Rates Of Intravenous Drug Use Research Articles

Surgical Treatment Methods for Tricuspid Valve Infective Endocarditis

Introduction: In recent years, there has been a significant increase in the incidence of tricuspid valve infective endocarditis (IE), which is associated with both the increased number of invasive examinations and procedures and the high rates of intravenous drug use. The initial treatment for tricuspid valve IE was surgical removal of the focus of infection and restoration of intracardiac hemodynamics.Reconstructive surgery aimed at preserving the valve is the preferred method of surgical treatment. If a valve-­preserving operation is not possible due to significant valvular apparatus destruction, implantation of artificial heart valves (both mechanical and biological) is the method of choice.Objective: To analyze the results of reconstructive valve-­preserving surgery and tricuspid valve replacement for tricuspid valve IE treatment.Materials and methods: In the Scientific Research Institute – Specialized Cardiac Surgery Clinical Hospital named after Academician B.A. Korolev (Nizhny Novgorod, Russian Federation) 110 patients underwent surgery for tricuspid valve IE. Primary surgery was performed in 97 patients, and 13 patients underwent repeated surgery. The patients were divided into 2 groups based on the chosen surgical method for correcting tricuspid valve disease. Group 1 included 62 patients who successfully underwent tricuspid valve replacement: mechanical prostheses in 10 patients and biological prostheses in 52 patients. Group 2 included 38 patients who underwent reconstructive valve­preserving surgery. All patients underwent De Vega annuloplasty. In 10 patients it was directly associated with bicuspidalization of the tricuspid valve and plastic surgery of intact leaflets. Two patients had suture annuloplasty of the tricuspid valve based on the modified technique. In 2 of 3 patients, an infected right atrial thrombus was removed. Three patients underwent removal of the left ventricular wall abscess and aortic valve replacement for critical stenosis. After translocation of the chords, triangular resection of the anterior leaflet was performed to separate the chord of the left side of the chest and the myxoma of the right and left chest.Results: In the early postoperative period, no valve­related complications were observed in group 1. The most common nonlethal complication was a third­-degree atrioventricular block. Multiple organ dysfunction syndrome occurred in 3 patients; cardiac tamponade was reported in 2 patients, and 1 patient had postoperative bleeding that required resternotomy for serous mediastinitis in the mid­term period and reosteosynthesis. At the hospital stage, 1 patient from group 1 died, whereas there were no deaths in group 2. In­-hospital mortality in the groups of operated patients was 0.9%.Functional ultrasound imaging findings in the postoperative period show that patients from group 1 had the peak gradient across the prosthetic tricuspid valve of 9.4 ± 1.8 mm Hg, while the mean gradient was 5.8 ± 1.75 mm Hg. There was a significant decrease in the estimated right ventricle pressure from 54.0 ± 16.2 to 35.0 ± 5.5 mm Hg. In group 2 tricuspid valve regurgitation was not observed in 27 patients, while mild and moderate regurgitation was reported in 8 and 3 patients, respectively. The peak gradient during the tricuspid valve reconstruction was 6.2 ± 1.7 mm Hg, while the mean gradient was 2.8 ± 0.75 mm Hg. The annulus fibrosus size during tricuspid valve annuloplasty averaged 30.8 ± 2.5 (28­33) mm. There was a decrease in the right ventricle pressure from 44.0 ± 18.4 to 32.0 ± 7.3 mm Hg. In the mid-­term follow­up, surviving patients were classified as NYHA classes I­-II. Of 110 patients discharged from the clinic, we were able to trace the fate of 69 patients, which accounted for 62.7%. In the long-­term period, 3 patients from group 1 died. Thus, long­term mortality in the general group was 2.72%.Conclusions: Reconstructive surgery has significant advantages over tricuspid valve replacement using various artificial heart valve models: lower rates of in-­hospital and long­-term mortality and specific complications, higher quality of life. Compliance with principles and methods of pathogenetic treatment of electrode­induced IE guarantees a success in the cohort of severe patients. The technique of reconstruction and restoration of tricuspid valve structures and functions in case of active tricuspid valve IE with detachment of the chords and destruction of the leaflets demonstrated high surgical efficiency.

Adaptation of the NIDA Standard for delivery via Facebook with justice-involved women in rural Appalachia.

Rising rates of intravenous drug use (IDU) in Appalachia have necessitated new approaches to providing risk-reduction interventions in a manner which will be acceptable and accessible to specific at-risk populations-particularly those with limited access to traditional evidence-based interventions. Using the ADAPT-ITT framework, the overall goal of this study is to adapt an evidence-based HIV prevention intervention-the NIDA Standard-to meet the needs of rural drug-using women post-release from jail. Through a series of focus groups with rural incarcerated women, theater-testing with members of the target population, and iterative refinements with topical experts, we aimed to identify potential adaptations to content and context to improve the fit, feasibility, and acceptability of the NIDA Standard for this population using social media. Study findings confirmed the need for a preventive risk-reduction intervention targeting this population post-release. Adaptations to intervention content focused on adding, simplifying, and ensuring continuous access to content in the NIDA Standard. Adaptations to context included modifications to how the intervention will be delivered and by whom, including consideration of unique issues related to delivery using Facebook (such as privacy and confidentiality). The use of Facebook for delivery of the NIDA Standard may hold promise for increasing reach, acceptability, and feasibility of intervening with rural women with IDU released from jails, particularly when compared with traditional face-to-face sessions. With minor content adaptations to meet participant needs and preferences, plus multiple context adaptations to enhance accessibility and acceptability, the adapted NIDA Standard is intended to retain its original effectiveness while improving important implementation outcomes key to scaling-up and increasing public health impact. What is known about the topic? Injection drug use rates are high in rural Appalachia, and new approaches are needed to reduce the risk of HIV and HCV among injection drug using women involved in the criminal justice system in this region. While there are effective risk-reduction interventions for HIV and HCV, they are difficult to deliver in rural Appalachia and do not reach the women who need them. What does this paper add? This study describes the use of a systematic approach to improve the "fit" of an evidence-based intervention-the NIDA Standard-with the preferences and perspectives of injection drug using women involved with the justice system, aided by guidance from experts in a specific risk-reduction intervention (the NIDA Standard) and delivery of interventions using Facebook. Changes to the intervention to increase its acceptability and accessibility in this population included shifting delivery of the intervention to a closed Facebook group rather than in person; use of brief videos rather than written text to provide information; use of trusted local women to provide information through videos and Facebook posts; and inclusion of local information on community risk factors and resources. Implications for practice, research, or policy: The use of Facebook for delivery of the NIDA Standard holds promise for increasing reach, acceptability, and feasibility of risk reduction among rural injection drug using women released from jails. Next steps include testing the feasibility, acceptability, and effects of the adapted intervention in several rural Appalachian counties.

Infective endocarditis: trends, surgical outcomes, and controversies.

The number of hospitalizations and surgical cases of infective endocarditis (IE) are increasing. The aim of this study was to review these trends, surgical outcomes, and controversies related to IE. A search of MEDLINE of studies published between 1960 and 2018 was conducted. Search terms included "infective endocarditis", "history of", "trend", "epidemiology", "outcome", "medical management", "surgery", "indication", and "re-operative surgery", or any combination thereof. The United States has the highest incidence of IE in the world at 15 per 100,000 people, with increases in incidence due to the aging population as well as increasing rates of intravenous drug use (IVDU). National guidelines support early surgical intervention in specific clinical settings in both left and right-sided IE. However, only 11% of the evidence used in formulating guidelines for surgical therapy in IE are based on level A evidence. Ongoing controversies include whether to perform surgery in the setting of continued or recurrent IVDU in a patient with a prior valve operation, timing of surgery after acute stroke due to IE, and general indications for surgery for tricuspid valve IE. IE has a surging incidence and increasing burden on the healthcare system in the United States. Multiple controversies exist, and formulating level A evidence and multidisciplinary collaboration will be essential components to effectively treating this complex patient population.

Characteristics and outcomes of patients with right-sided endocarditis undergoing cardiac surgery.

There has been an increasing incidence of right-sided infective endocarditis (RSIE) due to the global rise of intravenous drug use (IVDU) and an increasing number of implantable cardiac electronic devices and central venous catheters. Our aim was to investigate differences in the clinical presentation, microbiological findings and prognosis of patients undergoing surgery for RSIE compared to left-sided infective endocarditis (LSIE). Relevant clinical data of all 432 consecutive patients undergoing valve surgery for infective endocarditis (IE) at our institution between January 2009 and December 2018 were retrospectively analyzed. Acquired data included patients' demographic and preoperative comorbidities, manifestation of IE according to the recently modified Duke Criteria, perioperative data and relevant clinical outcomes. A total of 403 patients (93.3%) underwent surgery for LSIE and twenty-nine patients (6.7%) for RSIE. Eleven patients with RSIE (37.9%) showed a concomitant left-sided infection. Compared to LSIE, RSIE patients were significantly younger [47.5 (40.4-69.3) vs. 65.1 (53.7-74.6); P=0.008] and presented with less comorbidities such as hypertension (41.4% vs. 65.3%; P=0.010) and coronary artery disease (6.9% vs. 29.0%; P=0.010). Rates of IVDU (34.5% vs. 4.5%; P<0.001), human immunodeficiency virus (HIV) (10.3% vs. 1.7%; P=0.023) and hepatitis C virus (HCV) infection (24.1% vs. 5.2%; P=0.001) were greater in RSIE. The proportion of Staphylococcus aureus IE was significantly higher in RSIE compared to LSIE (37.9% vs. 21.1%; P=0.035). 30-day mortality was 6.9% after surgery for RSIE compared to 14.6% after operation for LSIE (P=0.372). Patients undergoing surgery for RSIE compared to LSIE presented with a higher rate of pulmonary septic emboli, more Staphylococcus aureus infections and larger vegetations. Larger multicenter prospective trials are needed to provide more reliable data on the clinical profile of these patients, in order to determine optimal surgical management.

336. Disparities in Cardiovascular Disease Prevention Among Persons Living with HIV in the United States Military Natural History Study

BackgroundThe use of antiretroviral therapy has reduced morbidity and mortality associated with HIV infection primarily due to the reduction of AIDS-related events. Although guidelines have aimed to standardize preventive care, disparities in prevention of cardiovascular disease remain prevalent across multiple cohorts.MethodsThe US Military HIV Natural History Study is an open cohort of Department of Defense beneficiaries. We included subjects aged 21–75 whose most recent study visit was between October 2015 and September 2016 and conducted a retrospective cross-sectional analysis of established cardiovascular disease risk factors and statin use. To determine statin eligibility we used the American College of Cardiology/American Heart Association 2013 atherosclerotic cardiovascular disease management guidelines and included subjects who had all necessary data elements for analysis.ResultsThe participants (n = 1223) were predominantly middle-aged (median 47 years, Interquartile Range [IQR] 33–55), male (95%), and were racially diverse (46% African-American, 16% Hispanic/other). The rate of tobacco use was 16%, diabetes was 11%, and 36% had hypertension. In total, 486 (40%) patients met criteria for statin therapy, with 17% of those being for secondary prevention. As of their last visit, 52 (4%) had a detectable HIV viral load. Statins were prescribed to only 302 (62%) of those with an indication, with lower prescription rates in African Americans (52%) and Hispanics (58%) than Caucasians (73%). Average blood pressure, rates of tobacco use, and prevalence of diabetes were equal between the African American and Caucasian groups.ConclusionWe found significant racial disparities in both primary and secondary cardiovascular disease mitigation within the military healthcare system. Previous studies have found similar racial differences attributed to socioeconomic factors and higher rates of intravenous drug use. As active duty service members have a stable income, open access to healthcare, and low rates of injection drug use, our findings challenge that premise. Understanding whether this is due to prescribing practices, physician-patient relationships, or healthcare uptake is critical to narrowing this major gap in care. Disclosures All authors: No reported disclosures.

198. Chart Validation of an Algorithm for Identifying Patients with Intravenous Drug Use-Associated Endocarditis Using Administrative Code Data

BackgroundStudies using administrative data have described increasing rates of intravenous drug use (IVDU)-associated infective endocarditis (IE) in the United States. These studies used International Classification of Disease (ICD) diagnosis codes to identify hospitalized patients with IE and any illicit drug use (i.e., opioid, amphetamine, cocaine or sedative), but were hindered by absence of specific ICD codes for IVDU. We reviewed charts to determine the positive predictive value (PPV) of ICD codes for identifying patients with IE and IVDU.MethodsWe examined national Veterans Affairs (VA) administrative data from January 2010 to December 2017 to identify patients hospitalized for a first episode of potential IVDU-associated IE based on inpatient ICD 9 and 10 codes for both IE and any illicit drug use, the algorithm used to identify IVDU-IE in most prior studies. We randomly selected 100 of these patients nationally and reviewed hospital charts to confirm clinical documentation of: (1) IE, (2) any illicit drug use, and (3) current or past IVDU.ResultsWe identified 340 patients with concurrent ICD codes for IE and drug use, increasing from 28 in 2010 to 51 in 2017 (82% increase). In chart review of 100 randomly selected patients, the PPV of ICD codes was 93% (95% CI 88–98%) for a documented clinical diagnosis of IE; 96% (95% CI 92–100%) for documented drug use by any route; and 63% (95% CI 53–73%) for documented IVDU. Among the 37% of patients without clinically documented IVDU, 30% (i.e.,11% of total patients) had clinical documentation stating that drug use was only by non-IV routes, 59% (22% of total) had documented drug use without mention of route of use, and 11% (4% of total) had clinical documentation that patients denied any drug use.ConclusionThe incidence of first hospitalization for IE among patients with ICD codes for drug use increased by 82% from 2010 to 2017 in VA care. Concurrent ICD codes for illicit drug use had moderate PPV for identifying IVDU in setting of IE, largely due to identification of patients using drugs without documented intravenous use. There is a need to develop more accurate case-finding algorithms for identifying patients with IVDU-associated endocarditis, for both epidemiologic surveillance and quality improvement applications.Disclosures All authors: No reported disclosures.

“If He Looks Clean…”: Condom Use Decisions in Prostitution

ABSTRACTProstitutes engage in sex acts with multiple partners and have higher than average rates of intravenous drug use. For these reasons, unprotected sexual contact with a prostitute constitutes high-risk activity. The present study includes interviews with 34 indoor and outdoor sex workers that explore the factors involved in their condom use decisions. Three themes common to participants’ protective behavior decisions (interpersonal, situational, and personal factors) were elucidated and then analyzed within a rational choice framework. Policy implications include court-ordered sex education programs for women cited for prostitution and the expansion of harm reduction programs.

Systematic Review of Endovascular, Surgical, and Conservative Options for Infectious Intracranial Aneurysms and Cardiac Considerations

IntroductionWith rising rates of intravenous drug use, Infectious Intracranial aneurysms (IIAs) are a relevant topic for investigation. We performed a systematic review to better understand current practice patterns and limits of current published literature. Method131 publications with a total of 499 patients (665 aneurysms) were included. Of the 499 patients, 83 were single case reports, and 20.5% of the total had multiple aneurysms. 35.8% of all aneurysms were ruptured. Of those reporting treatment, options included conservative antibiotic therapy (30.0%), open surgical intervention (31.1%), and endovascular occlusion (31.8%). Chronologically, publication of IIAs has increased. Usage of endovascular therapies has grown, while conservative and surgical management have declined in the literature. Overall, 56.2% of aneurysms for which conservative therapy was initiated eventually either underwent intervention or death of patient occurred. ResultsThe issue of cardiac valve surgery in relationship to aneurysm therapy was discussed in 20.8% (80 patients) of all 384 infectious endocarditis patients; of which 15.0% (12) underwent valve surgery before aneurysm treatment and 85.0 patients (68)% underwent valve surgery after aneurysm treatment. For 51 of the patients where valve surgery followed aneurysm management, the corresponding aneurysm treatment modality could be determined; 58.8% (30) of whom were managed endovascularly. 32.7% (26) of all cases reporting cardiac surgery details underwent cardiac surgery during their admission with the IIA. ConclusionsOverall, increasing trend of endovascular management of IIAs is evident, and a strong temporal preference exhibited by providers to perform cardiac surgery subsequently to IIA management.

Hepatitis C transmission from seropositive, nonviremic donors to non-hepatitis C liver transplant recipients.

In this prospective cohort of non-HCV liver recipients receiving grafts from HCV antibody-positive/NAT-negative donors, the incidence of HCV transmission was 16%, with the highest risk conferred by donors who died of drug overdose; given the availability of safe and highly effective antiviral therapies, use of such organs could be considered to expand the donor pool. (Hepatology 2018;67:1673-1682).

A retrospective chart review of Hepatitis C prevalence and screening practices in pregnancy

Hepatitis C is a significant cause of morbidity and mortality. The CDC estimates that 2.7-3.9 million people in the US have chronic hepatitis C. Serious consequences of hepatitis C infection include cirrhosis, liver cancer and death. Hepatitis C is transmitted through intravenous drug use, sex, and through birth to an infant by an infected mother. Due to high rates of intravenous drug use, Baltimore has particularly high rates of hepatitis C infection. The Maryland Department of Health and Mental Hygiene estimates that in 2014, 26-40,000 individuals in Baltimore had Hepatitis C infection. However this is likely an underestimate due to the fact that many individuals carry asymptomatic infections and may not seek medical attention. A cure is available for hepatitis C, however individuals need to know they are infected in order to be treated. Pregnancy is a time when women have multiple regular encounters with healthcare providers. This unique period of access has been used with great success to screen and treat women for HIV infection, virtually eliminating perinatal transmission of HIV and connecting many women and their partners to treatment. A similar approach may prove useful for Hepatitis C. However, first it will be necessary to determine the frequency with which women are screened and tested under current guidelines. The purpose of this study is to determine the prevalence of known hepatitis C infection in the pregnant population of a major Baltimore City hospital and the frequency with which women are being tested for hepatitis C under current guidelines.

Dermatopathologic manifestations of intravenous drug use.

The rate of intravenous drug use (IVDU) has been increasing nationally; however, cutaneous manifestations of IVDU have infrequently been investigated. We report a series of the clinicopathological correlation of IVDU in the skin. A search of surgical pathology files between the years 2000 and 2014 was performed for cutaneous specimens from patients with a reported history of IVDU for which the histopathological findings could not be attributed to another etiology. Ten cases for which slides were available were included in the study. Patients had an average age of 39.7 years and had active or recent history of IVDU. Clinical impressions included ulcer, granulomatous dermatitis, vasculitis, pyoderma gangrenosum and hyperpigmentation at injection sites. Histopathology revealed leukocytoclastic vasculitis (n = 2), dermal pigment deposition (n = 3), non-specific ulceration/scarring (n = 4) and necrobiosis lipoidica-like dermatitis (n = 1). No infectious etiology or polarizable foreign material was identified in any case. Cutaneous manifestations of IVDU should be considered in the differential as an etiology for dermatopathologic findings in high-risk patients. We report histopathological findings beyond the scope of those most commonly associated with IVDU. We aim to raise awareness of the cutaneous manifestations of IVDU to improve clinicopathological correlation and patient management in light of the ongoing epidemic.

Multi-drug-resistant tuberculosis in HIV positive patients in Eastern Europe

Observational data from Eastern Europe on the management and outcome of multi-drug-resistant tuberculosis (MDR TB) in HIV positive populations remain sparse in the English-language literature. We compared clinical characteristics and outcomes of 55 patients who were diagnosed with HIV and MDR TB in Eastern Europe between 2004 and 2006 to 89 patients whose Mycobacterium tuberculosis isolates were susceptible to isoniazid and rifampicin. Patients with HIV and MDR TB were young and predominantly male with high rates of intravenous drug use, imprisonment and hepatitis C co-infection. Eighty-four per cent of patients with MDR TB had no history of previous TB drug exposure suggesting that the majority of MDR TB resulted from transmission of drug-resistant M. tuberculosis. The use of non-standardized tuberculosis treatment was common, and the use of antiretroviral therapy infrequent. Compared to those with susceptible tuberculosis, patients with MDR TB were less likely to achieve cure or complete tuberculosis treatment (21.8% vs. 62.9%, p<0.0001), and they were more likely to die (65.5% vs. 27.0%, p<0.0001). Our study documents suboptimal management and poor outcomes in HIV positive patients with MDR TB. Implementation of WHO guidelines, rapid TB diagnostics and TB drug susceptibility testing for all patients remain a priority in this region.

Prevalence and Risk Factors of Hepatitis B Virus Genotype D Amongst Inmates in Alborz Province, Iran: A Cross-Sectional Survey

Results: Hepatitis B surface antigen (HBsAg) was found in 122/3000 (4.1%) prisoners. Hepatitis B e antigen (HBeAg), anti-HIV, anti-HCV and anti-HIV/anti-HCV were detected in 52/122 (42.6%), 12/122 (10%), 22/122 (18%) and 3/122 (2.4%) prisoners, respectively. The HBV-DNA was found in 115/122 (94.3%) prisoners. The most high risk behavior was to utilize the collaborative syringe by injecting drug users (IDUs) with or without other risk factors (75.3%). Genotype D1 was obviously the only predominant type (100%). Conclusions: The rate of HBV in prisoners was significantly higher than that reported for the general population (4.1% vs. < 2%). Blood borne viral co-infections were prevalent in HBsAg positive prisoners. Continual tracing of genotypes and risk factors are helpful for identifying transmission patterns and target at-risk groups for preventive programs. High rates of HBV in prisoners indicates the need for extensive free of charge vaccination of this subpopulation.Hepatitis B is the most serious type of viral hepatitis infection. It can cause chronic liver disease and puts people at a high risk of death from cirrhosis of the liver and liver cancer. Worldwide, about two billion people have been infected with the hepatitis B virus (HBV) and more than 240 million have chronic (long-term) liver infections. About 600,000 people die every year from this serious infection. Unfortunately, high rate of intravenous drug use, high-risk sexual behaviors and overcrowding have increasingly made prisons a breeding ground for hepatitis B infection.

Hepatitis C Virus Infection in Canada’S First Nations People: A Growing Problem

Hepatitis C Virus Infection in Canada’S First Nations People: A Growing Problem

Anonymous survey on infectious diseases and related risk behaviour among Armenian prisoners and prison staff

The prevalence of hepatitis B, hepatitis C and HIV in a representative sample of the Armenian male adult prison population has been determined and prisoners and staff were anonymously asked on risk behaviours (542 prisoners) and on knowledge, attitude and behaviour towards infectious diseases (348 staff members) Prisoners’ knowledge about the sources of transmission of HIV is quite poor, most of the wrong answers relate to activities in the daily prison life. The acceptance of HIV‐infected inmates tends towards extremely negative attitudes. The reported rate of intravenous drug use was 13.3%, and 51% among those are current injectors. Of the ‘ever injectors’, between 15% and 30% reported high‐risk behaviour. Of particular interest was the fact that the self‐reported HIV test results did not correlate at all with the results of the saliva tests. In the study the prevalence of HIV was 2.4%, a rate which is 27 times higher than in the general population. The prevalence rate for hepatitis B among prisoners is 3.7% and for hepatitis C 23.8%. The most important risk factor for contracting an HCV infection was drug use and the second, time spent in prison within the last 10 years, which is an independent risk factor. A substantial number of prison employees perceive their working condition as risky and themselves as at risk for TB, hepatitis B/C or HIV, but large groups had no idea about infection rates. Regarding HIV and hepatitis, knowledge is poor and patchy. While staff show quite good knowledge regarding the main transmission routes via blood and unprotected sex, a low level of knowledge becomes obvious when considering everyday‐life situations, which may cause fears in such a closed setting like prison. Standards including confidentiality and non‐segregation are not accepted in respect of HIV positive prisoners. Here, attitudes range between ‘inclusion’ and ‘exclusion’, which might express uncertainty and insecurity about the risks HIV‐positive persons carry. The provision of sterile needles for tattooing and sterile syringes and needles for injecting drugs users to prevent the spread of infectious diseases are not agreed by the majority of prison staff.

Health Care-AssociatedStaphylococcus aureusPneumonia

While Staphylococcus aureus is an uncommon but serious cause of traditional community-acquired pneumonia (CAP), it is a predominant cause of nosocomial pneumonia in addition to the unique clinical entity of health care-associated pneumonia (HCAP). A cohort of bacteremic S aureus pneumonia cases was reviewed to determine the role of HCAP among the cohort, and to assess for differences between CAP and HCAP. Bacteremic S aureus pneumonia cases were identified from a prospective study of all patients diagnosed with CAP who presented to hospitals in Edmonton, Alberta, between November 2000 and November 2002. These cases were subsequently reviewed retrospectively. Demographic, clinical and microbiological data were obtained, and patients were classified as having CAP or HCAP. Relatedness of isolates was determined by pulsed-field gel electrophoresis analysis in conjunction with epidemiological information. There were 28 cases of bacteremic S aureus pneumonia identified. Fifty-seven per cent were reclassified as having HCAP, and 43% remained classified as having CAP. The CAP cohort was significantly younger than the HCAP cohort (mean age 49.0+/-23.7 years versus 67.8+/-18.6 years; P=0.035) with higher rates of intravenous drug use (50% versus 0%; P=0.002). Long-term care facility residence (44%) was common in the HCAP cohort. The HCAP cohort presented with more severe illness, having a higher mean pneumonia severity index score (143.1+/-41.1 versus 98.2+/-54.6; P=0.028), and despite fewer embolic complications, there was a trend toward a significantly higher mortality rate (31% versus 0%; P=0.052). Two community-acquired isolates cultured in the setting of intravenous drug use were methicillin-resistant, and no isolates were positive for Panton-Valentine leukocidin. There was evidence of relatedness involving 44% of the HCAP isolates by pulsed-field gel electrophoresis analysis. HCAP accounts for a significant number of cases that, when using traditional definitions, would be classified as CAP. Severity of illness and mortality was excessive within the HCAP group. There was evidence of relatedness and spread of common strains in the HCAP cohort. The present study supports recommendations for treatment guidelines directed toward the entity of HCAP and the empirical coverage of S aureus among certain high-risk groups.

A Gendered Analysis of Canadian Aboriginal Individuals Admitted to Inpatient Substance Abuse Detoxification: A Three‐Year Medical Chart Review

This study examined gender differences within a sample of Canadian Aboriginal individuals admitted to an inpatient, hospital-based substance abuse detoxification program. Even though alcohol was the most frequent primary drug of detoxification for both genders, women received proportionately higher rates of cocaine or opiate detoxification diagnoses. In addition to a younger age, females reported higher rates of physical and sexual abuse. Women were also administered antidepressants, antibiotic medication protocols, and more medical evaluation tests. It appears that Canadian Aboriginal women have a diverse set of psychological and medical needs. This study demonstrates the need for detoxification programs to address the substantial rates of intravenous drug use and the associated risk of infectious disease (eg, Hepatitis C, HIV) among this treatment-seeking population.

Body shape and composition in HIV‐infected women: an urban cohort

Alterations in body shape and composition are associated with HIV/AIDS. Wasting remains prevalent; increasingly, lipodystrophy is reported. Obesity is also epidemic in the USA. In this study, we sought to characterize the body changes reported by women attending a US urban clinic, and to evaluate contributing factors using inexpensive methods that are readily available in clinical practice. In an urban Maryland clinic, a cross-section of HIV-infected women were evaluated by self report, anthropomorphic measurements, bioelectric impedance analysis (BIA) and chart review; they were categorized as no change, lipodystrophy, weight loss/wasting or weight gain/obesity. One hundred and sixty-one women were evaluated: 144 (89%) were African-American; 100 (62%) had used intravenous drugs and 40 (25%) were actively injecting drugs, while 39 (24%) smoked crack. Ninety-five (59%) were on highly active antiretroviral therapy (HAART) for a median period of 11.7 months [interquartile range (IQR)=4.5-24.2]. Since starting current HAART or in the previous year, 12 (7.4%) reported lipodystrophy changes, 85 (52.8%) weight gain, 27 (16.8%) overall weight loss, and 37 (23.0%) no change. Lipodystrophy was associated with higher CD4 percentage (P=0.03), lower frequency of crack use (P=0.04) and higher educational level (P=0.03). Weight loss correlated with longer duration of infection (P=0.01), select BIA results and increased rate of crack use (P=0.005). Weight gain was associated with higher fat mass (P=0.005), higher peak viral load (P=0.02), and lower rate of intravenous drug use (P=0.03). Self-reported changes in body shape were common. Obesity and complications of illicit drug use were more prevalent than lipodystrophy in this inner-city population of HIV-positive women.

Human immunodeficiency virus in Uzbekistan: epidemiological and genetic analyses.

This study investigates the molecular epidemiology of HIV in Uzbekistan--a former Soviet Union (FSU) country located in central Asia. A total of 18,910,370 subjects were involved in an HIV serological examination through a population survey conducted in 1987-2002. Rapid changes in epidemiological dynamics and transmission modes have been observed since 1999: incidence rose from 25 newly HIV-infected subjects per year to more than 100 new cases per month within the first half of 2002, and the rate of intravenous drug use (IVDU)-associated HIV infection increased to 75% per year during the same period. Thirty HIV-1 strains, isolated from specimens obtained in 1999-2000, were directly sequenced in the env region. Phylogenetic analysis revealed a relationship to genotype A in 56.7%, and to 03_CRFAB in 13.3%; both variants have been previously reported in the FSU. The majority (85.7%) of these strains were isolated from IVDUs. The demographic history of the most prevalent HIV strain in Uzbekistan was inferred from reconstructed molecular phylogenies; exponential growth of the viral population size was thus observed to occur after the mid-1990s. In summary, detectable HIV seroprevalence remains low in the general population of Uzbekistan. However, the current study demonstrates a substantially increasing number of new infections, in association with IVDU, and an exponentially growing effective population size of the IVDU-associated HIV strain.

Safety and Tolerance of Efavirenz in Different Antiretroviral Regimens: Results from a National Multicenter Prospective Study in 1,033 HIV-Infected Patients

Purpose: To evaluate the incidence and severity of adverse events (AEs) and treatment interruption (TI) with efavirenz in a population with a high rate of intravenous drug use (IVDU). Method: This was a national, multicenter, and observational study of HIV-infected adult patients who were starting an efavirenz-containing regimen. Evaluations of AEs were made in routine clinical practice at baseline and at least 3 months later. A total of 1,033 patients were included from 60 participating hospitals; 20% were antiretroviral naive. The risk factor for HIV infection was IVDU in 62.3%, and 6.6% of participants were on methadone. Results: AEs affected 29.3% of participants, and treatment was interrupted in 8.23%. The most frequent AEs were CNS disturbances that affected 24.1% participants; these AEs were considered related to efavirenz in 18.5% patients. AEs were not severe, and treatment had to be interrupted in 6% of patients. Other AEs were cutaneous rash (incidence of 5.9%; 2.4% of TI), gastrointestinal disturbances (1.45%; no TI), and elevation of liver function test (0.68%; no TI). Patients taking methadone had more AEs (39.7%), mainly CNS disturbances, and TI (19.1%). Cutaneous rash was more frequent among women. Psychoactive drug consumption, previous history of psychiatric disorders, antiretroviral experience, or previous nevirapine intolerance were not associated with higher incidence of AEs. Conclusion: Safety and tolerance of efavirenz is good in most patients, even in a population with a high rate of IVDU. The most common AEs are CNS disturbances; they are not severe and rarely lead to TI.