Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

Palliative Management of Inoperable Malignant Bowel Obstruction: Prospective, Open Label, Phase 2 Study at an NCI Comprehensive Cancer Center

CONTEXT

Malignant bowel obstruction (MBO) is a common complication of intra-abdominal cancer, frequently seen in advanced gastrointestinal and gynecologic cancer. Management of MBO can be challenging, particularly if the patient is not a surgical candidate. No consensus exists on how best to manage these patients medically. Retrospective studies suggest that the combination of dexamethasone, octreotide and metoclopramide may lead to relief of obstruction and improvement in symptoms associated with the obstruction.

OBJECTIVES

This study seeks to prospectively evaluate the combination of drug "triple therapy" dexamethasone 4 mg BID, metoclopramide 10 mg Q6 and octreotide 300 mcg TID to assess tolerability, safety, and effect on symptoms and deobstruction.

METHODS

Adults admitted at Roswell Park Comprehensive Cancer Center with malignant bowel obstruction were eligible. Eligible patients who constented to the study were started on the triple therapy with close monitoring of symptoms and for adverse effects.

RESULTS

A total of 15 patients enrolled in the study. Two patients experienced bradycardia as adverse effect and there was no incidence of bowel perforation. All patients who completed the study had complete resolution of their nausea, and improvement in other symptoms including pain, constipation, tolerance of oral intake and resumption of bowel movements. Only two of the 15 patients were alive to complete the six-month post study follow up.

CONCLUSION

"Triple therapy" with dexamethasone, metoclopramide, and octreotide for management of nonsurgical MBO in this small sample size appears safe and well tolerated however a diagnosis of inoperable MBO remains associated with poor prognosis and death within months.

Concordance of three approaches for operationalizing outcome definitions for multidrug-resistant TB

BACKGROUND: The WHO provides standardized outcome definitions for rifampicin-resistant (RR) and multidrug-resistant (MDR) TB. However, operationalizing these definitions can be challenging in some clinical settings, and incorrect classification may generate bias in reporting and research. Outcomes calculated by algorithms can increase standardization and be adapted to suit the research question. We evaluated concordance between clinician-assigned treatment outcomes and outcomes calculated based on one of two standardized algorithms, one which identified failure at its earliest possible recurrence (i.e., failure-dominant algorithm), and one which calculated the outcome based on culture results at the end of treatment, regardless of early occurrence of failure (i.e., success-dominant algorithm).METHODS: Among 2,525 patients enrolled in the multi-country endTB observational study, we calculated the frequencies of concordance using cross-tabulations of clinician-assigned and algorithm-assigned outcomes. We summarized the common discrepancies.RESULTS: Treatment success calculated by algorithms had high concordance with treatment success assigned by clinicians (95.8 and 97.7% for failure-dominant and success-dominant algorithms, respectively). The frequency and pattern of the most common discrepancies varied by country.CONCLUSION: High concordance was found between clinician-assigned and algorithm-assigned outcomes. Heterogeneity in discrepancies across settings suggests that using algorithms to calculate outcomes may minimize bias.

Deciphering the inflection points to achieve proficiency for each procedure step during training in laparoscopic appendicectomy

Background

Laparoscopic appendicectomy is a common procedure early in surgical training. A minimum number is usually required for certification in general surgery. However, data on proficiency are scarce. This study aimed to investigate steps towards proficiency in laparoscopic appendicectomy.

Methods

This was a prospective observational cohort study of laparoscopic appendicectomies performed by junior trainees under supervision scored on a six-point performance scale. Structured assessment was done within a defined programme. Procedures performed for uncomplicated appendicitis in adults were included. The procedures were evaluated with LOWESS graphs generated to investigate inflection points. Factors associated with proficiency rates were reported with odds ratios and 95 per cent confidence intervals.

Results

In total 142 laparoscopic procedures were included for 19 trainees (58 per cent female). The cumulative number of procedures during the study was a median of 20 (i.q.r. 8–33). For overall proficiency, an inflection point occurred at 30 procedures. Proficiency rate increased from 51 per cent for 30 or fewer procedures to 93 per cent for more than 30 procedures (odds ratio 11.9 (95 per cent c.i. 3.4 to 40.9); P < 0.001). Inflection points for proficiency for each procedure step varied considerably, with lowest numbers (fewer than 15 procedures) for removing the specimen, and highest for dividing the mesoappendix (more than 55 procedures). Operating time was significantly reduced by a median of 7 minutes after 30 procedures, from median 62 (i.q.r. 25–120) minutes to median 55 (i.q.r. 30–110) minutes for more than 30 procedures.

Conclusion

For junior trainees, variation in proficiency is related to specific procedure steps. Targeted training on specific procedure skills may reduce numbers needed to achieve proficiency in laparoscopic appendicectomy during training.

P1329 An unexpected finding in a patient wth previous coronary artery bypass grafts and atypical chest pain

A 79-year-old male with a previous history of ischaemic heart disease and previous coronary artery bypass grafting (CABG) in 2005 presented with atypical chest pain. He also had past medical history of hypertension, hyperlipidaemia and bladder diverticulum which has been previously investigated by an abdominal CT. The latter had showed an incidental finding of what was reported to be a large pericardial cyst. Despite poor acoustic window, transthoracic echocardiography revealed a spherical echo–free structure in the area of the right atrioventricular groove (Figure 1, panel A white arrow). As the patient was too claustrophobic to undergo cardiac MRI, he was subsequently referred for a cardiac CT in order to further investigate the cystic mass and assess graft patency. The CT revealed an occluded left internal mammary artery (LIMA) to the LAD, severe left main (LM) and proximal LAD disease, a patent vein graft to an obtuse marginal (OM) branch and identified a largely thrombosed giant aneurysm (62x65x89 mm) of an otherwise patent vein graft to the RCA (Figure 1, panels B–E, white arrows point to the thrombosed and yellow arrows point to the non-thrombosed segments of the vein graft aneurysm). Coronary angiography confirmed occlusion of the LIMA, patency of the OM vein graft and identified only the non-thrombosed segment of the RCA vein graft aneurysm (Figure 1, panel F). The case was discussed at an MDT meeting and it was decided to proceed with LM and LAD stenting, and initially conservative management and close surveillance of the RCA vein graft aneurysm as the patient was high–risk for repeat CABG due to age, frailty and other comorbidities.

Abstract P1329 Figure 1

New insights into the plasmonic enhancement for photocatalytic H2 production by Cu–TiO2 upon visible light illumination

Cu nanoparticles were deposited on the surface of commercial TiO₂ nanoparticles (Cu–TiO₂) using different methods aiming at the production of highly efficient visible light photocatalysts.

[A series of 20 cases of endogenous endophthalmitis]

BACKGROUND

The purpose of this case series was to evaluate both the visual and systemic prognosis of patients with endogenous endophthalmitis.

MATERIAL AND METHODS

We reported a series of 20 cases of endogenous endophthalmitis occurring between 2012 and 2015 at the university medical center in Toulouse.

RESULTS

The mean age was 67 (±43.3) years with a male predominance (n=11). The site of entry was found in 14 cases (87.5%). In 11 cases (69%), the causative agent was a bacterium; a fungal infection was found in five cases. Visual acuity after maximal medical and surgical treatment was limited to "no light perception" in 7 cases (35%), "hand motion" in 2 cases (10%), "finger counting" in 3 cases (15%) and 10/10 in 2 cases (10%). One case had no final data. The main site of entry was found to be associated endocarditis (n=7), central venous line or venipuncture (n=6). The main local complications were retinal detachment (n=6), cataract (n=5) and choroidal neovascularization secondary to scarring (n=2).

CONCLUSIONS

Endogenous endophthalmitis is associated with poor visual prognosis. It is also often associated with systemic complications that may be life-threatening.

Phenotypic and genotypic characterization of methicillin-resistant Staphylococcus aureus from bovine mastitis

Aim:

This study was conducted to determine the occurrence of methicillin-sensitive and Staphylococcus aureus (MSSA) methicillin-resistant S. aureus (MRSA) from bovine mastitis and to characterize them with respect to antibiotic resistance gene mecA.

Materials and Methods:

A total of 160 mastitic milk samples were screened for the presence of S. aureus. The presumptive positive isolates were confirmed using nuc and 23S rRNA gene-based polymerase chain reaction. All the confirmed isolates were subjected to in vitro antibiogram using a number of antibiotics. Isolates which showed resistance against methicillin were characterized for the presence of mecA gene.

Results:

Out of the total 160 milk samples, 36 (22.5%) samples yielded S. aureus. The in vitro antibiogram revealed that 16.6% S. aureus isolates were resistant to all antibiotics screened for and 5.5% isolates were sensitive to all of them. Furthermore, the study found 94.4%, 83.3%, 77.7%, 66.6%, 50%, and 27.7% of S. aureus isolates resistant to penicillin, ampicillin, amoxicillin-sulbactam, enrofloxacin, ceftriaxone, and methicillin, respectively. Out of the 36 S. aureus isolates, only 6 (16.6%) isolates were confirmed as MRSA while rest were MSSA.

Conclusion:

The higher occurrence of S. aureus-mediated mastitis was concluded due to improper hygienic and poor farm management. The multiple drug resistance reveals the indiscriminate use of drugs and presence of methicillin resistance gene determinant is an alarming situation as such infections are difficult to treat.

Patient-reported outcome measure for neuromyelitis optica: pretesting of preliminary instrument and protocol for further development in accordance with international guidelines

OBJECTIVE

This study outlines the development of a patient-reported outcome measure (PROM), an instrument to obtain self-reported health status for neuromyeltis optica (NMO), a disabling neurological condition.

DESIGN

Development was conducted in accordance with international guidance for PROMs including systematic review of existing literature, item generation guided by qualitative interviews, health-related quality of life conceptual framework and clinical expert panel and cognitive interviews with NMO patients.

SETTING

Participants were identified through a national NMO clinic in a tertiary NHS neurosciences service.

PARTICIPANTS

15 individuals with NMO participated in cognitive interviews requiring review and ranking of proposed PROM items and qualitative feedback on content, layout and response options.

RESULTS

Participants endorsed the draft instrument as reflecting their experience of the condition and as being easy to understand. Rating and ranking of item relevance and importance reduced the draft instrument from 106 to 48 items. Participant feedback on overlapping items eliminated a further 2 items and resulted in a preliminary instrument of 46 items. As a direct result of participant feedback ordering of the 10 domains was revised, a 4 option Likert scale was employed and a 4-week recall period for impact of symptoms was selected.

CONCLUSIONS

A 46-item instrument developed in accordance with international PROM development guidelines through literature review, developed by subject matter experts and refined through pretesting examining content validity provides a preliminary measure for assessing patient-report of health status in NMO. Further evaluation is proposed including sensitivity to clinical change, and international contributions to evaluating the measure are encouraged.

Prostate cancer recurrence after Focal Therapy: Treatment options

Focal therapy is a novel treatment option in localised prostate cancer with or without a visible lesion on MRI. Treatment for low to intermediate risk prostate cancer with focal therapy has demonstrated good short to medium term outcomes with fewer undesirable genitourinary side effects. This has made focal therapy more appealing to men who find the implications of radical treatment unacceptable or are unable to tolerate active surveillance. In this paper we review the literature for treatment options in prostate cancer recurrence post focal therapy. We also cover the different definitions of failure agreed upon in previous consensus meetings, as well as their implications on future management focal therapy patients.

[Treatment delay in patients with first episode of retinal detachment in the studied eye in Midi-Pyrénées]

INTRODUCTION

Retinal detachment (RD) is a potentially blinding condition. Delay in management is a major prognostic factor. In our study, we analyzed the treatment delay for retinal detachments in the Midi-Pyrenees area, and factors which may influence it.

MATERIAL AND METHODS

Observational, cross-sectional, multicentric study, carried out over a 6-month period.

PRIMARY OUTCOME

time between diagnosis and surgery. Secondary outcome: time between first symptoms and surgery. Non-parametric tests were used to analyze the influence of sociodemographic features, clinical features, distance between home and surgical center, and occurrence over a weekend.

RESULTS

One hundred and fiftty-nine patients were included. The mean time between diagnosis and surgery was 4.4 ± 12.3 days (2.7 ± 4.3 for recent RD, less than 1 month), and was increased by the presence of a weekend (P<0.001), or of a weekend with public holiday (P=0.023), and by macular detachment (P=0.008). The mean time between first symptoms and surgery was 12.0 days and was increased by the absence of RD history (P=0.023), and by macular detachment (P=0.046). No association was observed between these times to surgery and the distance between the patient's home address and the place of surgery.

CONCLUSION

The time between diagnosis and surgery was relatively short in the Midi-Pyrénées area, but we often noted a delayed diagnosis, which may be due to the patient's lack of awareness of the symptoms and difficult access to specialty consultations. However, no relationship was found between this time-to-surgery and the distance between the patient's home and the surgical center.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

[What were the obstacles to the development of outpatient cataract surgery in Toulouse University Hospital in 2013?]

INTRODUCTION

Cataract surgery is an ideal candidate for outpatient care. In 2013, in the Toulouse University Hospital, outpatient care rate for phacoemulsification was 75.8%. We conducted this study to identify the barriers that limit the development of outpatient cataract surgery in our establishment.

MATERIAL AND METHODS

A retrospective observational study was conducted. We included all patients who underwent phacoemulsification (Medical Act Code BFGA004) as a traditional inpatient in 2013. We excluded admissions for which the medical, anesthesia or nursing records, as well as scheduling sheets, were incomplete. Patients were classified according to the reason for inpatient hospitalization and the type of surgery: cataract as primary surgery or cataract as combined procedure.

RESULTS

Two hundred and ninety-eight stays were included with a mean age of 66.8 ± 16.8 years, and a male/female ratio of 0.76. The indication for inpatient hospitalization was a social, surgical or anesthetic reason in the following respective proportions: 41, 34 and 8% of cases. Failure of ambulatory care represented 7% of cases. Social isolation represented 89% of social reasons. In a combined gesture, the reason was surgical in 89% of cases.

CONCLUSION

Development of outpatient surgery requires the participation of all involved. Taking into account the social factors is an essential element for developing ambulatory surgery. Social isolation is a frequent situation requiring a societal response. With regard to surgical considerations, practice patterns must target outpatient combined procedures in particular.

[Multimodal imaging in the diagnosis of acute macular neuroretinopathy]

INTRODUCTION

Acute macular neuroretinopathy is a retinal disease, usually presenting with a "normal fundus". Thus, this condition can be mistaken for optic neuropathy. Herein we present five clinical cases of patients affected with acute macular neuroretinopathy; one of them is a retrospective diagnosis while the others were diagnosed on initial examination. In the five cases, multimodal imaging with infrared photography and OCT helped to establish the diagnosis.

MATERIAL AND METHODS

Retrospective study of five clinical cases. Initial and final best visual acuities as well as infrared and OCT imaging were collected for all patients.

RESULTS

All patients initially reported a visual disturbance associated with a more or less severe decrease in visual acuity. Infrared imaging showed a dark, perifoveolar appearance of the lesions. In all cases, OCT images showed thickening and hyperreflectivity of the outer plexiform layer, extending towards the outer retinal layers.

CONCLUSION

Acute macular neuroretinopathy is a clinical entity that has been long-described, which now benefits widely from new imaging technologies, allowing an earlier and more accurate diagnosis, but calling into question the actual name of this condition. The exact pathophysiology of the condition remains nonetheless incompletely elucidated.

Enhancing co-metabolic degradation of trichloroethylene with toluene using Burkholderia vietnamiensis G4 encapsulated in polyethylene glycol polymer

The biodegradation potential of Burkholderia vietnamiensis G4 (B. vietnamiensis G4) was evaluated under encapsulation in comparison with direct exposure to trichloroethylene (TCE) (0.1, 0.5, 1 and 5 mg/L) and toluene (10 and 50 mg/L), maintaining aerobic conditions. B. vietnamiensis G4 was encapsulated in polyethylene glycol (PEG) polymer. Under suspended conditions, the degradation rate decreased as the initial TCE concentration increased, even with a higher amount of substrate available. However, the encapsulated systems were less suppressed, presumably by mitigated toxicity, and completely removed TCE with 50 mg/L of toluene. The transformation yield (Ty) was as high as 0.427 mg-TCE/mg-toluene for the encapsulated cultures and 0.1007 mg-TCE/mg-toluene for the suspended cultures. The Ty value for the encapsulated cultures was one to two orders higher than what has been reported in the literature. The higher Ty values in the encapsulated cultures compared with those from suspended cultures showed that the PEG encapsulation provided more a favourable environment for efficient substrate use.

Seroprevalence of hepatitis E and Helicobacter pylori in a low socioeconomic area of a metropolitan city in a developing country

This study aims to determine the prevalence of coinfection of H. pylori and hepatitis E virus (HEV) in the paediatric age group in an urban slum area of Karachi and identify risk factors associated with co-infection. Five hundred and forty children aged one to 15 years were investigated. Blood samples were collected and questionnaires completed on socio-demographic characteristics. Anti-H. pylori, HEV IgG and IgM antibodies were analysed by enzyme immunoassays (EIAs). The seroprevalence of H. pylori antibody was 47.2%, while that of HEV IgG and IgM was 14.4% and 2.4%, respectively. 12.4% exhibited seroprevalence for both H. pylori and HEV (IgG). In 67 (26%) cases positive for H. pylori IgG, HEV IgG positivity was also seen (P < 0.001). Only 13 (5%) positive for H. pylori were also positive for HEV IgM (P < 0.001). Only 11 (4%) HEV IgG-positive cases were H. pylori antibody-negative (P < 0.001). Hepatitis E virus was common in children who had access to municipal piped water (P = 0.025). H. pylori was common in children who used a non-flush toilet system (P < 0.001). Children exposed to H. pylori infection were also exposed to the risk of HEV.

Comparative analysis of case screening with varying cough duration and sputum samples for diagnosis of tuberculosis in patients attending the OPD at a tertiary care hospital at Srinagar, India

RESEARCH QUESTION

Can we minimize cough duration and number of sputum samples in chest symptomatic patients for screening of TB?

OBJECTIVE

To evaluate cough of 3 weeks versus 2 weeks duration using two sputum samples versus three samples in chest symptomatic patients attending the OPD.

STUDY DESIGN

Hospital-based cross-sectional study.

MATERIALS AND METHODS

Outpatients (2810) with H/O cough of 3 weeks and 2 weeks duration were screened by subjecting them to sputum microscopy for tuberculosis using two sputum samples as well as three samples following standard procedure for sputum collection, staining and acid-fast bacillus (AFB) identification. Those on drugs were not included.

RESULTS

Using ≥2 weeks cough, sputum positivity rate was 12%, nearly as high as the sputum positivity among patients with ≥3 weeks cough, i.e. 14%. First sputum smear alone on an average could detect 91.8% cases, while the first two sputum smears could detect on an average 96% cases. The study showed that maximum number of cases was diagnosed by only two sputum smears and added diagnostic value of third specimen was small, i.e. 4%.High sputum positivity rate using ≥2 weeks cough with two sputum samples was seen.

CONCLUSION

The sensitivity analysis of the study showed that using ≥2 weeks cough with two sputum samples gives almost similar values as ≥3 weeks cough with three sputum samples, but this needs further confirmatory results of culture sensitivity. Hence, using ≥2 weeks cough with two sputum samples as the diagnostic criteria for screening of cough patients for TB should be recommended as one way of improving efficient use of scarce resources.

Prevalence of Cryptosporidium species among HIV positive asymptomatic and symptomatic immigrant population in Kashmir, India

BACKGROUND AND OBJECTIVES

Cryptosporidiosis has not been reported as an endemic disease in Kashmir, but high prevalence of Cryptosporidium sp. has been found among asymptomatic (non-diarrheic) HIV positive immigrants in present study. Due to increasing number of HIV positive immigrants in Kashmir, Cryptosporidium may become a public health problem in Kashmir.

MATERIALS AND METHODS

A total of 45 stool samples were obtained from symptomatic (diarrheic n = 9) and asymptomatic (non-diarrheic n = 36) patients infected with HIV. The stool samples were concentrated using formalin ethyl acetate concentration technique, stained with modified Kinyoun's cold stain and oocysts were identified by microscopy under 1000 x magnification. It was confirmed by detection of antigens in stool samples by ELISA.

RESULTS

It was established that all the patients studied were carriers of Cryptosporidium. In present study though 80% of patients were asymptomatic (non-diarrheic) and HIV positive which involved non-Kashmiri army personals and travelers (immigrants) but were carriers of Cryptosporidium and 20% of HIV positive patients were emigrants (local Kashmiri traders) who travelled different states of India were having diarrhea (symptomatic) as well as carrier of Cryptosporidium.

CONCLUSION

Though Cryptosporidium infection causes chronic diarrhea but in present study all HIV positive patients screened whether diarrheic or non-diarrheic were positive for Cryptosporidium. To prevent the transmission of Cryptosporidium oocyst in environment and endemic spread of cryptosporidiosis as non-diarrheic HIV positive population may be potential source of infection, obligatory laboratory testing for Cryptosporidium in HIV positive immigrant population like traders and travelers is highly recommended in order to have a better understanding of the cause of spread Cryptosporidium infection in Kashmir.

Trends, indications and outcomes of cardiac implantable device system extraction: a single UK centre experience over the last decade

BACKGROUND

The rising number of device implantation has seen a parallel in the rising numbers of lead extraction. Herein we have analysed our experience in cardiac device and lead extraction in a single tertiary centre over the last decade.

METHOD

Retrospective analysis of all consecutive patients undergoing lead extractions performed between 2001 and 2010. Procedural success and complications as defined by the Heart Rhythm Society policy.

RESULTS

A total of 745 leads were extracted with a procedural success of 98.9% [382 cases; partial success in 6.9% (26) cases] and failure in 1.1% (4). Major complication rate was 1% (four cases) and minor complication rate was 3.6%. By both univariate and multivariate analysis only duration of lead implantation was an indicator for success (p < 0.0001). The mean implantation time for failed lead extraction was 203 ± 64 months compared with 71.8 ± 16.5 months in the successful cohort (p < 0.0001). Laser-assisted extraction was required in 176 cases. With regard to extraction indication, lead malfunction/recall showed a significant increase during the study period (p = 0.03). On time trend analysis the rise in coronary sinus (CS) lead extraction over time was significant. (p = 0.02) Despite a trend for increased laser use over time this did not achieve statistical significance, p = 0.06.

CONCLUSIONS

A decade's experience of percutaneous lead extraction suggests that a high procedural success rate with a low complication rate is achieved in a high-volume centre. During this time, an increase in both defibrillator and CS lead explantation and a rising trend in laser assistance with almost 50% of cases needing laser usage were observed.

Abstract P4-11-13: A Multi-Institutional Assessment of the Feasibility, Implementation, and Early Clinical Results with Noninvasive Image-Guided Breast Brachytherapy for Tumor Bed Boost

Background: Noninvasive image-guided breast brachytherapy (NIIGBB) is an FDA-approved, commercially available (AccuBoost®, Billerica, MA) mammography-based, breast brachytherapy system whereby the treatment applicators are centered on the planning target volume (PTV) to direct 192Ir emissions along orthogonal axes. This study evaluates the feasibility, implementation, and early results of NIIGBB for breast tumor bed boost in combination with external beam whole breast radiation therapy (WBRT), as part of post-lumpectomy radiation.

Material and Methods: A privacy-encrypted online data registry was created to collect clinical and technical information from 8 independent academic and community-based institutions. Data were collected from consecutive 110 individual women with early stage breast cancer after breast conserving surgery, who received adjuvant WBRT (mean dose 48.3 ± 2.5 Gy) and tumor bed boost with NIIGBB between July, 2007 and March, 2010. Of the patients, 74% had invasive cancer, with 80% ER+ and 34% HER2+. NIIGBB was delivered before, during, or after WBRT in 57%, 39%, or 4% of the patients. Patient age and lumpectomy cavity size ranged from 32-88 yrs and 0.1-5.3 cm, respectively. Boost dose was delivered in 1.9 ± 0.3 Gy/fx for a total of 12.9 ± 3.4Gy. Toxicity and cosmesis were evaluated after radiation therapy and graded according to the Common Toxicity Criteria (v3.0) and the Harvard scale. Median follow up was 6 months (1-17 months).

Results: Grade 1-2 skin toxicity was observed in 18%, 7%, and 0% during the acute (1-3wks), intermediate (4-26 wks), and late-intermediate (&gt;26wks) periods. There were no Grade 3 or higher skin toxicity events. At 6 months, for the entire cohort, cosmetic grading was excellent, good, fair/poor in 52%, 48%, and 0%. The breast compression achieved for each treatment session was remarkably consistent with a mean mammographic plate separation of 6.4 ± 0.3 cm. Breast compression was scored as “uncomfortable” when NIIGBB was delivered before or during WBRT. The mean total duration of set-up and treatment per fraction was 16.7 ± 2.1 min. For each patient, the fraction-to-fraction variability in estimated PTV was low as 69% of treatments were completed with the same applicator size.

Discussion: These data indicate that NIIGBB is feasible and can be consistently implemented in a broad array of practice settings. Preliminary evaluation suggests that NIIGBB is associated with acceptably mild normal tissue toxicity and favorable early cosmetic results. The application of

NIIGBB before completion of WBRT may be associated with better patient tolerance at the expense of slightly less favorable short-term cosmetic outcome.

Extraction of cardiac rhythm devices: indications, techniques and outcomes for the removal of pacemaker and defibrillator leads

Cardiac rhythm management devices (pacemakers) are being increasingly implanted worldwide not only for symptomatic bradycardia, but also for the management of arrhythmia and heart failure. Their use in more elderly patients with significant comorbidities is rising steeply and consequently long-term complications are increasingly arising. Such an increase in device therapy is being paralleled by an increase in the requirement for system extraction. Safe lead extraction is central to the management of much of the complications related to pacemakers. The most common indication for lead extraction is system infection Adhesions in chronically implanted leads can become major obstacles to safe lead extraction and life-threatening bleeding and cardiac perforations may occur. Over the last 20 years, specific tools and techniques for transvenous lead extraction have been developed to assist in freeing the lead body from the adhesions. This article provides a comprehensive review of the indications, tools, techniques and outcomes for transvenous lead extraction. The success rate largely depends on the time from implant. Up to 12 months from implant, it is rare that traction alone will not suffice. For longer lead implant duration, no single technique is sufficient to address all extractions, but laser provides the best chance of extracting the entire lead. Operator experience is vital in determining success as familiarity of a wide array of techniques will increase the likelihood of uncomplicated extraction. Long implantation time, lack of operator experience, ICD lead type and female gender are risk factors for life-threatening complications. Lead extraction should therefore, ideally be performed in high volume centres with experienced staff and on-site support from a cardiothoracic surgical team able to deal with bleeding complications from cardiovascular perforation.

Health care risk factors among women and personal behaviours among men explain the high prevalence of hepatitis C virus infection in Karachi, Pakistan

To estimate the prevalence and identify factors associated with hepatitis C virus (HCV) infection among men and women in Karachi, Pakistan. We conducted a cross-sectional study of adult men and women in a peri-urban community of Karachi (Jam Kandah). Households were selected through systematic sampling from within all villages in the study area. All available adults within each household were interviewed about potential HCV risk factors. A blood specimen was collected to test for anti-HCV antibodies by enzyme immunoassay. We used generalized estimating equations while accounting for correlation of responses within villages to identify the factors associated with HCV infection. Of 1997 participants, 476 (23.8%) were anti-HCV positive. Overall, HCV infection was significantly associated with increasing age, ethnicity, and having received > or =2 blood transfusions, > or =3 hospitalizations, dental treatment and >5 injections among women. Among women, > or =2 blood transfusions [adjusted odds ratio (aOR) = 2.32], >5 injections during the past 6 months (aORs = 1.47), dental treatment (aOR = 1.31) and increasing age(aOR = 1.49), while among men, extramarital sexual intercourse (aOR = 2.77), at least once a week shave from barber (aOR = 5.04), > or =3 hospitalizations (aOR = 2.50) and increasing age (aOR = 1.28) were associated with HCV infection. A very high prevalence of HCV was found in the study population. Among women, unsafe health care practices, while among men extramarital sex, shaving from a barber and hospitalizations were associated with HCV infection. Efforts are needed to improve the safety of medical procedures to reduce the transmission of HCV in Pakistan [Corrections made in Summary after initial online publication.].