An Outbreak of Covid-19 on an Aircraft Carrier.

BACKGROUND: An outbreak of coronavirus disease 2019 (Covid-19) occurred on the U.S.S. Theodore Roosevelt, a nuclear-powered aircraft carrier with a crew of 4779 personnel. METHODS: We obtained clinical and demographic data for all crew members, including results of testing by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). All crew members were followed up for a minimum of 10 weeks, regardless of test results or the absence of symptoms. RESULTS: The crew was predominantly young (mean age, 27 years) and was in general good health, meeting U.S. Navy standards for sea duty. Over the course of the outbreak, 1271 crew members (26.6% of the crew) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by rRT-PCR testing, and more than 1000 infections were identified within 5 weeks after the first laboratory-confirmed infection. An additional 60 crew members had suspected Covid-19 (i.e., illness that met Council of State and Territorial Epidemiologists clinical criteria for Covid-19 without a positive test result). Among the crew members with laboratory-confirmed infection, 76.9% (978 of 1271) had no symptoms at the time that they tested positive and 55.0% had symptoms develop at any time during the clinical course. Among the 1331 crew members with suspected or confirmed Covid-19, 23 (1.7%) were hospitalized, 4 (0.3%) received intensive care, and 1 died. Crew members who worked in confined spaces appeared more likely to become infected. CONCLUSIONS: SARS-CoV-2 spread quickly among the crew of the U.S.S. Theodore Roosevelt. Transmission was facilitated by close-quarters conditions and by asymptomatic and presymptomatic infected crew members. Nearly half of those who tested positive for the virus never had symptoms.

Overactive bladder medication adherence when medication is free to patients.

PURPOSE: We examined overactive bladder medication compliance in a health care system in which patients do not pay for medication. MATERIALS AND METHODS: Pharmacy dispensing records were reviewed for antimuscarinic agents from January 2003 to December 2006 for the United States Military Health System National Capital Region. Medication nonpersistence, switching and adherence were examined. Kaplan-Meier survival analysis was done to compare medication persistence duration. RESULTS: Overactive bladder medications were dispensed to 7,879 adults. Tolterodine extended release (4,716 patients or 60%) and oxybutynin immediate release (2,003 or 25.5%) were most commonly prescribed. The medication nonpersistence rate, defined as the proportion of patients who never refilled a prescription for antimuscarinics during the study period, was 35.1% (2,760 of 7,858). Of 5,098 patients who refilled a prescription 1,305 changed the medication or dose at least once for a medication switch rate of 25.6%. The overall median medication possession ratio, defined as the total days of medication dispensed except for the last refill divided by the number of days between the first dispense date and the last refill date, was 0.82 in all cases. Men had a significantly higher median medication possession ratio than women (0.86 vs 0.81, p <0.001). Of patients who obtained at least 1 refill women remained on medication longer than men (median 606 vs 547 days, p = 0.01). Patients on tolterodine extended release had a higher medication nonpersistence rate than those on oxybutynin immediate release (0.89 vs 0.68, p <0.01). There was no difference between extended release medications. CONCLUSIONS: In a health care system in which patients do not pay for medications 35% of patients did not refill a prescription for overactive bladder medication, similar to previous reports. However, other measures of medication compliance were higher than those published previously in systems with copays.

The racial distribution of female pelvic floor disorders in an equal access health care system.

PURPOSE: We examined ethnic differences in female pelvic disorders in an equal access health care system. MATERIALS AND METHODS: An electronic medical record review was performed for patients with pelvic floor disorders at a military female pelvic medicine and reconstructive surgery division for a 1-year period. Primary diagnosis codes and patient reported race were reviewed. RESULTS: Mean +/- SD cohort age was 55 +/- 16.3 years. A total of 720 patients were identified, of whom 68.8% were white and 18.6% were black. Pelvic organ prolapse was the primary diagnosis in 34.2% of the women, while 19.7% had stress urinary incontinence and 10.8% had urge urinary incontinence. There was no difference in the prevalence of prolapse between black and white women. However, of patients with incontinence there was a statistically significant difference with urge incontinence in more black women (51.2%) and stress incontinence in more white women (66.2%) (chi-square p <0.05). CONCLUSIONS: There is a similar ethnic distribution of pelvic organ prolapse in an equal access health care system. Of women with incontinence there was a higher prevalence of urge urinary incontinence in black women and a higher prevalence of stress urinary incontinence in white women.

Use of end-to-end anastomotic sizer with occlusion balloon to prevent loss of pneumoperitoneum in robotic vesicovaginal fistula repair.

Maintaining the pneumoperitoneum in robotic-assisted surgery can be difficult when vaginal integrity is compromised, such as in vesicovaginal fistula. We report an approach using an anastomotic sizer modified with an occlusion balloon for manipulation of the vaginal apex and maintenance of the pneumoperitoneum for robotic-assisted vesicovaginal fistula repair.

Multilocular cystic renal cell carcinoma with osseous metaplasia in a 25-year-old woman.

Multilocular cystic renal cell carcinoma, clear cell type, accounts for less than 1% of all renal tumors. It is characterized by variably sized, noncommunicating cysts separated by irregular, thick, and fibrous septa covered with clear cells microscopically. We report a case of a markedly calcified multilocular renal cell carcinoma, clear cell type, with diffuse osseous metaplasia.

Prospective comparison of computerized tomography and excretory urography in the initial evaluation of asymptomatic microhematuria.

PURPOSE: The ideal imaging study for evaluation of the upper urinary tract in patients with microhematuria has been debated. We prospectively compared the diagnostic yield of computerized tomography (CT) to excretory urography (IVP) in the initial evaluation of asymptomatic microhematuria. MATERIALS AND METHODS: Between December 1998 and June 2001, 115 patients presenting with asymptomatic microhematuria underwent CT and IVP before cystoscopy. Helical CT images with 5 mm. adrenal and kidney slices with and without contrast material were followed by delayed 5 mm. ureteral contrast images through the bladder base. Each CT and IVP was examined by a radiologist who was blinded to the result of the other imaging study. Diagnostic yields of the imaging techniques were compared using the test of 2 proportions and chi-square analysis. RESULTS: Radiographic abnormalities were noted on CT or IVP in 38 patients. Sensitivity was 100% for CT and 60.5% for IVP, and specificity 97.4% for CT and 90.9% for IVP. CT accuracy was 98.3% compared to IVP accuracy which was 80.9% (p <0.001). A total of 40 nonurological diagnoses were made by CT, including 3 abdominal aortic aneurysms and 1 iliac artery aneurysm. No additional diagnoses were made by IVP. Fewer additional radiographic studies were recommended after CT than after IVP. CONCLUSIONS: The use of CT in the initial evaluation of asymptomatic microhematuria results in better diagnostic yield. In addition, more nonurological diagnoses can be made and less additional radiography is needed to confirm a diagnosis.