Richard Mathias

Diffuse lamellar keratitis related to endotoxins released from sterilizer reservoir biofilms.

OBJECTIVE To investigate the risk factors and control mechanisms used to control the outbreak of diffuse lamellar keratitis (DLK) associated with laser in situ keratomileusis (LASIK) and examine the relationship between DLK and endotoxins released from sterilizer biofilm reservoirs. DESIGN Clinic-based cohort and laboratory study. PARTICIPANTS All patients undergoing LASIK at our clinic from October 7, 1998 through August 31, 1999. The case definition was a diffuse infiltrate in the interface developing within the first week after surgery. INTERVENTIONS Biofilm control in the sterilizer, changes in sterilizer, distilled water, instruments, and irrigating fluids. MAIN OUTCOME MEASURES The incidence of DLK after LASIK surgery. RESULTS There were 983 evaluable patients, with three whose DLK status was not recorded. There were 52 cases of DLK. Burkholderia pickettii was isolated from the sterilizer reservoir. Potential risk factors and associations, for which there was no significant difference, included age and sex of the patients, surgeon, operating suite temperature or humidity, drapes used, saline solutions used, time of day the surgery was performed, and microkeratome use. Sterilizers 1 and 2, before biofilm control, were compared with sterilizer 3, after control. The relative risk was 9.4 (confidence limits [CL], 7.5-11.8) for sterilizer 1 versus 3 and 18. 7 (CL, 11-32) for sterilizer 2 versus 3. Three cases occurred after biofilm control, but were sporadic in nature and associated with epithelial defects. CONCLUSIONS Clusters of DLK may be related to endotoxins released from gram-negative biofilms in sterilizer reservoirs. We experienced an outbreak of DLK affecting 52 patients and isolated B. pickettii from the sterilizer reservoir. Epidemiologic investigation showed that biofilm control in the sterilizer reservoirs was associated with a significant reduction in the development of DLK. We encourage any clinics that experience a cluster of DLK to consider microbiologic and epidemiologic investigation for the effectiveness of sterilizer biofilm control.

Randomised double-blind placebo-controlled study on adverse effects of rubella immunisation in seronegative women

BACKGROUND The objective of our study was to investigate the association of adverse clinical musculoskeletal and neurological events in healthy postpartum women with live attenuated (RA27/3 strain) rubella-virus vaccine, and to assess the frequency of acute and recurrent arthralgia and arthritis and associations with acute and recurrent muscle pain (myalgia) and neurological manifestations (paraesthesias). METHODS We used a randomised placebo-controlled, double-blind design in a community setting. 636 women were enrolled and, after 90 women dropped out, 546 healthy women aged 18-41 years, who were rubella seronegative on routine screening were immunised parenterally with either monovalent live attenuated (RA27/3 strain) rubella vaccine (n = 270) or saline placebo (n = 276) in the postpartum period. Outcome measures were the occurrence of acute and persistent or recurrent joint manifestations (arthralgia or arthritis) at 1, 3, 6, 9, and 12 months after immunisation. Occurrence of muscle pain (myalgia), and neurological symptoms (paraesthesia) was also assessed at the same times. FINDINGS 543 women completed 1-month follow-up. 456 women completed the 12-month assessment. There were no differences at the time of immunisation between rubella vaccine and placebo groups in distribution of age, ethnic origin, parity, time between delivery and immunisation, breastfeeding history, or histories of earlier rubella vaccination or joint complaints. Results indicated a significantly higher incidence (p = 0.006; odds ratio = 1.73 [95% CI = 1.17-2.57]) of acute joint manifestations in rubella-vaccine recipients (30%) than in placebo recipients (20%). Frequency of chronic (recurrent) arthralgia or arthritis was only marginally significant (p = 0.042; 1.58 [1.01-2.45]). INTERPRETATION RA27/3 rubella vaccine given to seronegative women during the postpartum period was significantly associated with development of acute arthralgia or arthritis. Although the numbers of women assessed and length of follow-up revealed only marginally significant differences in persistent or recurrent joint manifestations between rubella vaccine and placebo recipients, it is possible that susceptible women who are given rubella vaccination may experience this outcome.

Towards Effective Ponseti Clubfoot Care : The Uganda Sustainable Clubfoot Care Project

AbstractNeglected clubfoot is common, disabling, and contributes to poverty in developing nations. The Ponseti clubfoot treatment has high efficacy in correcting the clubfoot deformity in ideal conditions but is demanding on parents and on developing nations’ healthcare systems. Its effectiveness and the best method of care delivery remain unknown in this context. The 6-year Uganda Sustainable Clubfoot Care Project (USCCP) aims to build the Ugandan healthcare system’s capacity to treat children with the Ponseti method and assess its effectiveness. We describe the Project and its achievements to date (March 2008). The Ugandan Ministry of Health has approved the Ponseti method as the preferred treatment for congenital clubfoot in all its hospitals. USCCP has trained 798 healthcare professionals to identify and treat foot deformities at birth. Ponseti clubfoot care is now available in 21 hospitals; in 2006–2007, 872 children with clubfeet were seen. USCCP-designed teaching modules on clubfoot and the Ponseti method are in use at two medical and three paramedical schools. 1152 students in various health disciplines have benefited. USCCP surveys have (1) determined the incidence of clubfoot in Uganda as 1.2 per 1000 live births, (2) gained knowledge surrounding attitudes, beliefs, and practices about clubfoot across different regions, and (3) identified barriers to adherence to Ponseti treatment protocols. USCCP is now following a cohort of treated children to evaluate its effectiveness in the Ugandan context. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Non-Fatal Overdose Among a Cohort of Active Injection Drug Users Recruited from a Supervised Injection Facility

Non-fatal overdose among injection drug users (IDU) is a source of significant morbidity. Since it has been suggested that supervised injecting facilities (SIF) may increase risk for overdose, we sought to evaluate patterns of non-fatal overdose among a cohort of SIF users. We examined recent non-fatal overdose experiences among participants enrolled in a prospective study of IDU recruited from within North Americas first medically supervised safer injecting facility. Correlates of recent non-fatal overdoses were identified using generalized estimating equations (GEE). There were 1,090 individuals recruited during the study period of which 317 (29.08%) were female. At baseline, 638 (58.53%) reported a history of non-fatal overdose and 97 (8.90%) reported at least one non-fatal overdose in the last six months. This proportion remained approximately constant throughout the study period. In the multivariate GEE analysis, factors associated with recent non-fatal overdose included: sex-trade involvement (Adjusted Odds Ratio [AOR]: 1.45 [95% Confidence Interval [CI] 1.07–1.99], p = 0.02) and public drug use (AOR: 1.50 [95% CI 1.09–2.06]; p = 0.01). Using the SIF for ≥ 75% of injections was not associated with recent non-fatal overdose in univariate (Odds Ratio: 1.05, p = 0.73) or multivariate analyses (AOR: 1.01, p = 0.96). The proportion of individuals reporting recent non-fatal overdose did not change over the study period. Our findings indicate that a sub-population of IDU might benefit from overdose prevention interventions. Our findings refute the suggestion that the SIF may increase the likelihood of overdose.

BOOSTER IMMUNISATION FOR DIPHTHERIA AND TETANUS: NO EVIDENCE OF NEED IN ADULTS

Recommendations to give adults diphtheria and tetanus toxoid every ten years have been based on serological surveys that have shown lower antibody levels in older populations. The purpose of an immunisation programme, however, is to prevent disease and not merely to produce antibodies. In Canada, although an immunisation programme against diphtheria has been in operation for nearly sixty years, age-specific morbidity and mortality rates for diphtheria do not show an increase with age. Similarly, age-specific death rates from tetanus do not show any increase. From Canadian surveillance data, there is no evidence to suggest that people are leaving the immune pool and entering the susceptible pool. Immunisation programmes do not need to include routine administration of booster doses of diphtheria and tetanus toxoids to adults since the benefits of the procedure do not justify the risks or costs. Continuing case-surveillance will bring to light any increase in incidence of disease justifying a need for an adult programme.

Knowledge of Determinants of Mental Health Among Iranian Immigrants of BC, Canada: “A Qualitative Study”

Background When individuals enter a new community, they face many challenges in terms of adjusting to a new language, different customs and unfamiliar norms. These challenges may result in mental and/or general health problems. Objectives and methods The primary purpose of this study was to ascertain the mental health knowledge of Iranian immigrants and the impact of immigration on the development of mental health problems among these immigrants. Results Participants defined “mental health” in terms of psychological, social and emotional aspects and an absence of mental illnesses. Several immigration-related risk factors, such as lack of English, under- or unemployment, cultural differences, and lack of social support were revealed as barriers to successful acculturation. Conclusions Culturally sensitive and competent programs are needed to understand the needs of Iranian immigrants to be able to design and implement appropriate mental health programs.

Socio-Cultural Factors Associated with the Initiation of Opium Use in Darab, Iran.

This study aimed to identify socio-cultural factors facilitating initiation of opium use among drug users in Darab, Iran. A qualitative study using in-depth interviews was conducted. The study began in June 2006 and included 76 drug users, aged 20–43, of whom 95% (72) were male, and 5% (4) were female. The five most common factors facilitating initiation of drug use were revealed to be: lack of hobbies, treatment of general medical problems, modeling, peer networks, and cultural norms. Partner pressure was a common complaint among women in this study. Cultural factors perceived to facilitate initiation of drug use revealed in this study have not been fully addressed by current prevention and rehabilitation programs. Programs can be targeted at social and family levels to alter drug use culture.

A follow-up study of drug users in Southern Iran

Iran has the highest rate of opium addiction per capita in the world. The aim of this study was to examine the outcome of substance use among a cohort of drug users living in a rural area in Southern Iran. A semi-structured interview was conducted at baseline and at each follow-up visit on 211 substance users. Of the total of 211 drug users, 145 were non-injection drug users (non-IDUs) and 66 were injection drug users (IDUs). The most common method of drug use among all participants was revealed to be opium smoking. Other methods of choice were injection drug use (IDUs) and opium ingestion among 31% and 20% of participants, respectively. From the total of 211 participants in this cohort, on average (SD), each drug user gave up drugs 3.2 (2.7) times over the study period. Among those who were non-IDUs at the base line visit (145), 17 (12%) were abstinent for more than 6 months compared to 9 of 66 non-IDUs (14%) at the end of the study. By the end of the study period, 9 of 145 non-IDUs switched to non-IDUs while 11 of 66 IDUs (17%) switched to non-IDUs (chi-square = 5.78; p = 0.016). One main reason for a higher rate of transition among IDUs was mentioned by them as observing the deaths of several IDUs in their community that were a result of overdose.

The corneal ulcer one-touch study: a simplified microbiological specimen collection method.

PURPOSE To determine if a new, single-sample device (ESwab; Copan Diagnostics, Inc) can simplify the traditional multi-sample approach to specimen collection in infectious keratitis. DESIGN Prospective, diagnostic test evaluation. METHODS In this institutional study, patients with suspected infectious keratitis meeting traditional criteria for diagnostic corneal specimen collection and culture were randomized to the order of first specimen collection method: ESwab or a sample directly plated for growth on chocolate agar. This was followed by standard samples for blood agar, Gram stain, Sabouraud agar, thioglycolate broth, and brain heart infusion broth in all cases. The specimens collected using the 2 approaches were analyzed separately by the laboratory in a masked fashion. The main outcome measure was positive growth on cultured media. RESULTS Eighty-one eyes from 80 consecutive patients were sampled. Culture positivity rate for the multi-sample method and ESwab was 70% and 69%, respectively, with a 75% agreement rate. ESwab sensitivity was 84% (95% confidence interval [CI]: 72%-93%), with a specificity of 67% (95% CI: 45%-84%). Positive and negative predictive values of the ESwab were 86% (95% CI: 74%-94%) and 64% (95% CI: 43%-82%), respectively. There was no difference in positive culture reports with respect to the order of specimen collection technique used. CONCLUSIONS The single-sample ESwab method is a more accessible and less cumbersome approach to corneal culturing for ophthalmologists, particularly those in the community setting who do not have access to the full set of traditional culture materials. Culture results using this single-sample approach were comparable to the multi-sample method.

Ethical and scientific issues surrounding solid organ transplantation in HIV-positive patients: Absence of evidence is not evidence of absence

End-stage liver disease is emerging as a leading cause of death among HIV-positive patients. Historically, an HIV diagnosis was a contraindication for a liver transplant; however, because of the efficacy of highly active antiretroviral therapy (HAART), HIV-positive patients have one-year, two-year, and three-year post-transplantation survival rates similar to that of HIV-negative patients. Based on this evidence, HIV-positive patients are now considered eligible for transplantation. However, newly emerging guidelines include the stipulation that HIV-positive patients must be on HAART to be placed on a waiting list for transplantation. The purpose of the present paper is to evaluate the scientific and ethical probity of requiring HIV-positive patients to be on HAART as a condition for being on a liver transplant waiting list. It is argued that the emphasis should be placed on the probability of post-transplantation HAART tolerance, and that concerns about pretransplantation HAART tolerance are of secondary importance.