Impact of 5 years of hepatitis C testing and treatment in the North East of England prisons.

Hepatitis C virus infection (HCV) is prevalent in prisons. Therefore, effective prison HCV services are critical for HCV elimination programmes. We aimed to evaluate the efficacy of a regional HCV prison testing and treatment programme. Between July 2017 and June 2022, data were collected prospectively on HCV test offer and uptake rates, HCV Antibody (HCV-Ab) and HCV-RNA positivity, treatment starts and outcomes for new inmates incarcerated in three prisons. Rates of HCV-Ab and RNA positivity at reception, incidence of new HCV infections and reinfection following treatment were determined. From a total of 39,652 receptions, 33,028 (83.3%) were offered HCV testing and 20,394 (61.7%) completed testing. Including all receptions, 24.5% of tests (n = 4995) were HCV-Ab positive and 8.4% of tests (n = 1713) were HCV-RNA positive. When considering the first test for each individual (median age 34 years; 88.1% male), 14.8% (n = 1869) and 7.2% (n = 905) were HCV-Ab and HCV-RNA positive, respectively. The incidence of new HCV-Ab and RNA positivity was 5.1 and 3.3 per 100 person-years, respectively. Of 1145 HCV viraemic individuals, 18 died within 6 months and 150 were rapidly transferred out of area, leaving 977 individuals with outcomes. Of these, 835 (85.5%) received antivirals and 47 spontaneously cleared the infection, leaving 95 (9.7%) untreated. 607 (72.7%) achieved SVR. 95 patients had reinfection post-treatment (rate 10.1 cases per 100 person-years). Testing for HCV has increased in our prisons and the majority with viraemia are initiated on antiviral treatment. Reassuringly, a significant fall in frequency of HCV-RNA positivity at prison reception was observed suggesting progress towards HCV elimination.

Determining the role of natural SARS-CoV-2 infection in the death of domestic pets: 10 cases (2020-2021).

OBJECTIVE: To establish a pathoepidemiological model to evaluate the role of SARS-CoV-2 infection in the first 10 companion animals that died while infected with SARS-CoV-2 in the US. ANIMALS: 10 cats and dogs that tested positive for SARS-CoV-2 and died or were euthanized in the US between March 2020 and January 2021. PROCEDURES: A standardized algorithm was developed to direct case investigations, determine the necessity of certain diagnostic procedures, and evaluate the role, if any, that SARS-CoV-2 infection played in the animals' course of disease and death. Using clinical and diagnostic information collected by state animal health officials, state public health veterinarians, and other state and local partners, this algorithm was applied to each animal case. RESULTS: SARS-CoV-2 was an incidental finding in 8 animals, was suspected to have contributed to the severity of clinical signs leading to euthanasia in 1 dog, and was the primary reason for death for 1 cat. CONCLUSIONS AND CLINICAL RELEVANCE: This report provides the global community with a standardized process for directing case investigations, determining the necessity of certain diagnostic procedures, and determining the clinical significance of SARS-CoV-2 infections in animals with fatal outcomes and provides evidence that SARS-CoV-2 can, in rare circumstances, cause or contribute to death in pets.

Low SARS-CoV-2 Seroprevalence and No Active Infections among Dogs and Cats in Animal Shelters with Laboratory-Confirmed COVID-19 Human Cases among Employees.

Human-to-animal and animal-to-animal transmission of SARS-CoV-2 has been documented; however, investigations into SARS-CoV-2 transmission in congregate animal settings are lacking. We investigated four animal shelters in the United States that had identified animals with exposure to shelter employees with laboratory-confirmed COVID-19. Of the 96 cats and dogs with specimens collected, only one dog had detectable SARS-CoV-2 neutralizing antibodies; no animal specimens had detectable viral RNA. These data indicate a low probability of human-to-animal transmission events in cats and dogs in shelter settings with early implementation of infection prevention interventions.

High rate of hepatitis C reinfection following antiviral treatment in the North East England Prisons.

To achieve elimination of hepatitis C (HCV), a critical group to prioritise for diagnosis and treatment is the prison population, where HCV prevalence is high. A universal offer of blood-borne virus testing (UOBBVT) programme and a new treatment pathway were introduced to seven North East England (NEE) Prisons. Our aim was to assess: (a) the proportion of individuals with active HCV commencing direct-acting antivirals (DAAs); (b) the outcomes following DAA treatment; (3) the reinfection rate following sustained virological response (SVR). Data were collected prospectively on BBVT uptake, HCV positivity, HCV treatment outcomes and reinfection from March 2016 onwards. 8538 individuals had BBV testing. In total, 612 (7.2%) and 374 (4.4%) were HCV antibody positive and HCV RNA positive, respectively. Ultimately, 266 (71%) individuals commenced DAAs. Overall 111 achieved a documented SVR (42%), 17 (6%) failed treatment, 30 (11%) were still on treatment or had not reached 12 weeks post-treatment at time of analysis, and 108 (41%) were lost to follow-up. In those with a known outcome (n = 128), 87% achieved SVR. Worryingly, of those who achieved SVR, 21 (19%) were subsequently identified as having been reinfected (median time from SVR to documented reinfection 13 (range 7-25) months). The reinfection rate was 0.406 cases per person-year follow-up. In conclusion, Implementation of a UOBBVT programme and new treatment pathway resulted in increased diagnosis and treatment of HCV in the NEE prison population. However, the high HCV reinfection rate suggests a need to improve harm reduction approaches.

Increased diagnosis and treatment of hepatitis C in prison by universal offer of testing and use of telemedicine.

With recent advances in antiviral therapy, there is an opportunity to eliminate hepatitis C virus (HCV) from the UK population. HCV is common in incarcerated individuals, with previous estimates suggesting ~7% of the UK prison population is anti-HCV antibody positive. Increasing diagnosis and treatment of HCV in prison is a priority in seeking to eliminate transmission in the general population. Thus the study aimed to assess the impact implementation of: (a) A universal offer of blood borne virus testing (UOBBVT) using dry blood spot testing for prisoners at reception to increase diagnosis; (b) Telemedicine clinics (TC) within North East England (NEE) prisons to increase HCV treatment rates. UOBBVT was initially implemented at Her Majesty's Prison (HMP) Durham, commencing March 2016. From March 2016 to February 2017, 2831 of 4280 (66%) new receptions were offered blood borne virus (BBV) testing. Of these, 1495 (53% of offered) accepted BBV testing, of whom 95 (6.4%) were HCV antibody positive, with 47 of those 95 (49.5%) HCV RNA positive, suggesting a prevalence of active infection in the tested population of 3.1% (95% CI 2.4%-4.2%). Between August 2015 and October 2017, 80 individuals were seen in the TC and 57 (71%) commenced antiviral therapy. Of those with known outcome (n = 29), 100% achieved sustained virological response. In the year prior to implementation, only four patients received HCV treatment. In conclusion, a universal offer of BBV testing to inmates presenting at HMP reception coupled with linkage into specialist care via TC can substantially increase rates of testing, diagnosis and treatment of HCV in this high-prevalence population.

The North Carolina State Health Plan for Teachers and State Employees: Strategies in Creating Financial Stability While Improving Member Health.

The North Carolina State Health Plan provides health care coverage to more than 700,000 members, including teachers, state employees, retirees, current and former lawmakers, state university and community college personnel, and their dependents. The State Health Plan is a division of the North Carolina Department of State Treasurer, self-insured, and exempt from the Employee Retirement Income Security Act as a government-sponsored plan. With health care costs rising at rates greater than funding, the Plan must take measures to stem cost growth while ensuring access to quality health care. The Plan anticipates focusing on strategic initiatives that drive results and cost savings while improving member health to protect the Plan's financial future.

North Carolina Medicaid Reform: Seizing Opportunities and Addressing Challenges.

North Carolina has made progress toward improving the health of its citizens, yet much more needs to be done. Now is the right time for the state to transform its Medicaid and North Carolina Health Choice programs into a managed care delivery system that gives providers more flexibility to deliver care that focuses on the whole person and benefits people's lives beyond the medical setting. The North Carolina Department of Health and Human Services is focused on maximizing opportunities and managing challenges, and the department understands that collaboration of health care professionals and other stakeholders is essential to achieve the right results for North Carolinians.

Book discussion course: timely topics for medical students.

Several library faculty members at the Louisiana State University Health Shreveport Health Sciences Library offered a book discussion course as an elective for first-year medical students. This article provides details on how the librarians developed, taught, and evaluated this elective. The librarians took a team-teaching approach, required the students to read two books, and outlined the criteria for participation. At the end of the course, the students completed an evaluation, commenting on positive and negative aspects of the course. The elective proved to be successful, and the librarians look forward to offering the course again in the spring of 2014.

Cardiac rehabilitation and mortality reduction after myocardial infarction: the emperor's new clothes? Evidence against cardiac rehabilitation.

No trial of cardiac rehabilitation (CR) following myocardial infarction (MI) (not even the WHO European collaborative) demonstrates significant reduction of mortality, as do trials of secondary prevention. There is potential conflict of interest when therapists report self-evaluations. Reviews of published reports exaggerate publication bias. Meta-analyses show no significant effect of CR on mortality in recent years - since 1990, 23 trials, 6527 patients, relative risk 1.01 (0.88-1.15). It does no service to MI patients - or rehabilitation therapists - to repeat claims derived from poolings of historic trials, undertaken before many significant advances in diagnosis, acute treatment and effective secondary prevention. While CR has a role in good medical/nursing practice and continuity of care, rehabilitation therapists could be more effective elsewhere in the NHS.

Combining history of medicine and library instruction: an innovative approach to teaching database searching to medical students.

Library faculty members at the Health Sciences Library at the LSU Health Shreveport campus offer a database searching class for third-year medical students during their surgery rotation. For a number of years, students completed "ten-minute clinical challenges," but the instructors decided to replace the clinical challenges with innovative exercises using The Edwin Smith Surgical Papyrus to emphasize concepts learned. The Surgical Papyrus is an online resource that is part of the National Library of Medicine's "Turning the Pages" digital initiative. In addition, vintage surgical instruments and historic books are displayed in the classroom to enhance the learning experience.

Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction.

BACKGROUND: It is widely believed that cardiac rehabilitation following acute myocardial infarction (MI) reduces mortality by approximately 20%. This belief is based on systematic reviews and meta-analyses of mostly small trials undertaken many years ago. Clinical management has been transformed in the past 30-40 years and the findings of historical trials may have little relevance now. OBJECTIVES: The principal objective was to determine the effect of cardiac rehabilitation, as currently provided, on mortality, morbidity and health-related quality of life in patients following MI. The secondary objectives included seeking programmes that may be more effective and characteristics of patients who may benefit more. DESIGN, SETTING, PATIENTS, OUTCOME MEASURES: A multi-centre randomised controlled trial in representative hospitals in England and Wales compared 1813 patients referred to comprehensive cardiac rehabilitation programmes or discharged to 'usual care' (without referral to rehabilitation). The primary outcome measure was all-cause mortality at 2 years. The secondary measures were morbidity, health service use, health-related quality of life, psychological general well-being and lifestyle cardiovascular risk factors at 1 year. Patient entry ran from 1997 to 2000, follow-up of secondary outcomes to 2001 and of vital status to 2006. A parallel study compared 331 patients in matched 'elective' rehabilitation and 'elective' usual care (without rehabilitation) hospitals. RESULTS: There were no significant differences between patients referred to rehabilitation and controls in mortality at 2 years (RR 0.98, 95% CI 0.74 to 1.30) or after 7-9 years (0.99, 95% CI 0.85 to 1.15), cardiac events, seven of eight domains of the health-related quality of life scale ('Short Form 36', SF36) or the psychological general well-being scale. Rehabilitation patients reported slightly less physical activity. No differences between groups were reported in perceived overall quality of cardiac aftercare. Data from the 'elective' hospitals comparison concurred with these findings. CONCLUSION: In this trial, comprehensive rehabilitation following MI had no important effect on mortality, cardiac or psychological morbidity, risk factors, health-related quality of life or activity. This finding is consistent with systematic reviews of all trials reported since 1983. The value of cardiac rehabilitation as practised in the UK is open to question.

The role of a mentoring group for family therapy trainees and therapists of color.

This article discusses the development, process, and impact of a mentoring group for family therapists of color. A within-group process for trainees of color in a predominantly White institution can provide a valuable resource for support, validation, empowerment, and collective action. The article examines how such mentoring promotes the effectiveness of therapists of color, as well as the practices and goals of social justice and diversity within training institutions and the field in general. Reflections and recommendations for implementing such a group are offered, as well as a personal narrative of a group member's experience of finding her voice in the group.

Prevalence of cognitive impairment: results from the MRC trial of assessment and management of older people in the community.

BACKGROUND: cognitive impairment is an important part of the diagnostic criteria for dementia. The Mini-Mental State Examination (MMSE) is recommended to test for cognitive impairment and to monitor medication response. OBJECTIVES: we examined the prevalence of cognitive impairment in the UK and assessed associations with cognitive impairment. DESIGN: cross-sectional survey as part of a cluster randomised trial. SUBJECTS: representative sample of people aged 75 years and over. METHODS: all subjects had a detailed baseline health assessment including the MMSE. RESULTS: a total of 15,051 subjects completed the assessment (71.9%). Almost two-thirds of subjects were female (61.5%) and almost half were aged between 75 and 79 years (47.0%). The prevalence of cognitive impairment was 18.3% (95% confidence intervals (CI) = 16.0-20.9) at a cut-off of 23/24, and 3.3% (95% CI = 2.8-4.0) at 17/18. Those with impairment (MMSE 23/24) were significantly more likely to have hearing (odds ratio (OR) 1.7), vision (OR 1.7) and urinary incontinence problems (OR 1.3), have two or more falls in the previous 6 months (OR 1.4), and report poorer health (OR 1.9). Almost half the participants lived alone (n = 7,073; 47.0%) and of these almost one-fifth were impaired (MMSE 23/24; 19.4%). CONCLUSIONS: there was a high prevalence of cognitive impairment. This representative sample demonstrates the potential burden of disease and service demands. It supports the need for a broader assessment of functioning as recommended by the National Service Framework for Older People, particularly in people with cognitive impairment.

Population-based multidimensional assessment of older people in UK general practice: a cluster-randomised factorial trial.

BACKGROUND: The benefit of multidimensional assessment and management of older people remains controversial. Most trials have been too small to produce adequate evidence to inform policy. We aimed to measure the effects of different approaches to assessment and management of older people. METHODS: We undertook a cluster-randomised factorial trial in 106 general practices (43219 eligible patients aged 75 years and older, 78% participation), comparing (1) universal versus targeted assessment and (2) subsequent management by hospital outpatient geriatric team versus the primary-care team. All participants received a brief multidimensional assessment followed by a nurse-led in-depth assessment in the universal group, whereas in the targeted group the in-depth assessment was offered only to those with problems established at the brief assessment. Referrals to the randomised team (geriatric management or primary care), other medical or social services, health-care workers, or agencies, and emergency referrals to the general practitioner were based on a standard protocol at the in-depth assessment. The primary endpoints were mortality, admissions to hospital and institution, and quality of life. Analysis was by intention to treat and per protocol. This trial has been assigned the International Standardised Randomised Controlled Trial Number ISRCTN23494848. FINDINGS: Mortality and hospital or institutional admissions did not differ between groups. During 3 years' follow-up, significant improvements in quality of life resulted from universal versus targeted assessment in terms of homecare, and from management by geriatric team versus primary-care team, in terms of mobility, social interaction, and morale. However, only the result for social interaction was consistent with a small but important effect. INTERPRETATION: The different forms of multidimensional assessment offered almost no differences in patient outcome.

Association of quality of life in old age in Britain with socioeconomic position: baseline data from a randomised controlled trial.

STUDY OBJECTIVE: To identify socioeconomic differentials in quality of life among older people and their explanatory factors. DESIGN: Baseline data from a cluster randomised controlled trial of the assessment and management of older people in primary care. Outcome measures were being in the worst quintile of scores for, respectively, the Philadelphia geriatric morale scale and four dimensions of functioning from the sickness impact profile (home management, mobility, self care, and social interaction). SETTING: 23 general practices in Britain. PARTICIPANTS: People aged 75 years and over on GP registers at the time of recruitment, excluding those in nursing homes or terminally ill. Of 9547 people eligible, 90% provided full information on quality of life and 6298 also did a brief assessment. RESULTS: The excess risk of poor quality of life for independent people renting rather than owning their home ranged from 27% for morale (95% CI 9% to 48%) to 62% for self care (95% CI 35% to 94%). Self reported health problems plus smoking and alcohol consumption accounted for half or more of the excess, depending on the outcome. Having a low socioeconomic position in middle age as well as in old age exacerbated the risks of poor outcomes. Among people living with someone other than spouse the excess risk from renting ranged from 24% (95% CI -10% to 70%) for poor home management to 93% (95% CI 30% to 180%) for poor morale. CONCLUSIONS: Older people retain the legacy of past socioeconomic position and are subject to current socioeconomic influences.

Factors associated with depression in a representative sample of 14 217 people aged 75 and over in the United Kingdom: results from the MRC trial of assessment and management of older people in the community.

BACKGROUND: Several social, demographic and physical factors have been shown to be associated with depression in later life, but results have been inconsistent. We aimed to assess factors associated with depression in old age, using data from the MRC trial of assessment and management of older people in the community. METHOD: Analysis of cross-sectional data. Depression was measured with a threshold of <6/6+ on the GDS-15. Independent associations with social, demographic, physical and social network variables were assessed by logistic regression. RESULTS: In a fully adjusted analysis, odds ratios (OR) for depression were greater in older people, (adjusted OR for those aged 80-84 years = 1.1, 85-90 years = 1.5 and 90+ years = 1.8), those in rented (OR:1.3) or sheltered/residential accommodation (OR:1.5), and those widowed, divorced or separated (OR:1.2). Life events, (OR:1.4), smoking (OR:1.6), having two or more physical illnesses (OR:1.6) or no confiding relationship (OR:3.4) were also significantly associated with depression. Higher alcohol consumption was not predictive. Female sex and living alone were associated with depression in a crude analysis, but not after full adjustment for confounding. CONCLUSIONS: The importance of these results lies in the large size and representative nature of the sample. In contrast to some previous reports, increasing age was associated with increasing risk of depression, but sex, living alone and alcohol were not associated. Social isolation was more important than living alone per se. Other associations largely concurred with previous work.

Performance of a single screening question for depression in a representative sample of 13 670 people aged 75 and over in the UK: results from the MRC trial of assessment and management of older people in the community.

BACKGROUND: A concise, accurate screening question for depression would be an important contribution to the Single Assessment Process for Older People. OBJECTIVE: To examine the performance of a previously validated screening question for depression, in a large community sample. METHODS: Both the single screening question, and the Geriatric Depression Scale (GDS-15) were completed by 13 670 people aged 75 and over in the community. Responses to the question were compared with a "standard" of scoring above different thresholds on the Geriatric Depression Scale (GDS-15). RESULTS: For more severe GDS-15 depression, the best performance of the question was a sensitivity of only 52% and a specificity of 93%. CONCLUSION: Even at its best, the question therefore misses almost half the cases. This highlights the problems of such simple approaches to routine screening.

Reduced hearing, ownership, and use of hearing aids in elderly people in the UK--the MRC Trial of the Assessment and Management of Older People in the Community: a cross-sectional survey.

BACKGROUND: Reduced hearing in elderly people is important because it is disabling and potentially treatable. We aimed to assess the prevalence of reduced hearing in elderly people and levels of ownership of hearing aids and use. METHODS: We have done a cross-sectional survey of people aged at least 75 years in 106 family practices in the UK. We obtained self-reported data on hearing difficulties for 32,656 people and gave 14,877 a whispered voice test (response rate 78%). FINDINGS: 2537 (8%) of 32,656 participants reported a lot of difficulty hearing and 13,630 (42%) a little or a lot of difficulty. 3795 (26%) of 14877 participants who completed the whispered voice test (95% CI 23-29) failed the test, the proportion rising sharply with age. Following wax removal, 343 passed a retest, leaving 3452 (23%, 20-26) who failed the test, even after wax removal if present. 998 (46%) of 2180 people wearing a hearing aid at the time of testing failed the whispered voice test. More than half the people who failed the test did not own a hearing aid. 2200 (60%) of 3846 people who owned a hearing aid said they used it regularly. Level of use was strongly related to perceived benefit. INTERPRETATION: Reduced hearing is common and provision of hearing aids inadequate in elderly people. Many people who own a hearing aid do not use it regularly, and even when wearing their aid many still have socially disabling levels of hearing loss. A major source of morbidity in elderly people could be alleviated by improvements in detection and management of reduced hearing.

Geriatric Depression Scale Scores in a representative sample of 14 545 people aged 75 and over in the United Kingdom: results from the MRC Trial of Assessment and Management of Older People in the Community.

BACKGROUND: The 15-item Geriatric Depression Scale (GDS-15) is recommended for screening older people, but there are no large epidemiological studies using this instrument in the UK. We describe the age and sex distribution of GDS-15 scores in the largest ever UK sample of people aged 75 and over. METHOD: We used cross-sectional data from the MRC Trial of the Assessment and Management of Older People in the Community. The GDS-15 was offered to a representative sample of UK people aged 75 and over. Proportions of people attaining thresholds on the GDS-15 were calculated by age group and sex. Crude Odds ratios (ORs) for the effect of age and sex were calculated and the sex/age adjusted ORs estimated using logistic regression for surveys, at three GDS-15 thresholds. RESULTS: Of 21 241 (71.2%; 95% Confidence intervals (CI): 67.9-74.3) eligible people, 15 126 received the assessment including the GDS-15. Of these, 14 545 (96.2%; 94.7-97.2) completed > or =13 GDS-15 answers and were included in the study. Scores showed a marked right skew, with a median of 2 (interquartile range: 1-3; range: 0-14). 34.6% (95% CI: 32.1-37.3) people scored > or =3, 8.0% (6.9-9.2) scored > or =6 and 3.1% (2.5-3.7) scored > or =8. Women were significantly more likely to score above all three thresholds than men, as were older participants. CONCLUSIONS: Depression may be common in later life. The data provide a national picture of the numbers of older people who will score positively for depression in health screens which include the GDS-15, as recommended by the Royal College of General Practitioners.