HIV pre-exposure prophylaxis and opportunities for vaccination against hepatitis A virus, hepatitis B virus and human papillomavirus: an analysis of the Ontario PrEP cohort study.

OBJECTIVES: Populations who seek HIV pre-exposure prophylaxis (PrEP) are disproportionately affected by hepatitis A virus (HAV), hepatitis B virus (HBV) and human papillomavirus (HPV). We examined immunity/vaccination against these infections among participants in the Ontario PrEP cohort study (ON-PrEP). METHODS: ON-PrEP is a prospective cohort of HIV-negative PrEP users from 10 Ontario clinics. We descriptively analysed baseline immunity/vaccination against HAV (IgG reactive), HBV (hepatitis B surface antibody >10) and HPV (self-reported three-dose vaccination). We further performed multivariable logistic regression to identify characteristics associated with baseline immunity/vaccination. We used cumulative incidence functions to describe vaccine uptake among participants non-immune at baseline. RESULTS: Of 633 eligible participants, 59.1% were white, 85.8% were male and 79.6% were gay. We found baseline evidence of immunity/vaccination against HAV, HBV and HPV in 69.2%, 81.2% and 16.8% of PrEP-experienced participants and 58.9%, 70.3% and 10.4% of PrEP-naïve participants, respectively. Characteristics associated with baseline HAV immunity were greater PrEP duration (adjusted OR (aOR) 1.41/year, 95% CI 1.09 to 1.84), frequent sexually transmitted and bloodborne infection (STBBI) testing (aOR 2.38, 95% CI 1.15 to 4.92) and HBV immunity (aOR 3.53, 95% CI 2.09 to 5.98). Characteristics associated with baseline HBV immunity were living in Toronto (aOR 3.54, 95% CI 1.87 to 6.70) or Ottawa (aOR 2.76, 95% CI 1.41 to 5.40), self-identifying as racialised (aOR 2.23, 95% CI 1.19 to 4.18), greater PrEP duration (aOR 1.39/year, 95% CI 1.02 to 1.90) and HAV immunity (aOR 3.75, 95% CI 2.19 to 6.41). Characteristics associated with baseline HPV vaccination were being aged ≤26 years (aOR 9.28, 95% CI 2.11 to 40.77), annual income between CAD$60 000 and CAD$119 000 (aOR 3.42, 95% CI 1.40 to 8.34), frequent STBBI testing (aOR 7.00, 95% CI 1.38 to 35.46) and HAV immunity (aOR 6.96, 95% CI 2.00 to 24.25). Among those non-immune at baseline, overall cumulative probability of immunity/vaccination was 0.70, 0.60 and 0.53 among PrEP-experienced participants and 0.93, 0.80 and 0.70 among PrEP-naïve participants for HAV, HBV and HPV, respectively. CONCLUSIONS: Baseline immunity to HAV/HBV was common, and a sizeable proportion of non-immune participants were vaccinated during follow-up. However, HPV vaccination was uncommon. Continued efforts should be made to remove barriers to HPV vaccination such as cost, inclusion in clinical guidelines and provider recommendation.

Modification of hurling helmets causing penetrating upper limb injury: A case series demonstrating opportunity for improved player safety.

BACKGROUND: The games of hurling and camogie involve fast ball movement and a substantial physical contact with opposing players. The wearing of protective helmets with faceguards became obligatory 10 years ago and resulted in a significant reduction of craniofacial injuries. However since then a trend has emerged of players modifying helmets to improve comfort and vision. As officials are not yet required to perform pre-match checks, many players enter competition with defective protective equipment which poses a risk to both themselves and others. METHODS: We present 4 cases of penetrating upper limb injury in hurlers sustained as a result of helmet faceguards. These injuries were sustained during competitive play and the affected patients presented with portions of the faceguards embedded in their wounds. Each patient required admission to hospital and exploration of their wounds under general anaesthetic. CONCLUSIONS: This case series demonstrates the dangers of modification and damage to protective helmet faceguards used in hurling and camogie. We encourage helmet manufacturers to re-engage with players to ensure that current safety equipment meets the functional demands of the modern player while adhering to approved manufacturing standards. Mandatory helmet checks before competitive games would reduce the likelihood of penetrating upper limb injury to players.

Breast lipofilling as a treatment for breast hypoplasia in Becker naevus syndrome: a case report.

A Becker's naevus is a rare, pigmented, cutaneous hamartoma, which when associated with other cutaneous or musculoskeletal anomalies is termed Becker naevus syndrome. Female patients commonly seek medical attention for breast hypoplasia. Here, we describe our experience in the surgical management of unilateral breast hypoplasia in a patient with Becker naevus syndrome, using high-volume autologous fat grafting. This is, to our knowledge, the second report in the literature describing the aforementioned management technique in this patient cohort.

Extrusion of bone anchor suture following flexor digitorum profundus tendon avulsion injury repair.

Flexor digitorum profundus (FDP) zone I tendon avulsion injury is traditionally repaired with a pullout suture technique. More recently, bone anchor sutures have been used as a viable alternative and have largely replaced areas in hand surgery where pullout suture technique was once required. To date, there have been very few complications reported related to bone anchor suture use in FDP tendon reattachment to the bone. We report a very unusual case of extrusion of bone anchor through the nailbed, 6 years after zone I FDP tendon avulsion injury repair and a brief review of literature.

Cost awareness among doctors in an Irish university-affiliated teaching hospital.

Previous studies in USA and Canada have found that physicians and physicians in training have a limited understanding of medical care costs. In this study, we set out to survey all grades of doctors in the surgical department, emergency department, and anaesthetic department in a university-affiliated, Irish teaching hospital. Open-ended questionnaires on cost of 25 routinely used items in the hospital were sent to each department. The aims of the study were to assess the present knowledge of cost among the various grades of doctors, and to evaluate the level of professional experience on cost awareness and their confidence in their estimates. We had an overall response rate of 56.8% with 68.5% of doctors admitted to have estimated more than 90% of their responses. Ninety three percent of doctors have no confidence in their estimates on cost of listed items. We found that the lack of cost awareness was universal among doctors of all grades (P = 0.236). The doctors in our study population showed a high level of inaccuracy on their estimates of cost of routinely used items with 84% of the items overestimated. Our results were discouraging and demonstrated that considerable educational activity will be necessary if doctors are to be more cost effective in meeting the national health care budget.

Intraocular pressure variations during zygomatic fracture reduction and fixation: a clinical study.

BACKGROUND: The reduction of midface fractures has been associated with the rare but devastating complication of blindness. An increase in intraocular pressure is important in the mechanism of blindness in this setting. In this study, the authors assessed the intraocular pressure in patients who underwent zygomatic fracture reduction (with or without fixation). METHODS: Using applanation tonometry, 29 patients underwent intraocular pressure measurements before, during, and after fracture fixation. The contralateral pressures were measured and used as the control. RESULTS: There were 29 patients with a mean age of 35 years, and the mean time to surgery was 5 days. Preoperatively, all patients had normal intraocular pressures and normal visual acuity. All patients underwent a Gillies lift and 18 patients required open reduction and fixation of the frontozygomatic suture (n = 4) or the infraorbital margin (n = 2), and the remainder (n = 12) required fixation of both points. There was no statistically significant increase in the intraocular pressures following the reduction of uncomplicated zygomatic fractures. Statistically significant pressure reductions were noted immediately after reduction and fixation. CONCLUSIONS: The surgical reduction of uncomplicated zygomatic fractures has no adverse effect on the intraocular pressure. It is the authors' opinion that adjunctive measures to reduce the pressures are unnecessary.

Lawnmower injuries in children.

OBJECTIVE: Power lawnmowers can pose significant danger of injury to both the operator and the bystander, from direct contact with the rotary blades or missile injury. Our objective was to review our experience with paediatric lawnmower-associated trauma, and the safety recommendations available to operators of power lawnmowers. METHODS: The patient cohort comprised paediatric (<16 years of age) patients treated for lawnmower-associated trauma, by the plastic surgery service, between 1996 and 2003. These patients were identified retrospectively. Age at the time of injury, location and extent of bony and soft tissue injuries sustained, treatment instituted and clinical outcome were recorded. Brochures and instruction manuals of six lawnmower manufacturers were reviewed, and safety recommendations noted. RESULTS: Fifteen patients were identified. The majority of injuries occurred from direct contact with the rotary blades (93%); the remaining child sustained a burn injury. Fourteen children (93%) required operative intervention. Seven patients (46%) sustained injuries resulting in amputation, two of whom had major limb amputations. All children, except the burns patient, underwent wound debridement and received antibiotic therapy. Reconstructive methods ranged from primary closure to free tissue transfer. Many patients required multiple procedures. In all instruction manuals, instructions to keep children and pets indoors or out of the yard when mowing were found. CONCLUSIONS: Lawnmower injuries can be devastating, particularly in children. Many victims have lasting deformities as a result of their injuries. Awareness of and stringent adherence to safety precautions during use of power lawnmowers can prevent many of these accidents.