Impact of COVID-19 & Response Measures on HIV-HCV Prevention Services and Social Determinants in People Who Inject Drugs in 13 Sites with Recent HIV Outbreaks in Europe, North America and Israel

HIV/HCV prevention among people who inject drugs (PWID) is of key public health importance. We aimed to assess the impact of COVID-19 and associated response measures on HIV/HCV prevention services and socio-economic status of PWID in high-HIV-risk sites. Sites with recent (2011-2019) HIV outbreaks among PWID in Europe North America and Israel, that had been previously identified, were contacted early May 2020. Out of 17 sites invited to participate, 13 accepted. Semi-structured qualitative site reports were prepared covering data from March to May 2020, analyzed/coded and confirmed with a structured questionnaire, in which all sites explicitly responded to all 103 issues reported in the qualitative reports. Opioid maintenance treatment, needle/syringe programs and antiretroviral treatment /hepatitis C treatment continued, but with important reductions and operational changes. Increases in overdoses, widespread difficulties with food and hygiene needs, disruptions in drug supply, and increased homelessness were reported. Service programs rapidly reformed long established, and politically entrenched, restrictive service delivery policies. Future epidemic control measures should include mitigation of negative side-effects on service provision and socio-economic determinants in PWID.

Predicting Antarctic Net Snow Accumulation at the Kilometer Scale and Its Impact on Observed Height Changes

Sub-grid-scale processes occurring at or near the surface of an ice sheet have a potentially large impact on local and integrated net accumulation of snow via redistribution and sublimation. Given observational complexity, they are either ignored or parameterized over large-length scales. Here, we train random forest (RF) models to predict variability in net accumulation over the Antarctic Ice Sheet using atmospheric variables and topographic characteristics as predictors at 1 km resolution. Observations of net snow accumulation from both in situ and airborne radar data provide the input observable targets needed to train the RF models. We find that local net accumulation deviates by as much as 172% of the atmospheric model mean. The correlation in space between the predicted net accumulation variability and satellite-derived surface-height change indicates that surface processes operate differently through time, driven largely by the seasonal anomalies in snow accumulation.

Decreasing surface albedo signifies a growing importance of clouds for Greenland Ice Sheet meltwater production

Clouds regulate the Greenland Ice Sheet’s surface energy balance through the competing effects of shortwave radiation shading and longwave radiation trapping. However, the relative importance of these effects within Greenland’s narrow ablation zone, where nearly all meltwater runoff is produced, remains poorly quantified. Here we use machine learning to merge MODIS, CloudSat, and CALIPSO satellite observations to produce a high-resolution cloud radiative effect product. For the period 2003–2020, we find that a 1% change in cloudiness has little effect (±0.16 W m⁻²) on summer net radiative fluxes in the ablation zone because the warming and cooling effects of clouds compensate. However, by 2100 (SSP5-8.5 scenario), radiative fluxes in the ablation zone will become more than twice as sensitive (±0.39 W m⁻²) to changes in cloudiness due to reduced surface albedo. Accurate representation of clouds will therefore become increasingly important for forecasting the Greenland Ice Sheet’s contribution to global sea-level rise.

Here the authors use remote sensing observations and machine learning to show that clouds will become increasingly important for determining the Greenland Ice Sheet’s contribution to global sea levels due to decreasing albedo in the ablation zone.

Chemsex, G&T, and The Club Drugs Clinic Ireland

Introduction

Chemsex refers to the intentional consumption of specific substances, Gamma Hydroxybutyrate/Gamma Butyrolactone (GHB/GBL), Crystal Methamphetamine and/or Cocaine to facilitate or enhance the sexual experience. However, there was a plethora of associated problems ranging in severity to complex, life-threatening situations. Since its inception in 2014, The Club Drugs Clinic Ireland, the first outpatient-based clinic for GHB/GBL Detoxification in Ireland, had evolved to include managing problematic chemsex.

Objectives

The Chemsex Working Group Ireland is a collaborative response from governmental and non-governmental agencies. Details of current medical and psychiatric management along with preliminary outcome findings on detoxification, relapse risk and associated factors will be presented.

Methods

Data collected include socio-demographic variables, gender and sexuality, detoxification setting, relapse history and attendance for counselling or aftercare. Descriptive analyses were conducted on referral counts, drug trends, success of first treatment episode, subsequent relapse rate, and uptake of counselling and aftercare.

Results

There have been over 200 referrals to the Club Drugs Clinic Ireland. A number of predisposing and precipitating factors, contributed to the relapse rate (up to 70%) both in Ireland and internationally. The salutogenic, biopsychosocial-based model of addiction recovery produced the best outcomes. This integrated Dual Diagnosis Psychiatry, Sexual Health Medicine, Emergency Medicine and external services for a more comprehensive care.

Conclusions

The pattern of referrals reflects population trends in chemsex, despite the COVID-19 restrictions. While detoxification is largely successful, the high relapse rate highlights the challenge of maintaining abstinence. In order to competently address problematic chemsex, service coordination across various medical professions and ongoing monitoring of the substances consumed is quintessential.

Disclosure

No significant relationships.

Evaluation of the cognitive benefits of intrathecal baclofen pump implantation in people with intractable multiple sclerosis related spasticity

BACKGROUND

Spasticity is a common problematic symptom in Multiple Sclerosis with over one third of patients failing first line therapies. Intrathecal baclofen is a safe and efficacious option for treatment resistant spasticity. Anecdotally patients report improved concentration/cognitive performance when switching to intrathecal baclofen (ITB) from systemic medications.

AIM

To explore whether subjects who proceed with ITB pump implantation for spasticity management and reduce oral anti-spasticity agents will have improved cognitive function.

METHODS

Subjects were admitted for trial of ITB via lumbar puncture and subsequent pump implantation. Spasticity and cognitive measures before ITB trial and 3 months post implant were recorded. Paired t-test or Wilcoxon Signed Ranks test was used for within subject change and effect sizes (Cohen's d_z) were calculated. Subgroup analysis of those on ≥2, or ≤ 1 spasticity medications at baseline was performed.

RESULTS

27 subjects with MS completed per protocol. Mean age 46 years [26 - 56], disease duration 15 years [6 - 26], RRMS = 3, SPMS = 17 and PPMS=7. The majority were on multiple spasticity medications. Spasticity scores significantly improved post pump implant. Mean ITB dose at 3 months was 143 mcg / day and 19 discontinued all other treatments for spasticity. There was no deterioration on any cognitive or mood measure. An improvement of moderate effect size was found in Backwards Digit Span (d=0.41, p=0.059) and HADS - anxiety (d=0.37, p=0.097). Fatigue Severity Scale score decreased substantially (d=0.81, p=0.005). Small improvements in Symbol Digit Modalities Test score (d=0.24) and Sustained Attention to Response Task response time (d=0.23) were non-significant. Performance on other measures did not change. Effect sizes were larger in subgroup on ≥2 oral spasticity medications at baseline, compared to the group on ≤1 medication (SDMT, d=0.42 vs d=0.07; Backwards digit span 0.45 vs 0.28; HADS-anxiety 0.39 vs 0.32; HADS-depression d=0.32 vs 0.05 and FSS, d= 1.14 vs 0.42).

CONCLUSIONS

In a pilot study exploring the impact of ITB on cognition, spasticity scores improved universally and beneficial effects on some measures of fatigue, anxiety, auditory attention and verbal working memory were found. Improvement of speed of processing in those withdrawing higher doses of oral medication was also demonstrated suggesting that switching to ITB has added cognitive and psychological benefits for people with MS.

Observations of Buried Lake Drainage on the Antarctic Ice Sheet

Between 1992 and 2017, the Antarctic Ice Sheet (AIS) lost ice equivalent to 7.6 ± 3.9 mm of sea level rise. AIS mass loss is mitigated by ice shelves that provide a buttress by regulating ice flow from tributary glaciers. However, ice-shelf stability is threatened by meltwater ponding, which may initiate, or reactivate preexisting, fractures, currently poorly understood processes. Here, through ground penetrating radar (GPR) analysis over a buried lake in the grounding zone of an East Antarctic ice shelf, we present the first field observations of a lake drainage event in Antarctica via vertical fractures. Concurrent with the lake drainage event, we observe a decrease in surface elevation and an increase in Sentinel-1 backscatter. Finally, we suggest that fractures that are initiated or reactivated by lake drainage events in a grounding zone will propagate with ice flow onto the ice shelf itself, where they may have implications for its stability.

WP1-12 Reducing infection rates in an intrathecal baclofen service; closing the audit cycle

Objectives

Intrathecal baclofen (ITB) is a recognised treatment strategy for the management of spasticity. We have 30 years of experience, and 160 patients currently receiving treatment.

Design

An audit (Jan 13 – Jul 15) demonstrated complication rates of 4.4% (infection) and 4.92% (catheter). After this we recommended 1 vancomycin wash of the pump pocket, 2 occlusive dressing of pressure sores, 3 timely MRSA pre-screening, and this was introduced June-August 2016. We present a re-audit of the service.

Subjects

All patients admitted for ITB pump surgery between June 2016 and June 2018.

Methods

The database of patients was used, from which the patient notes were reviewed with information relating to each surgical procedure recorded.

Results

There were 92 surgical procedures and 78 patients (M 30, F 48). 12 patients had complications, requiring 18 surgical procedures. Out of 18 surgical procedures, 10 were catheter- and 7 pump-related). Our infection rate was lower at 1% of all surgeries (compared with 4.4%), or 0.6% of all ITB pump patients per year (compared with 3.4%), and our catheter complication rate was 6.25% of all patients per year. Our annual incidence rate of all complications was 5.6% in both groups.

Conclusions

The infection risk is lower and complication rate remains stable. We will discuss factors which may influence the risk of complication, and consider recommendations for the future.

Diagnosis of MS: a comparison of three different clinical settings

In order to compare a newly established diagnostic clinic with two existing clinical settings in the management of the diagnostic phase of multiple sclerosis (MS), a retrospective audit was performed over a 12-month period comparing the length of time, adherence to recently published standards and price charged in diagnosing MS in three different clinical diagnostic settings operating within the same hospital: a specifically designed demyelinating disease diagnostic clinic (DDC), a general neurology clinic (GNC) and an inpatient investigation unit (IIU). A n audit tool was created to measure the standards advocated by the UK MS Society on management of the diagnostic phase of MS. The costing tool was the price charged to health authorities. A randomized retrospective case note and referral letter review method was used. The entry criterion was a confirmed diagnosis of MS documented in the medical notes following investigation during the period A pril 1999-A pril 2001. The time between referral and first appointment favoured the DDC with a mean time of 5.9 weeks, compared to 7.7 weeks for the G NC and 10.0 weeks for the IIU. The mean times between the first appointment and receipt of results were 4.7 weeks (DDC), 18.8 weeks (GNC) and 21.2 weeks (IIU). Prices ranged from £395-£790 (DDC), £95-£380 (GNC) and £1940-£2700 (IIU). This study suggests that the UK MS Society standards are achievable in most areas without excessive additional costs and provides evidence that the DDC offers a better service than other existing models.

Effect of integrating HIV and addiction care for non-engaging HIV-infected opiate-dependent patients

BACKGROUND

HIV-positive substance dependent patients contribute disproportionally to HIV morbidity and mortality as a result of poor compliance with their HIV treatment. For HIV-positive opiate-dependent patients integrating HIV and addiction care improves HIV morbidity but the effect on addiction morbidity is not known.

AIMS

This study aims to establish if integrating HIV and addiction care has a significant effect on addiction and HIV morbidity for non-engaging HIV-positive opiate-dependent patients.

METHODS

Patients attending the National Drug Treatment Centre who had disengaged from their HIV treatment in St James's Hospital were recruited to receive HIV care integrated into their methadone maintenance programme. Outcome was investigated in terms of urine toxicology (opiates, cocaine, cannabis and amphetamines); adherence to methadone; proportion receiving directly observed antiretroviral therapy; proportion HIV virally suppressed; and the CD4 cell count.

RESULTS

No significant change in substance use or methadone adherence was demonstrated in the 19 recruited participants. There was a significant increase in the proportion receiving directly observed antiretroviral therapy, and in the CD4 cell count.

CONCLUSION

Integration of HIV and addiction care optimises the physical health of non-engaging HIV-positive opiate-dependent patients with no substantial effect on their methadone maintenance programme.

Use of the Alcohol Use Disorders Identification Test (AUDIT) to determine the prevalence of alcohol misuse among HIV-infected individuals

The aim of the paper is to evaluate alcohol misuse among an inner city adult HIV clinic population with AUDIT (Alcohol Use Disorders Identification Test). A cross-sectional HIV outpatient clinic analysis between 28 February 2011 and 11 March 2011 was carried out. AUDIT, demographic and clinical data were collected. Univariate analysis was performed to look for the associations between variables. Backward stepwise multivariate analyses were performed on significant variables from the univariate analysis to assess for predictors of alcohol dependence. In total, 111 patients were included (60% uptake of clinic attendees); 66% were men and 26% were hepatitis C virus (HCV) co-infected. The median AUDIT score was 5 (within normal range). Thirty-four 'AUDIT positive' cases were identified: five (4.5%) indicated consumption of hazardous levels of alcohol; 21 (19%) indicated harmful levels of alcohol; and eight (7%) were likely alcohol dependent. Younger age (<40 years old) was significantly associated with AUDIT positivity (P = 0.006). On multivariate analysis younger age (P = 0.045, odds ratio 13.8) and lower level of education (P = 0.006, odds ratio 6.7) were predictive of scores indicative of alcohol dependence (AUDIT ≥20). In conclusion, younger age and lower educational levels were associated with scores consistent with alcohol dependence. AUDIT was well tolerated and easy to administer in this outpatient HIV clinic population.

P5-13-19: Borderline Estrogen and Progesterone Receptor Expression and Efficacy of Anti-Estrogen Therapy Analyzed by Subpopulation Treatment Effect Pattern Plot Analysis

Background: The American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP) recently recommended that estrogen receptor (ER) and progesterone receptor (PR) values be considered positive in the evaluation of breast cancer specimens if there are at least 1% positive tumor nuclei by immunohistochemisty (IHC) scoring. This change constitutes a lower cutoff value than the 5% or 10% widely used in the past and increases the number of patients that can now be treated with anti-estrogen therapy, a therapy which carries significant treatment efficacy and a favorable toxicity profile. Despite the new recommendation however, it remains unclear if patients whose tumors display borderline ER and/or PR expression truly benefit from anti-estrogen therapy.

Methods: We examined a total of 608 patient samples from the OHSU Knight Cancer Institute Breast Cancer Tissue Repository for which we have quantitative ER and PR information and their clinical outcome. Of those, 282 patients did not receive any systemic treatment and 165 received anti-estrogen therapy (the majority tamoxifen). Cytosolic steroid hormone receptors were quantitated by conventional steroid binding assay and Scatchard plot analysis or by enzyme-linked immunoassay system. For immunoassays, human estrogen receptor (ER) and progesterone receptor (PR) kits were obtained from Abbott Laboratories and assays were conducted according to manufacturer's specification. We performed subpopulation treatment effect pattern plot (STEPP) analysis to explore the presence of interaction between treatment effects and quantitative ER and PR levels. Clinical outcome used in this study includes 5-year overall survival and 5-year breast cancer free interval.

Results: Multi-variate analysis finds neither ER nor PR expression adjusted by treatment status is associated with either overall survival (P= 0.20, median follow up of 63 months) or breast cancer free interval (P= 0.82, median follow up of 60 months). For both ER and PR, there is no interaction between treatment outcome (5 year survival probability) and levels of hormone receptor expression based on Kaplan-Meier estimate (P=0.36 and P= 0.65, respectively). Patients with borderline ER expression appear to benefit from anti-estrogen therapy while patients with borderline PR expression appear to have worse outcome with anti-estrogen therapy.

Conclusions: Though descriptive in nature, our STEPP analysis provides support for the recommendation by ASCO and CAP to lower the cutoff for ER positivity in breast cancer specimens. There is overall no interaction between the level of hormone receptor and treatment benefit for all patients from low ER to high ER. Therefore, treatment will benefit all patients including those with low ER levels. Extending hormone therapies to the group of patients whose tumors express borderline PR values, however does not seem to confer therapeutic benefit. More study is needed to determine the benefits of offering anti-estrogen therapy to patients whose tumors express low PR.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-19.

Abstract P4-08-03: False Positive HER-2 Testing by Fluorescence In Situ Hybridization in Human Breast Cancer

Background: Testing for human epidermal growth factor receptor-2 (HER-2) is routinely performed after breast cancer diagnosis by either immunohistochemistry (IHC) or fluorescence in situ hybridization (FISH). FISH is more accurate and reproducible, often considered the gold standard, and a more reliable predictor of a patient's response to HER-2 directed therapies in clinical practice. The growth factor receptor-bound protein-7 gene (GRB7) encodes a multi-domain signal transduction molecule located in close proximity to HER-2 on chromo some 17q11-12 and has been shown to be an independent adverse prognostic marker in breast cancer. Methods: We performed western blotting analysis of protein extracts from 563 annotated frozen breast tumors, collected from 1988 - 1998. GRB7 and HER-2 bands were assigned low or high values compared to specific protein controls, and tubulin bands. HER-2 FISH was performed on a subset of these tumors using an FDA approved Path Vysion kit on 4 μm frozen sections. HER-2 and chromosome 17 centromere (CEP17) signals were enumerated according to ASCO/CAP guidelines. Results: Sixty-six tumors (11.5%) over-expressed HER-2 and GRB7 proteins by Western analysis, 66 (11.5%) over-expressed HER-2 but not GRB7, and 30 (5.5%) over-expressed GRB7 but not HER-2. All 32 tumors (32/32) submitted to FISH analysis that over-expressed both HER-2 and GRB7 proteins demonstrated HER-2 gene amplification, while only one out of thirty-five (1/35) tumors that over-expressed HER-2 without GRB7 protein over-expression were HER-2 amplified. Interestingly, 7 of 28 tumors over-expressing GRB7 but not HER-2 protein were amplified for the HER-2 gene. Clinical laboratory HER-2 IHC testing confirmed the absence of HER-2 protein over-expression in all 7 of these tumors. Conclusions: Our study demonstrates that about ten percent of human breast cancers that test positive with FISH for HER-2 gene amplification do not over-express HER-2 protein, which may influence sensitivity to HER-2 directed therapy. All tumors that show false positive HER-2 gene amplification over-express GRB7 protein, suggesting the presence of GRB7 driven gene amplification in these tumors. Given that the HER-2 FISH probe contains GRB7 sequences, it is possible that HER-2 FISH false positivity may reflect GRB7 gene amplification.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-08-03.

Lapse and relapse following inpatient treatment of opiate dependence

We conducted a prospective follow-up study of consecutive opiate dependent patients admitted to a residential addiction treatment service for detoxification. We measured the rate of relapse following discharge, and sought to identify factors that were associated with early relapse (i.e., a return to daily opiate use). Follow-up interviews were conducted with 109 patients, of whom, 99 (91%) reported a relapse. The initial relapse occurred within one week in 64 (59%) cases. Multivariate survival analysis revealed that earlier relapse was significantly predicted by younger age, greater heroin use prior to treatment, history of injecting, and a failure to enter aftercare. Unexpectedly, those who were in a relationship with an opiate user had significantly delayed relapse. Those who completed the entire six-week inpatient treatment programme also had a significantly delayed relapse. In order to reduce relapse and the associated increased risk of fatal overdose, services providing residential opiate detoxification should prepare people for admission, strive to retain them in treatment for the full admission period and actively support their entry into planned aftercare in order to improve outcome.

HIV infection among heroin users and area of residence

The aim of this study was to develop a hypothesis to explain the link between HIV prevalence and area of residence. The study was conducted in two parts using two existing data sources. In Part 1, the bloodborne viral test status and test results of a sample of clients attending treatment in December 2001 in two areas of Dublin, an inner city area (Dublin 8) and a suburban area (Dublin 24), were extracted from the Bloodborne Viral Status Dataset created by Grogan. In Part 2 the characteristics of heroin users seeking treatment for the first time at treatment services in their respective areas of residence, Dublin 8 or Dublin 24, between 1997 and 2000 were examined, using data from the National Drug Treatment Reporting System. A higher proportion of heroin users in Dublin 8 had HIV and hepatitis C than did their counterparts in Dublin 24. The analysis suggests that heroin users in Dublin 8 were more likely both to have ever used cocaine and to have used heroin daily, than were those who lived in Dublin 24. Also, a higher proportion of injectors living in Dublin 8 used heroin and cocaine concurrently than did their counterparts in Dublin 24. In both samples, heroin users who lived in Dublin 8 were older than those who lived in Dublin 24. The findings led to a hypothesis:'The risk of acquiring HIV is associated with area of residence and may be linked to cocaine use.

Epidemiological findings and medical, legal, and public health challenges of an investigation of severe soft tissue infections and deaths among injecting drug users -- Ireland, 2000

In May 2000, public health authorities in Dublin, Ireland, identified a cluster of unexplained severe illness among injecting drug users (IDUs). Similar clusters were also reported in Scotland and England. Concurrent investigations were undertaken to identify the aetiology and source of the illnesses. In Dublin, 22 IDUs were identified with injection-site inflammation resulting in hospitalization or death; eight (36%) died. Common clinical findings among patients with severe systemic symptoms included leukaemoid reaction and cardiogenic shock. Seventeen (77%) patients reported injecting heroin intramuscularly in the 2 weeks before illness. Of 11 patients with adequate specimens available for testing, two (18%) were positive by 16S rDNA PCR for Clostridium novyi. Clinical and laboratory findings suggested that histotoxic Clostridia caused a subset of infections in these related clusters. Empiric treatment for infections among IDUs was optimized for anaerobic organisms, and outreach led to increased enrolment in methadone treatment in Dublin. Many unique legal, medical, and public health challenges were encountered during the investigation of this outbreak.

Bloodborne virus infections among drug users in Ireland: a retrospective cross-sectional survey of screening, prevalence, incidence and hepatitis B immunisation uptake

BACKGROUND

Injecting drug users are at high-risk of bloodborne virus infections including hepatitis C (HCV), hepatitis B (HBV) and HIV.

AIMS

To document screening for and immunisation against bloodborne viruses and to determine the known prevalence and incidence of these infections.

METHODS

A cross-sectional survey of clients attending 21 specialist addiction treatment clinics in one health board area in greater Dublin. Data collected on demographic characteristics, serology for HCV, HBV and HIV and immunisation against HBV.

RESULTS

A total of 316 (88%) had been tested for anti-HCV antibody, 244 (68%) had been tested for anti hepatitis B core antibody (anti-HBc), 299 (84%) had been tested for hepatitis B surface antigen (HBsAg) and 307 (86%) had been tested for anti-HIV antibody. The prevalence of anti-HCV, anti-HBc, HBsAg, and anti-HIV were: 66%, 17%, 2% and 11% respectively. The incidence of HCV, HBV and HIV infections were: 24.5, 9.0 and 3.4 per hundred person years respectively. Eighty-one per cent of those in whom it was indicated, had started a targeted HBV immunisation programme in the clinics.

CONCLUSION

The proportion of clients screened for HCV, HBV and HIV infection has increased since the introduction of a screening protocol in 1998. Targeted vaccination for opiate users against hepatitis B is more successful than previously shown in Ireland. The prevalence and incidence of bloodborne viruses remains high among opiate users attending addiction treatment services, despite an increase in availability of harm reduction interventions.

Hepatitis C viral clearance in an intravenous drug-using cohort in the Dublin area

BACKGROUND

The rate of spontaneous HCV viral clearance is reported as 20-25% but recent data indicate a higher frequency in some cohorts. The rate of spontaneous clearance in intravenous drug users has not been reported in an Irish setting.

AIMS

To determine the rate of spontaneous hepatitis C viral clearance and genotype in an Irish intravenous drug-using cohort.

METHODS

Drug users attending five drug treatment clinics in the Dublin were investigated. Data were prospectively recorded from January 1997 to June 2001 and follow-up testing completed in 2003. There were 496 HCV antibody positive patients identified and assessed for HCV RNA clearance. All were HIV and hepatitis B negative, 68.8% were male.

RESULTS

HCV RNA negativity (viral clearance) was documented in 38% of patients. Viral clearance was 47.4% in females and 34.5% in males (p = 000.6). Clearance was independent of age or duration of intravenous drug use. Viral clearance as defined as two negative consecutive HCV RNA tests, a minimum of one year apart, was sustained in 82.2% at two-year follow-up, giving an overall viral clearance of 31.1%. HCV genotype 1 and 3 were most commonly identified at 48.8% and 48.5% respectively in those with chronic infection.

CONCLUSIONS

Spontaneous HCV viral clearance occurs at a higher frequency than previously reported. Genotype 1 and 3 are commonest in the patient cohort.

Interferon beta in multiple sclerosis: experience in a British specialist multiple sclerosis centre

BACKGROUND

The efficacy of interferon beta (IFN beta) is well established in relapsing-remitting multiple sclerosis (MS). However, the use of this drug in clinical practice is complex, especially because it is only partially effective, its long term efficacy and side effects are unknown, its efficacy may be abrogated by the development of neutralising antibodies, compliance is variable, and its cost effectiveness is controversial.

OBJECTIVES AND METHODS

Analysis of a prospectively followed up series of 101 MS patients treated with IFN beta was undertaken to: (1) monitor the outcome of IFN beta treatment in clinical practice; (2) compare the immunogenicity of the three commercial IFN beta preparations available; (3) assess the proportion of patients fulfilling the current guidelines of the Association of British Neurologists for stopping IFN beta therapy.

RESULTS

During a median treatment period of 26 months (range 2-85), the relapse rate decreased by 41%. Although the reduction in the relapse rate was similar for all three commercial products, none of the Avonex treated patients were relapse free, compared with 19% of the Betaferon treated and 27% of the Rebif treated patients (p=0.02). Neutralising antibodies were not detected in Avonex treated patients (0 of 18), compared with 12 of 32 (38%) Betaferon treated and 10 of 23 (44%) Rebif treated patients (p=0.02). Forty of 101 (40%) patients satisfied the current (2001) Association of British Neurologists criteria for stopping IFN beta treatment at some stage during their treatment.

CONCLUSION

IFN beta is effective in reducing the relapse rate in patients with relapsing-remitting MS in routine clinical practice. However, after a median treatment duration of 26 months, 40% of initially relapsing-remitting MS patients seem to have ongoing disease activity, presenting as disabling relapses or insidious progression.

Induction and Concurrent Paclitaxel/Carboplatin Every 3 Weeks with Thoracic Radiotherapy in Locally Advanced Non–Small-Cell Lung Cancer: An Interim Report

The paclitaxel/carboplatin combination has demonstrated promising activity in metastatic non-small-cell lung cancer (NSCLC); therefore, we mounted an exploratory study of these agents with thoracic radiation (TRT) in locally advanced NSCLC. Eligibility stipulated a Karnofsky performance status >or= 70%, weight loss <or= 5%, and primarily stage IIIB or bulky IIIA NSCLC. Induction chemotherapy (CT), 2 cycles of paclitaxel 175-225 mg/m2 over 3 hours and carboplatin (targeted area under the curve [AUC] of 7.5), was administered on days 1 and 22. Granulocyte colony-stimulating factor (G-CSF) 5 microg/kg was given on days 2-15 and 23-36 to all patients; half were randomized to priming G-CSF every day x 5 prior to day 1 of induction therapy. On day 43, TRT (60-63 Gy/30-34 fx) was initiated. At dose level 1, only Fox Chase Cancer Center patients received carboplatin (initial target AUC 3.75) and paclitaxel (67.5 mg/m2 over 3 hours) days 43 and 64. In the absence of dose-limiting toxicity, phase I dose escalation in 3-patient cohorts was scheduled to proceed to a maximum carboplatin AUC 7.5 and paclitaxel dose of 210 mg/m2. To date, 53 patients have received induction therapy; 4 are too early to evaluate. The portion of the study evaluating G-CSF priming revealed no myeloprotective effect, likely due to a lack of myelosuppressive toxicity with the conventionally dosed cohort. Twenty-two patients have received concurrent TRT/CT. In sequential cohorts, the chemotherapy doses on days 43 and 64 have been escalated (to paclitaxel 175 mg/m2 and carboplatin AUC 5) with 1 episode each of grade 4 granulocytopenia and grade 3 anemia. The occurrence of grade >or= 2 esophagitis has corresponded to length (> 16 cm) of esophagus in the radiation treatment field (Fisher's exact test, P = 0.006). The partial response rate to induction therapy was 40% and to the combined modality therapy was 60%. The median survival for all 49 patients is 15.3 months, with a median disease-free survival (DFS) of 7.8 months. In the subset of 22 patients treated on the phase I portion of the study, the median survival and DFS were 18.5 months and 13.5 months, respectively. Induction therapy with paclitaxel and carboplatin followed by concurrent chemoradiotherapy with the same agents is an active and well-tolerated treatment approach in locally advanced NSCLC. To date, paclitaxel 175 mg/m2 plus carboplatin AUC 5 administered at 3-week intervals for 2 cycles is safe in combination with TRT.

The changing epidemiology of HIV infection in injecting drug users in Dublin, Ireland

INTRODUCTION

Injecting drug users (IDUs) represent 41.6% of the total cohort of HIV-infected patients in Ireland. Between January 1999 and December 2000, referrals to the largest tertiary centre for HIV infection in Dublin have increased dramatically. This has occurred on a background of a reduction in the overall incidence of HIV infection in Ireland between 1990 and 1998. Here we describe the changing epidemiology of HIV disease in IDUs and explore potential aetiological factors.

METHODS

This is a retrospective study, collecting all data relating to new HIV diagnoses occurring in IDUs, referred to the GenitoUrinary Medicine and Infectious Diseases (GUIDE) clinic between 1987 and 2000. We calculated 6-month incidence rates of new HIV diagnoses in IDUs referred to the GUIDE clinic and performed a more detailed analysis of those patients diagnosed between January 1999 and December 2000, documenting age, sex, time and place of diagnosis, drug use history and primary drug of misuse, needle sharing history, attendance at a drug treatment clinic, prior HIV testing history, hepatitis B and hepatitis C status, and CD4 cell counts and HIV RNA levels at diagnosis.

RESULTS

The number of new HIV diagnoses in IDUs increased fivefold between 1995 and 2000. Moreover, 40% of patients diagnosed since then have been under 22 years old. There has also been a significant reversal of the initial male to female ratio seen in the initial epidemic of the 1980s.

CONCLUSION

There has been a significant increase in the incidence of HIV infection in IDUs between 1995 and 2000. Similar trends have been described recently in other risk groups. The aetiology of these trends is multifactorial, and a multidisciplinary, rejuvenated approach is required to focus on improving health education to reduce both sexual and needle sharing practices.

Heroin smoking by "chasing the dragon" in young opiate users in Ireland: stability and associations with use to "come down" off "Ecstasy"

We explored the frequency of commencing opiate use by "chasing the dragon" to "come down" off Ecstasy and the stability of heroin smoking in young opiate takers by assessing 102 subjects in Dublin using a semistructured interview. Ninety-two subjects had used Ecstasy. Of these, 68 reported "chasing" to "come down" off Ecstasy at some point in their history and were found to have used Ecstasy more frequently and in larger amounts. Thirty-six reported that their first experience of using opiates was to "come down" off Ecstasy, 28 citing this as their main reason for commencement.Eighty-six of the 102 commenced opiates by "chasing" heroin, 61 of whom progressed to injecting after a mean of 2.9 years. This was associated with starting illicit drug use earlier, starting heroin earlier, and a history of using Ecstasy. Implications for service planners in developing responses to illicit drug use among adolescents are discussed.

Syringe borrowing persists in Dublin despite harm reduction interventions

AIMS

To measure the frequency of syringe borrowing in young Irish injecting drug users (IDUs) and identify associated characteristics.

DESIGN

Cross-sectional survey.

SETTING

Addiction treatment services in Dublin.

PARTICIPANTS

Treated IDUs (N = 246).

MEASUREMENTS

Data on drug injecting and syringe borrowing in the previous 6 months.

FINDINGS

The median age was 22 years and the median length of injecting history was 19 months. Syringe borrowing was reported by 173 (70.3%) participants. A multivariate analysis identified seven characteristics significantly associated with syringe borrowing. These included early school leaving and parental unemployment. IDUs with long injecting histories who had injected less frequently were more likely to borrow. Injection of more than one substance was significantly associated with borrowing of syringes. Syringe borrowing was associated with having more intimate social relationships with other IDUs, less perceived risk in borrowing from acquaintances and usually opting to inject in the company of other IDUs.

CONCLUSIONS

Syringe borrowing is commonly practised by young IDUs. Those with a background of social deprivation are more likely to engage in this risk behaviour. IDUs who report borrowing are more intimately involved with other IDUs and tend to perceive less risk or dangerousness in borrowing. In addition to syringe exchange, there is a need to work cognitively with IDUs to identify and challenge assumptions that they may have regarding the safety involved in borrowing from others, particularly from those with whom they have close social relationships.

Assessment of hepatitis C infection in injecting drug users attending an addiction treatment clinic

BACKGROUND

Injecting drug users represent a high risk group for hepatitis C (HCV) infection. Currently, screening of this group for HCV is inconsistently implemented.

AIM

We designed a HCV assessment algorithm and sought to determine the frequency with which injecting drug users completed the assessment process.

METHODS

Prospective study of a HCV assessment algorithm in the setting of a specialist outpatient addiction treatment clinic. Participants consisted of consecutive new attenders over a six-month period with a history of injecting.

RESULTS

Only 21 (18%) of 119 patients reached a satisfactory endpoint of assessment. Forty-eight injectors were tested for antibody to HCV, of whom 26 (54%) tested positive. Thirteen of those with positive test results were no longer attending when the test result became available. Only four of the 19 patients who were referred, attended the on-site hepatology clinic.

CONCLUSIONS

Thorough screening of injecting drug users for HCV within one treatment service is difficult. There is a need for explicit policies on this issue involving co-operation between primary care providers and addiction services and hepatology services.

Homologous androgen receptor up-regulation in osteoblastic cells may be associated with enhanced functional androgen responsiveness

Although androgens have myriad effects on the skeleton, the regulation of androgen action in bone is not well understood. Androgen receptors (ARs) are known to play an important role in mediating androgen action. We have examined the effects of androgens and other sex steroids on AR levels in osteoblastic cells in vitro using two clonal human cell lines, SaOS-2 and U-2 OS. AR protein levels were quantitated both by specific androgen binding studies and Western analyses, and AR messenger RNA was measured with RNase protection assays. Potential changes in AR functionality was assessed by reporter assays. Treatment of osteoblastic cells with the nonaromatizable androgen 5alpha-dihydrotestosterone (DHT) increased specific androgen binding 2-to 4-fold. Similar increases in AR protein levels were documented by Western analysis in both cell lines. The androgen-mediated increase in receptor levels was time and dose dependent as well as androgen specific. Steady-state AR messenger RNA levels were also increased by DHT. When AR concentrations in osteoblastic cells were elevated with exogenous receptor, there was an enhancement of DHT responsiveness, measured by increased trans-activation of an androgen-responsive promoter. Thus, androgen exposure increased androgen receptor protein levels and specific androgen binding in osteoblastic cells. Androgen action as measured by androgen-mediated transcriptional activation is enhanced in the presence of elevated AR levels. Consequently, these studies have revealed an additional means by which androgens may modulate skeletal metabolism.

Bloodborne viral infection in Irish injecting drug users

AIMS

In Dublin, harm reduction strategies have greatly expanded since 1990. We sought to determine the prevalence of, and factors associated with, hepatitis C (HCV), hepatitis B (HBV) and HIV infections among injecting drug users (IDUs) against this background.

DESIGN

Cross-sectional survey.

SETTING

Addiction treatment clinic.

PARTICIPANTS

Seven hundred and thirty-five IDU tested for antibody to HCV (anti-HCV) between September 1992 and September 1997.

MEASUREMENTS

Socio-demographic and drug use characteristics. Serology tests for anti-HCV, HBV surface antigen (HBsAg) and HIV.

FINDINGS

The vast majority (89%) commenced injecting since 1990. Prevalence of anti-HCV was 61.8% (453/733), of HBsAg was 1.0% (7/729) and of HIV was 1.2% (7/600). Logistic regression analyses indicated that longer history of injecting and increased daily drug expenditure were the only independent variables associated with significantly increased risk of HCV. The only characteristic associated with increased prevalence of HBsAg was a history of injecting prior to 1990 (3.8%, 3/80). HIV prevalence was significantly higher when aged over 24 years (3.7%, 6/162), when injecting commenced prior to 1990 (6.3%, 4/64) and when injecting over 5 years (6.5%, 4/62).

CONCLUSIONS

HIV prevalence has sustained a low level in this population. Interventions which aim to halt transmission of HCV are necessary and will need to target IDU very early in their injecting careers and also those at risk of commencing to inject.

HIV risk behaviour in Irish intravenous drug users

The aim of the study was to measure HIV prevalence and risk behaviour in 185 Irish Intravenous Drug Misusers. Information was obtained by application of a standardised WHO questionnaire covering HIV risk behaviour in the preceding 6 months. HIV serostatus was obtained by saliva/blood sample testing. One hundred and 3 (55.7 per cent) shared and 114 (61.6 per cent) lent used injecting equipment in the previous 6 months. 97 (94.2 per cent) of those who shared always cleaned the needles before use but only 48 (49.5 per cent) of these always cleaned in an efficient manner. One hundred and 14 (79.2 per cent) males and 28 (68.3 per cent) females reported heterosexual activity in the preceding 6 months. On examination sexual risk behaviour was found to be high. 50.5 per cent of males and 63 per cent of females never used condoms with regular partners. 32.6 per cent of males never used condoms with casual partners. The large majority of partners of male I.D.U'.s (both regular and casual) were non injectors. Therefore there is potential for sexual spread of HIV into the non-injecting heterosexual population. Conversely the vast majority of partners of female IDU's were injectors. This suggests that female IDU's are at higher risk of HIV infection than their male counterparts. HIV prevalence in the study group was 8.4 per cent. Implications of results for future intervention are discussed.

Induction paclitaxel and carboplatin followed by concurrent chemoradiotherapy in patients with unresectable, locally advanced non-small cell lung carcinoma: report of Fox Chase Cancer Center study 94-001

The paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ)/carboplatin combination has demonstrated promising activity in patients with incurable non-small cell lung cancer (NSCLC). Our exploratory study is designed to evaluate the efficacy of this combination as induction therapy in patients with locally advanced NSCLC, to determine the maximally tolerated doses of paclitaxel and carboplatin administered every 3 weeks during radical thoracic radiation after induction treatment, and to determine the efficacy of granulocyte colony-stimulating factor (G-CSF) priming before induction treatment, followed by conventional G-CSF, compared with conventional G-CSF alone. Eligibility stipulated Karnofsky performance status > or =70%, < or =5% weight loss, and stages IIIB or bulky IIIA NSCLC. Induction treatment consisted of two cycles of paclitaxel 175 to 225 mg/m2 infused over 3 hours combined with carboplatin (target area under the concentration-time curve of 7.5) given on days 1 and 22. On days 2 through 15 and 23 through 36, all patients received G-CSF 5 microg/kg; half were randomized to receive priming G-CSF daily for 5 days before day 1 of treatment. On day 43, thoracic radiation (60 Gy in 30 2-Gy fractions daily, 5 days a week for 6 weeks) was initiated. At dose level 1, patients received carboplatin dosed to a target area under the concentration-time curve of 3.75 and paclitaxel 67.5 mg/m2 over 3 hours on days 43 and 64. In the absence of dose-limiting toxicity, phase I escalation in three-patient cohorts proceeded to a maximum carboplatin area under the concentration-time curve of 5.0 and a paclitaxel dose of 175 mg/m2, delivered over 3 hours. To date, 35 patients (83% stage IIIB) have received induction treatment, 29 of whom are evaluable for response. Myelosuppression and neurotoxicity have been mild during induction treatment, prompting a paclitaxel dose increase to 225 mg/m2 on days 1 and 22 after the first seven patients were accrued. The phase III portion of the study evaluating G-CSF priming remains coded. Sixteen patients have received concurrent thoracic radiation and chemotherapy and are evaluable for response and toxicity. In sequential cohorts, the paclitaxel dose on days 43 and 64 has been escalated to 175 mg/m2 with only one episode each of grade 4 granulocytopenia and grade 3 anemia. In the first 13 patients evaluated, the severity of esophagitis corresponded to the length of the esophagus in the radiation treatment field: grade 1 in all six patients with esophageal exposure < or =16 cm and grade > or =2 in six of seven patients with > or =16 cm of the esophagus irradiated. Three episodes of grade > or =2 steroid-responsive pulmonary toxicity have occurred 2 to 6 months after the conclusion of concurrent thoracic radiation and chemotherapy. The major response rate is 38% to induction treatment and 59% to combined-modality treatment. Of the first 21 patients accrued, 62% survived 1 year. Induction paclitaxel/carboplatin therapy is active and well tolerated by patients with locally advanced NSCLC. The maximum tolerated doses of paclitaxel and carboplatin during concurrent thoracic radiation and the role of G-CSF priming are not yet established. Severity of esophagitis corresponds to the extent of esophagus irradiated during concurrent thoracic radiotherapy and chemotherapy.

The prevalence of chemical substance and alcohol abuse in an obstetric population in Dublin

OBJECTIVE

To determine the prevalence of illicit drug abuse and alcohol use in an obstetric population based in an urban maternity hospital.

SETTING

A collaborative study between the Rotunda Hospital, Dublin and the Irish National Drug Advisory & Treatment Centre.

DESIGN

A prospective study consisting of anonymous, unlinked urine testing of 504 'first visit' antenatal patients and a separate group of 515 patients six weeks after delivery.

METHODS & OUTCOME MEASURES

Toxicological screening using enzyme-linked immunoassay techniques, with all positive samples being reanalysed. Drug histories were taken and samples were tested for alcohol and six of the most commonly abused drugs. The pre- and postnatal prevalence of abuse was matched with demographic data.

RESULTS

The prevalence of chemical substance misuse in the antenatal population was 2.8% and 5.6% in the postnatal population. Substances identified included benzodiazepines, cannabis, amphetamines, opiates and cocaine. Less than 2% of samples tested positive for alcohol. None of the women yielding positive samples had been pre-identified on the basis of history. A significant proportion of the women were in the high risk categories with regard to age and socio-economic status.

CONCLUSION

The prevalence of drug misuse antenatally was nearly 3% and postnatally almost 6%. Substance abusers in pregnancy are more likely to be single, unemployed, and to have had a previous pregnancy.

Transcriptional up-regulation of the human androgen receptor by androgen in bone cells

Androgen regulation of androgen receptor (AR) expression has been observed in a variety of tissues, generally as inhibition, and is thought to attenuate cellular responses to androgen. AR is expressed in osteoblasts, the bone-forming cell, suggesting direct actions of androgens on bone. Here we characterized the effect of androgen exposure on AR gene expression in human osteoblastic SaOS-2 and U-2 OS cells. Treatment of osteoblastic cells with the nonaromatizable androgen 5alpha-dihydrotestosterone increased AR steady state messenger RNA levels in a time- and dose-dependent fashion. Reporter assays with 2.3 kilobases of the proximal 5'-flanking region of the human AR promoter linked to the chloramphenicol acetyltransferase gene in transfected cultures showed that up-regulation of AR promoter activity by androgen was time and dose dependent. Treatment with other steroid hormones, including progesterone, 17beta-estradiol, and dexamethasone, was without effect. The antiandrogen hydroxyflutamide completely antagonized androgen up-regulation. Thus, in contrast to many other androgen target tissues, androgen exposure increases steady state AR messenger RNA levels in osteoblasts. This regulation occurs at least partially at the level of transcription, is mediated by the 5'-promoter region of the AR gene, and is dependent on functional AR. These results suggest that physiological concentrations of androgens have significant effects on AR expression in skeletal tissue.

Severity of alcohol dependence and its relationship to neurological soft signs, neuropsychological impairment and family history

We examined the relationship between severity of alcohol dependence, subtle neurological impairment, neuropsychological deficits and genetic vulnerability among 36 day hospital attenders who satisfied the DSM-III-R criteria for alcohol dependence. Severity of alcohol dependence was unrelated to the presence of a family history, but was correlated with neurological soft signs and neuropsychological impairment. Neurological soft signs were correlated with neuropsychological impairment on both Trail A and Trail B. Patients with an affected first-degree relative exhibited more neurological soft signs. These data indicate that severity of alcohol dependence is related not only to neuropsychological impairment, but also to subtle neurological deficits which may not be apparent on conventional neurological examination. Patients with a positive family history of alcohol dependence may be particularly susceptible to the neurological sequelae of alcohol dependence, or may have neurological deficits which antedate their alcohol dependence.

Phase I trial of tirapazamine in combination with cisplatin in a single dose every 3 weeks in patients with solid tumors

PURPOSE AND METHODS

Tirapazamine (SR4233, WIN 59075) is a benzotriazine-di-N-oxide bioreductive agent that is selectively activated to a reactive DNA-damaging species in hypoxic tumors. Preclinical studies show that synergistic antitumor activity results from a schedule-dependent interaction between tirapazamine and several cytotoxic drug classes, including cisplatin. In a phase I combination study, tirapazamine (130 to 260 mg/m2) was administered as a 1-hour intravenous (IV) infusion beginning 3 hours before cisplatin (75 to 100 mg/m2). Thirteen patients received 41 courses of therapy. These patients had an excellent performance status and were not heavily pretreated. The predominant diagnosis was lung cancer.

RESULTS

The major acute side effects were nausea and vomiting, which were controlled with an intensive antiemetic regimen. Other acute effects included diarrhea and muscle cramping, while with repeated dosing, anorexia and fatigue predominated. Full doses of each agent were well tolerated in combination, although in this previously treated population, fatigue increased markedly after three cycles of therapy. Partial responses were observed in two patients (one with non-small-cell lung cancer and one with breast cancer), and a minor response occurred in a patient with mesothelioma. Tirapazamine pharmacokinetics were linear with respect to increasing dose with a mean maximum plasma concentration (Cmax) of 5.97 +/- 2.25 microg/mL and an area under the concentration-time curve (AUC) of 811.4 +/- 311.9 microg/mL.min at 260 mg/m2. These results are consistent with other ongoing single-agent and combination studies and indicate that therapeutically relevant levels of tirapazamine are achievable in patients based on animal models. The mean cisplatin AUC was 285.6 +/- 46.4 microg/mL.min with mean Cmax values of 3.38 +/- 0.43 microg/mL at 75 mg/m2. The clearance of cisplatin was unaffected by coadministration with tirapazamine.

CONCLUSION

This trial shows that in previously treated patients, full doses of cisplatin are well tolerated with increasing doses of tirapazamine up to 260 mg/m2. The observation of clinical responses in this trial supports the phase II investigation of this regimen.