following 12 months (RR for infants in the lowest quartile of weight for age z-scores 1.28 [95% CI 1.08 to 1.51]). Poor growth in smaller than average infants was also associated with an increased risk of pneumonia (RR for those in the lowest quartile of growth in early infancy 1.31 [95%CI 1.02 to 1.68]). At a population level, we found that seasonal undernutrition preceded the seasonal increase in pneumonia and respiratory syncytial virus admissions by approximately 10 weeks (pairwise correlation at this lag was −0.41 [95%CI −0.53 to −0.27] for pneumonia admissions, and −0.63 [95%CI −0.72 to −0.51] for respiratory syncytial virus admissions). This lag appears biologically plausible. These results suggest that in addition to being an individual level risk factor for pneumonia, poor nutrition may act as a population level driver of seasonal pneumonia epidemics in the tropics. Further investigation of the seasonal level association, in particular the estimation of the expected lag between seasonal undernutrition and increased pneumonia incidence, is recommended.
doi:10.1371/journal.pone.0067528
PMCID: PMC3695907  PMID: 23840731
8.  Geographical Information Systems for Dengue Surveillance 
This review provides details on the role of Geographical Information Systems (GIS) in current dengue surveillance systems and focuses on the application of open access GIS technology to emphasize its importance in developing countries, where the dengue burden is greatest. It also advocates for increased international collaboration in transboundary disease surveillance to confront the emerging global challenge of dengue.
doi:10.4269/ajtmh.2012.11-0650
PMCID: PMC3335676  PMID: 22556070
9.  Leptospirosis in American Samoa 2010: Epidemiology, Environmental Drivers, and the Management of Emergence 
Leptospirosis has recently been reported as an emerging disease worldwide, and a seroprevalence study was undertaken in American Samoa to better understand the drivers of transmission. Antibodies indicative of previous exposure to leptospirosis were found in 15.5% of 807 participants, predominantly against three serovars that were not previously known to occur in American Samoa. Questionnaires and geographic information systems data were used to assess behavioral factors and environmental determinants of disease transmission, and logistic regression was used to identify factors associated with infection. Many statistically significant factors were consistent with previous studies, but we also showed a significant association with living at lower altitudes (odds ratio [OR] = 1.53, 95% confidence interval [CI]: 1.03–2.28), and having higher numbers of piggeries around the home (OR = 2.63, 95% CI: 1.52–4.40). Our findings support a multifaceted approach to combating the emergence of leptospirosis, including modification of individual behavior, but importantly also managing the evolving environmental drivers of risk.
doi:10.4269/ajtmh.2012.11-0398
PMCID: PMC3269286  PMID: 22302868
10.  Seroprevalence of Dengue in American Samoa, 2010 
Emerging Infectious Diseases  2013;19(2):324-326.
doi:10.3201/eid1902.120464
PMCID: PMC3559036  PMID: 23343610
dengue; dengue virus; viruses; seroprevalence; IgG; American Samoa
12.  Prevention of Both Neutrophil and Monocyte Recruitment Promotes Recovery after Spinal Cord Injury 
Journal of Neurotrauma  2011;28(9):1893-1907.
Abstract
Strategies that block infiltration of leukocytes into the injured spinal cord improve sparing of white matter and neurological recovery. In this article, we examine the dependency of recovery on hematogenous depletion of neutrophils and monocytes. Mice were depleted of neutrophils or monocytes by systemic administration of anti-Ly6G or clodronate-liposomes. A third group was depleted of both subsets. Neurological improvement, based on a battery of tests of performance, and white matter sparing, occurred only in animals depleted of both neutrophils and monocytes. We also attempted to define the nature of the environment that was favorable to recovery. Hemeoxygenase-1 and malondialdehyde, markers of oxidative stress and lipid peroxidation, respectively, were reduced to similar levels in animals depleted of both neutrophils and monocytes, or only monocytes, but remained elevated in the group only depleted of neutrophils. Matrix metalloproteinase-9, a protease involved in early damage, was most strongly reduced in animals depleted of both leukocyte subsets. Finally, disruption of the blood–spinal cord barrier and abnormal nonheme iron accumulation were reduced only in animals depleted of both neutrophils and monocytes. Together, these findings indicate cooperation between neutrophils and monocytes in mediating early pathogenesis in the contused spinal cord and defining long-term neurological recovery.
doi:10.1089/neu.2011.1860
PMCID: PMC3172879  PMID: 21657851
functional recovery; monocytes; mouse; neutrophils; spinal cord injury
13.  Leptospirosis in American Samoa – Estimating and Mapping Risk Using Environmental Data 
Background
The recent emergence of leptospirosis has been linked to many environmental drivers of disease transmission. Accurate epidemiological data are lacking because of under-diagnosis, poor laboratory capacity, and inadequate surveillance. Predictive risk maps have been produced for many diseases to identify high-risk areas for infection and guide allocation of public health resources, and are particularly useful where disease surveillance is poor. To date, no predictive risk maps have been produced for leptospirosis. The objectives of this study were to estimate leptospirosis seroprevalence at geographic locations based on environmental factors, produce a predictive disease risk map for American Samoa, and assess the accuracy of the maps in predicting infection risk.
Methodology and Principal Findings
Data on seroprevalence and risk factors were obtained from a recent study of leptospirosis in American Samoa. Data on environmental variables were obtained from local sources, and included rainfall, altitude, vegetation, soil type, and location of backyard piggeries. Multivariable logistic regression was performed to investigate associations between seropositivity and risk factors. Using the multivariable models, seroprevalence at geographic locations was predicted based on environmental variables. Goodness of fit of models was measured using area under the curve of the receiver operating characteristic, and the percentage of cases correctly classified as seropositive. Environmental predictors of seroprevalence included living below median altitude of a village, in agricultural areas, on clay soil, and higher density of piggeries above the house. Models had acceptable goodness of fit, and correctly classified ∼84% of cases.
Conclusions and Significance
Environmental variables could be used to identify high-risk areas for leptospirosis. Environmental monitoring could potentially be a valuable strategy for leptospirosis control, and allow us to move from disease surveillance to environmental health hazard surveillance as a more cost-effective tool for directing public health interventions.
Author Summary
Leptospirosis is the most common bacterial infection transmitted from animals to humans. Infected animals excrete the bacteria in their urine, and humans can become infected through contact with animals or a contaminated environment such as water and soil. Environmental factors are important in determining the risk of human infection, and differ between ecological settings. The wide range of risk factors include high rainfall and flooding; poor sanitation and hygiene; urbanisation and overcrowding; contact with animals (including rodents, livestock, pets, and wildlife); outdoor recreation and ecotourism; and environmental degradation. Predictive risk maps have been produced for many infectious diseases to identify high-risk areas for transmission and guide allocation of public health resources. Maps are particularly useful where disease surveillance and epidemiological data are poor. The objectives of this study were to estimate leptospirosis seroprevalence at geographic locations based on environmental factors, produce a predictive disease risk map for American Samoa, and assess the accuracy of the maps in predicting infection risk. This study demonstrated the value of geographic information systems and disease mapping for identifying environmental risk factors for leptospirosis, and enhancing our understanding of disease transmission. Similar principles could be used to investigate the epidemiology of leptospirosis in other areas.
doi:10.1371/journal.pntd.0001669
PMCID: PMC3362644  PMID: 22666516
14.  Emergence of new leptospiral serovars in American Samoa - ascertainment or ecological change? 
Background
Leptospirosis has recently been discussed as an emerging infectious disease in many contexts, including changes in environmental drivers of disease transmission and the emergence of serovars. In this paper, we report the epidemiology of leptospiral serovars from our study of human leptospirosis in American Samoa in 2010, present evidence of recent serovar emergence, and discuss the potential epidemiological and ecological implications of our findings.
Methods
Serovar epidemiology from our leptospirosis seroprevalence study in 2010 was compared to findings from a study in 2004. The variation in geographic distribution of the three most common serovars was explored by mapping sero-positive participants to their place of residence using geographic information systems. The relationship between serovar distribution and ecological zones was examined using geo-referenced data on vegetation type and population distribution.
Results
Human leptospirosis seroprevalence in American Samoa was 15.5% in 2010, with serological evidence that infection was caused by three predominant serovars (Hebdomadis, LT 751, and LT 1163). These serovars differed from those identified in an earlier study in 2004, and were not previously known to occur in American Samoa. In 2010, serovars also differed in geographic distribution, with variations in seroprevalence between islands and different ecological zones within the main island.
Conclusions
Our findings might indicate artefactual emergence (where serovars were long established but previously undetected), but we believe the evidence is more in favour of true emergence (a result of ecological change). Possibilities include changes in interactions between humans and the environment; introduction of serovars through transport of animals; evolution in distribution and/or abundance of animal reservoirs; and environmental changes that favour transmission of particular serovars.
Future research should explore the impact of ecological change on leptospirosis transmission dynamics and serovar emergence, and investigate how such new knowledge might better target environmental monitoring for disease control at a public health level.
doi:10.1186/1471-2334-12-19
PMCID: PMC3305655  PMID: 22273116
15.  Chikungunya Virus: A Novel and Potentially Serious Threat to New Zealand and the South Pacific Islands 
There has never been a locally transmitted outbreak of mosquito-borne disease in New Zealand, but the risk of an outbreak occurring is increasing with on-going interceptions of exotic mosquito vectors across its border, increasing traffic of goods and passengers, higher numbers of viremic travelers arriving, and local, regional, and global environmental change. The risk posed to New Zealand by chikungunya virus is potentially high because of the transmissibility of this virus in subtropical climates, compounded by a population that is predominantly immunologically naive to exotic arboviruses. However, risk reduction in New Zealand should not be considered in isolation but must be viewed within a wider South Pacific context. In this report, we discuss the potential threat posed by chikungunya to the region, focusing in particular on New Zealand, and re-emphasizing the need for a South Pacific–wide approach towards mosquito-borne disease prevention.
doi:10.4269/ajtmh.2010.10-0123
PMCID: PMC2946738  PMID: 20889861
16.  Empowering Head Start to Improve Access to Good Oral Health for Children from Low Income Families 
Maternal and child health journal  2008;15(7):876-882.
Surveys over 20 years have documented worsening in the dental health of preschoolers. Healthy People 2010 Midcourse Review reports the country moving away from oral health goals for young children; the slip is 57%. Exacerbating this is the inability of Medicaid to provide for those in need. Most children receive examinations only: few receive comprehensive care. We urge Head Start grantees to adopt a new approach to oral health goals and in this paper offer: (1) a review of the problem and premises preventing a solution; (2) a proposal that Head Start adopt a public health perspective; and (3) specific roles staff and dental personnel can take to mount aggressive strategies to arrest tooth decay at the grantee site.
doi:10.1007/s10995-008-0316-6
PMCID: PMC2914140  PMID: 18246416
oral health; preschool children; Head Start; tooth decay
17.  A Review of Frameworks for Developing Environmental Health Indicators for Climate Change and Health 
The role climate change may play in altering human health, particularly in the emergence and spread of diseases, is an evolving area of research. It is important to understand this relationship because it will compound the already significant burden of diseases on national economies and public health. Authorities need to be able to assess, anticipate, and monitor human health vulnerability to climate change, in order to plan for, or implement action to avoid these eventualities. Environmental health indicators (EHIs) provide a tool to assess, monitor, and quantify human health vulnerability, to aid in the design and targeting of interventions, and measure the effectiveness of climate change adaptation and mitigation activities. Our aim was to identify the most suitable framework for developing EHIs to measure and monitor the impacts of climate change on human health and inform the development of interventions. Using published literature we reviewed the attributes of 11 frameworks. We identified the Driving force-Pressure-State-Exposure-Effect-Action (DPSEEA) framework as the most suitable one for developing EHIs for climate change and health. We propose the use of EHIs as a valuable tool to assess, quantify, and monitor human health vulnerability, design and target interventions, and measure the effectiveness of climate change adaptation and mitigation activities. In this paper, we lay the groundwork for the future development of EHIs as a multidisciplinary approach to link existing environmental and epidemiological data and networks. Analysis of such data will contribute to an enhanced understanding of the relationship between climate change and human health.
doi:10.3390/ijerph8072854
PMCID: PMC3155333  PMID: 21845162
climate change; DPSEEA; environmental health; frameworks; indicators; monitoring; policy
18.  Use of a total traffic count metric to investigate the impact of roadways on asthma severity: a case-control study 
Environmental Health  2011;10:52.
Background
This study had two principal objectives: (i) to investigate the relationship between asthma severity and proximity to major roadways in Perth, Western Australia; (ii) to demonstrate a more accurate method of exposure assessment for traffic pollutants using an innovative GIS-based measure that fully integrates all traffic densities around subject residences.
Methods
We conducted a spatial case-control study, in which 'cases' were defined as individuals aged under 19 years of age with more severe asthma (defined here as two or more emergency department contacts with asthma in a defined 5-year period) versus age- and gender-matched 'controls' with less severe asthma (defined here as one emergency department contact for asthma). Traffic exposures were measured using a GIS-based approach to determine the lengths of the roads falling within a buffer area, and then multiplying them by their respective traffic counts.
Results
We examined the spatial relationship between emergency department contacts for asthma at three different buffer sizes: 50 metres, 100 metres and 150 metres. No effect was noted for the 50 metre buffer (OR = 1.07; 95% CI: 0.91-1.26), but elevated odds ratios were observed with for crude (unadjusted) estimates OR = 1.21 (95% CI: 1.00-1.46) for 100 metre buffers and OR = 1.25 (95% CI: 1.02-1.54) for 150 metre buffers. For adjusted risk estimates, only the 150 metre buffer yielded a statistically significant finding (OR = 1.24; 95% CI:1.00-1.52).
Conclusions
Our study revealed a significant 24% increase in the risk of experiencing multiple emergency department contacts for asthma for every log-unit of traffic exposure. This study provides support for the hypothesis that traffic related air pollution increases the frequency of health service contacts for asthma. This study used advanced GIS techniques to establish traffic-weighted buffer zones around the geocoded residential location of subjects to provide an accurate assessment of exposure to traffic emissions, thereby providing a quantification of the ranges over which pollutants may exert a health effect.
doi:10.1186/1476-069X-10-52
PMCID: PMC3127974  PMID: 21631953
19.  Environmental monitoring to enhance comprehension and control of infectious diseases† 
In a world of emerging and resurging infectious diseases, dominated by zoonoses, environmental monitoring plays a vital role in our understanding their dynamics and their spillover to humans. Here, we critically review the ecology, epidemiology and need for monitoring of a variety of directly transmitted (Sin Nombre virus, Avian Influenza) and vector-borne (Ross River virus, West Nile virus, Lyme disease, anaplasmosis and babesiosis) zoonoses. We focus on the valuable role that existing monitoring plays in the understanding of these zoonoses, the demands for new monitoring, and how improvements can be made to existing monitoring. We also identify the fruitful outcomes which would result from implementation of the monitoring demands we have highlighted. This review aims to promote improvements in our understanding of zoonoses, their management, and public health by encouraging discussion among researchers and public health officials.
doi:10.1039/c0em00046a
PMCID: PMC2990948  PMID: 20957286
20.  Critical Issues in the Development of Health Information Systems in Supporting Environmental Health: A Case Study of Ciguatera 
Environmental Health Perspectives  2010;119(5):585-590.
Background
Emerging environmental pressures resulting from climate change and globalization challenge the capacity of health information systems (HIS) in the Pacific to inform future policy and public health interventions. Ciguatera, a globally common marine food-borne illness, is used here to illustrate specific HIS challenges in the Pacific and how these might be overcome proactively to meet the changing surveillance needs resulting from environmental change.
Objectives
We review and highlight inefficiencies in the reactive nature of existing HIS in the Pacific to collect, collate, and communicate ciguatera fish poisoning data currently used to inform public health intervention. Further, we review the capacity of existing HIS to respond to new data needs associated with shifts in ciguatera disease burden likely to result from coral reef habitat disruption.
Discussion
Improved knowledge on the ecological drivers of ciguatera prevalence at local and regional levels is needed, combined with enhanced surveillance techniques and data management systems, to capture environmental drivers as well as health outcomes data.
Conclusions
The capacity of public HIS to detect and prevent future outbreaks is largely dependent on the future development of governance strategies that promote proactive surveillance and health action. Accordingly, we present an innovative framework from which to stimulate scientific debate on how this might be achieved by using existing larger scale data sets and multidisciplinary collaborations.
doi:10.1289/ehp.1002575
PMCID: PMC3094406  PMID: 21163721
ciguatera; climate change; ecosystem health; environmental health; health information systems
21.  Thinking about going to the dentist: a Contemplation Ladder to assess dentally-avoidant individuals' readiness to go to a dentist 
BMC Oral Health  2011;11:4.
Background
The Transtheoretical Model suggests that individuals vary according to their readiness to change behavior. Previous work in smoking cessation and other health areas suggests that interventions are more successful when they are tailored to an individual's stage of change with regards to the specific behavior. We report on the performance of a single-item measure ("Ladder") to assess the readiness to change dental-avoidant behavior.
Methods
An existing Contemplation Ladder for assessing stage of change in smoking cessation was modified to assess readiness to go to a dentist. The resulting Ladder was administered to samples of English-speaking adolescents (USA), Spanish-speaking adults (USA), and Norwegian military recruits (Norway) in order to assess construct validity. The Ladder was also administered to a sample of English-speaking avoidant adolescents and young adults who were enrolled in an intervention study (USA) in order to assess criterion validity. All participants also had dental examinations, and completed other questionnaires. Correlations, chi square, t tests and one-way ANOVAs were used to assess relationships between variables.
Results
In two samples, participants who do not go to the dentist had significantly more teeth with caries; in a third sample, participants who do not go to the dentist had significantly worse caries. Ladder scores were not significantly related to age, gender, caries, or dental fear. However, Ladder scores were significantly related to statements of intention to visit a dentist in the future and the importance of oral health. In a preliminary finding, Ladder scores at baseline also predicted whether or not the participants decided to go to a dentist in the intervention sample.
Conclusions
The data provide support for the convergent and divergent construct validity of the Ladder, and preliminary support for its criterion validity. The lack of relationship between dental fear and Ladder scores suggests that avoidant individuals may be helped to decide to go to a dentist using interventions which do not explicitly target their fear.
doi:10.1186/1472-6831-11-4
PMCID: PMC3045398  PMID: 21272356
22.  An Intergenerational Approach to Oral Health Promotion: Pregnancy and Utilization of Dental Services 
Purpose
Dental services during pregnancy can improve maternal oral health, reduce mother-child transmission of cariogenic bacteria, and create opportunities for anticipatory guidance. This study aimed to understand why low-income women did or did not utilize dental services in a pilot program to promote dental visits during pregnancy in Klamath County, Oregon.
Methods
Sixty women were contacted and 51 participated in semi-structured telephone interviews regarding utilization of dental services during pregnancy. Women were selected randomly from the pilot program: 45 women (88%) utilized dental services and six did not. Transcripts were content analyzed using a mixed method qualitative approach - grounded theory and Stages of Change model - to identify themes and sub-themes.
Results
Most women overcame stress or dentally-related barriers to use care. Stressors included poor domestic relationships, personal finances, and employment. Dentally-related factors included perception of dental experience, attitude toward dental providers, importance/valuing of oral health, perceived ability to pay for care, time constraints, dental providers’ and office staff attitudes toward clients.
Conclusions
Identifying barriers that prevent low-income women from taking action to access dental care during pregnancy provides information essential for enhancing public-private health programs to promote dental visits, reduce mother-child transmission, and provide guidance to new mothers.
PMCID: PMC2891449  PMID: 19341579
Oral Health Disparities; Dental Services; Utilization; Pregnancy; Medicaid
23.  Additional psychometric data for the Spanish Modified Dental Anxiety Scale, and psychometric data for a Spanish version of the Revised Dental Beliefs Survey 
BMC Oral Health  2010;10:12.
Background
Hispanics comprise the largest ethnic minority group in the United States. Previous work with the Spanish Modified Dental Anxiety Scale (MDAS) yielded good validity, but lower test-retest reliability. We report the performance of the Spanish MDAS in a new sample, as well as the performance of the Spanish Revised Dental Beliefs Survey (R-DBS).
Methods
One hundred sixty two Spanish-speaking adults attending Spanish-language church services or an Hispanic cultural festival completed questionnaires containing the Spanish MDAS, Spanish R-DBS, and dental attendance questions, and underwent a brief oral examination. Church attendees completed the questionnaire a second time, for test-retest purposes.
Results
The Spanish MDAS and R-DBS were completed by 156 and 136 adults, respectively. The test-retest reliability of the Spanish MDAS was 0.83 (95% CI = 0.60-0.92). The internal reliability of the Spanish R-DBS was 0.96 (95% CI = 0.94-0.97), and the test-retest reliability was 0.86 (95% CI = 0.64-0.94). The two measures were significantly correlated (Spearman's rho = 0.38, p < 0.001). Participants who do not currently go to a dentist had significantly higher MDAS scores (t = 3.40, df = 106, p = 0.003) as well as significantly higher R-DBS scores (t = 2.21, df = 131, p = 0.029). Participants whose most recent dental visit was for pain or a problem, rather than for a check-up, scored significantly higher on both the MDAS (t = 3.00, df = 106, p = 0.003) and the R-DBS (t = 2.85, df = 92, p = 0.005). Those with high dental fear (MDAS score 19 or greater) were significantly more likely to have severe caries (Chi square = 6.644, df = 2, p = 0.036). Higher scores on the R-DBS were significantly related to having more missing teeth (Spearman's rho = 0.23, p = 0.009).
Conclusion
In this sample, the test-retest reliability of the Spanish MDAS was higher. The significant relationships between dental attendance and questionnaire scores, as well as the difference in caries severity seen in those with high fear, add to the evidence of this scale's construct validity in Hispanic samples. Our results also provide evidence for the internal and test-retest reliabilities, as well as the construct validity, of the Spanish R-DBS.
doi:10.1186/1472-6831-10-12
PMCID: PMC2887771  PMID: 20465835
24.  Hypoglycemia Prevents Increase in Lactic Acidosis During Reperfusion After Temporary Cerebral Ischemia in Rats 
NMR in biomedicine  1995;8(4):171-178.
Sequential 31P and 1H MRS was used to measure cerebral phosphate metabolites, intracellular pH, and lactate in normoglycemic and hypoglycemic rats during 30 min of complete cerebral ischemia and 5.5 h of reperfusion. These results were correlated with brain levels of free fatty acids (FFAs), excitatory amino acids, cations, and water content at death. The lactate/N-acetyl aspartate ratio was not significantly different between groups before or during occlusion. During reperfusion, the ratio was higher in normoglycemic rats from 3 to 85 min (p≤ 0.05), and recovery time was faster in hypoglycemic rats (29 vs 45 min; p = 0.04), suggesting reduced lactate production and faster recovery of aerobic metabolism. During occlusion, significant but comparable decrease of intracellular pH occurred in each group. Intracellular pH was higher in hypoglycemic rats at 140 min and 260 min of reperfusion. Water content, Na and K+ concentrations, and FFA and excitatory amino acid levels were not significantly different between groups, but hypoglycemic rats had less depletion of levels of Mg2+ (p=0.011). These results show that hypoglycemia has a limited but potentially beneficial effect on postischemic lactic acidosis.
PMCID: PMC2744691  PMID: 8771092
25.  Correlation of Early Reduction in the Apparent Diffusion Coefficient of Water with Blood Flow Reduction During Middle Cerebral Artery Occlusion in Rats 
To determine the relationship between reductions in the apparent diffusion coefficient of water (ADC) and in cerebral blood flow (CBF) during focal ischemia, we used diffusion-weighted magnetic resonance (D-MR) imaging and autoradiographic CBF analysis to examine rats subjected to 30 or 90 min of permanent middle cerebral artery (MCA) occlusion. In the 30-min occlusion group (n = l0), the area with substantially reduced ADC (15% or more below the contralateral level [ADCJ15]) corresponded best to the area with CBF below 25 ml/lOO g/min and was significantly smaller than the area with CBF below 50 m1/100 g/min (CBF50), a level associated with reduced protein synthesis and delayed necrosis (40 ± 13% versus 74 ± 8% of the ischemic hemisphere; P < 0.OOOl). In the 90-min occlusion group (n = 6), the ADC15 area corresponded best to the CBF30 to CBF35 area and was again significantly smaller than the CBF50 area (54 ± 13% versus 73 ± 20%, P < 0.05). Thus, the area of substantially reduced ADC at 30 and 90 min represents only 53% and 74%, respectively, of the tissue at risk for infarction. These findings indicate a potential limitation in using early D-MR imaging to predict stroke outcome.
PMCID: PMC2733355  PMID: 7500876
diffusion-weighted MRI; focal cerebral ischemia; rat; cerebral blood flow

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