Suboptimal uptake, retention, and adherence of daily oral PrEP among people with OUD receiving HCV treatment

Background

Daily oral preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) prevents human immunodeficiency (HIV) among people who inject drugs (PWID). Despite rising HIV incidence and injection drug use (IDU), PrEP use remains low and there is limited research about uptake, adherence, and retention among PWID.

Methods

The ANCHOR investigation evaluated a community-based care model collocating hepatitis C virus (HCV) treatment, medication for opioid use disorder (OUD), and PrEP in individuals in Washington, DC, and Baltimore, Maryland. PrEP counseling was conducted from HCV treatment day 0 until week 24. Subjects could start any time during this window, were followed for 48 weeks, and were assessed for adherence by self-report and dried blood spot TDF analysis.

Results

One hundred ninety-eight participants were enrolled, of whom 185 (93%) were HIV negative. Twenty-nine individuals (15.7% of HIV-negative cohort) initiated PrEP. One hundred sixteen participants (62.7%) met 2014 Centers for Disease Control and Prevention (CDC) PrEP criteria due to IDU (82 [44.3%]), sex (9 [4.9%]), or both practices (25 [13.5%]). Providers recommended PrEP to 94 individuals (50.8%), and recommendation was associated with PrEP uptake. Median treatment duration was 104 days (interquartile range, 28–276 days), with 8 participants retained through week 48. Adherence was variable over time by self-report and declined by TDF analysis. No HIV seroconversions occurred.

Conclusions

This cohort of people with HCV and OUD experienced low uptake of PrEP despite the majority meeting CDC criteria. High rates of disruption and discontinuation, compounded by variable adherence, made TDF/FTC a suboptimal prevention strategy. Emerging modalities like long-acting formulations may address these barriers, but PWID have been excluded from their development to date.

Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study

OBJECTIVES

The aim of this study was to examine a large cohort of adults who received the zoster vaccine for evidence of an increased risk of prespecified adverse events requiring medical attention.

DESIGN

Two self-comparison approaches, including a case-centred approach and a self-controlled case series (SCCS) analysis were used.

SETTING

Eight managed-care organizations participating in the Vaccine Safety Datalink project in the United States.

SUBJECTS

A total of 193 083 adults aged 50 and older receiving a zoster vaccine from 1 January 2007 to 31 December 2008 were included.

MAIN OUTCOME MEASURES

Prespecified adverse events were identified by aggregated International Classification of Diseases, Ninth Revision (ICD-9) codes in automated health plan datasets.

RESULTS

The risk of allergic reaction was significantly increased within 1-7 days of vaccination [relative risk = 2.13, 95% confidence interval (CI): 1.87-2.40 by case-centred method and relative rate = 2.32, 95% CI: 1.85-2.91 by SCCS]. No increased risk was found for the following adverse event groupings: cerebrovascular events; cardiovascular events; meningitis; encephalitis; and encephalopathy; and Ramsay-Hunt syndrome and Bell's palsy.

CONCLUSIONS

The results of this study support the findings from the prelicensure clinical trials, providing reassurance that the zoster vaccine is generally safe and well-tolerated with a small increased risk of allergic reactions in 1-7 days after vaccination.

Reason for medical hospitalization among adult alcohol and drug abusers

This study attempts to identify the associations between types of substance use and particular medical problems as causes of acute hospital admission on an inpatient substance abuse consultation service. Records of all consultations performed from 1994 to 1998 were analyzed. A total of 4,526 complete records were available. Cocaine (p < .01), heroin (p < .001), and injection drug (p < .001) users were more likely to be admitted to the hospital for infection. Both alcohol (p < .001) and marijuana (p < .001) users were more likely to be hospitalized for trauma related injuries. Individuals that used alcohol were also more likely to be admitted for the treatment of gastrointestinal disorders (p < .001). Clinicians who treat patients with these diagnoses should have a high index of suspicion of co-morbid substance use disorders. Effective treatment of substance use disorders can lead to a decrease in medical morbidity, improved outcomes for individual patients, and decreased costs for the health care system.

A case of monosymptomatic hypochondriacal psychosis treated with olanzapine

OBJECTIVE

To emphasize the availability of safer alternatives to currently standard therapy for monosymptomatic hypochondriacal psychosis (MHP).

METHOD

We report a case of treatment of monosymptomatic hypochondriacal psychosis in an elderly woman with the atypical neuroleptic olanzapine.

RESULTS

Treatment with rather low doses of olanzapine led to complete resolution of delusional symptoms.

CONCLUSIONS

Olanzapine, like other atypical neuroleptic agents, shows promise as a treatment for this syndrome, and it offers considerable safety and side-effect advantages over older agents.

Catastrophic medical complication in psychogenic excoriation

Compulsive skin picking generally has limited potential health consequences. We describe a case with severe neurologic sequelae and review the literature to assess factors that likely contributed to the failure to prevent this severe outcome. Despite efforts to integrate treatment, our patient had severe medical complications, an epidural abscess and subsequent paralysis, as a result of compulsive skin picking. Psychogenic excoriation should not be underestimated as a cause of medical complications or as a treatment challenge, particularly in light of the numerous complicating factors often present in such cases.

Medical complications due to mothball abuse

Inhalant abuse is a major public health problem that has been associated with numerous acute and chronic medical problems. Inhalants are defined as volatile organic substances and are found in common household and commercial products that are easily accessible, inexpensive, and legally obtained. We discuss a rare case of mothball abuse predominantly by inhalation. The patient had acute peripheral neuropathy and chronic renal failure, both of which were concluded to be casually related to mothball abuse. We briefly review the abuse potential and medical complications of naphthalene and paradichlorobenzene, the compounds in mothballs. Our case illustrates that common household products not usually identified as recreational drugs can be abused; furthermore, linking specific medical problems with particular inhalants can be difficult because of confounding variables.

Engaging hospitalized heroin-dependent patients into substance abuse treatment

The purpose of this study was to evaluate a 6-month outpatient program developed to improve abstinence and other health and social problems of heroin-addicted persons hospitalized in an urban academic medical center's medical or surgical unit and referred from the Substance Abuse Consult Service. Treatment intervention consisted of methadone therapy, daily group therapy, individual case management, medical and psychiatric consultation, and social services. The first 67 patients referred were followed for 6 months. Outcome measures were retention in treatment, urine drug screens, and health and social indicators. Patients averaged 19 weeks in treatment, with 52% of patients completing the 6-month program. Urine toxicology screens showed a reduction of illicit drug use. Patients improved deficits in health and social indicators by obtaining medical coverage, keeping outpatient medical appointments, and improving their housing conditions. Findings suggest that this combination of intensive psychosocial treatment with opioid substitution following an acute illness substantially impacts treatment outcomes. Implications for service delivery and health-care economics are discussed.

Recruitment into psychiatry: increasing the pool of applicants

OBJECTIVE

To demonstrate that it is possible to identify the cohort of students in their first year of medical school from which future psychiatrists will be recruited.

METHOD

During a 3-year period, all first-year medical students at the University of Maryland completed a form indicating their specialty preference. Of those students, 403 pursued the regular psychiatry curriculum, and 34 participated in an enriched behavioural science and psychiatry program. Specialty was chosen after graduation.

RESULTS

The higher the first-year student ranked psychiatry as a preferred specialty, the more likely the student was to choose psychiatry as a career after graduation. This was true both for students in the regular psychiatry program and for those in the enriched program. Students in the enriched program were significantly more likely to choose psychiatry as a career than were "regular" psychiatry students who gave psychiatry the same ranking in their first year. Freshman students who ranked psychiatry 4th or lower were not likely to choose psychiatry, no matter how much encouragement they received from their psychiatry departments.

CONCLUSIONS

1) Specialty preferences in the freshman year are predictive of future career choices. 2) An enriched medical school program in psychiatry can increase the number of graduates choosing careers in psychiatry. To help resource-poor medical schools increase the number of American medical graduates choosing psychiatry, the authors propose 2 inexpensive enriched programs.

A substance abuse consultation service. Enhancing the care of hospitalized substance abusers and providing training in addiction psychiatry

The authors review the literature on the high prevalence but underrecognition of substance abuse among hospitalized patients and the general unavailability of hospital-based substance abuse consultation services. They describe the development, clinical operations, staffing, and teaching activities of a large substance abuse consultation service in one urban academic medical center and detail the service's growth and changing utilization patterns over an 8-year period, reporting the clinical characteristics of 1,819 patients seen over a 1-year period. Differences in patient demographics, patterns of substance use, and diagnoses were highly significant from one referring service to another. The authors discuss the implications of such a service for patient care and teaching.

Medical school electives and recruitment into psychiatry : a 20-year experience

Part of psychiatry's recruitment problem is a result of defections among students who were planning careers in psychiatry when they entered medical school. The authors present data from a 20-year (1974-1993) experience at the University of Maryland that shows that students who expressed a preference for psychiatry as a career in the freshman year were four times more likely to enter psychiatric residency training after graduation if they participated in the Combined Accelerated Program in Psychiatry (CAPP), a 4-year psychiatric elective program, than if they pursued the regular undergraduate psychiatric program. More than 20% of the CAPP students who preferred nonpsychiatric careers as freshmen were "converted" to psychiatry and later entered psychiatric residency programs. Recent changes in the ideology and economics of our profession have neither lessened the popularity of the CAPP nor diminished its apparent ability to shelter students preferring psychiatry from the stigmatizing experiences of medical school.

Ineffectiveness of aprotinin on psoralen-UVA-(PUVA)-induced erythema

Because bradykinin constitutes a possible candidate for mediation of topical 8-methoxypsoralen-UVA-(PUVA)-induced erythema, aprotinin (Trasylol), inhibitor of kallikrein and interrupter of the cascade leading to kinin production was assessed in guinea pigs. Response was assessed at 24, 48, and 72 hr after topical PUVA and there was no significant difference between normal saline and aprotinin by intradermal or intraperitoneal routes of administration. The results of this study indicate that intradermal and intraperiotoneal aprotinin, in the dose and method tested, is not capable of significantly decreasing erythema induced by topical PUVA in guinea pigs.