Publications

BACKGROUND

Although HIV and injury contribute substantially to disease burdens in lowand middle-income countries (LMIC), their intersection is poorly characterized.

OBJECTIVE

This systematic review assessed the prevalence and associated mortality impact of HIVseropositivity among injured patients in LMIC.

METHODS

A systematic search of PubMed, EMBASE, Global Health, CINAHL, POPLINE and Cochrane databases through August 2016 was performed. Prospective and cross-sectional reports of injured patients from LMIC that evaluated HIV-serostatus were included. Two reviewers identified eligible records (kappa=0.83); quality was assessed using GRADE criteria. HIV-seroprevalence and mortality risks were summarized and pooled estimates were calculated using random-effects models with heterogeneity assessed.

RESULTS

Of 472 retrieved records, sixteen met inclusion. All reports were of low or very low quality and derived from sub-Saharan Africa. HIV-serostatus was available for 3,994 patients. Individual report and pooled HIV-seroprevalence estimates were uniformly greater than temporally matched national statistics (range: 4.5-35.0%). Pooled reports from South Africa were three-fold greater than matched national prevalence (32.0%, 95% CI, 28.0-37.0%). Mortality data were available for 1,398 patients. Heterogeneity precluded pooled mortality analysis. Among individual reports, 66.7% demonstrated significantly increased relative risks (RR) of death; none found reduced risk of death among HIV-seropositive patients. Increased mortality risk among HIV-seropositive patients ranged from 1.86 (95% CI, 1.11-3.09) in Malawi to 10.7 (95% CI, 1.32-86.1) in South Africa.

CONCLUSION

The available data indicate that HIV-seropositivity among the injured is high relative to national rates and may increase mortality, suggesting that integrated HIV-injury programming could be beneficial. Given the data limitations, further study of the HIV-injury intersection is crucially needed.

OBJECTIVE

Otologic methicillin-resistant (MRSA) infection has historically been rare, but given the rise in community-acquired MRSA carriage and infection at other body sites, prevalence rates may be changing. The goal of this study was to determine the prevalence of MRSA in recent otologic cultures from patients with acute otitis externa (AOE).

STUDY DESIGN

Retrospective review of an institutional microbiologic database.

METHODS

A retrospective analysis was performed on serial culture isolates taken from the ear at a quaternary care hospital from January 2014 to April 2016. The causative pathogen and antibiotic sensitivity was determined by culture isolation and end point mean inhibitory concentration (MIC) testing. Medical records were reviewed to document patient characteristics, chronicity of infection, symptomatology, and previous treatments.

RESULTS

Over the study period, 173 patients were diagnosed with AOE and underwent otologic cultures of the ear. Fifty-three (30.6%) of cultures grew (SA). Of SA infections, 15 (28.3%) were identified as MRSA. MRSA patients were typically older than patients with methicillin-sensitive SA (MSSA) (mean age 46.7 ± 17.9 29 ± 19.4,  = 0.003) and had more medical comorbidities (4 1.7,  = 0.001). Compared to patients with MSSA, patients with MRSA were significantly more likely to have had prior ototopical antibiotic exposure (37% 73%,  = 0.019).

CONCLUSION

Contemporary ear culture isolates at quaternary care center show higher rates of MRSA compared to historical reports in the literature. Clinicians should consider ear cultures to identify MRSA AOE.

LEVEL OF EVIDENCE

IV.

BACKGROUND & AIMS

During endoscopy, the resect and discard strategy, if performed with high confidence, can be used to determine histologic features of diminutive colorectal polyps (5 mm or less). These polyps can then be removed and discarded without pathology assessment. However, the complexities of real-time optical assessment and follow-up management have provided challenges to widespread use of this approach. We aimed to determine the outcomes of simple alternative strategies, in which all diminutive polyps can be resected and discarded.

METHODS

We collected data from 2 previous studies that used narrow-band imaging to assess polyps, performed at 5 medical centers (1658 patients with 2285 diminutive polyps; 15 endoscopists). We compared 3 resect and discard strategies: the currently used optical strategy, which relies on high confidence optical assessment of all diminutive polyps; a location-based strategy that classifies all recto-sigmoid diminutive polyps a priori as hyperplastic and all polyps proximal to the recto-sigmoid colon a priori as neoplastic; and a simplified optical strategy, in which all recto-sigmoid diminutive polyps are classified as hyperplastic unless confidently assessed as neoplastic, and all polyps proximal to the recto-sigmoid colon are classified as neoplastic unless confidently assessed as hyperplastic polyps. The primary outcome was the agreement of the surveillance interval calculated for each strategy with the surveillance interval determined by pathology analysis.

RESULTS

The proportion of surveillance intervals that agreed with pathology-based surveillance recommendations was slightly higher when the optical strategy was used compared to the location-based strategy or simplified optical strategy (94% vs 89% and 90%, respectively; P < .001). When the 5-10 year recommendations for patients with low-risk polyps were applied as a 10-year surveillance interval, all 3 strategies resulted in surveillance interval agreement compared to pathology above 90% (the quality benchmark). Use of the simplified or location-based strategy could have avoided pathology analysis for 77% of all polyps, compared to 59% if the optical strategy was used (P < .001). In addition, a higher proportion of patients could receive recommendations immediately after colonoscopy with use of the simplified or location based strategy (65%) compared to the optical strategy (40%) (P < .001).

CONCLUSION

A location-based and a simplified optical resect and discard strategy produced surveillance recommendations that were in agreement with those from pathology analysis for at least 90% of patients, assuming a 10-year surveillance interval for patients with low-risk polyps. These strategies could further reduce the number of pathology examinations and provide more patients with immediate surveillance recommendations. Optical assessment might be reduced or might not be required for resect and discard. Clintrials.gov no: NCT01935180 and NCT01288833.