Hip resurfacing as an outpatient procedure: a comparison of overall cost and review of safety

Abstract

Recent advancements in arthroplasty surgical techniques and perioperative protocols have reduced the duration of hospitalization and length of recovery, allowing surgeons to perform joint replacement as an outpatient procedure. This study aims to evaluate the cost-effectiveness and safety of outpatient hip resurfacing. Two experienced surgeons performed 485 resurfacing surgeries. We retrospectively compared clinical outcomes and patient satisfaction with published outpatient total hip results. Furthermore, we compared average insurance reimbursement with that of local inpatient hip replacement. No major complications occurred within 6 weeks. Of the 39 patients with previous inpatient experience, 37 (95%) believed their outpatient experience was superior. The average reimbursement for hip arthroplasty at local hospitals was $50,000, while the average payment for outpatient resurfacing at our surgery center was $26,000. We conclude that outpatient hip resurfacing can be accomplished safely, with high patient satisfaction, and at a tremendous financial savings to the insurer/patient.

Level of evidence

III

Electronic supplementary material

The online version of this article (10.1007/s12306-020-00637-z) contains supplementary material, which is available to authorized users.

Vertebroplasty and kyphoplasty are associated with an increased risk of secondary vertebral compression fractures: a population-based cohort study

To better understand the risk of secondary vertebral compression fracture (VCF) following a vertebroplasty or kyphoplasty, we compared patients treated with those procedures to patients with a previous VCF. The risk of subsequent fracture was significantly greater among treatment patients, especially within 90 days of the procedure.

INTRODUCTION

Predominantly uncontrolled studies suggest a greater risk of subsequent vertebral compression fractures (VCFs) associated with vertebroplasty/kyphoplasty. To further understand this risk, we conducted a population-based retrospective cohort study using data from a large regional health insurer.

METHODS

Administrative claims procedure codes were used to identify patients receiving either a vertebroplasty or kyphoplasty (treatment group) and a comparison group of patients with a primary diagnosis of VCF who did not receive treatment during the same time period. The main outcomes of interest, validated by two independent medical record reviewers, were any new VCFs within (1) 90 days, (2) 360 days, and (3) at adjacent vertebral levels. Multivariable logistic regression examined the association of vertebroplasty/kyphoplasty with new VCFs.

RESULTS

Among 48 treatment (51% vertebroplasty, 49% kyphoplasty) and 164 comparison patients, treated patients had a significantly greater risk of secondary VCFs than comparison patients for fractures within 90 days of the procedure or comparison group time point [adjusted odds ratio (OR) = 6.8; 95% confidence interval (CI) 1.7-26.9] and within 360 days (adjusted OR = 2.9; 95% CI 1.1-7.9).

CONCLUSIONS

Patients who had undergone vertebroplasty/kyphoplasty had a greater risk of new VCFs compared to patients with prior VCFs who did not undergo either procedure.

Improving patient care by reporting problems with medical devices

Healthcare practitioners are the primary users of medical devices for direct patient care. As such, they are in the best position to recognize problems that result from the use of medical devices. The outcome of a device-related adverse event or product problem, as with any other medical product, can be serious and result in illness injury, or even death. The sooner that FDA learns about a problem, the sooner the agency can take action to protect patient and user safety. Healthcare practitioners are major contributors to the knowledge base related to device use and safety through astute monitoring, rapid identification of device-related problems, and reporting these problems. An understanding of the voluntary and mandatory mechanism of reporting will ensure that device problems are reported appropriately and in a timely manner. As the primary users of medical equipment for direct patient care, health care professionals have the training and expertise to improve patient care by reporting actual and suspected problems with medical devices.

Injury and death associated with hospital bed side-rails: reports to the US Food and Drug Administration from 1985 to 1995

OBJECTIVES

Hospital bed side-rails, while intended for patient protection, can contribute to injury and death. Reports to the Food and Drug Administration (FDA) of hospital bed side-rail entrapment have increased. In this paper entrapment cases are reviewed and the population potentially at risk identified.

METHODS

FDA's database was searched for events involving hospital beds from January 1985 to August 1995 and entrapment cases were identified.

RESULTS

Of 111 entrapments, 65% were associated with death and 23% with injury.

CONCLUSIONS

Advanced age, female sex, low body weight, and cognitive impairment may be associated with increased risk. Preventive measures are detailed.

Home oxygen therapy in Medicare beneficiaries, 1991 and 1992

STUDY OBJECTIVE

Obtain descriptive data on the use of home oxygen by Medicare beneficiaries and study the impact of certain demographic factors and diagnoses on oxygen use.

METHODS

A home oxygen user was defined as any Medicare beneficiary with at least one claim for home oxygen in the Health Care Financing Administration National Claims History 5% Physician Supplier Files for 1991 and 1992. Railroad board beneficiaries, health maintenance organization members, and those without continuous part B coverage were excluded.

RESULTS

In 1991, there were 21,489 beneficiaries in the sample who received oxygen therapy. In 1992, there were 8,418 new users. Twenty-six percent of new users died in 1992. Factors significantly associated with death included age 76 years or older (relative risk [RR], 1.3), pneumonia (RR, 1.3), lung cancer (RR, 3.8), male gender (RR, 1.2), heart failure (RR, 1.3), and diagnoses suggestive of COPD (RR, 0.45). Seven percent of new users discontinued therapy within 1 month, 28% within 6 months. Liquid oxygen was used by 19% of current and 14% of new users. Factors significantly associated with liquid oxygen use included portable oxygen claims (odds ratio [OR], 2.4), nonmetropolitan residence (OR, 0.73), and white race (OR, 1.2).

CONCLUSIONS

Descriptive information on patterns of home oxygen use, including associated medical conditions, types and duration of therapy, and survival is useful for regulatory purposes. This information supports concerns that current payment policy may discourage suppliers from providing liquid oxygen in underserved areas.

Use and effectiveness of condoms during anal intercourse. A review

BACKGROUND AND OBJECTIVES

Anal intercourse has been associated with a high risk of human immunodeficiency virus transmission. Survey data suggest that unprotected anal intercourse is practiced by a substantial proportion of the sexually active population, regardless of sexual orientation.

GOAL

To review the literature related to the use and effectiveness of condoms during anal intercourse, with emphasis on prevention of human immunodeficiency virus transmission.

STUDY DESIGN

Literature review.

RESULTS

Epidemiologic studies have shown that consistent, correct condom use reduces the overall risk of sexual transmission of human immunodeficiency virus. Evidence for the effectiveness of condoms used during anal intercourse is less definitive. Survey and clinical trials data indicate that condom breakage and slippage rates vary during anal intercourse and may be considerably higher than during vaginal intercourse. Although condoms designed for anal intercourse have been studied and marketed in Europe, data on their actual performance are scarce. In addition, no information exists on the effectiveness of polyurethane or other nonlatex condoms for use during anal intercourse.

CONCLUSIONS

Development of newer and more effective condoms for use during anal intercourse requires consideration of the ethical issues involved in testing and marketing devices used during an activity that carries with it the potential for a substantial risk to health.

Prevalence of latex-specific IgE antibodies in hospital personnel

BACKGROUND

Rubber latex hypersensitivity is an important concern for health care workers.

PURPOSE

The Center for Devices and Radiological Health, in collaboration with the Consumer Product Safety Commission, conducted a multicenter study of the prevalence of latex-specific IgE antibodies among United States hospital personnel.

MATERIALS AND METHODS

Nine hospitals participated in the cross-sectional study. A total of 504 hospital personnel completed questionnaires that provided an array of demographic, occupational, and clinical information, including a history, if any, of allergies and the use of latex and nonlatex gloves. More than three-quarters (76.5%) of the participants were tested for total IgE and latex specific IgE.

RESULTS

A total of 21 (5.5%, 95% CI = 3%-7%) of the tested participants were positive for the presence of latex specific IgE antibodies, defined as a latex IgE level of > or = 0.6 ng/mL. Latex specific IgE antibodies were more prevalent in participants who reported tachycardia, palpitations, flushing, or wheezing associated with latex gloves (Odds Ratio = 10.2, 95% CI = 3.7-28.6).

CONCLUSION

The study's results suggest that the prevalence of latex-specific IgE antibodies among hospital personnel is appreciable and these personnel and their health care providers should be aware of this entity.

Medical device vigilance at FDA

This overview of medical device vigilance at the U.S. Food and Drug Administration (FDA) discusses the basic reporting regulation and program at FDA. The FDA program has grown to the point where we now receive over 100,000 reports per year. How FDA examines the data patterns in overall reporting, to identify signals in the database, and the potential actions FDA takes to respond to these problems are also presented. New initiatives include, for example, new methods to triage reports and the move developing an internationally harmonised nomenclature.

The epidemiology of prosthetic heart valves in the United States

The Center for Devices and Radiological Health of the Food and Drug Administration, in collaboration with the National Center for Health Statistics, conducted the Medical Device Implant Supplement to the 1988 National Health Interview Survey, generating the 1st available population-based estimates of the use of prosthetic heart valves in the United States. The 1988 National Health Interview Survey was a massive, nationally representative cross-sectional survey that encompassed 47,485 households and 122,310 individuals. Data from the Medical Device Implant Supplement indicate that an estimated 253,283 persons with 279,175 heart valves were present in the civilian, non-institutionalized US population (population prevalence of 1.1/1,000, 95% CI 0.8-1.3). Prevalence of valve prostheses ranged from 0.2 per 1,000 in those age 44 and under to 5.3 per 1,000 in those 75 years of age and older. Age-adjusted prevalence of valve prostheses did not differ significantly according to sex, race, region of residence, education, or income of recipients. Two thirds of aortic valve recipients identified by the survey were male, compared with only one third of mitral valve recipients. Approximately two thirds of both aortic and mitral valve implants were reported as mechanical. Reported use of anticoagulative agents was significantly more common in recipients of mechanical than of bioprosthetic valves. The single most common reported reason for prosthetic valve implantation was rheumatic heart disease. These data provide useful epidemiologic and public health planning information on prosthetic heart valve use.

The epidemiology of pacemaker implantation in the United States

Data on pacemaker implantation were obtained from the Medical Device Implant Supplement to the 1988 National Health Interview Survey, a nationally representative, population-based survey of 47,485 households (122,310 persons). The survey yielded an estimate of 456,482 noninstitutionalized adults with pacemakers (prevalence, 2.6 per 1,000). Prevalence rose significantly with age, from 0.4 per 1,000 among persons ages 18-64 to 26 per 1,000 among those ages 75 or older. Age-adjusted prevalence in males was 1.5 times that in females, and in whites 1.6 times that in nonwhites, although these differences were of borderline statistical significance. Prevalence did not vary significantly by region of residence, educational level, or income, but was significantly increased (more than threefold) in those reporting any activity limitation compared with those with no limitation. Fifteen percent of pacemakers in use were replacements; about one-fifth of these had been replaced more than twice. Sixty percent of previous pacemakers had been in place for at least 5 years. These data provide the first nationwide, population-based estimates of the epidemiology of pacemaker implantation, focusing particularly on the demographics of U.S. pacemaker recipients.

The estimated effect of oral contraceptive use on the cumulative risk of epithelial ovarian cancer

OBJECTIVE

To determine the effect of oral contraceptive (OC) use on the cumulative incidence of epithelial ovarian cancer from ages 20-40, 20-50, and 20-55 years among four groups of women: positive family history, negative family history, parous, and nulliparous.

METHODS

Cancer and Steroid Hormone Study data were combined with data from the Surveillance, Epidemiology, and End Results Network to provide estimates of the age-specific incidence rates of epithelial ovarian cancer among never-users of OCs in the four specified groups of women. These rates provided the basis for calculating cumulative incidences. The rates in women using OCs were estimated from meta-analyses of the epidemiologic literature, using regression equations expressing the log-relative rate of epithelial ovarian cancer as a function of duration of use and recency.

RESULTS

In all four groups, the cumulative number of epithelial ovarian cancer cases estimated to occur per 100,000 OC users, compared to never-users, decreased with increasing duration of OC use. Our results suggest that 5 years of OC use by nulliparous women can reduce their ovarian cancer risk to the level seen in parous women who never use OCs, and that 10 years of OC use by women with a positive family history can reduce their risk to a level below that for women whose family history is negative and who never use OCs.

CONCLUSION

These data represent the first published estimates of the effect of OC use on the cumulative incidence of epithelial ovarian cancer by family history and by parity. The demonstrated substantial noncontraceptive benefit from OCs justifies their judicious use as a potentially powerful resource for primary prevention in women at high risk of ovarian cancer.

The risk of epithelial ovarian cancer in short-term users of oral contraceptives

Short-term use (less than 1 year) or oral contraceptives has been associated with increased to slightly decreased risks of epithelial ovarian cancer in several studies. To determine what might account for a statistically significant 40% reduction in risk associated with as little as 3 to 6 months of use, a finding previously reported from the Cancer and Steroid Hormone Study, and to consider the implications for mechanisms of pathogenesis, the authors compared numerous characteristics of short-term users of oral contraceptives (41 cases, 412 controls) with those of never users (242 cases, 1,517 controls). The reduced risk among short-term users was consistently restricted to women who stopped using oral contraceptives for medical reasons, which were essentially side effects; there was little evidence of a protective effect among women who stopped for nonmedical reasons. Factors such as age, parity, family history of ovarian cancer, estrogen dose, history of sterilization, and latency (interval from first use) could not account for the finding. These analyses suggest that short-term use of oral contraceptives has little to no effect per se on reducing the risk of epithelial ovarian cancer and that side effects resulting in cessation of oral contraceptive use shortly after it was begun may be indicative of factors that are protective against the disease.

Pain and cyanosis associated with alpha 1-proteinase inhibitor

PURPOSE

The purpose of this study was to investigate adverse reaction reports of pain and/or cyanosis attributed to alpha 1-proteinase inhibitor (A1PI), a plasma alpha-globulin protein used to treat A1PI deficiency.

PATIENTS AND METHODS

The Food and Drug Administration's (FDA) Spontaneous Reporting System for the collection and analysis of suspected adverse reactions to drugs and biologics was searched for all reports with dates from January 1, 1988, through October 31, 1989, in which A1PI was named as the suspect biologic. A case of pain and/or cyanosis was defined and characteristics of cases were compared with all other reactions. Information about the production of A1PI and results from animal studies conducted by the manufacturer were also gathered.

RESULTS

Fourteen cases of acute chest pain, back pain, and/or cyanosis among patients receiving A1PI infusions were reported to the FDA. The clinical aspects of reported cases were consistent with a rapidly acting, nonallergic mechanism and were easily distinguished from other reactions associated with A1PI. The characteristics of reported cases, the epidemic curve, and lot-specific analyses suggested a point source and strongly implicated two A1PI lots. Information about the production of A1PI and results from animal studies further implicated high-molecular-weight polysaccharides associated with sucrose stabilization of the suspect lots.

CONCLUSION

These cases resemble adverse reactions attributed to complexes of protamine and heparin (a mucopolysaccharide). Similar vasoactive mechanisms are suggested. Research is needed to further define the pathophysiology associated with polysaccharide moieties.

Haemophilus b disease after vaccination with Haemophilus b polysaccharide or conjugate vaccine

The reported frequency of invasive Haemophilus influenzae type b disease occurring within 1 year after immunization was compared in American children who received either Praxis Biologics' Haemophilus b polysaccharide vaccine or Connaught Laboratories' Haemophilus b conjugate vaccine during the first year of distribution. All domestic cases reported to the Food and Drug Administration or the Centers for Disease Control were included in the study. An estimated 4.5 million and 2.0 million doses of polysaccharide and conjugate vaccines were administered, respectively. Approximately three cases of early-onset disease (disease developing less than 15 days after vaccination) per million doses were reported for the polysaccharide compared with four cases per million doses for the conjugate vaccine. There were 30.7 reported vaccine failures per million doses of the polysaccharide vaccine compared with 9.0 per million doses of the conjugate vaccine, a 3.4-fold difference. The reporting rate ratios (cases of vaccine failure to cases of early-onset disease) for the polysaccharide and conjugate were 11.5 and 2.3, respectively, a fivefold difference. Thus, compared with recipients of the polysaccharide vaccine, vaccine failures reported among recipients of the conjugate vaccine were 80% fewer than expected.

Trends in the content and use of oral contraceptives in the United States, 1964-88

Drug marketing and physician survey data were used to examine trends in the use and hormonal content of oral contraceptives in the United States between 1964 and 1988. Retail prescriptions for oral contraceptives peaked at approximately 68 million in 1973 and have remained between 50 million and 60 million since 1981. Despite this relative consistency in the number of prescriptions, physician "mentions" of oral contraceptives have increased by approximately 75 percent. This increase may reflect closer monitoring of women on oral contraceptives. Use of multiphasic formulations has steadily risen, accounting for 37 percent of the oral contraceptive prescriptions in 1988. Mean estrogen and progestin doses in all types of formulations have steadily declined. A change in the type of estrogen and progestin used in preparations has coincided with this decline in dose. The association between age and use of high-dose formulations seen in the past was no longer evident in 1988. The data demonstrate that oral contraceptive formulations in wide use today differ in hormone content from those of the past, when most of the major studies addressing the risks associated with oral contraceptive use were completed. There is therefore a need to determine the risks and long-term effects associated with these newer formulations.

Thyroid hormone use: trends in the United States from 1960 through 1988

Thyroid hormone preparations comprised over 1% of all prescriptions filled by retail pharmacies during 1988 in the conterminous United States, i.e., the 48 contiguous states. Their large market share gives the patterns of their use substantial public health importance. This article describes prescription thyroid hormone use in the United States from 1960 through 1988, using pharmaceutical marketing research data collected from panels of retail pharmacies and office-based physicians. Although the use of natural products has declined by over 50% since 1960, about one fourth of all thyroid hormone prescriptions were for natural preparations as recently as 1988. Per capita thyroid mentions (i.e., patient-physician contacts during which a thyroid agent of any kind was recommended, prescribed, dispensed, administered, ordered to be given by a hospital, or given as a sample) doubled during this period among those over 59 years old. Per capita mentions for synthetic thyroid products increased fourfold and tenfold among men and women in this age group, respectively. Use for weight loss, despite the label's boxed warning indicating it to be ineffective and potentially dangerous, has diminished but persists. Obesity was second only to hypothyroidism among the diagnoses underlying thyroid product mentions.

Deaths due to accidents and violence in two recent trials of cholesterol-lowering drugs

The Helsinki Heart Study and the Lipid Research Clinics Coronary Primary Prevention Trial both reported higher rates of deaths due to homicides, suicides, and accidents in the groups receiving cholesterol-lowering agents compared with the groups receiving placebos. We examined these deaths in the active treatment arms of the two trials to determine if there were some readily explainable causes or if the cholesterol-lowering agents might be a factor. Our examination showed that the two homicides were victims, not offenders, and one had stopped treatment because of myocardial infarction 1 year before his death. Five of the eight suicides had dropped out of the trials and had not taken the cholesterol-lowering drugs for periods of months to years prior to committing suicide. Of the 10 deaths due to accidents, two were dropouts from the trials, three others had high blood alcohol concentrations detectable at autopsy, and another three reported a history of psychiatric symptoms and/or treatment prior to entry. When dropouts and known risk factors for these deaths such as alcohol intoxication and psychiatric histories are considered, little evidence remains to support the hypothesis that cholesterol-lowering drugs are causally associated with deaths due to homicides, suicides, and accidents in these trials.

Prescribed use of cholesterol-lowering drugs in the United States, 1978 through 1988

Data from two pharmaceutical marketing research databases, the National Prescription Audit and the National Disease and Therapeutic Index, were used to study trends in outpatient use of cholesterol-lowering drugs in the United States from 1978 through 1988. Retail pharmacies dispensed an estimated 4.4 million prescriptions for cholesterol-lowering drugs in 1978. This declined to 2.6 million in 1983 and increased dramatically to nearly 13 million in 1988. This fivefold increase between 1983 and 1988 was accounted for primarily by the introduction and use of two new drugs, gemfibrozil and lovastatin, and, to a lesser extent, by the increasing use of some older drugs. In 1988, after 1 full year of marketing, lovastatin was the leading cholesterol-lowering drug, followed closely by gemfibrozil; both drugs are currently considered second-line agents. Clofibrate and dextrothyroxine, drugs that ranked first and second in 1978, declined to ranks of sixth and eighth out of eight in 1988. Cholestyramine, gemfibrozil, and lovastatin accounted for about 75% of all lipid-lowering prescriptions in 1988. From 1978 through 1988, an average 54% of individuals using cholesterol-lowering drugs were 60 years of age or older. The 13 million prescriptions for cholesterol-lowering drugs in 1988 represent a maximum estimate of 13 million treated individuals. This number compares with the 60 million Americans with high cholesterol levels who are candidates for dietary advice, and, if cholesterol levels do not improve, for combined diet and drug intervention.

Outpatient antiarrhythmic drug use from 1970 through 1986

Antiarrhythmic drugs have been marketed in the United States for more than three decades. However, little is known about the prevalence of use of these drugs. Using data from the National Prescription Audit, we examined trends in outpatient use of oral antiarrhythmic agent types 1 and 3 from 1970 through 1986. Using the National Disease and Therapeutic Index, we assessed prescribing physician specialty and general demographic and clinical characteristics of recipients. We adjusted the numbers of prescriptions dispensed for broad changes in the US population demographics over the 17-year period. From 1970 through 1986 the number of antiarrhythmic agent prescriptions dispensed increased by 200%, from 3.8 million to 11.5 million. This increase is greater than that expected due to changes in size of the US population, estimated changes in prevalence of heart disease, or estimated changes in the proportion of patients with heart disease who have arrhythmias. The weight of evidence suggests that more persons were receiving antiarrhythmic agents in 1986 than in 1970. Physicians probably recognized and/or treated arrhythmias more frequently in 1986 than in 1970.

Prevalence and treatment of asthma in the Michigan Medicaid patient population younger than 45 years, 1980-1986

The prevalence and outpatient treatment of asthma were studied in the Michigan Medicaid patient population by use of computerized physician, hospital, and pharmacy reimbursement data to mark and track asthma-related medical transactions. Asthma cases were defined as patients with evidence of at least two diagnoses and prescription drug transactions consistent with asthma. More than 52,000 cases were thus identified. The period prevalence of asthma was estimated on a year-by-year basis. The prevalence of asthma in the population increased from 2.0 per 100 Medicaid patients in 1980 to 2.8 per 100 Medicaid patients in 1986. Prevalence decreased with age until the age of 20 years and increased thereafter, and was higher in male children than in female children. In contrast, asthma was more prevalent in female adults than in male adults. Prevalence was higher in black subjects than in other races and higher in urban residents than in rural residents. The total number of reimbursements for antiasthma medications increased from 60,000 per year to 120,000 per year, and the average number of antiasthma prescriptions per Michigan Medicaid asthma case increased at the rate of 6.6% per year during the study interval. Changes in the preferred types of asthma treatment consistent with changes that have occurred in the general population were observed. These data suggest that the relative and absolute occurrence of asthma and asthma treatment in the Michigan Medicaid population is increasing.

Antihypertensive drug use. Trends in the United States from 1973 to 1985

Hypertension, a major public health problem, often requires drug therapy. We examined trends in outpatient antihypertensive drug use in the United States from 1973 to 1985. The numbers of prescriptions and the diagnostic and drug treatment information were obtained from the National Prescription Audit (Ambler, Pa, IMS America, 1985) the National Disease and Therapeutic Index (Ambler, Pa, IMS America, 1985), ongoing surveys of pharmacies, and office-based physicians. We adjusted drug-use data for the fact that several antihypertensive drugs also have other uses. During the study period, the annual numbers of prescriptions for treatment of hypertension progressively increased from 128.1 to 208.6 million, an average change of 5% per year. In 1973, the three leading classes of antihypertensive drugs were thiazide diuretic agents, peripheral neuronal inhibitors, and central alpha-adrenergic receptor stimulators. By 1985, the thiazide drugs were still the leader, followed by beta-adrenergic receptor blockers and potassium-sparing diuretic drugs. The use trends presented are consistent with surveys indicating increased drug therapy of hypertension from 1960 to the present.

Clostridium perfringens food poisoning: use of serotyping in an outbreak setting

An outbreak of Clostridium perfringens food poisoning occurred among attendees of a firehouse luncheon. The predominant symptoms of diarrhea (100%) and abdominal pain (81%) among case-patients, the mean incubation period (13.4 h), and the mean duration of illness (21.2 h) were all characteristic of C. perfringens enteritis. Roast beef, although not epidemiologically implicated, was the most likely vehicle of transmission. Fecal specimens from case-patients contained a median C. perfringens spore count of greater than 10(6) and yielded isolates that were heat sensitive and predominantly nonhemolytic, produced C. perfringens enterotoxin A, and, in the majority of specimens (four of five), were identical in serotype. Food samples were negative. This outbreak demonstrates that following enumeration of C. perfringens from a suitable number of fecal specimens from case-patients, serotyping of the isolates may be helpful in implicating C. perfringens as the cause of foodborne illness. This is especially true when implicated food items test negative or are no longer available for testing.

An outbreak of tuberculosis in rural Delaware

A total of 35 patients diagnosed with tuberculosis in 1976-1984 were identified as part of a sustained outbreak involving five communities located in southern Delaware. The index case, a 25-year-old black female with sputum smear-positive, cavitary pulmonary tuberculosis, was a sexual partner of three other persons with cavitary pulmonary tuberculosis and a close contact of 10 other persons with tuberculosis. The median age of the 35 patients was 23 years (range 15 months to 77 years), and 13 (37%) were less than 15 years of age. Sixteen patients (46%) were male, and 34 (97%) were black. Pulmonary parenchymal disease was noted in 18 cases (51%), including nine (26%) with cavitary lesions; 11 (31%) had lymphatic disease (hilar and/or mediastinal); five (14%) had pleural disease; and one (3%) had a normal chest radiograph. Infection prevalence (per 100 tested) was 44.7 for close contacts of cases and 18.3 for other than close contacts, and disease prevalence (per 100 tested) was 8.9 and 1.4 for those two groups, respectively. This outbreak highlights several points: Outbreaks of tuberculosis may go undetected for several years; aggressive and complete surveillance and containment efforts are needed to control tuberculosis; and tuberculosis in children and minorities is still a problem in the United States.

An outbreak of acute infectious nonbacterial gastroenteritis in a high school in Maryland

An outbreak of acute infectious nonbacterial gastroenteritis (AING) occurred in a high school in Maryland in 1984. Thirty-six percent of students surveyed met the case definition of gastroenteritis, as did 24 percent of school employees. Eating lunch in the cafeteria on January 30 was significantly associated with illness. After controlling for other food items consumed during the January 30 lunch, only the sandwiches were significantly associated with illness, but the source of the contamination was not identified. Four of 17 serum pairs from sick students and none of the 8 serum pairs from exposed controls (a nonsignificant difference) showed at least a 4-fold rise in antibody titre to Norwalk virus between acute- and convalescent-phase specimens. This outbreak of AING is believed to be the first to implicate epidemiologically sandwiches as vehicles of transmission. The outbreak highlights the need for investigators to look for a viral etiology in gastroenteritis outbreaks.

Hemolytic-uremic syndrome: a population-based study in Washington, DC and Baltimore, Maryland

A population-based study of hemolytic-uremic syndrome (HUS) revealed that 20 child residents of Washington, DC and Baltimore, Maryland were hospitalized with HUS from January 1979 through September 1983. The number of cases peaked during the summer and fall; none occurred during the winter. Incidence of hospitalized cases was higher in Whites and girls than in Blacks or boys, and the average annual incidence was 1.08 cases/100,000 children less than 5 year old. This study demonstrates that HUS is not unique to the West Coast, as previously suggested.

Vaccine-associated poliomyelitis in a household contact with Netherton's syndrome receiving long-term steroid therapy

Paralytic poliomyelitis developed in a man 51 days after his two-month-old daughter received her first dose of trivalent live oral poliovirus vaccine. The patient was receiving long-term glucocorticosteroid therapy (tapered to 12.5 mg per day for the eight months prior to his poliomyelitis) for Netherton's syndrome, a congenital syndrome characterized by bamboo-like hair, hyperkeratotic and hyperhidrotic skin, and multiple allergies. The patient was ventilator-dependent and quadriplegic throughout most of his hospital stay and died in the hospital 10 months after the onset of paralysis. "Vaccine-like" type 3 poliovirus was isolated from a stool specimen and his serum showed a significant rise in neutralizing antibody titer against type 3 virus. This case report represents the first documented case of vaccine-associated poliomyelitis in a household contact receiving glucocorticosteroids, although evidence of immunosuppression was not documented. Nevertheless, the case reinforces current recommendations not to administer oral poliovirus vaccine to persons known to be immune deficient or suppressed or to normal persons with close contacts known to be immune deficient or suppressed.

Shelters for battered women and their children: an under-recognized source of communicable disease transmission

A survey of 73 full-time government-funded shelters for battered women and their children from five geographic regions in 15 states provided information on communicable disease problems and control measures (focusing on diarrheal illness). Outbreaks of diarrheal illness involving more than 10 persons were reported by 12 per cent (9/73) of shelter directors. Less than half reported screening potential residents for communicable diseases before admitting them, and the majority reported that most of their staff are trained in basics of first aid, principles of hygiene, and experienced in day care work. More than half of the staff in the majority of shelters are counselors, but only 5 per cent (4/73) of shelters have health care workers. Less than one-fourth of the shelters have areas designated for diapering infants and less than half of the shelter directors knew of specified health regulations applying to their shelter. For most shelters, limitations on staff size, training, and funding may restrict the types of disease control measures they can apply. However, basic hygienic practices, such as strict handwashing and identification and cohorting of sick clients, may be effective in disease prevention.

Adverse reactions reported following receipt of Haemophilus influenzae type b vaccine: an analysis after 1 year of marketing

An analysis of adverse reactions occurring after receipt of Haemophilus influenzae type b vaccine and reported to the Food and Drug Administration during the first year of marketing of the product was performed. During the period April 1985 to May 1986, adverse reaction reports on 152 patients, excluding those of vaccine failure and concurrent infection, were received. Several adverse reactions not previously recognized, including convulsions, allergic reactions such as anaphylactoid-like and serum sickness-like reactions, and vomiting were received. The vast majority of adverse reactions were benign. Because there are many biases that result in the reporting of or failure to report an adverse reaction, it is not possible to derive a rate of reactions from these data. Furthermore, causality cannot be inferred from any single report. The data, however, indicate that, in light of widespread use of the vaccine, its use appears to be safe.

An outbreak of phototoxic dermatitis due to limes

During the week beginning July 29, 1984, 12 children in a day camp in a suburb of Baltimore, Maryland, were noted to have skin eruptions consistent with phototoxic dermatitis. These eruptions were confined to the hands, wrists, and forearms, and appeared as discrete and confluent polymorphous patches and linear streaks. These eruptions were also macular, hyperpigmented, and nonpruritic. Clinical examination revealed that 97 (16%) of 622 children, seven (7%) of 104 counselors, and no adult staff members had a similar rash. Onsets of the rash ranged from July 19-August 11, with peak occurrence on July 25-27. All camp members were white. Sex did not vary significantly between those affected and not affected. The mean age (5.3 years) of affected children was significantly different from the mean age (6.9 years) of unaffected children (p less than 0.001). Attack rates for the eight camp units were highest in two units (57% and 74%, respectively) and ranged between 0-6% for the other six units. Activities involving work with hands by various camp units were investigated. Only exposure to making pomander balls (sachets) in arts and crafts class (when other activities were controlled for) was significantly associated with illness (p less than 0.03). In making pomander balls, children punctured the skin of limes (the principal component) with scissors, releasing oils known to contain photoreactive furocoumarin (psoralen) compounds. These compounds evidently coated the children's skin and, upon exposure to the sun, caused a phototoxic dermatitis. An environmental and botanical survey of the camp did not reveal other phototoxic agents with which campers may have had contact. This is one of the largest reported outbreaks of phototoxic dermatitis and the first in which a citrus fruit was implicated on a large scale.