Continuum of HIV care of newly diagnosed individuals in Israel, 2011-2015: a population-based cohort study

Our aim was to assess the linkage to care (LTC) and treatment for people newly diagnosed with HIV in Israel during 2011–2015. The Ministry of Health estimated the annual prevalence of undiagnosed HIV; new diagnoses were identified by the Central Virology Laboratory. Only adult Israeli citizens were included. LTC at HIV centers within 90 days of diagnosis was assessed. Demographic and clinical data were collected from patient files. A total of 1538 individuals were diagnosed in 2011–2015. A moderate improvement over time was observed in the calculated proportions of undiagnosed individuals (23.1–17.3%) but no change occurred in LTC rates (82.6–81%). The proportion of diagnosed patients initiating treatment within six months increased from 54.7% in 2011 to 89.7% in 2015, with a parallel increase in the viral suppression rate from 30.5% in 2011 to 59.9% in 2015. Of 1159 patients with detailed records, 79.4% were men, median age 36 years (16–92), median CD4 cell count 342 cells/µl. Younger age, intravenous drug use, and imprisonment were independent risk factors for loss to follow-up. HIV is diagnosed late in Israel and LTC rates remain stagnated; higher awareness is still needed. Once in care, however, treatment and outcomes were in line with international standards.

The PROCLIPI international registry of early-stage mycosis fungoides identifies substantial diagnostic delay in most patients

BACKGROUND

Survival in mycosis fungoides (MF) is varied and may be poor. The PROCLIPI (PROspective Cutaneous Lymphoma International Prognostic Index) study is a web-based data collection system for early-stage MF with legal data-sharing agreements permitting international collaboration in a rare cancer with complex pathology. Clinicopathological data must be 100% complete and in-built intelligence in the database system ensures accurate staging.

OBJECTIVES

To develop a prognostic index for MF.

METHODS

Predefined datasets for clinical, haematological, radiological, immunohistochemical, genotypic, treatment and quality of life are collected at first diagnosis of MF and annually to test against survival. Biobanked tissue samples are recorded within a Federated Biobank for translational studies.

RESULTS

In total, 430 patients were enrolled from 29 centres in 15 countries spanning five continents. Altogether, 348 were confirmed as having early-stage MF at central review. The majority had classical MF (81·6%) with a CD4 phenotype (88·2%). Folliculotropic MF was diagnosed in 17·8%. Most presented with stage I (IA: 49·4%; IB: 42·8%), but 7·8% presented with enlarged lymph nodes (stage IIA). A diagnostic delay between first symptom development and initial diagnosis was frequent [85·6%; median delay 36 months (interquartile range 12-90)]. This highlights the difficulties in accurate diagnosis, which includes lack of a singular diagnostic test for MF.

CONCLUSIONS

This confirmed early-stage MF cohort is being followed-up to identify prognostic factors, which may allow better management and improve survival by identifying patients at risk of disease progression. This study design is a useful model for collaboration in other rare diseases, especially where pathological diagnosis can be complex.

The prevalence of mental disorders in incarcerated contact sexual offenders

OBJECTIVE

Mental disorders in sexual offenders are relevant in terms of risk assessment and psychotherapeutic and pharmacological treatment.

METHODS

The present cross-sectional study was conducted between 2001 and 2017 and included 1511 sexual offenders who were assessed at the Federal Evaluation Center for Sexual and Violent Offenders in the Austrian Prison System. All sexual offenders were assessed with the Structured Clinical Interview for Axis I (SCID I) and Axis II disorders (SCID II).

RESULTS

N = 1250 (92.9%) sexual offenders were diagnosed with a mental disorder, whereby the great majority received multiple diagnoses. The most frequently found disorders were alcohol misuse (40.0%), paraphilic (43.3%), and personality disorders (53.6%) with a special emphasis on Cluster B personality disorders (47.8%). While sexual offenders against children were more likely to be diagnosed with paraphilic disorders, sexual offenders against adults were more likely to be diagnosed with a personality disorder.

CONCLUSION

Prevalence rates of mental disorders in sexual offenders are considerable. Besides specific risk reducing treatment, the psychological and social sequelae of the mental disorder have to be addressed in interventions in order to reach an effective and sustainable risk reduction.

Implementing Intensive Insulin Therapy: Development and Audit of the Bath Insulin Protocol

Intensive insulin therapy to control blood glucose has been found to reduce mortality among critically ill patients in a surgical intensive care unit, though a simple prescriptive insulin infusion protocol to achieve this has not been published previously. This study documents the development and routine use of a simple prescriptive intravenous insulin infusion protocol for critically ill patients and compares the results with previous practice. During development the protocol was optimized and practical issues of implementation addressed. The optimized protocol was then used for all ICU admissions, and a prospectively defined retrospective chart audit performed for the first month of use. Results were compared with a similar time period the previous year. In September 2002, 27 admissions were started on the protocol. Blood glucose for the time on the protocol had a median value of 6.2 (IQR 5.9-7.1) mmol/l compared with 9.2 (IQR 8.1-10.2) mmol/l for those on insulin in 2001. Blood glucose for the whole ICU stay for those on the protocol in 2002 had a median value of 6.6 (IQR 6.0-7.4) mmol/l compared with 8.6 (IQR 8.0-9.4) mmol/l in 2001. Blood glucose for all ICU patients in 2002 had a median value of 6.5 (IQR 6.0-7.3) mmol/l compared with 7.2 (IQR 6.3-8.3) mmol/l in 2001.

Three blood glucose recordings were less than 2.2 mmol/l in September 2002. This study provides initial effectiveness and safety data for the Bath Insulin Protocol. Further audits in a larger patient population are now needed.

Identification and characterization of HIV positive Ethiopian elite controllers in both Africa and Israel

OBJECTIVES

HIV elite controllers (ECs) are a unique subgroup of HIV-positive patients who are long-term virologically suppressed in the absence of antiretroviral treatment (ART). The prevalence of this subgroup is estimated to be < 1%. Various cohorts of ECs have been described in developed countries, most of which have been demographically heterogeneous. The aim of this study was to identify ECs in two large African cohorts and to estimate their prevalence in a relatively genetically homogenous population.

METHODS

We screened two cohorts of HIV-positive Ethiopian patients. The first cohort resided in Mekelle, Ethiopia. The second was comprised of HIV-positive Ethiopian immigrants in Israel. In the Mekelle cohort, ART-naïve subjects with stable CD4 counts were prospectively screened using two measurements of viral load 6 months apart. Subjects were defined as ECs when both measurements were undetectable. In the Israeli cohort, subjects with consistently undetectable viral loads (mean of 17 viral load measurements/patient) and stable CD4 count > 500 cells/μL were defined as ECs.

RESULTS

In the Mekelle cohort, 16 of 9515 patients (0.16%) fitted the definition of EC, whereas seven of 1160 (0.6%) in the Israeli cohort were identified as ECs (P = 0.011).

CONCLUSIONS

This is the first large-scale screening for HIV-positive ECs to be performed in entirely African cohorts. The overall prevalence of ECs is within the range of that previously described in developing countries. The significant difference in prevalence between the two cohorts of similar genetic background is probably a consequence of selection bias but warrants further investigation into possible environmental factors which may underlie the EC state.

Global Health Strategy for Cancer: Think Globally, Act Locally! Building a Collaborative Partnership Between Manitoba (Canada) and Jaffna (Sri Lanka)

Background and context: The number of people diagnosed with cancer worldwide is estimated to double by 2035. The greatest increase is expected in low- and middle-income countries (LMIC) due to demographic changes, such as ageing and growing populations, and increasing exposure to risk factors. Approximately 8.8 million people die each year of cancer, or one in 6 deaths globally. The Canadian government has recently renewed its commitment as a progressive global citizen with efforts including improvement of global health equity. CancerCare Manitoba is the provincial agency responsible for cancer and blood disorders, including the delivery of a wide range of clinical services from prevention to screening to treatment and supportive services, as well as cancer surveillance, research, and education. CancerCare Manitoba has identified potential partnerships with governments, nongovernmental organizations, academic institutions, and funders to address current and future challenges related to global cancer control. This includes several LMIC partners who have expressed an interest in working with Manitoba on cancer-related issues. In this presentation, we will describe our plans and early experience with a team from the University of Jaffna, the northern region of Sri Lanka. With a focus initially on surveillance and cancer control planning, there is an excellent opportunity for mutual learning and advancement of programs for cancer surveillance and planning. Aim: To establish a local partnership by connecting Manitoba, Canada with an engaged team from the University of Jaffna, Sri Lanka to advance cancer surveillance and planning, and contribute to the “global war on cancer”. Strategy/Tactics: A phased approach is being taken to address locally identified needs for cancer control. CancerCare Manitoba staff will be part of the mentorship team working with local partners in Jaffna to ensure development of local capacity. Specifically, we will: initiate cancer surveillance and establish a cancer registry in Jaffna (building from a cross-sectional study → hospital based registry → regional registry); analyze data and report on patterns; and establish a strategic plan for cancer control. Program/Policy process: Early planning is underway, involving collaborators from Manitoba and Jaffna. A project proposal has been developed to provide scope and acquire seed funding. Outcomes: Success will be determined based on the context of each program, including: establishing a framework for cancer surveillance; satisfaction of local and international partners (e.g., the Global Cancer Surveillance unit at the International Agency for Research in Cancer); and production of reports as a basis for cancer control. What was learned: Early learnings include the importance of local engagement and dedicated mentorship to advance global health equity, manage challenges around (sustained) funding, and establish a foundation of motivated partners.

Malignancy and mortality in paediatric-onset inflammatory bowel disease: a 3-year prospective, multinational study from the paediatric IBD Porto group of ESPGHAN

BACKGROUND

Risk benefit strategies in managing inflammatory bowel diseases (IBD) are dependent upon understanding the risks of uncontrolled inflammation vs those of treatments. Malignancy and mortality in IBD have been associated with disease-related inflammation and immune suppression, but data are limited due to their rare occurrence.

AIM

To identify and describe the most common causes of mortality, types of cancer and previous or current therapy among children and young adults with paediatric-onset IBD.

METHODS

Information on paediatric-onset IBD patients diagnosed with malignancy or mortality was prospectively collected via a survey in 25 countries over a 42-month period. Patients were included if death or malignancy occurred after IBD diagnosis but before the age of 26 years.

RESULTS

In total, 60 patients were identified including 43 malignancies and 26 fatal cases (9 due to cancer). Main causes of fatality were malignancies (n = 9), IBD or IBD-therapy related nonmalignant causes (n = 10; including 5 infections), and suicides (n = 3). Three cases, all fatal, of hepatosplenic T-cell lymphoma were identified, all were biologic-naïve but thiopurine-exposed. No other haematological malignancies were fatal. The 6 other fatal cancer cases included 3 colorectal adenocarcinomas and 3 cholangiocarcinomas (CCAs). Primary sclerosing cholangitis (PSC) was present in 5 (56%) fatal cancers (1 colorectal carcinoma, 3 CCAs and 1 hepatosplenic T-cell lymphoma).

CONCLUSIONS

We report the largest number of paediatric-onset IBD patients with cancer and/or fatal outcomes to date. Malignancies followed by infections were the major causes of mortality. We identified PSC as a significant risk factor for cancer-associated mortality. Disease-related adenocarcinomas were a commoner cause of death than lymphomas.

Central nervous system relapse of diffuse large B-cell lymphoma in the rituximab era: results of the UK NCRI R-CHOP-14 versus 21 trial

Background

Central nervous system (CNS) relapse of diffuse large B-cell lymphoma (DLBCL) is associated with a dismal prognosis. Here, we report an analysis of CNS relapse for patients treated within the UK NCRI phase III R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone) 14 versus 21 randomised trial.

Patients and methods

The R-CHOP 14 versus 21 trial compared R-CHOP administered two- versus three weekly in previously untreated patients aged ≥18 years with bulky stage I–IV DLBCL (n = 1080). Details of CNS prophylaxis were retrospectively collected from participating sites. The incidence and risk factors for CNS relapse including application of the CNS-IPI were evaluated.

Results

177/984 patients (18.0%) received prophylaxis (intrathecal (IT) methotrexate (MTX) n = 163, intravenous (IV) MTX n = 2, prophylaxis type unknown n = 11 and IT MTX and cytarabine n = 1). At a median follow-up of 6.5 years, 21 cases of CNS relapse (isolated n = 11, with systemic relapse n = 10) were observed, with a cumulative incidence of 1.9%. For patients selected to receive prophylaxis, the incidence was 2.8%. Relapses predominantly involved the brain parenchyma (81.0%) and isolated leptomeningeal involvement was rare (14.3%). Univariable analysis demonstrated the following risk factors for CNS relapse: performance status 2, elevated lactate dehydrogenase, IPI, >1 extranodal site of disease and presence of a ‘high-risk’ extranodal site. Due to the low number of events no factor remained significant in multivariate analysis. Application of the CNS-IPI revealed a high-risk group (4-6 risk factors) with a 2- and 5-year incidence of CNS relapse of 5.2% and 6.8%, respectively.

Conclusion

Despite very limited use of IV MTX as prophylaxis, the incidence of CNS relapse following R-CHOP was very low (1.9%) confirming the reduced incidence in the rituximab era. The CNS-IPI identified patients at highest risk for CNS recurrence.

ClinicalTrials.gov

ISCRTN number 16017947 (R-CHOP14v21); EudraCT number 2004-002197-34.

Outcome of elderly patients with diffuse large B-cell lymphoma treated with R-CHOP: results from the UK NCRI R-CHOP14v21 trial with combined analysis of molecular characteristics with the DSHNHL RICOVER-60 trial

BACKGROUND

There is an on-going debate whether 2- or 3-weekly administration of R-CHOP is the preferred first-line treatment for elderly patients with diffuse large B-cell lymphoma (DLBCL). The UK NCRI R-CHOP14v21 randomized phase 3 trial did not demonstrate a difference in outcomes between R-CHOP-14 and R-CHOP-21 in newly diagnosed DLBCL patients aged 19-88 years, but data on elderly patients have not been reported in detail so far. Here, we provide a subgroup analysis of patients ≥60 years treated on the R-CHOP14v21 trial with extended follow-up.

PATIENTS AND METHODS

Six hundred and four R-CHOP14v21 patients ≥60 years were included in this subgroup analysis, with a median follow-up of 77.7 months. To assess the impact of MYC rearrangements (MYC-R) and double-hit-lymphoma (DHL) on outcome in elderly patients, we performed a joint analysis of cases with available molecular data from the R-CHOP14v21 (N = 217) and RICOVER-60 (N = 204) trials.

RESULTS

Elderly DLBCL patients received high dose intensities with median total doses of ≥98% for all agents. Toxicities were similar in both arms with the exception of more grade ≥3 neutropenia (P < 0.0001) and fewer grade ≥3 thrombocytopenia (P = 0.05) in R-CHOP-21 versus R-CHOP-14. The elderly patient population had a favorable 5-year overall survival (OS) of 69% (95% CI: 65-73). We did not identify any subgroup of patients that showed differential response to either regimen. In multivariable analysis including individual factors of the IPI, gender, bulk, B2M and albumin levels, only age and B2M were of independent prognostic significance for OS. Molecular analyses demonstrated a significant impact of MYC-R (HR = 1.96; 95% CI: 1.22-3.16; P = 0.01) and DHL (HR = 2.21; 95% CI: 1.18-4.11; P = 0.01) on OS in the combined trial cohorts, independent of other prognostic factors.

CONCLUSIONS

Our data support equivalence of both R-CHOP application forms in elderly DLBCL patients. Elderly MYC-R and DHL patients have inferior prognosis and should be considered for alternative treatment approaches.

TRIAL NUMBERS

ISCRTN 16017947 (R-CHOP14v21); NCT00052936 (RICOVER-60).