Cook County Health Research Articles

Neurosarcoidosis in a public safety net hospital: a study of 82 cases.

To characterize clinical presentation, laboratory and imaging data, and treatment outcomes for neurosarcoidosis in an urban safety net hospital. The research database of Cook County Health and Hospitals system was queried for all cases of sarcoidosis from 2006 to 2013. These cases plus those identified through a survey of neurology faculty were reviewed and flagged if suspected to be neurosarcoidosis. Data were extracted in a standardized fashion, upon review by two experienced neurologists; patients were classified as definite, probable or possible neurosarcoidosis. Disagreements on classification were resolved by consensus conference. 1706 cases of sarcoidosis were identified, with 82 (4.8%) classified as neurosarcoidosis. The cohort was predominantly African American (89%). Six were classified as definite, 34 as probable, and 42 as possible neurosarcoidosis. Neurosarcoidosis was the presenting symptom of sarcoidosis in 74% of cases. The most common presenting phenotype was myelopathy (21.7%), followed by optic nerve/chiasm involvement (16.0%) and epilepsy (11.3%). The facial nerve was involved in only 2% of cases. Chest x-ray showed abnormalities of sarcoidosis in 43.3% of cases, while chest CT did so in 78.6%. Corticosteroids were the initial treatment in 91% of cases, and outcomes were good in 53% of cases. Neurosarcoidosis remains a challenging diagnosis with the majority of patients without a previous diagnosis of systemic sarcoidosis. Chest imaging was supportive of the diagnosis in a majority of patients. Our cohort differs from others in the literature due to a low prevalence of facial nerve involvement. Prospective registry studies are needed.

Abstract P1-02-01: Improvement of breast cancer screening access and quality in an underserved population through system interventions

Abstract Background: Differences in access to and quality of screening and treatment are proposed to contribute to racial disparities in breast cancer outcomes. Interventions designed to improve mammography access and quality encompass strategies at the individual patient, healthcare provider, and system levels. In 2016, an urban safety net healthcare system based in Chicago implemented several changes in response to collected data showing variations in quality at institutions performing mammography. These changes included the installation of digital machines at one of four sites, centralizing reading of images from all four sites to a single site with radiologists specialized in mammography and increasing care coordination including enhanced patient outreach efforts. We examined the impact of these systems-based interventions on the access to and quality of mammography services. Methods: Data was obtained on 15,918 screening mammograms performed across four mammography centers within the Cook County Health & Hospitals System from the six months prior to and one year after implementation of changes. Manual chart abstraction was performed for each study that was assessed as BIRADS 0 (Breast Imaging and Reporting Data System), meaning an incomplete study requiring additional imaging evaluation, or mammograms that appeared suspicious or highly suspicious and categorized as BIRADS 4 or 5. Screening mammogram volume at each site was recorded and compared. Quality of screening mammograms was assessed using eleven metrics reflecting radiologist performance and efficiency of facility care processes. These metrics included the rate of recall, cancer detection rate, proportion of cancers that were early stage or minimal in size, proportion of women with timely follow-up imaging and biopsy, and rates of loss to follow-up. Results: The volume of screening mammograms completed at each of the four sites increased from the six months prior to intervention to the six months after (range of 61-322% increase). At one-year post intervention, there were smaller, but sustained increases in volume (range of 12-70% increase). Improvements were seen in at least one quality metric at each site in the post-intervention period (range 1-8). The proportion of women with timely follow-up after abnormal mammogram also improved across all four sites: from 38% getting follow-up imaging within 30 days pre-intervention to 68% after, and from 62% to 75% of women with biopsy completion within 60 days. Rate of cancer detection improved at two of the sites with the lowest pre-intervention values, from 1.7 to 3.1 and 2.8 to 5.7 per 1,000 mammograms (quality benchmark: 3-10/1,000 screening tests). Conclusion: Improvements in access to and quality of screening mammography demonstrate the value of implementing system level changes in enhancing breast cancer care and may translate to better outcomes for all women. Citation Format: Manst DJ, Gil D, Marcus EA, Mullarkey P, Ganschow PS. Improvement of breast cancer screening access and quality in an underserved population through system interventions [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-02-01.

Electronic Clinical Decision Support (eCDS) Intervention to Increase Hepatitis C Virus (HCV) Screening and Linkage to Care among Baby Boomers in Urban Safety-Net Health System

Objective: An estimated 3.5 million Americans are living with hepatitis C virus (HCV) infection and the majority is unaware of their infection. HCV causes significant morbidity and mortality and is one of the leading causes of hepatocellular carcinoma (HCC) and other liver complications. Baby boomers (born between 1945 and 1965) account for approximately 75% of people chronically infected with HCV. The CDC and USPSTF recommend universal one-time screening of all Baby Boomers. Methods: Cook County Health (CCH) implemented an electronic clinical decision support (eCDS) tool in September 2016 to increase HCV screening among baby boomers throughout its outpatient clinic network. We evaluated the impact of the eCDS tool on screening and the successive stages of the care continuum by analyzing the proportion of patients who completed 1) anti-HCV screening, 2) HCV RNA confirmatory testing, 3) HCV RNA detectable result, 4) liver staging, and 5) treatment in the 12-month periods pre- and post-implementation. Results: The number of baby boomers newly tested system-wide each month increased by 344% over the 24-month evaluation period. Of 15,630 patients tested for anti-HCV, 844 (5.4%) tested positive. Patients with anti-HCV positive results were predominantly male (59%), between the ages of 52 and 64 (70%), Black/African American (71%) and Non-Hispanic (86%). 605 (72%) of anti-HCV positive patients completed HCV ribonucleic acid (RNA) testing; of those patients, 347 (58%) had confirmed HCV infection. Of 347 patients with confirmed HCV infection, 198 completed liver staging and 68 initiated treatment. Conclusions: Implementation of eCDS tools across large urban safety-net health systems is an effective strategy for ensuring adherence to national guidelines for HCV screening among baby boomers. The high prevalence of HCV infection in this primarily male, Black/African American baby boomer population highlights the urgency of universal screening programs at similar institutions.

576. Continuing Disparities in Virologic Control for People Living with HIV (PLWH) Receiving Care at a Large, Urban, Safety-Net Clinic

BackgroundThe National HIV/AIDS Strategy highlights reduction of HIV-related disparities as a key goal. Despite universal access to therapy in the United States, the CDC estimates that only 58% of PLWH have achieved virologic suppression. We carried out a recent analysis of virologic suppression, examining for associated factors for PLWH receiving care at one of the nation’s largest, urban, safety-net clinics in order to identify ongoing outcome disparities.MethodsRuth M. Rothstein CORE Center, Cook County Health and Hospital System’s large, urban, safety-net HIV clinic cares for nearly 5,000 PLHW in the Chicago area. We report rates of virologic suppression for PLWH who attended at least one primary care visit between March 31, 2017 and April 1, 2018. We assessed for associations between key demographic characteristics, inclusive of zip code of residence, and virologic suppression (VL < 200 copies/mL3).ResultsA total of 4,660 patients attended at least one visit primary care visit at CORE between March 31, 2017 and April 1, 2018, of whom 84% were virologically suppressed. Sixty-six percent of our patients were African-American (AA), and 25% identified as Hispanic; 74% were male; patients’ median age was 49. On multivariate analysis, AA race (OR 1.54, P = 0.006) correlated with ongoing viremia (VL > 200 copies/mL3), while older age (age group 30 – 49, OR 0.62, P < 0.001; age group > 50 OR 0.27, P < 0.001) and identification as Hispanic (OR 0.63, P = 0.011) associated with virologic suppression. Other HIV transmission categories and demographic characteristics, inclusive of a health literacy measure, did not associate with virologic control. Of the Top 10 most populated zip codes of residence for our patients, three had a significantly higher proportion of viremic patients; while one had significantly more suppressed patients.ConclusionDisparities in virologic suppression persist in younger and African-American PLWH who attended care at Chicago’s largest, safety-net HIV clinic, with our data highlighting particular geographic areas of need. Structural interventions and quality improvement initiatives, at the health system and regional level, must continue to focus on improving outcomes for PLWH who fall into these demographic categories.Disclosures R. Lubelchek, Viiv: Scientific Advisor, Salary.

2213. Hepatitis C Virus (HCV) Care Continuum Post-implementation of Electronic Clinical Decision Support (eCDS) Tool to Increase HCV Screening Among Baby Boomers in Large Urban Health System

BackgroundAn estimated 3–4 million Americans are living with Hepatitis C virus (HCV) infection and more than half of these individuals are unaware of their HCV status. Baby Boomers (born between 1945 and 1965) are significantly more likely to have HCV infection and should be universally screened. In September 2016, Cook County Health and Hospital System (CCHHS) implemented an electronic clinical decision support (eCDS) tool to increase HCV screening and treatment among Baby Boomers (BB) in primary care sites.MethodsTo assess the impact of the eCDS tool on screening and the successive stages of the HCV care continuum, we analyzed the proportion of patients who completed (1) HCV antibody screening, (2) RNA confirmatory testing, (3) HCV RNA detectable result, (4) liver staging, (5) treatment initiation, and (6) treatment completion.ResultsBetween August 2015 and September 2017, the number of BB patients tested for HCV increased by 325% post-implementation of the eCDS tool. During this period, 17,585 BB patients were screened for HCV (3,349 pre-eCDS and 14,236 post-eCDS) and 822 unique patients were HCV antibody reactive (4.7% reactivity). Of 822 HCV antibody reactive patients, 583 (70.9%) completed HCV RNA confirmatory testing (70.0% pre-RNA reflex and 92.0% post-RNA reflex). Of 583 patients with HCV RNA confirmatory testing, 338 (58.0%) had detectable HCV RNA. Of 338 patients with detectable HCV RNA, 190 (56.2%) completed Fibroscan liver staging. Of 190 patients who completed liver staging, 65 (34.2%) patients completed treatment (Illinois Medicaid plans only cover HCV treatment for patients with F-3 and F-4 results). Of 65 patients who initiated treatment, 65 (100%) completed treatment. SVR data were not available for all patients. ConclusionThe HCV care continuum illustrates the stages at which barriers to accessing HCV medical care attenuate successful treatment of patients. The barriers and (mitigating solutions) are as follows: policy-level (e.g., insurance coverage), institutional-level (e.g., HCV RNA reflex testing), provider-level (e.g., EMR prompts), and patient-level (e.g., provision of support services).Disclosures All authors: No reported disclosures.

603. Multi-morbidity and Impaired CD4/CD8 Ratios in Older Adults with Well-Controlled HIV

BackgroundOlder age has been associated with impaired CD4 recovery and a low CD4:CD8 ratio is an independent predictor of non-AIDS morbidity/mortality. In this study we describe the overall comorbidity burden and assess factors associated with CD4:CD8 <1 among HIV+ older adults 60 years+ seen at CORE Center, Cook County Health and Hospital System; a safety-net health system.MethodsWe evaluated demographic, clinical, and lab variables in all HIV+> 60 years who had at least 1 primary care visit from January 1, 2016 to May 31, 2017 at the RMR CORE center. Since HIV viremia is associated with CD4 recovery, analysis on CD4:CD8 ratios was restricted to the patients with viral suppression.ResultsThere were 809 patients with a median age of 63 (range: 60–89) years. Seventy-five percent were male, 74% black, 17% Hispanic and 8% white. Mean CD4 was 538 (+307) cells/mm; 107 (13%) had CD4 < 200 and 675 (84%) had undetectable HIVRNA (<40 copies/mL). 38% were HCV Ab+. Common comorbidities were hypertension 62%, COPD 23%, diabetes 22%, depression 17%, osteoarthritis 15%, neuropathy, chronic kidney disease (CKD) and coronary artery disease (CAD) 13% each. 50% had 1–2 comorbidities and 31% had >3 co-morbidities. Of the 675 patients with suppressed viremia, 470 patient (70%) had CD4:CD8 <1 and 245 (36%) had CD4:CD8 <0.5. Compared with patients with CD4:CD8 >1, patient with CD4:CD8 <1 had lower CD4 counts (451 vs. 739 cells/mm3; P < 0.001), were less likely to have CD4 > 500 (35% vs. 75%; P <0.001), more likely to have CD4 <200 (13% vs. 1%; P <0.001), be male (82% vs. 60%; P < 0.001), HCVab+ (39% vs. 32%; P 0.05). They also trended to have more CAD 7% vs. 4% (P = 0.1) and more CKD 15% vs. 11% (P = 0.2).ConclusionThere was a high rate of multi-morbidity among older, predominantly ethnic minorities HIV-infected adults with 56% having >2 comorbidities. In the setting of viral suppression, 70% still had a CD4:CD8 ratio <1 which likely reflects the effects of older age, and lower CD4 nadir. This impaired immune restoration and co-morbidity burden portend a higher risk of non-AIDS morbidity and mortality in these patients and highlights the need for comprehensive care in HIV clinic settings.Disclosures All authors: No reported disclosures.

Characteristics and Impacts of Venous Thromboembolism in Patients with Hepatocellular Carcinoma

Venous thromboembolism (VTE) is a common complication in cancer patients, and is associated with worse prognosis in such population. Hepatocellular carcinoma (HCC) poses high risk for VTE; however, data is scarce regarding the characteristics and consequences of VTE in HCC patients. We retrospectively reviewed the electronic medical records (EMR) of 270 patients diagnosed with HCC from 2000 to 2015 in Cook County Health and Hospitals System. We report the cumulative incidence of VTE in the present cohort, and identified through multivariate logistic regression the independent risk factors of the development of VTE. Overall prognosis of patients with and without VTE were presented and compared. Sixteen cases (5.93%) of VTE were documented in the present study. In multivariate analysis, obesity, Child B cirrhosis, intra-hepatic lesions more than 3, and multi-organ extrahepatic metastasis were significantly associated with VTE development (p<0.05). The presence of VTE was an independent risk factor for mortality in multivariate analysis (HR=3.62, p=0.021), together with male gender, Child C cirrhosis, and extrahepatic metastasis. Obesity, Child B cirrhosis, more intra-hepatic lesions, and multi-organ extrahepatic metastasis are associated with cancer-associated VTE. VTE will adversely affect the prognosis of patients with HCC; therefore, primary thromboprophylaxis may be warranted in such population.

Factors Associated with Appropriate Hepatocellular Carcinoma (HCC) Screening Among Chronic Hepatitis C (HCV) Patients with Cirrhosis at an Urban Safety-net Hospital System

Background Despite guidelines recommending liver ultrasound (US) every 6 months for HCC screening in cirrhotic patients with HCV, reported screening rates remain low. Our study evaluated (1) timely screening among patients with HCV cirrhosis identified by transient elastography (FibroScan [FS]) and (2) described factors associated with lack of screening.Methods All HCV patients with score ≥12.5 kPa (cirrhosis) on FS obtained 3/27/2014- 4/30/2016 for evaluation for HCV treatment within 6 months of index FS by a gastroenterology (GI) or infectious disease (ID) provider within the Cook County Health and Hospitals System were identified. Patient and provider factors and screening were determined through retrospective chart review. Relative risks (RR) for screening failure at 6 months and 12 months after index FS were calculated.ResultsAmong 243 patients, 64% were men and 38% were co-infected with HIV. Median age was 57 years (range 31 to 79). Median FS score was 21.1 kPa (12.1 to 75). ID requested the index FS in 47%; GI, 47%; and primary care, 5%. In the first 6 months after index FS, 54% underwent US screening; 40% did not have US scheduled; 4.9% had their US cancelled; and 1.2% were scheduled but did not show. Among 112 patients not screened in the first 6 months, 39% underwent US in the subsequent 6 months, 55% were not scheduled for one and 5.4% were scheduled but did not show. At 12 months 72% of all patients were screened. Screening rates at 6 months were significantly higher for index FS obtained in 2015 (62%) compared with in 2014 (44%; P = 0.018) but not in 2016 compared with 2015. Comparing GI vs. ID, RR for screening failure at 1 year was 0.51 (95% CI 0.33-0.80, P = 0.003).Conclusion In patients with HCV cirrhosis, failure to obtain timely HCC screening was prevalent and driven by failure to order or schedule imaging. ID management was associated with a higher risk of failure of timely screening. Algorithms to improve HCC screening rates will be vital as more ID providers take on a greater role in HCV care.Disclosures All authors: No reported disclosures.

Corticosteroid Monotherapy Is Usually Insufficient Treatment for Idiopathic Inflammatory Myopathy

Idiopathic inflammatory myopathies (IIM) are a rare group of autoimmune diseases characterized by muscle inflammation. High-dose corticosteroids are conventionally used as the first-line therapy for IIM, but early introduction of noncorticosteroid immunosuppressive agents has become increasingly common in recent years despite a paucity of compelling evidence to support this. Here, we systematically analyze therapeutic practice patterns of IIM in a large municipal safety net medical center. We conducted a retrospective chart review of all adult patients attending rheumatology clinics at the Cook County Health and Hospital Systems from 2006 to 2011 with a diagnosis of IIM. Data collected included patient demographics, diagnosis, immunosuppressive therapies, serial serum creatine kinase (CK) measurements, and serial muscle strength testing. One hundred eight patients fulfilled eligibility criteria. The mean duration of follow-up was 62 months (range, 1-351 months). At presentation, the mean strength in the weakest muscle group was rated as 3.6 out of 5 (range, 1-5; SD 0.9), the mean initial CK was 4720 U/L (range, 23-38, 461; SD 6, 795), and initial mean prednisone dosage was 48 mg/d (range, 0-100, SD 22). At the end of the follow-up period, mean strength in the weakest muscle group was 4.6 out of 5 (range, 2-5; SD 0.7), mean peak CK was 412 (24-7533; SD 875), and the mean prednisone dosage was 12.7 mg (0-80; SD 17.5). Only 15 patients (14%) received exclusively corticosteroid monotherapy during the follow-up period. Ninety-three patients (86%) received additional immunosuppressive agents. Over the course of their illness, only a minority of patients in our cohort of IIM patients was treated with corticosteroids alone. It is unlikely we will determine optimal therapy in the absence of a large controlled study comparing corticosteroids versus a combination regimen, but it seems that rheumatologists favor addition of second-line immunosuppressive agents.

Pulse Dose Methylprednisolone Therapy for Adult Idiopathic Inflammatory Myopathy.

Idiopathic inflammatory myopathies (IIM) are a rare group of autoimmune diseases characterized by muscle inflammation. Typically high-dose daily oral corticosteroids are used as the first-line therapy of IIM. Pulse dose intravenous methylprednisolone (IVMP) has been used for serious or refractory cases. Here, we systematically analyze the therapeutic effect of pulse dose IVMP in patients with IIM in a large municipal safety net medical center and review the literature on pulse IVMP in adult IIM. We conducted a retrospective chart review of patients who were diagnosed with IIM in the rheumatology clinics of the Cook County Health and Hospital Systems. Data collected included patient demographics, diagnosis, immunosuppressive therapies, serial serum creatine kinase (CK) measurements, and serial muscle strength testing. Seven patients received pulse dose IVMP for active myositis. At the time of pulse dose IVMP, the mean strength in the weakest muscle group was rated as 3.1 of 5 (range, 2-4; SD, 0.9) and the mean peak CK was 5746 U/L (range, 1602-14,039; SD, 4911). Dysphagia was reported in 5 of the 7 patients at the time of IVMP. Four to six weeks after IVMP, the mean strength in the weakest muscle group was 3.3 of 5 (range, 1-5; SD, 1.5) and mean peak CK was 1064 U/L (range, 63-1788, SD, 712). Four to six weeks after IVMP, dysphagia had resolved in 2 and improved in 3. At the end of follow-up, mean strength in the weakest muscle group was 4.7 of 5 (range, 4-5; SD, 0.5), mean peak CK was 480 U/L (range, 37-1016; SD, 337), and the mean prednisone dosage was 15 mg (range, 2.5-60; SD, 21). Although our study has certain limitations, our cohort of adult patients with IIM had marked improvement in clinical and biochemical outcomes. Four to six weeks after IVMP infusion, there was a rapid improvement in muscle enzyme levels, muscle strength, and dysphagia. This therapy warrants further controlled trials.

Implementation of an audio computer-assisted self-interview (ACASI) system in a general medicine clinic: patient response burden.

Routine implementation of instruments to capture patient-reported outcomes could guide clinical practice and facilitate health services research. Audio interviews facilitate self-interviews across literacy levels. To evaluate time burden for patients, and factors associated with response times for an audio computer-assisted self interview (ACASI) system integrated into the clinical workflow. We developed an ACASI system, integrated with a research data warehouse. Instruments for symptom burden, self-reported health, depression screening, tobacco use, and patient satisfaction were administered through touch-screen monitors in the general medicine clinic at the Cook County Health & Hospitals System during April 8, 2011-July 27, 2012. We performed a cross-sectional study to evaluate the mean time burden per item and for each module of instruments; we evaluated factors associated with longer response latency. Among 1,670 interviews, the mean per-question response time was 18.4 [SD, 6.1] seconds. By multivariable analysis, age was most strongly associated with prolonged response time and increased per decade compared to < 50 years as follows (additional seconds per question; 95% CI): 50-59 years (1.4; 0.7 to 2.1 seconds); 60-69 (3.4; 2.6 to 4.1); 70-79 (5.1; 4.0 to 6.1); and 80-89 (5.5; 4.1 to 7.0). Response times also were longer for Spanish language (3.9; 2.9 to 4.9); no home computer use (3.3; 2.8 to 3.9); and, low mental self-reported health (0.6; 0.0 to 1.1). However, most interviews were completed within 10 minutes. An ACASI software system can be included in a patient visit and adds minimal time burden. The burden was greatest for older patients, interviews in Spanish, and for those with less computer exposure. A patient's self-reported health had minimal impact on response times.

Transmission clustering among newly diagnosed HIV patients in Chicago, 2008 to 2011: using phylogenetics to expand knowledge of regional HIV transmission patterns.

HIV transmission cluster analyses can inform HIV prevention efforts. We describe the first such assessment for transmission clustering among HIV patients in Chicago. We performed transmission cluster analyses using HIV pol sequences from newly diagnosed patients presenting to Chicago's largest HIV clinic between 2008 and 2011. We compared sequences through progressive pairwise alignment, using neighbor joining to construct an unrooted phylogenetic tree. We defined clusters as >2 sequences among which each sequence had at least 1 partner within a genetic distance of ≤1.5%. We used multivariable regression to examine factors associated with clustering and used geospatial analysis to assess geographic proximity of phylogenetically clustered patients. We compared sequences from 920 patients, median age of 35 years, 75% male, 67% black, 23% Hispanic, and 8% had a rapid plasma reagin titer ≥1:16 concurrent with their HIV diagnosis. We had HIV transmission risk data for 54%; 43% identified as men who have sex with men (MSM). Phylogenetic analysis demonstrated 123 patients (13%) grouped into 26 clusters, the largest having 20 members. In multivariable regression, age <25, black race, MSM status, male gender, higher HIV viral load, and rapid plasma reagin ≥1:16 associated with clustering. We did not observe geographic grouping of genetically clustered patients. Our results demonstrate high rates of HIV transmission clustering, without local geographic foci, among young black MSM in Chicago. Applied prospectively, phylogenetic analyses could guide prevention efforts and help break the cycle of transmission.

Get Yourself Tested 2011-2012: findings and prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae at an urban public health system.

During April 2011 and April 2012 the Get Yourself Tested campaign was launched throughout the Cook County Health and Hospitals System to promote testing of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) among 15-25-year-olds in a high-prevalence urban community. Retrospective data were collected and analysed. Demographic differences by CT and GC positivity were evaluated along with factors associated with CT and GC status. A total of 2853 tests were conducted among individuals aged 15-25 years. A total of 2060 (72%) females and 793 (28%) males were tested. Of those tested, 488 (17%) individuals tested positive for either CT or GC or both; 400 (14%) were positive for CT, 139 (5%) were positive for GC. The prevalence for GC was 8.8% (n = 70) in males compared to 3.3% (n = 69) in females (p < 0.001) and the prevalence of CT was 16% (n = 127) for males compared to 13.3% (n = 273) for females (p = 0.057). Women in a high-risk population are more likely to get tested for sexually transmitted infections; however, men are more likely to test positive for CT and GC. Get Yourself Tested is an important campaign to encourage wider spread testing among populations at risk in Cook County.

Rheumatic heart disease in modern urban america: A cohort study of immigrant and indigenous patients in Chicago

It is widely reported that the natural history of rheumatic heart disease (RHD) is more aggressive in developing countries, manifesting symptoms and requiring interventions at a younger age than in industrialized nations [1–5]. As the demographics in urban America shift with growing immigrant minorities from Latin America and other developing countries, it is possible that the demographics and natural history of RHD in the U.S. are changing as well. We compared the natural history and disease burden between immigrant and indigenous patients with RHD receiving care at Cook County Health and Hospitals System, a large public health care network serving inner-city Chicago.

Journal Scan: ED HIV Testing: Ethical Duty or Unreasonable Burden?

Journal Scan: ED HIV Testing: Ethical Duty or Unreasonable Burden?

Contributions of Public Hospitals to Regional Health Care: A Population-Based Analysis of the County Health Care System Serving Metropolitan Chicago

To determine the proportions of countywide expenditures and service delivery for the Cook County Health and Hospitals System (CCHHS), we obtained data from the CCHHS budget; CCHHS registration, program, and pharmacy databases; public health departments and organization reports; and federal agency estimates. The annual CCHHS budget of $1.2B represents 3.4% of total Cook County health care expenditures. Eight of the nine population-based proportions of health care services delivered by the CCHHS exceeded this proportion of health expenditures by factors of 1.3-8 times. These services include diagnosis of tuberculosis, sexually transmitted diseases, and cancers; care of very low birth weight babies; primary care for HIV and diabetes; and emergency room and ambulatory visits. This county health care system is a productive contributor to overall health service delivery in Cook County, and its contributions exceed its proportionate funding in eight of nine priority health areas.

Community‐Associated Methicillin‐ResistantStaphylococcus aureusand HIV: Intersecting Epidemics

Single-site studies have suggested a link between human immunodeficiency virus (HIV) and community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Population-level incidence of HIV-infected patients with CA-MRSA versus community-associated methicillin-susceptible S. aureus (CA-MSSA) infection was assessed in the Cook County Health and Hospitals System (CCHHS), a multi-hospital and ambulatory care center. Rates in zip codes, including those with a high density of individuals with prior incarceration (ie, high-risk zip codes), were calculated. We did a nested case-control analysis of hospitalized HIV-infected patients with S. aureus skin and soft-tissue infections (SSTIs). In CCHHS, the incidence of CA-MRSA SSTIs was 6-fold higher among HIV-infected patients than it was among HIV-negative patients (996 per 100,000 HIV-infected patients vs 157 per 100,000 other patients; P < .001). The incidence of CA-MRSA SSTIs among HIV-infected patients significantly increased from 2000-2003 (period 1) to 2004-2007 (period 2) (from 411 to 1474 cases per 100,000 HIV-infected patients; relative risk [RR], 3.6; P<.001), with cases in period 1 clustering in an area 6.3 km in diameter (P=.035) that overlapped high-risk zip codes. By period 2, CA-MRSA SSTIs among HIV-infected patients were spread throughout Cook County. USA300 was identified as the predominant strain by pulsed-field gel electrophoresis (accounting for 86% of isolates). Among hospitalized HIV-infected patients, the incidence of CA-MRSA increased significantly from period 1 to period 2 (from 190 to 779 cases per 100,000 HIV-infected patients; RR, 4.1; P<.001). Risks for CA-MRSA by multivariate analysis were residence in alternative housing (eg, shelters), residence in high-risk zip codes, younger age, and infection in period 2. HIV-infected patients are at markedly increased risk for CA-MRSA infection. This risk may be amplified by overlapping community networks of high-risk patients that may be targets for prevention efforts.

Characteristics of Typhoid Fever in Children and Adolescents in a Major Metropolitan Area in the United States

To examine the epidemiology of typhoid fever in children in an area that was not endemic, we analyzed 55 cases of typhoid fever in children and adolescents who were < or = 18 years and whose cases were reported to the Chicago and suburban Cook County Health Departments over 7 years. Cases had positive blood and/or stool cultures for Salmonella typhi. The ethnic distribution of the patients was as follows: 25% Asian, 22% Hispanic, 15% African American, 9% Caucasian, 18% other, and 11% unknown. Of the 55 cases, 35% were aged 0-5 years, 25% were aged 6-10 years, 31% were aged 11-15 years, and 9% were aged 16-18 years. Twelve patients did not have a history of travel. All patients recovered; none became carriers. Symptoms in 41 patients whose charts were available for review included fever (100%), diarrhea (77%), vomiting (50%), and dehydration (30%). Bacteremia was documented in 27 (66%) of 41 cases. In 17 of 41 cases, the household contacts were food handlers or health care workers. Eight (31%) of 26 isolates were resistant to both ampicillin and trimethoprim-sulfamethoxazole. The findings in our study were as follows: typhoid fever occurred frequently in children aged 0-5 years (in contrast with reports from areas of endemicity), approximately 20% of patients did not have a history of travel, and multidrug-resistant strains were prevalent.

Cook County health care facilities and the state health department.

Cook County health care facilities and the state health department. F D Yoder, and S ReedCopyRight https://doi.org/10.2105/AJPH.60.9.1706 Published Online: August 29, 2011

United States Public Health Service: The Chicago - Cook County Health Survey

United States Public Health Service: The Chicago - Cook County Health Survey Roscoe P. Kandle CopyRight https://doi.org/10.2105/AJPH.40.4.487-a Published Online: August 29, 2011