John Pulvino

The Disease Profile of Texas Prison Inmates

PURPOSE Whereas prison inmates are reported to exhibit poorer overall health status and higher rates of health care utilization than the general population, no current information exists on the overall disease profile of the U.S. prison population. The present study examined the prevalence of major acute and chronic conditions in one of the nations largest prison populations. METHODS The study population consisted of 170,215 Texas Department of Criminal Justice (TDCJ) inmates who were incarcerated between August 1997 and July 1998. Information on medical conditions and sociodemographic factors was obtained from an institution-wide medical information system. RESULTS Infectious diseases (29.6%) constituted the most prevalent major disease category among inmates. This was followed by diseases of the musculoskeletal system and connective tissue (15.3%), diseases of the circulatory system (14.0%), mental disorders (10.8%), and diseases of the respiratory system (6.3%). Among the specific conditions examined, evidence of tuberculosis infection without active pulmonary disease (20.1%) was found to be the most prevalent condition, followed by hypertension (9.8%), asthma (5.2%), low back pain (5.1%), and viral hepatitis (5.0%). CONCLUSIONS The present study shows that for a number of conditions, the prison population exhibited prevalence rates that were substantially higher than those reported for the general population. Moreover, estimates for a number of diseases varied substantially according to age, race, and gender. Understanding the disease profile in U.S. incarcerated populations will permit correctional administrators to develop more efficient health care delivery systems for prison inmates.

Psychiatric disorders, HIV infection and HIV/hepatitis co-infection in the correctional setting

Abstract Psychiatric disorders such as bipolar disorder, schizophrenia and depression have long been associated with risk behaviors for HIV, hepatitis C virus (HCV) and hepatitis B virus (HBV). The US prison population is reported to have elevated rates of HIV, hepatitis and most psychiatric disorders. This study examined the association of six major psychiatric disorders with HIV mono-infection, HIV/HCV co-infection and HIV/HBV co-infection in one of the nations largest prison populations. The study population consisted of 370,511 Texas Department of Criminal Justice inmates who were incarcerated for any duration between January 1, 2003 and July 1, 2006. Information on medical conditions and sociodemographic factors was obtained from an institution-wide electronic medical information system. Offenders diagnosed with HIV mono-infection, HIV/HCV, HIV/HBV and all HIV combined exhibited elevated rates of major depression, bipolar disorder, schizophrenia, schizoaffective disorder, non-schizophrenic psychotic disorder and any psychiatric disorder. In comparison to offenders with HIV mono-infection, those with HIV/HCV co-infection had an elevated prevalence of any psychiatric disorder. This cross-sectional studys finding of positive associations between psychiatric disease and both HIV infection and hepatitis co-infection among Texas prison inmates holds both clinical and public health relevance. It will be important for future investigations to examine the extent to which psychiatric disorders serve as a barrier to medical care, communication with clinicians and adherence to prescribed medical regimens among both HIV-mono-infected and HIV/hepatitis-co-infected inmates.

The association of psychiatric disorders and HIV infection in the correctional setting

PURPOSE Psychiatric disorders, such as bipolar disorder, schizophrenia, and depression, have been associated with both HIV-associated risk behaviors and HIV infection. While the US prison population is reported to exhibit elevated rates of HIV/AIDS and most psychiatric disorders, scarce information currently exists on the association of these conditions in the prison setting. The present study examined the association of six major psychiatric disorders with HIV infection in one of the nations largest prison populations. METHODS The study population consisted of 336,668 Texas Department of Criminal Justice inmates who were incarcerated for any duration between January 1, 1999 and December 31, 2001. Information on medical conditions and sociodemographic factors was obtained from an institution-wide medical information system. RESULTS Inmates diagnosed with HIV infection exhibited elevated rates of major depression, dysthymia, bipolar disorder, schizophrenia, schizoaffective disorder, and non-schizophrenic psychotic disorder. These rates persisted in stratified analyses and in a multivariate analysis that statistically adjusted for gender, race, and age category. CONCLUSION The present cross-sectional studys finding of a positive association between HIV infection and psychiatric diagnoses among inmates holds both clinical and public health relevance. It will be important for future investigations to prospectively assess the underlying mechanisms of these associations in the correctional setting.

Chronic Liver Disease Mortality Among Male Prison Inmates in Texas, 1989–2003

OBJECTIVES:Alcohol abuse and chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the major etiologic factors for chronic liver disease/cirrhosis (CLD) in the United States. These CLD risk factors are highly prevalent in US adult incarcerated populations, but CLD-related mortality data from these populations are lacking. The primary objective of this study was to assess CLD-related mortality over time and across categories of race–ethnicity from 1989 through 2003 among male inmates in the Texas state prison system. The secondary objective was to examine patterns of recorded underlying, intervening, and contributing causes of death for CLD-related deaths.METHODS:Prisoner decedent data were linked with Texas Vital Statistics multiple-cause-of-death data. Deaths were considered CLD-related if CLD or common sequelae were recorded as the underlying, intervening, or contributing causes of death. CLD-related crude annual death rates, 5-year average annual death rates, and average annual percentage changes were estimated.RESULTS:Among male Texas prisoners from 1989 to 2003, CLD-related deaths accounted for 16% of deaths (688/4,316). CLD-related crude annual death rates were high and increased over the study period by an average of 4.5% annually, with similar rate increases across categories of race–ethnicity. CLD-related average annual death rates were higher among Hispanic prisoners than among black prisoners in each 5-year period, and were higher than those for white prisoners in the 1994–1998 and 1999–2003 periods. HBV or HCV was identified as a causal factor in more than a third (34%) of CLD-related deaths.CONCLUSIONS:From 1989 to 2003, CLD-related death rates among male Texas prisoners were high and increased over time, particularly among Hispanics. Targeted prevention, screening, and treatment of CLD risk factors, especially HCV, and early detection and treatment of CLD should be considered as priorities of the US prison healthcare systems.

Anti-depressant prescribing patterns for prison inmates with depressive disorders

BACKGROUND Although prison inmates are reported to exhibit elevated rates of depressive disorders, little is known about anti-depressant prescribing patterns in correctional institutions. METHODS The study population consisted of 5305 Texas Department of Criminal Justice (TDCJ) inmates who were diagnosed with one of three depressive disorders: major depression, dysthymia, and bipolar disorder (excluding those with manic episodes only). Information on medical conditions, sociodemographic factors, and pharmacotherapy was obtained from an institution-wide medical information system. RESULTS In 1998, 78.2% of all inmates diagnosed with depressive disorders were treated with antidepressant medication. Of these, 47.3% were treated exclusively with tricyclic anti-depressants (TCA); 30.9% were treated with selective serotonin re-uptake inhibitors (SSRI); and 21.8% were not treated with any form of anti-depressant medication. Prescribing patterns varied substantially according to a number of sociodemographic factors under study. LIMITATIONS Because the present study relied on retrospective, clinical data, the investigators had limited ability to assess: specific symptomatology for each diagnosed depressive condition under study; socio-economic status, pre-incarceration access to health care; and the overall reliability and validity of the data. CONCLUSION The proportion of prison inmates with depressive disorders who receive appropriate medication management is substantially higher than that reported among similarly diagnosed nonincarcerated samples. It will be important, however, for future investigators to examine the sources of sociodemographic variation in treatment patterns found in the present study.

Community-based case management for uninsured patients with chronic diseases: effects on acute care utilization and costs.

Purpose of the Study:To examine the effects of a community-based case management program on acute health care utilization and associated costs in uninsured patients with 1 or more chronic diseases. Primary Practice Setting:Large regional academic medical center that provides health care services for the vast majority of indigent patients in the area. Methodology and Sample:This was a retrospective study of 83 patients who enrolled in a case management program between April 2007 and August 2008 on the basis of 1 or more emergency department visits or acute hospitalizations. Paired t tests were used to compare utilization and costs before and after enrollment. Results:Overall, acute outpatient encounters decreased by 62% and inpatient admissions by 53%, whereas primary care visits increased by 162%. Participation in the case management program was also associated with a 41% reduction in overall aggregate costs, from

Leading medical causes of mortality among male prisoners in Texas, 1992--2003.

16,208 preintervention to

Gonadotropin-releasing hormone agonist use to guide diagnosis and treatment of autoimmune progesterone dermatitis.

9,541 postintervention (p = .004). Implications for Case management Practice:The results of this study suggest that intensive case management can reduce acute care utilization and costs and increase primary care follow-up among uninsured patients with certain chronic diseases.

The changing epidemiology of HIV in the criminal justice system

Data from the Texas prison system and the Texas Vital Statistics Bureau were used to identify and assess the leading medical causes of death from 1992 to 2003 among male prisoners in Texas (N = 4,026). The leading medical causes of death were infection, cancer, cardiovascular disease (CVD), liver disease, and respiratory disease. Of these, only cancer showed a significant average annual increase in crude death rates (2.5% [0.2% to 4.9%]). Among prisoners aged 55 to 84 years, crude average annual death rates due to cancer and CVD were high and substantially exceeded death rates due to other causes. Among prisoners aged 25 to 44 years, crude average annual death rates due to infection exceeded death rates due to other causes. Continued improvements in the prevention, screening, and treatment of these conditions are warranted in correctional health care settings.

Prevalence of chronic medical conditions among inmates in the Texas prison system.

BACKGROUND: Autoimmune progesterone dermatitis is a catamenial disorder traditionally diagnosed by subcutaneous or intramuscular progesterone challenge. Little has been reported regarding the use of a gonadotropin-releasing hormone (GnRH) agonist with a progestin add-back challenge to diagnose and guide management of this condition. CASE: A 50-year-old premenopausal woman presented with cyclic facial rash minimally responsive to standard treatment. Symptoms improved with depot leuprolide acetate and worsened with add-back progesterone therapy. Hysterectomy and oophorectomy were performed with resolution of symptoms. This surgery eliminated endogenous progesterone and permitted estrogen replacement to treat vasomotor symptoms experienced with GnRH agonist therapy. CONCLUSION: This case of autoimmune progesterone dermatitis exemplifies the utility of GnRH agonists with a steroid add-back challenge for diagnosing catamenial disorders and guiding treatment.