Red Herring in Orthopedics: A Case Report on Painful Os Vesalianum Pedis Masquerading as an Avulsion Fracture of 5th Metatarsal and Review of Literature.

Introduction: Os vesalianum pedis (OVP) is a rare accessory ossicle of the foot located proximal to the base of 5th metatarsal. It is usually asymptomatic but can mimic an avulsion fracture of proximal 5th metatarsal and is an infrequent cause of lateral foot pain. There have only been 11 cases of symptomatic OVP reported in the current literature. Case Report: Our patient, a 62-year-old male presented with lateral foot pain following an inversion injury of his right foot, with no history of any previous trauma. What was initially mistaken as an avulsion fracture of the 5th metacarpal base was later revealed to be an OVP on contralateral X-ray. Conclusion: Treatment is mostly conservative, but surgical excision can be done in cases following failed non-operative treatment. In the context of trauma, OVP must be differentiated from other causes of lateral foot pain such as Iselin's disease and avulsion fractures of base of 5th metatarsal. Understanding the various etiologies of the condition and what those etiologies are usually related to can help prevent unnecessary treatment.

Experiences of Intimate Partner Violence: Findings From Interviews With South Asian Women in the United States.

Eleven South Asian women were recruited from three domestic violence agencies in the United States and interviewed to examine their experiences with intimate partner violence (IPV). The interviews were analyzed using a grounded theory approach. Themes included detailed barriers and facilitators to disclosure of the abuse and leaving the abusive relationship. Findings suggest that families of origin and in-laws play a significant role in the process of leaving the relationship. Children are often cited as a source of strength for the women. The process of healing and recovery after leaving a relationship with IPV was also discussed by women enrolled in this study. Pragmatic approaches to addressing IPV among South Asian women in health care settings are also considered.

Bioequivalent pharmacokinetics for generic and originator hepatitis C direct-acting antivirals.

Mass production of low-cost, generic direct-acting antivirals (DAAs) will be required to achieve targets of eliminating hepatitis C (HCV) by 2030. The pharmaceutical companies Gilead and Bristol-Myers Squibb have granted voluntary licences (VLs) to generic companies to mass produce the DAAs sofosbuvir and daclatasvir at low cost. However, generic manufacturers need to demonstrate bioequivalent pharmacokinetics for their DAAs, compared to the originator versions, to fulfil World Health Organization standards for prequalification. The aim of this study was to determine whether generic forms of sofosbuvir and daclatasvir had bioequivalent pharmacokinetics to the originator versions. Generic companies were contacted for results of bioequivalence studies with sofosbuvir and daclatasvir, two of the most widely used DAAs in the developing world. Data on maximum concentration (Cmax) and area under the curve (AUC) were compiled from five generic companies. Pre-specified limits for the 90% confidence intervals were 80-125% of the originator pharmacokinetic concentrations for AUC, and 69-145% for Cmax. The pharmacokinetics of generic sofosbuvir and daclatasvir were shown to be bioequivalent to the originator versions for all five generic companies. This is a crucial step towards securing prequalification of the manufacture of these drugs from these companies. WHO prequalification of bioequivalent generic DAAs could then permit their export to eligible countries for mass-treatment programmes. Mass-treatment with low-cost generic HCV DAAs is the most promising method to achieve the ambitious World Health Organization targets for HCV elimination by 2030.

High sustained virological response rates using imported generic direct acting antiviral treatment for hepatitis C.

BACKGROUND: High prices of direct acting antivirals (DAAs) for hepatitis C virus (HCV) can lead to restrictions on access to treatment in high- and middle-income countries. An increasing number of people in these countries are treating their HCV infection with generic drugs produced in India, China, Bangladesh or Egypt. This analysis assessed the efficacy of generic imported DAAs. METHODS: Patients sourced generic versions of sofosbuvir (SOF), ledipasvir (LDV) and daclatasvir (DCV) from suppliers in India, Bangladesh, China and Egypt via three buyers' clubs. The choice of DAAs and the length of treatment were determined on baseline RNA levels, HCV genotype and stage of fibrosis. Patient HCV RNA levels were evaluated pre-treatment, during treatment, at end of treatment (EOT) and then for sustained virological response (SVR) at 4, 12, and 24 weeks, normally by a treating clinician. RESULTS: Overall 616 patients submitted results: 199 from an Australian buyers' club, 205 from a South-east Asian buyers' clubs, and 212 from an Eastern European buyers' club. Of the 616 patients treated, 276 received SOF/LDV (35 with ribavirin [RBV]) and 340 received SOF/DCV (61 with RBV). At baseline, 61% were male, 52% had HCV genotype 1 and 11% had liver cirrhosis. The mean age was 44.3 years and the mean baseline HCV RNA was 6.9 log10 IU/mL. A rapid virological response (RVR) was observed in 314/375 (84%) of the patients treated. Based on currently available data, the percentage of patients with HCV RNA below the lower limit of quantification (LLoQ) was 99% (234/237) at EOT, 99% (299/303) at SVR4 and 99% (247/250) at SVR12. CONCLUSIONS: In this analysis, treatment with imported generic DAAs achieved high rates of HCV RNA undetectability at the end of treatment, and SVR12 in 99% of patients evaluated to date. Mass treatment with generic DAAs is a feasible and economical alternative route of accessing curative DAAs, where the high prices for branded alternatives prevent access to treatment.

The road to elimination of hepatitis C: analysis of cures versus new infections in 91 countries.

BACKGROUND: Hepatitis C (HCV) can only be eradicated if annual rates of cure (SVR) are consistently and significantly higher than new HCV infections, across many countries. In 2016, the WHO called for a 90% reduction in new HCV infection by 2030. Direct-acting antivirals (DAA) can cure the majority of those treated, at around 90% in most populations, at potentially very low prices. We compared the net annual change in epidemic size across 91 countries using data on SVR, new HCV infections, and deaths. In a further 109 countries, we projected this figure using regional averages of epidemic size. METHODS: Epidemiological data for 2016 were extracted from national reports, publications and the Polaris Observatory. There were 91/210 countries with data on SVR, HCV-related deaths and new infections available for analysis; 109 countries had net change in epidemic size projected from the regional prevalence of HCV, extrapolated to their population size. 'Net cure' was defined as the number of people with SVR, minus new HCV infections, plus HCV-related deaths in 2016. RESULTS: For the 91 countries analysed, there were 57.3 million people with chronic HCV infection in 2016. In the remaining 109 countries, the projected epidemic size was 12.2 million, giving a global epidemic size of 69.6 million. Across the 91 countries, there was a fall from 57.3 to 56.9 million people in 2017, a 0.7% reduction. The projected global net change was from 69.6 to 69.3 million, a 0.4% reduction. Ten countries had at least five times more people reaching SVR than new HCV infections, including Egypt and USA. In 47/91 countries, there were more HCV infections than SVR in 2016. CONCLUSION: Very few countries are on target to achieve elimination of HCV as a public health problem by 2030. While the North American, North African/Middle East and Western European regions have shown small declines in prevalence, the epidemic is growing in sub-Saharan Africa and Eastern Europe. Far higher rates of DAA treatment are required for worldwide elimination of HCV.

Internet suicide in Japan: a qualitative content analysis of a suicide bulletin board.

Netto shinju, or Internet group suicide, is a contemporary form of Japanese suicide where strangers connect on the Internet and make plans to commit suicide together. In the past decade, numerous incidents have occurred whereby young Japanese make contact on the Internet, exchange tips on suicide methods, and make plans to meet offline for group/individual suicide. A systematic qualitative content/thematic analysis of online communications posted on a popular Japanese suicide bulletin board yielded a textured, thematic understanding of this phenomenon. Themes identified reflected Shneidman's theory of suicide but with an emphasis on interpersonal concerns that are embedded in Japanese culture.

Psychophysiological reactions to the response phase of the rorschach and 16PF.

In this pilot study, we investigated whether there was a differential psychophysiological response during the beginning, middle, and end of the administration of a performance-based instrument (Rorschach Inkblot Method, RIM; Exner, 2003) versus a self-report measure of personality (Sixteen Personality Factor Questionnaire, 5th ed. [16PF]; Cattell, Cattell, & Cattell, 1993). Results indicate that adult participants (n = 15) experienced greater electrodermal activity during the administration of the RIM as compared to the 16PF. Effect sizes for the differences between the instruments were all very large (Cohen's d = 1.71 at beginning, d = 1.1 at middle, and d = .98 at end).