Integration of a recent infection testing algorithm into HIV surveillance in Ireland: improving HIV knowledge to target prevention.

Recent infection testing algorithms (RITA) for HIV combine serological assays with epidemiological data to determine likely recent infections, indicators of ongoing transmission. In 2016, we integrated RITA into national HIV surveillance in Ireland to better inform HIV prevention interventions. We determined the avidity index (AI) of new HIV diagnoses and linked the results with data captured in the national infectious disease reporting system. RITA classified a diagnosis as recent based on an AI < 1.5, unless epidemiological criteria (CD4 count <200 cells/mm3; viral load <400 copies/ml; the presence of AIDS-defining illness; prior antiretroviral therapy use) indicated a potential false-recent result. Of 508 diagnoses in 2016, we linked 448 (88.1%) to an avidity test result. RITA classified 12.5% of diagnoses as recent, with the highest proportion (26.3%) amongst people who inject drugs. On multivariable logistic regression recent infection was more likely with a concurrent sexually transmitted infection (aOR 2.59; 95% CI 1.04-6.45). Data were incomplete for at least one RITA criterion in 48% of cases. The study demonstrated the feasibility of integrating RITA into routine surveillance and showed some ongoing HIV transmission. To improve the interpretation of RITA, further efforts are required to improve completeness of the required epidemiological data.

Inequalities in HIV testing uptake and needs among men who have sex with men living in Ireland: findings from an internet survey.

OBJECTIVES: HIV disproportionately affects men who have sex with men (MSM) in Ireland. The aim of this study was to improve understanding of HIV testing among MSM living in Ireland to inform prevention and testing initiatives. METHODS: We used data from the MSM Internet Survey Ireland 2015 (MISI 2015), a cross-sectional survey of MSM living in Ireland. We identified factors associated with never having tested for HIV using univariable and multivariable logistic regression. We identified preferred sites for future tests and examined the relationships between unmet HIV testing needs and socio-demographic groups. RESULTS: More than one-third (n = 1006; 36%) of MSM had never tested for HIV. Multivariable logistic regression showed that untested men were more likely to be aged 18-24 years, live outside Dublin, have a lower level of education, be born in Ireland, identify as bisexual, be out to fewer people, and not have had sex with a man in the previous 12 months. The same groups of men also had the least knowledge about HIV and were least confident in accessing an HIV test. Men who had never tested for HIV were more likely to prefer testing by their general practitioner (GP) or using home sampling HIV kits and less likely to prefer testing in a sexual health clinic. CONCLUSIONS: HIV prevention and testing programmes for MSM should be targeted towards younger men, those living outside Dublin and those with lower levels of education. We recommend increased promotion and availability of free HIV testing services in a range of clinical and nonclinical settings (including self-sampling and home testing).

Broadband Direct UVA irradiance measurement for clear skies evaluated using a smartphone.

UVA wavelengths (320-400 nm) have been implicated in recent studies to contribute to melanoma induction and skin photoaging in humans and damage to plants. The use of smartphones in UVA observations is a way to supplement measurements made by traditional radiometric and spectroradiometric technology. Although the smartphone image sensor is not capable of determining broadband UVA irradiances, these can be reconstructed from narrowband irradiances, which the smartphone, with narrowband and neutral density filters, can quantify with discrepancies not exceeding 5 %. Three models that reconstruct direct broadband clear sky UVA were developed from narrowband irradiances derived from smartphone image sensor pixel data with coefficients of determination of between 0.97 and 0.99. Reasonable accuracy and precision in determining the direct broadband UVA was maintained for observations made with solar zenith angles as high as 70°. The developed method has the potential to increase the uptake of the measurement of broadband UVA irradiances.

Measurements of occupational ultraviolet exposure and the implications of timetabled yard duty for school teachers in Queensland, Australia: preliminary results.

Simultaneous personal measurements of the occupational ultraviolet exposure weighted to the International Commission on Non-Ionising Radiation Protection hazard sensitivity spectrum (UVICNIRP) were made over a five week period (44 person-days) in the second half of the summer school term of 2012 in Queensland, Australia for individual high school teachers located at latitudes of 27.5°S and 23.5°S. These teachers were employed for the duration of the study in a predominately indoor classroom teaching role, excluding mandatory periods of lunch time yard duty and school sport supervisions. Data is presented from personal measurements made to the shirt collar using polyphenylene oxide (PPO) film UV dosimeters. UVICNIRP exposure data is presented for each week of the study period for the shirt collar measurement site and are further expressed relative to the measured ambient horizontal plane exposure. Personal exposures were correlated with time outdoors, showing a higher exposure trend on days when teachers were required to supervise outdoor areas for more than 2h per week (mean daily exposure: 168Jm(-2)UVICNIRP±5Jm(-2) (1σ)) compared to the study average (mean daily exposure: 115Jm(-2)UVICNIRP±91Jm(-2) (1σ)). Time spent in an open playground environment was found to be the most critical factor influencing the occupational UVICNIRP exposure. A linear model was developed showing a correlation (R(2)=0.77) between the time teachers spent on yard duty and UVICNIRP exposure, expressed relative to ambient. The research findings indicate a greater reduction in personal exposure can be achieved by timetabling for yard duty periods in playground areas which offer more shade from trees and surrounding buildings. All mean daily personal exposures measured at the shirt collar site were higher than the ICNIRP occupational daily exposure limit of 30Jm(-2) for outdoor workers.

Epidemiological findings and medical, legal, and public health challenges of an investigation of severe soft tissue infections and deaths among injecting drug users -- Ireland, 2000.

In May 2000, public health authorities in Dublin, Ireland, identified a cluster of unexplained severe illness among injecting drug users (IDUs). Similar clusters were also reported in Scotland and England. Concurrent investigations were undertaken to identify the aetiology and source of the illnesses. In Dublin, 22 IDUs were identified with injection-site inflammation resulting in hospitalization or death; eight (36%) died. Common clinical findings among patients with severe systemic symptoms included leukaemoid reaction and cardiogenic shock. Seventeen (77%) patients reported injecting heroin intramuscularly in the 2 weeks before illness. Of 11 patients with adequate specimens available for testing, two (18%) were positive by 16S rDNA PCR for Clostridium novyi. Clinical and laboratory findings suggested that histotoxic Clostridia caused a subset of infections in these related clusters. Empiric treatment for infections among IDUs was optimized for anaerobic organisms, and outreach led to increased enrolment in methadone treatment in Dublin. Many unique legal, medical, and public health challenges were encountered during the investigation of this outbreak.

Outcome of medical screening of Kosovan refugees in Ireland: 1999.

In March 1999 armed conflict broke out in Kosova and about 900,000 ethnic Albanians were displaced. We reviewed the health care offered to the 945 Kosovan refugees who arrived in Ireland in 1999, which included screening for tuberculosis (TB) and hepatitis B. On arrival in Ireland 540 refugees had already received oral polio vaccine (57%), 512 diphtheria, tetanus, and acellular pertussis or diphtheria and tetanus vaccine (54%), 310 BCG (33%), 207 measles, mumps, and rubella vaccine (22%) and 60 Haemophilus influenzae type b (6%). Twelve refugees were diagnosed with TB. Twenty-six refugees were HBsAg positive (3%) and 168 were anti-HBcAg positive (18%). Organised screening of Kosovan refugees on a voluntary basis (uptake > 95%) revealed low percentages who had been immunised and relatively high rates of TB and hepatitis B. The provision of optimum immunisation, screening, and treatment services to address these issues requires substantial staffing and financial resources.

A survey of Irish palliative care services.

There has been no national policy directing the development of palliative care services in Ireland. Over the last 25 years different palliative care services have been established around the country, due largely to a strong and concerted effort on the part of voluntary groups. A study was carried out to determine the structure and process of all adult palliative care services in Ireland, to determine, where possible, the costs of providing these services and to assess the need for palliative care services in Ireland. All adult palliative care services (24 home care services, three inpatient services and one acute hospital service) in existence at the end of 1993 were circulated and 26 returns received (response rate 93 per cent). Twenty-five counties were covered by palliative care services, serving approximately three-quarters of the national population. Less than 10 per cent of patients had non-cancer diagnoses. Wide variation in staffing levels, workload, travelling, assessment of need and finance arrangements was reported. There is a need for further debate on the breadth and scope of palliative care services that should ideally be provided in Ireland, and how they should be funded in the future.

The overnight dexamethasone test is the procedure of choice in screening for Cushing's syndrome.

This study was undertaken to examine the performance of the overnight dexamethasone test, i.e., plasma cortisol level at 8-9 AM following dexamethasone 1 mg by mouth at midnight, in screening for Cushing's syndrome. The participants included 19 patients with Cushing's syndrome (17 with Cushing's disease, 1 with adrenal carcinoma, and 1 with ectopic ACTH syndrome) and 96 patients in whom the possibility of Cushing's syndrome was raised but who did not have the disorder. Utilizing our original very conservative cutoff point of plasma 100 nmol/L (3.62 micrograms/dL) above which Cushing's syndrome was suspected, the sensitivity of the test was 100% but the false positive rate was an unsatisfactory 12.5%. However, the lowest plasma cortisol level achieved following the overnight dexamethasone test in patients with Cushing's syndrome was 259 nmol/L (9.39 micrograms/dL). A plasma cortisol cutoff point of 250 nmol/L (9.06 micrograms/dL) yielded no false negatives and the false positive rate fell to 6.25%. Using a cutoff point of 200 nmol/L (7.24 micrograms/dL) the false positive rate was 7.3%. These performance characteristics of the overnight dexamethasone test compare very favorably with the reported experience of all other screening procedures for Cushing's syndrome including the urinary free cortisol excretion rate and the 48 h dexamethasone test, while the overnight dexamethasone procedure is the simplest for both patients and medical personnel. Since it is possible that some very unusual patients may suppress to plasma cortisol levels lower than that seen in the present study, we now recommend the overnight dexamethasone test using a plasma cortisol cutoff point of 200 nmol/L as the procedure of choice when screening for patients with Cushing's syndrome.

TSH as an index of L-thyroxine replacement and suppression therapy.

When hypothalamic-pituitary function is normal, serum TSH levels measured by ultrasensitive assay yield bioassays of endogenous thyroid action and thus provide an ideal index of thyroid secretion and its relationship to fluctuating endogenous thyroid levels. It is theoretically possible that patients receiving exogenous L-thyroxine for primary hypothyroidism should have suppressed TSH levels if physiological needs are constantly met. To examine this possibility free thyroxine, FT4 and TSH were measured in 90 clinically euthyroid patients receiving treatment with L-thyroxine for primary hypothyroidism. TSH levels were normal in 44, suppressed in 16 and elevated in 30 patients. FT4 levels were normal in 68, elevated in 13 and suppressed in 9 patients. Normal TSH levels were associated with normal FT4 levels in 79.5% of patients, elevated FT4 levels in 13.6% and low FT4 in 6.8%. Suppressed TSH levels were associated with elevated FT4 levels in 37.5% of patients and normal FT4 levels in 62.5%. When FT4 levels were normal, however, TSH levels were normal in only 51.5% and abnormal in 48.5%. We also examined the possibility that FT4 levels may remain within normal range when TSH is suppressed during L-thyroxine treatment for goitre or cancer. FT4 and TSH were measured in 45 patients on L-thyroxine as TSH suppression treatment. TSH was suppressed in 23 patients (51.1%), normal in 20 (44.4%) and elevated in 2 (4.5%). When TSH was suppressed, FT4 was elevated in 30.4% but normal in 69.6% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Nelson's syndrome following partial pituitary microadenomectomy and pregnancy.

We report for the first time the development of Nelson's syndrome in a patient who had previously undergone unsuccessful pituitary microadenomectomy and subsequently bilateral adrenalectomy. The removal of a 3-mm portion of a microadenoma did not protect against the development of Nelson's syndrome within 3 years which was closely related to pregnancy, a previously noted association. This report suggests that the development of Nelson's syndrome depends not on the size of the initial pituitary tumour but rather on its individual potential for proliferating once free of the inhibitory effects of glucocorticoid excess.

Sex steroids, adiposity and smoking in the pathogenesis of idiopathic hirsutism and polycystic ovary syndrome.

Hyperestronemia may be central to the development of polycystic ovary syndrome. The present study was designed to examine whether increased availability of androstenedione or increased aromatase closely associated with adiposity, plays the dominant role in the development of hyperestronemia. We measured plasma androstenedione, estrone and the estrone/androstenedione ratio (an indirect index of peripheral aromatase activity), in 141 patients with idiopathic hirsutism and in 88 patients with polycystic ovary syndrome. Estrone levels were higher in polycystic ovary syndrome, 250.4 +/- 129 (mean +/- standard deviation) than in idiopathic hirsutism, 210.6 +/- 119 pmol/l, p less than 0.05. Plasma androstenedione levels were higher in polycystic ovary syndrome, 8.24 +/- 3.5, than in idiopathic hirsutism, 7.1 +/- 1.7 nmol/l, p less than 0.0025. However, the estrone/androstenedione ratio was similar in the two groups. In all patients who smoked, androstenedione was higher, 8.14 +/- 3.22 than in nonsmokers, 6.99 +/- 2.96 nmol/l, p less than 0.005. Smokers had a lower body mass index, 23.9 +/- 2.3, than non-smokers 25.6 +/- 4.8 kg/m2, p less than 0.025. However, estrone levels were similar in smokers and in non-smokers. These data indicate that elevated estrone is more closely related to increased availability of androstenedione than to increased aromatase activity. While cigarette smoking appears to increase androstenedione levels, it may inhibit aromatase activity either directly or indirectly because of an associated reduction in adiposity. However, since the relative frequency of polycystic ovary syndrome and idiopathic hirsutism was similar in smokers and non-smokers, smoking did not appear to reduce estrone bioactivity as had been claimed.