Overview of availability of harm reduction interventions in European prisons

Introduction

Prisons are high-risk environments for the transmission of drug related infections, due to over-incarceration of people who inject drugs; often inadequate healthcare, substandard prison conditions; and others. An overview of the availability and coverage of prison-based harm reduction interventions in Europe is presented.

Methods

National Focal Points of the EMCDDA (30) collected 2019 data, which were integrated with findings from the European funded project HA-REACT (Joint Action on HIV and Co-infection Prevention and Harm Reduction).

Results

Prison based harm reduction interventions are available in European countries, but only few of them are available in most countries and often with a low coverage (e.g. less than 10% of prison population in Opioid Substitution Treatment (OST) in most countries). Interventions available in most countries (20 or more) include: HIV, HBV, HCV testing (29), OST continued from community (29), Referral to HIV treatment upon release (28), HIV treatment (27), Referral to HCV treatment upon release (25), HCV antiviral treatment (25), Testing for TB (23), HBV antiviral therapy (25), OST initiated in prison (22), Treatment for TB (21), Vaccination for HBV (20). Interventions available in 10 to 19 countries are: condom distribution (19), OST (re)initiated before release (17), prison/community guidelines for implementation of OST (13). Interventions provided in < 10 countries include: distribution of disinfectant (9), condom with lubricant (9), take-home naloxone (5), needles and syringes programs (3).

Conclusions

Compared to the community, the availability and coverage of harm reduction interventions in European prisons are limited and large information gaps exist. Scaling up harm reduction in prison can achieve important individual and public-health benefits.

1232 Trust-Wide Assessment of Delirium in Post-Operative Elective Surgery

Aim

Delirium is an acute change in cognition and associated with adverse patient outcomes. The incidence of post-operative delirium after elective non-cardiac surgery is unknown. We aimed to assess the incidence of post-operative delirium in this group and the effect on patient outcomes.

Method

Patients aged 65 and over who underwent elective non-cardiac surgery were identified on post-operative day three. Delirium screening was performed in real time using the validated 4-AT assessment tool. A retrospective review of the patients’ preoperative and perioperative record was conducted to collect demographics and identify risk factors for delirium. Outcome data was collected at 30 days. Patients with a positive delirium score (>4) underwent a more in-depth assessment and managing teams given a delirium management pack.

Results

75 (39 male) consecutive patients were screened over a period of 4 months. Median age 77 years and 18% had frailty assessed as “vulnerable”. The majority of patients (37.3%) underwent thoracic surgery, followed by hepatobiliary (17.3%), gynaecological (17.3%), colorectal (12%), maxillofacial (9.3%) and ENT (4%). 5.3% (4) of patients had a positive 4-AT screen. No patients had a formal delirium screen or diagnosis in the initial 48 hours. The median length of stay for patients with a positive screen was 8.5 days (IQR 7.5-12) compared to 8 days (IQR 5-13) for patients with a negative screen.

Conclusions

Reassuringly, rate of post-operative delirium following elective operations in our Trust are low (5%). Larger numbers of patients are required to assess the impact this has on patient outcomes and identify correlation with risk factors.

Abstract P5-02-02: Improving efficiency of breast MRI utilization by coordinating primary care, breast imaging and surgeons

Introduction: Breast MRI in the workup of a new breast cancer diagnosis is both a valuable and costly imaging study. The decision to obtain a breast MRI is often made by the surgeon who is referred the newly diagnosed breast cancer patient. That is followed by a delay in their management due to scheduling the MRI. Our breast center program leadership developed a protocol to move the time of MRI prior to the surgeon's evaluation while avoiding unnecessary breast MRIs ordered by some well-intentioned primary care providers. Coordinating a breast MRI protocol can optimize timely performance of breast MRI, guiding primary care to become the ordering clinician while avoiding unnecessary breast MRIs.

Methods: Recognizing a delay in the journey of newly diagnosed breast cancer patients that have their breast MRI ordered only after the multidisciplinary conference or surgical consultation, we developed a protocol to improve timeliness of care. Guidelines were identified by our breast program leadership when a newly diagnosed breast cancer patient would warrant a breast MRI. Agreed upon indicators included dense breast tissue, invasive lobular breast cancer, patients typically under 50 years old, and vague imaging of primary lesions. When these findings were identified, the radiologist included a statement with the core needle biopsy report. It stated that our breast program leadership identified this patient as benefiting from a breast MRI ordered soon after the positive biopsy. This avoided the issue of self-referral since our breast leadership created the guidelines. The message went to the primary care provider who now ordered the breast MRI prior to conference or surgical consultation. We examined sixty consecutive patients from two time periods, half before and half after institution of the MRI protocol.

Results: Prior to this policy, patients who needed breast MRI would obtain the study on average 12 days after our multidisciplinary breast conference (MDC), while after institution of the policy breast MRI was obtained 3 days PRIOR to conference. Before only 43% of necessary breast MRIs were ordered prior to surgical consultation while after the protocol 100% of breast MRIs were ordered PRIOR to surgical consultation. Before the protocol rarely did primary care order breast MRIs. After the protocol primary care providers ordered 80% of all breast MRIs. While ordering more breast MRIs, primary care ordered less unnecessary studies. After the protocol was instituted, inappropriate studies as determined by the MDC decreased from 21% deemed unnecessary to only 10%.

Conclusions: Institution of a breast MRI ordering guideline by the breast program leadership with participation of primary care had the benefits of obtaining the breast MRI before the multidisciplinary conference and/or surgical consultation while avoiding unnecessary breast MRI orders. Institution of a breast MRI protocol enhances patient care, eliminates delays in treatment, avoids unnecessary tests, shifts appropriate care to primary care providers and allows initial surgical consultation to have all the data necessary to make definitive decisions. This quality improvement effort via program leadership improved comprehensive care.

Citation Format: Kaufman CS, Behrndt VS, Hall W, Moses K, Wolgamot GM, Crabo L, Backer L, Carpenter K, Smits S. Improving efficiency of breast MRI utilization by coordinating primary care, breast imaging and surgeons [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-02-02.

Abstract P5-13-10: Recommendations to improve the lived experience of early stage and metastatic breast cancer patients in Canada

Introduction: In 2017, the Canadian Breast Cancer Network (CBCN) undertook two surveys of Canadians who have experienced a breast cancer diagnosis to better understand the lived experience of patients and what opportunities exist to improve support for patients, survivors and their families and minimize the impact of this disease. There were 278 people diagnosed with early stage breast cancer, defined as stage I, II or III for the purpose of this report, and 180 people living with metastatic breast cancer, or stage IV breast cancer, who responded to these surveys.

Results: The survey data shows that while patients feel supported and well cared for in certain aspects there are still significant opportunities for improvement. CBCN has identified five overarching factors that could greatly improve health outcomes and the quality of life of Canadians who experience a breast cancer diagnosis.

1. Improved Educational Resources: The quality and availability of patient education has increased over the past couple of decades; however, there are still some patient friendly educational resources including, specific resources for newly diagnosed metastatic breast cancer patients; decision aids that support breast cancer surgery and post-surgery decisions; navigation of financial resources; treatment timelines and recovery expectations; private insurance navigation and information on dying-well.

2. Increased Access to Treatments: This challenge was specifically identified and vocalized by people living with metastatic breast cancer. Efforts need to continue to shorten the drug approval process time, increase equitable access to new medications for all Canadians, and ensure equitable access for take home oral cancer medications.

3. Increased Access to Information: Information available to patients about their health and treatment has increased; however, there is still information that isn't always communicated to patients that would help them make informed decisions about their health. This includes information about breast density, palliative care options and information around clinical trials.

4. Integrated Systemic Supports: The health care system as a whole is responsible for many of the services and supports that patients need to achieve optimal health and manage their breast cancer; however, these supports can be challenging to navigate and are sometimes lacking. Supports that need to be addressed at a systemic level include developing survivorship care plans for early stage patients, patient navigation, communication tools to support general practitioners during the diagnosis process, access to psychosocial professionals and increased Employment Insurance Sickness Benefits.

5. Increased Awareness and Understanding of Metastatic Breast Cancer: A lack of accurate statistics and overall awareness of metastatic breast cancer makes it challenging to truly understand the impact of this disease and also leaves people living with an incurable form of breast cancer feeling isolated and disconnected. Accurate statistics and increased awareness would help further the understanding of the impact of this stage of breast cancer and better support those with it.

Citation Format: Gordon J, Ammendolea C, Chari N, Armstrong R, Hall W. Recommendations to improve the lived experience of early stage and metastatic breast cancer patients in Canada [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-10.

Abstract P5-16-02: Enhance post-lumpectomy breast contour using oncoplastic surgery (OPS) plus a bioabsorbable 3-D tissue implant

Introduction: The appearance after breast surgery has become an important aspect of survivorship. The post lumpectomy/post radiation hollow surgical defect negatively impacts cosmesis and patient satisfaction. Oncoplastic procedures will mobilize surrounding tissues into the lumpectomy cavity but adds no volume to the breast. Use of a bioabsorbable 3-dimensional tissue implant (used for targeting radiation) has the additional benefit of adding volume to the breast and enhances the overall cosmetic appearance. Our experience over 3 years provides serial mammograms from which we may objectively categorize cosmetic contour. We report on our 2 and 3 year serial images of our treated patients compared with baseline.

Methods: Between May 2014 and June 2018, during lumpectomy for breast cancer we implanted a 3-D tissue implant marker in 170 patients, often combined with oncoplastic reconstruction and followed by radiation treatment. For long term follow-up we had 37 patients with serial mammograms at 2 or 3 years to assess cosmesis. All patients had interviews, physical exams, and serial mammograms to evaluate their cosmetic appearance. Both physician and patient graded their appearance. We also objectively measured and compared the pre-treatment mammogram and the 2-year and 3-year, post-treatment mammogram for symmetry and size using each breast as its own control. Using the post-treatment mammograms, we compared the relative anterior-posterior (depth) measurement of the quadrant bearing the implant as well as the non-cancer quadrant to the similar locations of the pre-treatment mammogram. Both mammogram positioning and radiation effects would balance. We compared the relative change from baseline in the non-cancer portion of the breast to the change from baseline in the cancer portion of the breast as a percent difference from baseline.

Results: Patients were treated with lumpectomy, oncoplastic reconstruction, and placement of a 3-D tissue implant. Three implants were removed due to positive margins. No implants were removed for any other reason. There have been no local recurrences. Overall, radiation oncologists felt the 3-D implant was useful for treatment planning in 85% of patients. Of the 37 consecutive patients who have completed an average of 27.8 months of follow-up, cosmesis was rated as excellent/good by clinicians (96%) and patients (94%). Mammograms taken at 2-3 years were compared with initial images. Whole-breast radiation effect varied among patients. Some had significant shrinkage while others had none. These changes were equal in the non-cancer post-radiation quadrants (86.2% vs 87%) demonstrating maintenance of normal breast contour. Our use of the 3-D implant and oncoplastic tissue advancement maintained the pre-operative contour of the breast after lumpectomy with radiation.

Conclusions: Breast cancer surgery and radiation is often complicated by poor cosmesis with retraction and volume loss. Using a combination of oncoplastic surgery combined with a 3-D tissue implant, we found the forward projection and contour of the breast at the lumpectomy site was preserved and patient satisfaction was good to excellent. Further investigation of the long-term cosmetic effects of breast cancer surgery should be encouraged.

Citation Format: Kaufman CS, Hall W, Behrndt VS, Wolgamot GM, Zacharias K, Rogers A, Smith A, Hill LM, Schnell N. Enhance post-lumpectomy breast contour using oncoplastic surgery (OPS) plus a bioabsorbable 3-D tissue implant [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-02.

Financial Resources Digital Navigation Tool for Metastatic Breast Cancer Patients

Background and context: Although Canadians enjoy a universal health care system, there continues to be costs to patients that are not covered by the system. The economic impact of breast cancer is huge and, in many cases, devastating for patients and their families. As a result there is a need for educational and navigational resources that assist patients with the financial burden of facing a metastatic breast cancer diagnosis. Aim: The aim of this project is to develop an online navigation tool that will assist Canadians living with metastatic breast cancer source financial supports and resources to help lessen the financial impact of their diagnosis. Strategy/Tactics: An advisory board of people living with metastatic breast cancer was convened to help guide this project and provide input on the lived experience and financially challenges of Canadians living with this stage of the disease. The input from the advisory board along with the responses from a survey of over 150 Canadian metastatic breast cancer patients informed the type of information that should be included in the resource. Through an environmental scan and research of various financial supports, a comprehensive list of financial resources available locally, regionally and nationally was compiled. This data were integrated into a database that will be accessed through an intuitive online interface that will be integrated with CBCN´s Web site. The advisory board reviewed the draft content and framework to ensure that identified needs and priorities have been addressed. All content was translated into French as this tool will be offered in both French and English. The anticipated launch of this resource is November 2018. Outcomes: CBCN anticipates that over 1200 people living with metastatic breast cancer will access this resource in the first year and that over 50 institutions will be informed that this tool is available for their patients. Given that this will be a unique resource, CBCN expects that patients, health care professionals and support workers will access this resource to better support people living with metastatic breast cancer. What was learned: This resource has not launched, but based on CBCN´s research and the feedback of the patient advisory board, it is understood that there is a great need for this financial resources navigation tool.

First isolation of West Nile virus in Zambia from mosquitoes

Mosquito surveillance studies to identify mosquito-borne flaviviruses have identified West Nile Virus (WNV) for the first time in Zambia. The Zambian WNV isolate from Culex quinquefasciatus mosquitoes collected in the Western Province was closely related genetically to WNV lineage 2 South African strains which have been previously shown to be highly neuroinvasive. These data provide the first evidence of the circulation of WNV in Zambia and suggest there should be an increased awareness of possible associated human and animal diseases in that country.

Abstract P3-13-20: Use of a 3-D bioabsorbable tissue marker in 61 patients over two years

Background: Breast conservation surgery (BCS) may preserve the breast but many women have less than optimal cosmetic outcomes. Increasingly, this has been addressed by the use of oncoplastic reconstruction.Now, targeting radiation treatment for boost or partial breast irradiation (PBI) using the seroma has become more difficult due to the adjacent tissue rearrangement and resultant “benign” seromas. Since the radiation dose generated increases by the third power of the radius (r3), there is a need to accurately focus radiation therapy to avoid chronic radiation side effects.We have used a 3-dimensional bioabsorbable tissue marker to accurately target the tumor bed while excluding inadvertent seromas caused by oncoplastic procedures. We report on tissue marker implantation on 61 consecutive breast conservation patients in regards to targeting, impact on cosmesis, imaging followup, ease of re-excision, as well as side effects and patient satisfaction.

METHODS: Consecutive lumpectomy patients who were candidates for targeted radiation therapy were considered for implantation with the 3-D bioabsorbable marker from May 2014 to June 2016. The tissue marker has a fixed array of 6 titanium clips and was sutured to the site of the excised breast cancer during lumpectomy.The framework of the implant resorbs slowly over time, while the clips remain permanently. All patients had oncoplastic reconstruction with total implant coverage. The marker was utilized for boost or partial breast irradiation (PBI) planning or treatment targeting. Data includes patient demographics, breast size, tumor characteristics, surgical and radiotherapy techniques, follow-up imaging, cosmesis and patient satisfaction.

Results:Data on 61 patients with median follow-up 12.7 months was analyzed (range 1.5–25.5). Median age was 62.4 years (range 33-74), 5 of women were postmenopausal and 15% had comorbidities. Cancer histology was in-situ (13%), invasive ductal (84%), invasive lobular (3%) of sizes T0 (13%), T1 (59%), T2 (25%), T3-4 (3%). Laterality and tumor location within the breast were typical. Re-excisions occurred in 11% of patients. No infections occurred in the postoperative period. One infection occurred with chemotherapy and another with repeated aspirations of oncoplastic area.No device was removed for infection, misplacement or patient-generated concerns. No cancer recurrences have been reported. Size of device used reflected size of the tumor; 2X2cm (44%), 2X3cm (34%) and 3X3cm (20%). The device was utilized by radiation oncologists for boost or PBI planning and treatment. Data on ease of setup and boost planning is being collected. Mammography at one year demonstrated marker clips coalescing as the bioabsorbable device dissolves. Evaluation of cosmetic appearance has shown good to excellent cosmesis as judged separately by both physicians and patients (92% and 94%).

Conclusions: Initial experience with 61 patients implanted with a novel 3-D absorbable device prospectively followed for an average of 12 months can be used in an array of breast cancer patients without device specific morbidity. Good to excellent cosmesis may be related to the addition of volume to the lumpectomy bed not seen with rearrangement of existing tissues.

Citation Format: Kaufman CS, Hall W, Behrndt V, Wolgamot G, Hill L, Zacharias K, Rogers A, Nix S, Schnell N. Use of a 3-D bioabsorbable tissue marker in 61 patients over two years [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-20.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

The use of paracetamol (acetaminophen) among a community sample of people with chronic non-cancer pain prescribed opioids

BACKGROUND

The regular use of simple analgesics in addition to opioids such as paracetamol (or acetaminophen) is recommended for persistent pain to enhance analgesia. Few studies have examined the frequency and doses of paracetamol among people with chronic non-cancer pain including use above the recommended maximum daily dose.

AIMS

To assess (i) the prevalence of paracetamol use among people with chronic non-cancer pain prescribed opioids, (ii) assess the prevalence of paracetamol use above the recommended maximum daily dose and (iii) assess correlates of people who used paracetamol above the recommended maximum daily dose including: age, gender, income, education, pain severity and interference, use of paracetamol/opioid combination analgesics, total opioid dose, depression, anxiety, pain self-efficacy or comorbid substance use, among people prescribed opioids for chronic non-cancer pain.

METHODS

This study draws on baseline data collected for the Pain and Opioids IN Treatment (POINT) study and utilises data from 962 interviews and medication diaries. The POINT study is national prospective cohort of people with chronic non-cancer pain prescribed opioids. Participants were recruited from randomly selected pharmacies across Australia.

RESULTS

Sixty-three per cent of the participants had used paracetamol in the past week (95% CI = 59.7-65.8). Among the paracetamol users 22% (95% CI = 19.3-24.6) had used paracetamol/opioid combination analgesics and 4.8% (95% CI = 3.6-6.3) had used paracetamol above the recommended maximum daily dose (i.e. > 4000 mg/day). Following binomial logistic regression (χ(2) = 25.98, df = 10, p = 0.004), people who had taken above the recommended maximum daily dose were less likely to have low income (AOR = 0.52, 95% CI = 0.27-0.99), more likely to use paracetamol/opioid combination analgesics (AOR = 2.01, 95% CI = 1.02-3.98) and more likely to take a higher opioid dose (AOR = 1.00, 95% CI = 1.00-1.01).

CONCLUSION

The majority of people with chronic non-cancer pain prescribed opioids report using paracetamol appropriately. High income, use of paracetamol/opioid combination analgesics and higher opioid dose were independently associated with paracetamol use above the recommended maximum daily dose.

Assessing the public health impacts of legalizing recreational cannabis use in the USA

A major challenge in assessing the public health impact of legalizing cannabis use in Colorado and Washington State is the absence of any experience with legal cannabis markets. The Netherlands created a de facto legalized cannabis market for recreational use, but policy analysts disagree about how it has affected rates of cannabis use. Some US states have created de facto legal supply of cannabis for medical use. So far this policy does not appear to have increased cannabis use or cannabis-related harm. Given experience with more liberal alcohol policies, the legalization of recreational cannabis use is likely to increase use among current users. It is also likely that legalization will increase the number of new users among young adults but it remains uncertain how many may be recruited, within what time frame, among which groups within the population, and how many of these new users will become regular users.