Dose-Escalated vs. Conventional Hypofractionated Radiotherapy for Lung Cancer Patients in Predominantly Central Locations

PURPOSE/OBJECTIVE(S)

Hypofractionated radiation therapy (HFRT) is an increasingly utilized treatment option for patients with lung cancers unamenable to stereotactic body radiotherapy (SBRT). Conventional HFRT (C-HFRT) is often prescribed to 60 Gy in 15 fractions, which has a lower biologically effective dose (BED10 of 84.0) than SBRT. We compared outcomes of patients treated with a dose-escalated HFRT regimen (DE-HFRT, 72 Gy in 18 fractions, BED10 of 100.8) to those treated with C-HFRT. We aimed to evaluate local control (LC), overall survival (OS), and grade 3+ toxicity between patients who received C-HFRT vs. DE-HFRT as we hypothesized DE-HFRT may be superior/equivalent to C-HFRT.

MATERIALS/METHODS

A database was created of all patients at our institution who received either thoracic C-HFRT or DE-HFRT between 2013 and 2020. Baseline variables were compared by chi-square analysis and logistic regression. We analyzed the association between treatment regimens with LC and OS (log-rank test and Cox proportional hazards regression), as well as grade 3+ toxicity.

RESULTS

A total of 107 patients were included, among whom 55 (51.4%) received C-HFRT and 52 (48.6%) received DE-HFRT. Median age was 73, 88.8% of patients had non-small cell lung cancer, 81.3% received lung-only treatment, and 52.3% had an ultra-central tumor location (within 1 cm of proximal tracheobronchial tree, esophagus, or heart). Patients with DE-HFRT were more likely to have lung-only treatment (92.3% vs. 70.9%, p = 0.005) and stage I disease (47.1% vs 24.1%, p = 0.01) than those with C-HFRT, but had a similar proportion of ultra-central tumors (57.1% vs. 54.9%, p = 0.82). Patients with DE-HFRT had a non-statistically significant trend towards higher LC (2-year 81.0% vs. 72.3%, 3-year 77.3% vs 52.3%, HR 0.53 [95% CI 0.26-1.09], p = 0.09) and OS (2-year 61.3% vs. 44.8%, 3-year 44.9% vs 33.9%, HR 0.68 [95% CI 0.41-1.11], p = 0.13) compared to those with C-HFRT. Similar findings were noted among those with lung-only treatment. Among those with ultra-central tumors, patients with DE-HFRT had statistically significantly higher LC (2-year 86.6% vs 71.2%, 3-year 86.6% vs 42.2%, HR 0.26 [95% CI 0.08-0.84] p = 0.02) and a non-statistically significant trend towards higher OS (2-year 63.8% vs 40.0%, 3-year 46.2% vs 31.1% HR 0.55 [95% CI 0.28-1.09] p = 0.09) compared to those with C-HFRT. There was no statistically significant difference in grade 3+ toxicities between DE-HFRT and C-HFRT (15.4% vs. 10.9%, OR 1.48 [95% CI 0.47-4.61], p = 0.49).

CONCLUSION

We noted promising local control and overall survival for patients treated with 72 Gy in 18 fractions compared to 60 Gy in 15 fractions, especially among those with ultra-central tumors. Grade 3+ toxicities were not significantly higher for patients undergoing dose escalation. Hence, our findings suggest that DE-HFRT to the lung is a safe and effective treatment regimen for highly selected patients who cannot undergo SBRT.

Benefit of inhalation aromatherapy as a complementary treatment for stress and anxiety in a clinical setting – A systematic review

OBJECTIVE

The purpose of this systematic review is to ascertain the impact of inhalation aromatherapy on stress and anxiety in clinical settings.

METHODS

A search strategy was developed using various databases. Randomised Controlled Trials (RCTs) as well as single and double-blind pilot clinical studies (non-RCT) using inhalation aromatherapy with an essential oil blend or a single essential oil were examined. All studies included a control intervention and use of a validated measurement tool. The time period under review was years 2000-2021. Due to the high level of heterogeneity and element of bias, a narrative synthesis was conducted.

RESULTS

The search strategy initially retrieved 628 studies and through application of the selection criteria and the removal of duplicates, 76 studies were selected for review with a total of 6539 patients. In 42% of the RCTs, physiological measures including vital signs and/or salivary cortisol were used in addition to questionnaires. Over 70% of the studies reported a positive effect on anxiety levels in the aromatherapy intervention groups compared with the control. However, in many cases this is limited by the absence of safety data, imprecise reporting of plant species and dosage of essential oil.

CONCLUSION

Inhalation aromatherapy has the potential to reduce stress and anxiety with data emerging to further support this result across a wide modality of clinical treatments. However, there is a clear need for the development of standard protocols for research in this area, generating measurable results which will create the opportunity for more rigorous evidence-based outcomes.

30th Annual GP2A Medicinal Chemistry Conference

The Group for the Promotion of Pharmaceutical Chemistry in Academia (GP2A) held their 30th annual conference in August 2022 in Trinity College Dublin, Ireland. There were 9 keynote presentations, 10 early career researcher presentations and 41 poster presentations.

The Traditional Chinese Medicine Houttuynia cordata Thunb decoction alters intestinal barrier function via an EGFR dependent MAPK (ERK1/2) signalling pathway

BACKGROUND

A traditionally prepared aqueous extract (= decoction) of Houttuynia cordata Thunb (Yu xing cao) (HC) is widely used in Traditional Chinese Medicine (TCM) to treat inflammatory disease. Previous chemical and biological studies on HC have mainly focused on organic extracts rather than the aqueous decoction, which is the traditional formulation.

PURPOSE

The study aimed to investigate whether the chemical composition of HC aqueous decoction (HCD) varies with geographical sourcing, to investigate the mechanism of action of HCD, and to determine if chemical variation impacts on HCDs anti-inflammatory activity.

METHOD

Sixteen samples of HC were purchased from Sichuan, Hubei and Anhui provinces in the People's Republic of China (PRC) and were prepared by the traditional decoction method to yield their corresponding HCDs. A Quality Control (QC) sample was prepared by combining individual HCD extracts. HCDs were analysed by Nuclear Magnetic Resonance (NMR) and High-Performance Liquid Chromatography-Mass Spectrometry (HPLC-MS). The anti-inflammatory activities associated with intestinal barrier function of HCD were studied by tumor necrosis factor-α (TNF-α) activated Caco-2 monolayers in vitro and in vivo using Dextran Sulfate Sodium (DSS)-induced murine colitis. Proteins involved in inflammation, mRNA levels, disease severity scores, and histology involved in intestinal inflammation were analysed.

RESULTS

HCD samples exhibited different chemical fingerprints and three regional outliers were identified by Principal Component Analysis (PCA). Fifteen phytochemical metabolites were identified and quantified. HCD showed in vitro anti-inflammatory activity, enhancing zonula occludens-1 (ZO-1), occludin, interleukin (IL)-10 and decreasing IL-1β, IL-6 and epidermal growth factor receptor (EGFR) via an EGFR-dependent mitogen-activated protein kinase (MAPK) extracellular signal-regulated kinase 1/2 (ERK 1/2) signaling pathway. This beneficial effect on intestinal inflammation was also seen in the in vivo colitis model at a molecular level in colonic tissues.

CONCLUSION

This study shows that the test HCDs were chemically different, resulting in different levels of activity on intestinal barrier function and inflammation. Moreover, a "Daodi" product showed the greatest biological activity in this study, thus validating the importance of the "Daodi" quality material in TCM and supporting the traditional used of HCD for the treatment of inflammation.

Antinociceptive and anti-inflammatory activities of Copaifera pubiflora Benth oleoresin and its major metabolite ent-hardwickiic acid

ETHNOPHARMACOLOGICAL RELEVANCE

Copaifera species folkloric names are "copaíbas, copaibeiras, copaívas or oil stick", which are widely used in Brazilian folk medicine. Among all ethnopharmacological applications described for Copaifera spp oleoresins, their anti-inflammatory effect stands out. However, the knowledge of anti-inflammatory and antinociceptive properties of Copaifera pubiflora Benth is scarce.

AIM OF THE STUDY

To investigate the cytotoxic, anti-inflammatory, and antinociceptive activities of C. pubiflora oleoresin (CPO), and its major compound ent-hardwickiic acid (HA).

MATERIAL AND METHODS

The phosphatase assay was used to evaluate the cytotoxicity of CPO and HA in three different cell lines. CPO and HA doses of 1, 3, and 10 mg/kg were employed in the biological assays. The assessment of motor activity was performed using open-field and rotarod tests. Anti-inflammatory activity of CPO and HA was assessed through luciferase assay, measurement of INF-γ, IL-1β, IL-6, IL-10, and TNF-α in a multi-spot system with the immortalized cell line THP-1, zymosan-induced arthritis, and carrageenan-induced paw edema. Acetic acid-induced abdominal writhing and formalin tests were undertaken to evaluate the antinociceptive potential of CPO and HA. In addition, the evaluation using carrageenan was performed to investigate the effect of CPO in pain intensity to a mechanical stimulus (mechanical hyperalgesia), using the von Frey filaments. A tail-flick test was used to evaluate possible central CPO and HA actions.

RESULTS

In the cytotoxicity evaluation, CPO and HA were not cytotoxic to the cell lines tested. CPO and HA (10 mg/kg) did not affect animals' locomotor capacity in both open-field and rotarod tests. In the luciferase assay, CPO and HA significantly reduced luciferase activity (p < 0.05). This reduction indicates a decrease in NF-κB activity. HA and CPO decreased INF-γ, IL-1β, IL-6, IL-10, and TNF-α at 24 and 72 h in the multi-spot system. In zymosan-induced arthritis, CPO and HA decreased the number of neutrophils in the joint of arthritic mice and the number of total leukocytes (p < 0.05). In experimental arthritis HA significantly decreased joint swelling (p < 0.05). CPO and HA also increased the mechanical threshold during experimental arthritis. HA and CPO significantly inhibited the carrageenan-induced paw edema, being the doses of 10 mg/kg the most effective, registering maximum inhibitions of 58 ± 8% and 76 ± 6% respectively, p < 0.05. CPO and HA reduced the nociceptive behavior in both phases of formalin at all tested doses. The highest doses tested displayed inhibitions of 87 ± 1% and 72 ± 4%, respectively, p < 0.001, in the first phase, and 87 ± 1% and 81 ± 2%, respectively, p < 0.001, in the second phase. Oral treatment of CPO and HA (1, 3, 10 mg/kg) significantly reduced the nociceptive response in acetic acid-induced abdominal writhings, and the 10 mg/kg dose was the most effective with maximum inhibitions of 86 ± 2% and 82 ± 1%, respectively, p < 0.001. Both HA and CPO significantly decreased the intensity of mechanical inflammatory hyper-nociception on carrageenan-induced hyperalgesia at all tested doses, and 10 mg/kg was the most effective dose with maximum inhibitions of 73 ± 5% and 74 ± 7%, respectively, p < 0.05.CPO increased the tail-flick latencies in mice, and concomitant administration of naloxone partially reduced its effect.

CONCLUSIONS

CPO and HA may inhibit the production of inflammatory cytokines by suppressing the NF-κB signaling pathway, resulting in anti-inflammatory and antinociceptive activities.

Exploring the Irish National Folklore Ethnography Database (Dúchas) for Open Data Research on Traditional Medicine Use in Post-Famine Ireland: An Early Example of Citizen Science

A rich archive of oral and ethnological literature is housed in the National Folklore Collection, in University College Dublin, Ireland. The Schools’ Manuscript Collection is one body of information that contains a wealth of ethnographic material, including that of an ethnomedicinal nature, collected by schoolchildren across Ireland in the 1930s, in an early example of Citizen Science. The collection has been digitized and is available online at Dúchas.ie. Furthermore, there is an on-going and related project, the Meitheal Dúchas.ie Community Transcription project that enables the database to be easily searched, and thus used for research purposes. This study analyses the user interface and functionality of the Dúchas database for ethnomedical research by utilizing probes in the form of plants, within the collection, that have been previously identified as used for medicinal purposes. Limitations and biases associated with both the original collection of the material and the Dúchas database, that impact on the quality and utility of extractable data have been identified, and where possible specific procedures adopted to counteract such limitations. This study provides an insight into; the use of Dúchas.ie for ethnographic research, the use of plants for medicinal purposes in post-famine Ireland and is the first tangible example of Citizen Science in ethnomedical research in Ireland.

In vivo study of anti-inflammatory and antinociceptive activities of Copaifera pubiflora Benth oleoresin

Copaifera pubiflora Benth oleoresin (CPO) is used as an anti-inflammatory, wound healing, and antimicrobial. This paper reports the cytotoxic, anti-inflammatory, and antinociceptive activities of CPO. CPO (10 mg/kg) did not affect locomotor capacity in the open-field and rotarod tests and was not cytotoxic to CHO-k1, THP-1, and L929 cell lines. It was active in the formalin test at 3 mg/kg by 86 ± 3% and 96 ± 3%, respectively, for the first and second phases. At 10 mg/kg, CPO inhibited 90 ± 7%, the pain in the mechanical hyperalgesia test. In the tail-flick test, CPO at 3 mg/kg affected the tail-flick latencies in mice by 77 ± 20%, which in combination with naloxone was only partially reduced. At 3 mg/kg CPO inhibited 80 ± 12% the carrageenan-induced paw edema, and at 3 mg/kg it reduced by 91 ± 5% the nociception on acetic acid-induced abdominal writhing. Therefore, CPO possesses anti-inflammatory and antinociceptive activities.

Non-invasive myocardial work: characterising the normal and ischaemic response to exercise

Background/Introduction

Myocardial work and work efficiency are new parameters for assessing left ventricular function. They have been shown to have value in a range of clinical settings but have not previously been applied to exercise stress echocardiography.

Purpose

We aim to characterize the normal myocardial work and work efficiency response to exercise in a mixed population and determine if myocardial work could be used to identify patients with inducible ischaemia.

Methods

Patients were retrospectively enrolled from an existing database of exercise stress echocardiography. Inclusion criteria were a clinical indication of possible ischemia and technical suitability to calculate myocardial work. Exclusion criteria were abnormal baseline left ventricular function or inadequate image quality. Echocardiograms positive for ischaemia were defined by independent visual assessment and compared with angiographic findings where available. Myocardial work and work efficiency were calculated using a proprietary algorithm.

Results

A total of 177 patients met inclusion criteria, 117 were excluded leaving 40 normal and 20 positive tests for analysis. During normal exercise global work increased 54% and efficiency remained at 96%. Segmental work showed a basal to apical gradient which became more prominent at peak exercise. In patients with inducible ischaemia during exercise there was a significant difference in response; work decreased by 1.9% and efficiency dropped to 87%. Receiver operating characteristic curve for myocardial work had an area under the curve of 0.94. Youden's J statistic suggested an optimum cut point of a 25% increase in work to define a normal test.

Conclusion

During normal exercise myocardial work increased and efficiency remained unchanged, however during exercise induced ischaemia both myocardial work and efficiency decreased. We have demonstrated that myocardial work can be applied to stress echocardiography to identify ischemia but the utility of this remains uncertain. Further research compared to an objective measure of functional ischemia is needed.

Response to exercise

Funding Acknowledgement

Type of funding source: None

Incidence rate, predictors and outcomes of interruption of HIV care: nationwide results from the Belgian HIV cohort

Objectives

We aimed to study the incidence rate, predictors and outcomes of HIV care interruption (HCI) in Belgium.

Methods

We analysed data for adult patients with at least two HIV care records in the Belgian HIV cohort between 1 January 2007 and 31 December 2016. An HCI episode was defined as 1 year without an HIV care record. The HCI incidence rate was analysed using Poisson regression, return to HIV care using a cumulative incidence function with death as a competing risk, and viral load (VL) status upon return to HIV care using logistic regression.

Results

We included 16 066 patients accounting for 78 625 person‐years of follow‐up. The incidence rate of HCI was 5.3/100 person‐years [95% confidence interval (CI) 5.1–5.4/100 person‐years]. The incidence of return to HIV care after HCI was estimated at 77.5% (95% CI 75.7–79.2%). Of those who returned to care, 43.7% had a VL ≤ 200 HIV‐1 RNA copies/mL, suggesting care abroad or suboptimal care (without an HIV‐related care record) in Belgium during the HCI, and 56.3% returned without controlled VL and were therefore considered as having experienced a real gap in HIV care; they represented 2.3/100 person‐years of follow‐up. Factors individually associated with HCI were no antiretroviral therapy (ART) uptake, lower age, injecting drug use, non‐Belgian nationality, male gender, not being a man who has sex with men, a shorter time since HIV diagnosis, no high blood pressure and CD4 count < 350 cells/µL.

Conclusions

This study highlights the need to investigate return to care and viral status at return, to better understand HCI. Identified predictors can help health care workers to target patients at higher risk of HCI for awareness and support.

Role of Neuroinflammation in Autism Spectrum Disorder and the Emergence of Brain Histaminergic System. Lessons Also for BPSD?

Many behavioral and psychological symptoms of dementia (BPSD) share similarities in executive functioning and communication deficits with those described in several neuropsychiatric disorders, including Alzheimer's disease (AD), epilepsy, schizophrenia (SCH), and autism spectrum disorder (ASD). Numerous studies over the last four decades have documented altered neuroinflammation among individuals diagnosed with ASD. The purpose of this review is to examine the hypothesis that central histamine (HA) plays a significant role in the regulation of neuroinflammatory processes of microglia functions in numerous neuropsychiatric diseases, i.e., ASD, AD, SCH, and BPSD. In addition, this review summarizes the latest preclinical and clinical results that support the relevance of histamine H1-, H2-, and H3-receptor antagonists for the potential clinical use in ASD, SCH, AD, epilepsy, and BPSD, based on the substantial symptomatic overlap between these disorders with regards to cognitive dysfunction. The review focuses on the histaminergic neurotransmission as relevant in these brain disorders, as well as the effects of a variety of H3R antagonists in animal models and in clinical studies.

Design and Implementation of an Integrated Competency-Focused Pharmacy Programme: A Case Report

This paper describes the design and implementation of elements of an integrated competency-focused pharmacy programme in the School of Pharmacy and Pharmaceutical Sciences (SoPPS), Trinity College Dublin (TCD), Ireland. Following a national review of pharmacy education and training in Ireland in 2010, and subsequent publication of legislation in 2014, the School has implemented a five-year integrated programme of pharmacy education and training, leading to the award of a Master's degree in Pharmacy (M. Pharm.). Curricular integration has been achieved by underpinning the new programme with a national competency framework for pharmacists and through the utilisation of curricular integration themes. Programme integration also encompasses embedded experiential learning placements in Years 2, 4 and 5 of the five-year programme. The new five-year integrated pharmacy programme, which commenced in 2015, replaced the 4 + 1 model of education and training where a four-year Bachelor's degree was followed by a one-year internship, which was a distinct and separate element of the students' training.

Current Enlightenment About Etiology and Pharmacological Treatment of Autism Spectrum Disorder

Autistic Spectrum Disorder (ASD) is a complex neurodevelopmental brain disorder characterized by two core behavioral symptoms, namely impairments in social communication and restricted/repetitive behavior. The molecular mechanisms underlying ASD are not well understood. Recent genetic as well as non-genetic animal models contributed significantly in understanding the pathophysiology of ASD, as they establish autism-like behavior in mice and rats. Among the genetic causes, several chromosomal mutations including duplications or deletions could be possible causative factors of ASD. In addition, the biochemical basis suggests that several brain neurotransmitters, e.g., dopamine (DA), serotonin (5-HT), gamma-amino butyric acid (GABA), acetylcholine (ACh), glutamate (Glu) and histamine (HA) participate in the onset and progression of ASD. Despite of convincible understanding, risperidone and aripiprazole are the only two drugs available clinically for improving behavioral symptoms of ASD following approval by Food and Drug Administration (FDA). Till date, up to our knowledge there is no other drug approved for clinical usage specifically for ASD symptoms. However, many novel drug candidates and classes of compounds are underway for ASD at different phases of preclinical and clinical drug development. In this review, the diversity of numerous aetiological factors and the alterations in variety of neurotransmitter generation, release and function linked to ASD are discussed with focus on drugs currently used to manage neuropsychiatric symptoms related to ASD. The review also highlights the clinical development of drugs with emphasis on their pharmacological targets aiming at improving core symptoms in ASD.

Are identities oral? Understanding ethnobotanical knowledge after Irish independence (1937-1939)

BACKGROUND

The Schools' Folklore Scheme (1937-1939) was implemented at a pivotal time in Irelands' political history. It resulted in a body of ethnological information that is unique in terms of when, why and how it was collected. This material consists of over 700,000 pages of information, including ethnomedicinal and ethnobotanical traditions, reflecting an oral identity that spans generations and that in many cases was not documented in writing until the 1930s. The intention of this study is to highlight the importance of the Schools' Folklore Scheme and to demonstrate an ethnographic approach based on recollections of original participants of the scheme, to further understand the material in the collection and the impact it had on the participants.

METHODS

This study involves an analysis of both oral and archival data. Eleven semi-structured interviews with original participants of the scheme were carried out between April and September 2016. Their corresponding schools' archival contributions to the scheme were located, and ethnomedicinal information was analysed and compared with the participants' recollections.

RESULTS

The majority of participants' stated the scheme had a positive impact on them. Five participants' recalled collecting ethnomedicinal information, and there was a direct correlation between three of the participants' ethnomedicinal recollections and their entries in the archives. One third of all the ethnomedicinal entries analysed included the use of a plant. There were 191 plant mentions and 64 plant species named.

CONCLUSIONS

Contacting the original participants offers a novel approach of analysing this archival material. It provides a unique first-hand account of this historical initiative, an insight into how the scheme was implemented and how it impacted upon the children. The ethnomedicinal and ethnobotanical information provides an understanding of the medicinal practices in Ireland during the 1930s. The plant species that were both orally recalled by participants and documented in the archives are in keeping with key ethnomedicinal systems throughout the world.

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.

Good continuum of HIV care in Belgium despite weaknesses in retention and linkage to care among migrants

Background

The Belgian HIV epidemic is largely concentrated among men who have sex with men and Sub-Saharan Africans. We studied the continuum of HIV care of those diagnosed with HIV living in Belgium and its associated factors.

Methods

Data on new HIV diagnoses 2007–2010 and HIV-infected patients in care in 2010–2011 were analysed. Proportions were estimated for each sequential stage of the continuum of HIV care and factors associated with attrition at each stage were studied.

Results

Of all HIV diagnosed patients living in Belgium in 2011, an estimated 98.2 % were linked to HIV care, 90.8 % were retained in care, 83.3 % received antiretroviral therapy and 69.5 % had an undetectable viral load (<50 copies/ml). After adjustment for sex, age at diagnosis, nationality and mode of transmission, we found lower entry into care in non-Belgians and after preoperative HIV diagnoses; lower retention in non-Belgians and injecting drug users; higher retention in men who have sex with men and among those on ART. Younger patients had lower antiretroviral therapy uptake and less viral suppression; those with longer time from diagnosis had higher ART uptake and more viral suppression; Sub-Saharan Africans on ART had slightly less viral suppression.

Conclusions

The continuum of HIV care in Belgium presents low attrition rates over all stages. The undiagnosed HIV-infected population, although not precisely estimated, but probably close to 20 % based on available survey and surveillance results, could be the weakest stage of the continuum of HIV care. Its identification is a priority along with improving the HIV care continuum of migrants.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1230-3) contains supplementary material, which is available to authorized users.

Late presentation to HIV testing is overestimated when based on the consensus definition

Objectives

In 2011, a consensus was reached defining “late presenters” (LPs) as individuals presenting for care with a CD4 count < 350 cells/μL or with an AIDS‐defining event, regardless of CD4 count. However, a transient low CD4 count is not uncommon in recent infections. The objective of this study was to investigate how measurements of late presentation change if the clinical stage at the time of diagnosis is taken into account.

Methods

Case surveillance data for newly diagnosed patients in Belgium in 1998–2012 were analysed, including CD4 count at diagnosis, the presence of AIDS‐defining events, and recent infections (< 6 months) as reported by clinicians in the case of acute illness or a recent negative test. First, proportions of LPs were calculated according to the consensus definition. Secondly, LPs were reclassified as “nonlate” if infections were reported as recent.

Results

A total of 7949 HIV diagnoses were included in the study. Recent infections were increasingly reported over time, accounting for 8.2% of new infections in 1998 and 37.5% in 2012. The consideration of clinical stage significantly modified the proportion of LPs: 18.2% of men who have sex with men (MSM) diagnosed in 2012 would be classified as LPs instead of 30.9% using the consensus definition (P < 0.001). The proportion of patients misclassified as LPs increased significantly over time: 5% in MSM in 1998 vs. 41% in 2012.

Conclusions

This study suggests that low CD4 counts in recent infections may lead to overestimation of late presentation when applying the consensus definition. The impact of transient CD4 count on late presentation estimates should be assessed and, if relevant, the introduction of clinical stage in the definition of late presentation should be considered.

HIV-1 resistance and trend analysis in newly diagnosed patients in Belgium

A total of 1055 nucleotide sequences obtained from HIV patients diagnosed in 2008 and 2009 in Belgium were included in this prevalence study. The study population is a group of patients whose visit was considered by the clinician as the first contact with a Belgian AIDS reference centre or with another clinical centre experienced in HIV care. Prevalences of surveillance drug resistance mutations (SDRM) of 11·7% (47/394) and 11·0% (73/661) were observed in 2008 and 2009, respectively. The highest level of SDRM was observed towards nucleoside reverse transcriptase inhibitors (NRTIs) (7·8%), followed by the non-nucleoside reverse transcriptase inhibitors (NNRTIs) (4·2%) and Protease inhibitors (PIs) (2·3%). A potential clinical impact of the SDRM was demonstrated when using the current first-line therapy. A particularly high prevalence of SDRM was observed among intravenous drug users (IDUs) (29·4%). Reanalysis and comparing the data from previous Belgian studies using similar interpretation algorithms could not reveal a significant trend in SDRM prevalence over the last 5 years.

A national cohort of HIV-infected patients in Belgium: design and main characteristics

In Belgium, individual laboratory and treatment data of all HIV-infected patients seen in the 9 AIDS Reference Centres and 7 AIDS Reference Laboratories are collected prospectively since 2006. We present here an analysis of patients recorded in the cohort database between 1st of January 2006 and 31st of December 2008. During that period, 11982 patients were under medical follow-up in Belgium. Sixty-one percent of the patients were male and the median age was 39.8 at the time of first recorded viral load. Among the patients whose nationality or probable mode of transmission was recorded, nearly half (48.0%) were Belgian and 38.3% originated from Sub-Saharan Africa; heterosexual contacts were reported in the majority of cases (56.0%) followed by homosexual contacts (35.3%). A total of 145 deaths were reported. Around three quarters of the patients were on ART. The median CD4 cell count rose from 470 cells/mm3 in 2006 to 501 cells/mm3 in 2008. This cohort enabled us to obtain comprehensive information on the numbers and characteristics of HIV-infected patients currently being followed up in Belgium, and on trends in antiretroviral therapy and biological results. This will serve for planning purposes, evaluation of access to care and as a source of information for further studies.