The impact of COVID-19 pandemic on the 2020 hepatitis C cascade of care in the Republic of Georgia.

OBJECTIVES: In 2015, the Republic of Georgia initiated a National Hepatitis C Elimination Program, with a goal of 90% reduction in prevalence of chronic hepatitis C virus (HCV) infections by 2020. In this article, we explore the impact of the COVID-19 pandemic on the 2020 hepatitis C cascade of care in Georgia. STUDY DESIGN: Retrospective analytic study. METHODS: We used a national screening registry that includes hospitals, blood banks, antenatal clinics, harm reduction sites, and other programs and services to collect data on hepatitis C screening. A separate national treatment database was used to collect data on viremia and diagnostic testing, treatment initiation, and outcome including testing for and achieving sustained virologic response (SVR). We used these databases to create hepatitis C care cascades for 2020 and 2019. Bivariate associations for demographic characteristics and screening locations per year and care cascade comparisons were assessed using a chi-squared test. RESULTS: In 2020 compared to 2019, the total number of persons screened for HCV antibodies decreased by 25% (from 975,416 to 726,735), 59% fewer people with viremic infection were treated for HCV infection (3188 vs. 7868), 46% fewer achieved SVR (1345 vs. 2495), a significantly smaller percentage of persons with viremic infection initiated treatment for HCV (59% vs. 62%), while the percentage of persons who achieved SVR (99.2% vs. 99.3%) remained stable. CONCLUSIONS: The COVID-19 pandemic had a negative impact on the hepatitis C elimination program in Georgia. To ensure Georgia reaches its elimination goals, mitigating unintended consequences of delayed diagnosis and treatment of hepatitis C due to the COVID-19 pandemic are paramount.

Asymptomatic spinal cord neoplasm detected during induction of spinal anesthesia.

We report a case of an asymptomatic spinal cord neoplasm detected during the placement of a 25-gauge Whitacre spinal needle for spinal anesthesia before elective cesarean delivery. Subarachnoid blood was repeatedly aspirated during otherwise uncomplicated induction of spinal anesthesia. Magnetic resonance imaging revealed a spinal cord ependymoma in the lumbar spine. Asymptomatic spinal cord neoplasms and ependymomas are reviewed. Central nervous system pathology should be considered in the presence of persistent subarachnoid blood.

Use of intravascular ultrasound as a "Quality Control" technique during carotid stent-angioplasty: are there risks to its use?

Intravascular ultrasound (IVUS) provides high-resolution vessel imaging and has been shown to improve clinical outcomes when used to assess the technical result of peripheral angioplasty procedures. Our vascular group compared anatomic and clinical outcomes of carotid artery stent-angioplasty (CAS) performed with angiogram monitoring alone, or in combination with IVUS imaging to select stent/balloon diameter and interrogate stent deployment region for residual stenosis. A retrospective review of our carotid stent registry (N=306) identified 220 CAS procedures performed with either a digital C-arm fluoroscopy alone (N=110) or in conjunction with IVUS (N=110) with at least 6-month of clinical follow-up. Outcome measures of procedure time, angioplasty balloon diameter, contrast dye volume, Duplex surveillance testing for recurrent stenosis, and procedure event (death, cardiac, neurologic) rates were compared to assess the risks and benefits of IVUS. All procedures utilized a cerebral protection device deployed prior to IVUS imaging. Procedure times were similar, but IVUS usage resulted in lower (P<0.05) contrast agent volumes due to fewer angiogram runs for stent sizing and verification of adequate stent deployment. IVUS imaging resulted in the use of larger diameter balloons (typically 6 mm) for final stent angioplasty based on distal internal carotid artery (ICA) dia measurements, and identified (P<0.01) more residual stent abnormalities (N=12, 11%) versus CAS with angiogram assessment alone (N=2, 1.8%). No procedural or 30-day cardiac events or deaths occurred. The overall stroke rate was 0.9%; two events (stroke-1; reperfusion injury-1) in the angio+IVUS group (1.8%) and none in the angio alone group. Duplex ultrasound surveillance following CAS demonstrated a higher (P<0.01) incidence of >50% diameter-reducing in-stent stenosis in the angio alone group (11% vs 7% at 1 month ; 24% vs 6% at last surveillance; mean 36 moontha; range: 6-66 months). The quality control of the CAS procedure was enhanced by IVUS imaging which directed stent /balloon sizing and was more accurate than angiography in confirming adequate stent expansion. No IVUS related adverse events occurred. Based on the anatomic information provided by IVUS, larger diameter angioplasty balloons were used which correlated with less residual stenosis after CAS based on duplex ultrasound testing.

Senior house officers and foundation year doctors in emergency medicine: do they perform equally? A prospective observational study.

INTRODUCTION: Implementing foundation and specialty training programmes within emergency medicine raised concerns about the potential work productivity and effectiveness of new junior doctors. Between August 2006 and July 2007 senior house officers (SHO) on 6-month posts and foundation year 2 (FY2) doctors on 4-month placements worked on the same roster, rotating between the emergency department at Ninewells Hospital, a university teaching hospital in Dundee, and a smaller affiliated unit at Perth Royal Infirmary. To compare the efficiency and productivity of both groups of junior medical staff. METHODS: A prospective observational study was performed at both departments using the number of patients seen per hour as an indicator of productivity. These rates were calculated using information gathered from a computerised patient record and management system. Analysis was performed using unpaired t tests. RESULTS: Both groups demonstrated a significant rise in performance between the first and last month of their attachment. There was no statistical performance difference between months 4 and 6 of the SHO group, and no significant statistical difference existed between the two groups over the study period. CONCLUSIONS: With FY2 trainees changing every 4 months, departments are potentially exposed to reduced productivity particularly in month 1. Whereas FY2 trainees have no performance difference when compared with their peers, their presence has undoubtedly impacted on middle and senior staff. Only 65% of patients attending this department are seen by junior medical staff and the vast majority of these are reviewed by senior doctors. Increasing supervision, teaching and assessments improve training, but has reduced shop floor presence and productivity.

An eye for trouble: orbital cellulitis.

Patients with orbital cellulitis present to emergency departments occasionally. Symptoms usually develop rapidly, with patients being distressed by painful ocular movements and systemic upset. The case of a 24-year-old man who had a 1-month gradual history of intermittent periorbital swelling after a flu-like illness, and subsequently developed a large intracranial extradural abscess eroding through the temporal bone, ultimately requiring neurosurgical intervention is presented. Although orbital and periorbital swelling is common after acute sinusitis, cellulitis and intracranial abscess are rare but potentially life threatening and sight threatening. Accurate diagnosis is therefore of great importance. In this case, the patient presented with few clinical signs but relevant pathology. The importance of assessing ocular movement, which is a major clinical abnormality indicating orbital disorder and thus an aid to accurate diagnosis, should be highlighted.

Effect of innappropriate naltrexone use in a heroin misuser.

Naltrexone is a long acting opioid receptor antagonist used in controlled opioid withdrawal drug programmes. When taken by an opioid dependent patient an acute withdrawal reaction will be precipitated. The case is presented where a known opioid drug misuser inadvertently ingested naltrexone in conjunction with heroin resulting in severe agitation, requiring heavy sedation followed by general anaesthesia to enable investigation and management of his clinical condition.

Diaphragmatic hernia seen as a late complication of laparoscopic cholecystectomy.

Laparoscopic surgery has emerged as the standard of care for the elective operative management of symptomatic gallbladder disease. The surgical literature is now beginning to accumulate sufficient case numbers that more clearly define the associated morbidity of this type of surgery. This article reports an instance of iatrogenic injury to the right muscular hemidiaphragm and subsequent hernia after laparoscopic cholecystectomy.

Reduced use of resources by early tracheostomy in ventilator-dependent patients with blunt trauma.

BACKGROUND: Early tracheostomy has been advocated for ventilator-dependent patients with blunt trauma, but its advantages have not been examined critically. METHODS: We retrospectively reviewed our experience with all patients with blunt trauma undergoing tracheostomy during the 6-year period from 1990 to 1995. Patients undergoing tracheostomy within the first 6 days of hospitalization were designated as early recipients (ET) and those undergoing the procedure at 7 or more days were defined as late recipients (LT). RESULTS: The entire study group consisted of 157 patients. The ET group contained 62 patients and the LT group contained 95 patients. No statistical differences were noted between the 2 groups with respect to sex distribution, injury severity scores, probability of survival scores, or mortality rates. The mean stay in the intensive care unit for the ET group was 15 days compared with 29 days for the LT group (P < or = .001). The mean total hospital stay for the ET group was 33 days compared with 68 days for the LT group (P < or = .001). The mean estimated per-patient hospital charges for only room and ventilator care were $36,609 for the ET group compared with $73,714 for the LT group. CONCLUSIONS: ET in this patient group resulted in significantly lowered use of resources with no adverse effect on outcome.

Improved selection criteria for ordering stat venous ultrasounds from the emergency department.

BACKGROUND: The accuracy and convenience of venous ultrasound (VU) to exclude deep vein thrombosis (DVT) has led to indiscriminate use and low positive yield rates. METHODS: A total of 256 patients were referred from our emergency department (ED) for stat VU during a 2-year period (1995 to 1996). The VUs were interpreted as normal in 198 (77%). Positive findings were discovered in 58 (23%), with DVT accounting for 43 (17%). Retrospective multivariant analysis was used to identify predictive indicators. RESULTS: Unilateral leg swelling/edema identified 36 of 40 (90%) patients with DVT and 8 of 10 (80%) with other thrombotic disorders (saphenous and/or chronic venous thrombosis). A history of leg pain with prior DVT or recent trauma < or =3 days' duration increased DVT duration to 98% (39 of 40). Using these criteria, a 47% charge reduction would have been recognized. CONCLUSIONS: Improving ED screening criteria can safely increase yield rate and reduce charges with minimal loss of VU sensitivity.

The effect of electric field gradient asymmetry on motionally averaged spin-1 powder patterns.

The effect of an asymmetric electric field gradient tensor on anisotropic NMR spectra of spin-1 nuclei is investigated for fast molecular rotations and 2-site jump processes. When molecular rotations are fast, continuous, and complete, the peak-to-peak splitting of motionally averaged spin-1 NMR spectra can depend significantly on the inherent electric field gradient asymmetry, eta, for eta > or = 0.05. Parameters describing low-symmetry molecular motion which are extracted from fitting experimental data depend strongly upon eta. One implication of these phenomena is that even the modest electric field gradient asymmetry around deuterons in covalent bonds can contribute considerably to motionally averaged lineshapes, especially when molecular motions are not highly symmetric.