Peri-orbital surgical emphysema following endoscopic dacryocystorhinostomy.

BACKGROUND: Peri-orbital surgical emphysema is a rare complication that can occur after lacrimal surgery. It has only been described in isolated cases, following external dacryocystorhinostomy (n = 2) and Lester Jones tube insertion (n = 1). METHOD: A retrospective, non-comparative case series was conducted of patients who developed surgical emphysema following endoscopic dacryocystorhinostomy. RESULTS: A total of 356 endoscopic dacryocystorhinostomy cases (primary, n = 316; revision, n = 40) were performed over a six-year period. Seven cases of post-operative surgical emphysema were identified, all of which were preceded by uncontrolled sneezing, nose-blowing or coughing within the first week of surgery. The occurrence of surgical emphysema post-endoscopic dacryocystorhinostomy in our centre was 7 in 356, or 2 per cent, over six years. CONCLUSION: This is the first study to report the occurrence of surgical emphysema post-endoscopic dacryocystorhinostomy. Clinicians may wish to suggest patients stifle the aforementioned triggers within the first week to reduce the potential for surgical emphysema.

Evaluation of contingency management as a strategy to improve HCV linkage to care and treatment in persons attending needle and syringe programs: A pilot study.

BACKGROUND: A greater proportion of HCV-infected people who inject drugs (PWID) need to be linked to care for HCV antiviral treatment. This study sets out to evaluate the efficacy of contingency management (CM) for improving HCV linkage to care, treatment initiation, adherence, and cure for PWID recruited from a needle and syringe program. METHODS: Between March 2015 and April 2016, 20 participants were enrolled into the CM arm, and then subsequently enrolled 20 participants in the enhanced standard of care (eSOC) arm. Participants in the eSOC arm received an expedited appointment and a round-trip transit card. Participants enrolled in the CM arm received eSOC plus $25 for up to ten HCV clinical visits and $10 for each returned weekly medication blister pack. Adherence was measured via electronic blister packs. RESULTS: Overall the median age was 47 years; most were men (67%) and Hispanic (69%). There were no significant differences in demographic characteristics between participants in the study arms. In the CM arm 74% were linked to HCV care, compared to 30% in the eSOC arm (p = 0.01). In the CM arm, 75% (9/12) of treatment eligible participants initiated treatment, compared to 100%(4/4) in the eSOC arm (p = 0.53). All patients (9/9) achieved cure in the CM arm, as compared to 75% (3/4) of patients in the eSOC arm. There were no differences in adherence between study arms. CONCLUSIONS: In this pilot study, contingency management led to higher rates of HCV linkage to care for PWID, as compared to standard of care. CM should be considered as a possible intervention to improve the HCV treatment cascade for PWID.

Evaluation of a hepatitis C clinical care coordination programme's effect on treatment initiation and cure: A surveillance-based propensity score matching approach.

Hepatitis C (HCV) is a viral infection that if left untreated can severely damage the liver. Project INSPIRE was a 3 year HCV care coordination programme in New York City (NYC) that aimed to address barriers to treatment initiation and cure by providing patients with supportive services and health promotion. We examined whether enrolment in Project INSPIRE was associated with differences in HCV treatment and cure compared with a demographically similar group not enrolled in the programme. INSPIRE participants in 2015 were matched with a cohort of HCV-infected persons identified in the NYC surveillance registry, using full optimal matching on propensity scores and stratified by INSPIRE enrolment status. Conditional logistic regression was used to assess group differences in the two treatment outcomes. Two follow-up sensitivity analyses using individual pair-matched sets and the full unadjusted cohort were also conducted. Treatment was initiated by 72% (790/1130) of INSPIRE participants and 36% (11 960/32 819) of study-eligible controls. Among initiators, 65% (514/790) of INSPIRE participants compared with 47% (5641/11 960) of controls achieved cure. In the matched analysis, enrolment in INSPIRE increased the odds of treatment initiation (OR: 5.25, 95% CI: 4.47-6.17) and cure (OR: 2.52, 95% CI: 2.00-3.16). Results from the sensitivity analyses showed agreement with the results from the full optimal match. Participation in the HCV care coordination programme significantly increased the probability of treatment initiation and cure, demonstrating that care coordination for HCV-infected individuals improves treatment outcomes.

Perceived benefits of the hepatitis C peer educators: a qualitative investigation.

BACKGROUND: Although opioid-dependent patients are disproportionately impacted by hepatitis C (HCV), many do not receive treatment. In addition to HCV treatment-access barriers, substance-using patients may be reluctant to pursue treatment because of wariness of the medical system, lack of knowledge, or stigma related to HCV treatment. Implementation of a formal peer education program is one model of reducing provider- and patient-level barriers to HCV treatment, by enhancing mutual trust and reducing stigma. METHODS: We used thematic qualitative analysis to explore how 30 HCV patients and peer educators perceived a HCV peer program within an established methadone maintenance program in the USA. RESULTS: Participants unanimously described the program as beneficial. Participants described the peer educators' normalization and dispelling of myths and fears around HCV treatment, and their exemplification of HCV treatment success, and reductions in perceived stigma. Peer educators described personal benefits. CONCLUSIONS: These findings indicate that HCV peer educators can enhance HCV treatment initiation and engagement within opioid substitution programs.

Retention in buprenorphine treatment is associated with improved HCV care outcomes.

Persons who inject drugs, most of whom are opioid dependent, comprise the majority of the HCV infected in the United States. As the national opioid epidemic unfolds, increasing numbers of people are entering the medical system to access treatment for opioid use disorder, specifically with buprenorphine. Yet little is known about HCV care in patients accessing buprenorphine-based opioid treatment. We sought to determine the HCV prevalence, cascade of care, and the association between patient characteristics and completion of HCV cascade of care milestones for patients initiating buprenorphine treatment. We reviewed electronic health records of all patients who initiated buprenorphine treatment at a primary-care clinic in the Bronx, NY between January 2009 and January 2014. Of the 390 patients who initiated buprenorphine treatment, 123 were confirmed to have chronic HCV infection. The only patient characteristic associated with achieving HCV care milestones was retention in opioid treatment. Patients retained (vs. not retained) in buprenorphine treatment were more likely to be referred for HCV specialty care (63.1% vs. 34.0%, p<0.01), achieve an HCV-specific evaluation (40.8% vs. 21.3%, p<0.05), be offered HCV treatment (22.4% vs. 8.5%, p<0.05), and initiate HCV treatment (9.2% vs. 6.4%, p=0.6). Given the current opioid epidemic in the US and the growing number of people receiving buprenorphine treatment, there is an unprecedented opportunity to access and treat persons with HCV, reducing HCV transmission, morbidity and mortality. Retention in opioid treatment may improve linkage and retention in HCV care; innovative models of care that integrate opioid drug treatment with HCV treatment are essential.

"Hepatitis C treatment turned me around:" Psychological and behavioral transformation related to hepatitis C treatment.

BACKGROUND: Hepatitis C (HCV) is a significant public health problem that primarily affects current and former substance users. However, individuals with a history of substance use are less likely to have access to or engage in HCV care. Psychological and behavioral barriers prevent many HCV-infected individuals from initiating or engaging in HCV treatment. This study aimed to investigate the psychological and behavioral experiences of current and former substance users receiving HCV treatment within a combined methadone and primary care clinic in the United States. METHODS: We conducted 31 semi-structured qualitative interviews with opioid-dependent adults enrolled in an integrated HCV treatment program within a methadone maintenance clinic in the Bronx, NY. We used thematic analysis, informed by grounded theory, and inquired about perceptions of HCV before and after initiating HCV treatment, reasons for initiating HCV treatment, and the decision to participate in individual versus group HCV treatment. RESULTS: Participants described psychological and behavioral transformation over the course of HCV treatment. These included reductions in internalized stigma and shame related to HCV and addiction, increases in HCV disclosure and self-care, reductions in substance use, and new desire to help others who are living with HCV. CONCLUSIONS: Integrating HCV treatment with methadone maintenance has the potential to create psychological and behavioral transformations among substance using adults, including reductions in HCV- and addiction-related shame and improvements in overall self-care.

The new paradigm of hepatitis C therapy: integration of oral therapies into best practices.

Emerging data indicate that all-oral antiviral treatments for chronic hepatitis C virus (HCV) will become a reality in the near future. In replacing interferon-based therapies, all-oral regimens are expected to be more tolerable, more effective, shorter in duration and simpler to administer. Coinciding with new treatment options are novel methodologies for disease screening and staging, which create the possibility of more timely care and treatment. Assessments of histologic damage typically are performed using liver biopsy, yet noninvasive assessments of histologic damage have become the norm in some European countries and are becoming more widespread in the United States. Also in place are new Centers for Disease Control and Prevention (CDC) initiatives to simplify testing, improve provider and patient awareness and expand recommendations for HCV screening beyond risk-based strategies. Issued in 2012, the CDC recommendations aim to increase HCV testing among those with the greatest HCV burden in the United States by recommending one-time testing for all persons born during 1945-1965. In 2013, the United States Preventive Services Task Force adopted similar recommendations for risk-based and birth-cohort-based testing. Taken together, the developments in screening, diagnosis and treatment will likely increase demand for therapy and stimulate a shift in delivery of care related to chronic HCV, with increased involvement of primary care and infectious disease specialists. Yet even in this new era of therapy, barriers to curing patients of HCV will exist. Overcoming such barriers will require novel, integrative strategies and investment of resources at local, regional and national levels.

"Damaging what wasn't damaged already": psychological tension and antiretroviral adherence among HIV-infected methadone-maintained drug users.

Active drug use among HIV-infected persons is associated with poor adherence to highly active antiretroviral therapy (HAART) and suboptimal treatment outcomes. To understand adherence experiences among HIV-infected drug users, we conducted semistructured interviews with 15 participants in a randomized controlled trial evaluating the efficacy of directly observed HAART delivered in methadone maintenance clinics. Interviews were recorded, transcribed, and thematically analyzed. We identified negative and positive psychological themes associated with both drug use and adherence. Participants described tension between negative feelings (denial, shame, and perceived isolation) and positive feelings (acceptance, motivation, empowerment, and perceived connectedness), and they associated this tension with their own drug using and adherence behaviors. Sustained antiretroviral therapy adherence may require increased emphasis on understanding the psychological experience of HIV-infected drug users.

Acquired lacrimal sac fistula mimicking basal cell carcinoma.

BACKGROUND: Lacrimal sac fistulae can arise after an episode of dacryocystitis, usually forming below the medial canthus. Preceding symptoms of a watery eye with mucous discharge and a history or signs of inflammation are typical. OBJECTIVES: To highlight the features of lacrimal sac fistulae and encourage readers to consider this in the differential diagnosis of apparently ulcerative medial canthal skin lesions. METHODS: We describe three patients with inferior-medial canthal ulcerative skin lesions, all referred to ophthalmic plastic surgeons either by dermatologists or plastic surgeons, presumed clinically to have basal cell carcinoma (BCC). RESULTS: All three were in fact due to acquired lacrimal sac fistulae, and syringing of the nasolacrimal system confirmed the presence of a fistula. CONCLUSIONS: These cases illustrate the importance of questioning patients about their previous ocular symptoms when dealing with less familiar periocular lesions.

Halitosis--a common medical and social problem. A review on pathology, diagnosis and treatment.

Bad breath is a condition that has health and social implications. This paper provides a comprehensive review of the classification of halitosis, it's etiology, it's prevalence, diagnosis and treatment strategies for the condition. Halitosis is affecting about 25-30% of world's population. It includes categories of genuine halitosis, pseudo-halitosis and halitophobia. It is believed that in 80-90% of cases halitosis origins in the oral cavity and the most common causes are: gingival pathologies, caries and poor oral hygiene. Extraoral sources of halitosis are responsible for 10-20% of all cases and are caused by poor diet, alcohol abuse, tobacco smoking, certain drugs and diseases of other parts of digestive tract as well as some systemic conditions. Diagnostics of halitosis includes subjective methods (examiner's sense of smell) and objective methods (instrumental analysis). Simple, subjective examination is considered a "golden standard" in clinical practice. In case of pathological halitosis identifying the direct cause of halitosis is essential. After excluding, or after successful treatment, of all oral pathologies, in case of remaining fetor ex ore identification and treatment of halitosis often requires multidisciplinary approach. Many unknowns remain in causes and mechanisms of halitosis. It can significantly impair quality of life, social interactions, lead directly to depression,low self-esteem or other mood disorders, therefore it is important to properly identify, treat and continue research on halitosis.

Measurement error in performance studies of health information technology: lessons from the management literature.

Just as researchers and clinicians struggle to pin down the benefits attendant to health information technology (IT), management scholars have long labored to identify the performance effects arising from new technologies and from other organizational innovations, namely the reorganization of work and the devolution of decision-making authority. This paper applies lessons from that literature to theorize the likely sources of measurement error that yield the weak statistical relationship between measures of health IT and various performance outcomes. In so doing, it complements the evaluation literature's more conceptual examination of health IT's limited performance impact. The paper focuses on seven issues, in particular, that likely bias downward the estimated performance effects of health IT. They are 1.) negative self-selection, 2.) omitted or unobserved variables, 3.) mis-measured contextual variables, 4.) mismeasured health IT variables, 5.) lack of attention to the specific stage of the adoption-to-use continuum being examined, 6.) too short of a time horizon, and 7.) inappropriate units-of-analysis. The authors offer ways to counter these challenges. Looking forward more broadly, they suggest that researchers take an organizationally-grounded approach that privileges internal validity over generalizability. This focus on statistical and empirical issues in health IT-performance studies should be complemented by a focus on theoretical issues, in particular, the ways that health IT creates value and apportions it to various stakeholders.

Drivers and barriers in health IT adoption: a proposed framework.

Despite near (and rare) consensus that the adoption and diffusion of health information technology (health IT) will bolster outcomes for organizations, individuals, and the healthcare system as a whole, there has been surprisingly little consideration of the structures and processes within organizations that might drive the adoption and effective use of the technology. Management research provides a useful lens through which to analyze both the determinants of investment and the benefits that can ultimately be derived from these investments. This paper provides a conceptual framework for understanding health IT adoption. In doing so, this paper highlights specific organizational barriers or enablers at different stages of the adoption process - investment, implementation, and use - and at different levels of organizational decision-making - strategic, operational, and frontline. This framework will aid both policymakers and organizational actors as they make sense of the transition from paper-based to electronic systems.

Hepatitis C testing practices and prevalence in a high-risk urban ambulatory care setting.

Approximately 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S.; most are not aware of their infection. Our objectives were to examine HCV testing practices to determine which patient characteristics are associated with HCV testing and positivity, and to estimate the prevalence of HCV infection in a high-risk urban population. The study subjects were all patients included in the baseline phase of the Hepatitis C Assessment and Testing Project (HepCAT), a serial cross-sectional study of HCV screening strategies. We examined all patients with a clinic visit to Montefiore Medical Center from 1/1/08 to 2/29/08. Demographic information, laboratory data and ICD-9 diagnostic codes from 3/1/97-2/29/08 were extracted from the electronic medical record. Risk factors for HCV were defined based on birth date, ICD-9 codes and laboratory data. The prevalence of HCV infection was estimated assuming that untested subjects would test positive at the same rate as tested subjects, based on risk-factors. Of 9579 subjects examined, 3803 (39.7%) had been tested for HCV and 438 (11.5%) were positive. The overall prevalence of HCV infection was estimated to be 7.7%. Risk factors associated with being tested and anti-HCV positivity included: born in the high-prevalence birth-cohort (1945-64), substance abuse, HIV infection, alcohol abuse, diagnosis of cirrhosis, end-stage renal disease, and alanine transaminase elevation. In a high-risk urban population, a significant proportion of patients were tested for HCV and the prevalence of HCV infection was high. Physicians appear to use a risk-based screening strategy to identify HCV infection.

Bevacizumab combined with gemcitabine and capecitabine for advanced pancreatic cancer: a phase II study.

A total of 50 patients with advanced pancreatic cancer were enrolled in a phase II study of bevacizumab 15 mg kg(-1), capecitabine 1300 mg m(-2) daily for 2 weeks and gemcitabine 1000 mg m(-2) weekly 2 times; cycles were repeated every 21 days. Radiological response rate was 22%; progression-free survival and over survival were 5.8 and 9.8 months respectively. Grade 3 or 4 toxicities included neutropaenia (22%), thrombocytopaenia (14%), thromboembolic events (12%), hypertension (8%) and haemorrhage (6%).

A new multifunctional platform based on high aspect ratio interdigitated NEMS structures.

A multifunctional NEMS platform based on a mass-producible, surface relief grating has been developed and fabricated directly in polymer materials. The pattern consists of high aspect ratio interdigitated nanometer-sized pairs of walls and can be produced in a low-complexity one-step patterning process with nanoimprint lithography. In this paper, we demonstrate the usefulness of the platform primarily by showing an application as a high-sensitivity mass sensor in air. The sensors, which are based on the high frequency resonant response of around 200 MHz, show a mass responsivity of the order of 0.1 Hz/zg per wall at room temperature and in ambient air. Their ability to selectively adsorb airborne target molecules, such as thiols, is also demonstrated. We also show that the same device can function as a varactor for electronic circuits based on its large tunable capacitive range.