Point-of-care Hepatitis C virus testing and linkage to treatment in an Australian inner-city emergency department.

BACKGROUND: In Australia, Hepatitis C Virus (HCV) treatment is declining, despite broad access to direct-acting antiviral medication. People who inject drugs are proportionally over-represented in emergency department presentations. Emergency department assessment of people who have injected drugs for HCV presents an opportunity to engage this marginalised population with treatment. We describe the outcomes of risk-based screening and point-of-care anti-HCV testing for emergency department patients, and linkage to outpatient antiviral treatment. METHODS: During the three-month study period, consecutive adult patients who presented to the emergency department during the study times were screened for risk factors and offered the OraQuick oral HCV antibody test. Those with reactive results were offered venepuncture in the emergency department for confirmatory testing and direct-acting antiviral treatment in clinic. The main outcome measures were the number and proportion of viremic participants that were linked to the hepatitis clinic, commenced treatment and achieved a sustained viral response. Secondary outcome measures were the proportion (%) of presentations screened that were oral antibody reactive, and the prevalence and type of HCV risk factors. RESULTS: During the study period, 2408 of the 3931 (61%) presentations to the emergency department were eligible for screening. Of these 2408 patients, 1122 (47%) participated, 307 (13%) declined participation and 977 (41%) could not be approached during their time in the emergency department. Among the 1122 participants, 378 (34%) reported at least one risk factor. Subsequently, 368 (97%) of the 378 participants underwent OraQuick anti-HCV test, and 50 (14%) had a reactive result. A risk factor of ever having injected drugs was present in 44 (88%) of participants who were sero-positive. Of the 45 that had blood tested, 30 (67%) were HCV ribonucleic acid (RNA) positive. Three participants died. Of the 27 remaining participants, 10 (37%) commenced treatment and 7 of these 10 (70%) obtained a cure. There was a high rate of homelessness (24%) among anti-HCV positive participants. CONCLUSION: Among emergency department participants with a risk factor for HCV, positive serology was common using a rapid point-of-care test. A history of injecting drug use was identified as the risk factor with highest yield for positive HCV serology, and is suitable as a single screening question. However, linkage to care post ED presentation was low in this marginalised population. There is a need for new pathways to improve the care cascade for marginalised individuals living with HCV infection.

Feasibility study of a candidate reference material for ions in PM2.5: does commutability matter also for inorganic matrices?

The existing Air Quality Directive 2008/50/EC establishes within the European Union (EU) member states limit values for fine air particulate matter (PM2.5) including the possibility to discount natural sources of pollution when assessing compliance with the legislation. In proving this, EU member states shall determine, amongst others, the rural background concentration of some anions (Cl-, NO3- and SO42-) and cations (Na+, NH4+, K+, Ca2+ and Mg2+). To deliver reliable data and to comply with the data quality objectives of the legislation, environmental control laboratories should use certified reference materials (CRMs) to validate or verify the performance of their analytical methods. Since no CRMs for anions and cations in PM2.5 are presently available, we present the commutability issues encountered during the first attempt to develop such a material. We demonstrate that a dust, collected in a road tunnel and previously used for the production of two CRMs of a PM10-like material, does not behave as an authentic fine particulate matter collected according to EN12341:2014 when measured by an established method proposed by the European Committee for Standardization (CEN/TR 16269:2011). The water-soluble fractions of SO42-, NH4+, K+, Ca2+ and Mg2+ in a PM2.5-like candidate CRM produced from that road tunnel dust are only fully extracted after 3 h of sonication and not after 30 min, as stated in the method. Moreover, we found that the particle size of the test material influenced the extraction yield of K+, Ca2+ and Mg2+, suggesting that these ionic species were incorporated in the core of the particles and inaccessible to the extraction procedure. These particular features make the material unsuitable for the measurements of ions with the CEN method. The difference in the extraction time can be seen as a commutability issue and the candidate CRM should be considered as not commutable with routine samples. This demonstrates that commutability studies should not only be considered for clinical CRMs, but also for inorganic CRMs when they are intended to be used to quantify operationally defined analytes.

Equivalence of cell survival data for radiation dose and thermal dose in ablative treatments: analysis applied to essential tremor thalamotomy by focused ultrasound and gamma knife.

Thermal dose and absorbed radiation dose have historically been difficult to compare because different biological mechanisms are at work. Thermal dose denatures proteins and the radiation dose causes DNA damage in order to achieve ablation. The purpose of this paper is to use the proportion of cell survival as a potential common unit by which to measure the biological effect of each procedure. Survival curves for both thermal and radiation doses have been extracted from previously published data for three different cell types. Fits of these curves were used to convert both thermal and radiation dose into the same quantified biological effect: fraction of surviving cells. They have also been used to generate and compare survival profiles from the only indication for which clinical data are available for both focused ultrasound (FUS) thermal ablation and radiation ablation: essential tremor thalamotomy. All cell types could be fitted with coefficients of determination greater than 0.992. As an illustration, survival profiles of clinical thalamotomies performed by radiosurgery and FUS are plotted on a same graph for the same metric: fraction of surviving cells. FUS and Gamma Knife have the potential to be used in combination to deliver a more effective treatment (for example, FUS may be used to debulk the main tumour mass, and radiation to treat the surrounding tumour bed). In this case, a model which compares thermal and radiation treatments is valuable in order to adjust the dose between the two.

Imaging findings in MR imaging-guided focused ultrasound treatment for patients with essential tremor.

BACKGROUND AND PURPOSE: MR imaging-guided focused sonography surgery is a new stereotactic technique that uses high-intensity focused sonography to heat and ablate tissue. The goal of this study was to describe MR imaging findings pre- and post-ventralis intermedius nucleus lesioning by MR imaging-guided focused sonography as a treatment for essential tremor and to determine whether there was an association between these imaging features and the clinical response to MR imaging-guided focused sonography. MATERIALS AND METHODS: Fifteen patients with medication-refractory essential tremor prospectively gave consent; were enrolled in a single-site, FDA-approved pilot clinical trial; and were treated with transcranial MR imaging-guided focused sonography. MR imaging studies were obtained on a 3T scanner before the procedure and 24 hours, 1 week, 1 month, and 3 months following the procedure. RESULTS: On T2-weighted imaging, 3 time-dependent concentric zones were seen at the site of the focal spot. The inner 2 zones showed reduced ADC values at 24 hours in all patients except one. Diffusion had pseudonormalized by 1 month in all patients, when the cavity collapsed. Very mild postcontrast enhancement was seen at 24 hours and again at 1 month after MR imaging-guided focused sonography. The total lesion size and clinical response evolved inversely compared with each other (coefficient of correlation = 0.29, P value = .02). CONCLUSIONS: MR imaging-guided focused sonography can accurately ablate a precisely delineated target, with typical imaging findings seen in the days, weeks, and months following the treatment. Tremor control was optimal early when the lesion size and perilesional edema were maximal and was less later when the perilesional edema had resolved.

Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre.

BACKGROUND: Retrosternal goitre (RSG) is an uncommon problem encountered rarely by anaesthetists working outside specialized head and neck (H&N) surgical units. Traditional anaesthetic teaching warns of difficult airway management in these patients. The incidence and extent of these problems is unclear. METHODS: We have performed a retrospective review of the anaesthetic management all patients with massive RSG (extending to the aortic arch or beyond) presenting for thyroidectomy at University Hospital Aintree from January 2007 to May 2012. RESULTS: Five hundred and seventy-three patients underwent a thyroidectomy procedure at Aintree University Hospitals NHS Foundation Trust (AUH) between January 2007 and May 2012. Of these, 34 cases were documented as having a RSG. Review of each patient's preoperative computerized tomography imaging identified 19 patients with massive RSG. There was one case of failed intubation. All other patients underwent uneventful tracheal intubation via direct laryngoscopy. All glands were removed through the neck with no requirement to proceed to sternotomy. There were no instances of postoperative respiratory problems or tracheomalacia. Three patients suffered recurrent laryngeal nerve (RLN) injuries. CONCLUSION: When managed within a dedicated H&N operating theatre we have found a low incidence of difficult tracheal intubation, difficult mechanical ventilation nor postoperative respiratory difficulties in patients with massive RSG and mid-tracheal compression because of benign multi-nodular goitre. Surgical complications, however, are more frequent than those associated with cervical thyroidectomy with RLN injury and postoperative bleeding more likely.

Gore-tex bags versus traditional hand bandaging: a comparison of range of motion, sensation and function in healthy subjects.

INTRODUCTION: Little evidence exists evaluating the possible effect of dressings on the recovery of function, sensation and joint motion following a hand burn. Hand burns are traditionally covered by a layer of non-adherent dressing followed by gauze and bandages. However, there is no evidence for the efficacy of this type of coverage relative to a functional recovery. The Gore-tex bag has a small body of research supporting its ability to provide a superior healing atmosphere, however there is no literature directly comparing it with the traditional dressing. METHOD: A randomised cross-over design was implemented to compare Gore-tex bags and traditional dressings in 30 healthy volunteers. Seven outcome measures of function, sensation, joint range of movement and subject perceptions were recorded before dressing, during both Gore-tex and traditional dressing interventions and between dressings. RESULTS: Statistically significant differences were found between the traditional dressings and Gore-tex bags. The Gore-tex bag dressings proved better for digit range of motion, 1st CMC joint motion and sensation. The traditional dressings were significantly better when perceived comfort was tested and there was no significant difference between the traditional dressing and Gore-tex bag regarding function and perceived function. CONCLUSION: The results of this study suggest that traditional dressings may detrimentally affect movement and reduce sensation but not necessarily affect function or comfort. Further investigation in a patient cohort with burnt hands is recommended.

Teaching face-name associations to survivors of traumatic brain injury: a sequential treatment approach.

Recalling names in real-world contexts is often difficult for survivors of traumatic brain injury despite successful completion of face-name association training programmes. This small number study utilized a sequential treatment approach in which a traditional training programme preceded real-world training. The traditional training component was identical across programmes: one-on-one intervention using visual imagery and photographs to assist in mastery of face-name associations. The real-world training component compared the effectiveness of three cueing strategies--name restating, phonemic cueing and visual imagery--and was conducted by the actual to-be-named people. Results revealed improved name learning and use by the participants regardless of cueing strategy. After treatment targeting six names, four of five participants consistently used two or more names spontaneously and consistently knew three or more names in response to questioning. In addition to documenting the effectiveness of real-world treatment paradigms, the findings call into question the necessity for preliminary traditional intervention.

Comparability of antimicrobial susceptibility test results from 22 European countries and Israel: an external quality assurance exercise of the European Antimicrobial Resistance Surveillance System (EARSS) in collaboration with the United Kingdom National External Quality Assurance Scheme (UK NEQAS).

The goal of this exercise was to organize external quality assurance (QA) of antibiotic susceptibility testing for laboratories participating in EARSS and to assess the comparability of susceptibility test results across countries, and guidelines. In September 2000, UK NEQAS distributed a set of three Streptococcus pneumoniae strains, two Staphylococcus aureus strains and one Streptococcus haemolyticus strain. Laboratories reported the guideline followed, the interpretation of the susceptibility test result and the MIC, if tested. In this study we considered results 'concordant' if the reported interpretation of the participating laboratory agreed with the designated interpretation of reference laboratories. Overall, 433 (92%) of 471 laboratories from 23 countries reported back. Of the 8685 tests that were assessed, 8322 (96%) were interpreted correctly by the participants. Concordance for detection of penicillin non-susceptibility in the three S. pneumoniae strains was 96%, 90% and 87%, respectively. Laboratories performed extremely well in detecting oxacillin resistance in the homogeneously methicillin-resistant S. aureus (MRSA) strain, but the concordance rate dropped from 100% to 77% in the heterogeneously resistant MRSA strain. Concordance for detection of teicoplanin resistance in the S. haemolyticus strain was 82%. We stratified concordance rates first for country and then for guideline used, but observed only minor differences among countries and guidelines. Quantitative methods yielding an MIC were more concordant than non-MIC methods for penicillin resistance in the S. pneumoniae strains (94% versus 79%). The NCCLS guideline was the most frequently followed, by 61% of laboratories from 19 countries. This exercise shows that, overall, countries participating in EARSS are capable of delivering susceptibility data of good quality. The comparability of susceptibility data for penicillin resistance in S. pneumoniae and for homogeneous methicillin resistance in S. aureus is satisfactory among European countries and across guidelines. However, we emphasize the importance of determining an MIC for suspected penicillin non-susceptible S. pneumoniae and for suspected glycopeptide non-susceptible S. aureus. Laboratories, particularly in some countries, may need to improve their capability to detect oxacillin resistance in heterogeneously resistant MRSA. For continuous external quality assessment we recommend that laboratories participate in national and international schemes with frequent distribution of control strains.

External quality assessment of antimicrobial susceptibility testing in Europe.

Comparability of results of antimicrobial susceptibility testing is essential for resistance surveillance studies. As different methods may be used in different countries, there may be particular problems with international comparisons of resistance rates. Data from external quality assessment (EQA) surveys participated in by laboratories from several European countries allow comparison of performance between countries. In this study, success rates with organism-antimicrobial agent combinations known to be difficult to test were examined. With penicillin resistance in pneumococci; vancomycin and high-level gentamicin resistance in enterococci; ampicillin, co-amoxiclav and chloramphenicol resistance in Haemophilus influenzae and methicillin resistance in staphylococci there were differences between countries in success rates for discrimination of resistant strains. This study suggests that differences between countries in rates of resistance for some organism-antimicrobial agent combinations should be interpreted with caution. International EQA is useful in the demonstration and clarification of such differences.

Effect of training frequency on face-name recall by adults with traumatic brain injury.

Many TBI survivors have difficulty recalling the names of people with whom they frequently interact. Researchers have established that mnemonics and visual imagery strategies are often effective in facilitating encoding and recall of such information; however, no research exists pertaining to the frequency that such training should occur. The purpose of this study was to assess the relative effectiveness of three frequencies of intervention sessions--once per day, two times per week, and five times per day--on TBI survivors' ability to recall face-name associations. Results showed that sessions held daily and twice a week were more effective than sessions held five times per day. Mnemonics and visual imagery strategies were effective for four of the seven participants, regardless of frequency of intervention sessions. Implications for treatment and future research are discussed.

Review of the Bethesda System atlas does not improve reproducibility or accuracy in the classification of atypical squamous cells of undetermined significance smears.

BACKGROUND: The Bethesda System (TBS) and its accompanying atlas were developed to promote uniform diagnosis and reporting of cervical and vaginal cytology, especially with respect to borderline abnormal smears. The authors assessed whether group study of TBS atlas improves the reproducibility and accuracy of the cytopathologic diagnosis of equivocal Papanicolaou smears. METHODS: One hundred "atypical" smears were divided into pretest and posttest sets containing equal numbers of negative, atypical squamous cells of undetermined significance (ASCUS), and squamous intraepithelial lesion (SIL) diagnoses based on a five-member panel review. Two comparable teams of four pathologists from George Washington University Medical Center (Washington, DC) and Kaiser Permanente (Portland, OR), each comprised of two more experienced cytopathologists and two less experienced pathologists, independently reviewed the 50 pretest slides and classified the slides according to TBS as negative, ASCUS, or SIL. The teams then conducted group study sessions using TBS atlas. After the review, the pathologists independently classified the 50 posttest slides in a similar manner. RESULTS: Pretest, pair-wise interobserver agreement ranged from 30% to 66% compared with 34-62% for posttest agreement. Absolute percent agreement of reviewers' diagnoses with a previously developed consensus diagnosis based on opinions of a five-expert panel (cytopathologic certainty scale) ranged from 44% to 62% for the pretest set and from 40% to 60% for the posttest set. Comparison of the detection of oncogenic human papilloma virus (HPV) DNA by hybrid capture tube test with smears classified as negative, ASCUS, or SIL revealed that seven of eight reviewers did not demonstrate a stronger association between HPV detection and cytologic diagnosis in the posttest set. CONCLUSIONS: Review of TBS atlas by itself does not appear to improve the reproducibility or accuracy of cytologic diagnoses. The lack of improvement was similar among the pathologists involved regardless of experience level or whether they had a close working relation. Cancer (Cancer Cytopathol)

Exposure at home to airborne concentrations of nitrogen mustard during topical application for the treatment of mycosis fungoides: a case study.

BACKGROUND: Although effective at treating mycosis fungoides (MF), nitrogen mustard (HN(2)) creates potential exposure risks to those who administer it, including health care workers and family members. OBJECTIVE: The main objective was to examine the potential for nontarget individuals to be exposed to HN(2) vapors during and shortly after treatment with HN(2) in a home environment. METHODS: Air concentrations of HN(2) were measured during the topical treatment of MF in a patients home. RESULTS: The results demonstrate that eye and mucous membrane irritation may occur at HN(2) levels commonly encountered during the treatment of MF in the home, hospital or health clinic. Because no exposure thresholds have been developed for HN(2), the exposure thresholds of a surrogate chemical (sulfur mustard) were used. CONCLUSIONS: The study findings show that eye and mucous membrane irritation may occur at HN(2) levels below the exposure thresholds of the surrogate chemical. Recommendations for controlling exposures to HN(2) in the home are given.

Prisonomics and the use of psychotropic drugs on incarcerated offenders: ethical considerations.

The authors discuss the ethical considerations involved in using psychotropic medications with incarcerated offenders. Medications cannot be used as tool of oppression. Medication cannot be used to justify overpopulation, to quietly terminate prisoners, and must be administered by licensed health professionals. There must be informed consent.