Comparative evaluation of postoperative outcomes and expenditure between robotic and conventional single-level lumbar fusion surgery: a comprehensive analysis of nationwide inpatient sample data.

INTRODUCTION: In this study, we investigate the evolution of lumbar fusion surgery with robotic assistance, specifically focusing on the impact of robotic technology on pedicle screw placement and fixation. Utilizing data from the Nationwide Inpatient Sample (NIS) covering 2016 to 2019, we conduct a comprehensive analysis of postoperative outcomes and costs for single-level lumbar fusion surgery. Traditionally, freehand techniques for pedicle screw placement posed risks, leading to the development of robotic-assisted techniques with advantages such as reduced misplacement, increased precision, smaller incisions, and decreased surgeon fatigue. However, conflicting study results regarding the efficacy of robotic assistance in comparison to conventional techniques have prompted the need for a thorough evaluation. With a dataset of 461,965 patients, our aim is to provide insights into the impact of robotic assistance on patient care and healthcare resource utilization. Our primary goal is to contribute to the ongoing discourse on the efficacy of robotic technology in lumbar fusion procedures, offering meaningful insights for optimizing patient-centered care and healthcare resource allocation. METHODS: This study employed data from the Nationwide Inpatient Sample (NIS) spanning the years 2016 to 2019 from USA, 461,965 patients underwent one-level lumbar fusion surgery, with 5770 of them having the surgery with the assistance of robotic technology. The study focused primarily on one-level lumbar fusion surgery and excluded non-elective cases and those with prior surgeries. The analysis encompassed the identification of comorbidities, surgical etiologies, and complications using specific ICD-10 codes. Throughout the study, a constant comparison was made between robotic and non-robotic lumbar fusion procedures. Various statistical methods were applied, with a p value threshold of < 0.05, to determine statistical significance. RESULTS: Robotic-assisted lumbar fusion surgeries demonstrated a significant increase from 2016 to 2019, comprising 1.25% of cases. Both groups exhibited similar patient demographics, with minor differences in payment methods, favoring Medicare in non-robotic surgery and more private payer usage in robotic surgery. A comparison of comorbid conditions revealed differences in the prevalence of hypertension, dyslipidemia, and sleep apnea diagnoses-In terms of hospitalization outcomes and costs, there was a slight shorter hospital stay of 3.06 days, compared to 3.13 days in non-robotic surgery, showcasing a statistically significant difference (p = 0.042). Robotic surgery has higher charges, with a mean charge of $154,673, whereas non-robotic surgery had a mean charge of $125,467 (p < 0.0001). Robotic surgery demonstrated lower rates of heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury compared to non-robotic surgery, with statistically significant differences (p < 0.05). Conversely, robotic surgery demonstrated increased post-surgery anemia and blood transfusion requirements compared to non-robotic patients (p < 0.0001). Renal disease prevalence was similar before surgery, but acute kidney injury was slightly higher in the robotic group post-surgery (p = 0.038). CONCLUSION: This is the first big data study on this matter, our study showed that Robotic-assisted lumbar fusion surgery has fewer post-operative complications such as heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury in comparison to conventional methods. Conversely, robotic surgery demonstrated increased post-surgery anemia, blood transfusion and acute kidney injury. Robotic surgery has higher charges compared to non-robotic surgery.

Robotic-assisted total knee arthroplasty reduces postoperative complications and length of stay without increased cost compared to navigation-guided techniques: A national analysis.

INTRODUCTION: This study compares postoperative outcomes of robotic-assisted total knee arthroplasty (RA-TKA) versus navigation-guided total knee arthroplasty (NG-TKA). Using Nationwide Inpatient Sample (NIS) data, it provides an analysis of postoperative complications, mortality, hospital costs and duration of stay. METHODS: The study analysed 217,715 patients (81,830 RA-TKA; 135,885 NG-TKA) using NIS data from 2016 to 2019. Elective TKA patients were identified through the International Classification of Diseases, 10th Revision codes. Statistical analyses, including logistic regression modelling, were performed using Statistical Package for the Social Sciences and MATLAB. RESULTS: RA-TKA patients were younger (66.1 vs. 67.1 years, p < 0.0001) and had similar mortality rates (0.024% vs. 0.018%, p = 0.342) but shorter length of stay (LOS) (1.89 vs. 2.1 days, p < 0.0001). Mean total charges were comparable between RA-TKA ($66,180) and NG-TKA ($66,251, p = 0.669). RA-TKA demonstrated lower incidences of blood-related complications (11.67% vs. 14.19%, p < 0.0001), pulmonary oedema (0.0306% vs. 0.066%, p < 0.0001), deep vein thrombosis (0.196% vs. 0.254%, p = 0.006) and acute kidney injury (AKI) (1.356% vs. 1.483%, p = 0.016). CONCLUSION: RA-TKA reduces postoperative complications and LOS without increasing costs, highlighting the relevance of this technology in patient care. LEVEL OF EVIDENCE: Level III.

Big data analysis reveals significant increases in complications, costs, and hospital stay in revision total knee arthroplasty compared to primary TKA.

INTRODUCTION: Despite significant advancements in total knee arthroplasty (TKA), some patients require revision surgery (R-TKA) due to complications such as infection, mechanical loosening, instability, periprosthetic fractures, and persistent pain. This study aimed to explore the specific causes leading to R-TKA, associated complications, including infection, mechanical failure, and wound issues, as well as costs, mortality rates, and hospital length of stay (LOS) using data from a large national database. METHODS: Data from the nationwide inpatient sample (NIS), the largest publicly available all-payer inpatient care database in the United States were analysed from 1 January 2016 to 31 December 2019. The study included 44,649 R-TKA cases, corresponding to 223,240 patients, with exclusions for nonelective admissions. Various statistical analyses were used to assess clinical outcomes, including in-hospital mortality, postoperative complications, LOS, and hospitalization costs. RESULTS: Among 2,636,880 TKA patients, 8.4% underwent R-TKA. R-TKA patients had higher rates of chronic conditions, including mental disorders (36.4%) and renal disease (9.9%). Additionally, these patients often experienced instability, necessitating revision surgery. Infection (22.3%) was the primary reason for R-TKA, followed by mechanical loosening (22.9%) and instability. Compared to primary TKA patients, R-TKA patients exhibited higher in-hospital mortality (0.085% vs. 0.025%), longer LOS (3.1 vs. 2.28 days), and higher total charges ($97,815 vs. $62,188). Postoperative complications, including blood transfusion (4.6% vs. 1.3%), acute kidney injury (4.4% vs. 1.8%), venous thromboembolism (0.55% vs. 0.29%), infection, and wound problems, were significantly higher in R-TKA patients. CONCLUSIONS: This study provides detailed insights into t LOS, costs, and complications associated with specific etiologies of revision TKA. Our findings emphasize the need for targeted preoperative optimization and patient education. This approach can help reduce the incidence and burden of R-TKA, improve patient care, optimize resource allocation, and potentially decrease the overall rates of complications in revision surgeries. LEVEL OF EVIDENCE: Level III.

Trends and epidemiology in robotic-assisted total knee arthroplasty: Reduced complications and shorter hospital stays.

INTRODUCTION: This study provides an in-depth analysis of the immediate postoperative outcomes and implications or robotic-assisted total knee arthroplasty (RA-TKA) compared with conventional TKA (C-TKA), particularly with regard to mortality, complications, hospital stay and costs, drawing from a comprehensive nationwide data set. METHODS: The Nationwide Inpatient Sample (NIS) database, the largest all-payer inpatient healthcare database in the United States, was used to identify all patients who underwent RA-TKA or C-TKA from 2016 to 2019. A total of 527,376 cases, representing 2,638,679 patients who underwent elective TKA were identified, of which 88,415 had RA-TKA. To mitigate potential variations and selection bias in baseline characteristics between the two groups, a propensity score-matched analysis was employed to further balance and refine our data set, resulting in 176,830 patients evenly distributed between the groups. Analysis was performed according to demographics, immediate post-operative complications, and economic data, including payor class, length of stay and total charges. RESULTS: There was a marked shift towards RA-TKA, from an initial 0.70% in 2016 to a notable 7.30% by 2019. Patients who underwent RA-TKA were slightly younger (66.2 ± SD years), compared to the C-TKA group (66.7 ± SD years). Hospital stay was 1.89 days and 2.29 days for RA-TKA and C-TKA, respectively. Charges metrics revealed slightly higher charges for RA-TKA. Less postoperative complications were found in the RA-TKA group, such as blood loss, anaemia, acute kidney injury, venous thromboembolism, pulmonary embolism, pneumonia and surgical wound complication. Even following the propensity score matching, these findings remained consistent and statistically significant. CONCLUSIONS: RA-TKA use in the United States has grown substantially in the last few years and has been associated with significantly reduced immediate post-operative complications and length of hospital stay compared to C-TKA, offering safer surgical management for TKA patients. Further studies on the short- and long-term outcomes of RA-TKA would improve the understanding of the full potential of this technology. LEVELS OF EVIDENCE: Level III.

Interest of seroprevalence surveys for the epidemiological surveillance of the SARS-CoV-2 pandemic in African populations: Insights from the ARIACOV project in Benin.

BACKGROUND: Many SARS-CoV-2 seroprevalence surveys since the end of 2020 have disqualified the first misconception that Africa had been spared by the pandemic. Through the analysis of three SARS-CoV-2 seroprevalence surveys carried out in Benin as part of the ARIACOV project, we argue that the integration of epidemiological serosurveillance of the SARS-CoV-2 infection in the national surveillance packages would be of great use to refine the understanding of the COVID-19 pandemic in Africa. METHODS: We carried out three repeated cross-sectional surveys in Benin: two in Cotonou, the economic capital in March and May 2021, and one in Natitingou, a semi-rural city in the north of the country in August 2021. Total and weighted-by-age-group seroprevalences were estimated and the risk factors for SARS-CoV-2 infection were assessed by multivariate logistic regression. RESULTS: In Cotonou, a slight increase in overall age-standardised SARS-CoV-2 seroprevalence from 29.77% (95% CI: 23.12%-37.41%) at the first survey to 34.86% (95% CI: 31.57%-38.30%) at the second survey was observed. In Natitingou, the globally adjusted seroprevalence was 33.34% (95% CI: 27.75%-39.44%). A trend of high risk for SARS-CoV 2 seropositivity was observed in adults over 40 versus the young (less than 18 years old) during the first survey in Cotonou but no longer in the second survey. CONCLUSIONS: Our results show that, however, rapid organisation of preventive measures aimed at breaking the chains of transmission, they were ultimately unable to prevent a wide spread of the virus in the population. Routine serological surveillance on strategic sentinel sites and/or populations could constitute a cost-effective compromise to better anticipate the onset of new waves and define public health strategies.

Comparative Effectiveness of Interventions to Improve the HIV Continuum of Care and HIV Preexposure Prophylaxis in Kenya: A Model-Based Analysis.

BACKGROUND: In Western Kenya up to one-quarter of the adult population was human immunodeficiency virus (HIV)-infected in 2012. The Ministry of Health, Médecins Sans Frontières, and partners implemented an HIV program that surpassed the 90-90-90 UNAIDS targets. In this generalized epidemic, we compared the effectiveness of preexposure prophylaxis (PrEP) with improving continuum of care. METHODS: We developed a dynamic microsimulation model to project HIV incidence and infections averted to 2030. We modeled 3 strategies compared to a 90-90-90 continuum of care base case: (1) scaling up the continuum of care to 95-95-95, (2) PrEP targeting young adults with 10% coverage, and (3) scaling up to 95-95-95 and PrEP combined. RESULTS: In the base case, by 2030 HIV incidence was 0.37/100 person-years. Improving continuum levels to 95-95-95 averted 21.5% of infections, PrEP averted 8.0%, and combining 95-95-95 and PrEP averted 31.8%. Sensitivity analysis showed that PrEP coverage had to exceed 20% to avert as many infections as reaching 95-95-95. CONCLUSIONS: In a generalized HIV epidemic with continuum of care levels at 90-90-90, improving the continuum to 95-95-95 is more effective than providing PrEP. Continued improvement in the continuum of care will have the greatest impact on decreasing new HIV infections.

High Prevalence of Anti-Severe Acute Respiratory Syndrome Coronavirus 2 (Anti-SARS-CoV-2) Antibodies After the First Wave of Coronavirus Disease 2019 (COVID-19) in Kinshasa, Democratic Republic of the Congo: Results of a Cross-sectional Household-Based Survey.

BACKGROUND: In October 2020, after the first wave of coronavirus disease 2019 (COVID-19), only 8290 confirmed cases were reported in Kinshasa, Democratic Republic of the Congo, but the real prevalence remains unknown. To guide public health policies, we aimed to describe the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) antibodies in the general population in Kinshasa. METHODS: We conducted a cross-sectional, household-based serosurvey between 22 October 2020 and 8 November 2020. Participants were interviewed at home and tested for antibodies against SARS-CoV-2 spike and nucleocapsid proteins in a Luminex-based assay. A positive serology was defined as a sample that reacted with both SARS-CoV-2 proteins (100% sensitivity, 99.7% specificity). The overall weighted, age-standardized prevalence was estimated and the infection-to-case ratio was calculated to determine the proportion of undiagnosed SARS-CoV-2 infections. RESULTS: A total of 1233 participants from 292 households were included (mean age, 32.4 years; 764 [61.2%] women). The overall weighted, age-standardized SARS-CoV-2 seroprevalence was 16.6% (95% CI: 14.0-19.5%). The estimated infection-to-case ratio was 292:1. Prevalence was higher among participants ≥40 years than among those <18 years (21.2% vs 14.9%, respectively; P < .05). It was also higher in participants who reported hospitalization than among those who did not (29.8% vs 16.0%, respectively; P < .05). However, differences were not significant in the multivariate model (P = .1). CONCLUSIONS: The prevalence of SARS-CoV-2 is much higher than the number of COVID-19 cases reported. These results justify the organization of a sequential series of serosurveys by public health authorities to adapt response measures to the dynamics of the pandemic.

Hepatitis C viraemic and seroprevalence and risk factors for positivity in Northwest Cambodia: a household cross-sectional serosurvey.

BACKGROUND: Despite a dramatic reduction in HCV drug costs and simplified models of care, many countries lack important information on prevalence and risk factors to structure effective HCV services. METHODS: A cross-sectional, multi-stage cluster survey of HCV seroprevalence in adults 18 years and above was conducted, with an oversampling of those 45 years and above. One hundred forty-seven clusters of 25 households were randomly selected in two sets (set 1=24 clusters ≥18; set 2=123 clusters, ≥45). A multi-variable analysis assessed risk factors for sero-positivity among participants ≥45. The study occurred in rural Moung Ruessei Health Operational District, Battambang Province, Western Cambodia. RESULTS: A total of 5098 individuals and 3616 households participated in the survey. The overall seroprevalence was 2.6% (CI95% 2.3-3.0) for those ≥18 years, 5.1% (CI95% 4.6-5.7) for adults ≥ 45 years, and 0.6% (CI95% 0.3-0.9) for adults 18-44. Viraemic prevalence was 1.9% (CI95% 1.6-2.1), 3.6% (CI95% 3.2-4.0), and 0.5% (CI95% 0.2-0.8), respectively. Men had higher prevalence than women: ≥18 years male seroprevalence was 3.0 (CI95% 2.5-3.5) versus 2.3 (CI95% 1.9-2.7) for women. Knowledge of HCV was poor: 64.7% of all respondents and 57.0% of seropositive participants reported never having heard of HCV. Risk factor characteristics for the population ≥45 years included: advancing age (p< 0.001), low education (higher than secondary school OR 0.7 [95% CI 0.6-0.8]), any dental or gum treatment (OR 1.6 [95% CI 1.3-1.8]), historical routine medical care (medical injection after 1990 OR 0.7 [95% CI 0.6-0.9]; surgery after 1990 OR 0.7 [95% CI0.5-0.9]), and historical blood donation or transfusion (blood donation after 1980 OR 0.4 [95% CI 0.2-0.8]); blood transfusion after 1990 OR 0.7 [95% CI 0.4-1.1]). CONCLUSIONS: This study provides the first large-scale general adult population prevalence data on HCV infection in Cambodia. The results confirm the link between high prevalence and age ≥45 years, lower socio-economic status and past routine medical interventions (particularly those received before 1990 and 1980). This survey suggests high HCV prevalence in certain populations in Cambodia and can be used to guide national and local HCV policy discussion.

Sustainable HIV treatment in Africa through viral-load-informed differentiated care.

There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.

Cost and cost-effectiveness of a simplified treatment model with direct-acting antivirals for chronic hepatitis C in Cambodia.

BACKGROUND & AIMS: In 2016, Médecins Sans Frontières established the first general population Hepatitis C virus (HCV) screening and treatment site in Cambodia, offering free direct-acting antiviral (DAA) treatment. This study analysed the cost-effectiveness of this intervention. METHODS: Costs, quality adjusted life years (QALYs) and cost-effectiveness of the intervention were projected with a Markov model over a lifetime horizon, discounted at 3%/year. Patient-level resource-use and outcome data, treatment costs, costs of HCV-related healthcare and EQ-5D-5L health states were collected from an observational cohort study evaluating the effectiveness of DAA treatment under full and simplified models of care compared to no treatment; other model parameters were derived from literature. Incremental cost-effectiveness ratios (cost/QALY gained) were compared to an opportunity cost-based willingness-to-pay threshold for Cambodia ($248/QALY). RESULTS: The total cost of testing and treatment per patient for the full model of care was $925(IQR $668-1631), reducing to $376(IQR $344-422) for the simplified model of care. EQ-5D-5L values varied by fibrosis stage: decompensated cirrhosis had the lowest value, values increased during and following treatment. The simplified model of care was cost saving compared to no treatment, while the full model of care, although cost-effective compared to no treatment ($187/QALY), cost an additional $14 485/QALY compared to the simplified model, above the willingness-to-pay threshold for Cambodia. This result is robust to variation in parameters. CONCLUSIONS: The simplified model of care was cost saving compared to no treatment, emphasizing the importance of simplifying pathways of care for improving access to HCV treatment in low-resource settings.

Field evaluation of GeneXpert® (Cepheid) HCV performance for RNA quantification in a genotype 1 and 6 predominant patient population in Cambodia.

GeneXpert® (Cepheid) is the only WHO prequalified platform for hepatitis C virus (HCV) nucleic acid amplification testing that is suitable for point-of-care use in resource-limited contexts. However, its application is constrained by the lack of evidence on genotype 6 (GT6) HCV. We evaluated its field performance among a patient population in Cambodia predominantly infected with GT6. Between August and September 2017, we tested plasma samples obtained from consenting patients at Médecins Sans Frontières' HCV clinic at Preah Kossamak Hospital for HCV viral load (VL) using GeneXpert® and compared its results to those obtained using COBAS® AmpliPrep/Cobas® TaqMan® HCV Quantitative Test, v2.0 (Roche) at the Institut Pasteur du Cambodge. Among 769 patients, 77% of the seropositive patients (n = 454/590) had detectable and quantifiable VL using Roche and 43% (n = 195/454) were GT6. The sensitivity and specificity of GeneXpert® against Roche were 100% (95% CI 99.2, 100.0) and 98.5% (95% CI 94.8, 99.8). The mean VL difference was -0.01 (95% CI -0.05, 0.02) log10  IU/mL for 454 samples quantifiable on Roche and -0.07 (95% CI -0.12, -0.02) log10  IU/mL for GT6 (n = 195). The limit of agreement (LOA) was -0.76 to 0.73 log10  IU/mL for all GTs and -0.76 to 0.62 log10 IU/mL for GT6. Twenty-nine GeneXpert® results were outside the LOA. Frequency of error and the median turnaround time (TAT) for GeneXpert® were 1% and 0 days (4 days using Roche). We demonstrated that the GeneXpert® HCV assay has good sensitivity, specificity, quantitative agreement, and TAT in a real-world, resource-limited clinical setting among GT6 HCV patients.

Voluntary Community Human Immunodeficiency Virus Testing, Linkage, and Retention in Care Interventions in Kenya: Modeling the Clinical Impact and Cost-effectiveness.

Background: In southwest Kenya, the prevalence of human immunodeficiency virus (HIV) infection is about 25%. Médecins Sans Frontières has implemented a voluntary community testing (VCT) program, with linkage to care and retention interventions, to achieve the Joint United Nations Program on HIV and AIDS (UNAIDS) 90-90-90 targets by 2017. We assessed the effectiveness and cost-effectiveness of these interventions. Methods: We developed a time-discrete, dynamic microsimulation model to project HIV incidence over time in the adult population in Kenya. We modeled 4 strategies: VCT, VCT-plus-linkage to care, a retention intervention, and all 3 interventions combined. Effectiveness outcomes included HIV incidence, years of life saved (YLS), cost (2014 €), and cost-effectiveness. We performed sensitivity analyses on key model parameters. Results: With current care, the projected HIV incidence for 2032 was 1.51/100 person-years (PY); the retention and combined interventions decreased incidence to 1.03/100 PY and 0.75/100 PY, respectively. For 100000 individuals, the retention intervention had an incremental cost-effectiveness ratio (ICER) of €130/YLS compared with current care; the combined intervention incremental cost-effectiveness ratio was €370/YLS compared with the retention intervention. VCT and VCT-plus-linkage interventions cost more and saved fewer life-years than the retention and combined interventions. Baseline HIV prevalence had the greatest impact on the results. Conclusions: Interventions targeting VCT, linkage to care, and retention would decrease HIV incidence rate over 15 years in rural Kenya if planned targets are achieved. These interventions together would be more effective and cost-effective than targeting a single stage of the HIV care cascade.

High Proportions of Patients With Advanced HIV Are Antiretroviral Therapy Experienced: Hospitalization Outcomes From 2 Sub-Saharan African Sites.

Background: Human immunodeficiency virus (HIV) remains an important cause of hospitalization and death in low- and middle- income countries. Yet morbidity and in-hospital mortality patterns remain poorly characterized, with prior antiretroviral therapy (ART) exposure and treatment failure status largely unknown. Methods: We studied HIV-infected inpatients aged ≥13 years from cohorts in Kenya and the Democratic Republic of Congo (DRC), assessing clinical and demographic characteristics and hospitalization outcomes. Kenyan inpatients were prospectively enrolled during hospitalization; identical retrospective data were extracted for Congolese patients meeting the study criteria using routine medical information. Results: Among 338 HIV-infected patients in Kenya and 411 in DRC, 83.7% (95% confidence interval [CI], 79.4%-87.3%) and 97.3% (95% CI, 95.2%-98.5%), were admitted with advanced disease (defined as CD4 <200 cells/µL or World Health Organization stage 3/4 illness). Among inpatients with advanced HIV, 35.4% and 21.7% were ART-naive at admission. Patients under care had a median time of 44.1 (interquartile range [IQR], 18.4-90.5) months and 55.9 (IQR, 28.1-99.6) months on treatment; 17.2% (95% CI, 13.5%-21.6%) and 29.6% (95% CI, 25.4%-34.3%) died, 25.9% (95% CI, 16.0%-39.0%) and 22.5% (95% CI, 15.8%-31.0%) of these within 48 hours. Conclusions: Across 2 diverse clinical contexts in sub-Saharan Africa, advanced HIV inpatients were frequently admitted with low CD4 counts, often failing first-line ART. Earlier identification of treatment failure and rapid switching to second-line ART are needed.

Progress towards the UNAIDS 90-90-90 goals by age and gender in a rural area of KwaZulu-Natal, South Africa: a household-based community cross-sectional survey.

BACKGROUND: The Joint United Nations Programme on HIV/AIDS (UNAIDS) has developed an ambitious strategy to end the AIDS epidemic. After eight years of antiretroviral therapy (ART) program we assessed progress towards the UNAIDS 90-90-90 targets in Mbongolwane and Eshowe, KwaZulu-Natal, South Africa. METHODS: We conducted a cross-sectional household-based community survey using a two-stage stratified cluster probability sampling strategy. Persons aged 15-59 years were eligible. We used face-to-face interviewer-administered questionnaires to collect information on history of HIV testing and care. Rapid HIV testing was performed on site and venous blood specimens collected from HIV-positive participants for antiretroviral drug presence test, CD4 count and viral load. At the time of the survey the CD4 threshold for ART initiation was 350 cells/µL. We calculated progression towards the 90-90-90 UNAIDS targets by estimating three proportions: HIV positive individuals who knew their status (first 90), those diagnosed who were on ART (second 90), and those on ART who were virally suppressed (third 90). RESULTS: We included 5649/6688 (84.5%) individuals. Median age was 26 years (IQR: 19-40), 62.3% were women. HIV prevalence was 25.2% (95% CI: 23.6-26.9): 30.9% (95% CI: 29.0-32.9) in women; 15.9% (95% CI: 14.0-18.0) in men. Overall progress towards the 90-90-90 targets was as follows: 76.4% (95% CI: 74.1-78.6) knew their status, 69.9% (95% CI: 67.0-72.7) of those who knew their status were on ART and 93.1% (95% CI: 91.0-94.8) of those on ART were virally suppressed. By sex, progress towards the 90-90-90 targets was: 79%-71%-93% among women; and 68%-68%-92% among men (p-values of women and men comparisons were < 0.001, 0.443 and 0.584 respectively). By age, progress was: 83%-75%-95% among individuals aged 30-59 years and 64%-58%-89% among those aged 15-29 years (p-values of age groups comparisons were < 0.001, < 0.001 and 0.011 respectively). CONCLUSIONS: In this context of high HIV prevalence, significant progress has been achieved with regards to reaching the UNAIDS 90-90-90 targets. The third 90, viral suppression in people on ART, was achieved among women and men. However, gaps persist in HIV diagnosis and ART coverage particularly in men and individuals younger than 30 years. Achieving 90-90-90 is feasible but requires additional investment to reach youth and men.

Potential impact of multiple interventions on HIV incidence in a hyperendemic region in Western Kenya: a modelling study.

BACKGROUND: Multiple prevention interventions, including early antiretroviral therapy initiation, may reduce HIV incidence in hyperendemic settings. Our aim was to predict the short-term impact of various single and combined interventions on HIV spreading in the adult population of Ndhiwa subcounty (Nyanza Province, Kenya). METHODS: A mathematical model was used with data on adults (15-59 years) from the Ndhiwa HIV Impact in Population Survey to compare the impacts on HIV prevalence, HIV incidence rate, and population viral load suppression of various interventions. These interventions included: improving the cascade of care (use of three guidelines), increasing voluntary medical male circumcision (VMMC), and implementing pre-exposure prophylaxis (PrEP) use among HIV-uninfected women. RESULTS: After four years, improving separately the cascade of care under the WHO 2013 guidelines and under the treat-all strategy would reduce the overall HIV incidence rate by 46 and 58 %, respectively, vs. the baseline rate, and by 35 and 49 %, respectively, vs. the implementation of the current Kenyan guidelines. With conservative and optimistic scenarios, VMMC and PrEP would reduce the HIV incidence rate by 15-25 % and 22-28 % vs. the baseline, respectively. Combining the WHO 2013 guidelines with VMMC would reduce the HIV incidence rate by 35-56 % and combining the treat-all strategy with VMMC would reduce it by 49-65 %. Combining the WHO 2013 guidelines, VMMC, and PrEP would reduce the HIV incidence rate by 46-67 %. CONCLUSIONS: The impacts of the WHO 2013 guidelines and the treat-all strategy were relatively close; their implementation is desirable to reduce HIV spread. Combining several strategies is promising in adult populations of hyperendemic areas but requires regular, reliable, and costly monitoring.

Errors generated by a point-of-care CD4+ T-lymphocyte analyser: a retrospective observational study in nine countries.

OBJECTIVE: To estimate the proportion of invalid results generated by a CD4+ T-lymphocyte analyser used by Médecins Sans Frontières (MSF) in field projects and identify factors associated with invalid results. METHODS: We collated 25,616 CD4+ T-lymphocyte test results from 39 sites in nine countries for the years 2011 to 2013. Information about the setting, user, training, sampling technique and device repair history were obtained by questionnaire. The analyser performs a series of checks to ensure that all steps of the analysis are completed successfully; if not, an invalid result is reported. We calculated the proportion of invalid results by device and by operator. Regression analyses were used to investigate factors associated with invalid results. FINDINGS: There were 3354 invalid test results (13.1%) across 39 sites, for 58 Alere PimaTM devices and 180 operators. The median proportion of errors per device and operator was 12.7% (interquartile range, IQR: 10.3-19.9) and 12.1% (IQR: 7.1-19.2), respectively. The proportion of invalid results varied widely by country, setting, user and device. Errors were not associated with settings, user experience or the number of users per device. Tests performed on capillary blood samples were significantly less likely to generate errors compared to venous whole blood. CONCLUSION: The Alere Pima CD4+ analyser generated a high proportion of invalid test results, across different countries, settings and users. Most error codes could be attributed to the operator, but the exact causes proved difficult to identify. Invalid results need to be factored into the implementation and operational costs of routine CD4+ T-lymphocyte testing.

Comparing Complication Rates, Costs, and Length of Stay between Unicompartmental and Total Knee Arthroplasty: Insights from a Big Data Analysis Using the National Inpatient Sample Dataset.

Background: Unicompartmental knee arthroplasty (UKA) is increasingly used for knee osteoarthritis due to faster recovery, better range of motion, and lower costs compared to total knee arthroplasty (TKA). While TKA may offer longer-lasting results with lower revision rates, this study compares the relative benefits and limitations of UKA and TKA using the National Inpatient Sample (NIS) database. Methods: This retrospective analysis examined outcomes of elective UKA and TKA procedures from 2016 to 2019, identifying 2,606,925 patients via ICD-10 codes. Propensity score matching based on demographics, hospital characteristics, and comorbidities resulted in a balanced cohort of 136,890 patients. The present study compared in-hospital mortality, length of stay, postoperative complications, and hospitalization costs. Results: The results showed that UKA procedures increased significantly over the study period. Patients undergoing UKA were generally younger with fewer comorbidities. After matching, both groups had low in-hospital mortality (0.015%). UKA patients had shorter hospital stays (1.53 vs. 2.47 days) and lower costs (USD 55,976 vs. USD 61,513) compared to TKA patients. UKA patients had slightly higher rates of intraoperative fracture and pulmonary edema, while TKA patients had higher risks of blood transfusion, anemia, coronary artery disease, pulmonary embolism, pneumonia, and acute kidney injury. Conclusions: UKA appears to be a less-invasive, cost-effective option for younger patients with localized knee osteoarthritis.

Etiology, Outcomes, and Complications of Total Hip Arthroplasty in Younger Patients: A Nationwide Big Data Analysis.

Background: This study investigates the rising trend of total hip arthroplasty (THA) in patients under 55 years old, commonly referred to as "younger" THA patients. Traditionally a procedure for older adults with osteoarthritis, THA is increasingly performed on younger patients. Methods: Using data from the Nationwide Inpatient Sample (NIS) from 2016 to 2019, we analyze the factors driving this trend, including the causes of hip issues, patient characteristics, and coexisting medical conditions. The study examines in-hospital mortality, length of stay, post-surgical complications, and hospitalization costs for 231,630 THA patients aged 18-54.9, identified using ICD-10 codes. Results: Statistical analysis revealed that younger patients (aged 18-34.9) had higher rates of chronic anemia, inflammatory bowel disease, sickle cell disorders, connective tissue disorders, and coagulation defects compared to patients aged 35-44.9 and 45-54.9. They also experienced the longest hospital stays (2.08 days) and highest costs ($70,540). Significant odds ratios were found for sickle cell disorders (36.078), coagulation defects (1.566), inflammatory bowel disease (2.582), connective tissue disorders (11.727), hip dislocation (3.447), and blood transfusion (1.488) in younger patients compared to other THA patients. Conclusions: Comprehensive analysis of these unique needs is crucial for optimizing care, tailoring treatment, managing co-existing conditions, and personalizing recovery strategies to improve outcomes and quality of life for younger THA patients.

Characteristics of injuries related to traffic crashes in Israel before and during the COVID-19 pandemic.

OBJECTIVES: This study explored differences in patient characteristics, injury characteristics, treatment modalities, and treatment outcomes among patients who presented to the Emergency Department (ED) following traffic crashes during the COVID-19 period (from March 15, 2020 to March 15, 2022) in comparison to the previous corresponding period between 2017 and 2019. METHODS: The study is a retrospective chart review study. The study included a random sample of 610 patients who presented to the ED of a major hospital located in northern-central Israel following traffic crashes: 305 patients who presented during the COVID-19 period (from March 15, 2020 to March 15, 2022) and 305 patients who presented during the previous corresponding period (from March 15, 2017 to March 15, 2019). Socio-demographic data, data regarding the traffic crashes, and medical data of the patients were collected from their medical records, and the data were compared. RESULTS: In the context of the COVID-19 period, a notable surge in the percentage of cyclist victims was evident, marking an increase from 7.5% to 19% compared to the corresponding period. Conversely, the incidence of pedestrian victims during the COVID-19 period dropped to 19.7%, in contrast to 30.8% in the corresponding period. Notably, patients involved in pedestrian crashes amid the COVID-19 period exhibited a shorter hospital stay (M = 2.8 days, SD = 3.3) compared to the corresponding period (M = 4.3 days, SD = 7.1) [t = 1.8 (df = 141), p < 0.05]. However, a higher fatality rate was observed among these patients during the COVID-19 period compared to the corresponding period (6.7% vs. 0%) [χ2 = 6.4 (df = 1), p < 0.05]. CONCLUSIONS: The study reveals significant changes in traffic crashes characteristics during the pandemic period, including a notable increase in cyclist victims and a decrease in pedestrian incidents. These shifts may be attributed to factors such as changes in transportation patterns, increased use of bicycles for essential travel. Despite these changes, the proportion of severe crashes remained relatively consistent. These findings underscore the importance of understanding the underlying causes behind these shifts and highlight the ongoing need for public education and awareness initiatives to promote traffic safety, particularly for vulnerable road users, during pandemic periods.

Exploring Factors Influencing Orthopedic Patients' Willingness to Recommend a Hospital: Insights From a Cross-Sectional Survey.

Patient satisfaction and the willingness to recommend a hospital are critical for healthcare quality improvement. This study focuses on orthopedic patients, recognizing their unique healthcare experiences. We aimed to explore factors influencing orthopedic patients' willingness to recommend the hospital, considering various demographic and clinical variables. A cross-sectional survey of 200 orthopedic patients hospitalized between July and December 2023 in north-central Israel was conducted. Results revealed a positive association between age and willingness to recommend (odds ratio [OR] = 2.44), while emergency department stay length showed a negative association (OR = 0.58). Satisfaction with hospital care positively influenced the willingness to recommend (OR = 1.96). Gender, comorbidities, and hospital stay length did not significantly impact willingness to recommend. The study highlights the role of satisfaction and the impact of extended emergency department stays, emphasizing the need for nuanced strategies to optimize orthopedic patient experiences. Valuable insights are offered for healthcare providers and policymakers.