Man With Disappearing Subconjunctival Foreign Body

A 33-year-old man reported a “pulling and popping sensation” in his left eye and had a photograph showing an irregular, serpiginous extension that was present during the episode. Examination was unremarkable. What would you do next?

Performance comparison of three commercial tests for the detection of SARS-CoV-2 antibodies in a common set of pediatric samples

BACKGROUND

Serologic testing for SARS CoV-2 is useful for detection of past infection and assisting in diagnosis of post-COVID-19 syndromes such as MIS-C. Immune responses to SARS-CoV-2 infection in children differ from adults but most antibody performance studies are limited to adults.

OBJECTIVE

The objective of this study was to compare three commercial SARS-CoV-2 antibody kits in a common set of children being evaluated for SARS-CoV-2 infection.

METHODS

Three SARS-CoV-2 antibody tests: Abbott anti-nucleocapsid (N) IgG (AA), Epitope Diagnostics anti-N IgG (EDI) and EUROIMMUN anti-S1 Spike IgG (EU) were compared against two references: 1) RT-PCR and 2) consensus IgG (consIgG).

RESULTS

All three tests had a sensitivity <53% compared to RT-PCR, with EU outperforming EDI (p = 0.03). When all samples were compared to consIgG, positive percent agreement was comparable (AA-90%, EU- 98% and EDI- 88%) but EDI had significantly better negative percent agreement than EU (p = 0.009). No difference in test performance was observed using either reference when samples were collected ≥15 days post-symptom onset (PSO).

CONCLUSIONS

Our findings suggest good performance of commercial SARS-CoV-2 IgG assays in pediatric patients with samples collected ≥15 days PSO. Additional studies investigating antibody response and assay performance in children are warranted.

Barriers and facilitators to targeted anxiety prevention programmes in families at risk: a qualitative interview study

Anxiety disorders are the most common psychiatric disorder in children and young people. They can be prevented in those at risk, but families do not always take up opportunities to participate in prevention programmes. This qualitative study aimed to understand what families with children who were at prospective risk of anxiety disorders perceived to be the barriers to access to targeted anxiety prevention programmes, and to explore what would help facilitate access. We used Information Power to determine our sample size, and individually interviewed seven young people (14-17 years) who had anxiety disorders and their mothers, each of whom had pre-natal anxiety disorders. We transcribed all interviews and thematically analyzed them to identify perceived barriers and facilitators to targeted anxiety prevention programmes. Perceived potential barriers to access included possible negative consequences of anxiety prevention, difficulties in identifying anxiety as a problem and concerns about how professions would respond to raising concerns about anxiety. Possible facilitators included promoting awareness of anxiety prevention programmes and involvement of schools in promotion and delivery of prevention. Our findings illustrate that implementation of targeted anxiety prevention could be improved through (i) the provision of tools for parents to recognize anxiety in their children as a problem, (ii) promotion of awareness, as well as delivery, of anxiety prevention via schools and (iii) the involvement of parents and possibly adolescents in the intervention programme, but not younger children.

Early initiation of direct anticoagulation after stroke in patients with atrial fibrillation

BACKGROUND AND PURPOSE

The safety of early initiation of anticoagulant therapy in patients with ischaemic stroke related to atrial fibrillation (AF) is unknown. We investigated the safety of early initiation of direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs) or no anticoagulation.

METHODS

This observational, retrospective, single-centre study included consecutive patients with recent (<4 weeks) ischaemic stroke and AF. The primary outcome was the rate of major (intracranial and extracranial) bleeding in patients on different treatment schemes, i.e. DOACs, VKAs and not anticoagulated. We also investigated the rate of ischaemic cerebrovascular events and mortality.

RESULTS

We included 959 consecutive patients with AF and ischaemic stroke followed up for an average of 16.1 days after the index event. A total of 559 out of 959 patients (58.3%) were anticoagulated with either VKAs (n = 259) or DOACs (n = 300). Anticoagulation was started after a mean of 7 ± 9.4 days in the DOAC group and 11.9 ± 19.7 days in the VKA group. Early initiation of any anticoagulant was not associated with an increased risk of any major bleeding [odds ratio (OR), 0.49; 95% confidence intervals (CI), 0.21-1.16] and in particular of intracranial bleeding (OR, 0.47; 95% CI, 0.17-1.29; P = 0.143) compared with no anticoagulation. In contrast to VKAs (OR, 0.78; 95% CI, 0.28-2.13), treatment with DOACs (OR, 0.32; 95% CI, 0.10-0.96) reduced the rate of major bleeding compared with no anticoagulation. Early recurrences of ischaemic stroke did not differ significantly among the three groups.

CONCLUSIONS

Starting DOACs within a mean of 7 days after stroke appeared to be safe. Randomized controlled studies are needed to establish the added efficacy of starting anticoagulation early after stroke.

AB0373 TREATMENT OF SLE WITH THE IMMUNOPROTEASOME INHIBITOR KZR-616: RESULTS FROM THE FIRST 4 COHORTS OF THE MISSION STUDY, AN OPEN-LABEL PHASE 1B DOSE ESCALATION TRIAL

Background:

Non-specific proteasome inhibitors, such as bortezomib (BTZ), target the constitutive proteasome and immunoproteasome and are approved treatments for multiple myeloma1. BTZ has also been used to treat systemic lupus erythematosus (SLE) and lupus nephritis (LN); however, treatment emergent adverse events (TEAEs), such as gastrointestinal (GI) effects, hematologic abnormalities, asthenia and peripheral neuropathy, limit its use as a long-term treatment option for chronic autoimmune disease2. KZR-616 is a first-in-class selective immunoproteasome inhibitor and is highly active in murine SLE3. Subcutaneous (SC) administration of KZR-616 (30 and 45 mg weekly [QW]) was demonstrated as safe and well-tolerated, and successfully achieved target levels of immunoproteasome inhibition in healthy volunteers4, 5.

Objectives:

We report the preliminary safety and efficacy of KZR-616 in the first 4 cohorts of the Phase 1b portion of Study KZR-616-002 in patients with active SLE (NCT03393013).

Methods:

SLE patients (per SLICC Classification Criteria) with SLEDAI ≥4 despite stable background immunosuppressant, anti-malarial, and/or corticosteroid (≤20 mg prednisone equivalent) therapy in this open-label multicentric dose-escalation trial received KZR-616 at doses of 45mg (Cohort 1), 60mg (Cohort 2), or 30mg with escalation to 60mg (Cohorts 2a and 2b) SC weekly through Week 13 (W13) with 12 weeks of follow-up. Efficacy measures included SLEDAI, Cutaneous Lupus Erythematous Disease Area and Severity Index, 28 tender and swollen joint counts, Physicians Global Assessment, Patient Global Assessment, and Patient Assessment of Pain, in evaluable patients (those who received ≥1 month of KZR-616).

Results:

As of 16 January 2020, 33 patients had enrolled and received at least 1 dose of KZR-616. The majority of TEAEs have been mild or moderate with no reported peripheral neuropathy, prolonged GI-related AEs, and no clinically significant laboratory AEs. There were 3 treatment emergent SAEs, one each of thrombotic microangiopathy (Cohort 2), localized herpes zoster (Cohort 2a), and systemic inflammatory response syndrome (Cohort 2a) with the latter 2 patients completing the full 13 weeks of treatment after resolution. When compared to baseline, improvement in all measures of disease activity were seen at W13 and maintained or improved during the follow-up period, and 94% of evaluable patients had improvements on at least 2 measures/assessments of disease activity. A single patient with active class IV/V nephritis was enrolled on prednisone 10 mg, leflunomide 10 mg, and hydroxychloroquine 200mg/day; nephrotic-range proteinuria at baseline (3.85 g/day) decreased to 0.6 g/day 4 weeks after the last dose of KZR-616.

Conclusion:

Weekly subcutaneous administration of KZR-616 at 45 and 60 mg was safe and well-tolerated. Evidence of disease suppression at W13 in active SLE patients on stable background therapy was observed. In addition, one study participant with active proliferative nephritis was enrolled with significant reduction in proteinuria. The Phase 2 portion of this study in active proliferative LN is open for enrollment.

References:

[1]Scott K.et al.Cochrane Database Syst Rev 2016;4:CD010816

[2]Alexander Tet al.Ann Rheum Dis 2015;74: 1474–8

[3]Muchamuel T.et al.Ann Rheum Dis 2018;77: A685

[4]Lickliter J.et al.Ann Rheum Dis 2018;77: A1413

[5]Furie Ret al.Ann Rheum Dis 2019;78: A776

Disclosure of Interests:

Richard Furie Grant/research support from: AstraZeneca, Biogen, Consultant of: AstraZeneca, Biogen, SV Parikh Grant/research support from: Aurinia Pharmaceuticals, EMD-Serono, Consultant of: Aurinia, BMS, GSK, Adonis Maiquez: None declared, Amber Khan: None declared, Orlando Moreno: None declared, Miguel Soneira: None declared, Christopher Kirk Shareholder of: Kezar Life Sciences, LLC, Employee of: Kezar Life Sciences, LLC, Darrin Bomba Shareholder of: Kezar Life Sciences, LLC, Employee of: Kezar Life Sciences, LLC, Ken Harvey Shareholder of: Kezar Life Sciences, LLC, Employee of: Kezar Life Sciences, LLC, Mary Katherine Farmer Shareholder of: Kezar Life Sciences, Employee of: Kezar Life Sciences

Looking Through Dementia: What Do Commercial Stock Images Tell Us About Aging and Cognitive Decline?

Commercial stock images are existing, artificially constructed visuals used by businesses and media outlets to articulate certain values, assumptions and beliefs. Despite their pervasiveness and accessibility, little is known about the ways in which stock images communicate meanings relating to health and illness. This study examines a broad range of common stock images that depict dementia and aging, revealing the tendency for older people with dementia to be represented in objectifying and de-humanizing terms-emphasizing disease and deficit at the expense of the whole person, whereas precluding any possibility of enduring personhood. As well as introducing a multimodal critical discourse approach that can be adopted by other researchers examining the ideological underpinnings of health and illness imagery, this study underscores the importance of critically interrogating stock photography-a much neglected, yet profoundly influential, cultural resource that can shape the ways we think about and respond to illness and disease.

Stronger together: learning from an interdisciplinary dementia, arts and well-being network (DA&WN)

Background This paper reports on the learning from a 12-month interdisciplinary project (Dementia, Arts and Wellbeing Network- DA&WN) and its activities. These featured a series of four workshops on dance, visual art, theatre and music. The network was comprised of clinicians, academics, creative practitioners and people with lived experience of dementia and their carers. Methods The workshops were designed to draw out tacit knowledge about well-being in dementia through an action-based learning and research approach. This included, guided activities combined with reflective group discussions, visual documentation and baseline and follow-up questionnaires. Results Outcomes included new collaborations between group members, changes in creative practice for artists, and active and sustained involvement of people living with dementia and their carers in similar opportunities and participatory research. Conclusion This participatory and inclusive workshop model should be considered to develop and enhance interdisciplinary activities in dementia care.

Emotional distress with dementia: A systematic review using corpus-based analysis and meta-ethnography

OBJECTIVE

More understanding is needed about the emotional experiences of dementia from the perspective of the individual. This understanding can then inform the provision of health care to meet individual needs. This systematic review aimed to present all available descriptions of emotional distress and explanations for emotional distress experienced by individuals with dementia, articulated personally and by others.

METHODS

A systematic mixed-method review identified literature that was screened and quality appraised. Data were analysed quantitatively and qualitatively using corpus-based methods and meta-ethnography.

RESULTS

The 121 included studies showed that individuals with dementia have expressed emotional distress comprehensibly. Family, professional caregivers, clinicians, and academic writers have also observed and described extreme emotional experiences. Feeling fearful and lonely were predominant and show the importance of anxiety in dementia. Explanations for emotional distress included threats to universal, human needs for identity, belonging, hope, and predictability.

CONCLUSIONS

The variable and personal emotional experiences of individuals with dementia are well described and should not continue to be overlooked. Limitations, future research, and clinical implications are discussed.

High prevalence of psychiatric and substance use disorders among persons seeking treatment for HIV and other STIs in Jamaica: a short report

This cross-sectional study explored the range of psychiatric and substance use disorders and unmet need for mental health care among 84 HIV-positive and 44 HIV-negative public clinic attendees in Jamaica. We used a brief interviewer-administered diagnostic tool, the Client Diagnostic Questionnaire. Two-thirds (65.6%) screened positive for at least one psychiatric disorder; 30.5% screened positive for multiple disorders. The most common disorders were post-traumatic stress disorder (PTSD) (41.4%), alcohol abuse (22.7%), and depressive disorders (21.9%). One in fourteen (7.1%) participants with at least one diagnosis received care in the last 6 months. Adjusting for age and sex, PTSD was associated with non-adherence to antiretroviral treatment (AOR = 5.32), anxiety disorders (AOR = 5.82), depression (AOR = 4.29), and suicidal ideation (AOR = 8.17). Psychiatric and substance use disorders, particularly PTSD, were common among STI/HIV clinic attendees in Jamaica. Such clinics may be efficient places to screen, identify, and treat patients with psychiatric disorders in low- and middle- income countries.

Evaluation of OneStep Dengue NS1 RapiDip™ InstaTest and OneStep Dengue Fever IgG/IgM RapiCard™ InstaTest during the course of a dengue type 1 epidemic

We determined the diagnostic performance of the OneStep NS1 and the OneStep IgG/IgM RDT kits against a panel of samples which comprised of 174 dengue positive and 165 dengue negative sera characterized by three reference enzyme-linked immunosorbent assays (ELISAs). The diagnostic sensitivities of the OneStep kits for the detection of individual biomarkers of NS1, IgM and IgG were 90% (95% CI: 82.1-94.7), 32.4% (95% CI: 24.8-40.8) and 44.4% (95% CI: 38.2-50.7), respectively. The combination of the OneStep IgG/IgM kit with the OneStep NS1 kit demonstrated significantly higher sensitivities for the combined NS1/IgM (96.8%; 95% CI: 90.9-99.3) and NS1/IgM/IgG (99.5%; 95% CI: 97.1-99.9)(P<0.001). In conclusion, the OneStep NS1 kit has high sensitivity and specificity and is highly recommended for use. The low sensitivities for IgG (44.4%) and for IgM (32.4%) of the OneStep IgG/IgM kit when used alone suggest it is best used in combination with the OneStep NS1 kit to enhance its overall diagnostic performance.

Nutrition Modulation of Cachexia/Proteolysis

Cachexia represents progressive wasting of muscle and adipose tissue and is associated with increased morbidity and mortality. Although anorexia usually accompanies cachexia, cachexia rarely responds to increased food intake alone. Our knowledge of the underlying mechanisms responsible for cachexia remains incomplete. However, most states of cachexia are associated with underlying inflammatory processes and/or cancer. These processes activate protein degradation and lipolytic pathways, resulting in tissue loss. In this article, we briefly review the pathophysiology of cachexia and discuss the role of specific nutrient supplements for the treatment of cachexia. The branched chain amino acid leucine, the leucine metabolite beta-hydroxy-beta-methylbutyrate, arginine, glutamine, omega-3 long chain fatty acids, conjugated linoleic acid, and polyphenols have demonstrated some efficacy in animal and/or human studies. Optimal treatment for cachexia is likely aimed at maximizing muscle and adipose synthesis while minimizing degradation.

ASCT2/SLC1A5 controls glutamine uptake and tumour growth in triple-negative basal-like breast cancer

Alanine, serine, cysteine-preferring transporter 2 (ASCT2; SLC1A5) mediates uptake of glutamine, a conditionally essential amino acid in rapidly proliferating tumour cells. Uptake of glutamine and subsequent glutaminolysis is critical for activation of the mTORC1 nutrient-sensing pathway, which regulates cell growth and protein translation in cancer cells. This is of particular interest in breast cancer, as glutamine dependence is increased in high-risk breast cancer subtypes. Pharmacological inhibitors of ASCT2-mediated transport significantly reduced glutamine uptake in human breast cancer cell lines, leading to the suppression of mTORC1 signalling, cell growth and cell cycle progression. Notably, these effects were subtype-dependent, with ASCT2 transport critical only for triple-negative (TN) basal-like breast cancer cell growth compared with minimal effects in luminal breast cancer cells. Both stable and inducible shRNA-mediated ASCT2 knockdown confirmed that inhibiting ASCT2 function was sufficient to prevent cellular proliferation and induce rapid cell death in TN basal-like breast cancer cells, but not in luminal cells. Using a bioluminescent orthotopic xenograft mouse model, ASCT2 expression was then shown to be necessary for both successful engraftment and growth of HCC1806 TN breast cancer cells in vivo. Lower tumoral expression of ASCT2 conferred a significant survival advantage in xenografted mice. These responses remained intact in primary breast cancers, where gene expression analysis showed high expression of ASCT2 and glutamine metabolism-related genes, including GLUL and GLS, in a cohort of 90 TN breast cancer patients, as well as correlations with the transcriptional regulators, MYC and ATF4. This study provides preclinical evidence for the feasibility of novel therapies exploiting ASCT2 transporter activity in breast cancer, particularly in the high-risk basal-like subgroup of TN breast cancer where there is not only high expression of ASCT2, but also a marked reliance on its activity for sustained cellular proliferation.

Seroprevalence of human toxocariasis, Jamaica

Seroprevalence of human toxocariasis was studied, based on 1544 samples selected from a total of 3524 submitted to the University of the West Indies in Kingston, Jamaica for diagnosis of dengue during an epidemic in 2010. The prevalence of anti-Toxocara IgG using the CELISA® (Cellabs) ELISA was 21.2% and males (24.4%) were significantly more likely to be exposed than females (17.5%) [χ² =10.4; p=0.001]. No association was foundbetween exposure to Toxocara and area of residence (rural vs. urban) [χ² =0.835; p = 0.409]. Prevalence of infection peaked in adolescents (10-19 years-old) and declined thereafter although a rise in prevalence was seen in older age classes. There was a high prevalence of toxocariasis in Jamaica with significant exposure among school age children with no predilection to either sex. The study will inform future work on elucidating the public health and clinical significance of toxocariasis in Jamaica.

Response of 33 UK patients with infantile-onset Pompe disease to enzyme replacement therapy

BACKGROUND

Enzyme replacement therapy (ERT) for infantile-onset Pompe disease has been commercially available for almost 10 years. We report the experience of its use in a cohort treated at three specialist lysosomal treatment centres in the UK.

METHODS

A retrospective case-note review was performed, with additional data being gathered from two national audits on all such patients treated with ERT. The impact on the outcome of various characteristics, measured just prior to the initiation of ERT (baseline), was evaluated using logistic regression.

RESULTS

Thirty-three patients were identified; 13/29 (45%) were cross-reactive immunological material (CRIM) negative, and nine were immunomodulated. At baseline assessment, 79% were in heart failure, 66% had failure to thrive and 70% had radiological signs of focal pulmonary collapse. The overall survival rate was 60%, ventilation-free survival was 40% and 30% of patients were ambulatory. Median follow-up of survivors was 4 years, 1.5 months (range 6 months to 13.5 years). As with previous studies, the CRIM status impacted on all outcome measures. However, in this cohort, baseline failure to thrive was related to death and lack of ambulation, and left ventricular dilatation was a risk factor for non-ventilator-free survival.

CONCLUSION

The outcome of treated patients remains heterogeneous despite attempts at immunomodulation. Failure to thrive at baseline and left ventricular dilation appear to be associated with poorer outcomes.

Breast-conserving surgery in patients with Paget's disease

Background

Paget's disease of the breast is a rare condition that is associated with underlying breast cancer in the majority of patients. The conventional treatment for Paget's disease has been mastectomy, but there is an increasing trend to consider breast-conserving surgery (BCS) in selected patients. Owing to the uncommon nature of the disease, research studies tend to be small and retrospective. This systematic review presents the published evidence regarding BCS for patients with Paget's disease with a focus on patient selection and oncological safety.

Methods

A search of Ovid and PubMed databases was conducted to identify all papers published regarding BCS for Paget's disease.

Results

The search identified 172 papers of which 43 were clinically relevant. BCS is a safe alternative to mastectomy, provided a clear surgical margin is achieved and adjuvant radiotherapy used. However, patients with Paget's disease should be assumed to have underlying breast cancer, and these cancers tend to have poor biological profiles. When BCS is considered, careful preoperative investigation should be undertaken to identify the presence and extent of an underlying cancer. These cancers can be mammographically occult, multifocal or multicentric. Although the evidence is limited, there may be a role for MRI in selecting patients with Paget's disease for BCS.

Conclusion

Patients with Paget's disease are candidates for breast conservation with appropriate preoperative investigations. Oncological outcomes are equivalent to those of mastectomy if surgical margins are achieved and adjuvant radiotherapy is given.

‘Am I anorexic?’ Weight, eating and discourses of the body in online adolescent health communication

This article explores the communicative choices of adolescents seeking advice from an internet-based health forum run by medical professionals. Techniques from the disciplines of sociolinguistics and corpus linguistics are integrated to examine the strategies used in adolescents’ health questions. We focus on the emergent theme of Weight and Eating, a concern which features prominently in adolescents’ requests to medical practitioners. The majority of advice requests are authored by adolescent girls, with queries peaking at age 12. A combined quantitative and qualitative analysis provides detailed insights into adolescents’ communicative strategies. Examinations of question types, register and a discourse-based analysis draw attention to dominant discourses of the body, including a ‘discourse of slenderness’ and a ‘discourse of normality’, which exercise negative influences on adolescents’ dietary behaviours. The findings are of applied linguistic relevance to health practitioners and educators, as they provide them with access to adolescents’ health queries in their own language.

The language of compassion in acute mental health care

In this article we examine the language of compassion in acute mental health care in the United Kingdom. Compassion is commonly defined as being sensitive to the suffering of others and showing a commitment to relieve it, yet we know little about how this is demonstrated in health professional language and how it is situated in the context of acute mental health care services. We report on a corpus-assisted discourse analysis of 20 acute mental health practitioner interview narratives about compassion and find a striking depletion in the use of "compassionate mentality" words, despite the topic focus. The language used by these practitioners placed more emphasis on time pressures, care processes, and organizational tensions in a way that might compromise best practice and point to the emergence of a "production-line mentality."

Using estimation and projection package and Spectrum for Jamaica's national HIV estimates and targets

Background

Adequate coverage of target populations ensures that desired outcomes, such as increased survival of people living with HIV, are achieved. However, estimates of coverage and impact of HIV programmes using available data are limited by the complex natural history of HIV, underreporting of cases and inadequate information systems.

Methods

Jamaica's national HIV estimates were generated using the 2009 version of the UNAIDS estimation and projection package (EPP) and Spectrum. National data used included sentinel surveillance data on antenatal clinic attendees (1986–2005 and 2007), distribution of antiretroviral regimes for prevention of mother-to-child transmission, distribution of antiretroviral therapy (ART) among adults and ART distribution in subpopulations (eg, men who have sex with men (MSM) and sex workers). Surveys of MSM (2007), sex worker (2001, 2005, 2008), STI clinic attendees (1990–2002) and inmates (2006) also provided inputs.

Results

In 2009, Jamaica's HIV prevalence was estimated at 1.7% (range 1.1–2.5) and 31 000 (range 20 000–43 000) adults (>15 years) were living with HIV. The number of adults in need of treatment was 15 000 (range 11 000–19 000) and approximately 2100 new infections occurred in 2009. The EPP/Spectrum estimates were generally consistent with locally available data. However, the number of persons with advanced HIV targeted by the national treatment programme was significantly lower than Spectrum's estimated target population.

Conclusion

EPP/Spectrum can provide important data for national HIV programme planning. Improved monitoring and evaluation systems will provide quality data and result in more robust estimates.

Single-institution experience using transarterial chemoembolization (TACE) with carboplatinum (carbo) and doxorubicin in patients (pts) with hepatocellular carcimona (HCC) awaiting liver transplantation (LTx)

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Background: LTx is the best treatment option for multinodular HCC and those with advanced liver dysfunction. Tumor progression occurs in 20-50% of pts on liver transplant list. TACE is increasingly used as locoregional therapy and as a bridge to LTx. We report here our single institutional experience with TACE using carbo and doxorubicin in pts with HCC awaiting LTx.

Methods: Retrospective chart review was performed in all pts who had TACE between 2008 and June 2010. Our institutional protocol uses a fixed dose of carbo 300mg, doxorubicin 50mg, in 10ml of lipoidol solution. We analyzed pt demographics, etiologies of liver disease, Child-Pugh status, CLIP scores, size of tumor, alpha-fetoprotein (AFP), toxicity, length of stay, and transplantation statistics.

Results: 32 pts (28 men) were treated with 39 TACE procedures. The median age was 57 (32-83). 28 of 32 had cirrhosis with Child's A/B/C 36/51/18% respectively. The major etiologies of cirrhosis were hepatitis C (HCV) 8, alcohol and HCV 19, alcohol 7; portal vein thrombosis in 8 pts. The median tumor size was 6.2 cm (range 2-12 cm) and 81% were multifocal CLIP score 0,1/2,>3 were 5/62/38%. There were no mortality within 30 days of TACE procedure. The majority of the pts were discharged after 24 hr observation; 6 pts require readmissions within 30days. There was no systemic hematologic toxicity. 11 pts had elevated AFP at baseline and 6/11 (54%) had >50 % reduction in AFP value. 11pts (34%) received Ltx; 3 pts came off the LTx list due to disease progression, 2 pts are still on transplant list, and 16pts not able to be listed. 42% of pts received sorafenib in addition to TACE. The median time from last TACE to LTx was 55 days and 4 pts received transplantation within 30days. Very good pathological treatment effect was observed in 8/11 explanted liver.

Conclusions: Our regimen of TACE with carbo/doxorubicin appears to be a safe and tolerable approach for localized treatment as a bridge to liver transplantation. It has acceptable toxicity and is associated with good AFP and pathological responses. We plan to evaluate different baseline parameters for better pt selection.

No significant financial relationships to disclose.

An analysis of three opportunistic infections in an outpatient HIV clinic in Jamaica

OBJECTIVES

To determine the occurrence of opportunistic infection (OI) in HIV-positive patients and to identify any risk factors which may be associated with such.

METHODS

A cross-sectional study of all patients attending the HIV out-patient clinic was conducted. Their hospital notes were examined between January 1 and December 31, 2007 inclusive, to identify any occurrence of opportunistic infection. In addition, the patient list was also cross-referenced with all patients hospitalized on the medical wards during the same time period. Clinical and demographic data were collected for all participants. The occurrence of opportunistic infections and the variables of age, gender CD4 counts and viral loads: (first ever last in 2007 and at diagnosis of OI [or within six months]), the use of primary and secondary prophylaxis, the discontinuation of prophylactic regimens and the HAART regime at diagnosis of an OI and the diagnostic and treatment protocols of these infections were calculated.

RESULTS

Six hundred and three patients participated in the study and 4.7% (n = 28) were found to have experienced at least one opportunistic infection in 2007. Significant associations were found between first and last CD4 cell count, viral load in 2007, year of entry into the clinic and death (p < 0.05).

CONCLUSIONS

Opportunistic infections continue to cause significant morbidity and mortality in the HIV-patient population in this study. Earlier entry to treatment facilities and the use of HAART and appropriate prophylaxis can reduce this impact and lead to improved quality of life for HIV-positive individuals.

A comprehensive response to the HIV/AIDS epidemic in Jamaica: a review of the past 20 years

Jamaica has a well-established, comprehensive National Human Immunodeficiency Virus (HIV) programme that has slowed the HIV epidemic and mitigated its impact. Adult HIV prevalence has been stable at approximately 1.5% since 1996. HIV rates are high among those most at risk such as sex-workers (9%) and men who have sex with men [MSM] (31.8%). Risk behaviour among adults with AIDS includes multiple sexual partners (80%), a history of a sexually transmitted infection [STI] (51.1%), commercial sex (23.9%) and crack/cocaine (8.0%). Approximately 20% of all reported AIDS cases, mainly women, give no history of any of the usual risk factors for HIV infection. The national programme is based in the Ministry of Health. Since 1988, Jamaica has had a national plan to guide its HIV response. A National AIDS Committee was established in 1988 to lead the multi-sectoral response. Prevention approaches have included information, education and communication campaigns, condom promotion, sexually transmitted infections (STI) control, targeted interventions, cultural approaches, outreach and peer education, workplace programmes and HIV counselling and testing. Concerted efforts have been made to reduce HIV stigma and discrimination. Antiretroviral therapy (ARV) was introduced for prevention of mother-to-child transmission in 2001 and a public access treatment programme introduced in 2004. A national HIV/AIDS Policy was adopted unanimously in parliament in 2005. The National Strategic plan 2007-2012 commits Jamaica to achieving universal access to HIVprevention, treatment and care. Awareness of HIV and how to prevent it is near universal though belief in myths remains strong. The condom market has increased from approximately 2.5 million in 1985 to 12 million in 2006 while condom use has grown significantly with nearly 75% of men and 65% of women reporting condom use at last sex with a non-regular partner The proportion of women 15-24 years reporting ever having a HIV test increased from 29.8% in 2004 to 48.9% in 2008. HIV transmission from mother-to-child has declined from 25% prior to 2000 to less than 8% in 2007. As of September 2008, 4450 persons or an estimated 68.5% of persons with advanced HIV and AIDS have been placed on ARV treatment resulting in a significant decline in mortality and morbidity due to HIV

Health communication and adolescents: what do their emails tell us?

BACKGROUND

It is widely known that barriers exist in communication between adolescents and health professionals. However, little is known about the actual language used by young people articulating such difficulties and whether email might allow them to overcome these problems.

OBJECTIVES

The aims of this study were to investigate concerns and difficulties relating to communication among adolescents seeking online health advice.

METHODS

The study design was a corpus linguistic analysis of a million-word adolescent health email database based on 62 794 emails from young people requesting health advice from a prominent UK-hosted and doctor-led website.

RESULTS

Young people reported various concerns about their health. They described numerous difficulties in disclosing such concerns to other people, in particular to parents and doctors. However, they readily expressed their concerns by email, displaying elevated levels of directness, particularly in relation to potentially sensitive or embarrassing topics.

CONCLUSION

Email has the potential to facilitate and supplement face-to-face consultations with health professionals. Increased adoption of email by health providers may be an efficient means of engaging with a generation often reluctant to access more traditional health care services and thus encourage them to enter the primary care setting more readily.

Paediatric and perinatal HIV/AIDS in Jamaica an international leadership initiative, 2002-2007

BACKGROUND

Paediatric and Perinatal HIV/AIDS remain significant health challenges in the Caribbean where the HIV seroprevalence is second only to Sub-Saharan Africa.

METHOD

We describe a collaborative approach to the prevention, treatment and care ofHIVin pregnant women, infants and children in Jamaica. A team of academic and government healthcare personnel collaborated to address the paediatric and perinatal HIV epidemic in Greater Kingston as a model for Jamaica (population 2.6 million, HIV seroprevalence 1.5%). A five-point plan was utilized and included leadership and training, preventing mother-to-child transmission (pMTCT), treatment and care of women, infants and children, outcomes-based research and local, regional and international outreach.

RESULTS

A core group of paediatric/perinatal HIV professionals were trained, including paediatricians, obstetricians, public health practitioners, nurses, microbiologists, data managers, information technology personnel and students to serve Greater Kingston (birth cohort 20,000). During September 2002 to August 2007, over 69 793 pregnant women presented for antenatal care. During these five years, significant improvements occurred in uptake of voluntary counselling (40% to 91%) and HIV-testing (53% to 102%). Eight hundred and eighty-three women tested HIV-positive with seroprevalence rates of 1-2% each year The use of modified short course zidovudine or nevirapine in the first three years significantly reduced mother-to-child transmission (MTCT) of HIV from 29% to 6% (RR 0.27; 95%0 CI--0.10, 0.68). During 2005 to 2007 using maternal highly active antiretroviral therapy (HAART) with zidovudine and lamivudine with either nevirapine, nelfinavir or lopinavir/ritonavir and infant zidovudine and nevirapine, MTCT was further reduced to an estimated 1.6% in Greater Kingston and 4.75% islandwide. In five years, we evaluated 1570 children in four-weekly paediatric infectious diseases clinics in Kingston, St Andrew and St Catherine and in six rural outreach sites throughout Jamaica; 24% (377) had HIV/AIDS and 76% (1193) were HIV-exposed. Among the infected children, 79% (299 of 377) initiated HAART resulting in reduced HIV-attributable childhood morbidity and mortality islandwide. An outcomes-based research programme was successfully implemented.

CONCLUSION

Working collaboratively, our mission of pMTCT of HIV and improving the quality of life for families living and affected by HIV/AIDS in Jamaica is being achieved.

A review of instruments developed to measure outcomes for carers of people with mental health problems

OBJECTIVE

Community-based care for mental disorders places considerable burden on families and carers. Measuring their experiences has become a priority, but there is no consensus on appropriate instruments. We aimed to review instruments carers consider relevant to their needs and assess evidence for their use.

METHOD

A literature search was conducted for outcome measures used with mental health carers. Identified instruments were assessed for their relevance to the outcomes identified by carers and their psychometric properties.

RESULTS

Three hundred and ninety two published articles referring to 241 outcome measures were identified, 64 of which were eligible for review (used in three or more studies). Twenty-six instruments had good psychometric properties; they measured (i) carers' well-being, (ii) the experience of caregiving and (iii) carers' needs for professional support.

CONCLUSION

Measures exist which have been used to assess the most salient aspects of carers outcome in mental health. All require further work to establish their psychometric properties fully.

"Elicitation hooks": a discourse analysis of chaplain-patient interaction in pastoral and spiritual care

The article considers the communicative role of the hospital chaplain and maps some of the language strategies deployed to facilitate disclosure of the patients' concerns and achieve enhanced spiritual care. These include: i) involvement, ii) politeness and iii) encouraging disclosure or exploring emotion.