background. Independent risk factors for surgical site infection (SSI) after cesarean section have not been well documented, despite the large number of cesarean sections performed and the relatively common occurrence of SSI.

Background Patients with end-stage renal disease (ESRD) receiving dialysis have been reported to have increased risk of cancer. However, contemporary cancer burden estimates in this population are sparse and do not account for the high competing risk of death characteristic of dialysis patients. Study Design Retrospective cohort study. Setting & Participants US adult patients enrolled in Medicare's ESRD program who received in-center hemodialysis. Factors Demographic/clinical characteristics. Outcomes For overall and site-specific cancers identified using claims-based definitions, we calculated annual incidence rates (1996-2009). We estimated 5-year cumulative incidence since dialysis therapy initiation using competing-risk methods. Results We observed a constant rate of incident cancers for all sites combined, from 3,923 to 3,860 cases per 100,000 person-years (annual percentage change, 0.1; 95% CI, −0.4 to 0.6). Rates for some common site-specific cancers increased (ie, kidney/renal pelvis) and decreased (ie, colon/rectum, lung/bronchus, pancreas, and other sites). Of 482,510 incident hemodialysis patients, cancer was diagnosed in 37,128 within 5 years after dialysis therapy initiation. The 5-year cumulative incidence of any cancer was 9.48% (95% CI, 9.39%-9.57%) and was higher for certain subgroups: older age, males, nonwhites, non-Hispanics, nondiabetes primary ESRD cause, recent dialysis therapy initiation, and history of transplantation evaluation. Among blacks and whites, we observed 35,767 cases compared with 25,194 expected cases if the study population had experienced rates observed in the US general population (standardized incidence ratio [SIR], 1.42; 95% CI, 1.41-1.43). Risk was most elevated for cancers of the kidney/renal pelvis (SIR, 4.03; 95% CI, 3.88-4.19) and bladder (SIR, 1.57; 95% CI, 1.51-1.64). Limitations Claims-based cancer definitions have not been validated in the ESRD population. Information for cancer risk factors was not available in our data source. Conclusions These results suggest a high burden of cancer in the dialysis population compared to the US general population, with varying patterns of cancer incidence in subgroups.

Data are limited on the attributable outcomes of Clostridium diffi cile-associated disease (CDAD), particularly in CDAD-endemic settings. We conducted a retrospective cohort study of nonsurgical inpatients admitted for >48 hours in 2003 (N = 18,050). The adjusted hazard ratios for readmission (hazard ratio 2.19, 95% confi dence interval [CI] 1.87-2.55) and deaths within 180 days (hazard ratio 1.23, 95% CI 1.03-1.46) were signifi cantly different among CDAD case-patients and noncase patients. In a propensity score matched-pairs analysis that used a nested subset of the cohort (N = 706), attributable length of stay attributable to CDAD was 2.8 days, attributable readmission at 180 days was 19.3%, and attributable death at 180 days was 5.7%. CDAD patients were signifi cantly more likely than controls to be discharged to a long-term-care facility or outside hospital. Even in a nonoutbreak setting, CDAD had a statistically signifi cant negative impact on patient illness and death, and the impact of CDAD persisted beyond hospital discharge.C lostridium diffi cile-associated disease (CDAD) is an increasingly common cause of hospital-associated diarrhea (1,2). The emerging NAP1 strain of C. diffi cile has been associated with numerous outbreaks and appears to be more virulent than other endemic and epidemic C. diffi cile strains (3-9). Despite the increasing importance of this pathogen, few data exist on outcomes attributable to CDAD (10-14). The attributable mortality for CDAD has recently been estimated at 6.9% and 16.7% (9,12). However, these studies were performed during CDAD outbreaks caused by the NAP1 strain. Published estimates of CDAD-attributable deaths in disease-endemic settings are much lower (1.2%-1.5%) (10,13). Kyne et al. did not fi nd endemic CDAD to be an independent predictor of death within 1 year of CDAD, but that study was relatively small (47 CDAD cases) (11). Thus, additional data with larger sample sizes are needed to determine outcomes associated with CDAD in nonoutbreak settings. With a large cohort of CDAD patients at a tertiary-care center, we evaluated CDAD outcomes including length of stay, hospital discharge status, time-to-readmission, and deaths in a CDADendemic setting. MethodsThis study was conducted at Barnes-Jewish Hospital (BJH), a 1,250-bed, tertiary-care academic hospital in St. Louis, Missouri. Eligibility was limited to nonsurgical patients admitted for >48 hours from January 1 through December 31, 2003. Nonsurgical patients were defi ned as those without operating room costs. Surgical patients were excluded because of their heterogeneity. Specifi cally, risk factors for length of stay, readmission to the hospital, and death were different in this population compared with other hospitalized patients. Data were primarily collected from the hospital's Medical Informatics database. The database was queried to collect patient demographics; admission and discharge dates; International Classifi cation of Diseases, 9th edition, Clinical Modifi cation (ICD-9-CM), diagnosis and procedur...

Background-Little is known concerning the impact of HIV status disclosure on quality of life, leaving clinicians and families to rely on research of children with other terminal illnesses.

BackgroundIn 2011, The Infectious Diseases Society of America released a clinical practice guideline (CPG) that recommended short-course antibiotic therapy and avoidance of fluoroquinolones for uncomplicated urinary tract infections (UTIs). Recommendations from this CPG were rapidly disseminated to clinicians via review articles, UpToDate, and the Centers for Disease Control and Prevention website; however, it is unclear if this CPG had an impact on national antibiotic prescribing practices.MethodsWe performed a retrospective cohort study of outpatient and emergency department visits within a commercial insurance database between January 1, 2009, and December 31, 2013. We included nonpregnant women aged 18–44 years who had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a UTI with a concurrent antibiotic prescription. We performed interrupted time series analyses to determine the impact of the CPG on the appropriateness of the antibiotic agent and duration.ResultsWe identified 654 432 women diagnosed with UTI. The patient population was young (mean age, 31 years) and had few comorbidities. Fluoroquinolones, nonfirstline agents, were the most commonly prescribed antibiotic class both before and after release of the guidelines (45% vs 42%). Wide variation was observed in the duration of treatment, with >75% of prescriptions written for nonrecommended treatment durations. The CPG had minimal impact on antibiotic prescribing behavior by providers.ConclusionsInappropriate antibiotic prescribing is common for the treatment of UTIs. The CPG was not associated with a clinically meaningful change in national antibiotic prescribing practices for UTIs. Further interventions are necessary to improve outpatient antibiotic prescribing for UTIs.

Background:Oncogenic human papillomavirus (HPV) has been hypothesised as a risk factor for oesophageal squamous cell carcinoma (OSCC), but aetiological research has been limited by the varying methodology used for establishing HPV prevalence. The aims of this systematic review and meta-analysis were to estimate the prevalence of HPV DNA detected in OSCC tumours and the influence of study characteristics.Methods:Study-level estimates of overall and type-specific HPV prevalence were meta-analysed to obtain random-effects summary estimates.Results:This analysis included 124 studies with a total of 13 832 OSCC cases. The average HPV prevalence (95% confidence interval) among OSCC cases was 0.277 (0.234, 0.320) by polymerase chain reaction; 0.243 (0.159, 0.326) by in situ hybridisation; 0.304 (0.185, 0.423) by immunohistochemistry; 0.322 (0.154, 0.490) by L1 serology; and 0.176 (0.061, 0.292) by Southern/slot/dot blot. The highest HPV prevalence was found in Africa and Asia, notably among Chinese studies from provinces with high OSCC incidence rates.Conclusions:Future research should focus on quantifying HPV in OSCC cases using strict quality control measures, as well as determining the association between HPV and OSCC incidence by conducting large, population-based case–control studies. Such studies will provide a richer understanding of the role of HPV in OSCC aetiology.

Objective To compare Clostridium difficile infection (CDI) incidence rates during a 6-year period among five geographically diverse academic medical centers across the United States using recommended standardized CDI surveillance definitions that incorporate recent healthcare facility (HCF) exposures. Methods Data on C. difficile toxin assay results and dates of admission, discharge and assays were collected from electronic hospital databases. Chart review was performed for patients with a positive C. difficile toxin assay identified within 48 hrs of admission to determine HCF exposures in the 90 days prior to hospital admission. CDI cases, defined as any inpatient with a positive stool toxin assay for C. difficile, were categorized into five surveillance definitions based on recent HCF exposure. Annual CDI rates were calculated and evaluated with chi-square test for trend and chi-square summary tests. Results Over the study period, there were significant increases in the overall incidence rates of hospital-onset, HCF-associated CDI (7.0 to 8.5 cases/10,000 patient days (p < 0.001)); community-onset, HCF-associated – study hospital CDI (1.1 to 1.3 cases/10,000 patient-days (p = 0.003)); and community-onset, HCF-associated – other HCF CDI (0.8 to 1.5 cases/1,000 admissions overall (p < 0.001)). For each CDI surveillance definition, there were significant differences in total incidence rates between institutions. Conclusions The increasing incidence rates of CDI over time and across institutions, and correlation of CDI incidence in different categories suggest that CDI may be a regional problem, and not isolated to single healthcare facilities.

Objective The purpose of this study was to develop and validate a risk prediction model that could identify patients at high risk for Clostridium difficile infection (CDI) before they develop disease. Design Retrospective cohort. Setting Tertiary care medical center. Patients Patients admitted to the hospital for ≥48 hours from 1-1-2003 through 12-31-2003. Methods Data were collected electronically from the hospital’s Medical Informatics database and analyzed with logistic regression to determine variables that best predicted patients’ risk for development of CDI. Model discrimination and calibration were calculated. The model was bootstrapped 500 times to validate the predictive accuracy. A receiver operating characteristic (ROC) curve was calculated to evaluate potential risk cut-offs. Results 35,350 admissions with 329 CDI cases were included. Variables in the risk prediction model were age, CDI pressure, admissions in previous 60 days, modified Acute Physiology Score, days on high risk antibiotics, low albumin, admission to an ICU, and receipt of laxatives, gastric acid suppressors, or antimotility drugs. The calibration and discrimination of the model were very good to excellent (C index=0.88; Brier score 0.009). Conclusions The CDI risk prediction model performed well. Further study is needed to determine if it could be used in a clinical setting to prevent CDI-associated outcomes and reduce costs.