Over 11k dental patients in Sydney at risk of HIV, hepatitis exposure over poor cleaning — RT News


More than 11,000 dental patients in Sydney are in danger of having contracted HIV or other blood-transmitted diseases due to improper equipment cleaning throughout the city.

Reuters / John Gress

The ongoing probe has seen six dentists’ registration suspended and one dental practice shut down.

At the end of last year, patient complaints led to an investigation into the local dental clinic network Gentle Dentist, and infection breaches were discovered. In particular, Dr. Robert Starkenburg’s practice was closed in December.

The dentist told Fairfax Media outlet that he was “very sorry,” and that his age – 75 – had made it hard for him to follow the changing cleaning regulations.

“In the last eight years, they have upgraded the protocols a lot. I was a little lax on getting the latest protocols … [but] I have [since then] taken a couple of courses and taken steps to rectify the problem,” he said.

In February, it was revealed that the breaches in cleaning and sterilization had been more severe than considered.

Patients of several dentists’ offices were instructed to get HIV, hepatitis B and C testing.

New South Wales Health’s director of health protection, Jeremy McAnulty, stressed that the risks are“low”, and there have been no cases of blood-borne diseases so far.

Patients were written to individually, he added.

Over the past decade, some 11,250 patients have had invasive dental procedures at the Gentle Dentist, and are now all being tested.

Meanwhile, other Gentle Dentist clinics remain open.

Dr. Chan, the owner the enterprise, employs 21 dentists in two surgeries. He declined to comment on the situation to Fairfax Media.

The representative of the Dental Council of New South Wales, Shane Fryer, told the Guardian that the medics need better training in sterilization and cleaning.

“While we believe the vast majority of dentists in New South Wales are complying with the guidelines, we recognize there may be a need for a greater education within the profession <…> The risk, if indeed there is a risk, is low, the vast majority of dental practitioners do the right thing, they’re professional healthcare providers and they abide by the guidelines,” he said.

The dentists’ union, the Australian Dental Association, echoed the statement, saying the hazard of contracting blood-transmitted infections at the dentist’s was “extremely low”.

Association President Deb Crockrell, however, said that they take infection control very seriously.

“There are very rare cases. We have nearly 4,000 members in NSW and the ACT, performing more than 6 million procedures each year. The overall standard of care is outstanding. The risk of patients being infected by blood-borne diseases is extremely low.”

Low-dose testosterone induced protein anabolism in postmenopausal women


Low-dose testosterone therapy could be a promising treatment option for reducing protein breakdown and oxidation in elderly men and postmenopausal women, according to researchers.

“Oral testosterone administration resulted in a significant reduction in the rate of leucine appearance, an index of protein breakdown, and the rate of Lox, an index of irreversible loss of protein,” Vita Birzniece, MD, PhD,senior lecturer at the University Western Sydney, clinical researcher in endocrinology and metabolism at the Garvan Institute of Medical Research and St. Vincent’s Hospital, Sydney and a senior lecturer at the University New South Wales, and colleagues wrote.

The researchers studied eight healthy postmenopausal women (mean age: 64.2 years; BMI: 26.8 kg/m2) administered 40-mg oral testosterone daily. Treatment effect was examined based on the concentration of testosterone, markers of hepatic function, resting energy expenditure and fat oxidation, as well as whole-body leucine turnover. Evaluations of liver transaminases, sex hormone-binding globulin (SHBG) and insulin-like growth factor 1 (IGF-1), in addition to all other measurements, were collected at baseline and after 2 weeks of treatment.

Data indicate testosterone therapy significantly decreased the leucine rate of appearance by 7.1% and the leucine oxidation by 14.6% (P<.05). Although SHBG remained within normal range (16.8%), IGF-1 increased by 18.4% (P<.05), researchers wrote. However, there were no significant changes to liver transaminases. Peripheral testosterone concentrations increased from 0.4 nmol/L to 1.1 nmol/L (P<.05), according to data.

“In the post-absorptive state, oral testosterone administration did not significantly affect resting energy expenditure and carbohydrate and fatty acid oxidation in healthy postmenopausal women,” the researchers wrote.

These findings add to the literature that low-dose oral testosterone may be beneficial for both men and women, they wrote.

Source: Endocrine Today

 

 

H. Pylori Eradication Might Reduce Recurrent Gastric Cancer After Surgery.


 

Thirty-six months after subtotal gastrectomy for gastric cancer, patients who were H. pylori-free had less glandular atrophy and intestinal metaplasia than infected patients.

Intestinal metaplasia (IM) and glandular atrophy (GA) have been identified as preneoplastic conditions in patients infected with Helicobacter pylori. The role of H. pylori eradication in improving these conditions after subtotal gastrectomy for gastric cancer is unclear.

To investigate this issue, researchers in Korea randomized 190 patients with gastric cancer and H. pylori infection to receive 7 days of proton-pump inhibitor–based triple therapy or placebo prior to surgery. The greater and lesser gastric curvatures were biopsied prior to surgery and at 12 and 36 months after surgery and evaluated according to the updated Sydney criteria. H. pylori infection was determined by both a rapid urease test and histologic examination of endoscopic biopsies. Histological findings of GA and IM were scored to indicate presence and severity (absent, 0; mild, 1; moderate, 2; severe, 3).

At 36 months, 75% of patients in the treatment group were free of H. pylori compared with 41% of the placebo group. The mean GA and IM scores did not differ between the two groups. However, compared with H. pylori-infected patients, those without H. pylori had less atrophy (P=0.005) and IM (P=0.03).

COMMENT

The lack of difference in glandular atrophy or intestinal metaplasia between study groups at 36 months might be explained by a type II error. Histological scores for both were lower in the treatment group, but these differences did not reach statistical significance, possibly because of the low eradication rate in the treatment group, the high spontaneous remission rate in the placebo group, or the relatively large number of patients lost before the final analysis. As the authors concluded, the findings suggest that successful H. pylori eradication might reduce the preneoplastic changes in the gastric remnant after gastric surgery, but the clinical significance of the histologic changes remains to be determined.

Source: NEJM

Angiostrongylus meningoencephalitis: survival from minimally conscious state to rehabilitation.


The nematode Angiostrongylus cantonensis has spread down the eastern coast of Australia over recent decades. A healthy 21-year-old man developed life-threatening eosinophilic meningoencephalitis following ingestion of a slug in Sydney. We describe the first case of this severity in which the patient survived.

Clinical record

A 21-year-old man presented with a 3-day history of insomnia and paraesthesia affecting his lower limbs bilaterally. He had no associated headache, meningism or fever. He was previously well with no significant medical history.

On admission, he had begun to develop progressive weakness of his lower limbs associated with pain and dysaesthesia. A full blood count showed a total white cell count of 10.6 × 109/L (reference interval [RI], 4.0–11.0 × 109/L) with mild eosinophilia (0.5 × 109/L [RI, < 0.4 × 109/L]). Magnetic resonance imaging (MRI) scans of his brain and spine showed no abnormality. His cerebrospinal fluid (CSF) was acellular, with normal glucose and protein levels.

A provisional diagnosis of Guillain–Barré syndrome was made and the patient was treated with a 5-day course of intravenous immunoglobulin. Over 1 week he developed evidence of autonomic instability with urinary retention, fluctuating sinus tachycardia and hypertension, and a paralytic ileus. By the second week of hospitalisation he had developed hallucinations and a fluctuating level of consciousness.

A repeat CSF sample revealed a raised protein level of 1.20 g/L (RI, 0.15–0.45 g/L), a low glucose level of 2.3 mmol/L (RI, 2.5–5.6 mmol/L), with 2 × 109/L red cells (RI, < 5 × 109/L), 406 × 109/L mononuclear cells (RI, < 5 × 109/L), and 30 × 109/L polymorphs (RI, nil). The opening pressure was elevated at 31 cm H2O (RI, 6–20 cm H2O). He was commenced on empirical antibiotic and antiviral treatment, with intravenous hydrocortisone (100 mg four times daily) to cover the possibility of a steroid-responsive encephalopathy. An electroencephalogram was consistent with generalised encephalopathy without focal epileptiform activity. CSF bacterial cultures, cryptococcal antigen testing and polymerase chain reaction testing for herpes simplex virus and enterovirus were negative. HIV serological testing was negative. The patient’s condition continued to deteriorate, with a declining level of consciousness, progressive quadriparesis and respiratory failure necessitating endotracheal intubation and mechanical ventilation on Day 12 after admission.

Progress computed tomography (CT) brain imaging results remained normal. His peripheral eosinophil count had risen, later peaking at 1.9 × 109/L on Day 24. A third lumbar puncture was performed. His CSF protein remained elevated at 0.71g/L, CSF red cell count was 216 × 109/L and CSF white cell count was 504 × 109/L. Specific staining for eosinophils was performed, showing 37% of the leukocytes to be eosinophils (RI, < 10%,Box 1).

By this stage it had emerged that the patient had eaten a slug from a Sydney garden, as a dare, 7 days before presentation. An enzyme immunoassay for Angiostrongylus IgG performed on the CSF was positive. A progress MRI scan, performed on Day 26 after admission, revealed multiple foci of hyperintensity in the cerebral hemispheres, brainstem and cerebellum as well as within the spinal cord (Box 2). Several of the lesions showed restricted diffusion and some showed contrast enhancement. Pial enhancement was seen within the posterior fossa and over the spinal cord.

Treatment with high-dose corticosteroids was continued but the patient’s condition continued to decline. An unresponsive state developed, with flaccid tone in all four limbs and the loss of brainstem reflexes. Given the severity of the patient’s condition, a trial of albendazole 400 mg twice daily was given, with continued corticosteroid cover (dexamethasone 4 mg intravenously four times daily) and he remained on this treatment for 1 month. There was no change in his condition and he remained supported by mechanical ventilation via a tracheostomy in a minimally conscious state for 8 months.

During this time, there was much discussion between the patient’s family and treating doctors about his prognosis and probable outcome. Treatment was continued on the basis of his age and the uncertainty of the natural history of this rare disease. His clinical course was complicated by hydrocephalus requiring a ventriculoperitoneal shunt, recurrent episodes of ventilator-associated pneumonia, and seizures that were difficult to control despite multiple antiepileptic drugs. After 13 months, there was a very slow improvement in his level of consciousness, such that a slow weaning of respiratory support could be attempted. He could successfully maintain his own ventilation during the day (though with an ataxic respiratory pattern), but remained dependent on nocturnal mechanical ventilation.

The patient was discharged to the ward from intensive care in the 15th month of admission, where he continued to make slow but definite progress. There was gradual recovery of some distal power in his upper and lower limbs and he developed the ability to communicate with head movements. He was discharged to a rehabilitation facility 22 months after admission, where there has been ongoing gradual improvement. He now has antigravity power in his limbs and is capable of more complex non-verbal communication.

Discussion

Angiostrongylus cantonensis, also known as the rat lungworm, is the most common cause of eosinophilic meningitis globally. This condition generally follows a benign, self-limited course.1 Rarely, the parasite causes meningoencephalitis, which should be considered a related but distinct clinical entity with a dramatically poorer prognosis. The mortality rate has been reported at 79%2 and, of patients who become comatose, at least 90% do not survive.3

A. cantonensis is endemic in South-East Asia and the Pacific region, and has spread down the eastern coast of Australia over the past 50 years.4 In Australia, it has been observed that cases tend to be particularly severe. This reflects the higher total larval load ingested from terrestrial hosts, which feed on rat faecal pellets harbouring thousands of larvae. In comparison, aquatic snails, which commonly cause the disease in South-East Asia, generally carry a smaller larval load.5,6 The first reported human case acquired in Sydney occurred in 2001,7 in the remarkably similar circumstances of a young man accepting a dare to eat a slug, highlighting the importance of specific questioning in the patient’s history. Our patient’s case is only the second reported case acquired in Sydney and, internationally, our patient is the first with the disease of this severity to have survived.

Recent investigations have sought to identify factors associated with the development of clinically severe angiostrongyliasis. In one study, clinical features including headache, abnormal CSF pressure and abnormal peripheral blood eosinophil count were associated with severe disease.8 An Activation Criteria for Angiostrongyliasis (ACA) scoring system, incorporating these factors, was proposed and validated in a population of Chinese patients, with a score of ≥ 7 predictive of severe disease. If we had used the presenting eosinophil count, our patient would only have had an ACA score maximum of 5, and most likely lower than this if his CSF opening pressure had been recorded at the first lumbar puncture. He would have scored 8 if his peak peripheral eosinophil count and his highest recorded CSF pressure had been used.

A second study investigated factors specifically associated with the development of the encephalitic form of the disease.2 In a cohort of 94 patients with angiostrongyliasis, of whom 14 developed encephalitis, it was found that the clinical factors predictive of encephalitis were temperature > 38°C at presentation, older age and longer duration of headache. Fever at presentation was associated with a remarkable 37-fold risk of encephalitis. Interestingly, other variables such as CSF opening pressure, peripheral or CSF eosinophil counts or paraesthesia were not predictive of encephalitis in this study. Our case indicates that caution should be used when applying the predictive factors reported in these studies, and suggests that peak eosinophil count and delayed CSF pressure results may be more useful when calculating the ACA.

The initial difficulty with diagnosis in this case emphasises the need for clinical suspicion of this condition in the setting of acute-onset neurological symptoms and peripheral eosinophilia in endemic areas, including the eastern coast of Australia. It is essential to seek a history of consuming raw or undercooked food, and specifically any ingestion of molluscs. The case illustrates the importance of repeat CSF examination if the diagnosis is suspected and the initial CSF test results are negative. It also highlights the need to request specific CSF examination to ensure any eosinophils are not mistaken for neutrophils.

The optimal treatment for Angiostrongylus meningoencephalitis remains poorly defined. Corticosteroids are commonly used, with the rationale of dampening the inflammatory reaction to the nematode, and have been shown in a double-blind, placebo-controlled trial to provide symptomatic relief in eosinophilic meningitis.9 However, studies of patients with the encephalitic form of the disease have not found corticosteroids to be effective.3 Anthelmintics are generally not used due to the theoretical possibility of exacerbating cerebral inflammation and damage as a result of larval death in the central nervous system (CNS), and the lack of evidence of their efficacy.9,10 We used albendazole when there was little to lose and, perhaps as expected, it did not lead to any appreciable benefit. In the absence of effective treatment of angiostrongyliasis, it is important in endemic areas that the public understand the small but very serious risks associated with ingestion of uncooked molluscs.

It is known that time spent in a minimally conscious state following traumatic brain injury does not correlate with the chance of functional recovery.11 This observation may extend to patients with diffuse brain injury caused by severe cerebral infection or inflammation. This case shows the potential for the CNS to recover following a severe, generalised insult in a young patient with supportive care. It is important for doctors to appreciate this capacity when wrestling with difficult decisions about continuation of care for critically unwell patients.

Source: MJA

MY BLOG SUPPORTS “EARTH HOUR.”


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Earth Hour 2013 – Dare the World to Save the Planet. Switch off your lights on Saturday 23rd March at 8:30pm to be part of the world’s largest voluntary action for the environment.

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Join the world for Earth Hour 2012 by switching off your lights at 8.30pm on Saturday 31 March and sharing the positive action you will take for the planet beyond the hour.

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From its inception as a single-city initiative – Sydney, Australia – in 2007, Earth Hour has grown into a global symbol of hope and movem
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Earth Hour 2011: 8.30pm, Saturday 26 March, celebrate your action for the planet with the people of world, and add more to your Earth Hour. Sign up to earthhour.org, switch off your lights for the hour, and share the positive actions you will sustain for earth beyond the hour.

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