Amanda Noska

A pilot study of rapid hepatitis C virus testing in the Rhode Island Department of Corrections.

BACKGROUND The correctional population bears a heavy burden of hepatitis C virus (HCV) infection necessitating expansion of HCV testing and treatment opportunities. Rapid HCV testing provides point-of-care antibody results and may be ideal for correctional facilities, particularly jails, where persons are often incarcerated for short periods of time, yet feasibility has not been established. METHODS We conducted a pilot study of a rapid HCV testing algorithm among short-term inmates with unknown HCV status. Participants completed a questionnaire, viewed an informational video and underwent rapid HCV testing and confirmatory testing, when indicated. Persons with chronic infection were referred to community care after release. Baseline characteristics, risk behaviors, test results and linkage were examined by descriptive analyses. RESULTS Two hundred and fifty-two inmates were enrolled and 249 completed all study activities. Twenty-five participants (10%) had reactive rapid tests and 23 (92%) completed confirmatory testing. 15/23 (65%) had detectable HCV RNA, but only 4 linked to care after release. Persons with reactive HCV tests were more likely to be White (P = 0.01) and to have ever injected (P < 0.0001) and/or recently injected (P < 0.0001) drugs. CONCLUSIONS Rapid HCV testing within jails is feasible, identifies previously unrecognized cases of HCV infection, and implementation should be considered. Low rates of linkage to care after release remain a barrier to care.

Managing Opioid Use Disorder During and After Acute Hospitalization: A Case-Based Review Clarifying Methadone Regulation for Acute Care Settings.

OBJECTIVE Treatment with an opioid agonist such as methadone or buprenorphine is the standard of care for opioid use disorder. Persons with opioid use disorder are frequently hospitalized, and may be undertreated due to provider misinformation regarding the legality of prescribing methadone for inpatients. Using a case-based review, this article aims to describe effective management of active opioid withdrawal and ongoing opioid use disorder using methadone or buprenorphine among acutely ill, hospitalized patients. METHODS We reviewed pertinent medical and legal literature and consulted with national legal experts regarding methadone for opioid withdrawal and opioid maintenance therapy in hospitalized, general medical and surgical patients, and describe a real-life example of successful implementation of inpatient methadone for these purposes. RESULTS Patients with opioid use disorders can be effectively and legally initiated on methadone maintenance therapy or buprenorphine during an inpatient hospitalization by clinical providers and successfully transitioned to an outpatient methadone maintenance or buprenorphine clinic after discharge for ongoing treatment. CONCLUSIONS Inpatient methadone or buprenorphine prescribing is safe and evidence-based, and can be used to effectively treat opioid withdrawal and also serves as a bridge to outpatient treatment of opioid use disorders.

History of Sex Exchange in Women with a History of Incarceration

Sex exchange among incarcerated women is not well-described in the literature. Sex exchange can lead to numerous adverse health outcomes, especially when combined with individual factors (e.g., depression and homelessness) and larger systemic inequalities. The purpose of this study was to explore factors associated with having a history of sex exchange among a sample of incarcerated women. Of 257 women surveyed in this study, 68 women (26.5%) reported a history of sex exchange. In multivariate logistic regression analysis, physical abuse history (p=.05, OR 2.20), history of two or more sexually transmitted infections (p=.01, OR 2.90), injection drug use (p=.04, OR 2.46) and crack-cocaine use (p<.01, OR 3.42) were associated with prior sex exchange. This is one of only two studies to examine factors associated with prior sex exchange among incarcerated women. Our study has important implications for corrections providers to provide more comprehensive care, directly addressing the unique needs of this population.

Characterizing the Burden of Hepatitis C Infection Among Entrants to Pennsylvania State Prisons, 2004 to 2012

Although hepatitis C (HCV) infection is common among prisoners, relatively few undergo evaluation for treatment. This study reports the prevalence of chronic infection and the genotype distribution among an incarcerated population. HCV antibody testing was provided to adults entering Pennsylvania prisons; confirmatory and genotype testing were offered to those eligible for treatment. Antibody prevalence among 101,727 individuals was 18.1%. Among 7,633 individuals who underwent confirmatory testing, 69.3% had detectable RNA. Among 3,247 individuals who underwent genotype testing, genotype 1 was the most common (76.6%). The rate of chronic infection after HCV exposure is similar to that reported in the community, as is genotype distribution. Correctional facilities provide access to a population with a high disease burden, creating a public health opportunity for evaluation and treatment.

Urothelial cell carcinoma after BK polyomavirus infection in kidney transplant recipients: A cohort study of veterans

BK polyomavirus (BKPyV) reactivation is a common clinical occurrence in kidney transplant recipients (KTR). Several other polyomaviruses have been implicated as pathogens with a direct role in the development of malignancies, raising the question of whether BKPyV might also be oncogenic.

A Pilot Study of Rapid Hepatitis C Testing in Probation and Parole Populations in Rhode Island

Hepatitis C virus (HCV) affects between five and seven million individuals in the United States and chronic infection can lead to liver disease, cirrhosis, and hepatocellular carcinoma. Probation/parole offices are a novel setting for rapid HCV testing, providing outreach to populations at increased risk for HCV infection and/or transmitting HCV to others. While some correctional facilities offer HCV testing, many individuals who present to probation/parole offices are never or briefly incarcerated and may not access medical services. We conducted a rapid HCV testing pilot at probation/parole offices in Rhode Island. Overall, 130 people accepted rapid HCV testing, of whom 12 had reactive tests. Only four of these individuals presented to a community-based clinic for confirmatory testing, despite being offered a monetary incentive. Identifying and addressing barriers to HCV confirmatory testing and follow-up care is critical to increasing the uptake of HCV care and treatment in this vulnerable population.

Central Nervous System Infections in the Elderly

Central nervous system (CNS) infections are a major cause of morbidity and mortality among the elderly. Meningitis and encephalitis are two common presentations of CNS infection, and have distinct clinical presentations that frequently require prompt diagnosis and treatment. In elderly patients with acute bacterial meningitis, empiric antimicrobial therapy with vancomycin, ampicillin, and a third-generation cephalosporin (either cefotaxime or ceftriaxone), along with adjunctive dexamethasone therapy in those with suspected pneumococcal meningitis, is the recommended approach. In those patients with suspected viral encephalitis, improved diagnostics (such as the use of polymerase chain reaction for herpes simplex encephalitis) have enabled the rapid and accurate identification of the causative pathogen. Prompt initiation of empiric acyclovir therapy is another cornerstone of care for elderly patients with presumed herpes simplex encephalitis, in order to prevent the substantial morbidity, mortality, and, in many cases, chronic neurologic sequelae that can be associated with untreated disease.

Methadone for prisoners – Authors' reply

1 Rich JD, McKenzie M, Larney S, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386: 350–59. 2 Zaller N, Bazazi A, Velazquez L, Rich JD. Attitudes toward methadone among out-oftreatment minority injection drug users: implications for health disparities. Int J Environ Res Public Health 2009; 6: 787–97. 3 Rich JD, Wakeman SE, Dickman SL. Medicine and the epidemic of incarceration in the United States. N Engl J Med 2011; 364: 2081–83. 4 McKenzie M, Zaller N, Dickman S, et al. A randomized trial of methadone initiation prior to release from incarceration. Subst Abus 2012; 33: 19–29. 5 Gordon MS, Kinlock TW, Schwartz RP, O’Grady KE. A randomized clinical trial of methadone maintenance for prisoners: fi ndings at 6 months post-release. Addiction 2008; 103: 1333–42. 6 Zaller N, McKenzie M, Friedmann P, Green T, McGowan S, Rich J. Initiation of buprenorphine during incarceration and retention in treatment upon release. J Subst Abuse Treat 2013; 45: 222–26. overwhelmingly positive outcomes associated with opioid substitution therapy, which starkly contrast with the poor outcomes and high relapse rates associated with incarceration. Ion Anghelescu encourages a scientific rather than an emotional or moral approach to addiction and also asks whether illicit drug use was monitored during incarceration in our study. We did not monitor illicit drug use because of the complexities of required reporting of illegal behaviour in this setting. However, especially for correctional institutions where substantial illicit opioid use occurs, treatment with methadone or other effective medication for opioid dependence can reduce use and associated problems, including overdose, violence, and corruption of correctional staff. Anghelescu also inquires about racial disparities; our study reflected the population enrolled in methadone on entry to custody, which is predominantly white in Rhode Island, USA. Our study population, like most incarcerated people, had a substantial burden of mental illness, with 83% reporting history of depression, 65% having been prescribed psychiatric medications, and 39% previously being admitted to hospital for psychiatric reasons. Similar to most correctional institutions in the USA, psychiatric care was scarce. Finally, our study included only patients on methadone treatment at the time of incarceration. We, and others, have shown the feasibility and benefi ts of initiating methadone or buprenorphine before release. Since prevalence of opioid dependence is 12–15% among prisoners, and the root cause of behaviour leading to incarceration is often opioid dependence in this population, eff orts should be made to screen all entrants to the criminal justice system for opioid dependence, and offer individually tailored, evidence-based opioid substitution therapy with continuation in the community after release. common feature in incarcerated people and might also be associated with other psychiatric disorders. Therefore, the frequency of comorbid psychiatric disorders in the study population would be interesting to know. Additionally, I would like to know whether Rich and colleagues recommend initiation of methadone in opiate-dependent prisoners if they did not receive it before incarceration. Remarkably, most opiate-dependent prisoners in this study were white people, although this ethnic group is a minority in the overall population in prisons. I would like to know whether Rich and colleagues have a hypothesis about where this mismatch stems from.

Intrauterine device infection causing concomitant streptococcal toxic shock syndrome and pelvic abscess with Actinomyces odontolyticus bacteraemia

Intrauterine devices (IUDs) are rarely associated with serious infections. We report an unusual concomitant infection of group A Streptococcus (GAS) causing toxic shock syndrome and pelvic abscess with Actinomyces odontolyticus associated with an IUD in a healthy 50-year-old patient. The IUD was subsequently removed and the patient recovered on the appropriate antibiotics. This case highlights the importance of clinicians’ high index of suspicion of an IUD infection and prompt removal of the infected foreign body to obtain source control.