The effect of public health-oriented drug law reform on HIV incidence in people who inject drugs in Tijuana, Mexico: an epidemic modelling study

Background As countries embark on public health-oriented drug law reform, health impact evaluations are needed. In 2012, Mexico mandated the narcomenudeo reform, which depenalised the possession of small amounts of drugs and instituted drug treatment instead of incarceration. We investigated the past and future effect of this drug law reform on HIV incidence in people who inject drugs in Tijuana, Mexico. Methods In this epidemic modelling study, we used data from the El Cuete IV cohort study to develop a deterministic model of injecting and sexual HIV transmission in people who inject drugs in Tijuana between 2012 and 2030. The population was stratified by sex, incarceration status, syringe confiscation by the police, HIV stage, and exposure to drug treatment or rehabilitation (either opioid agonist treatment or compulsory drug abstinence programmes). We modelled the effect of these exposures on HIV risk in people who inject drugs, estimating the effect of observed and potential future reform enforcement levels. Findings In 2011, prior to the narcomenudeo reform, 547 (75%) of 733 people who inject drugs in the El Cuete cohort reported having ever been incarcerated, on average five times since starting injecting. Modelling estimated the limited reform implementation averted 2% (95% CI 0·2–3·0) of new HIV infections in people who inject drugs between 2012 and 2017. If implementation reduced incarceration in people who inject drugs by 80% from 2018 onward, 9% (95% CI 4–16) of new HIV infections between 2018 and 2030 could be averted, with 21% (10–33) averted if people who inject drugs were referred to opioid agonist treatment instead of being incarcerated. Referral to compulsory drug abstinence programmes instead of prison could have a lower or potentially negative impact with −2% (95% CI −23 to 9) infections averted. Interpretation Mexican drug law reform has had a negligible effect on the HIV epidemic among people who inject drugs in Tijuana. However, appropriate implementation could markedly reduce HIV incidence if linked to opioid agonist treatment. Unfortunately, compulsory drug abstinence programmes are the main type of drug rehabilitation available and their expansion could potentially increase HIV transmission

Central Corneal Thickness in Patients With Neovascular Age-Related Macular Degeneration

Purpose: To compare the central corneal thickness (CCT) measurements of patients with neovascular age-related macular degeneration (AMD) and control subjects. Methods: The CCT value (measured with ultrasound corneal pachymetry) of 130 eyes (130 patients, 1 eye from each patient) with neovascular AMD (AMD group) and 98 eyes (98 patients, 1 eye from each patient) of similar age, sex, and eye's axial length healthy control subjects (normal group) was compared. Results: The mean age (AMD group: 69.1 years vs. control group: 69.5 years, P = 0.81), sex (AMD group: 77 women, 59% vs. control group: 59 women, 60%, P = 0.77), and eye's axial length (AMD group: 25.05-mm vs. control group: 24.61-mm, P = 0.38) of patients with neovascular AMD and healthy control subjects were comparable. There were no statistically significant differences in the mean CCT measurements in the neovascular AMD group in comparison with the control group (549.44 vs. 544.35 mm, P = 0.11). Conclusions: CCT measurements do not differ in patients with neovascular AMD compared with healthy control subjects

'Statins in retinal disease'

Statins are known for their blood cholesterol-lowering effect and are widely used in patients with cardiovascular and metabolic diseases. Research over the past three decades shows that statins have diverse effects on different pathophysiological pathways involved in angiogenesis, inflammation, apoptosis, and anti-oxidation, leading to new therapeutic options. Recently, statins have attracted considerable attention for their immunomodulatory effect. Since immune reactivity has been implicated in a number of retinal diseases, such as uveitis, age-related macular degeneration (AMD) and diabetic retinopathy, there is now a growing body of evidence supporting the beneficial effects of statins in these retinopathies. This review evaluates the relationship between statins and the pathophysiological basis of these diseases, focusing on their potential role in treatment. A PubMed database search and literature review was conducted. Among AMD patients, there is inconsistent evidence regarding protection against development of early AMD or delaying disease progression; though they have been found to reduce the risk of developing choroidal neovascular membranes (CNV). In patients with retinal vein occlusion, there was no evidence to support a therapeutic benefit or a protective role with statins. In patients with diabetic retinopathy, statins demonstrate a reduction in disease progression and improved resolution of diabetic macular oedema (DMO). Among patients with uveitis, statins have a protective effect by reducing the likelihood of uveitis development

Evaluating the population-level effects of overdose prevention sites and supervised consumption sites in British Columbia, Canada: controlled interrupted time series.

BACKGROUND: On 14 April 2016, British Columbia's Provincial Medical Health Officer declared the overdose crisis a public health emergency, sanctioning the implementation of new overdose prevention sites (OPS) and supervised consumption sites (SCS) across the province. METHODS: We used the BC Centre for Disease Control's Provincial Overdose Cohort of all overdose events between 1 January 2015 and 31 December 2017 to evaluate the population-level effects of OPSs and SCSs on acute health service use and mortality. We matched local health areas (LHA) that implemented any site with propensity score matched controls and conducted controlled interrupted time series analysis. RESULTS: During the study period, twenty-five OPSs and SCSs opened across fourteen of British Columbia's 89 LHAs. Results from analysis of LHAs with matched controls (i.e. excluding Vancouver DTES) were mixed. Significant declines in reported overdose events, paramedic attendance, and emergency department visits were observed. However, there were no changes to trends in monthly hospitalization or mortality rates. Extensive sensitivity analyses found these results persisted. CONCLUSIONS: We found OPSs and SCSs reduce opioid-related paramedic attendance and emergency department visit rates but no evidence that they reduce local hospitalization or mortality rates

How access, appropriateness, and quality of care affect patient outcomes for time-sensitive medical emergencies in British Columbia, Canada

ABSTRACT Objectives Cox Proportional Hazards models tested the relationship between access to care for time sensitive medical events and 30-day survival while controlling for appropriateness and quality of care. Approach A population study of all acute myocardial infarction (AMI), trauma, and stroke events treated within British Columbia between April 1st 1999 and March 31st 2013. Data sources included: the Discharge Abstract Database (DAD); a registry file; the Vital Statistics Mortality data; and the Medical Services Plan (MSP) Payment Information. Access to care was estimated with a de-identified residential postal code to hospital distance matrix developed using origin-destination network analysis in ArcGIS 10.2. Appropriateness of care compared national protocols with treatment received. Care that was contraindicated, outdated, or at an inexperienced facility was inappropriate. Quality of care was an outcome measure that used risk-standardized mortality ratios and funnel plots to identify hospitals that offered poor care. Results There were 106,409 AMI, 220,602 trauma, and 88,136 stroke events that occurred during the study period and used in condition specific hierarchical hazards models. Adjusted hazards ratios (aHR) found access to care were not associated with 30-day mortality after controlling for appropriateness and quality of care along with patient (i.e. age, sex, income, rurality, frailty) and system specific (i.e. method of transport, transfer patterns, facility volume, rurality, peer group) characteristics. Appropriate care reduced the hazard of mortality for all three conditions: AMI aHR=0.860 (95% CI=0.792-0.993, p-value=0.0003); stroke aHR=0.448 (95% CI=0.324-0.619, p-value<0.0001) and trauma aHR=0.824 (95% CI=0.703-0.967, p-value=0.0176). Quality of care reduced hazards of mortality for trauma (aHR=0.689, 95% CI=0.586-0.808, p-value<0.0001) and stroke (aHR=0.762, 95% CI=0.689-0.842, p-value<0.0001). Inter-hospital transfers were protective for AMI (aHR=0.513, 95% CI=0.406-0.649, p-value<0.0001) and stroke (aHR=0.768, 95% CI=0.630-0.936, p-value=0.0089) but detrimental for trauma (aHR=1.583, 95%CI=1.310-1.913, p-value<0.0001). Method of transport was also significant. Self-transport was protective for trauma (aHR=0.462, 95% CI=0.417-0.513, p-value<0.0001) and stroke (aHR=0.330, 95% CI=0.301-0.363, p-value<0.0001). Older age was associated with higher mortality rates across all three conditions (p-value<0.0001) and being female increased the hazard of death for AMI (aHR=1.049, 95% CI=1.010-1.088, p-value=0.0125) but was protective for trauma (aHR=0.583, 95% CI=0.551-0.617, p-value<0.0001) events. Conclusion As health systems evolve to meet the needs of their patients and work to provide equitable care under economic pressure for efficiency, it is important to understand how access, appropriateness and quality of care affect patient outcomes and distribute services accordingly

The effects of British Columbia hospital closures on delivery of health care services and the population's health

Background: In 2002, British Columbia (BC) began redistributing its hospital services. Existing facilities closed, were downsized or became specialized. Reasons for these changes included the centralization of the health authorities and subsequently the redistribution of services, along with safety concerns regarding small units, difficulties recruiting and retaining staff, and policy changes in the province’s Standards of Accessibility. At the same time, innovations in service delivery, such as inter-hospital transfer practices and telehealth initiatives (e.g. telestroke), modified how health care is provided. Effective health service delivery is a complex matter. Over a decade since redistribution began, there has been no evaluation of the changes in service distribution and their impact on patient health. Methods: This is a retrospective cohort study of all adult (18 years and over) acute myocardial infarction (AMI), stroke, and severe trauma events that occurred within the province between April 1 1999 and March 31 2013. Using administrative data, segmented regression and hierarchical hazards modelling techniques, this study examines the effect of service redistribution on patients’ mortality outcomes. Results: The interrupted time series models found service redistribution was not associated with changes in 30-day mortality outcomes, and was likely a response to facility underutilization. Although there was extensive variation in patient access to care (travel burden) across health authorities, the hierarchical Cox proportional hazards models showed that long travel time (>30 mins) was not associated with patient short term mortality after controlling for appropriateness and quality of care along with compensating mechanisms such as inter-hospital transfers, and telehealth services. Conclusion: This work demonstrates that efficiencies in health system delivery can be gained by eliminating underutilized acute care services but also identifies challenges in ensuring equitable access to care.Medicine, Faculty ofGraduat

Ocular rigidity measurement in patients with non-proliferative diabetic retinopathy

PURPOSE: To compare ocular rigidity (OR) and outflow facility (C) in patients with non-proliferative diabetic retinopathy (NPDR) and control subjects.METHODS: Twenty-four patients with NPDR (NPDR-group) and 24 controls (control group) undergoing cataract surgery were enrolled. NPDR-group was further divided in patients with mild NPDR (NPDR1-group) and patients with moderate and/or severe NPDR (NPDR2-group). After cannulation of the anterior chamber, a computer-controlled device, featuring a motor-driven syringe and a pressure sensor, was used to infuse saline and increase the intraocular pressure (IOP) in a stepping procedure from 15 to 40 mm Hg. The intraocular pressure was continuously recorded for 2 seconds after each infusion step. Ocular rigidity and outflow facility coefficients were estimated from intraocular pressure and volume recordings. RESULTS: Ocular rigidity was 0.0205 ± 0.125μl-1 in NPDR group and 0.0202 ± 0.0118μl-1 in control group (p = 0.942). In NPDR1-group, ocular rigidity was 0.017 ± 0.009 and in NPDR2-group it was 0.025 ± 0.015μl-1 (p = 0.192). Outflow facility was 0.120 ± 0.048 μl/min/mmHg in NPDR-group compared to 0.153 ± 0.078μl/min/mmHg in the control-group at an IOP of 35mmHg (p = 0.151). There was no difference in outflow facility between NPDR1-group and NPDR2-group (0.011 ± 0.048μl/min/mmHg and 0.120 ± 0.059μl/min/mmHg respectively, p = 0.709). CONCLUSIONS: No statistically-significant differences in ocular rigidity and outflow facility could be documented between diabetic patients and controls in this study. No difference in ocular rigidity was detected between mild NPDR and severe NPDR. A trend for lower ocular rigidity in patients with mild NPDR, and a lower outflow facility in all NPDR patients at 35mmHg may merit further investigation in a bigger sample.ΣΚΟΠΟΣ: Σκοπός της παρούσας διδακτορικής διατριβής είναι η σύγκριση των τιμών του συντελεστή της οφθαλμικής ακαμψίας και της ευχέρειας εκροής του υδατοειδούς υγρού σε ασθενείς με μη παραγωγική διαβητική αμφιβληστροειδοπάθεια και σε υγιή ομάδα ελέγχου, όπως αυτά μετρήθηκαν με την πειραματική επεμβατική συσκευή που αναπτύχθηκε στο Πανεπιστήμιο Κρήτης. ΥΛΙΚΑ ΚΑΙ ΜΕΘΟΔΟΙ: Είκοσι τέσσερις ασθενείς με μη παραγωγική διαβητική αμφιβληστροειδοπάθεια (NPDR) (24 οφθαλμοί) οι οποίοι υποβλήθηκαν σε επέμβαση καταρράκτη, συμμετείχαν στη ομάδα μελέτης. Πρόκειται για 8 άνδρες και 16 γυναίκες. Την ομάδα ελέγχου σχημάτισαν 24 άτομα χωρίς σακχαρώδη διαβήτη (24 οφθαλμοί από 13 άνδρες και 11 γυναίκες) που ήταν σε αντιστοιχία με την ομάδα μελέτης αναφορικά με την ηλικία και το αξονικό μήκος των οφθαλμών.Για τις μετρήσεις, χρησιμοποιήθηκε διεγχειρητικά συσκευή ελεγχόμενη από ειδικά διαμορφωμένο λογισμικό, αποτελούμενη από μικροδοσιμετρική αντλία και αισθητήρα πίεσης. Στην αρχή της μέτρησης, καθετηριάζεται ο πρόσθιος θάλαμος του οφθαλμού και η ενδοφθάλμιας πίεσης (ΕΟΠ) του οφθαλμού ρυθμίζεται στα 15 mmHg. Ακολούθως, η ΕΟΠ αυξάνεται από τα 15 στα 40mmHg, με βηματική έγχυση υδατικού διαλύματος. Όταν η ΕΟΠ του οφθαλμού φτάνει τα 40mmHg, η έγχυση διακόπτεται και ο αισθητήρας καταγράφει για διάστημα 4min τη φθίνουσα ΕΟΠ.Ο συντελεστής Κ υπολογίστηκε από τις καταγραφές πίεσης-όγκου σε κάθε οφθαλμό. Ο συντελεστής C υπολογίστηκε από την καμπύλη εκροής με βάση μαθηματικό μοντέλο που δημιουργήθηκε. ΑΠΟΤΕΛΕΣΜΑΤΑ: Είκοσι τέσσερις ασθενείς με μη παραγωγική αμφιβληστροειδοπάθεια είχαν μέσο όρο συντελεστή οφθαλμικής ακαμψίας 0.0205 ± 0.125μl-1, ενώ οι 24 οφθαλμοί των ασθενών της ομάδας ελέγχου είχαν 0.0202 ± 0.0118μl-1(p = 0.942). Ο συντελεστής ευχέρειας εκροής βρέθηκε 0.120 ± 0.048μl/min/mmHg στην ομάδα των αμφιβληστροειδοπαθών, ενώ στην ομάδα ελέγχου ήταν 0.153 ± 0.078μl/min/mmHg όταν η ενδοφθάλμια πίεση ήταν 35mmHg. Η ομάδα μελέτης στη συνέχεια διαχωρίστηκε σε 2 υποομάδες: την ομάδα των ασθενών με ήπια διαβητική αμφιβληστροειδοπάθεια (NPDR1) που αποτελούνταν από 14 ασθενείς, και την ομάδα των ασθενών με μέτρια και βαριά διαβητική αμφιβληστροειδοπάθεια, που αποτελούνταν από 10 ασθενείς (NPDR2). Ο συντελεστής οφθαλμικής ακαμψίας ήταν 0.017 ± 0.009 μl-1 στην ομάδα NPDR1 και 0.025 ± 0.015 μl-1 στην ομάδα NPDR2 (p = 0.192). Δεν βρέθηκε διαφορά στο συντελεστή ευχέρειας εκροής του υδατοειδούς υγρού μεταξύ των υποομάδων NPDR1 και NPDR2 (0. 119 ± 0.048 και 0.120 ± 0.059 αντίστοιχα, p = 0.709). ΣΥΖΗΤΗΣΗ: Στη μελέτη αυτή ποσοτικοποιήθηκαν η σχέση πίεσης όγκου και η ευχέρεια εκροής σε ομάδα ασθενών με σακχαρώδη διαβήτη και ομάδα ελέγχου και διερευνήθηκαν πιθανές διαφορές στις παραμέτρους αυτές μεταξύ των δύο ομάδων.Στην ομάδα μελέτης συμπεριελήφθησαν 24 ασθενείς με μη παραγωγική διαβητική αμφιβληστροειδοπάθεια. Η ομάδα αυτή διαιρέθηκε σε μια υποομάδα με ήπια μη παραγωγική διαβητική αμφιβληστροειδοπάθεια και μια υποομάδα με μέτρια έως σοβαρή μη παραγωγική διαβητική αμφιβληστροειδοπάθεια. Στην ομάδα ελέγχου περιλήφθηκαν 24 οφθαλμοί από υγιείς ενήλικες. Δεν παρατηρήθηκε στατιστικά σημαντική διαφορά στο συντελεστή οφθαλμικής ακαμψίας μεταξύ της ομάδας μελέτης και της ομάδας ελέγχου. Παρατηρήθηκε όμως μία καθαρή τάση του συντελεστή οφθαλμικής ακαμψίας να είναι χαμηλότερος στην NPDR1 σε σχέση με την NPDR2, παρόλο που η διαφορά δεν έφτασε σε στατιστικά σημαντικά επίπεδα. Ο συντελεστής ευχέρειας εκροής υδατοειδούς υγρού εμφανίζει μία τάση να είναι χαμηλότερος στους διαβητικούς ασθενείς σε σχέση με τους υγιείς της ομάδας ελέγχου σε ενδοφθάλμια πίεση 35mmHg, χωρίς όμως στατιστικά σημαντική διαφορά. ΣΥΜΠΕΡΑΣΜΑΤΑ: Η παρούσα μελέτη παρέχει ποσοτικά στοιχεία για την οφθαλμική ακαμψία του οφθαλμού και την ευχέρεια εκροής του υδατοειδούς υγρού σε ανθρώπινους οφθαλμούς υγειών και διαβητικών ασθενών.Η μελέτη αυτή μπορεί να αποτελέσει μελέτη αναφοράς για μελλοντικές μελέτες με μεγαλύτερο αριθμό ασθενών και με τη χρήση λιγότερο επεμβατικών τεχνικών, οι οποίες θα μπορέσουν να διαφωτίσουν πτυχές της παθοφυσιολογίας της διαβητικής αμφιβληστροειδοπάθειας

Συσχέτιση ιστολογικού τύπου πρώιμου Μη Μικροκυτταρικού Καρκίνου Πνεύμονα με ύπαρξη λεμφαδενικών μεταστάσεων

ΕΙΣΑΓΩΓΗ: Ο καρκίνος του πνεύμονα αντιπροσωπεύει το 27% όλων των θανάτων από καρκίνο, τόσο στους άνδρες όσο και στις γυναίκες. Η διάγνωσή του αρχικά γίνεται απεικονιστικά και τίθεται ιστολογικά, καθορίζοντας το στάδιο, την τοπικά ή μη εκτεταμένη νόσο, δηλαδή μεταστάσεων, τόσο στους ομόπλευρους ενδοπνευμονικούς, όσο και/ή στους μεσοθωρακικούς λεμφαδένες και ανάλογα την περαιτέρω αντιμετώπιση και πρόγνωση της νόσου. ΣΚΟΠΟΣ: Η συσχέτιση του ιστολογικού τύπου του πρώιμου, έως τρία εκατοστά, μη μικροκυτταρικoύ καρκίνου του πνεύμονα, με την ύπαρξη λεμαφαδενικών μεταστάσεων. MEΘΟΔΟΣ: Πρόκειται για μία αναδρομική καταγραφή ασθενών, που επιλέχθηκαν από τα αρχεία του Θωρακοχειρουργικού τμήματος του Γενικού Νοσοκομείου Νοσημάτων Θώρακα «H Σωτηρία». Συλλέξαμε 200 ασθενείς, μέσου όρου ηλικίας τα 65.65 έτη, των ετών 2015 και 2019, με μη μικροκυτταρικό καρκίνο του πνεύμονα, σταδίου Τ1, Ν1/Ν2, Μ0 κατά Tumour Node Metastasis της 8ης σταδιοποίησης, συσχετίζοντας τον ιστολιγικό του τύπο με την ύπαρξη λεμφαδενικών μεταστάσεων. Οι ασθενείς χειρουργήθηκαν από 5 διαφορετικούς Θωρακοχειρουργούς και τα παρασκευάσματα γνωματεύτηκαν από διαφορετικούς ειδικούς παθολογοανατόμους. ΑΠΟΤΕΛΕΣΜΑΤΑ: Από τους 200 ασθενείς, 46 παρουσίασαν λεμφαδενικές μεταστάσεις τόσο ενδοπνευμονικές όσο και μεσοθωρακίου. Βρήκαμε ότι ο κυριότερος υπότυπος είναι το διηθητικό αδενοκαρκίνωμα με δεύτερο το πλακώδες καρκίνωμα, τα οποία σχετιζόμενα με την ηλικία άνω των 65 ετών, με όγκους μεγαλύτερους των δύο εκατοστών, υψηλής μιτωτικής δραστηριότητας, χαμηλής διαφοροποίησης και κυρίως όγκους οι οποίοι προσέγγιζαν το σπλαχνικό υπεζωκότα, χωρίς να τον διηθούν, είχαν λεμφαδενική συμμετοχή σε ποσοστό έως 23%. ΣΥΜΠΕΡΑΣΜΑΤΑ: Ανατρέχοντας στη διεθνή βιβλιογραφία διαπιστώσαμε ότι τα αποτελέσματα της μελέτης μας, ήταν σύμφωνα. Λόγω της όχι αμελητέας λεμφαδενικής συμμετοχής, ανεξάρτητα από τον ιστολογικό τύπο ( αδενοκαρκίνωμα ή πλακώδες καρκίνωμα ), ακόμα και σε όγκους έως τρία εκατοστά, τόσο η ριζική εκτομή αλλά και ο σχολαστικός λεμφαδενικός καθαρισμός, αποτελούν το χρυσό κανόνα για την επίτευξη, της καθυστέρησης της εμφάνισης λεμφαδενικής υποτροπής και της προσέγγισης του ανώτερου ποσοστού της πενταετούς επιβίωσης.INTRODUCTION: Lung cancer accounts for 27% of all cancer deaths in both men and women. Its diagnosis is initially imaging, further determined histologically, thereby defining the stage, local or non-extensive disease, that is metastases to both ipsilateral intrapulmonary and/or mediastinal lymph nodes respectively and accordingly to further treatment and prognosis. PURPOSE: To correlate the histological type in early, up to three centimeters, of non-small cell lung cancer, with the presence of lymph node metastases. MATERRIALS AND METHODS: This is a retrospective census of patients selected from the archives of the Thoracic Surgery Department of the General Hospital of Thoracic Diseases &quot;Sotiria&quot;. We recruited 200 patients, mean age 65,65 years, of separately 2015 year and 2019 year, with non-small cell lung cancer, stage T1,N1/N2,M0, according to 8th edition of Tumour Node Metastasis classification, correlating its histologic type with the presence of lymph node metastases. Patients were operated on by 5 different thoracic surgeons and the preparations were reviewed by different pathologists. RESULTS: Of the 200 patients, 46 developed both intrapulmonary and mediastinal lymph node metastases. We found that the main subtype is invasive adenocarcinoma, followed by squamous cell carcinoma, which associated with age over 65 years, tumors greater than two centimeters that approached visceral pleura without invading it, with high mitotic activity, and low differentiation, had a lymph node metastases up to 23%. CONCLUSION: The results of our study were consistent with those of the world literature. Due to the non-negligible lymph node involvement, regardless of the histological type, even in tumors up to three centimetres, radical tumor and lymph node resection, are the gold standard for delaying the onset of lymphatic recurrence and achieve the maximum of the five-year, disease free survival rate