Long-term functional success and patient-reported outcomes after female one-stage buccal mucosal graft urethroplasty

INTRODUCTION AND OBJECTIVES

Female urethral strictures are a rare condition that significantly impacts patients' quality of life. Patient-reported outcomes are crucial, yet data regarding sexual function and treatment satisfaction are scarce. We aimed to provide insights from a reconstructive referral center.

PATIENTS AND METHODS

We conducted a retrospective analysis of women treated with ventral onlay one-stage buccal mucosa graft urethroplasty for urethral strictures between 2009-2023. We assessed objective (retreatment-free survival, ΔQmax) and subjective outcomes (validated patient-reported outcomes).

RESULTS

Of 12 women, 83% and 17% had iatrogenic and idiopathic strictures, respectively. Median number of prior interventions was 6. Strictures were located meatal and mid-urethral in 25% and 75%, respectively, 22% had the bladder neck involved. Median graft length was 2 cm. At median follow-up of 66 months, 33% of patients underwent stricture retreatment, but only one case occurred within the first 2 years postoperatively. The median improvement in maximum flow rate (ΔQmax) was 10 ml/s. Median International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS) scores were 8 for filling symptoms, 6 for voiding symptoms, and 3 for incontinence symptoms. Median ICIQ-FLUTSsex score was 4. Higher scores indicate a higher symptom burden. Median ICIQ-Satisfaction outcome and satisfaction scores were 18 and 7, respectively, reflecting high treatment satisfaction.

CONCLUSIONS

Buccal mucosal graft urethroplasty by ventral onlay for female urethral strictures yields effective, durable, and positively received outcomes. However, larger studies across multiple institutions are necessary to further assess its efficacy, especially regarding patient-reported experiences and sexual function.

Mortality and mental health funding-do the dollars add up? Eating disorder research funding in Australia from 2009 to 2021: a portfolio analysis

Background

Eating Disorders (EDs) are among the deadliest of the mental disorders and carry a sizeable public health burden, however their research and treatment is consistently underfunded, contributing to protracted illness and ongoing paucity of treatment innovation.

Methods

We compare absolute levels and growth rates of Australian mental health research funding by illness group for the years 2009-2021, with a specific focus on eating disorders analysed at the portfolio level.

Findings

Actual and adjusted data obtained from Australia's three national medical research funding bodies (NHMRC, ARC and MRFF) shows eating disorders receive a disproportionately low allocation of mental health research funding despite having amongst the highest mortality rates. Forty-one category one research grants totalling $AUD28.1 million were funded for eating disorders over the period. When adjusted for inflation, this equates to $2.05 per affected individual, compared with $19.56 for depression, $32.11 for autism, and $176.19 for schizophrenia. Half of all research funded for eating disorders was 'basic' research (e.g., illness underpinning), with little investment in the development of innovative treatment models, novel therapeutics or translation, well reflected by recovery rates of less than 50% in individuals with Anorexia Nervosa.

Interpretation

Significant discrepancy remains between research funding dollars and disease burden associated with the mental health disorders. The extent to which eating disorders are underfunded may in part be attributable to inaccuracies in epidemiological and burden of disease data.

Funding

This work was in-part funded by the Australian Government Department of Health and the National Eating Disorder Research & Translation Strategy. The funder was not directly involved in informing the development of the current study.

Development of an intervention to manage knee osteoarthritis risk and symptoms following anterior cruciate ligament injury

INTRODUCTION

Anterior cruciate ligament (ACL) injury is a risk factor for developing knee osteoarthritis (OA). We developed an intervention to support people manage risk factors for OA.

METHODS

We conducted one-on-one interviews with 20 individuals with OA symptoms 6-15 years post ACL injury and used a nominal group process during a workshop with 40 patients and healthcare professionals (HCPs) to elicit information on the intervention content and delivery characteristics (timing, HCPs, and methods). Interview data were analyzed using content analysis. Nominal group ideas with importance ratings ≥5 of 7 met criteria for inclusion. Results were integrated, considering similarities and differences.

RESULTS

Eight content categories were identified: 1. understanding knee injury and expectations about recovery; 2. understanding OA risk; 3. understanding OA signs and symptoms; 4. managing OA risk; 5. managing knee OA symptoms; 6. information for influencers; 7. credible sources; and, 8. updates on new evidence and treatments. Delivery timing reflected a lifespan approach from time of injury through symptomatic knee OA management. Although multiple media for delivery were identified, introductory face-to-face discussions and opportunity for re-accessing HCPs were critical. All HCPs who treat people with ACL should be familiar with and able to deliver the intervention.

CONCLUSIONS

This co-development approach identified that an intervention to support people with ACL injury to limit and manage knee OA requires content embedded within an easily accessible, multi-media delivery model with capacity for check-back with HCPs that is appealing to different age groups and personal preferences over the lifespan post injury.

Sofosbuvir/velpatasvir for 12 vs. 6 weeks for the treatment of recently acquired hepatitis C infection

BACKGROUND & AIMS

Shortened duration therapy for acute and recent HCV infection has been shown to be highly effective in several small non-randomised studies with direct-acting antiviral regimens; however, large randomised studies are lacking.

METHODS

REACT was an NIH-funded multicentre international, open-label, randomised, phase IV non-inferiority trial examining the efficacy of short course (6-week) vs. standard course (12-week) therapy with sofosbuvir-velpatasvir for recent HCV infection (estimated duration of infection ≤12 months). Randomisation occurred at week 6. The primary endpoint was sustained virological response 12 weeks after treatment end (SVR12) in the intention-to treat (ITT) population. A total of 250 participants were due to be enrolled, but on advice of the data safety and monitoring board the study was halted early.

RESULTS

The primary analysis population consisted of 188 randomised participants at termination of study enrolment; short arm (n = 93), standard arm (n = 95). Ninety-seven percent were male and 69% HIV positive. ITT SVR12 was 76/93, 81.7% (95% CI 72.4-89.0) in the short arm and 86/95, 90.5% (95% CI 82.7-95.6) in the standard arm. The difference between the arms was -8.8 (95% CI -18.6 to 1.0). In modified ITT analysis, wherein non-virological reasons for failure were excluded (death, reinfection, loss to follow-up), SVR12 was 76/85, 89.4% (95% CI 80.8-95.0) in the short arm and 86/88, 97.7% in the standard arm (95% CI 92.0-99.7; difference -8.3%, p = 0.025).

CONCLUSIONS

In this randomised study in recent HCV infection, a 6-week course of sofosbuvir-velpatasvir did not meet the criteria for non-inferiority to standard 12-week therapy.

LAY SUMMARY

In this randomised trial, 188 people with recently acquired hepatitis C infection were randomly assigned to treatment using either a short 6-week course (93 people) or standard 12-week course (95 people) of the hepatitis C treatment sofosbuvir/velpatasvir. There were 9 cases of relapse after treatment with the short course and 2 following the standard course. A shortened course of 6-week therapy for hepatitis C infection appeared to be less effective than a standard 12-week course in people with recently acquired hepatitis C infection. CLINICALTRIALS.

GOV IDENTIFIER

NCT02625909.

Guidance on prevention of unintended and accidental radiation exposures in nuclear medicine

Nuclear medicine (NM) procedures for diagnosis and treatment of disease are performed routinely in hospitals throughout the world. These involve preparation and administration to patients of pharmaceuticals labelled with radioactive material. The International Atomic Energy Agency (IAEA) and the World Health Organisation highlighted the need for improvement in prevention of medical radiation incidents and accidents in the Bonn Call-for-Action in 2012. An IAEA Technical Meeting was held on prevention of unintended exposures and accidents in NM in 2018 to address the issue. Exposures can take place at any time when radioactive material is being produced and used, and the risk continues after procedures have been completed. Thus there is potential for staff or members of the general public to be exposed, as well as patients. This paper sets out guidelines for incident prevention based on presentations and discussions at the meeting, and review of reports from the literature. It deals with potential incidents in in-house radionuclide production, radiopharmaceutical preparation, administration to patients, and following a procedure, as well as aspects in management of radioactive materials. Special attention has been paid to therapeutic procedures, as these have the potential to cause more harm to patients from erroneous administrations, including tissue reactions from extravasation of radiopharmaceutical, and could lead to significant contamination events. Administration of NM therapy is generally contraindicated in pregnancy. Identification of any patient who may be pregnant is crucial and it might be necessary to verify this with a pregnancy test for patients within the age band considered to be fertile. Inclusion of NM therapy incidents in the IAEA automated reporting system SAFRON is recommended. In summary, the paper aims to highlight errors that could occur during different phases of NM procedures in order to aid prevention of incidents. The value of periodic audit in evaluating systems in place on a regular basis is emphasised. Approaches to incident investigation and follow-up are described, and the need to ensure corrective action is taken to address any deficiencies stressed.

A Randomized Trial of Ultrasound-guided Brachial Plexus Anaesthesia in Upper Limb Surgery

Ultrasound guidance allows real-time identification of relevant anatomy and needle position when performing brachial plexus regional anaesthesia. The aim of this investigation was to determine whether the use of surface ultrasound could improve the quality of brachial plexus anaesthesia for upper limb surgery. Forty patients were randomized to either conventional “landmark-based” plexus anaesthesia, or to an ultrasound-guided approach using a 13 mHz linear array transducer. Both interscalene and axillary techniques were used. The use of ultrasound significantly improved the onset and completeness of sensory (P=0.011) and motor (P=0.002) block. Ultrasound guidance also significantly reduced (P=0.012) the incidence of paraesthesia during the performance of the blocks. Ultrasound guidance increases the quality of sensory and motor blockade in brachial plexus regional anaesthesia, and by reducing the incidence of paraesthesia during performance of the blocks, may confer greater safety.

Shortened therapy of eight weeks with paritaprevir/ritonavir/ombitasvir and dasabuvir is highly effective in people with recent HCV genotype 1 infection

Paritaprevir/ritonavir/ombitasvir and dasabuvir with or without ribavirin for 12 weeks are approved for treatment of chronic HCV genotype 1 infection. This study assessed the efficacy of shortened duration paritaprevir/ritonavir/ombitasvir and dasabuvir with or without ribavirin for 8 weeks among people with recent HCV infection. In this open-label single-arm trial conducted in Australia, England and New Zealand, adults with recent HCV (duration of infection <12 months) received paritaprevir/ritonavir/ombitasvir and dasabuvir (with weight-based ribavirin for genotypes 1a and 1, no subtype) for 8 weeks. The primary endpoint was sustained virological response at 12 weeks post-treatment (SVR12) in the intention-to-treat (ITT) population. Thirty people (median age 38 years, male 93%) commenced treatment (with ribavirin, 97%), of whom 77% (n = 23) were HIV-positive, 93% (n = 28) had genotype 1a infection and 53% (n = 16) had ever injected drugs. Median maximum ALT in the preceding 12 months was 433 IU/L (IQR 321, 1012). Acute clinical hepatitis with ALT > 10 x ULN was documented in 83% (n = 25); one participant (3%) had jaundice. At baseline, median estimated duration of infection was 30 weeks (range 11, 51), and median HCV RNA was 5.7 log₁₀ IU/mL (range 2.7, 7.3). SVR12 was achieved in 97% (29/30; early discontinuation at week 2, n = 1; per protocol 100%, 29/29). No relapse or reinfection was observed. In conclusion, paritaprevir/ritonavir/ombitasvir and dasabuvir (with ribavirin) for eight weeks were highly effective among HIV-positive and HIV-negative individuals with recent HCV infection. These data support the use of this shortened duration direct-acting antiviral regimen in this population.

Ultrasound Determination of the Femoral Head-Neck Alpha Angle

The femoral head-neck alpha angle is used to quantify the degree of femoral head asphericity in patients suspected of cam-type femoroacetabular impingement. The measurement was first performed using magnetic resonance imaging and, more recently, three-dimensional computed tomography (CT). We set out to determine whether the alpha angle could be reliably measured using ultrasound. Patients were recruited from a cohort presenting for CT of the hip. Alpha angles were calculated following the departmental protocol by institutionally accredited radiographers. After the CT, patients were imaged with ultrasound and the alpha angle calculated from the ultrasound image by a sonographer blinded to the CT result. Statistical comparison of the two methods was performed with the Bland-Altman test using SPSS (version 21.0, Chicago, USA), and a p < 0.05 afforded significance. Twenty-eight patients were recruited. Eleven patients were bilateral examinations, providing 39 hips for analysis. There were 15 females and 13 males, with 21 right and 18 left hips examined. Average patient age (±standard deviation) was 40 y (±13.9 y). Mean (±standard deviation) measurements for CT and ultrasound were 62.5° (±14.2°) and 64.5° (±12.6°), respectively. The mean absolute difference between the two methods was 10.5° (95% confidence interval 6.9°-14.0°). Sensitivity of each individual ultrasound measurement was 91.3%. The specificity of ultrasound was 43.75%. The positive predictive value was 0.7, and the negative predictive value was 0.78. Overall accuracy of the ultrasound-derived alpha angle was calculated at 0.718. Ultrasound demonstrates good sensitivity and good negative predictive value in calculation of the femoral head-neck alpha angle compared with CT; however, specificity is low. Ultrasound measurement of the alpha angle can provide objective evidence of cam-type femoroacetabular impingement in symptomatic patients and can direct patients to more established imaging techniques where appropriate.

An Evaluation of the Antihistamine Activity of Acrivastine and Its Onset in Human Skin

In a double-blind, two-period crossover study, 24 healthy volunteers were evaluated to establish the time of onset of action of activity of acrivastine in suppressing the weal and flare response to intradermally injected histamine. Volunteers received single doses of 8 mg acrivastine and placebo according to a fully randomized, balanced treatment plan. Acrivastine significantly ( P < 0.002) reduced the flare response induced by 0.4 μg histamine challenge 15 min after oral acrivastine dosing when compared with placebo. A significant ( P < 0.001) reduction of the weal response was noted at 25 min, although trends in this direction were already present at earlier time points.

Dans d'une étude croisée à deux phase, réalisée en double aveugle et ayant porté sur 24 volontaires sains, on a tenté d'établir le moment du début de l'action de l'acrivastine dans la suppression de la réponse inflammatoire consécutive à l'injection intradermique d'histamine. Les volontaires ont reçu des doses uniques de 8 mg d'acrivastine et de placebo, selon un plan de traitement entièrement randomisé et équilibré. L'acrivastine a réduit significativement ( P < 0,002) la réponse de rubéfaction induite par 0,4 μg d'histamine 15 minutes après l'administration orale d'acrivastine, par rapport au placebo. Une réduction significative ( P < 0,001) de la réponse d'enflure a été notée à 25 minutes, bien qu'une tendance en ce sens ait déjà été observée à un stade plus précoce.

Evidence of dose saving in routine CT practice using iterative reconstruction derived from a national diagnostic reference level survey

OBJECTIVE

To assess the influence and significance of the use of iterative reconstruction (IR) algorithms on patient dose in CT in Australia.

METHODS

We examined survey data submitted to the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) National Diagnostic Reference Level Service (NDRLS) during 2013 and 2014. We compared median survey dose metrics with categorization by scan region and use of IR.

RESULTS

The use of IR results in a reduction in volume CT dose index of between 17% and 44% and a reduction in dose-length product of between 14% and 34% depending on the specific scan region. The reduction was highly significant (p < 0.001, Wilcoxon rank-sum test) for all six scan regions included in the NDRLS. Overall, 69% (806/1167) of surveys included in the analysis used IR.

CONCLUSION

The use of IR in CT is achieving dose savings of 20-30% in routine practice in Australia. IR appears to be widely used by participants in the ARPANSA NDRLS with approximately 70% of surveys submitted employing this technique.

ADVANCES IN KNOWLEDGE

This study examines the impact of the use of IR on patient dose in CT on a national scale.

Australian per caput dose from diagnostic imaging and nuclear medicine

The largest man-made contributor to the ionising radiation dose to the Australian population is from diagnostic imaging and nuclear medicine. The last estimation of this dose was made in 2004 (1.3 mSv), this paper describes a recent re-evaluation of this dose to reflect the changes in imaging trends and technology. The estimation was calculated by summing the dose from five modalities, computed tomography (CT), general radiography/fluoroscopy, interventional procedures, mammography and nuclear medicine. Estimates were made using Australian frequency data and dose data from a range of Australian and international sources of average effective dose values. The ionising radiation dose to the Australian population in 2010 from diagnostic imaging and nuclear medicine is estimated to be 1.7 mSv (1.11 mSv CT, 0.30 mSv general radiography/fluoroscopy, 0.17 mSv interventional procedures, 0.03 mSv mammography and 0.10 mSv nuclear medicine). This exceeds the estimate of 1.5 mSv per person from natural background and cosmic radiation.

Etiology and Risk Factors of 339 Cases of Infective Endocarditis: Report from a 10-year National Prospective Survey in the Slovak Republic

The authors studied the etiology, outcome and risk factors of 339 cases of infective endocarditis (IE) in Slovakia over the last 10 years. Aortic valve was infected in 59.9%, mitral in 38.1% and tricuspidal/pulmonary in 5.0% of cases. The majority of IE were caused by staphylococci (29.2%), 15.0% were due to viridans streptococci, 7.4% due to Enterococcus faecalis, 3.9% due to the HACEK group (Haemophilus spp., Actinobacillus spp., Corynebacterium spp., Eikenella spp., Kingella spp.) and 39.2% were culture negative. The following risk factors were the most frequently identified: rheumatic fever in 24.2%, dental surgery in 13.3%, previous cardiosurgery in 7.1% and neoplasia in 7.1%. All patients were treated with antimicrobials and 42.5% of patients also with surgery (valvular prosthesis replacement): 61 (18.0%) died, and 278 (82.0%) survived at day 60 after the diagnosis of endocarditis was made. Univariate analysis did not show significant differences in most of the recorded risk factors between patients who died and those who survived: apart from staphylococcal etiology (44.3% vs. 26.6%, P < 0.01), persistent bacteremia (with three or more positive blood cultures 24.6% vs. 9.7% P < 0.002) which were significantly associated with higher attributable mortality, as was absence of surgery (55.7% vs. 6.1% P < 0.001), whereas antibiotic therapy in combination with surgery significantly predicted better outcome (P < 0.001). We compared risk factors, etiology, therapeutic strategies and outcome of IE in two periods: from 1991-1997 (180 cases) and from 1998-2001 (159 cases). Rheumatic fever was less commonly observed in second period (1998-2001) P < 0.01 since its prevalence in Slovakia is rapidly decreasing. Dental surgery was less frequent as well (20.5% vs. 5.0% P < 0.001). There was a significant shift in etiology within the second study period: negative-culture endocarditis (despite better bacteriological techniques) (P < 0.001) was more frequently observed in the 1st period and represented 53.3% of all cases in 1998-2001 in comparison to 26.7% in 1991-1997. Enterococci (P < 0.0002) were also more frequent in the 2nd period. Persistent bacteremia (3 or more positive blood cultures 20.5% vs. 3.1%, P < 0.001 was less commonly observed within the 2nd period (1998-2001) in comparison to 1991-1997. More patients in the second period (1998-2001) had complications of IE (P < 0.001) than in the 1st period. However mortality was lower (22.2% vs. 13.2%, P < 0.044) because of more surgical intervention in the 2nd period (52.8% vs. 33.3%, P < 0.001).

Effects of anabolic steroids on acute phase responses in intra-abdominal sepsis

The acute phase response is an important adaptive response to sepsis and injury. As anabolic steroids increase protein synthesis we postulated that these agents might also increase hepatic acute phase protein synthesis. Male Wistar rats were pretreated with testosterone or danazol for 48 h prior to caecal ligation and puncture (CLP). Thirty-six h following surgery the animals were killed and blood taken for full blood count, total protein, albumin, alpha, beta and gamma globulin fractions on serum electrophoresis, complement C(3) and transferrin levels. Danazol increased the alpha1, alpha2 and beta1 globulin serum protein fractions in comparison with no surgery and CLP alone groups. These results indicate that danazol increases plasma acute phase proteins, as measured by electrophoresis, in this model of intra-abdominal sepsis.

The Effect of the Sitting Upright or ‘Beachchair’ Position on Cerebral Blood Flow during Anaesthesia for Shoulder Surgery

The sitting upright or ‘beachchair’ position is commonly used for shoulder arthroscopic surgery. There is a theoretical concern that anaesthetised patients placed in this posture are at risk of reduced cerebral blood flow (CBF), especially if there is associated hypotension. This study investigated the effect of anaesthetic-induced hypotension on estimated cerebral blood flow in patients placed in the beachchair position for shoulder surgery.

Forty patients were randomised to either sedation (propofol infusion 10 to 20 mg.hour-1, n=20) or general anaesthesia using sub minimum alveolar concentration of sevoflurane (n=20). All patients received an interscalene brachial plexus regional block. Internal carotid artery blood flow was measured using the time averaged velocity of the spectral Doppler waveform, and was then used as an estimate of global CBF. Following a pre-anaesthesia study, measurement of internal carotid artery blood flow was made before and after beachchair positioning, and at five-minute intervals during surgery.

Beachchair positioning during general anaesthesia significantly decreased the mean arterial pressure (34±10 mmHg) compared to sedation (4±2 mmHg, P <0.01), and vasopressor therapy was required more often. However, CBF remained constant in both anaesthetised (P=0.83) and sedated patients (P=0.68) despite beachchair positioning, and the fall in mean arterial pressure in the anaesthetised patients. There was no significant difference in CBF between groups (P=0.91). These findings indicate that in patients in the beachchair position receiving sevoflurane anaesthesia, CBF is maintained when mean arterial pressure is above 70 mmHg, consistent with intact autoregulation.

Patterns and characteristics of hepatitis C transmission clusters among HIV-positive and HIV-negative individuals in the Australian trial in acute hepatitis C

BACKGROUND

Injecting drug users remain the population at greatest risk of acquiring hepatitis C virus (HCV) infection, although a recent increase in cases of sexually transmitted HCV infection has been observed among human immunodeficiency virus (HIV)-infected individuals. The extent to which these separate epidemics overlap is unknown.

METHODS

The Australian Trial in Acute Hepatitis C (ATAHC) enrolled 163 individuals (29% of whom were HIV infected) with recent HCV infection. E1/HVR1 sequences were used to construct phylogenetic trees demonstrating monophyletic clusters or pairs, and viral epidemic history and phylogeography were assessed using molecular clock analysis. Individual clusters were characterized by clinical and demographic characteristics.

RESULTS

Transmission through injection drug use occurred for 73% of subjects, with sexual transmission occurring for 18% (92% of whom were HIV infected). Among 112 individuals with available E1/HVR1 sequences, 23 (20%) were infected with a strain of HCV identical to that of another subject, comprising 4 homologous clusters and 3 monophyletic pairs, the majority of which (78%) were HIV infected. Clusters contained individuals with both injection drug use-related and sex-related acquisition, and in all clusters (except for 1 female HIV-uninfected pair), individuals identified as men who have sex with men, irrespective of HIV status.

CONCLUSIONS

This large unique study of HIV-infected and HIV-uninfected individuals with recently acquired HCV infection demonstrates that clustering is common in the HIV-infected population and that it occurred almost invariably among men who have sex with men, irrespective of the actual mode of acquisition. These findings suggest the coexistence of both injection drug use and sexual risk behaviors for individuals in the same social networks and have implications for the development of public health messages. Clinical trial registration. NCT00192569.

Ultrasound of the posterior circumflex humeral artery

Quadrilateral space syndrome (QSS) is described as compression neuropathy of the axillary neurovascular bundle in the quadrilateral space of the shoulder. This neurovascular bundle includes the posterior circumflex humeral artery (PCHA). Historically, angiography and more recently magnetic resonance angiography have been used to assess occlusion and stenosis of the PCHA in cases of suspected QSS. These traditional imaging techniques have a number of disadvantages in terms of cost, availability, invasiveness and patient comfort. We undertook to examine the ability of ultrasound to reliably visualise the PCHA. Asymptomatic adult volunteers were recruited from staff, and patients attending the radiology department who presented for pathologies unrelated to the shoulder. We used a new technique to assess blood flow in the PCHA, performing the scan from a posterolateral approach on the upper arm just above the level of the surgical neck of the humerus. This technique enabled the scan to be undertaken with the patient seated comfortably. Fifty volunteers were recruited into the study. The mean (+/-SD) age was 35 (+/-14 years). The PCHA was visualised in all patients. Our method was able to maximise Doppler sensitivity and visualisation of the artery without discomfort to the patient in less than 10 min. Ultrasound can be used to reliably visualise the PCHA. Ultrasound has potential to be used in the assessment of the PCHA in cases of QSS.

Potential role for interleukin-28B genotype in treatment decision-making in recent hepatitis C virus infection

Polymorphisms in the IL28B (interleukin-28B) gene region are important in predicting outcome following therapy for chronic hepatitis C virus (HCV) infection. We evaluated the role of IL28B in spontaneous and treatment-induced clearance following recent HCV infection. The Australian Trial in Acute Hepatitis C (ATAHC) was a study of the natural history and treatment of recent HCV, as defined by positive anti-HCV antibody, preceded by either acute clinical HCV infection within the prior 12 months or seroconversion within the prior 24 months. Factors associated with spontaneous and treatment-induced HCV clearance, including variations in IL28B, were assessed. Among 163 participants, 132 were untreated (n = 52) or had persistent infection (infection duration ≥26 weeks) at treatment initiation (n = 80). Spontaneous clearance was observed in 23% (30 of 132 participants). In Cox proportional hazards analysis (without IL28B), HCV seroconversion illness with jaundice was the only factor predicting spontaneous clearance (adjusted hazards ratio = 2.86; 95% confidence interval = 1.24, 6.59; P = 0.014). Among participants with IL28B genotyping (n = 102 of 163 overall and 79 of 132 for the spontaneous clearance population), rs8099917 TT homozygosity (versus GT/GG) was the only factor independently predicting time to spontaneous clearance (adjusted hazard ratio = 3.78; 95% confidence interval = 1.04, 13.76; P = 0.044). Participants with seroconversion illness with jaundice were more frequently rs8099917 TT homozygotes than other (GG/GT) genotypes (32% versus 5%, P = 0.047). Among participants adherent to treatment and who had IL28B genotyping (n = 54), sustained virologic response was similar among TT homozygotes (18 of 29 participants, 62%) and those with GG/GT genotype (16 of 25, 64%, P = 0.884).

CONCLUSION

During recent HCV infection, genetic variations in IL28B region were associated with spontaneous but not treatment-induced clearance. Early therapeutic intervention could be recommended for individuals with unfavorable IL28B genotypes.

Factors associated with uptake of treatment for recent hepatitis C virus infection in a predominantly injecting drug user cohort: The ATAHC Study

Despite that the majority of hepatitis C virus (HCV) infection occurs among injection drug users (IDUs), little is known about HCV treatment uptake in this group, particularly during recent infection. We evaluated uptake of treatment for recent HCV infection, including associated factors, within a population predominantly made up of IDUs. The Australian Trial in Acute Hepatitis C was a study of the natural history and treatment of recent HCV infection. All participants with detectable HCV RNA at screening were offered HCV treatment, assessed for eligibility and those initiating treatment were identified. Logistic regression analyses were used to identify predictors of HCV treatment uptake. Between June 2004 and February 2008, 163 were enrolled, with 146 positive for HCV RNA at enrolment. The mean age was 35 years, 77% (n=113) participants had ever injected illicit drugs and 23% (n=34) reported having ever received methadone or buprenorphine treatment. The uptake of HCV treatment was 76% (111 of 146) among those who were eligible on the basis of positive HCV RNA. Estimated duration of HCV infection (OR=1.03 per week, 95% CI=1.00-1.06, P=0.035) and log(10) HCV RNA (OR=1.92 per log(10) increase, 95% CI=1.36-2.73, P<0.001) were independently associated with treatment uptake whereas injection drug use was not. This study demonstrates that a high uptake of HCV treatment can be achieved among participants with recently acquired HCV infection. Decisions about whether to initiate treatment for recently acquired HCV were mainly driven by clinical factors, rather than factors related to sociodemographics or injecting behaviors.

Effective treatment of injecting drug users with recently acquired hepatitis C virus infection

BACKGROUND & AIMS

Patients with acute hepatitis C virus (HCV) infection who receive treatment achieve high rates of sustained virologic response (SVR), but few studies have examined outcomes among injecting drug users (IDUs). We evaluated the efficacy of treatment of recent HCV infection in IDUs with acute and early chronic HCV.

METHODS

We analyzed data from the Australian Trial in Acute Hepatitis C-a prospective study of the natural history and treatment outcomes of patients with recent HCV infection. Participants eligible for the study had their first anti-HCV antibody-positive test result within the past 6 months and either acute clinical HCV within the past 12 months or documented anti-HCV seroconversion within 24 months. Participants with HCV received pegylated interferon-alfa-2a (180 microg/wk, n = 74); those with HCV/human immunodeficiency virus (HIV) co-infection received pegylated interferon-alfa-2a (180 microg/wk) with ribavirin (n = 35) for 24 weeks.

RESULTS

From June 2004 to February 2008, 167 participants were enrolled in the Australian Trial in Acute Hepatitis C; 79% had injected drugs in the previous 6 months. Among 74 with only HCV, the SVRs were 55% and 72% by intention-to-treat and per-protocol analysis, respectively. In multivariate analyses, baseline factors independently associated with lower SVR included decreased social functioning and current opiate pharmacotherapy. Adherent participants had higher SVR rates (63% vs 29%; P = .025). Of the 35 participants with HCV/HIV co-infection, the SVRs were 74% and 75% by intention-to-treat and per-protocol analysis, respectively.

CONCLUSIONS

Treatment of recent HCV infection among IDUs, including those with HIV co-infection, is effective. Strategies to engage socially marginalized individuals and increase adherence should improve treatment outcomes in this population.

Quantitative MR imaging evaluation of the cartilage thickness and subchondral bone area in patients with ACL-reconstructions 7 years after surgery

OBJECTIVE

To evaluate the cartilage thickness (ThC) and subchondral bone area (tAB) of the operated and contra-lateral non-operated (healthy) knees in patients with anterior cruciate ligament (ACL)-reconstruction 7 years after surgery using a quantitative and regional cartilage MR imaging (qMRI) technique.

METHODS

Charts of 410 patients with ACL-reconstructions were retrospectively reviewed. Fifty-two patients (male/female, 28/24; mean age, 33.3 years) were included. Patients underwent KT-1000 testing and qMRI of both knees using coronal fat-saturated 3D spoiled gradient-recalled echo (SPGR) sequences (TR/TE, 44/4 ms) at 1.5 T. Quantitative analyses of ThC and tAB in the femoro-tibial cartilage plates were performed using a subregional approach. In addition, qualitative and quantitative assessment of femoral condyle shapes was performed. t tests with Bonferroni corrections were used for statistical analysis of side-to-side differences between the operated and non-operated knees.

RESULTS

KT-1000 testing was abnormal in 3/52 patients (6%). Lateral femoral tAB was significantly lower (-9.2%), and medial tibial tAB was significantly larger (+2%) in the operated vs non-operated knee (P<0.001). Regional and subregional ThC side-to-side differences were less than 0.1mm and, except for the external lateral femoral subregion, they were not statistically significant. Flattened and broader shapes of medial femoral condyles (P<0.001) were found in operated knees. No significant association of presence of cartilage or meniscus lesions at surgery with ThC 7 years post-operatively was found (P=0.06-0.98).

CONCLUSION

There is evidence for changes in the tAB and femoral shape 7 years post-ACL-reconstruction, but no side-to-side differences in subregional ThC were found between the operated and contra-lateral non-operated knees.

Characteristics and treatment outcomes among HIV-infected individuals in the Australian Trial in Acute Hepatitis C

BACKGROUND

The Australian Trial in Acute Hepatitis C (ATAHC) is a National Institutes of Health-funded prospective cohort study of the natural history and efficacy of treatment in individuals with recently acquired hepatitis C. Enrollment is open to both human immunodeficiency virus (HIV)-infected and -uninfected individuals. The aim of this article was to evaluate characteristics and virological outcomes among HIV-infected individuals enrolled in ATAHC.

METHODS

Eligibility criteria included the first positive result of testing for anti-hepatitis C virus (HCV) antibody within 6 months and either clinical hepatitis diagnosed within the past 12 months or documented anti-HCV seroconversion within the past 24 months.

RESULTS

Of the initial 103 patients enrolled, 27 (26%) were HIV infected. HIV-infected patients were more likely to be older, to have HCV genotype 1 infection and high levels of HCV RNA at baseline than were HCV-monoinfected patients. Sexual acquisition accounted for the majority (56%) of HCV infections among HIV-infected patients, compared with only 8% of HCV-monoinfected patients. The median duration from estimated HCV infection to treatment was 30 weeks. Treatment with 24 weeks of pegylated interferon and ribavirin resulted in rates of undetectability of HCV RNA of 95%, 90%, and 80% at weeks 12, 24, and 48, respectively. Undetectability at week 4 was achieved in 44% of patients and yielded positive and negative predictive values for sustained virological response of 100% and 33%, respectively.

CONCLUSIONS

Significant differences were demonstrated between HIV-infected and HIV-uninfected individuals enrolled in ATAHC. Treatment responses among HIV-infected individuals with both acute and early chronic infection are encouraging and support regular HCV screening of high-risk individuals and early treatment for recently acquired HCV infection.

Trends in risk factors and etiology of 606 cases of infective endocarditis over 23 years (1984-2006) in slovakia

The aim of this study was to assess trends in risk factors, etiology, outcome and treatment strategies for endocarditis over 23 years in Slovakia. A prospective survey of 606 cases of infective endocarditis (IE) was conducted from 1984-2006. Rheumatic fever as well as previous dental surgery showed decreasing trends within the last 23 years. Also embolic complications of IE declined along with increasing rates of surgically treated patients. No significant changes in etiology were detected apart from the fact that culture-negative endocarditis increased from 10.7% to 55.4% between 1998-2001. Surgically treated patients increased from 22.7% (1984-1990) to 50.1% (2002-2006) and mortality dramatically decreased from 26.7% (1984-1990) to 5.3% (2002-2006). Staphylococcus aureus and coagulase-negative staphylococci were the leading causes (22.4% - 48%) followed by viridans streptococci (12.2%-18.2%) were a relatively stable trend over 23 years of IE in Slovakia.

Histologic anatomy of the lesser metatarsophalangeal joint plantar plate

The plantar plate is the fibrocartilaginous structure that supports the ball of the foot, withstanding considerable compressive and tensile forces. This study describes the morphology of the plantar plate in order to understand its function and the pathologic disorders associated with it. Eight lesser metatarsophalangeal joint plantar plates from three soft-embalmed cadavers (74-92 years, two males, one female), and eight lesser metatarsophalangeal joint plantar plates from a fresh cadaver (19-year-old male) were obtained for histology assessment. Paraffin sections (10 microm) in the longitudinal and transverse planes were analyzed with bright-field and polarized light microscopy. The central plantar plate collagen bundles run in the longitudinal plane with varying degrees of undulation. The plantar plate borders run transversely and merge with collateral ligaments and the deep transverse intermetatarsal ligament. Bright-field microscopic evaluation shows the plantar aspect of the plantar plate becomes ligament-like the further distally it tapers, containing fewer chondrocytes, and a greater abundance of fibroblasts. The enthesis reveals longitudinal and interwoven collagen bundles entering the proximal phalanx with multiple interdigitations. Longer interdigitations centrally compared to the dorsal and plantar aspects suggest that the central fibers experience the greatest loads.

Aortic valve replacement after previous coronary artery bypass grafting: experience with a simplified approach

AIM

Aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG), particularly in a patent left internal thoracic artery (ITA), is a challenge. Avoidance of injuring the patent graft and ensuring myocardial protection are important issues in the management of these patients. The aim of this study was to evaluate a simplified surgical approach to these reoperations.

METHODS

Between January 2003 and June 2005, 19 of 287 AVRs performed at our institution were in a patient subset (mean age 70 years, range: 62-82) who received AVR after previous CABG surgery. The aortic valve gradients were between 50 and 107 mm Hg. Our operation strategy followed the KIS-principle (keep it simple): both femoral vessels were cannulated using the Seldinger technique. Only the area around the ascending aorta and the right atrium was dissected to permit x-clamping, aortotomy, and catheterization for retrograde cardioplegia and a left ventricular vent. The anterior aspect of the heart and the left side, where the ITA was embedded and patent, were left untouched and not clamped.

RESULTS

The mean interval between the first and second operation was 6.5 years. Fourteen patients received biological prostheses. Four patients received an additional surgery at the time of AVR. The mean operating time was 267 min; the mean AoX-clamp time was 63 min. One patient died because of severe heart failure. In all others the postoperative course was uneventful.

CONCLUSIONS

We believe that the indication for AVR in patients scheduled for CABG should be re-evaluated. In those in which Redo-surgery for new or increased valve stenosis is indicated, a simple and safe surgical option is presented.

A new look into kicking a football: An investigation of muscle activity using MRI

The kicking action predominantly used in Australian Rules football is considered to be responsible for many lower limb injuries. The aim of this study was to describe a non-invasive method of identifying the thigh muscles involved in kicking an Australian Rules football, using MRI. Both upper thighs of 10 recreational footballers were examined using a 1.5-T General Electric MRI scanner before and immediately after carrying out a set kicking exercise protocol. The signal intensity (SI) changes in 14 individual muscles were investigated using a standardized region of interest to determine the levels of muscle activity. Significant SI changes were observed in several muscles of the kicking and stance legs among all participants. In the kicking leg, the greatest SI changes were observed in the adductor longus and tensor fascia latae muscles (49.38% (+/-8.95) and 45.47% (+/-7.91), respectively; P < 0.05), whereas in the stance leg, the muscles displaying the highest changes were the semitendinosus and tensor fascia latae muscles (46.48% (+/-9.97) and 33.68% (+/-8.36), respectively; P < 0.05). This study has shown that MRI can be useful for observing the activity of individual muscles in the upper thigh during the kicking motion. This non-invasive approach provides a detailed analysis of anatomy and emphasizes the muscles at high risk of injury.

The electromechanics of DNA in a synthetic nanopore

We have explored the electromechanical properties of DNA on a nanometer-length scale using an electric field to force single molecules through synthetic nanopores in ultrathin silicon nitride membranes. At low electric fields, E < 200 mV/10 nm, we observed that single-stranded DNA can permeate pores with a diameter >/=1.0 nm, whereas double-stranded DNA only permeates pores with a diameter >/=3 nm. For pores <3.0 nm diameter, we find a threshold for permeation of double-stranded DNA that depends on the electric field and pH. For a 2 nm diameter pore, the electric field threshold is approximately 3.1 V/10 nm at pH = 8.5; the threshold decreases as pH becomes more acidic or the diameter increases. Molecular dynamics indicates that the field threshold originates from a stretching transition in DNA that occurs under the force gradient in a nanopore. Lowering pH destabilizes the double helix, facilitating DNA translocation at lower fields.