Sociodemographic and Clinical Characteristics Associated With Recent Incarceration Among People With HIV, United States, 2015-2017

OBJECTIVES

We examined sociodemographic, clinical, and behavioral factors associated with previous incarceration among people with diagnosed HIV to inform HIV care efforts for this population.

METHODS

We used 2015-2017 data from a cross-sectional, nationally representative sample of US adults with diagnosed HIV (N = 11 739). We computed weighted percentages and 95% CIs to compare the characteristics of people with HIV incarcerated in the past 12 months (ie, recently) with people with HIV not recently incarcerated. We used adjusted prevalence ratios (aPRs) with predicted marginal means to examine associations between selected factors and incarceration status.

RESULTS

Adults with HIV who were recently incarcerated, when compared with those who were not, were more likely to be aged 18-29 years (prevalence ratio [PR] = 2.51), non-Hispanic Black (PR = 1.39), less educated (

CONCLUSIONS

Among people with HIV, recent incarceration was associated with increased health risks and worse health outcomes. Pre- and postrelease linkage-to-care interventions and reentry services might improve the health of recently incarcerated people with HIV.

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Key Words

• HIV
• correctional health
• incarceration
• justice-involved people

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MESH Headings

• Adult
• Humans
• Cross-Sectional Studies
• HIV Infections/epidemiology
• Prisoners
• United States/epidemiology
• Unsafe Sex
• Adolescent
• Young Adult
• Black or African American

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Affiliation(s)

Jovanni V. Reyes Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Ranell L. Myles Office of the Director, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Qingwei Luo Strategic Innovative Solutions, LLC, Clearwater, FL, USA
Linda Beer Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Deron C. Burton Office of the Director, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA

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COVID-19 Clinical Phenotypes: Presentation and Temporal Progression of Disease in a Cohort of Hospitalized Adults in Georgia, United States

BACKGROUND

The epidemiological features and outcomes of hospitalized adults with coronavirus disease 2019 (COVID-19) have been described; however, the temporal progression and medical complications of disease among hospitalized patients require further study. Detailed descriptions of the natural history of COVID-19 among hospitalized patients are paramount to optimize health care resource utilization, and the detection of different clinical phenotypes may allow tailored clinical management strategies.

METHODS

This was a retrospective cohort study of 305 adult patients hospitalized with COVID-19 in 8 academic and community hospitals. Patient characteristics included demographics, comorbidities, medication use, medical complications, intensive care utilization, and longitudinal vital sign and laboratory test values. We examined laboratory and vital sign trends by mortality status and length of stay. To identify clinical phenotypes, we calculated Gower's dissimilarity matrix between each patient's clinical characteristics and clustered similar patients using the partitioning around medoids algorithm.

RESULTS

One phenotype of 6 identified was characterized by high mortality (49%), older age, male sex, elevated inflammatory markers, high prevalence of cardiovascular disease, and shock. Patients with this severe phenotype had significantly elevated peak C-reactive protein creatinine, D-dimer, and white blood cell count and lower minimum lymphocyte count compared with other phenotypes (P < .01, all comparisons).

CONCLUSIONS

Among a cohort of hospitalized adults, we identified a severe phenotype of COVID-19 based on the characteristics of its clinical course and poor prognosis. These findings need to be validated in other cohorts, as improved understanding of clinical phenotypes and risk factors for their development could help inform prognosis and tailored clinical management for COVID-19.

Predictors at admission of mechanical ventilation and death in an observational cohort of adults hospitalized with COVID-19

Background

Coronavirus disease (COVID-19) can cause severe illness and death. Predictors of poor outcome collected on hospital admission may inform clinical and public health decisions.

Methods

We conducted a retrospective observational cohort investigation of 297 adults admitted to eight academic and community hospitals in Georgia, United States, during March 2020. Using standardized medical record abstraction, we collected data on predictors including admission demographics, underlying medical conditions, outpatient antihypertensive medications, recorded symptoms, vital signs, radiographic findings, and laboratory values. We used random forest models to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CI) for predictors of invasive mechanical ventilation (IMV) and death.

Results

Compared with age <45 years, ages 65–74 years and ≥75 years were predictors of IMV (aOR 3.12, CI 1.47–6.60; aOR 2.79, CI 1.23–6.33) and the strongest predictors for death (aOR 12.92, CI 3.26–51.25; aOR 18.06, CI 4.43–73.63). Comorbidities associated with death (aORs from 2.4 to 3.8, p <0.05) included end-stage renal disease, coronary artery disease, and neurologic disorders, but not pulmonary disease, immunocompromise, or hypertension. Pre-hospital use vs. non-use of angiotensin receptor blockers (aOR 2.02, CI 1.03–3.96) and dihydropyridine calcium channel blockers (aOR 1.91, CI 1.03–3.55) were associated with death.

Conclusions

After adjustment for patient and clinical characteristics, older age was the strongest predictor of death, exceeding comorbidities, abnormal vital signs, and laboratory test abnormalities. That coronary artery disease, but not chronic lung disease, was associated with death among hospitalized patients warrants further investigation, as do associations between certain antihypertensive medications and death.

Epidemiology of tuberculosis among children and adolescents in the USA, 2007-17: an analysis of national surveillance data

BACKGROUND

Understanding tuberculosis epidemiology among children and adolescents informs treatment and prevention efforts, and efforts to eliminate disparities in tuberculosis incidence and mortality. We sought to describe the epidemiology of children and adolescents with tuberculosis disease in the USA, including tuberculosis incidence rates by parental country of birth and for US territories and freely associated states, which have not been previously described.

METHODS

We analysed data for children aged younger than 15 years and adolescents aged 15-17 years with tuberculosis disease reported to the National Tuberculosis Surveillance System during 2007-17, and calculated tuberculosis incidence rates using population estimates from the US Census Bureau.

FINDINGS

During 2010-17, 6072 tuberculosis cases occurred among children and adolescents; of these, 5175 (85%) of 6072 occurred in the 50 US states or the District of Columbia and 897 (15%) of 6072 in US-affiliated islands. In US states, 3520 (68%) of 5175 cases occurred among US-born people overall, including 2977 (76%) of 3896 children and 543 (42%) of 1279 adolescents. The incidence rate among children and adolescents was 1·0 per 100 000 person-years during 2007-17 and declined 47·8% (95% CI -51·4 to -44·1) during this period. We observed disproportionately high tuberculosis rates among children and adolescents of all non-white racial or ethnic groups, people living in US-affiliated islands, and children born in or with parents from tuberculosis-endemic countries.

INTERPRETATION

Overall, tuberculosis incidence among children and adolescents in the USA is low and steadily declining, but additional efforts are needed to eliminate disparities in incidence and mortality.

FUNDING

US Centers for Disease Control and Prevention.

Weekly miscarriage rates in a community-based prospective cohort study in rural western Kenya

OBJECTIVE

Information on adverse pregnancy outcomes is important to monitor the impact of public health interventions. Miscarriage is a challenging end point to ascertain and there is scarce information on its rate in low-income countries. The objective was to estimate the background rate and cumulative probability of miscarriage in rural western Kenya.

DESIGN

This was a population-based prospective cohort.

PARTICIPANTS AND SETTING

Women of childbearing age were followed prospectively to identify pregnancies and ascertain their outcomes in Siaya County, western Kenya. The cohort study was carried out in 33 adjacent villages under health and demographic surveillance.

OUTCOME MEASURE

Miscarriage.

RESULTS

Between 2011 and 2013, among 5536 women of childbearing age, 1453 pregnancies were detected and 1134 were included in the analysis. The cumulative probability was 18.9%. The weekly miscarriage rate declined steadily with increasing gestation until approximately 20 weeks. Known risk factors for miscarriage such as maternal age, gravidity, occupation, household wealth and HIV infection were confirmed.

CONCLUSIONS

This is the first report of weekly miscarriage rates in a rural African setting in the context of high HIV and malaria prevalence. Future studies should consider the involvement of community health workers to identify the pregnancy cohort of early gestation for better data on the actual number of pregnancies and the assessment of miscarriage.

Risks of miscarriage and inadvertent exposure to artemisinin derivatives in the first trimester of pregnancy: a prospective cohort study in western Kenya

BACKGROUND

The artemisinin anti-malarials are widely deployed as artemisinin-based combination therapy (ACT). However, they are not recommended for uncomplicated malaria during the first trimester because safety data from humans are scarce.

METHODS

This was a prospective cohort study of women of child-bearing age carried out in 2011-2013, evaluating the relationship between inadvertent ACT exposure during first trimester and miscarriage. Community-based surveillance was used to identify 1134 early pregnancies. Cox proportional hazard models with left truncation were used.

RESULTS

The risk of miscarriage among pregnancies exposed to ACT (confirmed + unconfirmed) in the first trimester, or during the embryo-sensitive period (≥6 to <13 weeks gestation) was higher than among pregnancies unexposed to anti-malarials in the first trimester: hazard ratio (HR) = 1.70, 95 % CI (1.08-2.68) and HR = 1.61 (0.96-2.70). For confirmed ACT-exposures (primary analysis) the corresponding values were: HR = 1.24 (0.56-2.74) and HR = 0.73 (0.19-2.82) relative to unexposed women, and HR = 0.99 (0.12-8.33) and HR = 0.32 (0.03-3.61) relative to quinine exposure, but the numbers of quinine exposures were very small.

CONCLUSION

ACT exposure in early pregnancy was more common than quinine exposure. Confirmed inadvertent artemisinin exposure during the potential embryo-sensitive period was not associated with increased risk of miscarriage. Confirmatory studies are needed to rule out a smaller than three-fold increase in risk.

Risk of Injection-Site Abscess among Infants Receiving a Preservative-Free, Two-Dose Vial Formulation of Pneumococcal Conjugate Vaccine in Kenya

There is a theoretical risk of adverse events following immunization with a preservative-free, 2-dose vial formulation of 10-valent-pneumococcal conjugate vaccine (PCV10). We set out to measure this risk. Four population-based surveillance sites in Kenya (total annual birth cohort of 11,500 infants) were used to conduct a 2-year post-introduction vaccine safety study of PCV10. Injection-site abscesses occurring within 7 days following vaccine administration were clinically diagnosed in all study sites (passive facility-based surveillance) and, also, detected by caregiver-reported symptoms of swelling plus discharge in two sites (active household-based surveillance). Abscess risk was expressed as the number of abscesses per 100,000 injections and was compared for the second vs first vial dose of PCV10 and for PCV10 vs pentavalent vaccine (comparator). A total of 58,288 PCV10 injections were recorded, including 24,054 and 19,702 identified as first and second vial doses, respectively (14,532 unknown vial dose). The risk ratio for abscess following injection with the second (41 per 100,000) vs first (33 per 100,000) vial dose of PCV10 was 1.22 (95% confidence interval [CI] 0.37–4.06). The comparator vaccine was changed from a 2-dose to 10-dose presentation midway through the study. The matched odds ratios for abscess following PCV10 were 1.00 (95% CI 0.12–8.56) and 0.27 (95% CI 0.14–0.54) when compared to the 2-dose and 10-dose pentavalent vaccine presentations, respectively. In Kenya immunization with PCV10 was not associated with an increased risk of injection site abscess, providing confidence that the vaccine may be safely used in Africa. The relatively higher risk of abscess following the 10-dose presentation of pentavalent vaccine merits further study.

Epidemiology of respiratory syncytial virus infection in rural and urban Kenya

BACKGROUND

Information on the epidemiology of respiratory syncytial virus (RSV) infection in Africa is limited for crowded urban areas and for rural areas where the prevalence of malaria is high.

METHODS

At referral facilities in rural western Kenya and a Nairobi slum, we collected nasopharyngeal/oropharyngeal (NP/OP) swab specimens from patients with influenza-like illness (ILI) or severe acute respiratory illness (SARI) and from asymptomatic controls. Polymerase chain reaction assays were used for detection of viral pathogens. We calculated age-specific ratios of the odds of RSV detection among patients versus the odds among controls. Incidence was expressed as the number of episodes per 1000 person-years of observation.

RESULTS

Between March 2007 and February 2011, RSV was detected in 501 of 4012 NP/OP swab specimens (12.5%) from children and adults in the rural site and in 321 of 2744 NP/OP swab specimens (11.7%) from those in the urban site. Among children aged <5 years, RSV was detected more commonly among rural children with SARI (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.2-3.3), urban children with SARI (OR, 8.5; 95% CI, 3.1-23.6), and urban children with ILI (OR, 3.4; 95% CI, 1.2-9.6), compared with controls. The incidence of RSV disease was highest among infants with SARI aged <1 year (86.9 and 62.8 episodes per 1000 person-years of observation in rural and urban sites, respectively).

CONCLUSIONS

An effective RSV vaccine would likely substantially reduce the burden of respiratory illness among children in rural and urban areas in Africa.

Respiratory syncytial virus circulation in seven countries with Global Disease Detection Regional Centers

BACKGROUND

Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections in young children globally, with the highest burden in low- and middle-income countries where the association between RSV activity and climate remains unclear.

METHODS

Monthly laboratory-confirmed RSV cases and associations with climate data were assessed for respiratory surveillance sites in tropical and subtropical areas (Bangladesh, China, Egypt, Guatemala, Kenya, South Africa, and Thailand) during 2004-2012. Average monthly minimum and maximum temperatures, relative humidity, and precipitation were calculated using daily local weather data from the US National Climatic Data Center.

RESULTS

RSV circulated with 1-2 epidemic periods each year in site areas. RSV seasonal timing and duration were generally consistent within country from year to year. Associations between RSV and weather varied across years and geographic locations. RSV usually peaked in climates with high annual precipitation (Bangladesh, Guatemala, and Thailand) during wet months, whereas RSV peaked during cooler months in moderately hot (China) and arid (Egypt) regions. In South Africa, RSV peaked in autumn, whereas no associations with seasonal weather trends were observed in Kenya.

CONCLUSIONS

Further understanding of RSV seasonality in developing countries and various climate regions will be important to better understand the epidemiology of RSV and for timing the use of future RSV vaccines and immunoprophylaxis in low- and middle-income countries.

Demographic, socio-economic and geographic determinants of seasonal influenza vaccine uptake in rural western Kenya, 2011

Influenza-associated acute lower respiratory infections cause a considerable burden of disease in rural and urban sub-Saharan Africa communities with the greatest burden among children. Currently, vaccination is the best way to prevent influenza infection and accompanying morbidities. We examined geographic, socio-economic and demographic factors that contributed to acceptance of childhood seasonal influenza vaccination among children living in a population-based morbidity surveillance system in rural western Kenya, where influenza vaccine was offered free-of-charge to children 6 months-10 years old from April to June, 2011. We evaluated associations between maternal and household demographic variables, socio-economic status, and distance from home to vaccination clinics with family vaccination status. 7249 children from 3735 households were eligible for vaccination. Of these, 2675 (36.9%) were fully vaccinated, 506 (7.0%) were partially vaccinated and 4068 (56.1%) were not vaccinated. Children living in households located >5km radius from the vaccination facilities were significantly less likely to be vaccinated (aOR=0.70; 95% CI 0.54-0.91; p=0.007). Children with mothers aged 25-34 and 35-44 years were more likely to be vaccinated than children with mothers less than 25 years of age (aOR=1.36; 95% CI 1.15-1.62; p<0.001; and aOR=1.35; 95% CI 1.10-1.64; p=0.003, respectively). Finally, children aged 2-5 years and >5 years of age (aOR=1.38; 95% CI 1.20-1.59; p<0.001; and aOR=1.41; 95% CI 1.23-1.63; p<0.001, respectively) and who had a sibling hospitalized within the past year (aOR=1.73; 95% CI 1.40-2.14; p<0.001) were more likely to be vaccinated. Shorter distance from the vaccination center, older maternal and child age, household administrator's occupation that did not require them to be away from the home, and having a sibling hospitalized during the past year were associated with increased likelihood of vaccination against influenza in western Kenya. These findings should inform the design of future childhood seasonal influenza vaccination campaigns in rural Kenya, and perhaps elsewhere in Africa.

Influenza and malaria coinfection among young children in western Kenya, 2009-2011

BACKGROUND

Although children <5 years old in sub-Saharan Africa are vulnerable to both malaria and influenza, little is known about coinfection.

METHODS

This retrospective, cross-sectional study in rural western Kenya examined outpatient visits and hospitalizations associated with febrile acute respiratory illness (ARI) during a 2-year period (July 2009-June 2011) in children <5 years old.

RESULTS

Across sites, 45% (149/331) of influenza-positive patients were coinfected with malaria, whereas only 6% (149/2408) of malaria-positive patients were coinfected with influenza. Depending on age, coinfection was present in 4%-8% of outpatient visits and 1%-3% of inpatient admissions for febrile ARI. Children with influenza were less likely than those without to have malaria (risk ratio [RR], 0.57-0.76 across sites and ages), and children with malaria were less likely than those without to have influenza (RR, 0.36-0.63). Among coinfected children aged 24-59 months, hospital length of stay was 2.7 and 2.8 days longer than influenza-only-infected children at the 2 sites, and 1.3 and 3.1 days longer than those with malaria only (all P < .01).

CONCLUSIONS

Coinfection with malaria and influenza was uncommon but associated with longer hospitalization than single infections among children 24-59 months of age.

Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007

BACKGROUND

Over the past 2 decades, multiple interventions have been developed to prevent catheter-associated urinary tract infections (CAUTIs). The CAUTI prevention guidelines of the Healthcare Infection Control Practices Advisory Committee were recently revised.

OBJECTIVE

To examine changes in rates of CAUTI events in adult intensive care units (ICUs) in the United States from 1990 through 2007.

METHODS

Data were reported to the Centers for Disease Control and Prevention (CDC) through the National Nosocomial Infections Surveillance System from 1990 through 2004 and the National Healthcare Safety Network from 2006 through 2007. Infection preventionists in participating hospitals used standard methods to identify all CAUTI events (categorized as symptomatic urinary tract infection [SUTI] or asymptomatic bacteriuria [ASB]) and urinary catheter-days (UC-days) in months selected for surveillance. Data from all facilities were aggregated to calculate pooled mean annual SUTI and ASB rates (in events per 1,000 UC-days) by ICU type. Poisson regression was used to estimate percent changes in rates over time.

RESULTS

Overall, 36,282 SUTIs and 22,973 ASB episodes were reported from 367 facilities representing 1,223 adult ICUs, including combined medical/surgical (505), medical (212), surgical (224), coronary (173), and cardiothoracic (109) ICUs. All ICU types experienced significant declines of 19%-67% in SUTI rates and 29%-72% in ASB rates from 1990 through 2007. Between 2000 and 2007, significant reductions in SUTI rates occurred in all ICU types except cardiothoracic ICUs.

CONCLUSIONS

Since 1990, CAUTI rates have declined significantly in all major adult ICU types in facilities reporting to the CDC. Further efforts are needed to assess prevention strategies that might have led to these decreases and to implement new CAUTI prevention guidelines.

A qualitative study of pandemic influenza preparedness among small and medium-sized businesses in New York City

Small businesses need to engage in continuity planning to assure delivery of goods and services and to sustain the economy during an influenza pandemic. This is especially true in New York City, where 98 per cent of businesses have fewer than 100 employees. It was an objective therefore, to determine pandemic influenza business continuity practices and strategies suitable for small and medium-sized NYC businesses. The study design used focus groups, and the participants were owners and managers of businesses with fewer than 500 employees in New York City. The main outcome measures looked for were the degree of pandemic preparedness, and the feasibility of currently proposed business continuity strategies. Most participants reported that their businesses had no pandemic influenza plan. Agreement with feasibility of specific business continuity strategies was influenced by the type of business represented, cost of the strategy, and business size. It was concluded that recommendations for pandemic-related business continuity plans for small and medium-sized businesses should be tailored to the type and size of business and should highlight the broad utility of the proposed strategies to address a range of business stressors.

Healthcare-seeking behaviour for common infectious disease-related illnesses in rural Kenya: a community-based house-to-house survey

Community surveys of healthcare-use determine the proportion of illness episodes not captured by health facility-based surveillance, the methodology used most commonly to estimate the burden of disease in Africa. A cross-sectional survey of households with children aged less than five years was conducted in 35 of 686 census enumeration areas in rural Bondo district, western Kenya. Healthcare sought for acute episodes of diarrhoea or fever in the past two weeks or pneumonia in the past year was evaluated. Factors associated with healthcare-seeking were analyzed by logistic regression accounting for sample design. In total, 6,223 residents of 981 households were interviewed. Of 1,679 children aged less than five years, 233 (14%) had diarrhoea, and 736 (44%) had fever during the past two weeks; care at health facilities was sought for one-third of these episodes. Pneumonia in the past year was reported for 64 (4%) children aged less than five years; 88% sought healthcare at any health facility and 48% at hospitals. Seeking healthcare at health facilities was more likely for children from households with higher socioeconomic status and with more symptoms of severe illness. Health facility and hospital-based surveillance would underestimate the burden of disease substantially in rural western Kenya. Seeking healthcare at health facilities and hospitals varied by syndrome, severity of illness, and characteristics of the patient.

Socioeconomic and racial/ethnic disparities in the incidence of bacteremic pneumonia among US adults

OBJECTIVES

We examined associations between the socioeconomic characteristics of census tracts and racial/ethnic disparities in the incidence of bacteremic community-acquired pneumonia among US adults.

METHODS

We analyzed data on 4870 adults aged 18 years or older with community-acquired bacteremic pneumonia identified through active, population-based surveillance in 9 states and geocoded to census tract of residence. We used data from the 2000 US Census to calculate incidence by age, race/ethnicity, and census tract characteristics and Poisson regression to estimate rate ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

During 2003 to 2004, the average annual incidence of bacteremic pneumonia was 24.2 episodes per 100 000 Black adults versus 10.1 per 100 000 White adults (RR = 2.40; 95% CI = 2.24, 2.57). Incidence among Black residents of census tracts with 20% or more of persons in poverty (most impoverished) was 4.4 times the incidence among White residents of census tracts with less than 5% of persons in poverty (least impoverished). Racial disparities in incidence were reduced but remained significant in models that controlled for age, census tract poverty level, and state.

CONCLUSIONS

Adults living in impoverished census tracts are at increased risk of bacteremic pneumonia and should be targeted for prevention efforts.

Rotavirus disease burden and impact and cost-effectiveness of a rotavirus vaccination program in kenya

BACKGROUND

The projected impact and cost-effectiveness of rotavirus vaccination are important for supporting rotavirus vaccine introduction in Africa, where limited health intervention funds are available.

METHODS

Hospital records, health utilization surveys, verbal autopsy data, and surveillance data on diarrheal disease were used to determine rotavirus-specific rates of hospitalization, clinic visits, and deaths due to diarrhea among children <5 years of age in Nyanza Province, Kenya. Rates were extrapolated nationally with use of province-specific data on diarrheal illness. Direct medical costs were estimated using record review and World Health Organization estimates. Household costs were collected through parental interviews. The impact of vaccination on health burden and on the cost-effectiveness per disability-adjusted life-year and lives saved were calculated.

RESULTS

Annually in Kenya, rotavirus infection causes 19% of hospitalizations and 16% of clinic visits for diarrhea among children <5 years of age and causes 4471 deaths, 8781 hospitalizations, and 1,443,883 clinic visits. Nationally, rotavirus disease costs the health care system $10.8 million annually. Routine vaccination with a 2-dose rotavirus vaccination series would avert 2467 deaths (55%), 5724 hospitalizations (65%), and 852,589 clinic visits (59%) and would save 58 disability-adjusted life-years per 1000 children annually. At $3 per series, a program would cost $2.1 million in medical costs annually; the break-even price is $2.07 per series.

CONCLUSIONS

A rotavirus vaccination program would reduce the substantial burden of rotavirus disease and the economic burden in Kenya.

Methicillin-resistant Staphylococcus aureus central line-associated bloodstream infections in US intensive care units, 1997-2007

CONTEXT

Concerns about rates of methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections have prompted calls for mandatory screening or reporting in efforts to reduce MRSA infections.

OBJECTIVE

To examine trends in the incidence of MRSA central line-associated bloodstream infections (BSIs) in US intensive care units (ICUs).

DESIGN, SETTING, AND PARTICIPANTS

Data reported by hospitals to the Centers for Disease Control and Prevention (CDC) from 1997-2007 were used to calculate pooled mean annual central line-associated BSI incidence rates for 7 types of adult and non-neonatal pediatric ICUs. Percent MRSA was defined as the proportion of S aureus central line-associated BSIs that were MRSA. We used regression modeling to estimate percent changes in central line-associated BSI metrics over the analysis period.

MAIN OUTCOME MEASURES

Incidence rate of central line-associated BSIs per 1000 central line days; percent MRSA among S. aureus central line-associated BSIs.

RESULTS

Overall, 33,587 central line-associated BSIs were reported from 1684 ICUs representing 16,225,498 patient-days of surveillance; 2498 reported central line-associated BSIs (7.4%) were MRSA and 1590 (4.7%) were methicillin-susceptible S. aureus (MSSA). Of evaluated ICU types, surgical, nonteaching-affiliated medical-surgical, cardiothoracic, and coronary units experienced increases in MRSA central line-associated BSI incidence in the 1997-2001 period; however, medical, teaching-affiliated medical-surgical, and pediatric units experienced no significant changes. From 2001 through 2007, MRSA central line-associated BSI incidence declined significantly in all ICU types except in pediatric units, for which incidence rates remained static. Declines in MRSA central line-associated BSI incidence ranged from -51.5% (95% CI, -33.7% to -64.6%; P < .001) in nonteaching-affiliated medical-surgical ICUs (0.31 vs 0.15 per 1000 central line days) to -69.2% (95% CI, -57.9% to -77.7%; P < .001) in surgical ICUs (0.58 vs 0.18 per 1000 central line days). In all ICU types, MSSA central line-associated BSI incidence declined from 1997 through 2007, with changes in incidence ranging from -60.1% (95% CI, -41.2% to -73.1%; P < .001) in surgical ICUs (0.24 vs 0.10 per 1000 central line days) to -77.7% (95% CI, -68.2% to -84.4%; P < .001) in medical ICUs (0.40 vs 0.09 per 1000 central line days). Although the overall proportion of S. aureus central line-associated BSIs due to MRSA increased 25.8% (P = .02) in the 1997-2007 period, overall MRSA central line-associated BSI incidence decreased 49.6% (P < .001) over this period.

CONCLUSIONS

The incidence of MRSA central line-associated BSI has been decreasing in recent years in most ICU types reporting to the CDC. These trends are not apparent when only percent MRSA is monitored.

Group a streptococcal disease in long-term care facilities: descriptive epidemiology and potential control measures

Group A streptococci (GAS) are an important cause of severe, life-threatening illness among the elderly population, particularly those individuals residing in long-term care facilities (LTCFs). Outbreaks of GAS infection are potentially devastating in this vulnerable population and often require large-scale control efforts involving LTCF staff, public health officials, and infectious diseases practitioners. Although multiple outbreaks of GAS infection in LTCFs have been described in the medical literature, this topic has not been reviewed for 15 years, and there is a need for updated guidance on how to approach GAS infection outbreak control. We reviewed published documents on GAS infection in LTCFs to describe the current understanding of the disease's epidemiology in this setting, identify techniques for outbreak investigation and prevention, and expose areas where additional research is needed. We highlight well-accepted prevention and control strategies that can be employed during investigation and control of GAS infection outbreaks in LTCFs.

Treatment of selected neuromuscular patients with posterior instrumentation and arthrodesis ending with lumbar pedicle screw anchorage

STUDY DESIGN

This is a retrospective analysis of 23 patients with severe neuromuscular spinal deformity treated with posterior instrumentation and fusion ending in the lumbar spine.

OBJECTIVES

The purposes of this study were to determine the safety and efficacy of stopping posterior instrumentation constructs in the lumbar spine with pedicle screw anchorage.

SUMMARY OF BACKGROUND DATA

There are sparse data in the peer-reviewed literature regarding indications and outcomes in patients with neuromuscular disorders for instrumented fusion ended short of the pelvis with transpedicular fixation.

METHODS

The average age of patients at surgery was 18.4 years (range, 10-61 years). Additional anterior discectomy and fusion were performed in four patients with large, stiff curves. No patient received anterior instrumentation. Criteria for exclusion of the pelvis from the fusion were less than 15 degrees of pelvic obliquity as a result of a compensatory curve below the major curve(s), the absence of problematic lower extremity contractures, and, often, the potential for ambulation. Process and clinical outcomes and complications were analyzed.

RESULTS

Radiographic follow-up was available in 21 patients at an average of 62 months (range, 24-110 months) after surgery. Their average Cobb angle was 71 degrees before surgery, 25 degrees after surgery (64% correction), and 32 degrees at follow-up (54% correction). Their average spinal-pelvic obliquity was 6 degrees before surgery, 5 degrees after surgery, and 6 degrees at follow-up. The average lower instrumented vertebra was lumbar 3.7. Clinical follow-up was available for all 23 patients for an average of 61 months (range, 24-110 months). There were no perioperative deaths, deep wound infections, pseudarthroses, or instrument failures. Outcomes based on responses to questionnaires completed by patient, parent, or caregiver were highly satisfactory in 20 patients (87%), satisfactory in 2 patients (9%) and neither satisfactory nor unsatisfactory in 1 patient (4%).

CONCLUSION

Posterior instrumentation and arthrodesis using lumbar lower instrumented vertebra pedicle screw anchorage can be performed safely and effectively, in selected patients patients with scoliosis and minimal pelvic obliquity.

Further development and validation of the Scoliosis Research Society (SRS) outcomes instrument

STUDY DESIGN

Outcome study to determine response distribution, internal consistency, and validity of a Modified SRS Outcomes Instrument (MSRSI).

OBJECTIVES

Refinement and validation of the SRS Outcomes Instrument for idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Experience with the SRS Outcomes Instrument suggested several refinements and the need for validation.

METHODS

Following experience-based modification, the Modified SRS Outcomes Instrument and Short Form 36 (SF-36) questionnaires were administered to 35 previously surveyed postoperative idiopathic scoliosis patients.

RESULTS

Thirty (86%) patients with an average age of 25 years returned the questionnaires at an average of 10 years postoperative. Distribution of scores was acceptable. Internal consistency utilizing Cronbach's alpha was 0.80, 0.81, 0.77, 0.89, and 0.88 for pain, self-image/appearance, function/activity, mental health, and satisfaction with surgery, respectively. Validity, determined by Pearson correlation coefficients with comparable SF-36 domains, was 0.70 or greater for 13 of the 14 relevant domains between SF-36 and MSRSI (P < 0.001).

CONCLUSION

The SRS Outcomes Instrument is simple and internally consistent. Based on experience, a number of modifications have been made that improve the instruments scope and internal consistency. Finally, the instrument is valid in comparison to SF-36.

Scoliosis correction maintenance in skeletally immature patients with idiopathic scoliosis. Is anterior fusion really necessary?

STUDY DESIGN

A retrospective evaluation of the occurrence of the crankshaft phenomenon in skeletally immature patients with idiopathic scoliosis.

OBJECTIVE

To determine what factors, if any, contribute to a decreased occurrence of crankshaft phenomenon in patients treated with posterior surgery only.

SUMMARY OF BACKGROUND DATA

Reports have described the progression of scoliotic deformity, termed the crankshaft phenomenon, in a region of solid posterior arthrodesis in skeletally immature patients. This has led some authors to advocate the use of concomitant anterior discectomy and fusion to prevent crankshaft.

METHODS

From 1989 through 1994, 18 Risser 0 patients with thoracic or thoracolumbar idiopathic scoliosis underwent Isola (De Puy-Acromed, Raynham, MA) posterior instrumentation and fusion. They were assessed for evidence of the crankshaft phenomenon, identified by coronal plane deformity progression of 10 degrees or more, or a rib vertebra angle difference of 10 degrees or more. The average age of the patients was 12.5 years (range, 10.5-15.5 years), and the average follow-up period was 39 months (range, 24-68 months).

RESULTS

Eleven patients (10 girls and 1 boy) had closed triradiate cartilage at the time of surgery. Their average Cobb angle was 62 degrees before surgery, 21 degrees after surgery, and 22 degrees at follow-up assessment. No patients in this group met the criteria for crankshaft. Seven patients (6 girls and 1 boy) had open triradiate cartilage at the time of surgery. Their average Cobb angle was 62 degrees before surgery, 18 degrees after surgery, and 20 degrees at follow-up evaluation. No patient had a 10 degrees or more increase in rib vertebra angle difference. One patient had more than a 10 degrees increase in her Cobb angle (11 degrees) from postoperative to latest follow-up assessment. Her instrumentation construct, performed in 1989, used sublaminar wires as the caudal anchors. Hooks and pedicle screws are now used. Two of the seven patients with open triradiate cartilage underwent surgery during or before their peak height velocity and displayed no evidence of crankshaft. No deaths, neurologic complications, or infections occurred in either group.

CONCLUSIONS

These findings suggest that scoliotic deformity progression can be prevented in skeletally immature patients with idiopathic scoliosis as young as 10 years of age with the use of stiff segmental posterior instrumentation, without the necessity of concomitant anterior arthrodesis.

Patients' perceptions of overall function, pain, and appearance after primary posterior instrumentation and fusion for idiopathic scoliosis

STUDY DESIGN

This outcome study used patients' responses to the Scoliosis Research Society Outcomes Instrument to discriminate among patients who had undergone surgery for correction of juvenile or adolescent idiopathic scoliosis.

OBJECTIVES

To evaluate a surgically treated population by using the SRS Outcomes Instrument.

SUMMARY OF BACKGROUND DATA

The Scoliosis Research Society outcomes instrument was developed to help evaluate patient-perceived outcomes after treatment for idiopathic scoliosis. It includes 24 questions designed to investigate seven domains.

METHODS

Eligible patients underwent posterior surgery for the first time before their 21st birthdays. One surgeon performed the surgery at one medical center. Of 168 eligible patients, 121 (72%) completed the Scoliosis Research Society outcomes questionnaire.

RESULTS

Females reported better outcomes in the function after surgery (P = 0.005) and self-image after surgery (P = 0.01) domains. Preoperative curve pattern comparison demonstrated a significant difference in self-image after surgery among four groups classified according to curve pattern. The thoracolumbar and lumbar group recorded image scores of 5, the highest possible score, 85% of the time. The King-Moe (KM) V group scored 5, 75% of the time; the KM I and II group 48%; and the KM III and IV group 46% (P = 0.0015). After eliminating confounding variables, it was found that white patients reported experiencing less pain in follow-up than did black patients (P = 0.0098). Results were also suggestive that less pain was associated with increased number of fused vertebrae (P = 0.027).

CONCLUSIONS

The strongest predictors of self-perceived favorable outcome among patients were female sex and white race. It is also suggested that longer fusions to L1 through L3 lead to less perceived pain than with shorter fusions.

The selection of fusion levels using torsional correction techniques in the surgical treatment of idiopathic scoliosis

STUDY DESIGN

This is a retrospective, consecutive case series, with the index patient included.

OBJECTIVES

To evaluate the evolution and effectiveness of instrumentation techniques designed to untwist the scoliosis deformity.

SUMMARY OF BACKGROUND DATA

Three-dimensional studies of the idiopathic scoliosis deformity are consistent with the theory that the deformity or deformities evolve as an imperfect torsion or torsions.

METHODS

From 1989 through 1995, 102 consecutive patients (84 females, 18 males) underwent surgery with increasing emphasis on torsional correction. One hundred patients (98%), with an average age of 14.3 years (range, 10.5-20.8 years), were observed for an average of 40 months (range, 24-81 months). The upper instrumented vertebra evolved to be the centered vertebra. The lower instrumented vertebra was chosen based on its ability to become horizontal on contralateral bend radiographs and was termed the caudal foundation vertebra. Because these techniques evolved over the first 3 years of the study period, a split analysis was performed to evaluate improvements in correction and correction maintenance over the course of the study.

RESULTS

The average Cobb angle was 59 degrees before surgery, 18 degrees after surgery (69% correction), and 22 degrees (63% correction) at latest follow-up. A comparison of the first half of the series with the second half showed no significant demographic differences. Curve correction was significantly improved for King-Moe IIB (thoracolumbar-lumbar curve only), King-Moe III, and King-Moe V curve types in the second half of the series. In the last 4 years, curve correction at latest follow-up for King-Moe IIB curves was 61% for the thoracic curve and 65% for the thoracolumbar-lumbar curve. King-Moe III curves had a 68% correction, and King-Moe V curves had a 50% high thoracic and a 72% thoracic curve correction. Thoraco-lumbar, lumbar, and King-Moe I curves averaged 81% correction of the thoracolumbar-lumbar curve. The angle of thoracic curve inclination improvement at 1 year was maintained at latest follow-up.

CONCLUSIONS

This method of selecting instrumentation levels while using torsional correction techniques is safe and reliable. The results were improved with the evolution of these techniques and appear to provide improved correction and correction maintenance compared with that of historical controls.

A concept of idiopathic scoliosis deformities as imperfect torsion(s)

Scoliosis is a complex three-dimensional deformity. With continued improvement in spinal implant design, the options for corrective load application have increased. Visualization of the scoliosis deformity as a torsion or torsions, similar to an elongated helical line, and integration of this visualization with current deformity classification have proven useful in developing instrumentation sequences addressing scoliosis as a three-dimensional deformity. These instrumentation sequences, which have been evolving since 1989, have been applied in more than 150 patients who show improved deformity correction without serious complications.

Use of video in the informed consent process

We created a video-tape about the concept of telemedicine for informational and educational purposes. Two video-tapes, one with and one without the informed consent segment, were distributed to each of the Kentucky TeleCare sites. On the day of their teleconsultation, patients were asked to watch the video-tape (with the version containing the informed consent segment) before signing the informed consent to participate. Site coordinators then asked patients whether they had any specific questions about telemedicine. To date, patients have reported high levels of satisfaction with this method of consultation, using telecommunications technology to deliver health care.

Patient satisfaction with multispecialty interactive teleconsultations

Satisfaction with teleconsulting was evaluated for 96 patients using the Kentucky TeleCare telemedicine network. Consultant specialties included psychiatry (41), dermatology (24), clinical nutrition (20), anaesthesia (3), infectious diseases (3), rheumatology (2), internal medicine (1), neurology (1) and paediatric pulmonology (1). The results indicated a high level of patient satisfaction, with a mean score of 6.8 (on a 7-point Likert scale with 1 = strongly disagree and 7 = strongly agree) for the question 'Overall, I was very satisfied with today's consultation'. The results indicated that the majority of patients were satisfied with the telemedicine encounter although a minority, 16%, would have preferred to have seen the specialist in person.

Late results of subtalar distraction fusion

Between 1990 and 1994, 15 subtalar distraction fusions were performed on 14 patients for sequelae of calcaneus fractures. Twelve patients (13 feet) were available for a minimum 2-year follow-up and constituted the composition of this study. All patients complained of lateral ankle pain and had CT evidence of calcaneofibular abutment and radiographic evidence of loss of heel height preoperatively. The average age at time of surgery was 56 years (range, 23-81 years), and the average follow-up was 47 months (range, 25-75 months). The only change in surgical technique from that previously described was the use of a bone spreader rather than a femoral distractor for distraction of the subtalar joint. The average preoperative talocalcaneal angle improved from 27 degrees range, 19-37 degrees) to 33 degrees (range, 23-45 degrees) postoperatively (P < 0.003). The mean talar declination angle improved from 11 degrees (range, 6-18 degrees) to 16 degrees (range, 7-27 degrees) postoperatively (P < 0.003). The mean heel height increased from 71 mm (range, 60-83 mm) to 76 mm (range, 63-91 mm) postoperatively (P < 0.0001). All patients completed the AOFAS Ankle-Hindfoot scale at latest follow-up, and the average score was 76.1 (range, 57-94). Eleven of 13 outcomes were rated as very satisfactory or satisfactory. Twelve of 13 said they would 'definitely yes" do surgery again. We have found that subtalar distraction fusion for late complications of calcaneus fracture in a carefully selected population can provide a consistent and satisfactory outcome.