Effect of Modafinil on Cognitive Function in Intensive Care Unit Patients: A Retrospective Cohort Study.

Modafinil therapy, a nonamphetamine cognition-enhancing agent, holds the potential to improve recovery from cognitive impairment after intensive care unit (ICU) admission. To date, however, there is a paucity of data on modafinil use in the ICU setting. The purpose of this study was to explore the role of modafinil for improvement in cognition in ICU patients. This retrospective cohort study evaluated a total of 60 ICU patients with any ventilatory support who started on modafinil during their ICU stay from January 1, 2010, to March 19, 2016. The requirements of opioids and sedatives, as well as the lowest and average scores of the Glasgow Coma Scale (GCS) and Riker Sedation-Agitation Scale (SAS), were recorded during 48 hours before and after the start of modafinil therapy in 6-hour periods. The average daily modafinil dose of 170 mg was given for a median duration of 9 days. Modafinil administration was associated with a small, nonsignificant increase in GCS by 0.34 points after controlling for age, baseline severity of illness, and changes in sedation and analgesia over time (95%CI, -0.34 to 0.73 points; P = .0743). No major modafinil-associated adverse effects were observed. Modafinil administration did not significantly improve cognitive function in ICU patients within 48 hours of initiation. However, because of lack of robust evidence, the impact of modafinil on overall patient outcomes in the ICU remains unclear and needs further investigation.

Cervical intraepithelial neoplasia grade 3 and adenocarcinoma in situ: comparison of ICD-9 codes and pathology results--Kaiser Permanente, United States, 2000-2005.

BACKGROUND: Cervical intraepithelial neoplasia grade 3+ (CIN3+) and adenocarcinoma in situ incidence will be an important measure of HPV vaccine impact. Integrated healthcare delivery systems, such as Kaiser Permanente, could be used to monitor CIN3+ trends; however, limited evaluations of data from healthcare delivery systems for CIN3+ surveillance exist. METHODS: We compared CIN3+ diagnoses by ICD-9 code with CIN3+ diagnoses by pathology results among 121,211 females aged 11 to 30 years who were continuously enrolled from 2000 to 2005 in either Kaiser Permanente Northern California or Kaiser Permanente Northwest. We calculated sensitivity and positive predictive value of diagnosis by ICD-9 codes using pathology CIN3+ diagnosis as the gold standard. RESULTS: There were 1,090 women with at least one CIN3+ diagnosis by ICD-9 code 233.1 and 1,200 women with at least one CIN3+ diagnosis by pathology results. The sensitivity of the ICD-9 code for detecting a woman with at least one pathology diagnosis for CIN3+ was 62% (740/1,200); positive predictive value was 68% (740/1,090). Among women with at least one CIN3+ diagnosis by ICD-9 code, 679 (62%) had more than one visit with this code; whereas, among women with at least one CIN3+ diagnosis by pathology, 466 (39%) had more than one CIN3+ pathology result. CONCLUSIONS: ICD-9 codes may underestimate the number of women with at least one CIN3+ diagnosis. IMPACT: Pathology results, when available, may provide better estimates of CIN3+ incidence.

Use of home-obtained vaginal swabs to facilitate rescreening for Chlamydia trachomatis infections: two randomized controlled trials.

OBJECTIVE: To determine whether the use of home-based, self-obtained vaginal swabs among women who were treated for Chlamydia infection can increase rescreening rates in comparison with clinic-based rescreening, and to identify subgroups in which rescreening could be enhanced using self-obtained vaginal swabs. METHODS: Two randomized trials were conducted: one with enrollment in sexually transmitted disease (STD) clinics and the other in family planning clinics. Study participants were recruited from STD (n = 880) and family planning clinics (n = 412) in three cities. Females aged 16 years or older who were treated for Chlamydia infection were randomly assigned to the home group (swab collection kits mailed to home) or the clinic group (made clinic appointments) for rescreening at 3 months after treatment, with reminder calls about 2 weeks before the scheduled rescreening date. RESULTS: Groups were similar with respect to age and other demographic characteristics. Women assigned to the home group had higher rescreening rates than those in the clinic group. In STD clinics, rescreening rates were 26.7% (home) compared with 19.1% (clinic) (P = .01). In family planning clinics, rescreening rates were 40.8% (home) compared with 20.7% (clinic) (P<.001). Among women reached by reminder calls, rescreening rates were also significantly higher in the home groups: 43.5% compared with 33.0% in STD clinic participants and 59.2% compared with 37.8% in family planning clinic participants (both P<.05). The rates of reinfection ranged from 12.9% to 19.4%, and the differences by group were not statistically significant (P ≥ .3). CONCLUSION: In STD and family planning clinics, use of home-based, self-obtained vaginal swabs resulted in significant increases in rescreening rates compared with rescreening in the clinic. Home-based specimen collection can be an alternative to clinic-based rescreening for Chlamydia infection in women. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT 00132457. LEVEL OF EVIDENCE: I.

Brief counseling for reducing sexual risk and bacterial STIs among drug users--results from project RESPECT.

OBJECTIVE: Project RESPECT's brief risk reduction counseling (BRRC) reduced sexual risk and bacterial STIs among at-risk heterosexuals and has been packaged for use with this population. We assessed BRRC's efficacy with RESPECT participants who used drugs and examined BRRC's applicability to present-day users of heroin, cocaine, speedball, or crack. METHODS: We compared baseline demographic and economic variables, risk behaviors, and prevalence and correlates of bacterial STIs for ever-injectors ([EIs], N=335) and never-injectors ([NIs], N=3963). We assessed changes in risk behaviors and bacterial STIs for EIs and NIs at 12 months. We compared prevalence of HSV-2, hepatitis B core antigen virus (HBV), hepatitis C virus (HCV), and trichomonas among EIs with recently reported rates among drug users. RESULTS: At baseline, 19% of EIs and 29% of NIs had bacterial STIs. Both groups had similar baseline STI correlates. At 12 months, 4% of EIs and 7% of NIs had bacterial STIs. Twelve-month cumulative incidence of bacterial STIs in BRRC was 21% lower among EIs and 18% lower among NIs compared to the informational condition. At 12 months, EIs reported fewer sexual risk behaviors than at baseline. Baseline positivity rates of trichomoniasis in EIs (female: 15%) and in male and female EIs of HSV-2 (39%, 68%), HBV (41%, 37%), and HCV (60%, 58%) were similar to rates in present-day drug users. CONCLUSION: Efficacy of BRRC in reducing sexual risk and bacterial STIs in EIs, and similar profiles for EIs and present-day drug users suggest evaluating BRRC with present-day drug users.

Ventilator-associated pneumonia and oral care: a successful quality improvement project.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a nosocomial pneumonia that develops in patients on mechanical ventilation for >or=48 hours. VAP develops at an estimated rate of 1% to 3% per day of mechanical ventilation. METHODS: Quality improvement project. Mechanically ventilated patients received the following oral care every 4 hours: the teeth were brushed with cetylpyridinium chloride (changed to 0.12% chlorhexidine gluconate in 2007) using a suction toothbrush, the oral cavity was cleansed with suction swabs treated with hydrogen peroxide, a mouth moisturizer was applied, deep oropharyngeal suctioning was performed, and suction catheters were used to control secretions. The primary efficacy variable was a diagnosis of VAP in patients mechanically ventilated for >or=48 hours. RESULTS: The historical average rate of VAP in 2004 was 12.6 cases/1000 ventilator-days. After the inception of the quality improvement project, VAP rates decreased to 4.12 (VAP cases/days of ventilation x 1000) for May to December 2005, to 3.57 for 2006, and to 1.3 for 2007. CONCLUSION: The use of an oral care protocol intervention and ventilator bundle led to an 89.7% reduction in the VAP rate in mechanically ventilated patients from 2004 to 2007.

Incidence of neonatal herpes simplex virus infections in two managed care organizations: implications for surveillance.

OBJECTIVES: To estimate the incidence of neonatal herpes simplex virus (HSV) infections and to assess the utility of surveillance methods for neonatal herpes in 2 managed care populations. METHODS: We identified potential cases using 15 discharge International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes for neonatal HSV and other diseases clinically consistent with this diagnosis. We also searched laboratory databases for positive HSV tests and investigated deaths during the neonatal period. We performed medical chart review using a standardized form. Two pediatric infectious disease specialists reviewed the forms of infants who had a positive HSV test or received a herpes-related diagnosis and made a determination as confirmed, probable, or not a case. RESULTS: Among 270,703 infants born from 1997 to 2002, we identified 737 potential cases and completed medical chart abstraction for 699 (95%). Final review identified 35 confirmed or probable cases of neonatal HSV, and the incidence was 12.9 per 100,000 live births. Only 24 (69%) of the 35 cases were confirmed by laboratory testing. Among the 24 confirmed cases, 22 (92%) received an ICD-9 code of 054.xx or 771.2. Among the 60 infants that received an ICD-9 code of 054.xx or 771.2, only 31 (52%) were confirmed or probable cases of neonatal HSV after final review. CONCLUSIONS: About 30% of neonatal HSV cases were not laboratory confirmed. The use of ICD-9 codes of 054.xx and 771.2 was a sensitive but not specific method to identify cases of neonatal herpes.

Findings from STD screening of adolescents and adults entering corrections facilities: implications for STD control strategies.

BACKGROUND: Persons entering corrections facilities are at high risk for sexually transmitted diseases (STDs) because of risky sexual behavior and lack of access to routine screening. GOAL: The goal of the study was to develop a national picture of STD prevalence in this population. STUDY DESIGN: We analyzed information on age, race/ethnicity, urethral symptoms (men only), and test results for approximately 85,000 chlamydia, 157,000 gonorrhea, and 293,000 syphilis tests for persons entering 23 jails and 12 juvenile detention centers in 13 US counties from 1996 through 1999. RESULTS: At adult jails in nine counties, the median percentage of persons with reactive syphilis tests by county was 8.2% (range, 0.3-23.8%) for women and 2.5% (range, 1.0-7.8%) for men. At juvenile detention facilities in five counties, the median positivity for chlamydial infection was 15.6% (range, 8.0-19.5%) for adolescent girls and 7.6% (range, 2.8-8.9%) for adolescent boys; the median positivity for gonorrhea was 5.2% (range, 3.4-10.0%) for adolescent girls and 0.9% (range, 0.7-2.6%) for adolescent boys. Of adolescent boys testing positive for chlamydial infection at three juvenile facilities, approximately 97% did not report symptoms; of adolescent boys positive for gonorrhea, 93% did not report symptoms. CONCLUSION: STD positivity among persons entering corrections facilities is high. Most chlamydial and gonococcal infections are asymptomatic and would not be detected without routine screening. Monitoring the prevalence of STDs in this population is useful for planning STD prevention activities in corrections facilities and elsewhere in the community.