Intravenous Cocaine Use Research Articles

Addiction and pregnancy: case report on gender perspective.

IntroductionIn recent years, interest has grown in understanding the particularities of addiction in women. One of these singularities, with an important impact on public health, is pregnancy. Substance use during pregnancy has increased in recent decades. Given that addiction is mainly a chronic disease of the brain circuits of reward, motivation and memory, an event such as pregnancy does not exempt people who suffer from substance use disorder (SUD) from the difficulties of achieving abstinence. Moreover, as addiction often involves cycles of relapse and remission, pregnant women can also suffer a relapse even if they previously had achieved abstinence. On the other hand, given that addiction is a disease with a significant social component, we can find patients in precarious economic and social situations who suffer unwanted and therefore unplanned pregnancies.ObjectivesTo describe the case of a pregnant woman with SUD for multiple drugs who is admitted to the inpatient ward of the Hospital Clínic of Barcelona for detoxification. Also to reflect, taking in to account gender perspective, on the particularities of substance use in women on childbearing age.MethodsWe present the case of a 25-year-old woman, six weeks pregnant and homeless, who was admitted to the inpatient ward for presumed psychotic symptoms. Even if the patient had a history of intravenous heroin, cocaine, and methamphetamine use, during the admission she only admitted current alcohol consumption (3 UBE/day). During admission, the patient decided to undergo a legal voluntary abortion. Regarding this case, we did a literature review on the consequences of different substances use to pregnancy (to both the fetus and the mother’s health). Likewise, we reflected on interventions that could be carried out in community mental health facilities to detect cases like the one exposed and provide help.Results Poor obstetric outcomes are six times higher in patients who use substances. Newborns can have withdrawal syndrome, spontaneous abortion, pre-term birth, fetal malformations and fetal growth restriction. More than 50% of women of reproductive age use drugs, mainly alcohol. Routine screening and education of women of reproductive age is the best way to reduce substance use during pregnancy.ConclusionsWe consider it essential for a better management of these patients to remember that the evidence suggests that the decisions that addicts make are mainly driven by a pathology, not by a moral failure. However, pregnancy can be a moment of greater motivation to stop using drugs, given that it is a high risk situation for the mother and the fetus.Disclosure of InterestNone Declared

Cortical thickness and subcortical volume abnormalities in male crack-cocaine users

Crack-cocaine offers a higher risk of abuse than intranasal and intravenous use of cocaine. Yet, current treatments remain disappointing and our understanding of the mechanism of crack-cocaine neurotoxicity is still incomplete. Magnetic resonance images studies on brain changes of crack-cocaine addicts show divergent data. The present study investigated gray matter (GM) abnormalities in crack-cocaine dependents (n = 18) compared to healthy controls (n = 17). MRI data was analysed using FreeSurfer and voxel-based morphometry (VBM). FreeSurfer analysis showed that CD had decreased cortical thickness (CT) in the left inferior temporal cortex (lTC), left orbitofrontal cortex (lOFC) and left rostro frontal cortex (lRFC), enlargement in left inferior lateral ventricle, and smaller GM volume in right hippocampus and right ventral diencephalon. VBM analysis showed that CD had significantly decreased GM volume in left Putamen and left nucleus accumbens. Furthermore, we found a negative correlation between duration of crack-cocaine use and lTC CT. These results provide compelling evidence for GM abnormalities in CD and also suggest that duration of crack-cocaine use may be associated with CT alterations.

Retraction Note to: Multifocal multi-organ ischaemia and infarction in a preterm baby due to maternal intravenous cocaine use: a case report.

Introduction Although the adverse effects of cocaine use in pregnancy are well recognised, we believe this case highlights the importance of considering the route of administration, and suggests the possibility of multifocal damage relating to intravenous use.

Outbreak of invasive Streptococcus pneumoniae serotype 12F among a marginalized inner-city population in Winnipeg, Canada, 2009-2011.

In 2010, Winnipeg, Canada, experienced a doubling of invasive pneumococcal disease (IPD) rates, with a significant increase in the number of cases due to Streptococcus pneumoniae serotype 12F, which previously had accounted for very few cases each year. All serotype 12F IPD cases reported between September 2009 and January 2011 were reviewed. Pulsed-field gel electrophoresis (PFGE) and multilocus variable number tandem repeat analysis (MLVA) were conducted on all isolates. PFGE and MLVA patterns identified several possible clusters. Additional interviews were conducted to obtain information on risk factors and outcomes. Between September 2009 and January 2011, 169 cases of IPD were identified. The number of IPD cases due to 12F serotype increased sharply from about 3-4 cases per year (6% of IPD cases) in 2007-2009 to 28 (29%) in 2010. All 12F isolates belonged to a single sequence type (ST218), and they were generally susceptible to penicillin and fluoroquinolones but not to erythromycin. Compared with cases caused by other serotypes, patients with serotype 12F were more likely to be homeless, reside in low-income inner-city communities, and engage in substance abuse, including intravenous and crack cocaine use. Subclusters identified using MLVA had even higher rates of homelessness and substance use. An immunization campaign targeting high-risk groups was undertaken with pneumococcal polysaccharide vaccine, and subsequently rates of serotype 12F decreased. To our knowledge, this is the largest documented community outbreak of serotype 12F IPD and the first report of an outbreak of IPD serotype 12F in a marginalized urban population in Canada.

Psychotic Symptoms of Cocaine Self-Injectors in a Harm Reduction Program

ABSTRACT Background: Psychotic symptoms are common among cocaine users. Methods: An observational naturalistic study on the effects and events of intravenous cocaine use in a drug consumption room was carried out; the patients were diagnosed of cocaine dependence (according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). Results: Twenty-one patients, 81% men self-injected cocaine 375 times. Psychotic symptoms were observed in 62% of the patients and 21% of the self-injections; delusions were observed in 9.3%, psychotic self-reference with insight in 9.1%, illusions in 6.4%, and hallucinations in 5.3%. A higher presence of psychotic symptoms was noted with cannabis used in the previous month (76.9% versus 44.4%; P = .001) (no psychotic symptoms group); also, a greater use of benzodiazepines was observed: 75.6% versus 63.6% (P = .046). Lower use of methadone in the group with psychosis was observed: 75.6% versus 97.3% (P = .001). Motor alterations were tremor 58%, stereotyped movements 24%, and behaviour alteration 6%, significantly more frequent in the psychotic group. Conclusions: Thus, there was a high frequency of psychotic symptoms after intravenous cocaine use; patients with psychotic symptoms reported higher use of cannabis and benzodiazepines in the previous month and lower use of methadone. More tremors and stereotyped movements were observed in the group with psychotic symptoms. It is necessary to give a special approach to cocaine intravenous users.

ANCA-positive vasculitis induced by levamisole-adulterated cocaine and nephrotic syndrome: The kidney as an unusual target

Patient: Male, 36Final Diagnosis: Levamisole-induced vasculopathySymptoms: Purpuric skin lesionsMedication: LevamisoleClinical Procedure: —Specialty: Internal MedicineObjective:Unusual clinical courseBackground:Levamisole has been detected in seized cocaine samples and a levamisole-induced vasculopathy (LIV) has been described, mainly focused on skin.Case Report: A 36-year-old Caucasian man with history of antibodies to hepatitis C infection (negative hepatitis C virus RNA and negative HIV serology), smoking, and intravenous use of cocaine and brown heroin, presented to the hospital with purpuric skin lesions on extremities and earlobes. One month before the current presentation, a skin punch biopsy of one of these lesions was performed, showing histopathologic findings suggestive of mixed cryoglobulinemia. Laboratory testing revealed leukopenia, renal failure, and nephrotic syndrome. Antimyeloperoxidase antineutrophil cytoplasmic antibodies (MPO-ANCA) were positive. The previous skin punch biopsy was revised and demonstrated pathologic findings consistent with leukocytoclastic vasculitis. An analysis of a cocaine sample for personal use, provided by the patient, was performed using mass spectrometry-gas chromatography and levamisole was detected. Three boluses of intravenous methylprednisolone were administered, followed by oral prednisone 1 mg/Kg per day. Skin lesions and renal function improved.Conclusions:To our knowledge, this is the first report of nephrotic syndrome induced by levamisole-adulterated cocaine, proven by cocaine sample toxicology. Lack of renal biopsy is a limitation of this report.

Addiction services in Cyprus: Results of an EU Twinning Project

Introduction: This evaluation is part of a Twinning Project between Cyprus and Germany, aimed at evaluating the governmental drug services in Cyprus and promoting the improvement and introduction of new drug treatment services, in order to assist the new Member State in the implementation and harmonization with the European Community's legislation.Methods: A field investigation studied parameters as population in need, treatment demand and coverage, as well as high-risk patterns and their trend over the past years.Results: The main findings were a high level of problematic drug use, mainly high-risk intravenous heroin and cocaine use, and an increase treatment demand for women, adolescents and migrants. Expert interviews named gaps in treatment options, including a previous lack of maintenance treatment, insufficient harm reduction measures and inadequate treatment concepts to meet specific needs of problematic drug users.Discussion: Recommendations for improvement can be integrated into present services. Cypriot authorities have started implementing the suggestions, so that an overall improvement of services can be expected in the future.

Trends in Human Immunodeficiency Virus Incidence and Risk Behavior Among Injection Drug Users in Montreal, Canada: A 16-Year Longitudinal Study

The authors sought to investigate trends in the incidence of human immunodeficiency virus (HIV) infection, evaluate changes in risk behavior, and assess associations between syringe access programs and HIV seroconversion among injection drug users (IDUs) in Montreal, Canada, who were recruited and followed for a prospective cohort study between 1992 and 2008. Methods included Kaplan-Meier survival analysis and time-varying Cox regression models. Of 2,137 HIV-seronegative IDUs at enrollment, 148 became HIV-positive within 4 years (incidence: 3.3 cases/100 person-years; 95% confidence interval: 2.8, 3.9). An annual HIV incidence decline of 0.06 cases/100 person-years prior to 2000 was followed by a more rapid annual decline of 0.24 cases/100 person-years during and after 2000. Behavioral trends included increasing cocaine and heroin use and decreasing proportions of IDUs reporting any syringe-sharing or sharing a syringe with an HIV-positive person. In multivariate analyses, HIV seroconversion was associated with male gender, unstable housing, intravenous cocaine use, and sharing syringes or having sex with an HIV-positive partner. Always acquiring syringes from safe sources conferred a reduced risk of HIV acquisition among participants recruited after 2004, but this association was not statistically significant for participants recruited earlier. In conclusion, HIV incidence has declined in this cohort, with an acceleration of the reduction in HIV transmission after 2000.

Striatal regulation of ΔFosB, FosB, and cFos during cocaine self‐administration and withdrawal

Chronic drug exposure induces alterations in gene expression profiles that are thought to underlie the development of drug addiction. The present study examined regulation of the Fos-family of transcription factors, specifically cFos, FosB, and ΔFosB, in striatal subregions during and after chronic intravenous cocaine administration in self-administering and yoked rats. We found that cFos, FosB, and ΔFosB exhibit regionally and temporally distinct expression patterns, with greater accumulation of ΔFosB protein in the nucleus accumbens (NAc) shell and core after chronic cocaine administration, whereas ΔFosB increases in the caudate-putamen (CPu) remained similar with either acute or chronic administration. In contrast, tolerance developed to cocaine-induced mRNA for ΔFosB in all three striatal subregions with chronic administration. Tolerance also developed to FosB expression, most notably in the NAc shell and CPu. Interestingly, tolerance to cocaine-induced cFos induction was dependent on volitional control of cocaine intake in ventral but not dorsal striatal regions, whereas regulation of FosB and ΔFosB was similar in cocaine self-administering and yoked animals. Thus, ΔFosB-mediated neuroadaptations in the CPu may occur earlier than previously thought with the initiation of intravenous cocaine use and, together with greater accumulation of ΔFosB in the NAc, could contribute to addiction-related increases in cocaine-seeking behavior.

Endocarditis with pulmonary and systemic embolization

A 45-year-old woman with a history of intravenous drug use and tricuspidal endocarditis was admitted to our medical center with a 1-week history of fever and dyspnea. She reported recent intravenous cocaine use. On admission she was normotensive, febrile (temperature 38 C), mildly tachycardic (heart rate 105 beats/min) and tachypneic (respiratory rate 20 breaths/min) with an oxygen saturation of 92%. Examination revealed nonlabored breathing with equal breath sounds. No lymphadenopathy, splenomegaly, or rash was identified. Laboratory tests showed a leukocytosis and increased levels of C-reactive protein. Chest radiography revealed a peripheral right infiltrate. Electrocardiography was unremarkable. Transthoracic echocardiogram detected the presence of a mobile mass (10 mm) attached to the posterior leaflet of the tricuspid valve. A diagnose of right-sided endocarditis was made. Blood cultures demonstrated methicillin-sensitive Staphylococcus aureus. An HIV test was negative. Treatment with oxacillin, gentamicin, and ampicillin was started. During hospitalization, the fever resolved, but the patient complained of worsening dyspnea and left flank pain. Physical examination was unchanged except for the appearance of splinter hemorrhages and tender, subcutaneous nodules on the second finger of the right hand (Fig. 1). A CT scan of the chest and abdomen was performed, and revealed multiple peripheral pulmonary infiltrates consistent with septic pulmonary emboli (Fig. 2) and a splenic hypoperfusion area (Fig. 3). In consideration of pulmonary and systemic embolization, in order to make a differential diagnosis between paradoxical embolism and bilateral endocarditis, a transesophageal echocardiogram study was proposed, but the patient refused. Transthoracic echocardiogram was repeated. The examination confirmed the tricuspid valve vegetation, and revealed the presence of another vegetation attached to the posterior leaflet of the mitral valve (5 mm). Septal defects and cardiac complications were not observed. Based on these findings, pulmonary and systemic embolization was interpreted as a consequence of bilateral endocarditis. The patient was transferred to the Infectious Disease Unit. Antibiotic treatment was continued. The general condition improved, and no further complications occurred.

P03-257 - Psychotic symptoms in cocaine injecting drug users, report of healthcare professionals working in a medically supervised injection clinic (MSICS)

ObjectivesDescribe the prevalence and characteristics of psychotic symptoms in the context of cocaine injection use in a harm reduction program.To find associations between intravenous cocaine use and other drug use in cocaine dependent patients suffering from cocaine induced psychosis (CIP). Cannabis was found to be a risk factor for developing CIP in non-intravenous cocaine dependence.MethodsDuring a period of 6 months professionals from our Outpatient Drug Clinic completed a confidential questionnaire to describe the adverse clinical effects following cocaine injection. It included age, gender, ethnic group, daily consumption rate and other drugs used in the last 30 days.ResultsSurvey was achieved with a sample of 75 Caucasians patients, 69 men and 6 women with an average age of 32 years old. Seventeen percent (13/75) had psychotic symptoms, of which 84% (11/13) had hallucinations (visuals 4/11, auditive 7/11 and kinaesthetic 2/11), 15% (2/13) illusions.Eighteen percent (14/75) had stereotypy movements and 3% (2/75) had aggressive behaviour. Drugs used by CIP patients, the previous 30 days were: 61% (8/13) cannabis, 31% (4/13) opiates and 15% (2/13) alcohol.ConclusionsIntravenous cocaine use produced acute psychotic symptoms in 17% of our patients, of which 61% used cannabis. Despite the ethical and practical implications of this type of study, it is necessary to do more observational studies with bigger surveys to conclude these results with statistically significance.

RETRACTED ARTICLE: Multifocal multi-organ ischaemia and infarction in a preterm baby due to maternal intravenous cocaine use: a case report

IntroductionAlthough the adverse effects of cocaine use in pregnancy are well recognised, we believe this case highlights the importance of considering the route of administration, and suggests the possibility of multifocal damage relating to intravenous use.Case presentationA Caucasian female baby of 29-weeks' gestation was spontaneously delivered and subsequently developed multi-organ failure considered unrelated to simple prematurity. Intensive care was re-orientated following the development of massive intraventricular haemorrhage.ConclusionThis case illustrates the need for regular cranial ultrasound in babies of pregnancies at risk due to intravenous cocaine use and also the necessity of counselling women who misuse cocaine in the antenatal period. As such, this article will be of most interest to paediatric and obstetric staff.

Multifocal multi-organ ischaemia and infarction in a preterm baby due to maternal intravenous cocaine use: a case report

Although the adverse effects of cocaine use in pregnancy are well recognised, we believe this case highlights the importance of considering the route of administration, and suggests the possibility of multifocal damage relating to intravenous use. A Caucasian female baby of 29-weeks' gestation was spontaneously delivered and subsequently developed multi-organ failure considered unrelated to simple prematurity. Intensive care was re-orientated following the development of massive intraventricular haemorrhage. This case illustrates the need for regular cranial ultrasound in babies of pregnancies at risk due to intravenous cocaine use and also the necessity of counselling women who misuse cocaine in the antenatal period. As such, this article will be of most interest to paediatric and obstetric staff.

Multifocal multi-organ ischaemia and infarction in a preterm baby due to maternal intravenous cocaine use: a case report

IntroductionAlthough the adverse effects of cocaine use in pregnancy are well recognised, we believe this case highlights the importance of considering the route of administration, and suggests the possibility of multifocal damage relating to intravenous use.Case presentationA Caucasian female baby of 29-weeks’ gestation was spontaneously delivered and subsequently developed multi-organ failure considered unrelated to simple prematurity. Intensive care was re-orientated following the development of massive intraventricular haemorrhage.ConclusionThis case illustrates the need for regular cranial ultrasound in babies of pregnancies at risk due to intravenous cocaine use and also the necessity of counselling women who misuse cocaine in the antenatal period. As such, this article will be of most interest to paediatric and obstetric staff.

Increasing Prevalence of Cocaine as the Primary Detoxification Diagnosis among Admissions Presenting with Current Intravenous Drug Use

Abstract Objectives: This study sought to document the trends in drug use among intravenous drug users (IDUs) in northern British Columbia, and to discuss the public health implications. Method: We conducted a 7-year medical-chart review of all IDU-related admissions (n=2072) to an inpatient alcohol and drug detoxification centre in Prince George, British Columbia. Primary detoxification diagnosis was modeled onto year of admission using generalized estimating equations (GEE). Results: Our study demonstrated an increasing prevalence of cocaine as the primary detoxification diagnosis in IDU-related admissions in northern BC, from 32% of all IDU admissions in 1999 to 64% in 2001, and then a relatively steady elevated rate of approximately 60% between 2001-2005. Conclusions: Given that needle exchange programs and other harm reduction services for IDUs in British Columbia are not readily available in many northern and rural areas, the risks associated with intravenous cocaine use among northern IDUs represent a serious public health challenge. Tailored harm reduction strategies should take into account the prominence of intravenous cocaine use as an HIV risk factor. In areas without well-established intravenous drug use monitoring programs, such as rural and remote areas, detoxification treatment records may serve as important sentinels for changing drug use patterns among IDUs. Key words: Substance abuse, intravenous; cocaine; rural health services; treatment centers, substance abuse Resume Objectifs : Notre etude visait a documenter les tendances de la consommation de drogue chez les utilisateurs de drogue injectable (UDI) dans le Nord de la Colombie-Britannique et a examiner leurs consequences pour la sante publique. Methode : Nous avons examine les fiches medicales sur 7 ans de toutes les hospitalisations d’UDI (n=2 072) dans un centre de desintoxication de Prince George (Colombie-Britannique). Le principal diagnostic de desintoxication a ete modelise sur l’annee d’hospitalisation a l’aide d’equations d’estimation generalisees (EEG). Resultats : L’etude a montre une prevalence croissante de l’abus de cocaine comme principal diagnostic de desintoxication dans les hospitalisations liees a l’utilisation de drogues injectables du Nord de la Colombie-Britannique; ce diagnostic est passe de 32 % des hospitalisations d’UDI en 1999 a 64 % en 2001, puis il s’est stabilise a un niveau relativement eleve (environ 60 %) entre 2001 et 2005. Conclusion : Etant donne que les programmes d’echange de seringues et autres services de reduction des mefaits destines aux UDI en Colombie-Britannique ne sont pas aisement accessibles dans de nombreuses regions nordiques et rurales, les risques associes a l’injection de cocaine chez les UDI du Nord presentent un defi de taille pour la sante publique. Les strategies de reduction des mefaits adaptees doivent tenir compte de la predominance de la consommation de cocaine par voie intraveineuse comme facteur de risque du VIH. Dans les secteurs qui n’ont pas de programmes etablis pour la surveillance de l’utilisation de drogues injectables, les regions rurales et eloignees par exemple, les dossiers des centres de desintoxication peuvent etre d’importantes sentinelles des changements dans les habitudes de consommation de drogue des UDI. Mots cles : abus de drogues intraveineuses; cocaine; services de sante ruraux; centres de desintoxication

Pulmonary Complications of Illicit Drug Use

The aim of this manuscript is to summarize an approach to the differential diagnosis of the pulmonary complications of illicit drug use based on the computed tomography findings. The various pulmonary complications of illicit drug use result in 5 main patterns of parenchymal abnormality: nodules, ground-glass opacities, consolidation, air trapping, and emphysema. Other thoracic manifestations of illicit drug use include pulmonary arterial hypertension, pneumomediastinum, bacterial endocarditis, discitis, and septic arthritis.

High hepatitis C incidence in new injecting drug users: a policy failure?

Evidence of ongoing hepatitis C (HCV) transmission among injecting drug users (IDUs) suggests a need for a better understanding of seroconversion characteristics among new IDUs and other vulnerable subgroups. This study aimed to determine incidence of HCV and associated risk factors among new IDUs in Sydney. IDUs who had injected drugs in the past six months and who were unaware of their antibody HCV status or knew their serostatus to be negative were recruited through street-based outreach, methadone clinics and needle and syringe programs in south-western Sydney. Anti-HCV negative IDUs (n = 215) were enrolled and followed-up at 3-6 monthly intervals. New IDUs (n = 204) were defined as aged below 30 years or injecting for < or = 6 years at baseline. A total of 61 seroconversions were observed and incidence was 45.8 per 100 person years. Independent predictors of seroconversion were duration of injecting < 1 year (IRR = 3.10; 95% CI 1.47-6.54), female gender (IRR = 2.0; 95% CI 1.16-3.45), culturally and linguistically diverse background (CALDB) (IRR = 2.03; 95% CI 1.06-3.89) and intravenous cocaine use (IRR = 2.37; 95% CI 1.26-4.44). While new IDUs shared common risk factors, strong associations were observed between HCV seroconversion and sharing syringes, sharing other injecting equipment and backloading in CALDB new IDUs. Incidence of HCV infection among new IDUs in Sydney is unacceptably high. Extremely high rates of incident infection among newly initiated CALDB IDUs indicate an urgent need for enhanced policy and resource commitments to reduce the vulnerability of this group to HCV and other blood-borne infections.

High hepatitis C incidence in new injecting drug users: a policy failure?

Objective: Evidence of ongoing hepatitis C (HCV) transmission among injecting drug users (IDUs) suggests a need for a better understanding of seroconversion characteristics among new IDUs and other vulnerable subgroups. This study aimed to determine incidence of HCV and associated risk factors among new IDUs in Sydney. Methods: IDUs who had injected drugs in the past six months and who were unaware of their antibody HCV status or knew their serostatus to be negative were recruited through street-based outreach, methadone clinics and needle and syringe programs in south-western Sydney. Anti-HCV negative IDUs (n=215) were enrolled and followed-up at 3–6 monthly intervals. New IDUs (n=204) were defined as aged below 30 years or injecting for 6 years at baseline. Results: A total of 61 seroconversions were observed and incidence was 45.8 per 100 person years. Independent predictors of seroconversion were duration of injecting < 1 year (IRR=3.10; 95% Cl 1.47-6.54), female gender (IRR=2.0; 95% CI 1.16-3.45), culturally and linguistically diverse background (CALDB) (IRR=2.03; 95% CI 1.06-3.89) and intravenouscocaine use (IRR=2.37; 95% CI 1.26-4.44). While new IDUs shared common risk factors, strong associations were observed between HCV seroconversion and sharing syringes, sharing other injecting equipment and backloading in CALDB new IDUs. Conclusion: Incidence of HCV infection among new IDUs in Sydney is unacceptably high. Implications: Extremely high rates of incident infection among newly initiated CALDB IDUs indicate an urgent need for enhanced policy and resource commitments to reduce the vulnerability of this group to HCV and other blood-borne infections.

Methadone Maintenance Treatment (MMT) in General Practice or in Specialized Centers: Profile of Patients in the Swiss Canton of Vaud

We studied profile of patients (n = 1782) treated in specialized centers and general practice (GP) enrolled in methadone maintenance treatment (MMT) programs during 2001 in the Swiss Canton of Vaud. We found that GPs treated the majority of patients (76%). Specialized centers treated a higher proportion of patients with uncontrolled intravenous use of cocaine and heroin, and prescribed neuroleptics as concomitant medication three times more frequently than GPs. Patients treated in specialized centers were more likely to undergo screening for HIV, HBV, HCV, and receive complete HBV immunization. In conclusion, specialized centers are more likely to treat severely addicted patients and patients with a poor global assessment (physical, psychiatric, and social).

High Rate of Infection with Hepatitis C Virus Genotype 4 in a District of Galicia, Spain

It is estimated that 170 million individuals are infected with hepatitis C virus (HCV) worldwide (6). The genetic heterogeneity of the virus has revealed six major genotypes. Most of the information on treatment of chronic hepatitis C comes from genotypes 1, 2, and 3, the predominant strains in the United States and Europe. Genotype 4 is more prevalent in Africa and the Middle East and has been frequently associated with evolution to cirrhosis and a poor response to conventional alpha interferon-based regimens (2, 8). The aim of this study is to evaluate epidemiological factors, liver histology, and response to combination therapy with interferon and ribavirin of a series of patients infected with genotype 4. From a total of 350 patients with hepatitis C referred to our Liver Unit from January 1999 to June 2004, 33 patients infected with genotype 4 (9.4%) were identified. Information about their demographics, mode of transmission, and laboratory data was collected. The date of transmission of infection was established by the year of first use of drugs in the case of intravenous drug use and snorting of cocaine and the year of the transfusion, surgery, or tattoo for the remaining forms of transmission. Serum HCV RNA levels were quantified by reverse transcription-PCR assay (Amplicor Monitor HCV 2.0; Roche). HCV genotyping was carried out using a line probe assay (INNO-LIPA HCV II; Innogenetics, Ghent, Belgium). Liver histology was available for 25 patients, and the histological fibrosis stage was assessed according to the score of Scheuer. Thirteen patients were treated with alpha-2b interferon and ribavirin in combination at standard doses. Six were treated with pegylated interferon and ribavirin. HCV RNA was assessed at baseline and at 3, 12, and 18 months after starting treatment. Sustained virologic response was defined as negative HCV RNA 6 months after treatment was stopped. The baseline demographics, liver histology, and biochemical data from these patients are summarized in Table ​Table1.1. All the patients were natives of Galicia and denied having traveled to areas of endemicity. A risk factor for exposure to HCV was noted for most of the patients (90.9%), and the main route of infection was intravenous drug use. The estimated mean age at the moment of infection was 22.4 ± 9.8 years. TABLE 1. Characteristics of genotype 4 patients The baseline HCV RNA level was above 2 × 106 copies/ml in nine cases. Most of the patients had mild to moderate liver disease on biopsy. Only one patient had cirrhosis by clinical, endoscopic, and ultrasonographic criteria. Mixed-genotype HCV infection was not detected in this population. Twelve patients have completed 12 months of therapy. Only one patient discontinued therapy because of side effects. Ten of the patients who completed treatment were considered sustained responders, whereas one was a nonresponder and one relapsed. Overall, 10 of the 13 patients who initiated therapy (76.9%) had a sustained response. Six of them were treated with pegylated interferon and four with standard interferon in combination with ribavirin. Patients with pretreatment HCV-RNA levels lower than 2 × 106 copies/ml had a significantly higher rate of sustained virologic response than patients with a higher viral load (P = 0.03), whereas the liver fibrosis score did not affect the response. The rate of 9.4% for this genotype in our area is noteworthy for a Western country, though it has been found in other districts of northern and southern Spain, in the latter with an even higher frequency (4, 3). Epidemiological and clinical characteristics found in this series differ from those for African and Middle Eastern countries. All patients were white, and, as expected in the Occidental world, the predominant mode of acquisition of the infection was intravenous drug use in almost two-thirds of the cases. This is in agreement with reports from other Western countries. In contrast, a high proportion of HCV infection from an unknown source was observed in Egypt, a country with one of the highest prevalences of genotype 4, and in Kuwait (2). An iatrogenic route was suggested by a study in Egypt, with a major role for parenteral antischistosomal therapy in the spread of HCV (1). The histological stage assessment reflects mild to moderate liver disease. On the other hand, studies with African and Middle Eastern populations suggest a frequent association with cirrhosis and a rapid fibrosis progression rate following liver transplantation (5, 7). Although this genotype was previously categorized as difficult to treat, our results are in accordance with the more recent trials that suggest a response intermediate between those of genotype 1 and non-1 genotypes. In conclusion, the prevalence of genotype 4 in our area is high in comparison with that for other Western countries. The majority of patients acquired the infection through intravenous drug use and had a histological assessment of mild to moderate liver disease.