Community outbreak of hepatitis A disproportionately affecting men who have sex with men in Toronto, Canada, January 2017-November 2018.

BACKGROUND: In late 2016 and early 2017, a number of countries began reporting hepatitis A virus (HAV) outbreaks involving person-to-person transmission among men who have sex with men (MSM), people using illicit drugs and homeless or underhoused persons. OBJECTIVE: To describe the epidemiology and public health response to an outbreak of HAV disproportionately affecting MSM in Toronto, Canada from January 2017 to November 2018. METHODS: Following an increase in the number of cases of HAV in MSM being reported in other countries, enhanced surveillance was performed for all non-travel-related cases of HAV reported from June 1, 2017 to November 1, 2018, including a retrospective analysis of cases reported from January 2017 to June 2017. Descriptive analysis and viral sequencing were performed to describe person-to-person transmission patterns and target interventions. Control strategies included interventions to promote the uptake of preexposure HAV vaccination, including social media campaigns geared to MSM, messaging to healthcare providers and vaccine clinics. RESULTS: Based on the outbreak case definitions, 52 confirmed and probable cases of HAV were identified. Over 80% of outbreak cases were male (n=43/52) and, among those for whom data were available, 64% (n=25/39) reported an MSM exposure. Data on hospitalization was available for 51 cases; 56% of confirmed cases (n=23/41) and 40% of probable cases (n=4/10) required hospitalization. Of the cases with serum samples that had HAV sequencing, 83% (n=30/36) had one of the three strains seen circulating in outbreaks among MSM internationally; 72% (n=26/36) were VRD_521_2016, which had been detected in recently reported European outbreaks among MSM. Targeted promotion of publicly-funded vaccination using social media platforms popular with MSM and targeted vaccine clinics were developed to promote HAV awareness and vaccine uptake among MSM. CONCLUSION: Outbreaks of HAV, attributed to person-to-person transmission of strains of HAV that disproportionately affected MSM and were likely to have been imported from international MSM outbreaks, have now occurred in Canada. Genetic sequencing of HAV, risk factor analysis of cases, monitoring trends of vaccine coverage in high-risk groups and initiation of vaccination campaigns that address barriers to HAV preexposure vaccine coverage in the MSM population may prevent future outbreaks.

Identifying barriers to healthcare delivery and access in the Circumpolar North: important insights for health professionals.

Lack of access to healthcare services for people living in the Circumpolar North may have important consequences for their health and well-being, both in terms of the actual treatment and other possible health-related consequences intertwined with their life situation. The aim of the present study was to identify the specific challenges to healthcare service delivery and access for populations in the Circumpolar North that are addressed in contemporary literature. A scoping review of literature published between 2005 and 2016 was conducted and 43 articles were selected for inclusion into the review. The review findings address 4 main themes identified in the literature: (1) the influence of physical geography, (2) healthcare provider-related barriers, (3) the importance of culture and language and (4) the impact of systemic factors. The review of the literature enabled us to identify existing gaps in both health service access and issues discussed in the available literature, particularly for informing healthcare services in the Circumpolar North, as well as point towards opportunities for future research. The thematic findings drawn from interdisciplinary and international literature inform understandings of the impact of health system barriers on healthcare services and the opportunities for Northern residents to support their own health.

Investigation and management of a large community mumps outbreak among young adults in Toronto, Canada, January 2017-February 2018.

BACKGROUND: In 2017, a mumps outbreak was identified in a cohort of 18-34 year olds in Toronto, Canada. OBJECTIVE: To describe a large community mumps outbreak in an urban centre from January 2017 to February 2018 among young adults. METHODS: A broad range of interventions were implemented in an attempt to reach the target audience; including case and contact management, vaccination clinics at schools and clinicians' offices, school exclusions, bar inspections, traditional communication strategies (including health care provider updates and posters) and newer communication strategies (including three sequential social media campaigns). RESULTS: A total of 143 cases of mumps were identified. Although cases' ages ranged from three to 72 years, most (76%) were 18-34 year olds, many of whom had frequented bars and local food establishments in downtown Toronto. 84% (n=120) of the cases were community-acquired. Only 16% (n=23) of the cases reported exposures in schools and post-secondary school institutions. Of those, 39% (n=56) of cases had an unknown vaccination history; 34% (n=49) were either not vaccinated or partially vaccinated with one dose of measles-mumps-rubella vaccine; and 27% (n=38) had received the recommended two doses of mumps vaccine. Determining vaccination status was a challenge, in part due to the lack of a registry. Vaccination was recommended when subjects were known to have had fewer than two doses of vaccine or had an unknown vaccination status. A social media campaign, emphasizing the risk of social activities if not protected from the mumps, yielded over 500,000 impressions from Facebook and Twitter messages and ads and an impressive engagement rate of between 1% and 10x%. CONCLUSION: This was the largest mumps outbreak in Toronto in over 20 years. Among young adults, ongoing social media and traditional communication campaigns can contribute to the control of community mumps outbreaks. Encouraging vaccine uptake is desirable, but without a vaccine registry it is difficult to assess vaccination coverage among adults. Susceptible cohorts of young adults who were not adequately vaccinated pose a risk for future outbreaks. Given that almost 30% of the mumps cases were fully vaccinated with two doses of mumps-containing vaccine, even two doses may not provide complete protection.

There is good agreement between MR enterography and bowel ultrasound with regards to disease location and activity in paediatric inflammatory bowel disease.

AIM: To investigate concordance of bowel ultrasound and magnetic resonance enterography (MRE) in identifying active disease in children with inflammatory bowel disease. MATERIALS AND METHODS: The imaging of children with inflammatory bowel disease who had undergone bowel ultrasound and MRE within 30 days were retrospectively reviewed, from January 2009 to November 2015. Ultrasound was without oral contrast medium; MRI was conducted with patients unsedated with oral contrast medium and gadolinium. Imaging data included bowel thickness, markers of activity, and complications. Endoscopy and biopsy reports were also reviewed. RESULTS: Forty-nine patients (median age 14 years, 33 male) met the inclusion criteria, and 31 children also had endoscopy within 30 days. Active inflammation was seen in 17.6% of bowel segments at ultrasound and 17.3% at MRE. There was good agreement between ultrasound and MRE on the location and activity of disease (Cohen's kappa 0.75, 95% confidence interval [CI]: 0.66-0.83). One patient had an inflammatory phlegmon detected at MRE only; there was no other significant discrepancy in identifying complications. In patients with histopathology, MRE, and ultrasound demonstrated high specificity 85.1% (77.9-90.6) and 86.6% (79.6-91.8) at the bowel segment level. Technical difficulties, including poor tolerance of oral contrast medium and movement, were more common in MRE. CONCLUSION: There was good concordance between MRE and ultrasound for disease location and activity, and fewer technical difficulties with ultrasound. Bowel ultrasound is useful in children, and its use is advocated.

Regional challenges: evaluation of a hepatitis outreach programme using transient elastography (FibroScan) in Victoria.

BACKGROUND: Evaluation of an outreach programme using a mobile transient elastography (TE) device (FibroScan) to improve liver disease assessment in different clinical settings. AIMS: To evaluate a programme of liver fibrosis assessment by TE and to compare fibrosis scores between different sites and patient groups. METHODS: Prospective cohort study. TE was conducted at a tertiary hospital and during outreach clinics in three different settings: community clinics, clinics for people who use drugs (PWUD) and regional clinics in rural Victoria. All patients referred for TE at the participating locations were eligible during the study period. RESULTS: A total of 200 of 623 patients was assessed and evaluated during outreach sessions (regional 100; PWUD 18; community 82). While the majority of patients in community centres were infected with hepatitis B (68%), most patients in regional clinics and in PWUD settings had hepatitis C virus (HCV) (81 and 100%, respectively). Significantly more patients assessed at regional clinics and PWUD settings presented with severe fibrosis (F3-F4, F4): regional clinics 39%; PWUD 31%; tertiary 11%; community 7%, (P <0.001). Multivariable logistic regression analysis revealed that older age, alcohol consumption, male sex, increased alanine transferase levels, HCV infection and importantly, evaluation at regional sites were independently associated with severe fibrosis. CONCLUSIONS: A TE-based outreach programme allows for assessment of liver fibrosis in varied and regional populations. The finding that patients in regional settings and PWUD presented with more advanced fibrosis should prompt improvements in healthcare to improve access for these populations.

A validation of the use of names to screen for risk of chronic hepatitis B in Victoria, Australia, 2001 to 2010.

The burden of chronic hepatitis B (CHB) is increasing in Australia, particularly in those born in the Asia-Pacific region, and nearly half are undiagnosed. Primary care clinicians have a key role in diagnosing CHB, however identification of patients at risk is hindered by lack of awareness and limited information on country of birth in patient records. This study evaluates the potential of a validated list of names associated with Asian country of birth as a screening tool to predict risk of CHB, by comparing it with surveillance records for all people diagnosed with CHB or salmonellosis in Victoria from 2001 to 2010, and analysed using standard screening tools. Name list match was associated with CHB notification, with over 60% of cases having one name matching the list (sensitivity), and nearly one third matching both given name and surname; less than 15% and 2% of salmonellosis notifications matched for one name and both names, respectively (false positives). These results show that more than half of notified cases of CHB would have been identified by this name list, and that it could be used in support of initiatives to improve diagnosis of patients with diseases associated with country of birth when limited information is available.

Hepatitis D virus in Victoria 2000-2009.

BACKGROUND: Hepatitis D virus (HDV) coinfection can adversely affect prognosis and complicate management of chronic hepatitis B. The epidemiology and clinical practices surrounding HDV in Australia are poorly understood, with no robust estimates of the burden of disease, and the extent of appropriate testing and clinical follow up is unknown. AIMS: To determine the number of reported cases of HDV in Victoria, Australia between 2000-2009 and to explore screening practices in patients at risk of HDV infection over the same time period. METHODS: Data regarding HDV diagnoses in Victoria for 2000-2009 were obtained from notifiable disease surveillance and public health laboratory testing records. Notifications data were analysed to determine risk factors and demographics of HDV diagnoses where available, and laboratory records used to determine screening practices and follow up testing. RESULTS: Eighty-seven notifications for HDV were recorded between 2000 and 2009. The median age at diagnosis was 34 (interquartile range 27-44), and the majority of cases were men (77%) and born overseas (71.4% of those with country of birth reported). During the same period, 2314 Victorian residents were tested for HDV infection, with 110 (4.75%) found to be positive. Both the number of people testing positive and the number of tests conducted steadily increased between 2005 and 2009. Of those patients with positive HDV antibody results, less than half (44 patients, 40%) were subsequently evaluated for replicative infection by polymerase chain reaction. CONCLUSION: The number of people being tested for HDV has increased over the past decade; however, gaps in the appropriate follow-up of infected patients are apparent. Birth overseas has become an increasingly important risk factor in Victorian notifications, highlighting the need for routine testing of people living with chronic hepatitis B for HDV infection.

Cross-sectional imaging of gastric neoplasia.

The detection of gastric neoplasia has traditionally been limited to barium examination and direct visualization at endoscopy. The rapid development of techniques such as multidetector computed tomography (MDCT) and endoscopic ultrasound (EUS) has resulted in more accurate diagnosis and staging of gastric neoplasia. In this review we describe the normal anatomy of the stomach with multi-modality illustrations and review the imaging manifestations of gastric neoplasia, including adenocarcinoma, lymphoma, neuroendocrine and gastro-intestinal stromal tumours. We also describe the optimal techniques for up-to-date and accurate gastric imaging, outlining the role of MDCT and EUS.

[Bluetongue disease in Swiss sheep breeds: clinical signs after experimental infection with bluetongue virus serotype 8]. / Blauzungenkrankheit bei Schweizer Schafrassen: Klinische Symptome nach experimenteller Infektion mit dem BTV-Serotyp 8.

Clinical disease of bluetongue (BT) in sheep may differ depending on breed, age and immunity of infected sheep and may also vary between serotype and strain of BT virus (BTV). Since there are no data available on the susceptibility of Swiss sheep breeds for BT, we performed experimental infection of the 4 most common Swiss sheep breeds and the highly susceptible Poll Dorset sheep with the BTV serotype 8 (BTV-8) circulating in Northern Europe since 2006. Clinical signs were assessed regarding severity, localisation, progression and time point of their appearance. The results clearly show that the Swiss sheep breeds investigated were susceptible to BTV-8 infection. They developed moderate, BT-characteristic symptoms, which were similar to those observed in Poll Dorset sheep. Regardless of breed, the majority of infected animals showed fever, swelling of the head as well as erosions of the mouth and subcutaneous haemorrhages.

Previously treated oesophageal achalasia re-presenting with stridor.

Achalasia is a motility disorder of the oesophagus that typically presents with dysphagia, regurgitation and chest pain. A rare presenting symptom is stridor. A case of previously treated achalasia re-presenting with stridor is described and associated imaging presented.

Cholesterol oxidase: sources, physical properties and analytical applications.

Since Flegg (H.M. Flegg, An investigation of the determination of serum cholesterol by an enzymatic method, Ann. Clin. Biochem. 10 (1973) 79-84) and Richmond (W. Richmond, The development of an enzymatic technique for the assay of cholesterol in biological fluids, Scand. J. clin. Lab. Invest. 29 (1972) 25; W. Richmond, Preparation and properties of a bacterial cholesterol oxidase from Nocardia sp. and its application to enzyme assay of total cholesterol in serum, Clinical Chemistry 19 (1973) 1350-1356) first illustrated the suitability of cholesterol oxidase (COD) for the analysis of serum cholesterol, COD has risen to become the most widely used enzyme in clinical laboratories with the exception of glucose oxidase (GOD). The use is widespread because assays incorporating the enzyme are extremely simple, specific, and highly sensitive and thus offer distinct advantages over the Liebermann-Burchard analytical methodologies which employ corrosive reagents and can be prone to unreliable results due to interfering substances such as bilirubin. Individuals can now readily determine their own serum cholesterol levels with a simple disposable test kit. This review discusses COD in some detail and includes the topics: (1) The variety of bacterial sources available; (2) The various extraction/purification protocols utilised in order to obtain protein of sufficient clarification (purity) for use in food/clinical analysis; (3) Significant differences in the properties of the individual enzymes; (4) Substrate specificities of the various enzymes; (5) Examples of biological assays which have employed cholesterol oxidase as an integral part of the analysis, and the various assay protocols; (6) New steroidal products of COD. This review is not a comprehensive description of published work, but is intended to provide an account of recent and current research, and should promote further interest in the application of enzymes to analytical selectivity.

Surface partitioning studies of N-methylcarbamate-treated post-harvest crops using SFE-HPLC-postcolumn reaction-fluorescence.

The partitioning characteristics of selected carbamate insecticides (carbaryl, aldicarb, bendiocarb and pirimicarb) on five fruit and vegetable types were investigated. Post-harvest samples were surface-saturated with a methanolic-aqueous mixed carbamate spiking solution for a number of time periods. Samples were taken at 3, 7, 10 and 14 d, and extracted using supercritical CO2 at pressure = 300 atm modified with 10% dimethyl sulfoxide. Extracts were analysed by HPLC-postcolumn reaction-fluorescence detection at lambda ex = 330 nm and lambda em = 450 nm for N-methylcarbamates and at lambda ex = 315 nm and lambda em = 380 nm for pirimicarb. The relative partitioning of each insecticide between sample skin and flesh was investigated. This included the determination of both half-life and normalised matrix metabolic rate studies with respect to each carbamate. Multilinear regression (MLR) was applied to a number of insecticide and matrix-based variables to develop regression models for carbamate partitioning for each matrix type studied. Experimentally derived carbamate half-lives ranged from 3.6 d (carbaryl in pear flesh) to 8.0 d (bendiocarb in banana skin). Determinations of normalised metabolic rates were based on calculating the time period from the point of sampling through to the point where carbamate concentration was reduced to 5% of its initial value. These values ranged from 16.2 d (bendiocarb in potato skin) to 34.7 d (bendiocarb in banana skin). Although no practicable MLR partitioning models were obtained, it was found that the models created indicated that carbamate solubility in water (and hence log P) and the number of days in contact with the spiking solution were the most important parameters in model construction.

Application of new fluorescent thiol reagent to diagnosis of homocystinuria.

A new fluorescent thiol reagent, dansyl-aminophenylmercuric acetate (DAPMA), was applied to the diagnosis of homocystinuria, a disorder which can be associated with vascular disease at an early age. DAPMA was added to urine containing metabisulphite and the resulting fluorescent derivatives were extracted on a cyclohexyl silica column and separated by thin-layer chromatography. 102 coded samples were tested. The derivative of homocysteine was easily identified in samples from 4 children with homocystinuria but was absent from all samples from normal subjects and patients with unrelated disorders. Other thiols (cysteine, acetylcysteine, mercaptolactate, thiosulphate, and thiocyanate) were also identified in urine from healthy fasting subjects.

An extraction-derivatization method suitable for the analysis of biogenic amines by gas chromatography negative ion mass spectrometry.

An extraction-derivatization method suitable for the analysis of subnanogram amounts of biogenic amines in aqueous solution has been developed. The most satisfactory procedure for the analysis of these compounds was reaction with 3,5-ditrifluorobenzoylchloride (DTFMBCl) in phosphate buffer at pH 7.2 followed by extraction of the resultant amide esters into ethyl acetate. This was followed by hydrolysis of the phenolic ester functionalities by shaking the organic layer with 10 M ammonium hydroxide. The phenolic and alcoholic hydroxyl groups were then reacted with bistrimethylsilylacetamide and the trimethylsilyl-DTFMB amides were then analysed by gas chromatography/mass spectrometry in the negative ion chemical ionization mode with methane as reagent gas. The limits of detection for these derivatives was less than 1 pg and the method was readily applicable to the extraction and analysis of 0.5 ng of a given biogenic amine.

Selective reactions in the analytical characterisation of steroids by gas chromatography-mass spectrometry.

The analytical characterization, by GC-MS, of individual compounds in mixtures of steroids, such as occur frequently in biological extracts, is difficult because of the close similarities in structure and properties of many components. The improved separating power of capillary (open-tubular) columns alleviates the problem, but does not solve it fully: for example, the coincidence of retention times of two different compounds may still be virtually complete. Comparative analyses on two distinctively different phases afford one valuable application of selectivity, but may not always be feasible when costly columns are required. Comparative analyses of the sample, before and after effecting its modification by well-defined reactions, are inexpensive and are particularly when selective transformations are used. The use of the microbial enzyme cholesterol oxidase as a selective oxidant for 3 beta-hydroxysteroids (chiefly limited to 4-ene, 5-ene and 5 alpha-types) is illustrated for a model mixture of androstanols related to the boar pheromone (5 alpha, 16-androsten-3 alpha-ol). Retention regularities and changes in mass spectra enhance the reliability of identifications. An exploratory application of cholesterol oxidase in the analysis of minor "polar" sterols in human serum is reported. Most of the known minor sterols are good substrates for the enzyme, and their transformation products yield distinctive GC-MS data, as exemplified for the 7 alpha- and 7 beta-hydroxycholesterols. Another convenient and versatile selective reagent is methaneboronic acid, which yields cyclic esters of suitably constituted diols. These derivatives have shorter retention times (on "non-polar" phases) than the di-TMS ethers, chiefly by virtue of their much lower molecular weights. The mass spectra of cyclic boronates generally show clear molecular ions, also fragmentations that complement the information obtainable from the di-TMS ethers. These features are illustrated for a group of diols and triols of the 5 alpha-pregnane series.