Assessment of factors affecting response of direct-acting antivirals in chronic hepatitis C patients

Background

Hepatitis C virus (HCV) is a universally prevalent pathogen and a major cause of liver-related morbidity and mortality worldwide. The evolution of antiviral therapy for HCV has rapidly progressed from interferon (IFN)-based therapies to IFN-free combinations of direct-acting antivirals (DAAs).

Aims

This study aims to assess the response of DAAs in chronic hepatitis C (CHC) patients and to study the various factors affecting the response of DAAs in CHC.

Settings and Design

This longitudinal observational study spanning over a year was conducted in the Medicine department of a tertiary care teaching hospital.

Materials and Methods

The study was conducted on 400 adult CHC patients, diagnosed by a positive anti-HCV antibody test and a detectable viral load (HCV RNA) by real time polymerase chain reaction (RT-PCR), registered for treatment with DAAs. The first 400 patients satisfying the eligibility criteria were enrolled by non-probability consecutive sampling. All the participants were treated as per the National Viral Hepatitis Control Programme (NVHCP) guidelines. Repeat HCV viral load was done at or after 12 weeks of completion of anti-viral therapy to ascertain sustained virological response (SVR). Various factors which might predict treatment response were analyzed.

Statistical Analysis Used

The continuous variables were expressed as mean and standard deviation, while the categorical variables were summarized as frequencies and percentages. The Student's independent t-test was employed for the comparison of continuous variables. The Chi-square or Fisher's exact test, whichever is appropriate, was employed for the comparison of categorical variables. Multivariate Logistic Regression was used to identify the independent predictors of treatment nonresponse. A P < 0.05 was considered statistically significant.

Results

The mean age of the subjects was 42.3 ± 15.23 years with a male-to-female ratio of 1.96:1. Most of the patients (80.5%) were non-cirrhotic; among 19.5% cirrhotic, 13% were compensated while 6.5% were decompensated cirrhotic. The overall SVR done at or after 12 weeks of completion of treatment was 88.75%. Age, gender distribution, occupation, socioeconomic status, educational status, body mass index, treatment regimen, duration of treatment, and baseline viral load did not alter the treatment response. Among comorbidities, only diabetes mellitus (DM) and human immunodeficiency virus (HIV) co-infection adversely affected the treatment response (P = 0.009 and P < 0.001, respectively). Intravenous (IV) drug abuse was significantly associated with treatment failure (P < 0.001). The presence of liver cirrhosis (P < 0.001), thrombocytopenia (P < 0.001), elevated transaminases (alanine transaminase: P = 0.021, aspartate transaminase: P < 0.001), and previous treatment experience (P = 0.038) were other significant predictors of treatment failure.

Conclusions

DAAs are highly efficacious drugs in the treatment of CHC with a high rate of treatment response. Significant predictors of CHC treatment failure included comorbidities especially DM and HIV co-infection, IV drug abuse, presence of liver cirrhosis, thrombocytopenia, elevated transaminases, and previous treatment experience. However, independent predictors of treatment nonresponse observed in this study were thrombocytopenia, IV drug abuse, and liver cirrhosis.

Different drugs, different sides: injection use of opioids alone, and not stimulants alone, predisposes to right-sided endocarditis

Objectives

Many studies suggest that infective endocarditis (IE) in people who inject drugs is predominantly right sided, while other studies suggest left sided disease; few have differentiated by class of drug used. We hypothesised that based on differing physiological mechanisms, opioids but not stimulants would be associated with right sided IE.

Methods

A retrospective case series of 290 adult (age ≥18) patients with self-reported recent injection drug use, admitted for a first episode of IE to one of three hospitals in London Ontario between April 2007 and March 2018, stratified patients by drug class used (opioid, stimulant or both), and by site of endocarditis. Other outcomes captured included demographics, causative organisms, cardiac and non-cardiac complications, referral to addiction services, medical versus surgical management, and survival.

Results

Of those who injected only opioids, 47/71 (69%) developed right-sided IE, 17/71 (25%) developed left-sided IE and 4/71 (6%) had bilateral IE. Of those who injected only stimulants, 11/24 (46%) developed right-sided IE, 11/24 (46%) developed left-sided IE and 2/24 (8%) had bilateral IE. Relative to opioid-only users, stimulant-only users were 1.75 (95% CI 1.05 to 2.93; p=0.031) times more likely to have a left or bilateral IE versus right IE.

Conclusions

While injection use of opioids is associated with a strong predisposition to right-sided IE, stimulants differ in producing a balanced ratio of right and left-sided disease. As the epidemic of crystal methamphetamine injection continues unabated, the rate of left-sided disease, with its attendant higher morbidity and mortality, may also grow.

Septic arthritis of the sternoclavicular joint in a patient with human immunodeficiency virus infection

Septic arthritis is an unusual manifestation in patients with human immunodeficiency virus (HIV). The sternoclavicular joint is rarely affected, although it should be considered in immunosuppressed patients and users of intravenous drugs. Staphylococcus aureus is the most common pathogen detected and should be covered by empiric antibiotic therapy.

Human Immunodeficiency Virus-1 Subtype-C Genetically Diversify to Acquire Higher Replication Competence in Human Host with Comorbidities

Unusual disease progression is observed in the HIV-1 infected patients who are either coinfected with Mycobacterium tuberculosis (Mtb) or concomitantly on intravenous drug use (IDU). The mechanism involved in the breakdown of host immune defense and the synergistic effect in both the conditions are still not well understood. In this study, we aimed to highlight the emergence of genetically diversified variants of virus in these two cohorts among HIV-1 subtype-C infected population from a Northern state of India. A cross-sectional study was performed on treatment-naïve HIV-1 subtype-C infected individuals constituting three different cohorts of HIV-1 monoinfected, HIV-1-M. tuberculosis (HIV-TB) coinfected, and HIV-1 infected individuals on substance abuse (HIV-IDU) for acquisition of genetic alterations in terms of frequency of drug resistance (DR) mutations in reverse transcriptase gene. The data reveal a significantly higher viral load, higher death rate, and higher frequency of major DR mutations in the genome of viral isolates from HIV-TB and HIV-IDU cohorts as compared with HIV monoinfected. Majority of the mutations found in the HIV-TB coinfected and HIV-IDU cohorts conferred high level of resistance to the first-line treatment regimen (Lamivudine with Tenofovir or zidovudine or Abacavir and Nevirapine or Efavirenz). Our findings support the hypothesis that the HIV-1 evolve while replicating in the host with Mtb coinfection or substance abuse, with the emergence and accumulation of genetically diversified quasi-species. Further studies are warranted to understand the association of such genetic variations with increased replication competence and faster rate of disease progression in such individuals.

Immuno-hematological consequence of intravenous drug abuse?

Intravenous (IV) drug abuse has been well established to be the source of transfer of infections, such as HIV, hepatitis C virus, and hepatitis B virus. However, often overlooked fact is that IV drug abusers have a potential for developing alloimmunization due to universal practice of flushing/washing out the syringe by own blood to rinse out the drug in the syringe. We present here a case of a 28-year-old man who presented with a rather unique predicament of having developed four different alloantibodies after exposure to allogenic blood through IV drug abuse. This case was detected promptly due to routine usage of type and screen policy for all the patients receiving transfusion. Such screening for atypical antibodies must be instituted to preemptively identify these antibodies and arrange compatible blood, which could have been difficult otherwise, at short notice during routine crossmatch. This is the first of its kind case ever reported from India and has no precedence.

Promoting Safe Injection Practices, Substance Use Reduction, Hepatitis C Testing, and Overdose Prevention Among Syringe Service Program Clients Using a Computer-Tailored Intervention: Pilot Randomized Controlled Trial

BACKGROUND

Syringe service programs (SSPs) are safe, highly effective programs for promoting health among people who inject drugs. However, resource limitations prevent the delivery of a full package of prevention services to many clients in need. Computer-tailored interventions may represent a promising approach for providing prevention information to people who inject drugs in resource-constrained settings.

OBJECTIVE

The aim of this paper is to assess the effect of a computer-tailored behavioral intervention, called Hep-Net, on safe injection practices, substance use reduction, overdose prevention, and hepatitis C virus (HCV) testing among SSP clients.

METHODS

Using a social network-based recruitment strategy, we recruited clients of an established SSP in Wisconsin and peers from their social networks. Participants completed a computerized baseline survey and were then randomly assigned to receive the Hep-Net intervention. Components of the intervention included an overall risk synthesis, participants' selection of a behavioral goal, and an individualized risk reduction exercise. Individuals were followed up 3 months later to assess their behavior change. The effect of Hep-Net on receiving an HCV screening test, undergoing Narcan training, reducing the frequency of drug use, and sharing drug equipment was assessed. The individual's readiness to change each behavior was also examined.

RESULTS

From 2014 to 2015, a total of 235 people who injected drugs enrolled into the Hep-Net study. Of these, 64.3% (151/235) completed the follow-up survey 3-6 months postenrollment. Compared with the control group, individuals who received the Hep-Net intervention were more likely to undergo HCV testing (odds ratio [OR] 2.23, 95% CI 1.05-4.74; P=.04) and receive Narcan training (OR 2.25, 95% CI 0.83-6.06; P=.11), and they shared drug equipment less frequently (OR 0.06, 95% CI 0.55-0.65; P<.001). Similarly, individuals who received the intervention were more likely to advance in their stage of readiness to change these 3 behaviors. However, intervention participants did not appear to reduce the frequency of drug use or increase their readiness to reduce drug use more than control participants, despite the fact that the majority of the intervention participants selected this as the primary goal to focus on after participation in the baseline survey.

CONCLUSIONS

Implementing computer-based risk reduction interventions in SSPs may reduce harms associated with the sharing of injection equipment and prevent overdose deaths; however, brief computerized interventions may not be robust enough to overcome the challenges associated with reducing and ceasing drug use when implemented in settings centered on the delivery of prevention services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02474043; https://clinicaltrials.gov/ct2/show/NCT02474043.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/resprot.4830.

A Complicated Case of Vertebral Osteomyelitis by Serratia Marcescens

Osteomyelitis is an infection of the bone and bone marrow that can be caused by an exogenous source or by hematogenous spread. The hematogenous spread of bacteria usually results in bacteremia with subsequent infection of the bone. The most commonly associated pathogen with this type of infection is Staphylococcus aureus, with other gram-negative organisms, such as Pseudomonas aeruginosa, also frequently encountered. The microorganism Serratia marcescens is a rare and infrequently encountered cause of this condition known to cause nosocomial infections. This organism can be notoriously difficult to treat, with resistance to many commonly used antibiotics. The case presented is one of vertebral osteomyelitis in an intravenous drug user caused by Serratia marcescens with subsequent treatment and management of the condition. This case allows for investigation into the continued management of intravenous drug user infections, with the isolation and treatment of less commonly encountered pathogens.

Infected femoral pseudoaneurysms in intravenous drug abusers: a decade of experience from a Singapore tertiary centre

INTRODUCTION

A pseudoaneurysm (or false aneurysm) is a haematoma that communicates with an artery through a disruption in the arterial wall. The femoral artery is the most common injection site among drug users, and infected femoral pseudoaneurysms are the most common vascular complications.

METHODS

A retrospective review of medical records of intravenous drug abusers (IVDAs) who presented with infected femoral pseudoaneurysms from January 2006 to December 2016 was carried out. Patients who had pseudoaneurysms due to other aetiologies or trauma were excluded.

RESULTS

A total of 27 patients with infected femoral pseudoaneurysms were identified. The majority were male (92.6%) and of Malay ethnicity (55.6%). Median age was 50 (range 31-62) years. Commonly abused drugs were buprenorphine (or Subutex; 59.3%) and midazolam (or Dormicum; 51.9%). Groin pain and swelling (100.0%), fever (66.7%) and presence of a pulsatile mass (51.9%) were the most common presenting symptoms. Diagnosis was confirmed via computed tomography angiography in all patients. 25 patients underwent upfront arterial ligation with debridement, among whom three patients required concurrent surgical revascularisation. Only two patients underwent ultrasonography-guided thrombin injection - one eventually required surgery and the other was lost to follow-up. Postoperative complications included wound infection (42.3%), bleeding (11.5%) and necrotising fasciitis eventually resulting in limb loss (3.8%). There were no associated mortalities.

CONCLUSION

Infected pseudoaneurysms in IVDAs pose a unique challenge to vascular surgeons. We found that simple ligation and debridement was a safe and effective option for such patients.

Left-sided Pseudomonas Endocarditis with Disseminated Septic Emboli

A 59-year-old man presented with sharp chest pain, hypoxia, and tachycardia. His past medical history included intravenous drug use (IVDU). Pseudomonas aeruginosa was isolated from his blood. Pseudomonas aeruginosa is a rare cause of endocarditis. Patient revealed that he injected drugs intravenously with tap water. Transesophageal echocardiogram revealed vegetation on the anterior mitral leaflet with associated mitral regurgitation. Patient was successfully treated with meropenem and tobramycin and underwent mitral valve replacement without complications. Majority of IVDU-related endocarditis caused by Pseudomonas involve right-sided valves, but our case is unique as it demonstrates left-sided endocarditis in a patient with IVDU. A combination of aggressive medical and early surgical treatment with valve replacement has enabled this patient to successfully recuperate.

The Heroin Epidemic in America: A Surgeon's Perspective

Background: The United States is currently experiencing a heroin epidemic. Recent reports have demonstrated a three-fold increase in heroin use among Americans since 2007 with a shift in demographics to more women and white Americans. Furthermore, there has been a correlation between the recent opioid epidemic and an increase in heroin abuse. Much has been written about epidemiology and prevention of heroin abuse, but little has been dedicated to the surgical implications, complications, and resource utilization. Discussion: This article focuses on the surgical problems encountered from heroin abuse and how to manage them in a constant effort to improve morbidity and mortality for these heroin abusers.

Acute kidney injury is common with intravenous abuse of extended-release oral oxymorphone and delayed renal recovery rates are associated with increased KDIGO staging

AIM

Prescription opioid abuse poses a serious problem in the United States, representing 615 per 100 000 deaths annually. Extended-release oxymorphone (Opana-ER) is an oral opioid pain medication that has recently been found to cause thrombotic microangiopathy when intravenously abused. In this retrospective study, we attempted to determine the prevalence and outcomes of acute kidney injury (AKI) among patients intravenously abusing extended-release oral oxymorphone.

METHODS

A query of electronic medical records for 'drug abuse' at an academic medical centre during January 2012 to December 2015 was performed and yielded 2350 patients. Patients were further identified by documented intravenous abuse of extended-release oxymorphone. Patients were stratified based on multiple renal indices and outcomes. Potential confounders were also identified.

RESULTS

One hundred and sixty-five patients were found to have a documented history of intravenous abuse of extended-release oral oxymorphone. Prevalence of AKI in this population was a 47.8%. KDIGO stage-I patients consisted of 17.8% of patients with AKI, 40.5% were classified as KDIGO stage-II AKI, and 41.8% were classified as KDIGO stage-III AKI. Among patients with AKI, average age was found to be 37.5 years, 59.4% experienced renal recovery, 56.9% required intensive care unit admission, 13.9% progressed to end-stage renal disease (ESRD), and 7.6% expired during admission.

CONCLUSION

Clinicians should be educated to help recognize intravenous abuse of extended-release oral oxymorphone and its associated effects. Our data suggests AKI is common in these patients; higher KDIGO staging appears to be associated with slower rates of renal recovery, increased comorbidities and progression to both CKD and ESRD.

Hepatitis C viral infection and imprisonment among Aboriginal and Torres Strait Islander and non-Indigenous people who inject drugs

INTRODUCTION AND AIMS

An understanding of the relationship between hepatitis C viral (HCV) infection and contextual factors such as imprisonment may contribute to the development of targeted treatment and prevention programs. We examine the associations of imprisonment and drug dependence with lifetime exposure to HCV, and whether these associations differ for Aboriginal and Torres Strait Islander and non-Indigenous people who inject drugs.

DESIGN AND METHODS

Respondent-driven sampling was used in major cities and 'peer recruitment' in regional towns of Queensland to obtain a community sample of people who injected drugs, which comprised 243 Indigenous and 227 non-Indigenous participants who had ever been tested for HCV. Data are cross-sectional. Two binary Poisson models were developed to examine associations for variables relating to imprisonment, Indigeneity and drug use history.

RESULTS

Sharing needles and syringes in prison (adjusted risk ratio 1.25, 95% confidence interval 1.02-1.53) remained significantly associated with HCV infection after adjustment for Indigeneity, injecting drug use history and drug dependence. Opioid dependence and concurrent dependence on opioids and methamphetamine was also independently associated with HCV infection.

DISCUSSION AND CONCLUSIONS

Sharing needles and syringes in prison is linked with HCV infection, for both Aboriginal and Torres Strait Islander and non-Indigenous people who inject drugs. Further development of treatment and prevention programs in prisons is required, with consideration of the role of opioid and methamphetamine dependence in HCV exposure.

An Invasive Case of Left-Sided Endocarditis Caused by Pseudomonas aeruginosa in a Patient with History of Intravenous Drug Abuse

Infective endocarditis, caused by Pseudomonas aeruginosa, is rarely seen in clinical practice. It has been reported mainly in intravenous drug abusers (IVDA). We present a case of a 63-year-old male who presented with abdominal pain and fever. Computed tomography (CT) abdomen showed splenic and renal infarct. The blood culture grew Pseudomonas aeruginosa. A transthoracic echocardiogram showed aortic insufficiency with 13 mm mobile vegetation. The patient was started on ceftazidime and tobramycin and, later on, surgery was done for aortic valve replacement. His stay was complicated by multiple hemorrhagic emboli in the brain. This case highlights the importance of the early diagnosis and management of infective endocarditis caused by Pseudomonas aeruginosa.

Barriers to Access to Sterile Syringes as Perceived by Pharmacists and Injecting Drug Users: Implications for Harm Reduction in Lebanon

BACKGROUND

Access to sterile syringes to injecting drug users (IDU) reduces sharing behavior and prevents the transmission of HIV.

OBJECTIVES

To describe the barriers to access to sterile syringes for IDUs in Lebanon from the perspectives of pharmacists and IDUs.

METHODS

in this qualitative study conducted in Lebanon, data were collected from 72 syringe purchase tests at pharmacies, 64 interviewees with pharmacists and 2 focus groups with injecting drug users. Two independent researchers analyzed the verbatim transcripts.

RESULTS

Results revealed that pharmacists often deny access to sterile syringes to IDUs who are frequently stigmatized and intimidated at pharmacies. While no large gender differences in pharmacists' attitudes and practices were observed, inequalities in syringe access were noticed with men IDUs more often denied purchase. Pharmacists had several barriers to sell syringes to IDUs including fear of disease spread, increased drug use, inappropriately discarded syringes, staff and customer safety, and business concerns. IDUs had several challenges to purchase syringes including stigmatization, intimidation, physical harassment, concern to reveal identity, fear of arrest and syringe price abuse.

CONCLUSIONS

Identifying the barriers to and facilitators of access to sterile syringes to IDUs is important to guide the development of efficient policies. Findings implicate the importance of empowering IDUs to purchase syringes at pharmacies through reducing the negative attitude towards IDUs and strengthening pharmacists' role in the promotion of health of IDUs. Findings also suggest that the habit of syringe sharing would decrease if the legal and cultural barriers to access are reduced.

Epidemiology of HIV and hepatitis C infection among women who inject drugs in Northeast India: a respondent-driven sampling study

BACKGROUND AND AIMS

Despite extensive research on HIV and hepatitis C (HCV) among people who inject drugs (PWID), there remains a gap in knowledge on the burden among women who inject drugs and their unique contexts and risk factors. This analysis compares HIV and HCV prevalence in female and male PWID and estimates injection and sexual risk correlates of prevalent HIV and HCV infection among women in Northeast India.

DESIGN

Cross-sectional sample accrued using respondent-driven sampling.

SETTING

Seven cities in Northeast India, 2013.

PARTICIPANTS

A total of 6457 adult PWID.

MEASUREMENTS

Participants completed an interviewer-administered survey. HIV infection was diagnosed on-site and HCV antibody testing was performed on stored specimens. HIV and HCV prevalence estimates were stratified by gender. Among women, the association of risk correlates with HIV and HCV were estimated using multi-level logistic regression models.

FINDINGS

A total of 796 (15.9%) of the PWID were women, of whom 52.9% [95% confidence interval (CI) = 49.3-56.5%] were HIV-infected and 22.3% (CI = 19.9-24.7%) were HCV-infected. HIV and HCV prevalence among men was 17.4% (CI = 16.9-24.7%) and 30.4% (CI = 31.2-32.0%), respectively. Among women, correlates of HIV were widowhood [adjusted odds ratio (aOR) versus currently married = 4.03, CI = 2.13-7.60] and a higher number of life-time sexual partners (aOR ≥8 versus none = 3.08, CI = 1.07-8.86). Correlates of HCV were longer injection duration (aOR per 10 years = 1.70, CI = 1.25-2.27), injecting only heroin and a combination of drugs (aOR versus pharmaceuticals only = 5.63, CI = 1.68-18.9 and aOR = 2.58, CI = 1.60-4.16, respectively), sharing needles/syringes (aOR = 2.46, CI = 1.29-4.56) and a larger PWID network (aOR ≥ 51 versus 1-5 = 4.17, CI = 2.43-7.17).

CONCLUSIONS

Women who inject drugs in Northeast India have a high HIV prevalence, which was more than double their hepatitis C (HCV) prevalence, an opposite pattern than is observed typically among male PWID. HIV infection is associated with sexual risk factors while injection-related behaviors appear to drive HCV infection.

Infective Endocarditis Presenting as Bilateral Orbital Cellulitis: An Unusual Case

Orbital cellulitis is a severe and sight-threatening infection of orbital tissues posterior to the orbital septum. The most common causes of orbital cellulitis are rhinosinusitis, orbital trauma, and surgery. Infective endocarditis (IE) is a systemic infection that begins on cardiac valves and spreads by means of the bloodstream to peripheral organs. Septic emboli can spread to any organ including the eyes and can cause focal or diffuse ophthalmic infection. Ocular complications of IE classically include Roth’s spots, subconjunctival hemorrhages, chorioretinitis, and endophthalmitis. IE as a cause of orbital cellulitis has been described by only one author in the literature. Here, we present a very rare case of bilateral orbital cellulitis caused by IE. Through this case, we aim to create awareness of the potential for serious ocular complications in IE and provide an overview of the management.

Low mortality but increasing incidence of Staphylococcus aureus endocarditis in people who inject drugs: Experience from a Swedish referral hospital

Staphylococcus aureus is a leading cause of infective endocarditis in people who inject drugs (PWID). The management of S aureus endocarditis (SAE) in PWID can be problematic. The objective of this retrospective observational study was to assess the epidemiology, clinical characteristics, and mortality of S aureus endocarditis (SAE) in PWID in Stockholm, Sweden.The Department of Infectious Diseases at the Karolinska University Hospital serves as a regional referral center for drug users with severe infections. Patients with active intravenous drug use treated for SAE at the department between January 2004 and December 2013 were retrospectively identified. Clinical and microbiological data were obtained from medical records and the diagnosis verified according to the modified Duke criteria.In total, 120 SAE episodes related to intravenous drug use were identified. Its incidence in Stockholm was 0.76/100,000 adult person-years for the entire period, increasing from 0.52/100,000 person-years in 2004 to 2008 to 0.99 in 2009 to 2013 (P = 0.02). The SAE incidence among PWID specifically was 249 (range 153-649) /100,000 person-years. Forty-two (35%) episodes were left-sided, and multiple valves were involved in 26 (22%). Cardiac valve surgery was performed in 10 (8%) episodes, all left-sided. The in-hospital and 1-year mortality rates were 2.5% (3 deaths) and 8.0% (9 deaths), respectively.We noted a high and increasing incidence over time of SAE related to intravenous drug use in Stockholm. The increased incidence partly reflects a rising number of PWID during the study period. The low mortality noted, despite a substantial proportion with left-sided endocarditis, probably in part reflects the quality of care obtained at a large and specialized referral center for drug users with severe infections.

Patterns of drug dependence in a Queensland (Australia) sample of Indigenous and non-Indigenous people who inject drugs

INTRODUCTION AND AIMS

Despite over-representation of Indigenous Australians in sentinel studies of injecting drug use, little is known about relevant patterns of drug use and dependence. This study compares drug dependence and possible contributing factors in Indigenous and non-Indigenous Australians who inject drugs.

DESIGN AND METHODS

Respondent-driven sampling was used in major cities and 'peer recruitment' in regional towns of Queensland to obtain a community sample of Indigenous (n = 282) and non-Indigenous (n = 267) injectors. Data are cross sectional. Multinomial models were developed for each group to examine types of dependence on injected drugs (no dependence, methamphetamine-dependent only, opioid-dependent only, dependent on methamphetamine and opioids).

RESULTS

Around one-fifth of Indigenous and non-Indigenous injectors were dependent on both methamphetamine and opioids in the previous 12 months. Psychological distress was associated with dual dependence on these drugs for Indigenous [adjusted relative risk (ARR) 4.86, 95% confidence interval (CI) 2.08-11.34] and non-Indigenous (ARR 4.14, 95% CI 1.59-10.78) participants. Unemployment (ARR 8.98, 95% CI 2.25-35.82) and repeated (> once) incarceration as an adult (ARR 3.78, 95% CI 1.43-9.97) were associated with dual dependence for Indigenous participants only. Indigenous participants had high rates of alcohol dependence, except for those dependent on opioids only.

DISCUSSION AND CONCLUSIONS

The drug dependence patterns of Indigenous and non-Indigenous people who inject drugs were similar, including the proportions dependent on both methamphetamine and opioids. However, for Indigenous injectors, there was a stronger association between drug dependence and contextual factors such as unemployment and incarceration. Expansion of treatment options and community-level programs may be required. [Smirnov A, Kemp R, Ward J, Henderson S, Williams S, Dev A, Najman J M. Patterns of drug dependence in a Queensland (Australia) sample of Indigenous and non-Indigenous people who inject drugs. Drug Alcohol Rev 2016;35:611-619].

Cotton Fever: Does the Patient Know Best?

Fever and leukocytosis have many possible etiologies in injection drug users. We present a case of a 22-year-old woman with fever and leukocytosis that were presumed secondary to cotton fever, a rarely recognized complication of injection drug use, after an extensive workup. Cotton fever is a benign, self-limited febrile syndrome characterized by fevers, leukocytosis, myalgias, nausea and vomiting, occurring in injection drug users who filter their drug suspensions through cotton balls. While this syndrome is commonly recognized amongst the injection drug user population, there is a paucity of data in the medical literature. We review the case presentation and available literature related to cotton fever.

Protective factors associated with short-term cessation of injection drug use among a Canadian cohort of people who inject drugs

INTRODUCTION AND AIMS

Strategies are needed to transition persons who inject drugs out of injecting. We undertook this study to identify protective factors associated with cessation of injection drug use.

DESIGN AND METHODS

Data were derived from three prospective cohorts of people who use illicit drugs in Vancouver, Canada, between September 2005 and November 2011. Generalised estimating equations were used to examine protective factors and 6-month cessation of injection drug use.

RESULTS

Our sample of 1663 people who inject drugs included 563 (33.9%) women, and median age was 40 years. Overall, 904 (54.4%) individuals had at least one 6-month injection cessation event. In multivariable analysis, protective factors associated with cessation of injection drug use included the following: having a regular place to stay [adjusted odds ratio (AOR) = 1.30; 95% confidence interval (CI) 1.13-1.48]; formal employment (AOR = 1.12; 95% CI 1.01-1.23); social support from personal contacts (AOR = 1.22; 95% CI 1.10-1.35); social support from professionals (AOR = 1.26; 95% CI 1.14-1.39); ability to access health and social services (AOR = 1.21; 95% CI 1.09-1.34); and positive self-rated health (AOR = 1.21, 95% CI 1.11-1.32).

DISCUSSION AND CONCLUSIONS

Over half of people who inject drugs in this study reported achieving 6-month cessation of injection drug use, with cessation being associated with a range of modifiable protective factors. Policy makers and practitioners should promote increased access to stable housing, employment, social support and other services to promote cessation of injection drug use. [Luchenski S, Ti L, Hayashi K, Dong H, Wood E, Kerr T. Protective factors associated with short-term cessation of injection drug use among a Canadian cohort of people who inject drugs Drug Alcohol Rev 2016;35:620-627].

Gender differences in access to methadone maintenance therapy in a Canadian setting

INTRODUCTION AND AIMS

Methadone maintenance therapy (MMT) is an evidence-based treatment for opioid addiction. While gender differences in MMT pharmacokinetics, drug use patterns and clinical profiles have been previously described, few studies have compared rates of MMT use among community-recruited samples of persons who inject drugs (PWID).

DESIGN AND METHODS

The present study used prospective cohorts of PWID followed between May 1996 and May 2013 in Vancouver, British Columbia, Canada. We investigated potential factors associated with time to methadone initiation using Cox proportional hazards modelling. Stratified analyses were used to examine for gender differences in rates of MMT enrolment.

RESULTS

Overall, 1848 baseline methadone-naïve PWID were included in the study, among whom 595 (32%) were female. In an adjusted model, male gender was independently associated with increased time to MMT initiation and an overall lower rate of enrolment [adjusted relative hazard = 0.74 (95% confidence interval: 0.65-0.85)]. Among both female and male PWID, Caucasian ethnicity and daily injection heroin use were associated with decreased time to methadone initiation, while in females, pregnancy was also associated with more rapid initiation.

DISCUSSION AND CONCLUSIONS

These data highlight gender differences in methadone use among a population of community-recruited PWID. While factors associated with methadone use were similar between genders, rates of use were lower among male PWID, highlighting the need to consider gender when designing strategies to improve recruitment into MMT. [Bach P, Milloy M-J, Nguyen P, Koehn J, Guillemi S, Kerr T, Wood E. Gender differences in access to methadone maintenance therapy in a Canadian setting. Drug Alcohol Rev 2015;34:503-7].

Type of opioids injected: does it matter? A multicentric cross-sectional study of people who inject drugs

INTRODUCTION AND AIMS

Injecting pharmaceutical opioids for non-medical purposes is a major concern globally. Though pharmaceutical opioids injection is reported in India, the exact proportion of people who inject drugs (PWID) using pharmaceutical opioids is unknown. The objectives of this study were to describe the various types of drugs that are injected by people in India and to analyse the differences between the commonly injected drugs.

DESIGN AND METHODS

A cross-sectional, multicentric study covering 22 harm-reduction sites from different regions of the country was conducted. First 50 subjects, chosen randomly from a list of PWIDs accessing services from each site and fulfilling study criteria, were interviewed using a structured questionnaire. Data from 902 male subjects are presented here.

RESULTS

Pharmaceutical opioid injectors (POI) accounted for 65% of PWIDs (buprenorphine: 30.8%, pentazocine: 21.8% and dextropropoxyphene: 11.9%). Heroin, injected by 34.3%, was prevalent in most states surveyed. Buprenorphine and pentazocine were not injected in the north-east region, whereas dextropropoxyphene was injected in the north-east alone. Univariate and multivariate logistic regression showed that, compared with heroin injectors, the POI group was more likely to consume alcohol and pharmaceutical opioids orally, inject frequently, share needle/syringes and develop injection-site complications. Among individual POIs, buprenorphine injectors had significantly higher proportion of subjects injecting frequently, sharing needle/syringes and developing local complications. Irrespective of the opioid type, majority of subjects were opioid dependent.

DISCUSSION AND CONCLUSIONS

Pharmaceutical opioids are the most common drugs injected in India currently and have greater injection-related risks and complications. Significant differences exist between different pharmaceutical opioids, which would be important considerations for interventions.

Septic arthritis in intravenous drug abusers: a historical comparison of habits and pathogens

BACKGROUND

Intravenous drug abuse (IVDA) is a common problem; there were more than 16 million users worldwide in 2008. Numerous reports highlight the infectious skeletal complication associated with IVDA.

OBJECTIVE

To determine septic arthritis pathogens in IVDA in a U.S. hospital and compare the current causative organisms to a cohort from the 1980s at the same institution.

METHODS

An institutional review board-approved retrospective cohort study compared a consecutive series of IVDA septic arthritis patients over a 10-year period, 1999-2008 (Group B), with an IVDA septic arthritis database that was collected in the 1980s (Group A). Endpoints were: bacterial species and staph species antibiotic susceptibility.

RESULTS

Group B included 58 patients (35 men, 23 women) with a median age of 46.5 years. Group A included 38 patients (30 men, 8 women), with a median age of 32.5 years. The sets were significantly different in pathogens (p = 0.0443). The most common organisms were Staphylococcus (staph) species (B 74.51%, A 52.63%), followed by Streptococcus (strep) species (B 7.84%, A 31.58%), Pseudomonas (B 13.73%, A 13.16%), and Serratia (B 3.92%, A 2.63%). Of the total number of septic joints, methicillin-resistant Staphylococcus aureus (MRSA) made up 39% of Group B and 34% of Group A. However, within the staph species, MRSA made up 53% of Group B and 65% of Group A. Strep species made up 7.84% (Group B) vs. 31.58% (Group A), and Pseudomonas (13%) and Serratia (3-4%) were similar. In the Group B cohort, methicillin-susceptible Staphylococcus aureus (MSSA) had a predilection to infect the knee (94.4%), whereas MRSA was found more often in the hip (57.1%).

CONCLUSIONS

In IVDAs, MRSA is the most common pathogen causing septic arthritis. The ratio of staph species in septic joints is increasing, and the ratio of MRSA to MSSA remains high (>50%). Strep species are much less common.

Family history of alcohol and drug abuse, childhood trauma, and age of first drug injection

BACKGROUND

Childhood maltreatment may lead to development of future substance use; however the contributions of a family history of substance use is unclear.

OBJECTIVES

To better understand the relationship between childhood abuse, family history of alcohol and drug abuse, and injecting drug use initiation in a cohort of chronic opioid users.

METHODS

A cross-sectional survey of long-term and difficult to treat intravenous opiate users of the North American Opiate Medication Initiative (NAOMI) cohort was conducted in two Canadian cities (Vancouver and Montreal). For the analysis, we selected a subsample (n = 87) of the population reported experiencing childhood abuse and completed a 12-month follow up. The sample was 41.4% female and 14.9% First Nations, with a mean age of 38 years. This sample then completed the Childhood Trauma Questionnaire (CTQ) and the Addiction Severity Index (ASI) beside others.

RESULTS

Maternal alcohol and drug use was significantly associated with childhood sexual abuse, emotional abuse, and physical neglect. Paternal alcohol and drug use was significantly associated with childhood physical abuse. Increased severity of all types of childhood trauma was related to an earlier age of first injection. CONCLUSIONS/IMPORTANCE: Family history of drug and alcohol use is strongly associated with childhood trauma, which may, in turn, lead to an earlier initiation to the dangerous routes of drug injection.

Surgical treatment of infective endocarditis in active intravenous drug users: a justified procedure?

BACKGROUND

Infective endocarditis is a life threatening complication of intravenous drug abuse, which continues to be a major burden with inadequately characterised long-term outcomes. We reviewed our institutional experience of surgical treatment of infective endocarditis in active intravenous drug abusers with the aim of identifying the determinants long-term outcome of this distinct subgroup of infective endocarditis patients.

METHODS

A total of 451 patients underwent surgery for infective endocarditis between January 1993 and July 2013 at the University Hospital of Heidelberg. Of these patients, 20 (7 female, mean age 35 ± 7.7 years) underwent surgery for infective endocarditis with a history of active intravenous drug abuse. Mean follow-up was 2504 ± 1842 days.

RESULTS

Staphylococcus aureus was the most common pathogen detected in preoperative blood cultures. Two patients (10%) died before postoperative day 30. Survival at 1, 5 and 10 years was 90%, 85% and 85%, respectively. Freedom from reoperation was 100%. Higher NYHA functional class, higher EuroSCORE II, HIV infection, longer operating time, postoperative fever and higher requirement for red blood cell transfusion were associated with 90-day mortality.

CONCLUSIONS

In active intravenous drug abusers, surgical treatment for infective endocarditis should be performed as extensively as possible and be followed by an aggressive postoperative antibiotic therapy to avoid high mortality. Early surgical intervention is advisable in patients with precipitous cardiac deterioration and under conditions of staphylococcal endocarditis. However, larger studies are necessary to confirm our preliminary results.

Demographic description of the presentation and treatment of lower extremity skin and soft tissue infections secondary to skin popping in intravenous drug abusers

Skin popping refers to the act of subcutaneous injection of intravenous drugs, a practice that often results in the development of cellulitis and the formation of soft tissue abscesses. Although the foot and ankle represent common injection sites, few data have described the presentation and natural history of this pathologic entity. The objective of the present study was to retrospectively assess the descriptive demographic data of a patient cohort admitted for lower extremity skin and soft tissue infection caused by intravenous drug abuse. Fifty skin popping lesions in 49 patients were identified during a 733-day data collection period (August 1, 2010 to August 31, 2012) that had been treated by the in-patient podiatric surgical service for lower extremity infection caused by intravenous drug abuse at an urban, level-one trauma center. With respect to patient race, our hospital has a typical in-patient census of 55% black patients and 25% white patients. The present patient cohort consisted of 12% black patients and 65% white patients. The mean length of stay was 5.71 ± 3.56 days, and 42 patients (85.71%) underwent some form of surgical debridement, with 31 (63.27%) having undergone a formal procedure in the operating room. Six patients (12.24%) left the hospital against medical advice or refused intervention at some definitive point of care, and 36 (73.47%) did not return for scheduled outpatient follow-up visits. Three cases (6%) resulted in minor amputation. The microbiologic culture data and common antibiotic prescriptions used in the diagnosis and treatment, respectively, of these patients have been summarized. We hope these original descriptive data can be used by other physicians treating patients at similar urban practices to improve the care of these sometimes difficult-to-treat patients and better serve this population as a whole.

Peripheral blood RNA expression profiling in illicit methcathinone users reveals effect on immune system

Methcathinone (ephedrone) is relatively easily accessible for abuse. Its users develop an extrapyramidal syndrome and it is not known if this is caused by methcathinone itself, by side-ingredients (manganese), or both. In the present study we aimed to clarify molecular mechanisms underlying this condition. We used microarrays to analyze whole-genome gene expression patterns of peripheral blood from 20 methcathinone users and 20 matched controls. Gene expression profile data were analyzed by Bayesian modeling and functional annotation. Of 28,869 genes on the microarrays, 326 showed statistically significant differential expression with FDR adjusted p-values below 0.05. Quantitative real-time PCR confirmed differential expression for the most of the genes selected for validation. Functional annotation and network analysis indicated activation of a gene network that included immunological disease, cellular movement, and cardiovascular disease functions (enrichment score 42). As HIV and HCV infections were confounding factors, we performed additional stratification of subjects. A similar functional activation of the “immunological disease” category was evident when we compared subjects according to injection status (past versus current users, balanced for HIV and HCV infection). However, this difference was not large therefore the major effect was related to the HIV status of the subjects. Mn–methcathinone abusers have blood RNA expression patterns that mostly reflect their HIV and HCV infections.

Isolated cerebellar mucormycosis, slowly progressive over 1 year in an immunocompetent patient

Background:

Mucormycosis is a rare, aggressive fungal disease with high mortality, typically presenting as rhinosinusitis in immunocompromised patients.

Case Description:

A 43-year-old man with a history of intravenous drug use, Hepatitis C, and no evidence of immunocompromise presented with worsening balance problems. He had received intravenous antibiotics 2.5 years earlier for local infection after injecting heroin into a neck vein. Imaging studies revealed a lesion, likely of neoplastic origin. At resection, purulent fluid sampled by neuropathology revealed right-angled, branching hyphae, suggesting mucormycosis. No further resection was performed, no other disease sites were found, and HIV findings were negative. Two weeks postoperatively, he developed renal failure; intravenous antifungal treatment and hemodialysis were discontinued. When kidney function recovered 2 weeks later, he declined additional treatment.

Conclusion:

In our immunocompetent patient, both the location of the infection in the posterior fossa and its slowly progressive characteristic were unique variations of this typically aggressive disease.

Non-fatal overdose in the 12 months following treatment for substance use disorders

BACKGROUND

Overdose (OD) is a leading cause of mortality and morbidity for individuals with substance use disorders (SUDs), and there are limited prospective data on OD during the months following treatment for SUDs.

METHODS

Variables associated with an OD in the 12 months after leaving an initial treatment episode were examined in an analysis of the Drug Abuse Treatment Outcomes Study (DATOS), a longitudinal naturalistic multisite study. Participants included 2966 patients with one or more SUDs. Non-fatal OD was ascertained by a positive response to "In the past 12 months, have you overdosed on drugs?" Multivariate logistic regression analyses were used to identify variables associated with OD.

RESULTS

By 12 months, 93 (3.1%) participants reported one or more ODs. Variables associated with OD were lifetime history of OD, injection drug use (IDU), male sex, greater pain, and history of sexual abuse.

CONCLUSIONS

OD-risk appears to be increased by IDU, lifetime OD, sexual abuse history, and pain. The latter finding is novel for a prospective report and requires further study.

Femoral artery necrosis due to parenteral intravascular drug misuse: a case report and literature review

Accidental intra-arterial injection as a consequence of drug misuse has been described in both the upper and lower limbs. We present a case in which a drug abuser injected heroin into his femoral artery. This resulted in necrosis of the femoral artery requiring an autologous graft. A life threatening haemorrhage necessitated ligation of the common femoral artery. His limb survived.

Risk factors for hepatitis B in an outbreak of hepatitis B and D among injection drug users

During January-April, 2000, 12 cases of acute hepatitis B were reported in Pierce County, Washington, compared with seven in all of 1999. Seven (58.3%) case patients were injection drug users (IDUs), three of whom were coinfected with hepatitis D virus (HDV) and died of fulminant hepatitis. Vaccination clinics were implemented at the local health department and needle exchange program to control the outbreak. We investigated this outbreak to determine risk factors for hepatitis B virus (HBV) transmission among IDUs. Hepatitis B cases were ascertained through routine surveillance and prevaccination testing at vaccination clinics. We conducted a case-control study comparing IDU case patients with HBV-susceptible IDUs identified at the vaccination clinics. Fifty-eight case patients were identified during January-December, 2000, 20 (34.5%) of whom were coinfected with HDV. Thirty-eight case patients (65.5%) reported current IDU. In the case-control study, the 17 case patients were more likely than the 141 controls to report having more than one sex partner [odds ratio (OR) =4.8, 95% confidence interval (CI) =1.5-15.0], injecting more than four times a day (OR = 4.5, 95% CI =1.2-15.6) and sharing drug cookers with more than two people (58.8% vs. 14.0%, OR =14.0, 95% CI =2.4-81.5). Results were similar after controlling for syringe sharing in multivariable analysis. IDUs should be vaccinated against hepatitis B and should be advised against sharing drug injection equipment.

Impact of a positive hepatitis C diagnosis on homeless injecting drug users: a qualitative study

BACKGROUND

Increasing numbers of injecting drug users are presenting to primary care and a growing number of general practices are specifically providing care for homeless people. Injecting drug users are at the greatest risk of hepatitis C infection and homeless drug misusers, because of their drug-taking behaviour and patterns, have been identified as being at greater risk of harm of blood-borne diseases than the general population. However, little work has been conducted with injecting drug users or homeless people who have hepatitis C and little is known about how the virus may affect them.

AIM

To explore the impact of a positive hepatitis C diagnosis on homeless injecting drug users.

DESIGN OF STUDY

This study employed qualitative research. In-depth interviews allowed the exploration of the impact of a potentially life-threatening diagnosis within the context of a person's expressed hierarchy of needs.

SETTING

A primary care centre for homeless people in the north of England.

METHOD

In-depth interviews about the impact of a positive hepatitis C diagnosis on their lives were conducted with 17 homeless injecting drug users who had received a positive hepatitis C diagnosis. The interviews were audiotaped, transcribed, and analysed using the framework approach.

RESULTS

Receiving a positive diagnosis for hepatitis C resulted in feelings of shock, devastation, disbelief, anger, and questioning. A positive diagnosis had lasting social, emotional, psychological, behavioural, and physical effects on homeless injecting drug users, even years after the initial diagnosis. Most responders were diagnosed by a doctor in primary care or by hospital staff; however, not all had sought testing and a number were tested while inpatients and were unaware that blood had been taken for hepatitis C virus serology.

CONCLUSIONS

The implications for clinical policy and primary care practice are discussed, including the issues of patient choice, confidentiality, and pre- and post-test discussions. Posttest discussions should be followed up with additional social, psychological, and medical support and counselling.

Risk factors for hepatitis C virus infection among blood donors in southern Brazil: a case-control study

BACKGROUND

In Brazil, it is estimated that between 2.5 and 4.9% of the general population present anti-hepatitis C virus (HCV) antibodies, which corresponds to as many as 3.9 to 7.6 million chronic carriers. Chronic liver disease is associated with HCV infection in 20% to 58% of the Brazilian patients. The objective of this case-control study was to investigate the risk factors for presence of anti-HCV antibody in blood donors in southern Brazil.

METHODS

One hundred and seventy eight blood donors with two positive ELISA results for anti-HCV were cases, and 356 controls tested negative. A standardized questionnaire was used to collect data concerning demographic and socioeconomic aspects, history of previous hepatitis infection, social and sexual behaviors, and number of donations. Variables were grouped into sets of hierarchical categories. Cases and controls were compared using logistic regression, odds ratios, and 95% confidence intervals. The statistical significance of the associations was assessed through likelihood ratio tests based on a P value < 0.05.

RESULTS

The prevalence of anti-HCV among blood donors was 1.1%. Most of the donors were white and males. In the multivariate analysis, independent predictors of anti-HCV positivity were: intravenous drug use, blood transfusion >10 years earlier, having had two to four sexually transmitted diseases, incarceration, tattooing, sex with a hepatitis B or C virus carrier or with intravenous drug users.

CONCLUSION

Intravenous drug use, blood transfusion, and tattooing were the main risk factors for anti-HCV positivity among blood donors from southern Brazil, but sexual HCV transmission should also be considered.

Detection of HTLV-II-seropositive blood donors in South Vietnam but not in North Vietnam

Approximately 1% (4/500) of blood donors exhibited seropositivity for HTLV-II in South Vietnam, but none (0/500) did in North Vietnam. Further, all individuals seropositive for HTLV-II were intravenous drug abusers who were seronegative for HIV-1 and HTLV-I. These findings suggest that HTLV-II infection may be specifically prevalent in drug abusers in South Vietnam.