Outcomes of community-based hepatitis C treatment by general practitioners and nurses in Australia through remote specialist consultation.

BACKGROUND: A unique model of care was adopted in Australia following introduction of universal subsidised direct-acting antiviral (DAA) access in 2016 in order to encourage rapid scale-up of treatment. Community-based medical practitioners and integrated hepatitis nurses initiated DAA treatment with remote hepatitis specialist approval of the planned treatment without physical review. AIMS: To evaluate outcomes of community-based treatment of hepatitis C virus (HCV) through this remote consultation process in the first 12 months of this model of care. METHODS: A retrospective chart review of patients undergoing community-based HCV treatment from general practitioners and integrated hepatitis nurse consultants through the remote consultation model in three state jurisdictions in Australia from 1 March 2016 to 28 February 2017. RESULTS: Sustained virological response at 12 weeks (SVR12) was confirmed in 383 (65.1%) of 588 subjects intended for treatment with a median follow-up time of 12 months (interquartile range 9-14 months). The SVR12 test was not performed in 159 (27.0%) of 588 and 307 (52.2%) of 588 did not have liver biochemistry rechecked following treatment. Subjects who completed follow up exhibited high SVR12 rates (383/392; 97.7%). Nurse-led treatment was associated with higher confirmation of SVR12 (73.7% vs 62.4%; P = 0.01) and liver biochemistry testing post treatment (57.5% vs 45.0%; P = 0.01). CONCLUSIONS: Community-based management of HCV through remote specialist consultation may be an effective model of care. Failure to check SVR12, recheck liver biochemistry and appropriate surveillance in patients with cirrhosis may emerge as significant issues requiring further support, education and refinement of the model to maximise effectiveness of future elimination efforts.

Using telehealth to improve access to hepatitis C treatment in the direct-acting antiviral therapy era.

Introduction: One-third of the Australian population lives outside major cities and this group has worse health outcomes. Telehealth is becoming an accepted way to improve patient access to specialist healthcare. Over 200,000 Australian's have hepatitis C virus (HCV) and new treatments are very effective and well tolerated. We aim to demonstrate that HCV treatment utilising telehealth support for care delivery has cure rates similar to onsite care in clinical trials. We also report length of consultation and calculate reductions in travel and carbon output. Methods: Patient demographic, clinical, and treatment outcome data were collected prospectively from hospital software and analysed retrospectively. This was an audit of all patients treated for HCV in one year from a single tertiary hospital that included telehealth in their care delivery. Results: Sustained virological response was achieved in 51/52 (98%) patients with completed treatment courses, and 51/58 (88%) of those who had a planned telehealth consultation as part of their management. A median of 634 km of patient travel was saved per telehealth consultation. Discussion: We found that a telehealth-supported outreach programme for patients in regional Australia with HCV produced similar outcomes to clinical trials. There was a considerable saving in time and cost for the patients and significant environmental benefit through the reduction in carbon footprint associated with travel to distant specialist health services. We conclude that telehealth facilitated outreach is a feasible and effective way to access HCV treatment and cure in regional Australia.

Laparoscopic subtotal hysterectomy in a case of uterine didelphys.

INTRODUCTION: Major congenital uterine anomalies present a management dilemma in women who are symptomatic and not responsive to medical therapy. This case report discusses the role of laparoscopic subtotal hysterectomy in a woman with uterine didelphys, who presented with a long-standing history of menorrhagia, which had not responded to medical treatment. MATERIALS AND METHODS: This case report represents the role of laparoscopic subtotal hysterectomy in a woman with uterine didelphys, who presented with a long-standing history of menorrhagia, which had not responded to medical treatment with tranexamic acid and mefenamic acid, or cyclical norethisterone. Transvaginal ultrasound examination, performed as part of the routine investigation into the cause of her symptoms, was suggestive of a congenital uterine anomaly. Uterine didelphys was the suspected classification, and at the time of hysteroscopic examination, a double cervix with two separate uterine corpora was noted. An intravenous uretero-pyelogram confirmed an anatomically normal urinary tract. In view of the diagnosis and severity of symptoms, neither the Mirena intrauterine system, nor endometrial ablative techniques were considered appropriate treatments. Surgical options, including hysterectomy by the abdominal and laparoscopic routes, were discussed. She was counselled as to the potential difficulty of laparoscopic surgery, but she elected to proceed to laparoscopic subtotal hysterectomy. The procedure was performed as a Day-case and went uneventfully. CONCLUSION: Day-case laparoscopic subtotal hysterectomy may be considered as a potential treatment option in symptomatic women with major congenital uterine anomaly, in whom fertility potential is no longer an issue. Accurate pre-operative assessment of the upper urinary tract is considered essential.

Delivery of a baby with severe combined immunodeficiency at 31 weeks gestation following an extreme preterm prelabour spontaneous rupture of the membranes: a case report.

INTRODUCTION: If left untreated, severe combined immunodeficiency can lead to an acute susceptibility to infection. The intrauterine environment is sterile until the amniotic membranes rupture. The vaginal flora then ascends into the genital tract, thus increasing the risk of chorioamnionitis. An extremely premature and prolonged membrane rupture is associated with a dismal prognosis for an immunocompetent preterm fetus. There are no case reports to date that detail the outcome of an immunocompromised preterm baby following prolonged rupture of membranes. CASE PRESENTATION: We present the case of a 32-year-old Indian woman who delivered a 31-week gestational baby who had a severe combined immunodeficiency following premature prelabour prolonged rupture of the membranes at the 14(th )week of gestation. CONCLUSION: Extreme preterm prelabour spontaneous rupture of membranes in an underlying condition of severe combined immunodeficiency does not necessarily lead to an unfavourable outcome.