The peer to career pipeline: An observational study of peer worker trainee characteristics and training completion likelihood

INTRODUCTION

Peer recovery support services (PRSS) for substance use disorder (SUD) are a flexible and evidence-based intervention employed across multiple settings and for a variety of populations. These services have expanded over the past two decades, but there is little research on recruitment and training of prospective peer workers - the peer to career pipeline. This study observed training outcomes for applicants to a peer worker scholarship program in Texas.

METHODS

A total of 448 participants provided baseline personal history information, and a subset of participants (n = 239) completed optional psychosocial surveys. Logistic regression analysis tested associations of personal history and psychosocial variables with three training stage completion outcomes: classroom training completion, placement at an internship site, and full certification.

RESULTS

The greatest decline in advancement between stages occurred in the transition between classroom training (78.1 % of participants completed) and internship placement (43.3 % of participants completed). Participants were diverse in terms of race/ethnicity and life experiences salient to the peer worker role, but Hispanic/Latinx peer workers were under-represented. Past work with a SUD peer worker, age, and having a bachelor's degree were each positively associated with training stage completion across multiple models, while having basic technological access, being a woman, and veteran status were each positively associated with training stage completion in only one model. Years since recovery initiation date, non-monosexual orientation, White race, and quality of life were each negatively associated with training stage completion in only one model.

CONCLUSIONS

The existing peer workforce may be a key source of recruitment for new peer workers; thus retention of existing workers is key to ensuring continued expansion of these services. Additional support may be required to recruit and retain younger peer worker trainees, men trainees, Hispanic/Latinx trainees, trainees who lack basic technological access, or trainees without bachelor's degrees. Unanswered questions about the peer workforce remain and must be addressed to ensure that an appropriately diverse workforce is recruited, that disparities in training outcomes are minimized or prevented, and that existing peer workers are well-supported.

Mapping COVID vulnerability in relation to drug and alcohol recovery residence availability across the United States

Recovery housing is an important resource for those in recovery from substance use disorders. Unfortunately, we know little about its relationship to key community health risk and protective factors, potentially limiting the role it could play as a broader health resource. Leveraging county-level data on recovery residences from the National Study of Treatment and Addiction Recovery Residences (NSTARR), this study used multilevel modeling to examine Community COVID Vulnerability Index (CCVI) scores as well as availability of COVID testing and vaccination sites in relation to recovery housing. CCVI composite scores were positively associated with recovery housing availability. Analyses using CCVI thematic sub-scores found that population density and number of churches were positively associated with recovery housing availability, while epidemiological factors and healthcare system factors were negatively associated with recovery housing availability. In counties with recovery housing, there also was a positive association between CCVI and both COVID testing and vaccination availability. Recovery residences tend to be located in areas of high COVID vulnerability, reflecting effective targeting in areas with higher population density, more housing risk factors, and other high-risk environments and signaling a key point of contact to address broader health issues among those in recovery from substance use disorders.

Social Model Recovery and Recovery Housing

Recovery housing is an important resource for many in their recovery from alcohol and other drug use disorders. Yet providers of recovery housing face a number of challenges. Many of these challenges are rooted in stigma and bias about recovery housing. The ability to describe the service and purported mechanisms of action vis-a-vis an overarching framework, approach, or orientation could also go a long way in adding credence to recovery housing as a service delivery mechanism. Several aspects of social model recovery are often explicitly built or organically reflected in how recovery housing operates, yet describing recovery housing in these terms often does little to demystify key features of recovery housing. To more fully cement social model recovery as the organizing framework for recovery housing this article aims to: review the history, current status, and evidence base for social model recovery; comment on challenges to implementing the social model in recovery housing; and delineate steps to overcome these challenges and establish an evidence base for social model recovery housing.

Air Quality Dispersion Modelling to Evaluate CIPP Installation Styrene Emissions

Cured-in-place pipe (CIPP) is one of the most popular in situ rehabilitation techniques to repair sewer and water pipes. While there are multiple approaches to curing CIPP, steam-curing of styrene-based resins has been found to be associated with air-borne chemical emissions. Health officials, utilities and industry representatives have recognized the need to know more about these emissions, especially styrene. Such concern has led to multiple studies investigating the concentrations of volatile organic compounds on CIPP installation sites. This study expands upon previous effort by modeling worst-case, steam-cured CIPP emissions over a 5-year weather record. The effort also includes calibration of the model to emissions averages over the work day rather than instantaneous field measurements. Dispersion modelling software, AERMOD, was utilized to model the styrene component of CIPP emissions on two CIPP installation sites in the US. Based on the analysis results, it was found that the styrene emitted from stacks dissipates rapidly with styrene concentrations only exceeding minimum health and safety threshold levels at distances close to the stack (2 m or less). The values predicted by the model analysis are comparable with the field measured styrene concentrations from other studies. Current safety guidelines in the US recommend a 4.6-m (15-ft) safety perimeter for stack emission points. The results of this study indicate that significant and lasting health impacts are unlikely outside recommended safety perimeter. The results also validate the importance of enforcing recommended safety guidance on steam-cured CIPP sites.

608 Optimising Return to Elective Total Hip Arthroplasty (THA) Following the COVID-19 Pandemic: Lessons Learned and Future Directions

Aim

COVID-19 has led to unprecedented waiting times for elective surgery. Optimising patient pathways is paramount in tackling the backlog. Length of hospital stay (LOS) is an accepted surrogate for successful elective surgery.

The aims of our study were: 1) report on changes in LOS after restarting our elective THA service; 2) identify barriers to early discharge, 3) investigate effectiveness of implemented changes.

Method

A retrospective review of consecutive patients undergoing elective THA, comparing three groups: 1) enhanced care pathway (n=96; 09/2019–12/2019); 2) COVID group (n=56; 03/2021–04/2021); 3) intervention group (n=96; 05/2021–08/2021).

Results

LOS in the enhanced care pathway group was 2.6 ±2.1 days. During initial resumption of elective operating (COVID group) the LOS was 4.8 ±4.5 days (statistically significant increase; p=0.011). Factors affecting LOS included reduced physiotherapy provision; lack of pre-operative occupational therapy review; loss of educational classes and worse pre-operative functional status.

To address these our department employed three new physiotherapists, introduced training for nursing staff and created a post-operative proforma. The LOS subsequently reduced to 3.7 ±4.6days (p=0.166).

Subgroup analysis of the intervention group showed age <75 (p<0.001) and ASA1–2 (p=0.036) were associated with reduced LOS (2.1±1.5 days). Other variables analysed did not significantly affect LOS.

Conclusions

COVID-19 has had a significant effect on LOS, which is still not reversed. For effective resumption of THA services, pre-pandemic enhanced care pathways should be reinstated. With current restrictions preventing face-to-face classes, online educational sessions could be offered. Those younger than 75 years and ASA1–2 are most likely to be discharged without delay.

Sheltering in place and social distancing when the services provided are housing and social support: The COVID-19 health crisis and recovery housing

Recovery housing is a vital service for individuals with substance use disorders who need both recovery support and safe housing. Recovery housing is a residential service, and it relies heavily on social support provided by peers both within the residence and in outside mutual help groups. As such, efforts to keep residents safe from SARS CoV-2, the virus that causes the illness COVID-19, pose a number of challenges to social distancing. Further, residents are some of the more vulnerable individuals in recovery. They are more likely to have co-occurring health conditions that place them at risk for COVID-19, and they often have risk factors such as employment in low-wage jobs that increase their potential for negative economic impacts of the pandemic. Since most recovery housing operates outside formal substance use treatment, residents who pay out-of-pocket for services largely support these residences. Comprehensive support for those using, as well as those providing and ensuring the quality of recovery housing, is needed to ensure the viability of recovery housing.

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Recovery housing provides recovery support in a residential setting, serving highly-vulnerable individuals with substance use disorders.

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Efforts are underway to develop best practices for protecting residents and the peer-support community from COVID-19.

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Most recovery residences are not part of the formal substance use treatment system.

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Without adequate support for recovery housing, those who provide this service will be hampered in their ability to respond to increased resident needs.

Supporting individuals using medications for opioid use disorder in recovery residences: challenges and opportunities for addressing the opioid epidemic

Full and partial opioid agonists and opioid antagonist medications play an important role in containing the opioid epidemic. However, these medications have not been used to their full extent. Recovery support services, such as recovery residences (RRs), also play a key role. RRs may increase an individual's recovery capital, facilitate social support for abstinence, and foster a sense of community among residents. These processes may be critical for individuals with opioid use disorder (OUD). In combination these two recovery pathways have the potential to enhance one another and improve outcomes among residents with OUD. Barriers to doing so have resulted in a limited supply of residences that can support residents using opioid agonist and antagonist medications. This perspective describes key interpersonal and structural barriers to medication use among individuals with an OUD seeking support from a recovery residence and discusses measures for reducing these barriers. These measures include workforce development to address stigma and attitudinal barriers and enhancing residence capability to ensure resident safety and reduce potential diversion. The perspective also highlights the need for additional research to facilitate the identification of best practices to improve outcomes among residents treated with medications living in recovery residences.

DNA content equivalence in haploid and diploid maize leaves

The qPCR assay developed to differentiate haploid and diploid maize leaf samples was unsuccessful due to DNA content difference. Haploid cells are packed more closely together with less cellular expansion. Increased ploidy content (> 2 N) directly correlates with increased cell size in plants, but few studies have examined cell morphology in plants with reduced ploidy (i.e., haploids). To pioneer a scalable new ploidy test, we compared DNA content and cellular morphology of haploid and diploid maize leaves. The amount of genomic DNA recovered from standardized leaf-punch samples was equivalent between these two ploidy types, while both epidermal and mesophyll cell types were smaller in haploid plants. Pavement cells had a substantially smaller size than mesophyll cells, and this effect was more pronounced in the abaxial epidermis. Interveinal distance and guard cell size were significantly reduced in haploids, but the cell percentage comprising stomata did not change. These results confirm the direct correlation between ploidy content and cell size in plants, and suggest that reduced cell expansion predominantly explains DNA content equivalence between haploid and diploid samples, confounding efforts to develop a haploid detection method using DNA content.

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.

A paradigm for information needed to protect at-risk species: northern pine snake (Pituophis melanoleucus) in the pine barrens as a case study

New methods of examining the risk to endangered, threatened and rare species are required to identify vulnerability. A paradigm for examining risk is presented that describes anthropogenic threats, species activities, and vulnerabilities, and uses Northern pine snakes (Pituophis melanoleucus) in the New Jersey Pine Barrens as a case study. The paradigm includes (1) conceptual model of natural, anthropogenic, and interactive stressors, (2) template of the functional attributes of threats from human activities, and (3) template of effects from different human activities. Pine snake behavior throughout the year was used to examine the temporal overlap in high snake vulnerability periods and desired human activities in a shared habitat. New data on autumn behavior of pine snakes are also provided. Passive integrated transponders (PIT tag) tracking technology indicated that the fall basking activity period is both longer in duration, and at a higher intensity than previously presumed. During the autumn, individual snakes moved in and out of dens an average of 6 times over a two-month period. Younger snakes at a small hibernaculum were more active than those at hibernacula with larger and older snakes. The high activity period of pine snakes overlaps with the timing of preferred off-road-vehicle (ORV) use, controlled burns, and other human activities, increasing snake vulnerability, potentially causing behavioral disruptions, injury, and death. The conceptual model illustrating relationships between attributes of human activity and effects may be utilized to determine risks to other listed species, and those of special concern in different habitats. This paradigm also provides managers with template tools to assess risks to species that may also be used to provide information to the public.

Review article: delivering precision oncology in intermediate-stage liver cancer

BACKGROUND

Intermediate-stage hepatocellular carcinoma (HCC), for which trans-arterial chemoembolization (TACE) constitutes the standard of care, is a patient subgroup with significant heterogeneity in clinical outcome. Sources of variation relate to differences in tumour burden, hepatic reserve, ethnicity and treatment modalities. Increasing research efforts have been dedicated to minimise the clinical diversity of this patient population and enhance optimal provision of treatment.

AIM

To comprehensively review the diverse prognostic models that have been proposed to refine the prognostic prediction of patients with HCC undergoing TACE.

RESULTS

A number of prognostic algorithms (HAP, ART, ABCR score and many others) have shown potential to address the clinical heterogeneity characterising patients with intermediate-stage HCC and facilitate early identification of patients with poor prognostic features in whom alternative treatments or best supportive care might be more appropriate than TACE.

CONCLUSIONS

While an improved characterisation of intermediate-stage HCC is a highly important clinical aim, current evidence suggests that novel prognostic algorithms in this patient population may offer potential benefits but non-negligible challenges in the provision of TACE. This review summarises the currently available evidence to facilitate the development of precision oncology in intermediate-stage HCC.

On-target sorafenib toxicity predicts improved survival in hepatocellular carcinoma: a multi-centre, prospective study

BACKGROUND

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and has high mortality despite treatment. While sorafenib has a survival benefit for patients with advanced HCC, clinical response is highly variable.

AIM

To determine whether development of sorafenib toxicity is a prognostic marker of survival in HCC.

METHODS

In this prospective multicentre cohort study, patients with advanced-stage HCC receiving sorafenib were recruited from five international specialist centres. Demographic and clinical data including development and grade of sorafenib toxicity during treatment, radiological response to sorafenib and survival time (months) were recorded prospectively.

RESULTS

A total of 634 patients with advanced-stage HCC receiving sorafenib were recruited to the study, with a median follow-up of 6692.3 person-months at risk. The majority of patients were male (81%) with Child-Pugh A stage liver disease (74%) and Barcelona Clinic Liver Cancer stage C HCC (64%). Median survival time was 8.1 months (IQR 3.8-18.6 months). 94% experienced at least one sorafenib-related toxicity: 34% diarrhoea, 16% hypertension and 37% hand-foot syndrome (HFS). Twenty-one per cent ceased sorafenib due to toxicity and 59% ceased treatment due to progressive disease or death. On multivariate analysis, sorafenib-related diarrhoea (HR 0.76, 95% CI 0.61-0.95, P = 0.017), hypertension (HR 0.531, 95% CI 0.37-0.76, P < 0.0001) and HFS (HR 0.65, 95% CI 0.51-0.81, P < 0.0001) were all significant independent predictors of overall survival after adjusting for age, severity of liver disease, tumour stage and sorafenib dose.

CONCLUSION

Development of sorafenib-related toxicity including diarrhoea, hypertension and hand-foot syndrome is associated with prolonged overall survival in patients with advanced-stage HCC on sorafenib.

The genomic architecture of resistance to Campylobacter jejuni intestinal colonisation in chickens

BACKGROUND

Campylobacter is the leading cause of foodborne diarrhoeal illness in humans and is mostly acquired from consumption or handling of contaminated poultry meat. In the absence of effective licensed vaccines and inhibitors, selection for chickens with increased resistance to Campylobacter could potentially reduce its subsequent entry into the food chain. Campylobacter intestinal colonisation levels are influenced by the host genetics of the chicken. In the present study, two chicken populations were used to investigate the genetic architecture of avian resistance to colonisation: (i) a back-cross of two White Leghorn derived inbred lines [(61 x N) x N] known to differ in resistance to Campylobacter colonisation and (ii) a 9(th) generation advanced intercross (61 x N) line.

RESULTS

The level of colonisation with Campylobacter jejuni following experimental infection was found to be a quantitative trait. A back-cross experiment using 1,243 fully informative single nucleotide polymorphism (SNP) markers revealed quantitative trait loci (QTL) on chromosomes 7, 11 and 14. In the advanced intercross line study, the location of the QTL on chromosome 14 was confirmed and refined and two new QTLs were identified located on chromosomes 4 and 16. Pathway and re-sequencing data analysis of the genes located in the QTL candidate regions identified potential pathways, networks and candidate resistance genes. Finally, gene expression analyses were performed for some of the candidate resistance genes to support the results.

CONCLUSION

Campylobacter resistance in chickens is a complex trait, possibly involving the Major Histocompatibility Complex, innate and adaptive immune responses, cadherins and other factors. Two of the QTLs for Campylobacter resistance are co-located with Salmonella resistance loci, indicating that it may be possible to breed simultaneously for enhanced resistance to both zoonoses.

Maximizing social model principles in residential recovery settings

Peer support is integral to a variety of approaches to alcohol and drug problems. However, there is limited information about the best ways to facilitate it. The “social model” approach developed in California offers useful suggestions for facilitating peer support in residential recovery settings. Key principles include using 12-step or other mutual-help group strategies to create and facilitate a recovery environment, involving program participants in decision making and facility governance, using personal recovery experience as a way to help others, and emphasizing recovery as an interaction between the individual and their environment. Although limited in number, studies have shown favorable outcomes for social model programs. Knowledge about social model recovery and how to use it to facilitate peer support in residential recovery homes varies among providers. This article presents specific, practical suggestions for enhancing social model principles in ways that facilitate peer support in a range of recovery residences.

Prevention of materno-foetal transmission of hepatitis B in sub-Saharan Africa: the evidence, current practice and future challenges

Hepatitis B (HBV) infection is highly endemic in sub-Saharan Africa (SSA), where more than 8% of the population remain chronic HBV carriers. SSA has one of the highest HBV-related liver cancer rates in the world (CA Cancer J Clin, 55, 2005, 74) and HBV-related liver cancer is the most common cause of premature death in West Africa (Lancet Oncol, 9, 2008, 683; Hepatology, 39, 2004, 211). As such, HBV represents a significant global threat to health in the African continent. Most SSA countries have elected to vaccinate all children against HBV through the WHO-sponsored Expanded Program of Immunization and the current recommendation from WHO-AFRO is for birth-dose HBV vaccination to prevent maternal/child transmission (MFT) and early horizontal transmission of HBV. However, in Africa, HBV vaccine coverage remains low and HBV birth-dose vaccination has not been implemented. HBV transmission from mother to child in the early perinatal period therefore remains a significant contributor to the burden of HBV-related disease in SSA. This review explores the evidence for materno-foetal transmission of HBV in SSA, outlining current practice for HBV MFT prevention and identifying the significant challenges to implementation of HBV prevention in SSA.

Hepatitis C recurrence: the Achilles heel of liver transplantation

Hepatitis C virus (HCV) infection is the most common indication for liver transplantation worldwide; however, recurrence post transplant is almost universal and follows an accelerated course. Around 30% of patients develop aggressive HCV recurrence, leading to rapid fibrosis progression (RFP) and culminating in liver failure and either death or retransplantation. Despite many advances in our knowledge of clinical risks for HCV RFP, we are still unable to accurately predict those most at risk of adverse outcomes, and no clear consensus exists on the best approach to management. This review presents a critical overview of clinical factors shown to influence the course of HCV recurrence post transplant, with particular focus on recent data identifying the important role of metabolic factors, such as insulin resistance, in HCV recurrence. Emerging data for genetic markers of HCV recurrence and their usefulness for predicting adverse outcomes will also be explored.

Nursing the tropics: nurses as agents of imperial hygiene

BACKGROUND

Mrs Francis Piggott proposed the Colonial Nursing Association in 1895 as a means of supplying Britain's colonies and dominions with trained professional nurses, who would support the health of white colonists abroad. Over 8400 nurses were placed between 1896 and the Association's end in 1966. Despite the burgeoning of scholarship on gender and empire over the last few decades, there is still more research to be done examining nurses as professional, working women, who present a fascinating variation on the figure of the woman traveler.

METHODS

This essay focuses on 1896-1927, exploring how nurses were prepared for their labor abroad and how these skills were challenged and adapted within a foreign environment. We contextualize this discussion with examples from literary tales of exploration and adventure and discourses of empire.

RESULTS/CONCLUSIONS

Though the sources of disease against which nurses fought changed during this period, we assert that the underlying role of the nurse continued the same: she was meant to use the tools of personal as well as public 'hygiene' to create both physical and cultural boundaries around her white patients and herself, setting colonists apart from their colonial setting.

Identifying the superior measure of rapid fibrosis for predicting premature cirrhosis after liver transplantation for hepatitis C

BACKGROUND

Hepatitis C virus (HCV) recurrence post liver transplant is universal, with a subgroup of patients developing rapid hepatic fibrosis. Various clinical definitions of rapid fibrosis (RF) have been used to identify risks for rapid progression, but their comparability and efficacy at predicting adverse outcomes has not been determined.

METHODS

Retrospective data analysis was conducted on 100 adult patients with HCV who underwent liver transplantation at a single center. We measured year 1 fibrosis progression (RF defined as METAVIR F score ≥ 1 at 1-year liver biopsy), time to METAVIR F2-stage fibrosis, and fibrosis rate (calculated using liver biopsies graded by METAVIR scoring F0-4; fibrosis rate = fibrosis stage/year post transplant). RF was defined as ≥ 0.5 units/year.

RESULTS

Multivariate analysis revealed that donor age and peak HCV viral load were significant risks for RF, when fibrosis rate was used to define RF. Advanced donor age was a risk for rapid progression to F2-stage fibrosis, whereas genotype 2 or 3 HCV infection was protective. Fibrosis rate had the strongest correlation with time to cirrhosis development (P < 0.0001, r = -0.76) and was the most accurate predictor of rapid graft cirrhosis (P < 0.0001, area under the curve 0.979, sensitivity 100%, specificity 94%).

CONCLUSION

Different measures of RF progression identify different risks for RF and are not directly comparable. Fibrosis rate was the most accurate predictor of rapid graft cirrhosis.

Toll-like receptor 3 and 7/8 function is impaired in hepatitis C rapid fibrosis progression post-liver transplantation

Recurrence of hepatitis C (HCV) postliver transplant is universal, with a subgroup developing rapid hepatic fibrosis. Toll-like receptors (TLRs) are critical to innate antiviral responses and HCV alters TLR function to evade immune clearance. Whether TLRs play a role in rapid HCV recurrence posttransplant is unknown. We stimulated peripheral blood mononuclear cells (PBMCs) from 70 patients with HCV postliver transplant with TLR subclass-specific ligands and measured cytokine production, TLR expression and NK cell function. Rate of fibrosis progression was calculated using posttransplant liver biopsies graded by Metavir scoring (F0-4; R=fibrosis stage/year posttransplant; rapid fibrosis defined as >0.4 units/year). Thirty of 70 (43%) patients had rapid fibrosis progression. PBMCs from HCV rapid-fibrosers produced less IFNα with TLR7/8 stimulation (p=0.039), less IL-6 at baseline (p=0.027) and with TLR3 stimulation (p=0.008) and had lower TLR3-mediated monocyte IL-6 production (p=0.028) compared with HCV slow fibrosers. TLR7/8-mediated NKCD56 dim cell secretion of IFNγ was impaired in HCV rapid fibrosis (p=0.006) independently of IFNα secretion and TLR7/8 expression, while cytotoxicity remained preserved. Impaired TLR3 and TLR7/8-mediated cytokine responses may contribute to aggressive HCV recurrence postliver transplantation through impaired immune control of HCV and subsequent activation of fibrogenesis.

Toll-like receptor 3 and 7/8 function is impaired in hepatitis C rapid fibrosis progression post-liver transplantation

Recurrence of hepatitis C (HCV) postliver transplant is universal, with a subgroup developing rapid hepatic fibrosis. Toll-like receptors (TLRs) are critical to innate antiviral responses and HCV alters TLR function to evade immune clearance. Whether TLRs play a role in rapid HCV recurrence posttransplant is unknown. We stimulated peripheral blood mononuclear cells (PBMCs) from 70 patients with HCV postliver transplant with TLR subclass-specific ligands and measured cytokine production, TLR expression and NK cell function. Rate of fibrosis progression was calculated using posttransplant liver biopsies graded by Metavir scoring (F0-4; R=fibrosis stage/year posttransplant; rapid fibrosis defined as >0.4 units/year). Thirty of 70 (43%) patients had rapid fibrosis progression. PBMCs from HCV rapid-fibrosers produced less IFNα with TLR7/8 stimulation (p=0.039), less IL-6 at baseline (p=0.027) and with TLR3 stimulation (p=0.008) and had lower TLR3-mediated monocyte IL-6 production (p=0.028) compared with HCV slow fibrosers. TLR7/8-mediated NKCD56 dim cell secretion of IFNγ was impaired in HCV rapid fibrosis (p=0.006) independently of IFNα secretion and TLR7/8 expression, while cytotoxicity remained preserved. Impaired TLR3 and TLR7/8-mediated cytokine responses may contribute to aggressive HCV recurrence postliver transplantation through impaired immune control of HCV and subsequent activation of fibrogenesis.

Type 2 diabetes does not worsen prognosis in hepatocellular carcinoma

INTRODUCTION

Type 2 diabetes (T2DM) is associated with liver inflammation and carcinogenesis. The prevalence of T2DM among patients with liver cirrhosis and hepatocellular carcinoma is increasing. However, the effect of T2DM on the natural history of hepatocellular carcinoma is not known.

AIM

To examine the effect of T2DM on hepatocellular carcinoma (HCC) survival in treated and untreated disease.

METHODS

Retrospective analysis was performed on HCC cases diagnosed during 2000-2005, and prospectively during 2006-August 2007. Demographics, HCC staging, response to treatment, and survival were collected. A comparison was made between patients with T2DM and without T2DM.

RESULTS

One hundred and thirty-five patients were recruited in total; 58 (43%) had T2DM. Seventy (37 diabetic) patients were treated with percutaneous radiological therapies, with 168 treatments given. Treatment was determined by AASLD guidelines and patient tolerance, there was no randomisation. There was no significant difference in survival between diabetic and nondiabetic patients. There was a nonsignificant trend towards greater survival in diabetic patients (overall median survival diabetics 21 mths vs nondiabetics 5 mths, P=0.355).

CONCLUSIONS

T2DM does not negatively impact on the natural history of treated or untreated HCC.

Maximum daily 6 minutes of activity: an index of functional capacity derived from actigraphy and its application to older adults with heart failure

OBJECTIVES

To compare the correlation between the maximum 6 minutes of daily activity (M6min) and standard measures of functional capacity in older adults with heart failure (HF) with that in younger subjects and its prognostic utility.

DESIGN

Prospective, cohort study.

SETTING

Tertiary care, academic HF center.

PARTICIPANTS

Sixty, ambulatory, adults, New York Heart Association (NYHA) Class I to III, stratified into young (50.9 +/- 9.4) and older cohorts (76.8 +/- 8.0).

MEASUREMENTS

Correlation between M6min and measures of functional capacity (6-minute walk test; 6MWT) and peak oxygen consumption (VO(2)) according to cardiopulmonary exercise testing in a subset of subjects. Survival analysis was employed to evaluate the association between M6min and adverse events.

RESULTS

Adherence to actigraphy was high (90%) and did not differ according to age. The correlation between M6min and 6MWT was higher in subjects aged 65 and older than in those younger than 65 (correlation coefficient (r=0.702, P<.001 vs r=0.490, P=.002). M6min was also significantly associated with peak VO(2) (r=0.612, P=.006). During the study, 26 events occurred (2 deaths, 10 hospitalizations, 8 emergency department visits, and 6 intercurrent illnesses). The M6min was significantly associated with subsequent events (hazard ratio=2.728, 95% confidence interval=1.10-6.77, P=.03), independent of age, sex, ejection fraction, NYHA class, brain natriuretic peptide, and 6MWT.

CONCLUSION

The high adherence to actigraphy and association with standard measures of functional capacity and independent association with subsequent morbid events suggest that it may be useful for monitoring older adults with HF.

The prevalence and impact of anergia (lack of energy) in subjects with heart failure and its associations with actigraphy

BACKGROUND

Anergia (lack of energy) is a newly delineated, criterion-based geriatric syndrome. Because heart failure (HF) is a common chronic condition among older adults and a because a cardinal symptom of HF is reduced energy, we characterized the degree of anergia in subjects with HF and evaluated its relevance to disease severity, functional performance, and quality of life.

METHODS AND RESULTS

Prospective 3-month cohort study among a convenience sample of 61 subjects (61 +/- 15 years, 48% women, ejection fraction 41 +/- 16%) with New York Heart Association (NYHA) Class I-III HF were studied. The criterion for anergia was based on the major criterion "sits around for lack of energy" and any 2 of 6 minor criteria. Principal measures in addition to demographic and clinical characteristics included functional performance (NYHA class, 6-minute walk, cardiopulmonary exercise testing), plasma B-type natriuretic peptide, and quality of life (SF-12 and Minnesota Living with Heart Failure Questionnaire). To evaluate the relevance of anergia to daily function, each subject wore an Actigraph, a watch-like wrist device that continuously and automatically monitors patient activity levels and energy expenditure, for 3 months. Anergia was prevalent in 39% of this population. Anergia was associated with decrements in functional capacity (higher NYHA Class and lower 6-minute walk distance) as well as reduction in quality of life, but was not associated with ejection fraction. Actigraphy data demonstrated that HF subjects with anergia spent significantly less time performing moderate physical activity and the peak activity counts per day were significantly lower than HF subjects without anergia. Additionally, the amplitude of circadian rhythm was lower, suggesting altered sleep and activity patterns in HF subjects with anergia compared with those without anergia. Over the 3 months of follow-up, there was a significant association between anergia and intercurrent hospitalization.

CONCLUSIONS

Anergia is significantly associated with several of the cardinal domains of HF. Its presence is associated with demonstrable differences in both physical activity and circadian rhythm as measured by actigraphy and an increased risk of hospitalizations. Accordingly, anergia may be a target for intervention among HF subjects.

Ethics and opportunity costs: have NICE grasped the ethics of priority setting?

The Social Value Judgments consultation document reveals NICE's failure to understand its role in healthcare prioritisation

Faecal calprotectin in the assessment of Crohn's disease activity

BACKGROUND

Clinical and laboratory assessment of activity in Crohn's disease (CD) correlate poorly with endoscopic findings. Calprotectin is a calcium-binding protein abundant in neutrophil cytosol, and extremely stable in faeces. Faecal calprotectin (FC) is an excellent surrogate marker of neutrophil influx into the bowel lumen.

AIM

To assess whether FC concentration from a spot stool sample reliably detects active inflammation in patients with CD.

DESIGN

Cross-sectional comparative study.

METHODS

Subjects had a previously confirmed diagnosis of CD and were suspected on clinical grounds to be in the midst of a relapse. Thirty-five entered the study; they underwent radiolabelled white cell scanning (WCS) and had a stool sample collected for calprotectin measurement on the same day. A Crohn's disease activity index (CDAI) was also calculated for each. The WCS scans were scored at six standard sites to give a mean total, 'extent', 'severity' and 'combined extent and severity' scores.

RESULTS

FC was significantly and positively correlated with mean total (r = 0.73, p < 0.001), 'extent' (r = 0.71, p < 0.001), 'severity' (r = 0.64, p < 0.001) and combined 'extent and severity' WCS scores (r = 0.71, p < 0.001). A cut-off of faecal calprotectin > 100 microg/g gave a sensitivity of 80%, specificity of 67%, positive predictive value of 87% and a negative predictive value of 64% in identifying those with and without any inflammation on WCS. There was, however, no significant correlation between CDAI and mean total WCS score (r = 0.21, p = 0.24), nor between CDAI and FC (r = 0.33, p = 0.06).

DISCUSSION

While the CDAI does not accurately reflect inflammatory activity in CD, a one-off FC reliably detects the presence or absence of intestinal inflammation in adult patients with CD, compared to WCS.

Embolus of surgical adhesive to the extremities causing acute ischemia: Report of two cases

We present 2 cases in which a surgical adhesive embolized to the extremities. In the first case an adhesive was successfully used in the repair of a DeBakey type I aortic dissection. The patient was seen 2 months postoperatively with acute lower extremity ischemia, and a large piece of adhesive was extracted from the iliac and femoral arteries at embolectomy. In the second case the adhesive was used to seal a pericardial patch during repair of a ventricular septal defect. This patient was seen 1 day postoperatively with acute arm ischemia, and the adhesive particle was extracted from the brachial artery during embolectomy.