R. David Parker

Vertebral osteomyelitis: Retrospective review of 11 years of experience

Abstract Introduction: Infectious vertebral osteomyelitis (VO) is a significant source of morbidity that can lead to chronic sequelae. The objectives of this study were to describe the clinical presentations and assess the outcomes of VO. Methods: A retrospective review of cases of VO admitted to an inpatient service between 1 January 2000 and 31 March 2012 was carried out. Cases had evidence of VO by clinical syndrome, imaging, histopathology, and/or microbiology. Outcomes assessed were implantation of prosthetic material for stabilization, hospital readmission for management of VO, repeat surgical intervention, and additional or prolonged courses of antibiotics. Results: Of 117 VO cases, a causative organism was identified in the majority (88.0%). Staphylococcus aureus was the most common organism isolated, followed by Streptococcus species. The most common infection site was the lumbar spine (55.5%). Surgical intervention was required in 81.2% of cases. Infections involving the lumbar vertebrae were associated with a higher risk of all 4 outcomes. Individuals with methicillin-resistant S. aureus infection were more likely to require a readmission for management of VO (odds ratio (OR) 3.94, 95% confidence interval (CI) 1.25–12.42). Individuals with lumbar infections were more likely to require additional antibiotics (OR 4.08, 95% CI 1.34–12.40) and more likely to require readmission (OR 8.29, 95% CI 1.84–37.33) for management of VO. An early infectious disease consultation was associated with a decreased risk for additional antibiotics (OR 0.30, 95% CI 0.11–0.83). Conclusions: VO was frequently caused by S. aureus or Streptococcus species. Most cases required surgical intervention. An early infectious disease consult ensured a more appropriate antibiotic course.

Outcomes associated with anxiety and depression among men who have sex with men in Estonia.

BACKGROUND Evidence supports that gay, lesbian, and transgender populations are at increased risk for mental health problems. The current study was conducted to estimate the prevalence of anxiety and depressive symptoms and related factors among men who have sex with men (MSM) in Estonia. This is the only known study of its type in the Eastern European region. METHODS In 2013, an Internet-based survey was conducted among men who have sex with men, collecting data on socio-demographics, sexuality, drug and alcohol use, mental health, suicidality, and internalized homonegativity. RESULTS 265 MSM completed the questionnaire (median age 31 years, 90% Estonian, 71% from the capital; 73% employed full-time, 42% with at least college education; 44% in a steady relationship; 72% gay, 23% bisexual; 23% reported illegal drug use in the last 12 months). One third met criteria for problem drinking and depressive symptoms with one quarter for anxiety symptoms. Suicidality was 44% reported lifetime suicidal thoughts and 11% with at least one suicide attempt. LIMITATIONS The study instruments, EST-Q and CAGE, only measure symptoms and are not diagnostic tests. A non-random sample which could possibly include persons with easier internet access. Self-reported data and cross-sectional study design are prone to issues with recall bias and temporality. CONCLUSIONS With demonstrated high rates of anxiety, depression, drinking, and drug use among MSM which is consistent with similar studies in Western countries, further research could help determine effective MSM focused interventions to address the broad spectrum of issues among MSM.

Cause of death in HIV-infected patients in South Carolina (2005–2013)

Summary The life span of persons with HIV has been greatly extended over the past 30 years due to novel therapies. In the developed world and urban settings, this results in a lifespan rivaling the lifespan of a person without HIV. A retrospective study was conducted on 459 patients of an urban, academic medical center who died between 2005 and 2013 in a medium-sized US city. Using the established Cause of Death Project (CoDe) protocol, we measured multiple factors including comorbidities, risk behaviours, contributing and underlying causes of death. This study is one of the few US-based studies using this validated protocol. Among the deaths, 25.9% were sudden and 15.2% were unexpected. Almost one-fifth were related to AIDS-related infections; 47.5% related to non-AIDS causes; with the remainder unknown. Statistically significant increases in CD4 counts and decreasing viral loads were observed over the study period. There were no statistically significant differences observed by HIV risk behaviour, race, gender, age at death, or on antiretrovirals at death. In support of the existing literature, improved HIV management appears to reduce the AIDS-related attributable death among patients observed in this study.

Differences in Risk Behaviors, Care Utilization, and Comorbidities in Homeless Persons Based on HIV Status

&NA; This cross‐sectional pilot project measured differences by HIV status in chronic health conditions, primary care and emergency department use, and high‐risk behaviors of homeless persons through self‐report. Using selective random sampling, 244 individuals were recruited from a homeless shelter. The reported HIV prevalence was 6.56% (n = 16), with the odds of HIV higher in persons reporting crack cocaine use. HIV‐infected persons were more likely to report a source of regular medical care and less likely to use the emergency department than uninfected persons. Validation of findings through exploration of HIV and health care access in homeless persons is needed to confirm that HIV‐infected homeless persons are more likely to have primary care. Distinctions between primary care and specialty HIV care also need to be explored in this context. If findings are consistent, providers who care for the homeless could learn more effective ways to engage homeless patients.

Associations of high-risk behaviour and HIV status with HIV knowledge among persons in Tallinn, Estonia

Aim: The aim of this study was to determine the associations between the level of HIV knowledge, HIV-related risk behaviours, and HIV status among persons receiving voluntary counselling and testing services in Tallinn, Estonia. Design: A cross-sectional study design was used. Methods: A total of 772 subjects completed a 47-item questionnaire gathering information on demographics, HIV-related risk behaviours, and HIV-related knowledge. Participant’s HIV status was determined by an anonymous rapid test. Only incident HIV cases were included in regression analyses. An analysis of covariance (ANCOVA) modelling evaluated associations between HIV knowledge and high-risk behaviours while multivariable logistic regression assessed association between HIV status and HIV knowledge. Results: The final ANCOVA model indicates that HIV risk behaviours are significantly associated with HIV knowledge (p = 0.01). Compared to participants with no identified high-risk behaviour, the adjusted mean score of HIV knowledge was higher among persons sharing injection equipment (p = 0.05), and persons engaging in unprotected heterosexual intercourse (p = 0.03); there was no statistical difference observed among men engaging in unprotected sex with other men. Women had higher mean scores than men (p = 0.01) and persons of ‘‘other’’ ethnicities had a higher mean knowledge score than ethnic Estonians (p = 0.01) and Russians (p < 0.01). Logistic regression indicated that mean knowledge was higher among participants who tested HIV positive (OR = 1.42; 95% CI = 1.12—1.87). Conclusions: In this sample, higher knowledge scores were not associated with lower infection rates. These results indicate the importance of targeting all high-risk groups in HIV prevention and education programmes.

Piloting HIV rapid testing in community-based settings in Estonia

Background: In the European Union it is estimated that up to 30% of HIV-infected people are not aware of their status. Community-based testing (CBT) models are implemented to increase the uptake of HIV testing. Aims: The aim of this project was to assess the feasibility and acceptance of HIV rapid testing in CBT settings in Estonia to identify non-clinical recruitment venues for people more likely to engage in high-risk behaviours. Methods: Participants for this anonymous, cross-sectional study were recruited from a syringe exchange programme and gay-oriented locations using convenience sampling. Socio-demographic and HIV testing preferences data were collected using a semi-structured questionnaire. HIV rapid testing was performed using Determine HIV-1/2 (Abbott) rapid test system. Results: With a participation rate of 88.3%, this project enrolled 308 persons and identified 58 preliminary positive cases. Out of them, 52 reported injecting drug use in last 12 months and 30 reported no previous HIV test. Approximately 45% of all participants preferred rapid testing while 25% reported a preference for a full blood test. Conclusions: This project demonstrates that HIV rapid testing in community-based settings in Eastern Europe can be an effective approach for reaching people who engage in high-risk behaviours and increasing the number of HIV-infected people who are aware of their status.

An Inexpensive, Interdisciplinary, Methodology to Conduct an Impact Study of Homeless Persons on Hospital Based Services

Homelessness is a primary concern for community health. Scientific literature on homelessness is wide ranging and diverse. One opportunity to add to existing literature is the development and testing of affordable, easily implemented methods for measuring the impact of homeless on the healthcare system. Such methodological approaches rely on the strengths in a multidisciplinary approach, including providers, both healthcare and homeless services and applied clinical researchers. This paper is a proof of concept for a methodology which is easily adaptable nationwide, given the mandated implementation of homeless management information systems in the United States and other countries; medical billing systems by hospitals; and research methods of researchers. Adaptation is independent of geographic region, budget restraints, specific agency skill sets, and many other factors that impact the application of a consistent methodological science based approach to assess and address homelessness. We conducted a secondary data analysis merging data from homeless utilization and hospital case based data. These data detailed care utilization among homeless persons in a small, Appalachian city in the United States. In our sample of 269 persons who received at least one hospital based service and one homeless service between July 1, 2012 and June 30, 2013, the total billed costs were

Expanded Medicaid Provides Access to Substance Use, Mental Health, and Physician Visits to Homeless and Precariously Housed Persons

5,979,463 with 10 people costing more than one-third (

Needlestick Injuries Among Emergency Medical Services Providers in Urban and Rural Areas

1,957,469) of the total. Those persons were primarily men, living in an emergency shelter, with pre-existing disabling conditions. We theorize that targeted services, including Housing First, would be an effective intervention. This is proposed in a future study.

Designing an Effective, Small-Scope Practice-based Study

To describe the Medicaid costs associated with persons who are homeless or unstably housed. A retrospective secondary data analysis linked Medicaid recipient data with a statewide homeless management information system. A total of 19,950 persons received a housing service between 2012 and 2015 including 14,136 persons with Medicaid. Five of the most frequent diagnoses were substance abuse or mental health conditions in 42.83% of all diagnoses. The most frequent service was outpatient mental health and emergency department physician services. These costs totaled