Invasive methicillin-resistant Staphylococcus aureus infections among patients on chronic dialysis in the United States, 2005-2011

BACKGROUND

Approximately 15 700 invasive methicillin-resistant Staphylococcus aureus (MRSA) infections occurred in US dialysis patients in 2010. Frequent hospital visits and prolonged bloodstream access, especially via central venous catheters (CVCs), are risk factors among hemodialysis patients. We describe the epidemiology of and recent trends in invasive MRSA infections among dialysis patients.

METHODS

We analyzed population-based data from 9 US metropolitan areas from 2005 to 2011. Cases were defined as MRSA isolated from a normally sterile body site in a surveillance area resident who received dialysis, and were classified as hospital-onset (HO; culture collected >3 days after hospital admission) or healthcare-associated community-onset (HACO; all others). Incidence was calculated using denominators from the US Renal Data System. Temporal trends in incidence and national estimates were calculated controlling for age, sex, and race.

RESULTS

From 2005 to 2011, 7489 cases were identified; 85.7% were HACO infections, and 93.2% were bloodstream infections. Incidence of invasive MRSA infections decreased from 6.5 to 4.2 per 100 dialysis patients (annual decrease, 7.3%) with annual decreases of 6.7% for HACO and 10.5% for HO cases. Among cases identified during 2009-2011, 70% of patients were hospitalized in the year prior to infection. Among hemodialysis cases, 60.4% of patients were dialyzed through a CVC. The 2011 national estimated number of MRSA infections was 15 169.

CONCLUSIONS

There has been a substantial decrease in invasive MRSA infection incidence among dialysis patients. Most cases had previous hospitalizations, suggesting that efforts to control MRSA in hospitals might have contributed to the declines. Infection prevention measures should include improved vascular access and CVC care.

Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report

BACKGROUND

Bloodstream infections (BSIs) cause substantial morbidity in hemodialysis patients. In 2009, the US Centers for Disease Control and Prevention (CDC) sponsored a collaborative project to prevent BSIs in outpatient hemodialysis facilities. We sought to assess the impact of a set of interventions on BSI and access-related BSI rates in participating facilities using data reported to the CDC's National Healthcare Safety Network (NHSN).

STUDY DESIGN

Quality improvement project.

SETTING & PARTICIPANTS

Patients in 17 outpatient hemodialysis facilities that volunteered to participate.

QUALITY IMPROVEMENT PLAN

Facilities reported monthly event and denominator data to NHSN, received guidance from the CDC, and implemented an evidence-based intervention package that included chlorhexidine use for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff.

OUTCOMES

Crude and modeled BSI and access-related BSI rates.

MEASUREMENTS

Up to 12 months of preintervention (January 2009 through December 2009) and 15 months of intervention period (January 2010 through March 2011) data from participating centers were analyzed. Segmented regression analysis was used to assess changes in BSI and access-related BSI rates during the preintervention and intervention periods.

RESULTS

Most (65%) participating facilities were hospital based. Pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months during the preintervention period and 0.89 and 0.42 events per 100 patient-months during the intervention period, respectively. Modeled rates decreased 32% (P = 0.01) for BSIs and 54% (P < 0.001) for access-related BSIs at the start of the intervention period.

LIMITATIONS

Participating facilities were not representative of all outpatient hemodialysis centers nationally. There was no control arm to this quality improvement project.

CONCLUSIONS

Facilities participating in a collaborative successfully decreased their BSI and access-related BSI rates. The decreased rates appeared to be maintained in the intervention period. These findings suggest that improved implementation of recommended practices can reduce BSIs in hemodialysis centers.

Epidemiological survey of equine influenza in horses in India

A highly contagious virus infection in horses, influenza is the single most important equine respiratory disease in the world. This paper presents details of a one-year study (1 June 2008 to 31 May 2009) to determine the prevalence of equine influenza in the horses of Gujarat State in India. The prevalence of equine influenza A/equi-2 was 12.02%, but none of the samples were positive for equine influenza A/equi-1. The prevalence of equine influenza (A/equi-2) was 15.38%, 11.94%, 10.18%, and 9.09% in horses of the Kathiyawari breed, a non-descript breed, the Marwari breed and the Indian Thoroughbred breed, respectively. The highest prevalence of influenza was observed in yearlings (17.48%) and prevalence was at its highest in the month of April (28.89%). The prevalence rate in males, females and geldings was 11.95%, 10.38% and 8.47%, respectively. The mortality rate and case fatality rate were 1.28% and 10.64%, respectively.

Outbreak of hepatitis C virus infections at an outpatient hemodialysis facility: the importance of infection control competencies

In the United States, the prevalence of hepatitis C virus infection among patients treated in hemodialysis facilities is five times higher than among the general population. This study investigated eight new hepatitis C virus infections among patients treated at an outpatient hemodialysis facility. Epidemiologic investigation and viral sequencing demonstrated that transmission likely occurred between patients typically treated during the same or consecutive shifts at the same or a nearby station. Several infection control breaches were observed including lapses involving the preparation, handling, and administration of parenteral medications. Improved infection control education and training for all hemodialysis facility staff is an important component of assuring adherence to appropriate procedures and preventing future outbreaks.

Antimicrobial use in outpatient hemodialysis units

OBJECTIVE

To quantify and characterize overall antimicrobial use, including appropriateness of indication, among patients receiving chronic hemodialysis.

DESIGN

Retrospective and prospective observational study.

SETTING

Two outpatient hemodialysis units.

PATIENTS

All patients receiving chronic hemodialysis.

METHODS

The rate of parenteral antimicrobial use (number of doses per 100 patient-months) was calculated retrospectively from September 2008 through July 2011. Indication and appropriateness of antimicrobial doses were characterized prospectively from August 2010 through July 2011. Inappropriate administration was defined as occasions when criteria for infection based on national guidelines were not met, failure to choose a more narrow-spectrum antimicrobial on the basis of culture data, or occasions when indications for surgical prophylaxis were not met.

RESULTS

Over the 35-month retrospective study period, the rate of parenteral antimicrobial use was 32.9 doses per 100 patient-months. Vancomycin was the most commonly prescribed antimicrobial, followed by cefazolin and third- or fourth-generation cephalosporins. Over the 12-month prospective study, 1,003 antimicrobial doses were prescribed. Among the 926 (92.3%) doses for which an indication for administration was available, 276 (29.8%) were classified as inappropriate. Of these, a total of 146 (52.9%) did not meet criteria for infection, 74 (26.8%) represented failure to choose a more narrow-spectrum antimicrobial, and 56 (20.3%) did not meet criteria for surgical prophylaxis. The most common inappropriately prescribed antimicrobials were vancomycin and third- or fourth- generation cephalosporins.

CONCLUSIONS

Parenteral antimicrobial use was extensive, and as much as one-third was categorized as inappropriate. The findings of this study provide novel information toward minimizing inappropriate antimicrobial use.

Hepatitis B virus transmissions associated with a portable dental clinic, West Virginia, 2009

BACKGROUND

Although hepatitis B virus (HBV) transmission in dental settings is rare, in 2009 a cluster of acute HBV infections was reported among attendees of a two-day portable dental clinic in West Virginia.

METHODS

The authors conducted a retrospective investigation by using treatment records and volunteer logs, interviews of patients and volunteers with acute HBV infection as well as of other clinic volunteers, and molecular sequencing of the virus from those acutely infected.

RESULTS

The clinic was held under the auspices of a charitable organization in a gymnasium staffed by 750 volunteers, including dental care providers who treated 1,137 adults. Five acute HBV infections-involving three patients and two volunteers-were identified by the local and state health departments. Of four viral isolates available for testing, all were genotype D. Three case patients underwent extractions; one received restorations and one a dental prophylaxis. None shared a treatment provider with any of the others. One case volunteer worked in maintenance; the other directed patients from triage to the treatment waiting area. Case patients reported no behavioral risk factors for HBV infection. The investigation revealed numerous infection control breaches.

CONCLUSIONS

Transmission of HBV to three patients and two volunteers is likely to have occurred at a portable dental clinic. Specific breaches in infection control could not be linked to these HBV transmissions.

PRACTICAL IMPLICATIONS

All dental settings should adhere to recommended infection control practices, including oversight; training in prevention of bloodborne pathogens transmission; receipt of HBV vaccination for staff who may come into contact with blood or body fluids; use of appropriate personal protective equipment, sterilization and disinfection procedures; and use of measures, such as high-volume suction, to minimize the spread of blood.

Outbreak of hepatitis B virus infections associated with assisted monitoring of blood glucose in an assisted living facility-Virginia, 2010

Introduction

In January 2010, the Virginia Department of Health received reports of 2 hepatitis B virus (HBV) infections (1 acute, 1 chronic) among residents of a single assisted living facility (ALF). Both infected residents had diabetes and received assisted monitoring of blood glucose (AMBG) at the facility. An investigation was initiated in response.

Objective

To determine the extent and mechanism of HBV transmission among ALF residents.

Design

Retrospective cohort study.

Setting

An ALF that primarily housed residents with neuropsychiatric disorders in 2 adjacent buildings in Virginia.

Participants

Residents of the facility as of March 2010.

Measurements

HBV serologic testing, relevant medical history, and HBV genome sequences. Risk ratios (RR) and 95% confidence intervals (CIs) were used to identify risk factors for HBV infection.

Results

HBV serologic status was determined for 126 (91%) of 139 residents. Among 88 susceptible residents, 14 became acutely infected (attack rate, 16%), and 74 remained uninfected. Acute HBV infection developed among 12 (92%) of 13 residents who received AMBG, compared with 2 (3%) of 75 residents who did not (RR  = 35; 95% CI, 8.7, 137). Identified infection control breaches during AMBG included shared use of fingerstick devices for multiple residents. HBV genome sequencing demonstrated 2 building-specific phylogenetic infection clusters, each having 99.8–100% sequence identity.

Limitations

Transfer of residents out of the facility prior to our investigation might have contributed to an underestimate of cases. Resident interviews provided insufficient information to fully assess behavioral risk factors for HBV infection.

Conclusions

Failure to adhere to safe practices during AMBG resulted in a large HBV outbreak. Protection of a growing and vulnerable ALF population requires improved training of staff and routine facility licensing inspections that scrutinize infection control practices.

Outbreak of bacterial meningitis among patients undergoing myelography at an outpatient radiology clinic

PURPOSE

To investigate an outbreak of bacterial meningitis at an outpatient radiology clinic (clinic A) and to determine the source and implement measures to prevent additional infections.

METHODS

A case was defined as bacterial meningitis in a patient undergoing myelography at clinic A from October 11 to 25, 2010. Patients who underwent myelography and other procedures at clinic A during that period were interviewed, medical records were reviewed, and infection prevention practices were assessed. Case-patient cerebrospinal fluid (CSF) specimens, oral specimens from health care personnel (HCP), and opened iohexol vials were tested for bacteria. Bacterial isolates were compared using pulsed-field gel electrophoresis. A culture-negative CSF specimen was tested using a real-time polymerase chain reaction assay.

RESULTS

Three cases were identified among 35 clinic A patients who underwent procedures from October 11 to 25, 2010. All case-patients required hospitalization, 2 in an intensive care unit. Case-patients had myelography performed by the same radiology physician assistant and technician on October 25; all patients who underwent myelography on October 25 were affected. HCP did not wear facemasks and reused single-dose iohexol vials for multiple patients. Streptococcus salivarius (a bacteria commonly found in oral flora) was detected in the CSF of 2 case-patients (1 by culture, 1 using real-time polymerase chain reaction) and in HCP oral specimens; 1 opened iohexol vial contained Staphylococcus epidermidis. Pulsed-field gel electrophoresis profiles from the case-patient S salivarius and the radiology physician assistant were indistinguishable.

CONCLUSIONS

Bacterial meningitis likely occurred because HCP performing myelography did not wear facemasks; lapses in injection practices may have contributed to transmission. Targeted education regarding mask use and safe injection practices is needed among radiology HCP.

Vascular access hemorrhages contribute to deaths among hemodialysis patients

In 2007 the Maryland Medical Examiner noted a potential cluster of fatal vascular access hemorrhages among hemodialysis patients, many of whom died outside of a health-care setting. To examine the epidemiology of fatal vascular access hemorrhages, we conducted a retrospective case review in District of Columbia, Maryland, and Virginia from January 2000 to July 2007 and a case-control study. Records from the Medical Examiner and Centers for Medicare and Medicaid Services were reviewed, from which 88 patients were identified as fatal vascular access hemorrhage cases. To assess risk factors, a subset of 20 cases from Maryland was compared to 38 controls randomly selected among hemodialysis patients who died from non-vascular access hemorrhage causes at the same Maryland facilities. Of the 88 confirmed cases, 55% hemorrhaged from arteriovenous grafts, 24% from arteriovenous fistulas, and 21% from central venous catheters. Of 82 case-patients with known location of hemorrhage, 78% occurred at home or in a nursing home. In the case-control analysis, statistically significant risk factors included the presence of an arteriovenous graft, access-related complications within 6 months of death, and hypertension; presence of a central venous catheter was significantly protective. Psychosocial factors and anticoagulant medications were not significant risk factors. Effective strategies to control vascular access hemorrhage in the home and further delineation of warning signs are needed.

Severe methicillin-susceptible Staphylococcus aureus infections associated with epidural injections at an outpatient pain clinic

BACKGROUND

Recent outbreaks in ambulatory care settings have highlighted infection control breaches as risk factors for disease transmission. In May 2009, 3 patients were hospitalized with severe methicillin-susceptible Staphylococcus aureus (MSSA) infections after receiving epidural injections at a West Virginia outpatient pain clinic.

METHODS

We conducted a retrospective cohort study evaluating clinic patients who received injections during a 3-week period. A case was defined as laboratory-confirmed infection or clinical evidence of infection ≤ 14 days after a patient received an injection. Infection control procedures were assessed. MSSA isolates from patient infections and clinic staff nasal swabs were genotyped by using pulsed-field gel electrophoresis.

RESULTS

Eight (7%) of 110 cohort patients met the case definition; 6 (75%) cases were laboratory confirmed. Eight (12%) of 69 patients who received epidural injections were case patients compared with none of the other 41 patients (P = .02). During procedures, staff use of face masks and preparation of patient skin were suboptimal; epidural injection syringes were reused to access shared medication vials. MSSA isolates from 2 patients and 1 staff member were indistinguishable by pulsed-field gel electrophoresis.

CONCLUSION

Infection control breaches likely facilitated MSSA transmission to patients receiving epidural injections. Adhering to correct infection control practices in ambulatory care settings is critical to prevent disease transmission.

Integrated genomic analyses identify WEE1 as a critical mediator of cell fate and a novel therapeutic target in acute myeloid leukemia

Acute myeloid leukemia (AML) remains a therapeutic challenge despite increasing knowledge about the molecular origins of the disease, as the mechanisms of AML cell escape from chemotherapy remain poorly defined. We hypothesized that AML cells are addicted to molecular pathways in the context of chemotherapy and used complementary approaches to identify these addictions. Using novel molecular and computational approaches, we performed genome-wide shRNA screens to identify proteins that mediate AML cell fate after cytarabine exposure, gene expression profiling of AML cells exposed to cytarabine to identify genes with induced expression in this context, and examination of existing gene expression data from primary patient samples. The integration of these independent analyses strongly implicates cell cycle checkpoint proteins, particularly WEE1, as critical mediators of AML cell survival after cytarabine exposure. Knockdown of WEE1 in a secondary screen confirmed its role in AML cell survival. Pharmacologic inhibition of WEE1 in AML cell lines and primary cells is synergistic with cytarabine. Further experiments demonstrate that inhibition of WEE1 prevents S-phase arrest induced by cytarabine, broadening the functions of WEE1 that may be exploited therapeutically. These data highlight the power of integrating functional and descriptive genomics, and identify WEE1 as potential therapeutic target in AML.

Persistence of long-term immunity to hepatitis B among adolescents immunized at birth

The long-term duration of recombinant hepatitis B vaccine-induced immunity among persons vaccinated starting at birth is still not well understood. Waning of vaccine-induced immunity could leave young adults at risk of hepatitis B virus infection due to behavioral or occupational exposures. We followed a cohort of children immunized starting at birth with a 3-dose regimen of recombinant hepatitis B vaccine (5 mcg, 2.5 mcg, 2.5 mcg). They were challenged with a booster dose of the hepatitis B vaccine 10 and 15 years after vaccination to assess anamnestic response as a measure of persistence of protection. Among 108 participants who had lost protective antibody levels against hepatitis B, the majority (>70%) had an anamnestic response to the booster dose; response rates did not decline significantly between 10 and 15 years follow-up periods. A high antibody concentration following primary vaccination was independently associated with an anamnestic response later on in life. Nonetheless, ~20-30% of participants were unable to mount an immune response after boosting. Hepatitis B revaccination might be required for persons vaccinated starting at birth if opportunities for hepatitis B virus exposure exist. Future vaccine recommendations should be based on studies ascertaining protection against clinically significant disease.

Vulnerable populations and the association between periodontal and chronic kidney disease

BACKGROUND AND OBJECTIVES

Recent studies suggest an overall association between chronic kidney disease (CKD) and periodontal disease, but it is unknown whether this association is similar across various subpopulations.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study was a cross-sectional analysis of 2001 to 2004 National Health and Nutrition Examination Survey data. CKD was defined as a urinary albumin-to-creatinine ratio ≥30 mg/g or estimated GFR of 15 to 59 ml/min per 1.73 m(2). Adjusted odds ratios were calculated using multivariable logistic regression with U.S. population-based weighting.

RESULTS

These analyses included 6199 dentate adult participants (aged 21 to 75 years) with periodontal exams. The estimated prevalences of moderate/severe periodontal disease and CKD were 5.3% and 10.6%, respectively. Periodontal disease was associated with >2-fold higher risk of CKD that was moderately attenuated after adjustment for age, gender, race/ethnicity, tobacco use, hypertension, diabetes, educational attainment, poverty index ratio, and dental care use. There were no statistically significant interactions between periodontal disease and race/ethnicity, educational attainment, or poverty status. Less-than-recommended dental care use was associated with periodontal disease and CKD and was increasingly prevalent among nonwhites, lower educational attainment, and lower poverty status.

CONCLUSIONS

The association between periodontal disease and CKD is not significantly different among subgroups. However, because nonwhites, those with a lower educational level, and the poor less frequently report use of recommended dental care, the association between periodontal disease and kidney function over time may become stronger among these groups and warrants further investigation.

Production of Exo-polysaccharide by Rhizobium sp

Two fold increase in the yield of glucose and maltose containing exo-polysaccharide (EPS) by Rhizobium sp. was observed during its growth in modified YEMB. EPS production, plant growth promotion activity and root colonization of Rhizobium sp. studies showed enhanced EPS synthesis, more seed germination and over all improvement in plant growth over control and R. meliloti treatment. Groundnut seeds bacterized with Rhizobium sp. resulted in 69.75% more root length, 49.51% more shoot height, 13.75% more number of branches and 13.60% more number of pods over the control and R. meliloti treatment. Bacterization of wheat seeds increased the dry matter yield of roots (1.7-fold), and roots adhering soil (RAS) (1.5) and shoot mass (1.9-fold). Rhizobium sp. inoculation also increased the population density of EPS-producing bacteria on the rhizoplane. Roots of plants inoculated with Rhizobium sp. maintained a higher K(+)/Na(+) ratio and K(+)-Na(+) selectivity.

Hepatitis C virus infections from unsafe injection practices at an endoscopy clinic in Las Vegas, Nevada, 2007-2008

BACKGROUND

In January 2008, 3 persons with acute hepatitis C who all underwent endoscopy at a single facility in Nevada were identified.

METHOD

We reviewed clinical and laboratory data from initially detected cases of acute hepatitis C and reviewed infection control practices at the clinic where case patients underwent endoscopy. Persons who underwent procedures on days when the case patients underwent endoscopy were tested for hepatitis C virus (HCV) infection and other bloodborne pathogens. Quasispecies analysis determined the relatedness of HCV in persons infected.

RESULTS

In addition to the 3 initial cases, 5 additional cases of clinic-acquired HCV infection were identified from 2 procedure dates included in this initial field investigation. Quasispecies analysis revealed 2 distinct clusters of clinic-acquired HCV infections and a source patient related to each cluster, suggesting separate transmission events. Of 49 HCV-susceptible persons whose procedures followed that of the source patient on 25 July 2007, 1 (2%) was HCV infected. Among 38 HCV-susceptible persons whose procedures followed that of another source patient on 21 September 2007, 7 (18%) were HCV infected. Reuse of syringes on single patients in conjunction with use of single-use propofol vials for multiple patients was observed during normal clinic operations.

CONCLUSIONS

Patient-to-patient transmission of HCV likely resulted from contamination of single-use medication vials that were used for multiple patients during anesthesia administration. The resulting public health notification of approximately 50,000 persons was the largest of its kind in United States health care. This investigation highlighted breaches in aseptic technique, deficiencies in oversight of outpatient settings, and difficulties in detecting and investigating such outbreaks.

Health care-associated invasive MRSA infections, 2005-2008

CONTEXT

Methicillin-resistant Staphylococcus aureus (MRSA) is a pathogen of public health importance; MRSA prevention programs that may affect MRSA transmission and infection are increasingly common in health care settings. Whether there have been changes in MRSA infection incidence as these programs become established is unknown; however, recent data have shown that rates of MRSA bloodstream infections (BSIs) in intensive care units are decreasing.

OBJECTIVE

To describe changes in rates of invasive health care-associated MRSA infections from 2005 through 2008 among residents of 9 US metropolitan areas.

DESIGN, SETTING, AND PARTICIPANTS

Active, population-based surveillance for invasive MRSA in 9 metropolitan areas covering a population of approximately 15 million persons. All reports of laboratory-identified episodes of invasive (from a normally sterile body site) MRSA infections from 2005 through 2008 were evaluated and classified based on the setting of the positive culture and the presence or absence of health care exposures. Health care-associated infections (ie, hospital-onset and health care-associated community-onset), which made up 82% of the total infections, were included in this analysis.

MAIN OUTCOME MEASURES

Change in incidence of invasive health care-associated MRSA infections and health care-associated MRSA BSIs using population of the catchment area as the denominator.

RESULTS

From 2005 through 2008, there were 21,503 episodes of invasive MRSA infection; 17,508 were health care associated. Of these, 15,458 were MRSA BSIs. The incidence rate of hospital-onset invasive MRSA infections was 1.02 per 10,000 population in 2005 and decreased 9.4% per year (95% confidence interval [CI], 14.7% to 3.8%; P = .005), and the incidence of health care-associated community-onset infections was 2.20 per 10,000 population in 2005 and decreased 5.7% per year (95% CI, 9.7% to 1.6%; P = .01). The decrease was most prominent for the subset of infections with BSIs (hospital-onset: -11.2%; 95% CI -15.9% to -6.3%; health care-associated community-onset: -6.6%; 95% CI -9.5% to -3.7%).

CONCLUSION

Over the 4-year period from 2005 through 2008 in 9 diverse metropolitan areas, rates of invasive health care-associated MRSA infections decreased among patients with health care-associated infections that began in the community and also decreased among those with hospital-onset invasive disease.

Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients

Infections cause significant morbidity and mortality in patients undergoing hemodialysis. Bloodstream infections (BSIs) are particularly problematic, accounting for a substantial number of hospitalizations in these patients. Hospitalizations for BSI and other vascular access infections appear to have increased dramatically in hemodialysis patients since 1993. These infections frequently are related to central venous catheter (CVC) use for dialysis access. Regional initiatives that have shown successful decreases in catheter-related BSIs in hospitalized patients have generated interest in replicating this success in outpatient hemodialysis populations. Several interventions have been effective in preventing BSIs in the hemodialysis setting. Avoiding the use of CVCs in favor of access types with lower associated BSI risk is among the most important. When CVCs are used, adherence to evidence-based catheter insertion and maintenance practices can positively influence BSI rates. In addition, facility-level surveillance to detect BSIs and stimulate examination of vascular access use and care practices is essential to a comprehensive approach to prevention. This article describes the current epidemiology of BSIs in hemodialysis patients and effective prevention strategies to decrease the incidence of these devastating infections.

Epidemiology, surveillance, and prevention of hepatitis C virus infections in hemodialysis patients

Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States; the prevalence in maintenance hemodialysis patients substantially exceeds that in the general population. In hemodialysis patients, HCV infection has been associated with increased occurrence of cirrhosis and hepatocellular carcinoma and increased mortality. Injection drug use and receipt of blood transfusions before 1992 has accounted for most prevalent HCV infections in the United States. However, HCV transmission among patients undergoing hemodialysis has been documented frequently. Outbreak investigations have implicated lapses in infection control practices as the cause of HCV infections. Preventing these infections is an emerging priority for renal care providers, public health agencies, and regulators. Adherence to recommended infection control practices is effective in preventing HCV transmission in hemodialysis facilities. In addition, adoption of routine screening to facilitate the detection of incident HCV infections and hemodialysis-related transmission is an essential component of patient safety and infection prevention efforts. This article describes the current epidemiology of HCV infection in US maintenance hemodialysis patients and prevention practices to decrease its incidence and transmission.

Nephrogenic systemic fibrosis: a survey of nephrologists' perceptions and practices

BACKGROUND AND OBJECTIVES

Nephrogenic systemic fibrosis (NSF) is a disorder that can affect patients with renal dysfunction exposed to a gadolinium-based contrast agent (GBCA). Given the unique role nephrologists play in caring for patients at risk to develop NSF, this study surveyed their perceptions and practices regarding NSF.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

An internet-based, cross-sectional survey of clinical nephrologists in the United States was performed. Perceptions and self-reported practices regarding NSF and local facility policies were assessed concerning GBCA use in renal dysfunction.

RESULTS

Of the 2310 eligible nephrologists e-mailed to participate in the survey, 171 (7.4%) responded. Respondents spent 85% of their time in direct patient care and 83% worked in private practice; 59% had cared for a patient with NSF. Although over 90% were aware of the morbidity and mortality associated with NSF, 31% were unaware of an association with specific GBCA brand and 50% believed chronic kidney disease stage 3 patients were at risk to develop NSF. Changes in facility policies concerning GBCA use in renal dysfunction were widespread (>90%). Most nephrologists (56%) felt that enacted policies were appropriate, yet 58% were uncertain if the changes had benefited patients.

CONCLUSIONS

These results indicate that nephrologists are generally familiar with the risk factors and consequences of NSF, but their perceptions do not always align with current evidence. Local policy changes in GBCA use are pervasive. Most nephrologists are comfortable with these policy changes but have mixed feelings regarding their effectiveness.

Emergency department visits for antibiotic-associated adverse events

BACKGROUND

Drug-related adverse events are an under-appreciated consequence of antibiotic use, and the national magnitude and scope of these events have not been studied. Our objective was to estimate and compare the numbers and rates of emergency department (ED) visits for drug-related adverse events associated with systemic antibiotics in the United States by drug class, individual drug, and event type.

METHODS

We analyzed drug-related adverse events from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project (2004-2006) and outpatient prescriptions from national sample surveys of ambulatory care practices, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2004-2005).

RESULTS

On the basis of 6614 cases, an estimated 142,505 visits (95% confidence interval [CI], 116,506-168,504 visits) annually were made to US EDs for drug-related adverse events attributable to systemic antibiotics. Antibiotics were implicated in 19.3% of all ED visits for drug-related adverse events. Most ED visits for antibiotic-associated adverse events were for allergic reactions (78.7% of visits; 95% CI, 75.3%-82.1% of visits). One-half of the estimated ED visits were attributable to penicillins (36.9% of visits; 95% CI, 34.7%-39.2% of visits) and cephalosporins (12.2%; 95% CI, 10.9%-13.5%). Among commonly prescribed antibiotics, sulfonamides and clindamycin were associated with the highest rate of ED visits (18.9 ED visits per 10,000 outpatient prescription visits [95% CI, 13.1-24.7 ED visits per 10,000 outpatient prescription visits] and 18.5 ED visits per 10,000 outpatient prescription visits [95% CI, 12.1-25.0 ED visits per 10,000 outpatient prescription visits], respectively). Compared with all other antibiotic classes, sulfonamides were associated with a significantly higher rate of moderate-to-severe allergic reactions (4.3% [95% CI, 2.9%-5.8%] vs. 1.9 % [95% CI, 1.5%-2.3%]), and sulfonamides and fluoroquinolones were associated with a significantly higher rate of neurologic or psychiatric disturbances (1.4% [95% CI, 1.0%-1.7%] vs. 0.5% [95% CI, 0.4%-0.6%]).

CONCLUSIONS

Antibiotic-associated adverse events lead to many ED visits, and allergic reactions are the most common events. Minimizing unnecessary antibiotic use by even a small percentage could significantly reduce the immediate and direct risks of drug-related adverse events in individual patients.

Association of standing-order policies with vaccination rates in dialysis clinics: a US-based cross-sectional study

BACKGROUND

Patients with end-stage renal disease are at increased risk of morbidity and mortality because of infection. Quality improvement efforts for this patient population include assessment of institutional policies and practices that may increase vaccination rates for influenza, hepatitis B, and pneumococcal disease.

STUDY DESIGN

A survey of vaccination practices, beliefs, and attitudes was sent to all dialysis centers in End-Stage Renal Disease Networks 6, 11, and 15.

SETTING & PARTICIPANTS

Of 1,052 dialysis facilities considered, 683 returned the survey, reported vaccination rates for 2005 to 2006, and had 20 or more patients.

PREDICTOR OR FACTOR

Standing-order policy of the dialysis facility, categorized as facility-wide orders, preprinted admission orders for each patient (chart orders), physician-specific orders, and individual orders.

OUTCOMES

Vaccination rates for influenza, hepatitis B (full or partial series), hepatitis B, and pneumococcal vaccine.

MEASUREMENTS

Patient vaccination, given at or outside the center.

RESULTS

Overall vaccination rates were 76% +/- 18% (SD) for influenza, 73% +/- 22% for hepatitis B full or partial series, 62% +/- 25% for hepatitis B full series, and 44% +/- 34% for pneumococcal vaccine. Compared with individual orders, facility-wide standing orders and chart orders were not associated with greater vaccination rates for influenza (0.4%; confidence interval, -4 to 5; and 1.27%; confidence interval, -3 to 5, respectively), but were associated with greater vaccination rates for hepatitis B full or partial series (9%; confidence interval, 3 to 15; and 11%; confidence interval, 5 to 17, respectively), hepatitis B full series (11%; confidence interval, 4 to 17; and 13%; confidence interval, 7 to 19, respectively), and pneumococcal disease (21%; confidence interval, 14 to 29; and 20%; confidence interval, 13 to 27, respectively).

LIMITATIONS

Data are cross-sectional, and vaccinations outside the center were self-reported.

CONCLUSIONS

Existing facility-wide or chart-based order programs may be effective in promoting vaccination against hepatitis B and pneumococcal disease.

Outbreak of adverse reactions associated with contaminated heparin

BACKGROUND

In January 2008, the Centers for Disease Control and Prevention began a nationwide investigation of severe adverse reactions that were first detected in a single hemodialysis facility. Preliminary findings suggested that heparin was a possible cause of the reactions.

METHODS

Information on clinical manifestations and on exposure was collected for patients who had signs and symptoms that were consistent with an allergic-type reaction after November 1, 2007. Twenty-one dialysis facilities that reported reactions and 23 facilities that reported no reactions were included in a case-control study to identify facility-level risk factors. Unopened heparin vials from facilities that reported reactions were tested for contaminants.

RESULTS

A total of 152 adverse reactions associated with heparin were identified in 113 patients from 13 states from November 19, 2007, through January 31, 2008. The use of heparin manufactured by Baxter Healthcare was the factor most strongly associated with reactions (present in 100.0% of case facilities vs. 4.3% of control facilities, P<0.001). Vials of heparin manufactured by Baxter from facilities that reported reactions contained a contaminant identified as oversulfated chondroitin sulfate (OSCS). Adverse reactions to the OSCS-contaminated heparin were often characterized by hypotension, nausea, and shortness of breath occurring within 30 minutes after administration. Of 130 reactions for which information on the heparin lot was available, 128 (98.5%) occurred in a facility that had OSCS-contaminated heparin on the premises. Of 54 reactions for which the lot number of administered heparin was known, 52 (96.3%) occurred after the administration of OSCS-contaminated heparin.

CONCLUSIONS

Heparin contaminated with OSCS was epidemiologically linked to adverse reactions in this nationwide outbreak. The reported clinical features of many of the cases further support the conclusion that contamination of heparin with OSCS was the cause of the outbreak.

Developing a broader approach to management of infection control breaches in health care settings

Our experiences with health departments and health care facilities suggest that questions surrounding instrument reprocessing errors and other infection control breaches are becoming increasingly common. We describe an approach to management of these incidents that focuses on risk of bloodborne pathogen transmission and the role of public health and other stakeholders to inform patient notification and testing decisions.

Gadolinium-containing magnetic resonance imaging contrast and nephrogenic systemic fibrosis: a case-control study

BACKGROUND

Nephrogenic systemic fibrosis (NSF) is a newly described disorder occurring in persons with renal failure. Gadolinium-based contrast used in magnetic resonance imaging (MRI) has been suggested as a cause. A cluster of patients with NSF was investigated to identify risk factors. Limited preliminary findings from this investigation were presented in the Morbidity and Mortality Weekly Report.

STUDY DESIGN

Matched case-control.

SETTING & PARTICIPANTS

Dialysis patients with and without a diagnosis of NSF treated at an academic medical center.

PREDICTOR

Exposure to gadolinium-based contrast.

OUTCOMES & MEASUREMENTS

Laboratory and clinical characteristics of NSF.

RESULTS

19 of 28 cases identified at the hospital from December 2002 to August 2006 met inclusion criteria and were matched to 57 controls. In univariate analysis, receipt of gadolinium-containing MRI contrast in the preceding year (odds ratio [OR], 7.99; 95% confidence interval, 2.22 to 28.8) was associated with NSF; the measure of association increased as cumulative dose increased. Gadodiamide exposure (OR, 9.83; 95% confidence interval, 2.09 to 46.2) was associated more strongly with NSF than gadoversetamide (OR, 1.82; 95% confidence interval, 0.33 to 10.2). Although not statistically significant, cases were more likely than controls to have undergone primarily peritoneal dialysis in the preceding 6 months. There was no significant difference in receipt of high-dose recombinant erythropoietin between cases and controls. In multivariable analysis, gadolinium contrast exposure (OR, 8.97; 95% confidence interval, 1.28 to 63.0) remained significantly associated with NSF.

LIMITATIONS

Retrospective design, small sample size, inability to completely evaluate erythropoietin.

CONCLUSIONS

Receipt of gadolinium-containing MRI contrast is associated with NSF in a dose-dependent manner. The risk associated with gadolinium may differ by contrast agent and dialysis modality. Use of gadolinium-based contrast agents should be avoided when possible in patients with renal failure.

In search of a rational approach to chronic kidney disease detection and management

Rates of incident end-stage renal disease persist above established goals, driving efforts for early identification of chronic kidney disease (CKD) to reduce progression. The detection of CKD using existing electronic data sources has been proposed as an efficient identification method; however, this method is not without potential challenges and limitations.

[14C]bis(2-chloroethoxy)methane: comparative absorption, distribution, metabolism and excretion in rats and mice

bis(2-Chloroethoxy)methane (BCM) is used primarily as a precursor in the synthesis of polysulfide elastomers. After administration of [(14)C]BCM, radioactivity is readily absorbed from the gastrointestinal tract and moderately absorbed through skin. Following absorption, BCM-derived radioactivity is rapidly distributed to all tissues, rapidly metabolized and excreted primarily in urine. Minimal effects of sex, species or dose in the range studied (0.1-10 mg kg(-1)) were observed on the fate of BCM in rats and mice after all routes of administration. The major metabolite (about 40% of the dose) of BCM in rat was isolated and identified as thiodiglycolic acid (TDGA) indicating that the ether linkage of BCM is cleaved to form 2-chloroethyl fragments that may be further metabolized to 2-chloracetaldehyde, conjugated with glutathione and the latter subsequently metabolized to TDGA. 2-chloroacetaldehyde has also been shown to be cardiotoxic, possibly accounting for BCM cardiotoxicity observed in repeated dose studies.

Hepatitis C virus infections from a contaminated radiopharmaceutical used in myocardial perfusion studies

CONTEXT

Nuclear pharmacies prepare radiopharmaceutical products for use in common diagnostic procedures, including myocardial perfusion studies. Hepatitis C virus (HCV) transmission has not been reported previously in the setting of nuclear imaging studies.

OBJECTIVE

To investigate an outbreak of acute HCV infection identified among patients who underwent myocardial perfusion studies on October 15, 2004, using an injected radiopharmaceutical.

DESIGN, SETTING, AND PATIENTS

Outbreak investigation including molecular epidemiology and pharmacy site investigation at outpatient cardiology clinics and a nuclear pharmacy in Maryland. Ninety patients who received injections drawn from select radiopharmaceutical vials prepared on October 14-15, 2004, at a single nuclear pharmacy were offered testing for bloodborne pathogens. Pharmacy procedures were reviewed and HCV quasi species analysis was performed.

MAIN OUTCOME MEASURES

Hepatitis C virus infection and quasispecies sequence similarity.

RESULTS

Sixteen patients with acute HCV infection were identified from 3 separate clinics. All patients received radiopharmaceutical injections drawn from a single pharmacy vial (vial 1). None of the 59 tested patients who received doses from 6 other vials had acute HCV infection. Blood from a potential source patient with HCV and human immunodeficiency virus (HIV) infection was processed for a radiolabeled white blood cell study in the pharmacy 12 hours before vial 1 was prepared. The HCV quasispecies sequences from this potential source patient were nearly identical to those from cases (97.8%-98.5% similarity). No acute HIV infections were identified. Pharmacy practices that could have led to blood cross-contamination included reuse of needles and syringes during dilutions and use of common flow hoods for some steps in the preparation of sterile and blood-derived products.

CONCLUSIONS

Sixteen persons acquired HCV infection from a blood-contaminated radiopharmaceutical. The source and practices that could have facilitated breaks in aseptic technique were identified at the pharmacy. Nuclear pharmacies that handle biological products should follow appropriate aseptic technique to prevent contamination of sterile radiopharmaceuticals.

Transmission of hepatitis C virus to several organ and tissue recipients from an antibody-negative donor

BACKGROUND

Although hepatitis C virus (HCV) transmission through tissue transplantation has been rarely reported, a donor with undetected viremia may infect several recipients. A patient developed acute hepatitis C shortly after tissue transplantation. Ninety-one tissues or organs had been recovered from the donor.

OBJECTIVE

To determine whether the donor was the source of infection and the extent of transmission to other organ and tissue recipients.

DESIGN

Descriptive epidemiologic study; serum testing for HCV infection.

SETTING

Recipients were located in 16 states and 2 other countries.

PARTICIPANTS

Donor and graft recipients.

MEASUREMENTS

Hepatitis C virus infection was defined as the presence of anti-HCV or HCV RNA. The authors determined the genetic relatedness of viral isolates from the donor and recipients by genotype comparison and quasi-species analysis.

RESULTS

The donor was anti-HCV-negative but was HCV RNA-positive (genotype 1a). Forty persons received transplants during 22 months. Five persons were HCV-infected before transplantation or had a genotype other than 1a, and 5 persons had no post-transplantation serum specimens available. Of the remaining 30 recipients, HCV infection occurred in 8 recipients: 3 of 3 organ recipients, 1 of 2 saphenous vein recipients, 1 of 3 tendon recipients, and 3 of 3 tendon with bone recipients. These 8 recipients had viral isolates genetically related to those of the donor. No cases occurred in recipients of skin (n = 2), cornea (n = 1), or irradiated bone (n = 16).

LIMITATIONS

Post-transplantation serum specimens were unavailable for 5 recipients.

CONCLUSIONS

An anti-HCV-negative donor was the source of HCV infection for 8 recipients of organs or tissues. Although HCV transmission from anti-HCV-negative donors is probably uncommon, changes in donor screening to include routine testing for HCV RNA merit further consideration to improve the safety of transplantation.

SARS clinical features, United States, 2003

We compared the clinical features of 8 U.S. case-patients with laboratory-confirmed severe acute respiratory syndrome (SARS) to 65 controls who tested negative for SARS coronavirus (SARS-CoV) infection. Shortness of breath, vomiting, diarrhea, progressive bilateral infiltrates on chest radiograph, and need for supplemental oxygen were significantly associated with confirmed SARS-CoV infection.

Trauma care systems in India

Trauma-care systems in India are at a nascent stage of development. Industrialised cities, rural towns and villages coexist, with almost complete lack of organised trauma care. There is gross disparity between trauma services available in various parts of the country. Rural India has inefficient services for trauma care, due to the varied topography, financial constraints and lack of appropriate health infrastructure. There is no national lead agency to co-ordinate various components of a trauma system. No mechanism for accreditation of trauma centres and professionals exists. Education in trauma life-support (TLS) skills has only recently become available. A nation-wide survey encompassing various facilities has demonstrated significant deficiencies in current trauma systems.Although injury is a major public-health problem, the Government of India has failed to recognise it as a priority. Significant efforts to develop trauma-care systems across the country are seen mainly in the private sector. New initiatives under National Health Policy 2002 are expected to result in improvement in the systems, but the allocation of funds remains grossly inadequate for any significant impact on the outcome.

Post-transplant lymphoproliferative disorders

Post-transplant lymphoproliferative disorder (PTLD) is a serious complication of organ transplantation, with multiple factors being implicated in its pathogenesis. The clinical presentation of PTLD is atypical, therefore imaging and tissue biopsy are essential for diagnosis. Treatment requires drug combinations that are appropriate to the PTLD. Four patients with PTLD who had undergone orthotopic liver transplantation are documented, and their clinical characteristics and management described. These case histories identify neutropenia to be a problem and show that age does not seem to influence prognosis.

The spinoglenoid ligament and its relationship to the suprascapular nerve

Entrapment of the suprascapular nerve by the inferior transverse scapular ligament or spinoglenoid ligament (SGL) has been discussed frequently in the literature, but it has not been well documented anatomically. Therefore the mechanism of entrapment is not well understood. When isolated atrophy and denervation of the infraspinatus muscle have been noted, compression of the muscle's motor branch at the spinoglenoid notch has been implicated. This anatomic and morphologic study investigates the role of the SGL in entrapment neuropathy of the infraspinatus. We used 23 shoulders from 19 cadavers, 5 women (8 shoulders) and 14 men (15 shoulders), with a mean age of 67.9 (54 to 78) years. The presence or absence of the SGL was noted. The length, width, and orientation of the SGL; size and shape of the tunnel to the infraspinatus fossa; and distance of the notch to the posterior glenoid rim were determined. The SGL was present in 14 (60.8%) shoulders, 5 (36%) women and 9 (64%) men. The SGL was wider at the superior entrance of the tunnel and fanned and twisted toward the inferior aspect. In all specimens the SGL fibers inserted into the posterior shoulder capsule. The mean length for the upper part of the SGL was 17.5 +/- 2.6 mm in men and 15.8 +/- 1.8 mm in women, and the lower part was 14.1 +/- 2.4 mm and 12.9 +/- 1.8 mm, respectively. The widths of the SGL at the origin of the scapular spine were 12.2 +/- 3.9 mm for men and 10.4 +/- 2.7 mm for women, whereas the insertion site widths were 15.8 +/- 2.2 mm for men, and 16.1 +/- 3.8 mm for women. The midportion width of the SGL was 6.8 +/- 1.9 mm in men and 5.8 +/- 2.1 mm in women. During cross-body adduction and internal rotation of the glenohumeral joint, the interaction of the SGL and the posterior capsule resulted in a tightening of the SGL. The suprascapular nerve moved laterally and stretched underneath the SGL in this position.

Quantitative anthropometry of the subatlantal cervical longitudinal ligaments

STUDY DESIGN

The quantitative anthropometry of the cervical longitudinal ligaments was determined in 20 human cadaveric subatlantal cervical spines at the limits of flexion and extension.

OBJECTIVES

To provide measurements of cervical anterior and posterior longitudinal ligament lengths, widths, and cross-sectional areas at segmental levels.

SUMMARY OF BACKGROUND DATA

Although mathematical models of the cervical spine require specific data to predict kinematics, the anthropometry of the cervical spine has not been examined in detail. The dimensional changes of ligaments in physiologic motion are not well characterized.

METHODS

Segmental lengths and widths of the cervical longitudinal ligaments were measured in sagittal plane flexion and extension, using a three-dimensional electromagnetic digitizer. The cross-sectional areas of the ligaments at resting length were measured with a laser micrometer system. Comparisons between anterior and posterior location and among segmental levels were made. Several ligaments were examined histologically to determine the insertion sites and, thus, to define the segmental length.

RESULTS

The anterior longitudinal ligaments were shorter in flexion than in extension. In extension, they were longer than the posterior longitudinal ligaments in flexion. The resting isolated ligaments were longer than the longest in situ lengths at several vertebral levels. The anterior longitudinal ligaments were wider at the disc than at the body. The cross-sectional area at C2-C3 was smaller than at subaxial levels. The longitudinal ligaments were observed to insert along the entire underlying vertebral body.

CONCLUSIONS

The quantitative anthropometry of the cervical longitudinal ligaments is important in the development of accurate mathematical models of the cervical spine. The in situ ligaments may not be under tension in the physiologic range of motion.

The role of human papillomavirus in the development of pyogenic granulomas

BACKGROUND

Pyogenic granulomas (lobular capillary hemangiomas) and condyloma acuminata share similar locations and risk factors. Human papillomavirus (HPV) types 6 and 11 are commonly associated with condyloma acuminata, but their association with pyogenic granulomas has not been evaluated. The purpose of this study was to determine whether pyogenic granulomas contain evidence of infection with condyloma-producing HPVs.

METHODS

Polymerase chain reaction assays for the E6 and E7 gene sequences of HPV types 6 and 11 and another assay for the E7 region of HPV types 16, 31, 33, 35, 42, and 58 were used to evaluate deoxyribonucleic acid (DNA) extracted from archival pyogenic granuloma biopsies taken from cutaneous and oral epithelium.

RESULTS

Neither cutaneous nor oral pyogenic granulomas contain amplifiable E6 or E7 sequences from any of these viruses.

CONCLUSIONS

Pyogenic granulomas are not caused by HPV 6, 11, 16, 31, 33, 35, 42, or 58. This study does not exclude the possibility that other viruses may be responsible for these tumors.

Stability of meropenem in intravenous solutions

The stability of meropenem in various i.v. fluids stored in various containers for i.v. use was studied. Solutions of meropenem were prepared in a variety of i.v. diluents in polyvinyl chloride (PVC) bags, glass vials, and commercial easy-to-prepare infusion systems. Solutions for storage in PVC bags were prepared with meropenem concentrations of 1 and 20 mg/mL; in glass vials, 2.5 and 50 mg/mL; and in commercial easy-to-prepare infusion systems, 2.5 and 20 mg/mL (Baxter Minibag Plus system) and 1, 5, and 20 mg/mL (ADD-Vantage system, Abbott). The solutions were stored for up to 48 hours at 4-5 or 21-26 degrees C. Meropenem concentrations were determined by high-performance liquid chromatography. The stability of meropenem was influenced by the drug concentration; the drug was stable for a longer time in the 1-mg/mL solution than in the 20- and 50-mg/mL solutions. Stability was also influenced by storage temperature; the drug was stable for a longer time in solutions stored at 4-5 degrees C than in solutions stored at 21-26 degrees C. Meropenem was stable for the longest time in sterile water for injection and in 0.9% sodium chloride injection. The stability of meropenem in solutions in PVC bags, glass vials, Baxter Minibag Plus containers, and ADD-Vantage bags was influenced by the i.v. fluid used to reconstitute the drug, the concentration of the final solution, and the storage temperature.

The use of magnetic resonance imaging in the diagnosis of lumbar disc disease

Low back pain is a common malady, affecting up to 80% of adults at some time. Our diagnostic capabilities have been markedly improved with the introduction and evolution of magnetic resonance imaging. MRI is an accurate modality in the diagnosis of disc herniation, as well as recurrent disc herniation, degenerative disc disease, and other abnormalities that may present as back pain.

Human anterior and posterior cervical longitudinal ligaments possess similar tensile properties

One hundred bone-ligament-bone complexes were isolated from the cervical spines of 20 fresh-frozen human cadavers and mechanically tested in uniaxial tension. Load-elongation curves representing the structural properties of the complex were obtained, and stiffness, ultimate load, energy at failure, and elongation were determined from the curves. Stress-strain curves representing the mechanical properties of the ligament substance were also obtained, and elastic modulus was determined from these curves. Comparisons were made between anterior and posterior longitudinal ligaments and among cervical levels. The cross-sectional area of the anterior ligament was smaller at the C2-C3 level than at subaxial levels. There was a trend toward less stiffness but more energy at failure and greater elastic modulus for the anterior compared with the posterior ligaments at subaxial levels, although the differences were not statistically significant (p > 0.05).

Trends in HIV seroprevalence in men who have sex with men: New York City Department of Health sexually transmitted disease clinics, 1988-1993

OBJECTIVE

To measure HIV seroprevalence trends in a primarily non-white sample (n = 1618) of men who have sex with men (MSM). The MSM were sampled at New York City Department of Health (NYC-DOH) sexually transmitted disease (STD) clinics during 1988-1993.

DESIGN

Unlinked HIV-1 serosurvey using remnant serum originally drawn for routine syphilis screening.

METHOD

Demographic, clinical and risk exposure data were abstracted from clinic charts. No other sources of data were used, and patients were not interviewed.

RESULTS

HIV seroprevalence in the overall sample declined from 53 to 34% between 1988 and 1993. The most dramatic decline was observed in white MSM (from 47 to 17%; n = 457). Seroprevalence in black MSM also fell (from 60 to 45%; n = 691). Seroprevalence in Hispanic men (n = 332) showed no decline, starting and ending the 5-year period at 39%. Bisexual MSM, who comprised one-quarter of the sample, experienced a shallower decline than other MSM (from 41 to 33%). The magnitude of the decline decreased with increasing age--for example, seroprevalence in MSM aged 20-24 years dropped by 62% (from 39 to 15%), whereas seroprevalence in MSM aged 40-44 years dropped by 10% (from 48 to 43%)--up through age 45 years, at which point another dramatic decline (from 53 to 21%) was observed. There was no decline in the high seroprevalence associated with a discharge diagnosis of gonorrhea (58%) or any genital ulcer disease (GUD; e.g., primary or secondary syphilis, chancroid or genital herpes, 52%). The proportion of STD diagnoses attributed to GUD rose from 8 to 14%.

CONCLUSION

A small number of MSM continued to present to NYC-DOH STD clinics and to leave with a diagnosed STD at a time when safe sex was aggressively promoted. The biological and behavioral associations between GUD and gonorrhea and HIV seroprevalence warrant continued investigation. Prevention programs targeted to young, minority and bisexual MSM are needed.

Maurice Klippel

Maurice Klippel (1858-1942) was a turn-of-the-century French internist with a special interest in neurology and psychiatry. He authored numerous medical papers in these disciplines, but is best known to spine surgeons for his description, co-authored with Andre Feil, of a patient with congenital fusion of the cervical vertebrae, a condition now known as Klippel-Feil syndrome.