General Population Estimates Research Articles

Common mental health conditions among navy divers: A brief report.

A recent article reported on common mental health conditions among recreational scuba divers, and observed that the prevalence mirrored national population figures. This raised the question of the extent to which this might also be the case among professional divers. No data on commercial divers could be located; this paper presents the situation among navy divers. Mental health survey data from 132 South African Navy divers were reviewed to describe the 12-month prevalence of common mood, anxiety, and alcohol misuse disorders. Prevalence of common mood and anxiety conditions appeared to reflect local general population estimates, and the occurrence of alcohol misuse was higher than local population figures, although the usefulness of the population data could be challenged. It appeared that common mental health conditions in both sport and navy divers may generally conform to their respective local general population estimates. If this were to be the case in the broader professional diving environment as well, the inclusion of some form of formal mental health screening during commercial diving medical examinations may be beneficial.

Anxiety and depression in patients with Barrett's esophagus: estimates of disorder rates and associations with symptom load and treatment-seeking.

Patients with Barrett's esophagus (BE) may experience psychological burden from living with a chronic medical condition, which has been identified as the most important risk factor for esophageal adenocarcinoma. The aim of this study was to estimate rates of depression and anxiety in a large sample of patients with BE. A total of 794 patients with endoscopically and histologically confirmed diagnosis of BE completed validated screening instruments for depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7). Screening rates in the study sample were compared to general population estimates. Multivariable regression analyses were used to model associations between outcome variables and respondents' sociodemographic characteristics, BE-related symptom load and incidence of inpatient treatment due to BE in the last 12 months. Rates of positive screens were 14.2% for depression and 9.9% for anxiety. For several age by sex subgroups, rates of depression and anxiety were about three to five times higher in the study sample than in the general population. BE-related reflux and pain symptoms showed strong associations with higher levels of depressive and anxiety symptoms, while the effect of treatment was small. Study results indicate that a relevant proportion of patients with BE is at an increased risk for depression and anxiety, compared to general population controls. Lacking information on patients' disease characteristics limited generalizability of results.

Polygenic risk scores and breast and epithelial ovarian cancer risks for carriers of BRCA1 and BRCA2 pathogenic variants

PurposeWe assessed the associations between population-based polygenic risk scores (PRS) for breast (BC) or epithelial ovarian cancer (EOC) with cancer risks for BRCA1 and BRCA2 pathogenic variant carriers. MethodsRetrospective cohort data on 18,935 BRCA1 and 12,339 BRCA2 female pathogenic variant carriers of European ancestry were available. Three versions of a 313 single-nucleotide polymorphism (SNP) BC PRS were evaluated based on whether they predict overall, estrogen receptor (ER)–negative, or ER-positive BC, and two PRS for overall or high-grade serous EOC. Associations were validated in a prospective cohort. ResultsThe ER-negative PRS showed the strongest association with BC risk for BRCA1 carriers (hazard ratio [HR] per standard deviation=1.29 [95% CI 1.25–1.33], P=3×10−72). For BRCA2, the strongest association was with overall BC PRS (HR=1.31 [95% CI 1.27–1.36], P=7×10−50). HR estimates decreased significantly with age and there was evidence for differences in associations by predicted variant effects on protein expression. The HR estimates were smaller than general population estimates. The high-grade serous PRS yielded the strongest associations with EOC risk for BRCA1 (HR=1.32 [95% CI 1.25–1.40], P=3×10−22) and BRCA2 (HR=1.44 [95% CI 1.30–1.60], P=4×10−12) carriers. The associations in the prospective cohort were similar. ConclusionPopulation-based PRS are strongly associated with BC and EOC risks for BRCA1/2 carriers and predict substantial absolute risk differences for women at PRS distribution extremes.

Depression, anxiety, and suicidality in patients with prostate cancer: a systematic review and meta-analysis of observational studies.

Psychiatric implications of prostate cancer are increasingly recognised, having important effects on oncological and functional outcomes. However, findings for co-occurring depression, anxiety, and suicidality remain variable. Therefore, this review of observational studies aimed to establish best estimates of the prevalence and rates of these outcomes in prostate cancer patients. A systematic literature search was conducted using MEDLINE, Scopus, PsycInfo, and Cochrane Library databases from inception up to 26 May 2020. Observational studies using validated methods for evaluating prevalences of depression, anxiety and suicidal ideation, or suicide mortality rates post prostate cancer diagnosis were included. Random effect models were used to calculate pooled prevalences of depressive and anxiety symptoms or disorders, and suicidal ideation post diagnosis. Additionally, pooled crude suicide mortality rates per 100,000 person years were calculated. Heterogeneity was explored using a stratified analysis. Of 3537 articles screened, 117 were included. Pooled prevalence for depressive disorders was 5.81% (95% CI 4.36-7.46) in 11 studies, representing 655,149 patients. Significant depressive symptoms were identified in 17.07% (15.14-19.09) across 32,339 patients and 76 studies. In total, 16.86% (14.92-18.89) had significant anxiety symptoms in 56 studies combining 24,526 patients. In 6,173 patients and eight studies, recent suicidal ideation was present in 9.85% (7.31-12.70). Crude suicide mortality rate after diagnosis was 47.1 (39.85-54.96) per 100,000 person years in 12 studies. Significant heterogeneity was seen with potential sources identified through our sensitivity analysis including diagnostic method utilised, study size and location of study. The mental health impact in patients with prostate cancer is significant. Depressive, anxiety, and suicidal symptoms were common. Additionally, a high suicide mortality rate was identified when compared to general population estimates. Screening of patients and integration of physical and mental health care should be evaluated further to improve quality of life and functional outcomes.

Asthma in urban Aboriginal children: A cross-sectional study of socio-demographic patterns and associations with pre-natal and current carer smoking.

To describe socio-demographic patterns of asthma prevalence in urban Aboriginal children and quantify associations between asthma prevalence and pre-natal maternal and current carer smoking. Analyses used carer-reported survey data for 1290 urban Aboriginal children aged 2-17 years from the Study of Environment on Aboriginal Resilience and Child Health. Multilevel log-binomial regression was used to estimate asthma prevalence ratios (PRs) for child- and family-level socio-demographic factors, pre-natal maternal smoking and current carer smoking. Smoking-related PRs were compared with general-population estimates derived from meta-analyses of published cross-sectional data. Overall, 33.9% of children had ever had asthma, and 12.9% had received treatment for asthma in the past month. Prevalence estimates declined with increasing household income and increasing household size (posterior probabilities of decreasing trend >0.98), while children exposed to pre-natal maternal smoking had a higher risk of asthma ever than unexposed children (PR 1.18 (95% credible interval 1.00-1.40)). Recently treated asthma prevalence was not significantly associated with pre-natal maternal (0.98 (0.71-1.41)) or current carer smoking (0.97 (0.68-1.37)); however, there was substantial uncertainty in our PR estimates, and 95% credible intervals contained general-population estimates derived from the meta-analyses (1.37 (1.17-1.65) for pre-natal smoking, 1.28 (1.15-1.44) for current parental or household smoking). Among urban Aboriginal children in the Study of Environment on Aboriginal Resilience and Child Health cohort, asthma prevalence declines as household income and household size increase, while children exposed to pre-natal maternal smoking are at increased risk of ever having asthma. Our results emphasise the importance of reducing smoking in Aboriginal communities, particularly among pregnant women.

Suicidal Behaviors Among Nurses in Canada.

Nurses are regularly exposed to potentially psychologically traumatic events, experience high rates of burnout, and may be at an elevated risk of death by suicide. Few studies have assessed for suicidal behaviors among Canadian nurses, and factors that may increase risk for suicidal behaviors are unknown. The current study was designed to assess past-year and lifetime suicidal behavior (i.e., ideation, plans, and attempts) using a large sample of Canadian nurses. Participants (n = 3969; 94.3% women) completed an online survey including measures of suicidal behavior and symptoms of mental disorders. Considerable proportions of participants reported past-year and/or lifetime suicidal ideation (10.5%, 33.0%), plans (4.6%, 17.0%), and attempts (0.7%, 8.0%), considerably higher than general population estimates. Significant differences were identified across age groups, years of service, marital status, regional location, and nursing type (e.g., registered psychiatric nurses, licensed practical nurses, registered nurses). Participants who screened positive for almost all measured mental disorders had significantly higher rates of suicidal behavior. The results necessitate further research to evaluate risk factors contributing to suicidal behavior in Canadian nurses and methods to decrease the risk (e.g., developing effective monitoring and prevention measures).

Celiac Disease Symptoms in Athletes: Prevalence Indicators of Perceived Quality of Life.

Celiac disease (CD) is a common gastrointestinal pathology; however, prevalence and comorbidities are unknown in collegiate athletics. (1) Athletes will have similar odds of CD as general population estimates (approximately 1 in 141) based on self-report and signs and symptoms, (2) athletes scoring higher on the Celiac Symptom Index (CSI) will have lower self-reported quality of life (QoL), (3) athletes scoring higher on the CSI will have higher depression scores, and (4) athletes scoring higher on the CSI will have higher perceived stress scores. Epidemiological cross-sectional study. Level 4. The CSI, WHO Quality of Life-BREF, Beck Depression Inventory, and Perceived Stress Scale were used to assess patients' signs and symptoms of CD and psychosocial measures/QoL in male and female National Collegiate Athletic Association (all divisions) athletes (N = 141). Participants also self-reported a formal diagnosis of CD. Chi-square analyses determined CD prevalence. Odds ratios determined risk for either being diagnosed with CD or reporting more symptoms than the general population. Correlational analyses determined whether symptoms correlated with QoL and psychosocial measures. Athletes were 3.85 times (95% CI, 0.42-34.89) more likely to report a CD diagnosis and were 18.36 times (95% CI, 2.40-140.48) more likely to report a high degree of CD symptoms than the general population. Athletes with more symptoms had worse physical, psychological, social, and environmental QoL indicators and higher depression and perceived stress scores. Athletes may be a higher risk population for experiencing CD and report greater signs/symptoms compared with general population estimates. Additionally, athletes with higher CD symptom scores also reported poorer QoL. Allied health care professionals should be aware of the diversity of CD symptoms and be prepared to refer athletes when gastrointestinal symptoms persist to ensure proper care and unhampered performance.

Total Worker Health® Needs Assessment to Identify Workplace Mental Health Interventions in Rural and Urban Jails.

Jail officers are an underserved population of public safety workers at high risk for developing chronic mental health conditions. In response to national calls for the examination of stressors related to the unique work contexts of correctional facilities, we implemented a pilot study informed by the Total Worker Health® (TWH) strategy at two urban and two rural jails. Participatory teams guided areas of interest for a mixed-data needs assessment, including surveys with 320 jail officers to inform focus groups (N = 40). Urban and rural jails in the midwestern United States. Jail correctional officers and sheriff's deputies employed at participating jails. We measured mental health characteristics using the Patient-Reported Outcomes Measurement Information System Global Mental Health scale, the Center for Epidemiologic Studies Depression scale, and the two-item Posttraumatic Stress Disorder Checklist. Constructs to identify workplace characteristics included emotional support, work-family conflict, dangerousness, health climate, organizational operations, effectiveness of training, quality of supervision, and organizational fairness. On the basis of general population estimates, we found that jail officers were at higher risk for mental health disorders, including depression and posttraumatic stress disorder. Jail officers identified workplace health interventions to address individual-, interpersonal-, institutional-, and community-level needs. Implementation of a TWH needs assessment in urban and rural jails to identify evidence-informed, multilevel interventions was found to be feasible. Using this assessment, we identified specific workplace health protection and promotion solutions. Results from this study support the profession's vision to influence policies, environments, and systems through collaborative work. This TWH study has implications for practice and research by addressing mental health needs among jail officers and by providing practical applications to create evidence-informed, tailored interventions to promote workplace health in rural and urban jails.

Obstructive Sleep Apnea and Ambulatory Surgery: Who Is Truly at Risk? Response to Editorial.

To the Editor We thank Urman et al1 for their supportive editorial highlighting our recent publication2 reporting our experience providing safe anesthesia care to patients at-risk for or with known obstructive sleep apnea (OSA) in the ambulatory cancer surgery setting. Two points of clarification in the editorial are needed about our study. (1) The prevalence of OSA was indeed lower in our patients than is usually reported in the general population, but as the authors pointed out and we reported in the Discussion, this is mainly due to our predominantly female population. Among males at our center, 20% screened as high risk or diagnosed OSA, which is closer to the general population estimates for males. (2) We would not attribute our 3.5% high-risk OSA rate to under classification due to our 2-step implementation of the STOP-BANG questionnaire. As noted in the Methods, we did data checks based on patient’s body mass index (BMI), age, and gender on all low-risk individuals on whom the BANG score was not initially applied to confirm there were no false negatives nor missing patients who should have been high risk. Indeed, this manual check did not identify any patients who should have been reclassified as high risk. Therefore, we maintain that our low-moderate/high risk or diagnosed OSA classification accurately describes our study population. We encourage other multispecialty ambulatory surgery facilities to report outcomes that are similarly based on the clinical application of national OSA guidelines. Rebecca S. Twersky, MD, MPHBetsy Szeto, MPHBrett Simon, MD, PhDDepartment of Anesthesiology and Critical CareMemorial Sloan Kettering Cancer CenterJosie Robertson Surgery CenterNew York, New York[email protected]

Opioid misuse among persons with HIV engaged in care in the Southeastern US

ABSTRACT The prevalence of opioid misuse by people living with HIV (PLWH) during the current US opioid epidemic has not been fully described. Among a cohort of persons engaged in HIV care in North Carolina, we examined the prevalence of and risk factors for opioid misuse, defined as self-reported “street” opioid use (e.g., heroin) or nonmedical prescription opioid use on a patient reported outcomes survey. Recent (past three-month) opioid misuse among 1,440 PLWH in care 2012–2017 was 2% (95% CI 2-3%) and lifetime misuse 15% (13-16%). Persons reporting lifetime or recent misuse more commonly had hepatitis C and reported injecting drugs. In multivariable logistic regression models, male-to-male sexual contact was inversely associated with recent or lifetime misuse. White/non-Hispanic race/ethnicity was associated with lifetime misuse and CD4 count and viral load were not associated with opioid misuse. Among 32 persons reporting recent misuse, 81% had a contemporaneous viral load <50 copies/mL. In this cohort of PLWH engaged in care, recent opioid misuse prevalence was similar to general population estimates. Assessments of opioid misuse among PLWH not in care are urgently needed to fully characterize the impact of opioids on all PLWH.

The Turker Blues: Hidden Factors Behind Increased Depression Rates Among Amazon’s Mechanical Turkers

Data collection from online platforms, such as Amazon’s Mechanical Turk (MTurk), has become popular in clinical research. However, there are also concerns about the representativeness and the quality of these data for clinical studies. The present work explores these issues in the specific case of major depression. Analyses of two large data sets gathered from MTurk (Sample 1: N = 2,692; Sample 2: N = 2,354) revealed two major findings: First, failing to screen for inattentive and fake respondents inflates the rates of major depression artificially and significantly (by 18.5%–27.5%). Second, after cleaning the data sets, depression in MTurk is still 1.6 to 3.6 times higher than general population estimates. Approximately half of this difference can be attributed to differences in the composition of MTurk samples and the general population (i.e., sociodemographics, health, and physical activity lifestyle). Several explanations for the other half are proposed, and practical data-quality tools are provided.

Mental Health Correlates of Autism Spectrum Disorder in Gender Diverse Young People: Evidence from a Specialised Child and Adolescent Gender Clinic in Australia.

Research suggests an overrepresentation of autism spectrum diagnoses (ASD) or autistic traits in gender diverse samples, particularly in children and adolescents. Using data from the GENTLE (GENder identiTy Longitudinal Experience) Cohort at the Gender Diversity Service at the Perth Children’s Hospital, the primary objective of the current retrospective chart review was to explore psychopathology and quality of life in gender diverse children with co-occurring ASD relative to gender diverse children and adolescents without ASD. The Social Responsiveness Scale (Second Edition) generates a Diagnostic and Statistical Manual of Mental Disorders (DSM-5) score indicating a likely clinical ASD diagnosis, which was used to partition participants into two groups (indicated ASD, n = 19) (no ASD indicated, n = 60). Indicated ASD was far higher than would be expected compared to general population estimates. Indicated ASD on the Social Responsiveness Scale 2 (SRS 2) was also a significant predictor of Internalising behaviours (Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Thought Problems subscales) on the Youth Self Report. Indicated ASD was also a significant predictor of scores on all subscales of the Paediatric Quality of Life Inventory. The current findings indicate that gender diverse children and adolescents with indicated ASD comprise an especially vulnerable group that are at marked risk of mental health difficulties, particularly internalising disorders, and poor quality of life outcomes. Services working with gender diverse young people should screen for ASD, and also provide pathways to appropriate care for the commonly associated mental health difficulties.

ON4 REVIEW OF THE APPLICATION OF HEALTH-RELATED QUALITY OF LIFE (HRQOL) DATA IN RECENT HEALTH TECHNOLOGY ASSESSMENTS (HTAS) OF CANCER IMMUNOTHERAPIES (IOS) BY THE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (NICE)

The estimation of quality-adjusted life years (QALYs) for a given intervention necessitates the analysis of HRQOL data. For cancer treatments, this typically comprises an assessment of utility according to progression status; however, recent literature advocates an alternative approach for patients treated with IOs—using the time until a patient’s death (time to death [TTD]). We reviewed NICE assessments of IOs to understand which methods of analyzing HRQOL data have been previously used and accepted. Completed assessments of IOs published prior to December 2018 were identified via the NICE website. Manufacturer submissions and final appraisal determination documents were downloaded and searched. We extracted the preferred method submitted by each company and the corresponding committee discussion, including whether the method was ultimately accepted or rejected. A total of 21 assessments were identified, of which 20 received positive NICE recommendations. In 10 assessments, a TTD-based approach was presented (using the TTD as the only explanatory variable for utility [n=7] or using TTD in combination with progression status or treatment arm [n=3]). The remaining 11 assessments presented a progression-based approach. In 2 cases, NICE committees ultimately rejected the TTD-based method presented by the manufacturer, favoring a progression-based approach. Key committee criticisms across methods included selection bias (for progressed utilities or those near the end of life) and ‘implausibly high’ values for health states far from death (e.g. >360 days) versus comparable general population estimates. Alternative approaches to analyzing HRQOL data in submissions of IOs to NICE have been accepted other than the typical progression-based approach. Because of reporting limitations, it remains to be seen whether the use of alternative approaches for utility data may lead to markedly different cost-effectiveness results. Consequently, further research is required to establish the relative performance of each method and their appropriateness for decision making.

The prevalence of substance use in child welfare and general population eighth graders in the United States

Background: Early substance use is an established risk factor for substance abuse and dependence. Objective: The current study sought to examine whether child welfare-involved eighth graders have higher rates of early substance use than general population eighth graders. Data from the first National Survey of Child and Adolescent Well-Being (NSCAW) were analyzed to assess the prevalence of self-reported substance use, including alcohol, marijuana, and inhalant use in child welfare-involved eighth graders (N = 896). These figures were compared to general eighth grade student population estimates from the Monitoring the Future Study (N = 16,900) using 95% confidence intervals (CIs). Finally, regression analyses were conducted to examine demographic predictors (i.e., age, gender, race/ethnicity, and out-of-home placement) of substance use among child welfare eighth graders. Results: Results indicated comparable or lower incidence of substances among child welfare eighth graders relative to the general population, but higher past 30-day inhalant use among child welfare youth in out-of-home placement (17.1%, 95% CI: 6.0%, 40.2%) than the general population (4.2%, 95% CI: 3.7%, 4.7%). Out-of-home placement was associated with higher inhalant use (lifetime β = .659, p = .034; 30-day β = .763, p = .040) and alcohol use (lifetime β = .415, p = .028). Conclusions/Importance: These findings imply the need for screening and prevention education about substance use in child welfare populations, particularly in regards to inhalant use.

MON-605 Hypothyroidism in Erdheim-Chester Disease: Experience from a Tertiary Care National Referral Center

Background: Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis affecting multiple organs, including the endocrine system. While endocrine involvement in ECD is well characterized, infiltration of the hypothalamic-pituitary-thyroid axis may cause either primary or central hypothyroidism that is often underdiagnosed. The prevalence of hypothyroidism and the occurrence of isolated central hypothyroidism in ECD has not been thoroughly investigated. Methods: A prospective cohort study of biopsy-confirmed cases of ECD was conducted at the National Institutes of Health. Clinical, radiographic, and biochemical characteristics were assessed. All subjects underwent baseline evaluation with a thyroid function test, including TSH, free thyroxine (fT4) and total thyroxine (T4).Results: Sixty-one subjects with ECD (46 males, 54.3 ± 10.8 years) were evaluated. Sixteen subjects (26%) hadprimary hypothyroidism and were receiving thyroid hormone supplementation before enrollment, with a mean TSH 2.00 ±1.63 mcIU/mL (normal 0.27-4.20 mcIU/mL), fT4 1.52 ±1.51 ng/dL (normal 0.9-1.7 ng/dL), and T4 7.42 ±2.15 mcg/dL (normal 4.5-11.7 mcg/dL). The prevalence of primary hypothyroidism was higher than general population estimates (26% vs. 3.7%, P<0.05). No subject presented with myxedema coma or thyrotoxicosis. One subject (1.6%), a 61-year-old Caucasian female with ECD-related cerebellar dysfunction, retroperitoneal fibrosis, and osteosclerosis, harbored the BRAF V600E pathogenic variant and had a biochemical pattern suggestive of isolated central hypothyroidism: TSH 0.16 mcIU/mL, fT4 1.2 ng/dL and a normal baseline pituitary function test. She did not report symptoms suggestive of clinical thyroid disease and her physical examination was unremarkable. Pituitary MRI showed a small hypoenhancing lesion in the posterior aspect of the pituitary gland that is clinically insignificant. Dynamic TSH-secretion testing with a thyrotropin releasing hormone (200 μg IV synthetic TRH with serial TSH testing) demonstrated a blunted response in keeping with central hypothyroidism; baseline TSH 0.35 mcIU/mL, peak 2.90 mcIU/mL (ΔTSH <7 mcIU/mL). Conclusion: The prevalence of hypothyroidism (1 in 4) is high in subjects with ECD. Clinicians should have a low threshold to screen for hypothyroidism in this at-risk population. Central hypothyroidism is a rare manifestation of ECD and should be suspected in the setting of pituitary disease with a fT4 level below the laboratory reference range or low-normal levels in conjunction with a low, normal, or mildly elevated TSH.

Prevalence and potential determinants of subthreshold and major depression in the general population of Qatar

BackgroundThere is a paucity of epidemiological studies of depression in war-free Arab countries. This study estimated the prevalence and potential determinants of Subthreshold (SUBDE) and Major Depressive Episode (MDE) in migrants and non-migrants typical of Qatar and neighboring Gulf countries. MethodsA telephone survey of a probability-based sample of 2,424 participants was conducted in February 2017. The sample was divided based on nationality and income: Low-Income Migrants (LIMs), High Income Migrants (HIMs), and non-migrants or Qatari Nationals (QNs). Participants completed the nine-item Physician Health Questionnaire (PHQ-9). Ethnicity, sociodemographics, health- and work-related information was collected. Bivariate and multinomial logistic regression analyses were used. ResultsOverall prevalence of any depression ranged between 4.2% (95% CI: 3.3–5.3) and 6.6% (95% CI: 5.4–7.9) for a cut-off of 12 and 10, respectively. The diagnostic algorithm for SUBDE and MDE resulted in estimates of 5.5% (95% CI: 4.4–6.8) and 3.6% (95% CI: 2.8–4.5), respectively. SUBDE, but not MDE rates, were significantly increased in LIMs (OR=2.96, p = 0.004) and HIMs (OR = 2.00, p = 0.014) compared with non-migrants. Arab ethnicity was significantly associated with SUBDE: relative to South Asians (OR = 3.77, p < 0.001) and other ethnicities (OR = 3.61, p = 0.029). Arab ethnicity was significantly associated with MDE: relative to South Asians (OR = 10.42, p < 0.001) and South East Asians (OR = 3.54, p = 0.007). LimitationsClinical diagnostic interviews for depression were not included. ConclusionUsing the PHQ-9, depression prevalence in Qatar was comparable to general population estimates from Western countries. Migrant status and ethnicity were associated with SUBDE and MDE with implications for early screening and community intervention.

Clonal expansion of community-associated meticillin-resistant Staphylococcus aureus (MRSA) in people who inject drugs (PWID): prevalence, risk factors and molecular epidemiology, Bristol, United Kingdom, 2012 to 2017.

Background: In 2015, Bristol (South West England) experienced a large increase in cases of meticillin-resistant Staphylococcus aureus (MRSA) infection in people who inject drugs (PWID).Aim: We aimed to characterise and estimate the prevalence of MRSA colonisation among PWID in Bristol and test evidence of a clonal outbreak.Methods: PWID recruited through an unlinked-anonymous community survey during 2016 completed behavioural questionnaires and were screened for MRSA. Univariable logistic regression examined associations with MRSA colonisation. Whole-genome sequencing used lineage-matched MRSA isolates, comparing PWID (screening and retrospective bacteraemia samples from 2012-2017) with non-PWID (Bristol screening) in Bristol and national reference laboratory database samples.Results: The MRSA colonisation prevalence was 8.7% (13/149) and was associated with frequently injecting in public places (odds ratio (OR): 5.5; 95% confidence interval (CI):1.34–22.70), recent healthcare contact (OR: 4.3; 95% CI: 1.34–13.80) and injecting in groups of three or more (OR: 15.8; 95% CI: 2.51–99.28). People reporting any one of: injecting in public places, injection site skin and soft tissue infection or hospital contact accounted for 12/13 MRSA positive cases (sensitivity 92.3%; specificity 51.5%). Phylogenetic analysis identified a dominant clade associated with infection and colonisation among PWID in Bristol belonging to ST5-SCCmecIVg.Conclusions: MRSA colonisation in Bristol PWID is substantially elevated compared with general population estimates and there is evidence of clonal expansion, community-based transmission and increased infection risk related to the colonising strain. Targeted interventions, including community screening and suppression therapy, education and basic infection control are needed to reduce MRSA infections in PWID.

Severe mental illness and substance use disorders in prisoners in low-income and middle-income countries: a systematic review and meta-analysis of prevalence studies

SummaryBackgroundAlthough more than two thirds of the world's incarcerated individuals are based in low-income and middle-income countries (LMICs), the burden of psychiatric disorders in this population is not known. This review provides estimates for the prevalence of severe mental illness and substance use disorders in incarcerated individuals in LMICs.MethodsFor this systematic review and meta-analysis, we searched 17 electronic databases to identify prevalence studies of psychiatric disorders in prison populations in LMICs, published between January, 1987, and May, 2018. We included representative studies from general prison samples, providing information about four major psychiatric diagnoses: psychosis, major depression, alcohol use disorders, and drug use disorders. We pooled data from studies using random-effects meta-analyses and assessed the sources of heterogeneity by meta-regression. We extracted general population estimates from the Global Burden of Diseases 2016 database to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42015020905.FindingsWe identified 23 publications reporting prevalence estimates of severe mental illness and substance use disorders for 14 527 prisoners from 13 LMICs. In this population, the estimated pooled 1 year prevalence rates for psychosis were 6·2% (95% CI 4·0–8·6), 16·0% (11·7–20·8) for major depression, 3·8% (1·2–7·6) for alcohol use disorders, and 5·1% (2·9–7·8) for drug use disorders. We noted increased prevalence at prison intake and geographic variations for substance use disorders. For alcohol use disorders, prevalence was higher in the southeast Asian region than in the eastern Mediterranean region; and drug use disorders were more prevalent in the eastern Mediterranean region than in Europe. Prevalence ratios indicated substantially higher rates of severe mental illness and substance use disorders among prisoners than in the general population (the prevalence of non-affective psychosis was on average 16 times higher, major depression and illicit drug use disorder prevalence were both six times higher, and prevalence of alcohol use disorders was double that of the general population).InterpretationThe prevalence of major psychiatric disorders is high in prisoners in LMIC compared with general populations. As these findings are likely to reflect unmet needs, the development of scalable interventions should be a public health priority in resource-poor settings.FundingCONICYT of the Chilean government and the Wellcome Trust.

Use of combined hormonal contraceptives among women with systemic lupus erythematosus with and without medical contraindications to oestrogen.

To assess the prevalence of combined hormonal contraceptives (CHCs) in reproductive-age women with SLE with and without possible contraindications and to determine factors associated with their use in the presence of possible contraindications. This observational cohort study included premenopausal women ages 18-45 years enrolled in the SLICC Registry ⩽15 months after SLE onset, with annual assessments spanning 2000-2017. World Health Organization Category 3 or 4 contraindications to CHCs (e.g. hypertension, aPL) were assessed at each study visit. High disease activity (SLEDAI score >12 or use of >0.5 mg/kg/day of prednisone) was considered a relative contraindication. A total of 927 SLE women contributed 6315 visits, of which 3811 (60%) occurred in the presence of one or more possible contraindication to CHCs. Women used CHCs during 512 (8%) visits, of which 281 (55%) took place in the setting of one or more possible contraindication. The most frequently observed contraindications were aPL (52%), hypertension (34%) and migraine with aura (22%). Women with one or more contraindication were slightly less likely to be taking CHCs [7% of visits (95% CI 7, 8)] than women with no contraindications [9% (95% CI 8, 10)]. CHC use was low compared with general population estimates (>35%) and more than half of CHC users had at least one possible contraindication. Many yet unmeasured factors, including patient preferences, may have contributed to these observations. Further work should also aim to clarify outcomes associated with this exposure.

Hepatitis C Virus Infection in Indigenous Populations in the United States and Canada.

American Indian/Alaska Native (AI/AN) and Canadian Indigenous people are disproportionally affected by hepatitis C virus (HCV) infection yet are frequently underrepresented in epidemiologic studies and surveys often used to inform public health efforts. We performed a systematic review of published and unpublished literature and summarized our findings on HCV prevalence in these Indigenous populations. We found a disparity of epidemiologic literature of HCV prevalence among AI/AN in the United States and Indigenous people in Canada. The limited data available, which date from 1995, demonstrate a wide range of HCV prevalence in AI/AN (1.49%-67.60%) and Indigenous populations (2.28%-90.24%). The highest HCV prevalence in both countries was reported in studies that either included or specifically targeted people who inject drugs. Lower prevalence was reported in studies of general Indigenous populations, although in Canada, the lowest prevalence was up to 3-fold higher in Aboriginal people compared with general population estimates. The disparity of available data on HCV prevalence and need for consistent and enhanced HCV surveillance and reporting among Indigenous people are highlighted. HCV affects Indigenous peoples to a greater degree than the general population; thus we recommend tribal and community leaders be engaged in enhanced surveillance efforts and that funds benefitting all Indigenous persons be expanded to help prevent and cover health care expenses to help stop this epidemic.