Gerald L. Hoff

The emergence of Neisseria gonorrhoeae with decreased susceptibility to Azithromycin in Kansas City, Missouri, 1999 to 2000.

Background and Objectives We describe the first cluster of persons with Neisseria gonorrhoeae with decreased susceptibility to azithromycin (AziDS; minimum inhibitory concentration ≥1.0 &mgr;g/mL) in the United States. Goal The goal of this study was to identify risk factors for AziDS N. gonorrhoeae and to describe isolate microbiology. Study Design Persons with AziDS N. gonorrhoeae (cases) were identified in Kansas City, Missouri, through the Gonococcal Isolate Surveillance Project (GISP) in 1999 and expanded surveillance, January 2000 to June 2001. A case-control study using 1999 GISP participants was conducted; control subjects had azithromycin-susceptible N. gonorrhoeae. Results Thirty-three persons with AziDS N. gonorrhoeae were identified. Case patients were older than control patients (median age, 33 years vs. 23 years; P <0.001). Fifty percent of cases and 13% of control subjects had a history of sex with a female commercial sex worker (odds ratio, 7.0; 95% confidence interval, 1.3–36.0); 50% of cases and 4% of control subjects met sex partners on street A (P <0.01). AziDS N. gonorrhoeae isolates were phenotypically and genotypically similar and contained an mtrR gene mutation. Conclusions With few treatment options remaining, surveillance for antimicrobial-resistant N. gonorrhoeae is increasingly important, especially among persons at high risk.

Secular Trends in Hospital Emergency Department Visits for Dental Care in Kansas City, Missouri, 2001-2006

Objectives. We determined the trends, risk factors, and costs of emergency department (ED) visits for dental complaints during a six-year period in Kansas City, Missouri (KCMO). Methods. We used de-identified hospital discharge data from all facilities serving KCMO during 2001–2006. Using the International Classification of Diseases, Ninth Revision codes, we determined both counts and rates of ED visits related to toothache or tooth injury and analyzed the discharge diagnosis and costs of these visits. We used multivariable regression analysis to assess risk factors for the ED visits for dental complaints. Results. We found a significant increasing trend in dental complaint visits during the six-year period (from 13.1% to 19.0%, p<0.01). Dental caries accounted for 20.4%, pulpitis or periapical abscess accounted for 14.8%, dental injury accounted for 8.7%, temporomandibular joint (TMJ) disorders accounted for 1.5%, and all other unspecified dental diseases accounted for 54.6% of the ED visits for dental complaints. The mean charge was approximately

Pre-Pregnancy Overweight Status between Successive Pregnancies and Pregnancy Outcomes

360 per visit and was highest for TMJ disorders (

Risk factors for recurrent small-for-gestational-age birth.

747) and lowest for unspecified other dental diseases (

Multijurisdictional Approach to Biosurveillance, Kansas City

277). Self-pay (38.3%) and Medicaid (32.3%) constituted the majority of the payment sources. Multivariable regression analysis indicated that self-payers, nonwhite people, adults, people with lower family income, and weekends were associated with increased use of ED visits for dental complaints. Conclusions. There was a significant increasing trend in dental complaint-related ED visits. EDs have become an important site for people with dental problems to seek urgent care, particularly for individuals who self-pay or are on Medicaid.

Voluntary human immunodeficiency virus testing, recidivism, partner notification, and sero-prevalence in a sexually transmitted disease clinic : a need for mandatory testing

OBJECTIVE The two objectives of this study were to (1) examine factors associated with changes in pre-pregnancy overweight to pre-pregnancy normal/underweight or obese Body Mass Index (BMI) in the subsequent pregnancy, and (2) assess select pregnancy and newborn outcomes associated with changes in pre-pregnancy BMI. METHODS Birth certificates from 1995-2004 for residents of Kansas City, Missouri, were used to identify overweight nulliparous women who had a singleton birth and subsequently a second singleton birth. Maternal factors associated with changes in BMI between pregnancies were determined. Hypertension in pregnancy, preterm birth, emergency cesarean section, small-for-gestational age, and large-for-gestational age outcomes were examined. RESULTS At second pregnancy, 55% of the women remained overweight, 33% were obese, and 12% had normal/underweight BMIs. The upward shift in BMI was associated with being unmarried and having a birth interval of 18 or more months, while the downward shift was associated with gestational weight gain. Of the five outcomes variables, only emergency cesarean section was significantly associated with an upward shift in BMI. CONCLUSIONS Clinical interventions for pre-pregnancy overweight women should focus on appropriate weight gain during pregnancy and motivators for loss of pregnancy-related weight during the postpartum period.

Human Immunodeficiency Virus Partner Notification in a Low Incidence Urban Community

The factors associated with recurrent small-for-gestational-age birth (R-SGA) have not been previously studied in a multiracial population. This is a retrospective cohort study of 5932 black and white women who had consecutive singleton first and second births in a Midwestern metropolis, from 1995 through 2004, to measure the risk and determine the factors associated with R-SGA. The rates for second-born small-for-gestational-age birth and R-SGA were 10.3% and 4.0%, respectively. Compared with mothers of firstborns who were appropriate for gestational age, mothers of firstborns who were small for gestation age had a higher risk of second-born small-for-gestational-age infants (relative risk [RR] = 3.93; 95% confidence interval [95% CI] = 3.36 to 4.59). Among those with firstborns who were small for gestational age, the odds ratio (OR) and 95% CI of R-SGA were higher for lean body mass index + poor gain (2.83; 1.20 to 6.69), blacks (1.58; 1.09 to 2.29), and smokers (1.61; 1.05 to 2.47). R-SGA occurs in 4% of second births and is responsible for 40% of second-born small-for-gestational-age infants. R-SGA is potentially preventable because of its association with potentially modifiable factors such as smoking and weight gain in pregnancy.

When Bioterrorism Strikes: Communication Issues for the Local Health Department

An electronic reporting system for a network of 22 laboratories was implemented in Kansas City, Missouri, with an independent organization acting as a data clearinghouse between the reporting laboratories and public health departments. The system ran in tandem with conventional reporting methods. Laboratory test orders and results were aggregated and mapped to a common nomenclature. Reports were delivered through a secure Internet connection to the Kansas City Health Department (KCHD); during the first 200 days of operation, 359 qualified results were delivered electronically to KCHD. Data were received more quickly than they were with conventional reporting methods: notification of chlamydia cases arrived 2 days earlier, invasive group A streptococcal disease cases arrived 2.3 days sooner, and salmonellosis cases arrived 2.7 days sooner. Data were more complete for all demographic fields, including address, age, sex, race, and date of birth. Two hundred fourteen cases reported electronically were not received by conventional means.

TOBACCO USE AND CESSATION AMONG MEN WHO HAVE SEX WITH MEN

Universal, voluntary testing for antibodies to the human immunodeficiency virus (HIV) was offered to 17,092 eligible clients attending a public sexually transmitted disease clinic between March, 1988 and June, 1989. In an environment of legally mandated reporting and partner notification, 15,649 (91.6%) clients were tested, 160 of whom were HIV sero-positive. Client acceptance of testing is discussed, and the serologic data compared with results of a federally funded sero-prevalence survey conducted in-clinic. A recidivism rate of 20% was observed among sero-positive individuals. Of 159 contacts for whom HIV sero-status was determined, 66 (42%) were seropositive. It is proposed that, in the setting of sexually transmitted disease clinics, HIV testing be changed from a voluntary service to a mandatory test. Some benefits of this change are defined.

Secular Trends in Excess Fetal and Infant Mortality Using Perinatal Periods of Risk Analysis

Background Notification of the partners of a person newly diagnosed with human immunodeficiency virus (HIV) is legally mandated in Missouri. Methods In a four-year period, the Kansas City Health Department tested for HIV antibodies in 61,464 of 61,700 (99.6%) eligible persons using the sexually transmitted disease clinic. Results A total of 366 newly diagnosed HIV cases were identified of whom 291 named 662 sex or needle-sharing partners. Only 447 partners could be located, counseled and/or tested. Of these partners, 165 were HIV infected, but only 33 represented newly diagnosed cases. Conclusion HIV partner notification can be successfully conducted in an urban community.