Refining the hospitalization rate: A mixed methods approach to differentiate primary COVID-19 from incidental cases.

Purpose: Until now, the Hospitalization Rate (HR) served as an indicator (among others) for the COVID-19 associated healthcare burden. To ensure that the HR accomplishes its full potential, hospitalizations caused by COVID-19 (primary cases) and hospitalizations of patients with incidental positive SARS-CoV-2 test results (incidental cases) must be differentiated. The aim of this study was to synthesize the existing evidence on differentiation criteria between hospitalizations of primary cases and incidental cases. Methods: An online survey of the members of the German Network University Medicine (NUM) was conducted. Additionally, senior clinicians with expertise in COVID-19 care were invited for qualitative, semi-structured interviews. Furthermore, a rapid literature review was undertaken on publications between 03/2020 and 12/2022. Results: In the online survey (n=30, response rate 56%), pneumonia and acute upper respiratory tract infections were the most indicative diagnoses for a primary case. In contrast, malignant neoplasms and acute myocardial infarctions were most likely to be associated with incidental cases. According to the experts (n=6), the diagnosis, ward, and type of admission (emergency or elective), low oxygen saturation, need for supplemental oxygen, and initiation of COVID-19 therapy point to a primary case. The literature review found that respiratory syndromes and symptoms, oxygen support, and elevated levels of inflammatory markers were associated with primary cases. Conclusion: There are parameters for the differentiation of primary from incidental cases to improve the objective of the HR. Ultimately, an updated HR has the potential to serve as a more accurate indicator of the COVID-19 associated healthcare burden.

Establishing semi-automated infection surveillance in obstetrics and gynaecology.

BACKGROUND: Surveillance is an acknowledged method to decrease nosocomial infections, such as surgical site infections (SSIs). Electronic healthcare records create the opportunity for automated surveillance. While approaches for different types of surgeries and indicators already exist, there are very few for obstetrics and gynaecology. AIM: To analyse the sensitivity and workload reduction of semi-automated surveillance in obstetrics and gynaecology. METHODS: In this retrospective, single-centre study at a 1438-bed tertiary care hospital in Germany, semi-automated SSI surveillance using the indicators 'antibiotic prescription', 'microbiological data' and 'administrative data' (diagnosis codes, readmission, post-hospitalization care) was compared with manual analysis and categorization of all patient files. Breast surgeries (BSs) conducted in 2018 and caesarean sections (CSs) that met the inclusion criteria between May 2013 and December 2019 were included. Indicators were analysed for sensitivity, number of analysed procedures needed to identify one case, and potential workload reduction in detecting SSIs in comparison with the control group. FINDINGS: The reference standard showed nine SSIs in 416 BSs (2.2%). Sensitivities for the indicators 'antibiotic prescription', 'diagnosis code', 'microbiological sample taken', and the combination 'diagnosis code or microbiological sample' were 100%, 88.9%, 66.7% and 100%, respectively. The reference standard showed 54 SSIs in 3438 CSs (1.6%). Sensitivities for the indicators 'collection of microbiological samples', 'diagnosis codes', 'readmission/post-hospitalization care', and the combination of all indicators were 38.9%, 27.8%, 85.2% and 94.4%, respectively. CONCLUSIONS: Semi-automated surveillance systems may reduce workload by maintaining high sensitivity depending on the type of surgery, local circumstances and thorough digitalization.

Inability to work following COVID-19 vaccination-a relevant aspect for future booster vaccinations.

OBJECTIVES: COVID-19 vaccination is a key prevention strategy to reduce the spread and severity of SARS-CoV-2 infections. However, vaccine-related inability to work among healthcare workers (HCWs) could overstrain healthcare systems. STUDY DESIGN: The study presented was conducted as part of the prospective CoVacSer cohort study. METHODS: This study examined sick leave and intake of pro re nata medication after the first, second, and third COVID-19 vaccination in HCWs. Data were collected by using an electronic questionnaire. RESULTS: Among 1704 HCWs enrolled, 595 (34.9%) HCWs were on sick leave following at least one COVID-19 vaccination, leading to a total number of 1550 sick days. Both the absolute sick days and the rate of HCWs on sick leave significantly increased with each subsequent vaccination. Comparing BNT162b2mRNA and mRNA-1273, the difference in sick leave was not significant after the second dose, but mRNA-1273 induced a significantly longer and more frequent sick leave after the third. CONCLUSION: In the light of further COVID-19 infection waves and booster vaccinations, there is a risk of additional staff shortages due to postvaccination inability to work, which could negatively impact the already strained healthcare system and jeopardise patient care. These findings will aid further vaccination campaigns to minimise the impact of staff absences on the healthcare system.

High-affinity chromodomains engineered for improved detection of histone methylation and enhanced CRISPR-based gene repression.

Histone methylation is an important post-translational modification that plays a crucial role in regulating cellular functions, and its dysregulation is implicated in cancer and developmental defects. Therefore, systematic characterization of histone methylation is necessary to elucidate complex biological processes, identify biomarkers, and ultimately, enable drug discovery. Studying histone methylation relies on the use of antibodies, but these suffer from lot-to-lot variation, are costly, and cannot be used in live cells. Chromatin-modification reader domains are potential affinity reagents for methylated histones, but their application is limited by their modest affinities. We used phage display to identify key residues that greatly enhance the affinities of Cbx chromodomains for methylated histone marks and develop a general strategy for enhancing the affinity of chromodomains of the human Cbx protein family. Our strategy allows us to develop powerful probes for genome-wide binding analysis and live-cell imaging. Furthermore, we use optimized chromodomains to develop extremely potent CRISPR-based repressors for tailored gene silencing. Our results highlight the power of engineered chromodomains for analyzing protein interaction networks involving chromatin and represent a modular platform for efficient gene silencing.

Osteoporosis therapy in patients with inflammatory rheumatic diseases and osteonecrosis of the jaw.

BACKGROUND AND OBJECTIVES: The aim of the present study was to assess the prevalence of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients suffering from inflammatory rheumatic diseases, as well as to assess the prevalence of relevant dental, behavioral, and medical risk factors for MRONJ. MATERIALS AND METHODS: A total of 198 patients with inflammatory rheumatic diseases and osteoporosis therapy were recruited from a tertiary rheumatological/immunological referral center between June 2015 and September 2016. They were assessed using a structured interview. A maxillofacial surgeon later examined patients complaining of possible symptoms of osteonecrosis. In cases of osteonecrosis, dental records were obtained and evaluated. Preventive measures taken and dental as well as other clinical risk factors were evaluated. RESULTS: Of the 198 patients, three suffered from osteonecrosis of the jaw, none of whom had any history of malignant disease or radiation therapy, resulting in a prevalence of 1.5%. Of these three patients, only one was given bisphosphonates intravenously (i.v.), whereas all three had been treated orally. All three diagnoses of MRONJ had been previously known to the patients and their maxillofacial surgeons. Two of the patients had rheumatoid arthritis, and one patient suffered from large vessel vasculitis. Long anti-osteoporotic treatment duration, low functional status, and low bone density of the femur were significantly associated with MRONJ development. CONCLUSION: Inflammatory rheumatic diseases constitute a risk factor for MRONJ in patients treated with bisphosphonates for osteoporosis. Patients should be counseled accordingly and should be offered dental screening and regular dental check-ups.

Iodine and thyroid cancer risk among women in a multiethnic population: the Bay Area Thyroid Cancer Study.

Research on the relationship between iodine exposure and thyroid cancer risk is limited, and the findings are inconclusive. In most studies, fish/shellfish consumption has been used as a proxy measure of iodine exposure. The present study extends this research by quantifying dietary iodine exposure as well as incorporating a biomarker of long-term (1 year) exposure, i.e., from toenail clippings. This study is conducted in a multiethnic population with a wide variation in thyroid cancer incidence rates and substantial diversity in exposure. Women, ages 20-74, residing in the San Francisco Bay Area and diagnosed with thyroid cancer between 1995 and 1998 (1992-1998 for Asian women) were compared with women selected from the general population via random digit dialing. Interviews were conducted in six languages with 608 cases and 558 controls. The established risk factors for thyroid cancer were found to increase risk in this population: radiation to the head/neck [odds ratio (OR), 2.3; 95% confidence interval (CI), 0.97-5.5]; history of goiter/nodules (OR, 3.7; 95% CI, 2.5-5.6); and a family history of proliferative thyroid disease (OR, 2.5; 95% CI, 1.6-3.8). Contrary to our hypothesis, increased dietary iodine, most likely related to the use of multivitamin pills, was associated with a reduced risk of papillary thyroid cancer. This risk reduction was observed in "low-risk" women (i.e., women without any of the three established risk factors noted above; OR, 0.53; 95% CI, 0.33-0.85) but not in "high-risk" women, among whom a slight elevation in risk was seen (OR, 1.4; 95% CI, 0.56-3.4). However, no association with risk was observed in either group when the biomarker of exposure was evaluated. In addition, no ethnic differences in risk were observed. The authors conclude that iodine exposure appears to have, at most, a weak effect on the risk of papillary thyroid cancer.

Herpes simplex virus type 2 shedding in human immunodeficiency virus-negative men who have sex with men: frequency, patterns, and risk factors.

We investigated the frequency, site, and risk factors for herpes simplex virus (HSV) shedding in 30 human immunodeficiency virus (HIV)-negative HSV type 2 (HSV-2)-seropositive men who have sex with men. Subjects collected daily HSV culture samples from genital, perianal, and oral areas for 100 days and maintained diaries of signs and symptoms. Sixteen men (53.3%) shed HSV-2, and 9 (56.3%) of 16 men who were also HSV type 1 (HSV-1)-seropositive shed HSV-1. Overall, HSV-2 was isolated on 3.1% of the days; 68% of the isolations were on days that lesions did not occur. HSV-2 shedding was predominantly perianal (83.3%). HSV-1 was isolated on 2.1% of the days; 23 of 24 HSV-1 isolates were from oral areas. Rates of perianal or genital shedding were 6.6% on the days that participants reported prodromal symptoms and 1.9% on the days that participants did not report prodromal symptoms (P<.001). Men seropositive for both HSV-1 and HSV-2 were significantly more likely to shed HSV-2 (odds ratio, 4.1; 95% confidence interval, 1.4-11.9) than were HSV-2-seropositive men. HSV-2-seropositive men who have sex with men have frequent subclinical HSV-2 shedding, usually from the perianal area, and more frequent prodromal HSV-2 shedding.

Sexual and drug-use risk factors for HIV and STDs: a comparison of women with and without bisexual experiences.

OBJECTIVES: This study was done to compare risk factors for HIV/STDs in women who reported having had sex with both men and women and women who reported having had sex with men only. METHODS: Female participants in a multisite, randomized HIV/STD prevention study in the Seattle area reported both having had sex with a man in the 3 months before and having at least 1 risk factor for HIV/STDs during the year before the study. Of these women, 38% who reported ever having had sex with a woman were compared with those who reported having had sex with men only. RESULTS: Women who had had sex with both men and women were more likely than women who had had sex with men only to report drug use in the 3 months before the study, a greater lifetime number of male partners, a sex partner who had had sex with a prostitute, an earlier age at sexual debut, and forced sexual contact (P < .01 for all comparisons). Women who had had sex with both men and women had a mean of 3.2 of these 5 risk factors, vs 2.1 among women who had had sex with men only (P < .001). CONCLUSION: Women who had had sex with both men and women were more likely than women who had had sex with men only to engage in multiple risk behaviors. Health workers should be aware of bisexual experience among women, since this may be a marker for multiple risk behaviors for HIV/STDs.

Protection against human immunodeficiency virus type 1 infection in persons with repeated exposure: evidence for T cell immunity in the absence of inherited CCR5 coreceptor defects.

It has been hypothesized that protection against human immunodeficiency virus (HIV)-1 infection may result from either acquired host immunity, inheritance of a dysfunctional CCR5 HIV-1 coreceptor, or a low or attenuated virus inoculum. Thirty-seven HIV-1-uninfected persons engaging in repeated high-risk sexual activity with an HIV-1-infected partner were prospectively studied to determine the contribution of these factors in protecting against HIV-1 transmission. More than one-third (13/36) demonstrated HIV-1-specific cytotoxicity, and this activity significantly correlated with the wild type CCR5 genotype (P=.03). Only 1 subject (3%) demonstrated the homozygous CCR5 32-bp deletion (Delta32/Delta32). Median plasma HIV-1 RNA levels from 18 HIV-1-infected sex partners were not statistically different from those of matched infected control patients. These results indicate that inheritance of the Delta32 CCR5 mutation does not account for the majority of persistently HIV-1-resistant cases, and the presence of cellular immunity in these persons suggests either undetected infection or protective immunity.

Incidence of HIV and sexually transmitted diseases (STD) in a cohort of HIV-negative men who have sex with men (MSM).

OBJECTIVE: To determine the prevalence of sexually transmitted diseases (STD) and incidence of and risk factors for STD, including HIV-1, among a cohort of HIV-negative men who have sex with men (MSM). SETTING: Seattle, Washington, United States. PARTICIPANTS: Prospective cohort of 578 HIV-negative MSM in which risk factors for acquiring a STD over 12 months follow-up were evaluated using a cumulative incidence analysis. MAIN OUTCOME MEASURES: Baseline tests obtained were: herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) Western blots, hepatitis B, and syphilis serologies; anorectal and pharyngeal Neisseria gonorrhoeae (GC) cultures; first-catch urine for leukocyte esterase (LE) and Chlamydia trachomatis (CT) ligase chain reaction (LCR). Men with a positive urine LE had urethral GC cultures obtained. The following outcomes were measured over 12 months follow-up: incident symptomatic bacterial STD (urethritis, proctitis, epididymitis), HSV-1 and HSV-2 seroconversion, and HIV-1 seroconversion. The 31 incident cases of STD (men with bacterial STD) were compared with those 489 men without symptomatic bacterial STD or seroconversion to HSV-1, HSV-2 or HIV-1 infection. RESULTS: Bacterial STD were found in nine participants at enrollment; there were two cases of nonchlamydial urethritis, two cases of nonchlamydial epididymitis, and five cases of asymptomatic GC infection. At enrollment, HSV-2 antibodies were detected in 149 (26.0%) of 572 men and prior hepatitis B infection in 145 (34.8%) of 417 unvaccinated men. During the 1-year of follow-up, 31 men (5.7/100 person-years) had 34 episodes of a symptomatic bacterial STD syndrome (urethritis, epididymitis or proctitis). Urethritis was the most common STD syndrome, detected in 29 men, of whom 10 had GC and 19 had nongonococcal urethritis. In the 1-year of follow-up, five participants seroconverted to HIV-1 (1.3/100 person-years), four to HSV-2 (1.0/100 person-years), and seven to HSV-1 (4.3/100 person-years). Unprotected insertive anal sex [odds ratio (OR) 2.6; 95% confidence interval (CI) 1.2-5.6]; and nitrite inhalant ('poppers') use (OR, 2.3; 95% CI, 1.0-5.0) were independently associated with incident STD. CONCLUSIONS: STD and HIV infection continue to be acquired even in a city with an overall low bacterial STD prevalence and among educated MSM receiving regular HIV screening and risk-reduction. Urethritis was the most common STD detected, and public health messages aimed at MSM need to emphasize safe insertive as well as receptive sexual practices.

Herpes simplex virus shedding among human immunodeficiency virus-negative men who have sex with men: site and frequency of shedding.

The frequency and anatomic location of subclinical and symptomatic herpes simplex virus (HSV) shedding were evaluated among human immunodeficiency virus (HIV)-negative HSV-2-seropositive men who have sex with men (MSM). Eight men attended a research clinic daily for 30 days for a detailed genital examination and anoscopy with colposcopy to detect herpes lesions. HSV cultures were obtained daily from four sites (perianal, urethral, penile shaft, and oral) at home and the research clinic. Signs and symptoms of genital herpes were recorded by the participants and clinician. Three (37.5%) of the men shed HSV. Overall, the 8 men shed HSV on 5.5% of days cultures were obtained and shed subclinically on 2.7% of days. All HSV shedding was perianal or rectal; only 1 symptomatic recurrence, concurrent with an external perianal lesion, was detected by anoscopy. Subclinical HSV shedding was frequent among HIV-negative MSM, and anoscopy with colposcopy did not increase the detection rate of rectal HSV lesions or shedding.

Use of hospital services by AIDS patients with psychiatric illness.

The purpose of this study was to assess the effect of psychiatric illness on length of stay and patterns of admission among AIDS patients hospitalized for medical illnesses. Medical records were abstracted for AIDS patients admitted to hospitals in Washington State from 1990 through 1992. Psychiatric comorbidity was defined by the presence of an International Classification of Disease-9 code reflecting psychiatric illness. Medical morbidity was addressed using CD4 count and AIDS-defining illnesses as markers of disease severity. Of 2834 admissions, 15% included one or more psychiatric diagnoses. Psychiatric illness (F 39.1; df 1,2830; p < 0.001) and discharge disposition (F 81.2; df 2,2830; p < 0.001) contributed significantly to the model, explaining increased length of stay (F 67.2; df 3,2830; p < 0.001). Future research needs to address the possible etiology of psychiatric comorbidity's contribution to length of stay and the effect on quality and cost of care.

Diagnostic accuracy of HIV-associated central nervous system toxoplasmosis.

Our objective was to examine the accuracy of diagnosis of HIV-associated central nervous system (CNS) toxoplasmosis. Individuals diagnosed with HIV-associated CNS toxoplasmosis and controls were ascertained from a population-based database. Diagnosis was confirmed by response to therapy or by histology. Symptoms, results of anti-Toxoplasma serology and use of Pneumocystis carinii pneumonia (PCP) prophylaxis were recorded. Central nervous system toxoplasmosis was confirmed in 54 (76%) of 75 patients. Reactive anti-Toxoplasma serology was associated with CNS toxoplasmosis (OR=20.4, 95% CI 3.1-175.8). Adjusting for CD4 and use of dapsone or aerosolized pentamidine, trimethoprim-sulphamethoxazole (TMP-SMX) for PCP prophylaxis was associated with lower likelihood of CNS toxoplasmosis (OR 0.3, 95% CI 0.1-0.7). Diagnosis of CNS toxoplasmosis is often incorrect. Another diagnosis is most likely in patients who are anti-Toxoplasma seronegative or who are receiving prophylactic TMP-SMX.

Reproductive tract infections in primary healthcare, family planning, and dermatovenereology clinics: evaluation of syndromic management in Morocco.

OBJECTIVE: To determine where and with what symptoms women seek care for reproductive tract infections (RTI) in Morocco and to guide allocation of resources for training and treatment for RTIs. METHODS: A primary healthcare centre (PHC), a family planning centre (FPC), and a specialty dermatovenereology clinic (SC) were selected in each of three urban areas. Women with symptoms of vaginal discharge, lower abdominal or pelvic pain, or genital lesions (genital ulcer or warts) underwent interviews, physical examinations, serological testing for human immunodeficiency virus (HIV) and syphilis, and collection of vaginal fluid for microscopic examination, and urine for detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) by ligase chain reaction (LCR). RESULTS: Over 8 months, 1238 women enrolled, including 61.8% at PHCs, 34.8% at FPCs, and 3.4% at SCs. Overall, 54% complained of vaginal discharge, of whom 8.8% had GC or CT infection and 30.1% had trichomoniasis (TV) or bacterial vaginosis (BV); 24.9% complained of lower abdominal pain with or without vaginal discharge, of whom 7.3% had GC or CT and 22.6% had TV or BV. GC or CT infections were found in 10.1% of PHC and 5.4% of FPC patients; while TV and/or BV infections were found in 28.7% and 22.8%, respectively. GC or CT infection was associated with perceived risk behaviours of the male partner (for example, belief partner is unfaithful) more often than with reported risk behaviours of the women themselves. For vaginal infections, a modified World Health Organisation (WHO) test algorithm for vaginal discharge involving risk assessment plus speculum and bimanual examination was 98.0% sensitive at PHCs and 90.8% at FPCs, with positive predictive value (PPV) of 33.4% at PHCs and 26.8% at FPCs. For GC or CT infections this algorithm was 60.6% sensitive at PHCs and 85.7% sensitive at FPCs; but PPV was only 9.9% and 9.0% respectively, little higher than the background prevalence of these infections. An RTI algorithm (Morocco specific) had comparable sensitivity and PPV for vaginal infection, and for cervical infection was less sensitive but had much higher PPV (26.9% for PHCs and 26.7% for FPCs). CONCLUSION: Women with complaints of vaginal discharge and/or lower abdominal pain presented to PHC and FP clinics, not to SCs. PHCs and FPCs should therefore receive resources for management of vaginal discharge. Both the test algorithm and the new RTI algorithm were useful in allocating treatment for vaginal infection, but only the RTI algorithm discriminated in selecting women with cervical infection. Even with the RTI algorithm, which limited treatment for cervical infection to risk assessment positive patients with signs of cervical infection or PID, the PPV for cervical infection was low, potentially resulting in frequent overtreatment and problems of partner notification.

Patients attending STD clinics in an evolving health care environment. Demographics, insurance coverage, preferences for STD services, and STD morbidity.

OBJECTIVES: To characterize client demographics, sexually transmitted diseases (STD) morbidity, insurance status, reasons for attending public STD clinics, and future preferences for source of STD services. DESIGN: Cross-sectional study of 2,490 clients attending five urban STD clinics for new problems with interviewer-administered 23-item questionnaire and chart review to obtain clinical and laboratory STD diagnoses. RESULTS: Participants were young (51% < 25 years of age), minority (64% nonwhite), poor (43% < or = $10,000/year), and largely uninsured (59% uninsured, 27% private insurance, and 14% Medicaid). Half had previously visited the STD clinic, and 81% had used other providers for non-STD services in the prior 3 years. STD symptoms were cited as the reason for the visit by 63%. The most common factors associated with seeking care at these STD clinics were walk-in services, costs, and confidentiality concerns. STD morbidity was high; 66% of clients were diagnosed with one or more STD. Most (68%) clients preferred to be treated at the STD clinic in the future if they could go anywhere for STD services. CONCLUSIONS: STD clinics see young, minority, poor, and uninsured clients with high STD rates. Even with unlimited future choice, two thirds of the clients surveyed would still prefer to be treated at STD clinics. This study indicates the continuing need for publicly funded, categorical STD clinics in urban areas with high STD morbidity and the importance of easily accessible, confidential, expert STD services from the private sector and managed care organizations.

Bacterial infections in adult patients hospitalized with AIDS: case-control study of prophylactic efficacy of trimethoprim-sulfamethoxazole versus aerosolized pentamidine.

To determine the association between trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis for Pneumocystis carinii pneumonia and risk of bacterial infections in persons with AIDS, we abstracted hospital records from 6496 adult admissions to 42 hospitals in western Washington state. Of these admissions, 570 involved 637 bacterial infections diagnosed among patients who had been prescribed prophylactic TMP-SMX or aerosolized pentamidine. Cases [admissions with bacteraemia, bacterial pneumonia, acute or chronic sinusitis, or urinary tract infection (UTI)] were compared to controls (admissions not associated with any of the 5 bacterial infections). After adjusting for CD4 lymphocyte count and presence of P. carinii pneumonia, TMP-SMX prophylaxis, relative to aerosolized pentamidine prophylaxis, was associated with a reduced risk of bacteraemia (adjusted OR = 0.5; 95% CI, 0.2-1.0; P = 0.04), bacterial pneumonia (adjusted OR = 0.5; 95% CI, 0.3-0.8; P = 0.01), acute sinusitis (adjusted OR = 0.5; 95% CI, 0.2-1.3; P = 0.2), chronic sinusitis (adjusted OR = 0.3; 95% CI, 0.1-0.7; P = 0.01), and UTI (adjusted OR = 0.5; 95% CI, 0.2-1.2; P = 0.1), and all 5 bacterial infections combined (adjusted OR = 0.6; 95% CI, 0.5-0.8; P < 0.001).

Variations in medical care for HIV-related Pneumocystis carinii pneumonia: a comparison of process and outcome at two hospitals.

BACKGROUND: Institutional variation in the quality of medical care may be evaluated by examining process measures, such as use of diagnostic procedures or treatment modalities, or outcome measures, such as mortality. We undertook this study to examine variations in both process and outcome of care for patients with HIV-related Pneumocystis carinii pneumonia (PCP) at two geographically diverse, HIV-experienced, public municipal hospitals. DESIGN: Retrospective review of hospitalized patients diagnosed as having PCP cared for at two municipal hospitals from 1988 to 1990. At hospital A, charts of all patients diagnosed as having PCP were abstracted (n=209); at hospital B, a random sample of 15% were abstracted (=136). RESULTS: Among all hospitalized patients diagnosed as having PCP, the frequency of making a definitive diagnosis of PCP (as opposed to treating empirically) differed markedly at the two hospitals (85% in hospital A vs 26% in hospital B; p<0.001), as did the use of intensive care (18% vs 3%; p<0.001) and "do-not-resuscitate" orders (39% vs 14%; p<0.001), although the timing of starting anti-Pneumocystis medications (89% vs 88% within the first 2 hospital days) and the use of corticosteroids (21% vs 23%) were similar. Despite differences in the process of care, survival rates were similar at the two institutions (75% vs 76%; p=0.8) and remained similar when logistic regression was used to control for demographic variables and severity of illness (odds ratio for survival, hospital B vs A, 1.2 [95% confidence interval, 0.7, 2.0]). The 95% confidence intervals (0.7, 2.0), however, were consistent with a considerable (and clinically significant) disparity in survival (from 30% lower to a twofold higher odds of survival). Sample size calculations showed that a sample of 10 cases in each hospital would be required to detect the observed difference in definitive diagnosis rates (85% vs 26%), but 722 cases in each hospital would be required to detect a relevant difference in mortality. CONCLUSIONS: The process of care for hospitalized patients with PCP in these two institutions differed considerably, but the survival rates were not significantly different, even after adjusting for confounding factors. While sample sizes available at the individual institutions were sufficient for evaluation of the process of care, they did not provide the power necessary to evaluate outcomes. Comparisons of outcomes such as mortality between individual hospitals may not have the statistical power to exclude important differences.

High HIV prevalence, low condom use and gender differences in sexual behaviour among patients with STD-related complaints at a Nairobi primary health care clinic.

Of 22,274 patients > or = 12 years old attending a Nairobi primary health care (PHC) clinic, 1076 (4.8%) had STD-related complaints, of whom 980 underwent assessment of risk factors for human immunodeficiency virus (HIV) infection and infrequent condom use. Gonorrhoea, chancroid, syphilis seroactivity, trichomoniasis, or objective signs of STD were found in 78%, and HIV seropositivity in 15% of men and 19% of women. Most women were married, living with a spouse; while most men were single, or married, but living separated from a spouse. Among married men, last sex was with a female sex worker (FSW) or casual partner for 60% not living with a spouse and 26% living with a spouse (P<0.005). Two or more partners during the past year were reported by 82% of men and 25% of women (P <0.001), and 55% of men and 11% of women reported the last partner was high risk. HIV seropositivity among both genders was associated with numbers of partners, and among women, with being widowed or divorced. Only 3% reported use of a condom with the last partner. Among men whose last sex was with a FSW, 74% said the reason for not using a condom was not having one. Thus, infrequent condom use, low condom availability, and gender differences in behaviour necessitate modifying development policies that separate families; and better coordination between family planning, PHC, and AIDS/STD programmes, with improved supply, social marketing and community-based distribution of condoms in high-risk settings for STD/HIV prevention.