Background and Objectives Donor syphilis testing began in the 1940s amidst widespread transfusion‐transmitted syphilis (TTS). Since then, the introduction of penicillin, pre‐donation screening questionnaires and improved storage conditions have contributed to reducing transmission risk. Consequently, universal testing may no longer be cost‐effective. This study analysed alternative options for donor syphilis testing to determine the optimal strategy. Materials and Methods A model was developed using conservative parameter estimates for factors affecting TTS and 2009‐2015 Australian donations to calculate risk outcomes (TTS infections, tertiary syphilis in recipients and transfusion‐associated congenital syphilis) and cost‐effectiveness of alternative testing strategies. The strategies modelled were as follows: universal testing, targeted‐testing of high‐risk groups (males ≤50 years old and first‐time donors) and no testing. Results The estimated risk of TTS is one in 49·5 million transfusions for universal testing, one in 6 million for targeted‐testing of males ≤50 years old, one in 4 million for targeted‐testing of first‐time donors and one in 2·8 million for no testing. For all strategies, the risk of tertiary and congenital syphilis is <1 in 100 million. Universal testing is the least cost‐effective strategy with an incremental cost‐effectiveness ratio (ICER) estimated at $538·5 million per disability‐adjusted life year averted. Conclusion Universal testing is not required to maintain the risk of TTS within tolerable limits and is estimated to greatly exceed acceptable ICERs for blood safety interventions. However, despite a strong economic and risk‐based rationale, given the epidemiology of syphilis in Australia is changing, feedback from critical stakeholders is not currently supportive of reducing testing.
Large primary spontaneous pneumothorax (PSP) has traditionally been managed with needle aspiration, chest tube drainage and, in refractory cases, thoracic surgery. A recent randomized trial, however, provided evidence that a conservative observational approach was safe and 85% of patients recovered without requiring pleural drainage interventions. A conservative approach provided similar re‐expansion rates at 8 weeks compared with chest tube drainage and offered the advantages of early hospital discharge, fewer days off work and avoidance of procedural risks. Nonetheless, clinicians are understandably anxious with conservative (non‐drainage) management for patients with very large pneumothorax. Here, we report a patient with a right‐sided PSP and total lung collapse that was managed successfully without intervention with minimal time in hospital or off work.
Indwelling pleural catheter is an established management for malignant pleural effusions. Extending its use to patients with malignant ascites by insertion of a catheter intraperitoneally enables regular outpatient drainage and improves quality‐of‐life. However, indwelling pleural/peritoneal catheter (IPC/IPeC) is associated with catheter‐related infections, traditionally managed with systemic antibiotics and occasionally requires catheter removal. Direct administration of antibiotics intra‐abdominally via peritoneal dialysis (PD) catheters is a well‐established, efficacious practice in PD‐related peritonitis and minimizes systemic adverse effects. We applied the same principles to a patient with peritoneal mesothelioma who developed peritonitis 3 weeks after insertion of IPeC. Intraperitoneal vancomycin was administered via, and compatible with, the IPeC. The patient tolerated the treatment without adverse effects and made a full recovery without requiring catheter removal.
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