Assessing the cost-effectiveness of integrated case management of Neglected Tropical Diseases in Liberia.

BACKGROUND: In 2017, Liberia became one of the first countries in the African region to develop and implement a national strategy for integrated case management of Neglected Tropical Diseases (CM-NTDs), specifically Buruli ulcer, leprosy, lymphatic filariasis morbidities, and yaws. Implementing this plan moves the NTD program from many countries' fragmented (vertical) disease management. This study explores to what extent an integrated approach offers a cost-effective investment for national health systems. METHODS: This study is a mixed-method economic evaluation that explores the cost-effectiveness of the integrated CM-NTDs approach compared to the fragmented (vertical) disease management. Primary data were collected from two integrated intervention counties and two non-intervention counties to determine the relative cost-effectiveness of the integrated program model vs. fragmented (vertical) care. Data was sourced from the NTDs program annual budgets and financial reports for integrated CM-NTDs and Mass Drug Administration (MDA) to determine cost drivers and effectiveness. RESULTS: The total cost incurred by the integrated CM-NTD approach from 2017 to 2019 was US$ 789,856.30, with the highest percentage of costs for program staffing and motivation (41.8%), followed by operating costs (24.8%). In the two counties implementing fragmented (vertical) disease management, approximately US$ 325,000 was spent on the diagnosis of 84 persons and the treatment of twenty-four persons suffering from NTDs. While 2.5 times as much was spent in integrated counties, 9-10 times more patients were diagnosed and treated. CONCLUSIONS: The cost of a patient being diagnosed under the fragmented (vertical) implementation is five times higher than integrated CM-NTDs, and providing treatment is ten times as costly. Findings indicate that the integrated CM-NTDs strategy has achieved its primary objective of improved access to NTD services. The success of implementing an integrated CM-NTDs approach in Liberia, presented in this paper, demonstrates that NTD integration is a cost-minimizing solution.

Association of diabetes with frequency and cost of hospital admissions: a retrospective cohort study.

BACKGROUND: Acute inpatient hospital admissions account for more than half of all health care costs related to diabetes. We sought to identify the most common and costly conditions leading to hospital admission among patients with diabetes compared with patients without diabetes. METHODS: We used data from the General Internal Medicine Inpatient Initiative (GEMINI) study, a retrospective cohort study, of all patients admitted to a general internal medicine service at 7 Toronto hospitals between 2010 and 2015. The Canadian Institute for Health Information (CIHI) Most Responsible Diagnosis code was used to identify the 10 most frequent reasons for admission in patients with diabetes. Cost of hospital admission was estimated using the CIHI Resource Intensity Weight. Comparisons were made between patients with or without diabetes using the Pearson χ2 test for frequency and distribution-free confidence intervals (CIs) for median cost. RESULTS: Among the 150 499 hospital admissions in our study, 41 934 (27.8%) involved patients with diabetes. Compared with patients without diabetes, hospital admissions because of soft tissue and bone infections were most frequent (2.5% v. 1.9%; prevalence ratio [PR] 1.28, 95% CI 1.19-1.37) and costly (Can$8794 v. Can$5845; cost ratio [CR] 1.50, 95% CI 1.37-1.65) among patients with diabetes. This was followed by urinary tract infections (PR 1.16, 95% CI 1.11-1.22; CR 1.23, 95% CI 1.17-1.29), stroke (PR 1.13, 95% CI 1.07-1.19; CR 1.19, 95% CI 1.14-1.25) and electrolyte disorders (PR 1.11, 95% CI 1.03-1.20; CR 1.20, 95% CI 1.08-1.34). INTERPRETATION: Soft tissue and bone infections, urinary tract infections, stroke and electrolyte disorders are associated with a greater frequency and cost of hospital admissions in patients with diabetes than in those without diabetes. Preventive strategies focused on reducing hospital admissions secondary to these disorders may be beneficial in patients with diabetes.

Harnessing T Cells to Control Infections After Allogeneic Hematopoietic Stem Cell Transplantation.

Dramatic progress in the outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) from alternative sources in pediatric patients has been registered over the past decade, providing a chance to cure children and adolescents in need of a transplant. Despite these advances, transplant-related mortality due to infectious complications remains a major problem, principally reflecting the inability of the depressed host immune system to limit infection replication and dissemination. In addition, development of multiple infections, a common occurrence after high-risk allo-HSCT, has important implications for overall survival. Prophylactic and preemptive pharmacotherapy is limited by toxicity and, to some extent, by lack of efficacy in breakthrough infections. T-cell reconstitution is a key requirement for effective infection control after HSCT. Consequently, T-cell immunotherapeutic strategies to boost pathogen-specific immunity may complement or represent an alternative to drug treatments. Pioneering proof of principle studies demonstrated that the administration of donor-derived T cells directed to human herpesviruses, on the basis of viral DNA monitoring, could effectively restore specific immunity and confer protection against viral infections. Since then, the field has evolved with implementation of techniques able to hasten production, allow for selection of specific cell subsets, and target multiple pathogens. This review provides a brief overview of current cellular therapeutic strategies to prevent or treat pathogen-related complications after HSCT, research carried out to increase efficacy and safety, including T-cell production for treatment of infections in patients with virus-naïve donors, results from clinical trials, and future developments to widen adoptive T-cell therapy access in the HSCT setting.

Dangerous Pathogens as a Potential Problem for Public Health.

Pathogens are various organisms, such as viruses, bacteria, fungi, and protozoa, which can cause severe illnesses to their hosts. Throughout history, pathogens have accompanied human populations and caused various epidemics. One of the most significant outbreaks was the Black Death, which occurred in the 14th century and caused the death of one-third of Europe's population. Pathogens have also been studied for their use as biological warfare agents by the former Soviet Union, Japan, and the USA. Among bacteria and viruses, there are high priority agents that have a significant impact on public health. Bacillus anthracis, Francisella tularensis, Yersinia pestis, Variola virus, Filoviruses (Ebola, Marburg), Arenoviruses (Lassa), and influenza viruses are included in this group of agents. Outbreaks and infections caused by them might result in social disruption and panic, which is why special operations are needed for public health preparedness. Antibiotic-resistant bacteria that significantly impede treatment and recovery of patients are also valid threats. Furthermore, recent events related to the massive spread of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are an example of how virus-induced diseases cannot be ignored. The impact of outbreaks, such as SARS-CoV-2, have had far-reaching consequences beyond public health. The economic losses due to lockdowns are difficult to estimate, but it would take years to restore countries to pre-outbreak status. For countries affected by the 2019 coronavirus disease (COVID-19), their health systems have been overwhelmed, resulting in an increase in the mortality rate caused by diseases or injuries. Furthermore, outbreaks, such as SARS-CoV-2, will induce serious, wide-ranging (and possibly long-lasting) psychological problems among, not only health workers, but ordinary citizens (this is due to isolation, quarantine, etc.). The aim of this paper is to present the most dangerous pathogens, as well as general characterizations, mechanisms of action, and treatments.

Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study.

BACKGROUND: Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD. METHODS AND FINDINGS: We utilized the 2016 National Inpatient Sample-a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59-0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33-0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57-2.17; p < 0.001) or patient-directed discharge (also referred to as "discharge against medical advice") (aOR 3.47; 95% CI 2.80-4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts. CONCLUSIONS: Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.

What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers?

BACKGROUND: Orthopaedic sequelae such as skin and soft-tissue abscesses are frequent complications of intravenous drug use (IVDU) and comprise many of the most common indications for emergency room visits and hospitalizations within this population. Urban tertiary-care and safety-net hospitals frequently operate in challenging economic healthcare environments and are disproportionately tasked with providing care to this largely underinsured patient demographic. Although many public health initiatives have been instituted in recent years to understand the health impacts of IVDU and the spreading opioid epidemic, few efforts have been made to investigate its economic impact on healthcare systems. The inpatient treatment of orthopaedic sequelae of IVDU is a high-cost healthcare element that is critically important to understand within the current national context of inflationary healthcare costs. QUESTIONS/PURPOSES: (1) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of extraspinal orthopaedic sequelae of IVDU? (2) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of spinal orthopaedic sequelae of IVDU? (3) How did patient insurance status effect the economic burden of orthopaedic sequelae of IVDU? METHODS: An internal departmental record of all successive patients requiring inpatient treatment of orthopaedic sequelae of IVDU was initiated at Boston Medical Center (Boston, MA, USA) in 2012 and MetroHealth Medical Center (Cleveland, OH, USA) in 2015. A total of 412 patient admissions between 2012 to 2017 to these two safety-net hospitals (n = 236 and n = 176, respectively) for orthopaedic complications of IVDU were included in the study. These sequelae included cellulitis, cutaneous abscess, bursitis, myositis, tenosynovitis, septic arthritis, osteomyelitis, and epidural abscess. Patients were included if they were older than 18 years of age, presented to the emergency department for management of a musculoskeletal infection secondary to IVDU, and required inpatient orthopaedic treatment during their admission. Exclusion criteria included all patients presenting with a musculoskeletal infection not directly secondary to active IVDU. Patients presenting with an epidural abscess (Boston Medical Center, n = 36) were evaluated separately to explore potential differences in costs within this subgroup. A robust retrospective financial analysis was performed using internal financial databases at each institution which directly enumerated all true hospital costs associated with each patient admission, independent of billed hospital charges. All direct, indirect, variable, and fixed hospital costs were individually summed for each hospitalization, constituting a true "bottom-up" micro-costing approach. Labor-based costs were calculated through use of time-based costing; for instance, the cost of nursing labor care associated with a patient admission was determined through ascription of the median hospital cost of a registered nurse within that department (that is, compensation for salary plus benefits) to the total length of nursing time needed by that patient during their hospitalization. Primary reimbursements reflected the true monetary value received by the study institutions from insurers and were determined through the total adjusted payment for each inpatient admission. All professional fees were excluded. A secondary analysis was performed to assess the effect of patient insurance status on hospital costs and reimbursements for each patient admission. RESULTS: The mean healthcare cost incurred for the treatment of extraspinal orthopaedic sequelae of IVDU was USD 9524 ± USD 1430 per patient admission. The mean hospital reimbursement provided for the treatment of these extraspinal sequelae was USD 7678 ± USD 1248 per patient admission. This resulted in a mean financial loss of USD 1846 ± USD 1342 per patient admission. The mean healthcare cost incurred at Boston Medical Center for the treatment of epidural abscesses secondary to IVDU was USD 44,357 ± USD 7384 per patient. Hospital reimbursements within this subgroup were highly dependent upon insurance status. The median (range) reimbursement provided for patients possessing a unique hospital-based nonprofit health plan (n = 4) was USD 103,016 (USD 9022 to USD 320,123), corresponding to a median financial gain of USD 24,904 (USD 2289 to USD 83,079). However, the mean reimbursement for all other patients presenting with epidural abscesses (n = 32) was USD 30,429 ± USD 5278, corresponding to a mean financial loss of USD 5768 ± USD 4861. A secondary analysis demonstrated that treatment of extraspinal orthopaedic sequelae of IVDU for patients possessing Medicaid insurance (n = 309) resulted in a financial loss of USD 2813 ± USD 1593 per patient admission. Conversely, treatment of extraspinal orthopaedic sequelae for patients possessing non-Medicaid insurance (n = 67) generated a mean financial gain of USD 2615 ± USD 1341 per patient admission. CONCLUSIONS: Even when excluding all professional fees, the inpatient treatment of orthopaedic sequelae of IVDU resulted in substantial financial losses driven primarily by high proportions of under- and uninsured people within this patient population. These financial losses may be unsustainable for medical centers operating in challenging economic healthcare landscapes. The development of novel initiatives and support of existing programs aimed at mitigating the health-related and economic impact of IVDU must remain a principal priority of healthcare providers and policymakers in coming years. Advocacy for the expansion of Medicaid accountable care organizations and national syringe service programs (SSPs), and the development of specialized outpatient wound and abscess clinics at healthcare centers may help to substantially alleviate the economic burden of the orthopaedic sequelae of IVDU. LEVEL OF EVIDENCE: Level, IV, economic and decision analyses.

Current status of pediatric neurocritical care in Argentina. / Estado actual del soporte neurológico crítico en pediatría en la Argentina.

INTRODUCTION: Patients with neurocritical injuries account for 10-16 % of pediatric intensive care unit (PICU) admissions and frequently require neuromonitoring. OBJECTIVE: To describe the current status of neuromonitoring in Argentina. METHODS: Survey with 37 questions about neuromonitoring without including patients' data. Period: April-June 2017. RESULTS: Thirty-eight responses were received out of 71 requests (14 districts with 11 498 annual discharges). The PICU/hospital bed ratio was 21.9 (range: 4.2-66.7). Seventy-four percent of PICUs were public; 61 %, university-affiliated; and 71 %, level I. The availability of monitoring techniques was similar between public and private (percentages): intracranial pressure (95), electroencephalography (92), transcranial Doppler (53), evoked potentials (50), jugular saturation (47), and bispectral index (11). Trauma was the main reason for monitoring. CONCLUSION: Except for intracranial pressure and electroencephalography, neuromonitoring resources are scarce and active neurosurgery availability is minimal. A PICU national registry is required.

Introducción. Los pacientes con lesiones neurocríticas representan el 10-16 % de los ingresos a unidades de cuidados intensivos pediátricas (UCIP) y, frecuentemente, requieren neuromonitoreo. Objetivo. Describir el estado actual del neuromonitoreo en la Argentina. Métodos. Encuesta con 37 preguntas sobre neuromonitoreo sin incluir datos de pacientes. Período: abril-junio, 2017. Resultados. Se recibieron 38 respuestas a 71 solicitudes (14 distritos con 11 498 egresos anuales). La relación camas de UCIP/hospitalarias fue 21,9 (rango: 4,2-66,7). El 74 % fueron públicas; el 61 %, universitarias, y el 71 %, nivel 1. La disponibilidad fue similar entre públicas y privadas (porcentajes): presión intracraneana (95), electroencefalografía (92), doppler transcraneano (53), potenciales evocados (50), saturación yugular (47) e índice bispectral (11). El principal motivo de monitoreo fue trauma. Conclusión. Excepto la presión intracraneana y la electroencefalografía, los recursos de neuromonitoreo son escasos y la disponibilidad de neurocirugía activa es mínima. Se necesita un registro nacional de UCIP.

Management of infective complications of otitis media in resource-constrained settings.

PURPOSE OF REVIEW: Complications of otitis media are a cause of significant morbidity and mortality, compounded in resource-constrained settings in which human and physical resources to manage disease are suboptimal. Here, we examine the current best evidence to devise a protocol for management, in particular exploring the opportunity for conservative or nonspecialist management. RECENT FINDINGS: Reviews of the literature suggest that intratemporal and extracranial infections can be managed with antibiotics in the first instance, with aspiration or incision and drainage of abscess. Failure to respond necessitates mastoidectomy, which need not be extensive, and can be performed with hammer and gouge. Suspected or possible intracranial extension requires referral for computed tomography (CT) imaging. Intracranial infection can in some instances be managed with antibiotics, but large or persistent intracranial abscess, or the presence of cholesteatoma requires management in a centre for specialist surgery. SUMMARY: Many complications of otitis media could be managed by nonspecialists in appropriately equipped local or regional health facilities, and supported by appropriate training. However, regional centres with CT imaging and specialist surgery are required for assessment and treatment of cases that are suspected of having complex or advanced disease, or that fail to respond to initial treatment. Those involved in planning healthcare provision should look to develop infrastructure to support such management.

The Result of Treatment of Deep Neck Infection in Patients Referred According to Public Health System.

There are many factors that result in the treatment of deep neck infection (DNI). This study aims to compare the results of DNI treatment between referred and walk-in patients. This retrospective cohort study reviewed the data of 282 DNI patients. The peritonsillar abscesses and limited intraoral abscesses were excluded. The outcome of treatment such as duration of hospital stay, the expense of treatment, morbidity, and mortality were reviewed during staying in the hospital. A total of 282 patients were included in this study, there were 152 referred patients and 130 walk-in patients. Patients who were sent to have treatment results were not significantly different from those who had come directly to the hospital regardless of the length of stay, the cost of medical treatment, complications, and death due to complications with sepsis (P = .013). However, the referred patients exhibited a risk to have sepsis 1.1 times more than the patients who went straight to the medical specialists (univariate analysis risk ratio [RR]: 1.1, 95% confidence interval [CI]: 0.8-1.3; P = .620). The results were confirmed in the multivariate analysis after adjusting for age, gender, diabetes, chronic renal failure, cirrhosis, and dental care. It was found that the risk to have sepsis in the "refer in" group was 1.1 times more than the other group (multivariate analysis RR: 1.1, 95% CI: 0.8-1.3; P = .658). In conclusion, the results of treatment in referred patients were not different from walk-in patients. Deep neck infection patients at hospitals that do not have a specialized doctor will receive appropriate treatment because of the effective DNI referral system according to public health systems. However, in referred patients, sepsis should be maintained prior to delivery.

Assessment of latent infections in patients receiving biological therapies.

The use of biological (or targeted) therapies constitutes a major advance in the management of autoinflammatory and malignant diseases. However, due to the selective effect of these agents on the host's immune response, reactivation of certain pathogens that cause latent infection is to be expected. The most relevant concern is the risk of reactivation of latent tuberculosis infection (LTBI) and progression to active tuberculosis among patients treated with agents targeting tumor necrosis factor (TNF)-α. Systematic screening for LTBI at base-line with appropriate initiation of antituberculous treatment, if needed, is mandatory in this patient population as risk minimization strategy. In addition, reactivation of hepatitis B virus induced by B-cell-depleting (anti-CD20) and anti-TNF-α agents should be also prevented among HBsAg-positive patients and those with isolated anti-HBc IgG positivity (risk of "occult HBV infection"). The present review summarizes available evidence regarding the risk of reactivation of these latent infections induced by newer biological agents, as well as the recommendations included in the most recent guidelines.

Megatrends in Infectious Diseases: The Next 10 to 15 Years.

It has been about 100 years since the Spanish influenza pandemic of 1918-19 that killed an estimated 50 million individuals globally. While we have made remarkable progress in reducing infection-related mortality, infections still account for 13 to 15 million deaths annually. This estimate is projected to remain unchanged until 2050. We have identified 4 megatrends in infectious diseases and these are "emerging and re-emerging infections", "antimicrobial resistance", "demographic changes" and "technological advances". Understanding these trends and challenges should lead to opportunites for the medical community to reshape the future. Further inroads will also require broad approaches involving surveillance, public health and translating scientific discoveries into disease control efforts.

Age-Specific Distribution of Diagnosis and Outcomes of Children Admitted to ICUs: A Population-Based Cohort Study.

OBJECTIVES: Although several studies have reported outcome data on critically ill children, detailed reports by age are not available. We aimed to evaluate the age-specific estimates of trends in causes of diagnosis, procedures, and outcomes of pediatric admissions to ICUs in a national representative sample. DESIGN: A population-based retrospective cohort study. SETTING: Three hundred forty-four hospitals in South Korea. PATIENTS: All pediatric admissions to ICUs in Korea from August 1, 2009, to September 30, 2014, were covered by the Korean National Health Insurance Corporation, with virtually complete coverage of the pediatric population in Korea. Patients less than 18 years with at least one ICUs admission between August 1, 2009, and September 30, 2014. We excluded neonatal admissions (< 28 days), neonatal ICUs, and admissions for health status other than a disease or injury. The final sample size was 38,684 admissions from 32,443 pediatric patients. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The overall age-standardized admission rate for pediatric patients was 75.9 admissions per 100,000 person-years. The most common primary diagnosis of admissions was congenital malformation (10,897 admissions, 28.2%), with marked differences by age at admission (5,712 admissions [54.8%] in infants, 3,994 admissions [24.6%] in children, and 1,191 admissions [9.9%] in adolescents). Injury was the most common primary diagnosis in adolescents (3,248 admissions, 27.1%). The overall in-hospital mortality was 2,234 (5.8%) with relatively minor variations across age. Neoplasms and circulatory and neurologic diseases had both high frequency of admissions and high in-hospital mortality. CONCLUSIONS: Admission patterns, diagnosis, management, and outcomes of pediatric patients admitted to ICUs varied by age groups. Strategies to improve critical care qualities of pediatric patients need to be based on the differences of age and may need to be targeted at specific age groups.

Incorporating Voluntary Medical Male Circumcision Into Traditional Circumcision Contexts: Experiences of a Local Consortium in Zimbabwe Collaborating With an Ethnic Group.

Employing voluntary medical male circumcision (VMMC) within traditional settings may increase patient safety and help scale up male circumcision efforts in sub-Saharan Africa. In Zimbabwe, the VaRemba are among the few ethnic groups that practice traditional male circumcision, often in suboptimal hygienic environments. ZAZIC, a local consortium, and the Zimbabwe Ministry of Health and Child Care (MoHCC) established a successful, culturally sensitive partnership with the VaRemba to provide safe, standardized male circumcision procedures and reduce adverse events (AEs) during traditional male circumcision initiation camps. The foundation for the VaRemba Camp Collaborative (VCC) was established over a 4-year period, between 2013 and 2017, with support from a wide group of stakeholders. Initially, ZAZIC supported VaRemba traditional male circumcisions by providing key commodities and transport to help ensure patient safety. Subsequently, 2 male VaRemba nurses were trained in VMMC according to national MoHCC guidelines to enable medical male circumcision within the camp. To increase awareness and uptake of VMMC at the upcoming August-September 2017 camp, ZAZIC then worked closely with a trained team of circumcised VaRemba men to create demand for VMMC. Non-VaRemba ZAZIC doctors were granted permission by VaRemba leaders to provide oversight of VMMC procedures and postoperative treatment for all moderate and severe AEs within the camp setting. Of 672 male camp residents ages 10 and older, 657 (98%) chose VMMC. Only 3 (0.5%) moderate infections occurred among VMMC clients; all were promptly treated and healed well. Although the successful collaboration required many years of investment to build trust with community leaders and members, it ultimately resulted in a successful model that paired traditional circumcision practices with modern VMMC, suggesting potential for replicability in other similar sub-Saharan African communities.

Review article: Common emergency department presenting complaints of prisoners: A systematic review.

Prisoners are a particularly vulnerable minority group whose healthcare needs and management differ substantially from the general population. The overall burden of disease of prisoners is well documented; however, little is known regarding the aetiology and frequency of prisoners' acute medical complaints requiring an ED visit. Objectives of the review were to identify, review and appraise existing literature regarding prisoners' presentations to EDs. We performed systematic electronic searches in MEDLINE, EMBASE, PsycINFO, PubMed, Cochrane, and Web of Science using MeSH terms and keywords. Two reviewers abstracted data and conducted quality appraisal using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Nine articles met the predefined inclusion criteria. Apart from two European studies in the past 5 years, there is a scarcity of literature primarily addressing the common presenting complaints to EDs by prisoners. Existing studies demonstrated that prisoners have a disproportionately high burden of traumatic, infectious and psychiatric disease requiring emergency treatment. With the increasing number of emergency presentations made by prisoners each year, it is vital that further research is undertaken to identify trends of these acute medical complaints in order to ensure optimal therapeutic outcomes for prisoners.

The CRIOAc healthcare network in France: A nationwide Health Ministry program to improve the management of bone and joint infection.

BACKGROUND: Bone and joint infections (BJIs) have a major clinical and economic impact in industrialized countries. Its management requires a multidisciplinary approach, and a great experience for the most complicated cases to limit treatment failure, motor disability and amputation risk. To our best knowledge there is not currently national specific organization dedicated to manage BJI. Is it possible to build at a national level, a network involving orthopaedic surgeons, infectiologists and microbiologists performing locally multidisciplinary meetings to facilitate the recruitment and the management of patients with complex bone and joint infection in regional centers? HYPOTHESIS: A national healthcare network with regional labeled centers creates a dynamic that improves the recruitment, the management, the education, and the clinical research in the field of complex BJI. PATIENTS AND METHODS: We describe the history of this unique national healthcare network and how it works, specify the missions confided to the CRIOAcs, evaluate the activity of the network over the first decade, and finally discuss perspectives. RESULTS: The labelling of 24 centers in the CRIOAc network allowed for a meshing of the territory, with the possibility of management of complex BJI in each region of France. A dedicated secure national online information system was designed and used to facilitate decision-making during multidisciplinary consultation meetings. Since October 2012 to June 2017, 4553 multidisciplinary consultation meetings have been performed in the structures belonging to the network, with 34,607 cases discussed in 19,961 individual. Prosthetic joint infections represented 38% (7585/19,961) of all BJIs. Among all the cases discussed, the rate of complexity was of 61% (21,110/34,607) (related to antibiotic resistance, infection recurrence, patient co morbidities). A national scientific meeting was created and a national postgraduate diploma in the field of BJI was launched in 2014. The promotion of education, clinical research and interactivity between each academic discipline and between each labeled centers across the country has synergized the strengths and have greatly facilitated the management of patients with BJI. DISCUSSION: The setting up of the CRIOAc network in France took time, and has a cost for the French Ministry of Health. However, this network has greatly facilitated the management of BJI in France, and allowed to concentrate the management of complex BJI in centers that have significantly gained skills. There is, to our knowledge, no other exemple of such nationwide network in the field of BJI. LEVEL OF EVIDENCE: IV, case series without control group.

Behavioral incentives in a vaccination-dilemma setting with optional treatment.

Social dilemmas are situations wherein individuals choose between selfish interest and common good. One example of this is the vaccination dilemma, in which an individual who vaccinates at a cost protects not only himself but also others by helping maintain a common good called herd immunity. There is, however, a strong incentive to forgo vaccination, thus avoiding the associated cost, all the while enjoying the protection of herd immunity. To analyze behavioral incentives in a vaccination-dilemma setting in which an optional treatment is available to infected individuals, we combined epidemiological and game-theoretic methodologies by coupling a disease-spreading model with treatment and an evolutionary decision-making model. Extensive numerical simulations show that vaccine characteristics are more important in controlling the treatment adoption than the cost of treatment itself. The main effect of the latter is that expensive treatment incentivizes vaccination, which somewhat surprisingly comes at a little cost to society. More surprising is that the margin for a true synergy between vaccine and treatment in reducing the final epidemic size is very small. We furthermore find that society-centered decision making helps protect herd immunity relative to individual-centered decision making, but the latter may be better in establishing a novel vaccine. These results point to useful policy recommendations as well as to intriguing future research directions.

Use of physician billing claims to identify infections in children.

While medical records have detailed information, they are limited in reach to the availability and accessibility of those records. On the other hand, administrative data while limited in scope, have a much further reach in coverage of an entire population. However, few studies have validated the use of administrative data for identifying infections in pediatric populations. Pediatric patients from Ontario, Canada aged <18 years were randomly sampled from the Electronic Medical Record Administrative data Linked Database (EMRALD). Using physician diagnoses from the electronic medical record (EMR) as the reference standard, we determined the criterion validity of physician billing claims in administrative data for identifying infectious disease syndromes from 2012 to 2014. Diagnosis codes were assessed by infection category (respiratory, skin and soft tissue, gastrointestinal, urinary tract and otitis externa) and for all infections combined. Sensitivity analyses assessed the performance if patients had more than one reason to visit the physician. We analysed 2,139 patients and found 33.3% of all visits were for an infection, and respiratory infections accounted for 67.6% of the infections. When we combined all infection categories, sensitivity was 0.74 (95% CI 0.70-0.77), specificity was 0.95 (95% CI 0.93-0.96), positive predictive value (PPV) was 0.87 (95% CI 0.84-0.90), and negative predictive value (NPV) was 0.88 (95% CI 0.86-0.89). For respiratory infections, sensitivity was 0.77 (95% CI 0.73-0.81), specificity was 0.96 (95% CI 0.95-0.97), PPV was 0.85 (95% CI 0.81-0.88), and NPV was 0.94 (95% CI 0.92-0.95). Similar performance was observed for skin and soft tissue, gastrointestinal, urinary tract, and otitis externa infections, but with lower sensitivity. Performance measures were highest when the patient visited the physician with only one health complaint. We found when using linked EMR data as the reference standard, administrative billing codes are reasonably accurate in identifying infections in a pediatric population.

Management of oral and maxillofacial infections in a regional unit: a seven day service?

The provision of a seven-day National Health Service (NHS) has been proposed as a means to halt the weekend delay in treatment that has been described in some studies. We tested the emergency services in the Oral and Maxillofacial Surgery Department at Northampton General Hospital to find out whether they provided a seven-day service. Data were collected prospectively and retrospectively for all patients admitted to the Oral and Maxillofacial Department at Northampton General Hospital with infections of the head and neck during a period of 29months (January 2014-May 2016). Duration of hospital stay and waiting time for operation were compared for weekday and weekend admissions to find out if there were changes in either outcomes or waiting times. The severity of infection between the two periods was also assessed using the serum C reactive protein (CRP) concentration as a marker. A total of 293 patients were admitted with head and neck infections, and the mean (range) duration of stay for those admitted on weekdays was 3 (1-14) days and for patients admitted at a weekend was 3 (1-17) days (p=0.14). However, the waiting times for operation were significantly longer during the week (mean (range) 0.6 (0-8) days) than at the weekend (0.5 (0-3) days, p=0.04). We know of no other published studies about provision of a seven-day service in oral and maxillofacial surgery. Our results show that we are already working to that standard, and this raises the question of whether any changes are required to current practice in the NHS, with their associated costs and upheaval.