Validated methods for identifying tuberculosis patients in health administrative databases: systematic review.

BACKGROUND: An increasing number of studies are using health administrative databases for tuberculosis (TB) research. However, there are limitations to using such databases for identifying patients with TB. OBJECTIVE: To summarise validated methods for identifying TB in health administrative databases. METHODS: We conducted a systematic literature search in two databases (Ovid Medline and Embase, January 1980-January 2016). We limited the search to diagnostic accuracy studies assessing algorithms derived from drug prescription, International Classification of Diseases (ICD) diagnostic code and/or laboratory data for identifying patients with TB in health administrative databases. RESULTS: The search identified 2413 unique citations. Of the 40 full-text articles reviewed, we included 14 in our review. Algorithms and diagnostic accuracy outcomes to identify TB varied widely across studies, with positive predictive value ranging from 1.3% to 100% and sensitivity ranging from 20% to 100%. CONCLUSIONS: Diagnostic accuracy measures of algorithms using out-patient, in-patient and/or laboratory data to identify patients with TB in health administrative databases vary widely across studies. Use solely of ICD diagnostic codes to identify TB, particularly when using out-patient records, is likely to lead to incorrect estimates of case numbers, given the current limitations of ICD systems in coding TB.

[Furuncular myiasis caused by Dermatobia hominis. Fortuitous diagnosis on extemporaneous macroscopic analysis of an excised cutaneous nodule]. / Myiase furonculoïde à Dermatobia hominis: diagnostic fortuit sur la coupe macroscopique extemporanée d'un nodule cutané.

BACKGROUND: Furuncular myiasis is a parasitic disease caused by the development of human botfly larva in the skin. It affects people living in tropical countries and travelers returning from these countries and concerns a number of medical specialties. One form of treatment involves surgical extraction of the parasites. PATIENTS AND METHODS: We report the case of a 47-year-old man returning from Guyana presenting two furuncle-like nodules of the skin on the right buttock and on the right shoulder blade. Extemporaneous intraoperative macroscopic examination of the buttock nodule resulted in diagnosis of myiasis caused by the human botfly, Dermatobia hominis. DISCUSSION: The diagnosis of furuncular myiasis is made primarily on clinical grounds and should be suspected on observation of an abscess in subjects returning from a tropical region. It is consequently rare to find D. hominis in biopsy specimens. In the present case, macroscopic examination showed an extremely rare image of the edge of the intact larva in a longitudinal cut, which to our knowledge has never been published to date.

Risk factors for susceptibility to varicella in newly arrived adult migrants in Canada.

Varicella occurs at an older age in tropical compared to cold climates. Migrants from tropical countries provide the opportunity to gain insights into observed global differences in varicella epidemiology. Severity of varicella increases with age thus, description of risk factors for varicella susceptibility will identify those who would benefit most from vaccination. A total of 1480 migrants, with a mean age of 32 years, were recruited in the pre-vaccination period (2002-2004) in Montreal, Canada. A questionnaire was administered and serum varicella antibodies were measured. Overall 6% were susceptible and ranged from 0·8% to 14·1% in subgroups. Risk factors for susceptibility were younger age, recent arrival, and originating from a tropical country. This could be modified by conditions that increased the probability of person-to-person spread of varicella through direct contact in source countries such as larger community size or household crowding. Many new young adult migrants would benefit from targeted varicella vaccination programmes.

A cross-sectional study of risk factors for HIV among pregnant women in Guatemala City, Guatemala: lessons for prevention.

Although the Central American HIV epidemic is concentrated in high-risk groups, HIV incidence is increasing in young women. From 2005 to 2007, we conducted a cross-sectional study of pregnant women in a large public hospital and an HIV clinic in Guatemala City to describe risk factors for HIV infection and inform prevention strategies. For 4629 consenting patients, HIV status was laboratory-confirmed and participant characteristics were assessed by interviewer-administered questionnaires. Lifetime number of sexual partners ranged from 1 to 99, with a median (interquartile range) of 1 (1, 2). 2.6% (120) reported exchanging sex for benefits; 0.1% (3) were sex workers, 2.3% (106) had used illegal drugs, 31.1% (1421) planned their pregnancy and 31.8% (1455) experienced abuse. In logistic regression analyses, HIV status was predicted by one variable describing women's behaviour (lifetime sexual partners) and three variables describing partner risks (partner HIV+, migrant worker or suspected unfaithful). Women in our sample exhibited few behavioural risks for HIV but significant vulnerability via partner behaviours. To stem feminization of the epidemic, health authorities should complement existing prevention interventions in high-risk populations with directed efforts towards bridging populations such as migrant workers. We identify four locally adapted HIV prevention strategies.

Estimating the prevalence of polymyositis and dermatomyositis from administrative data: age, sex and regional differences.

OBJECTIVE: To estimate the prevalence of polymyositis and dermatomyositis using population-based administrative data, the sensitivity of case ascertainment approaches and patient demographics and these parameters. METHODS: Cases were ascertained from Quebec physician billing and hospitalisation databases (approximately 7.5 million beneficiaries). Three different case definition algorithms were compared, and statistical methods were also used that account for imperfect case ascertainment, to generate estimates of disease prevalence and case ascertainment sensitivity. A hierarchical Bayesian latent class regression model was developed to assess patient characteristics with respect to these parameter estimates. RESULTS: Using methods that account for the imperfect nature of both billing and hospitalisation databases, the 2003 prevalence of polymyositis and dermatomyositis was estimated to be 21.5/100,000 (95% credible interval (CrI) 19.4 to 23.9). Prevalence was higher for women and for older individuals, with a tendency for higher prevalence in urban areas. Prevalence estimates were lowest in young rural men (2.7/100,000, 95% CrI 1.6 to 4.1) and highest in older urban women (70/100,000, 95% CrI 61.3 to 79.3). Sensitivity of case ascertainment tended to be lower for older versus younger individuals, particularly for rheumatology billing data. Billing data appeared more sensitive in ascertaining cases in urban (vs rural) regions, whereas hospitalisation data seemed most useful in rural areas. CONCLUSIONS: Marked variations were found in the prevalence of polymyositis and dermatomyositis according to age, sex and region. These methods allow adjustment for the imperfect nature of multiple data sources and estimation of the sensitivity of different case ascertainment approaches.

Risk of hepatitis C virus transmission through drug preparation equipment: a systematic and methodological review.

The use of blood-contaminated drug preparation equipment is believed to be associated with the transmission of hepatitis C virus (HCV) among injection drug users (IDUs), but the extent of HCV infection risk is unclear. The objective of this review was to appraise the evidence regarding HCV incidence associated with the use of drug preparation equipment such as drug mixing containers, filters and water. In June 2007, cohort and case-control studies examining the association of HCV incidence with the sharing of drug preparation equipment were identified by searching electronic reference databases as well as the reference lists of published papers. Ten studies (seven cohort and three nested case-control) met the inclusion criteria for the review. The relative risk of HCV infection associated with drug preparation equipment were mainly between 2.0 and 5.9; however, the precision of the estimates from individual studies were marked by wide confidence intervals. Few studies exist to allow an adequate assessment of the individual contributions of containers, filters and water to HCV incidence. The major methodological limitations of reviewed studies were short follow-up times, inadequate control of confounders and lack of exclusion of periods when IDUs were not at risk for HCV infection through drug injection. Current evidence implicating the association of drug preparation equipment with HCV incidence is limited by several methodological concerns.

Antidepressants and risk of prostate cancer: a nested case-control study.

Although the association between antidepressant drug use and risk of cancer has received considerable attention in the past years, no work has been done specifically on prostate cancer. We carried out a population-based case-control study to assess the risk of prostate cancer in association with exposure to tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). 7767 prostate cancer cases diagnosed between 1981 and 2000 were accrued through the Saskatchewan Cancer Agency. Saskatchewan Health identified a total of 31,068 male controls who were matched on age and calendar time. Data on exposure to TCAs and SSRIs were compiled from the Saskatchewan outpatient prescription drug database, and covered a period upto 24 years. A positive significant association was found between TCA use and risk of prostate cancer, when exposure took place 2-5 years before diagnosis, with rate ratios of 1.31, 1.58, and 2.42 at the low, medium and high average daily dose levels, respectively. Exposure to SSRIs was not found to be significantly associated with the risk of prostate cancer. TCA use 2-5 years in the past was associated with a small dose-dependent increase in the risk of prostate cancer. Nevertheless, detection bias could have contributed to the observed association.

The relationship between cancer and medication exposures in systemic lupus erythaematosus: a case-cohort study.

OBJECTIVE: To examine if, in systemic lupus erythaematosus (SLE), exposure to immunosuppressive therapy (cyclophosphamide, azathioprine, methotrexate) increases cancer risk. METHODS: A case-cohort study was performed within a multi-site international SLE cohort; subjects were linked to regional tumour registries to determine cancer cases occurring after entry into the cohort. We calculated the hazard ratio (HR) for cancer after exposure to an immunosuppressive drug, in models that controlled for other medications (anti-malarial drugs, systemic glucocorticoids, non-steroidal anti-inflammatory drugs (NSAIDs), aspirin), smoking, age, sex, race/ethnicity, geographic location, calendar year, SLE duration, and lupus damage scores. In the primary analyses, exposures were treated categorically (ever/never) and as time-dependent. RESULTS: Results are presented from 246 cancer cases and 538 controls without cancer. The adjusted HR for overall cancer risk after any immunosuppressive drug was 0.82 (95% CI 0.50-1.36). Age > or = 65, and the presence of non-malignancy damage were associated with overall cancer risk. For lung cancer (n = 35 cases), smoking was also a prominent risk factor. When looking at haematological cancers specifically (n = 46 cases), there was a suggestion of an increased risk after immunosuppressive drug exposures, particularly when these were lagged by a period of 5 years (adjusted HR 2.29, 95% CI 1.02-5.15). CONCLUSIONS: In our SLE sample, age > or = 65, damage, and tobacco exposure were associated with cancer risk. Though immunosuppressive therapy may not be the principal driving factor for overall cancer risk, it may contribute to an increased risk of haematological malignancies. Future studies are in progress to evaluate independent influence of medication exposures and disease activity on risk of malignancy.

Lung cancer in systemic lupus erythematosus.

BACKGROUND: Evidence points to a link between systemic lupus erythematosus (SLE) and an increased risk of lung cancer. Our objective was to provide a brief report of the lung cancer cases from an SLE cohort, with respect to demographics, histology, and exposures to smoking and immunosuppressive medications. METHODS: Data were obtained from a multi-site international cohort study of over 9500 SLE patients from 23 centres. Cancer cases were ascertained through linkage with regional tumor registries. RESULTS: We analyzed information on histology subtype for 30 lung cancer cases that had occurred across five countries. Most (75%) of these 30 cases were female, with a median age of 61 (range 27-91) years. In eight cases, the histological type was not specified. In the remainder, the most common histological type reported was adenocarcinoma (N=8; two of the adenocarcinomas were bronchoalveolar carcinoma) followed by small cell carcinoma (N=6), and squamous cell carcinoma (N=6) with one case each of large cell carcinoma and carcinoid tumor. Most (71%) of the lung cancer cases were smokers; only the minority (20%) had been previously exposed to immunosuppressive agents. CONCLUSIONS: The histological distribution of the lung cancers from the SLE sample appeared similar to that of lung cancer patients in the general population, though the possibility of a higher proportion of more uncommon tumors (such as bronchoalveolar and carcinoid) cannot be excluded. A large proportion of the cancer cases were smokers, which is also not surprising. However, only a minority appeared to have been exposed to immunosuppressive agents. A large case-cohort study currently in progress should help shed light on the relative importance of these exposures in lung cancer risk for SLE patients.

The safety of endoscopic sphincterotomy in patients receiving antiplatelet agents: a case-control study.

OBJECTIVE: To determine whether antiplatelet agents are associated with endoscopic sphincterotomy-related haemorrhage as few well-controlled data exist on this controversial issue. METHODS: A case-control study in a tertiary care setting included cases with bleeding following endoscopic sphincterotomy, matched with 2-3 controls selected according to age +/- 15 years, sex, and procedural date+/- 2 years. Cases and controls were compared for possible risk factors of postendoscopic sphincterotomy bleeding (presence of a coagulopathy and cholangitis). The main outcome measurement was the association between the use of antiplatelet medications and postendoscopic sphincterotomy bleeding after adjustment for possible confounding. RESULTS: The 40 cases [mean age 68 +/- 17 (s.d.) years, 50% female] and 86 controls [68 +/- 16 years, 50% female] were comparable except for differences noted in International Normalized Ratio (INR) (>2 in four cases vs. two controls), and pre-endoscopic sphincterotomy cholangitis (45% vs. 20%). Amongst cases, 13% were on aspirin and 3% on clopidogrel; 17% of controls took aspirin, and 4% a non-steroidal anti-inflammatory drug. 53% of cases bled immediately; the remainder haemorrhaged at 2 +/- 3 days. After adjustment for an elevated INR and cholangitis, exposure to antiplatelet agents was not significantly associated with procedure-related bleeding (odds ratio = 0.41, 95% CI [ 0.13; 1.31]). CONCLUSION: This case-control study provides controlled data suggesting that antiplatelet agents do not significantly increase the risk of clinically-important bleeding related to endoscopic sphincterotomy. The low prevalences of non-steroidal anti-inflammatory drugs and clopidogrel use limit any definite conclusion on their elective use before endoscopic sphincterotomy.

Hodgkin's lymphoma in systemic lupus erythematosus.

OBJECTIVE: In systemic lupus erythematosus (SLE), there is a well-documented increased risk of non-Hodgkin's lymphoma (NHL), but little is known about the risk of Hodgkin's lymphoma (HL). The purpose of our work was to describe the phenomenon of HL in SLE. METHODS: A multi-site cohort of 9547 SLE subjects was assembled; HL cases were ascertained through cancer registry linkage, and the standardized incidence ratio (SIR) for HL was determined. We also performed a literature search for HL cases in SLE, and compared these with our sample. Finally, we pooled results from our cohort study with two large population-based cohort studies providing SIR estimates for HL in SLE. RESULTS: Five cases of HL occurred in our SLE cohort during the observation interval, for an SIR of 2.4 (95% CI 0.8, 5.5). The literature review documented 13 HL case reports developing in patients with SLE. A pooled analysis combining our data with the other large cohort studies yielded a standardized incidence ratio of 3.16 (95% CI, 1.63-5.51) for HL in SLE. CONCLUSIONS: Data suggest that risk in SLE is increased not only for NHL, but also for other malignancies arising from B-lymphocytes, including HL.

Mortality in systemic lupus erythematosus.

OBJECTIVE: To examine mortality rates in the largest systemic lupus erythematosus (SLE) cohort ever assembled. METHODS: Our sample was a multisite international SLE cohort (23 centers, 9,547 patients). Deaths were ascertained by vital statistics registry linkage. Standardized mortality ratio (SMR; ratio of deaths observed to deaths expected) estimates were calculated for all deaths and by cause. The effects of sex, age, SLE duration, race, and calendar-year periods were determined. RESULTS: The overall SMR was 2.4 (95% confidence interval 2.3-2.5). Particularly high mortality was seen for circulatory disease, infections, renal disease, non-Hodgkin's lymphoma, and lung cancer. The highest SMR estimates were seen in patient groups characterized by female sex, younger age, SLE duration <1 year, or black/African American race. There was a dramatic decrease in total SMR estimates across calendar-year periods, which was demonstrable for specific causes including death due to infections and death due to renal disorders. However, the SMR due to circulatory diseases tended to increase slightly from the 1970s to the year 2001. CONCLUSION: Our data from a very large multicenter international cohort emphasize what has been demonstrated previously in smaller samples. These results highlight the increased mortality rate in SLE patients compared with the general population, and they suggest particular risk associated with female sex, younger age, shorter SLE duration, and black/African American race. The risk for certain types of deaths, primarily related to lupus activity (such as renal disease), has decreased over time, while the risk for deaths due to circulatory disease does not appear to have diminished.

Non-Hodgkin's lymphoma in systemic lupus erythematosus.

BACKGROUND: Recent evidence supports an association between systemic lupus erythematosus (SLE) and non-Hodgkin's lymphoma (NHL). OBJECTIVES: To describe demographic factors, subtypes, and survival of patients with SLE who develop NHL. METHODS: A multi-site cohort of 9547 subjects with definite SLE was assembled. Subjects at each centre were linked to regional tumour registries to determine cancer cases occurring after SLE diagnosis. For the NHL cases ascertained, descriptive statistics were calculated, and NHL subtype frequency and median survival time of patients determined. RESULTS: 42 cases of NHL occurred in the patients with SLE during the 76,948 patient-years of observation. The median age of patients at NHL diagnosis was 57 years. Thirty six (86%) of the 42 patients developing NHL were women, reflecting the female predominance of the cohort. In the patients, aggressive histological subtypes appeared to predominate, with the most commonly identified NHL subtype being diffuse large B cell (11 out of 21 cases for which histological subtype was available). Twenty two of the patients had died a median of 1.2 years after lymphoma diagnosis. CONCLUSIONS: These data suggest aggressive disease in patients with SLE who develop NHL. Continuing work should provide further insight into the patterns of presentation, prognosis, and aetiology of NHL in SLE.

An international cohort study of cancer in systemic lupus erythematosus.

OBJECTIVE: There is increasing evidence in support of an association between systemic lupus erythematosus (SLE) and malignancy, but in earlier studies the association could not be quantified precisely. The present study was undertaken to ascertain the incidence of cancer in SLE patients, compared with that in the general population. METHODS: We assembled a multisite (23 centers) international cohort of patients diagnosed as having SLE. Patients at each center were linked to regional tumor registries to determine cancer occurrence. Standardized incidence ratios (SIRs) were calculated as the ratio of observed to expected cancers. Cancers expected were determined by multiplying person-years in the cohort by the geographically matched age, sex, and calendar year-specific cancer rates, and summing over all person-years. RESULTS: The 9,547 patients from 23 centers were observed for a total of 76,948 patient-years, with an average followup of 8 years. Within the observation interval, 431 cancers occurred. The data confirmed an increased risk of cancer among patients with SLE. For all cancers combined, the SIR estimate was 1.15 (95% confidence interval [95% CI] 1.05-1.27), for all hematologic malignancies, it was 2.75 (95% CI 2.13-3.49), and for non-Hodgkin's lymphoma, it was 3.64 (95% CI 2.63-4.93). The data also suggested an increased risk of lung cancer (SIR 1.37; 95% CI 1.05-1.76), and hepatobiliary cancer (SIR 2.60; 95% CI 1.25, 4.78). CONCLUSION: These results support the notion of an association between SLE and cancer and more precisely define the risk of non-Hodgkin's lymphoma in SLE. It is not yet known whether this association is mediated by genetic factors or exogenous exposures.

HIV risk profile of male street youth involved in survival sex.

OBJECTIVES: To compare HIV risk factors of male street youth involved in survival sex with those of their never involved peers and to describe the sexual activities of the involved youths. METHODS: From 2001 to 2003, street youth aged 14-23 years were recruited from street youth agencies in Montreal, Canada. Information was collected on sociodemographic characteristics, substance use, and sexual behaviours. Involvement in survival sex was defined as having ever exchanged sex for money, gifts, drugs, shelter, or other needs. Logistic regression was used to identify HIV risk factors associated with involvement in survival sex. RESULTS: Among the 542 male participants recruited, 27.7% reported involvement in survival sex. HIV risk factors independently associated with such involvement were injection drug using partners (modulated by length of homelessness), unprotected oral sex with male partners, steroid injection, history of sexual abuse, and drug injection. Among involved youths, 32.0% had only female clients, 41.3% only male clients, and 26.7% had clients of both sexes. Unprotected sexual activities were common with clients. However, even more risks were taken with non-commercial sexual partners. CONCLUSIONS: Male street youth involved in survival sex are at higher risk for HIV than their non-involved peers not only because of their unprotected commercial sexual activities. They have multiple other HIV risks related to non-commercial sexual activities, drug injection, and sexual abuse. All these risks need to be addressed when providing sexual health interventions for this population.

Characteristics of adolescent street youth with a history of pregnancy.

UNLABELLED: This study examines characteristics of adolescent street youth with histories of pregnancy and documents important factors that merit consideration when providing global sexual health care. STUDY OBJECTIVE: To determine social and behavioral factors associated with a history of pregnancy among adolescent street youth. DESIGN, SETTING, PARTICIPANTS: In a prospective cohort study, female adolescent street youth (14-19 years) ever pregnant (AEP) were compared with adolescents never pregnant (ANP) using data from baseline questionnaires. RESULTS: Among the 225 participants, 41.8% were ever pregnant. Both groups were similar with respect to age (mean 17.8 years) and other socio-economic characteristics. However, AEP were more likely to have been kicked out of home (62.8% vs. 47.3%, P=0.022) and to have run away (78.7% vs. 64.9%, P=0.025) and were homeless younger (mean age: 13.9 vs. 14.7 years, P=0.011) and since a longer period (mean: 4.0 vs. 3.0 years, P=0.001). Both groups had problematic alcohol and drug use: 31.3% had a CAGE score >2; 72.2% had a DAST score >6. Almost half (44.0%) had ever injected drugs and AEP were younger at initiation into drug injection (15.2 years vs. 16.0 years, P=0.049). More AEP had experienced intra-familial or extra-familial sexual abuse (71.3% vs. 56.5%, P=0.024), and had had more than one abuser (71.6% vs. 50.0%, P=0.009). Among those abused by family members, abuse occurred at an earlier age for AEP (mean age: 7.4 vs. 8.9 years, P=0.090) and more AEP reported severe abuse: vaginal penetration (62.2% vs. 26.7%, P=0.004) and anal penetration (29.7% vs. 3.3%, P=0.005). CONCLUSIONS: Histories of severe sexual abuse and early injection drug use are extremely frequent in ever pregnant street adolescents. These factors need to be addressed when planning global health care and sexual health education.