HIV prevalence among first‐presentation psychotic patients

Objectives

First‐episode psychosis is a frequent emergency department (ED) presentation that may potentially be secondary to an underlying life‐threatening HIV‐related condition. The aim of this study was to determine the prevalence of HIV infection in patients presenting with a first episode of psychosis.

Methods

Medical records of 159 consecutive African, Asian, White and mixed ethnicity patients presenting to a tertiary academic hospital ED with a first episode of psychotic features were prospectively reviewed.

Results

Of the 159 subjects, 63 (39.6%) were HIV positive. An underlying medical condition was the most common aetiology of psychosis in both HIV‐positive (84.2%) and HIV‐negative (35.4%) subjects, but was significantly more common in HIV‐positive individuals (P < 0.001). Substance‐induced psychotic disorders and other primary psychiatric disorders were significantly more common in subjects without HIV infection (P < 0.001 and P < 0.001, respectively). While there were more men in the HIV‐negative group (66.7%), gender distribution was almost equal in the HIV‐infected group (49.2% male). Overall, as well as in both groups, most subjects were of African race, were unemployed and had not completed high school.

Conclusions

Co‐occurrence of HIV infection was a frequent finding in first‐episode psychotic individuals residing in a high‐prevalence HIV setting. These individuals are more likely to have an underlying medical condition precipitating the onset of psychosis, not to have been initiated on antiretroviral therapy and to present with a low CD4 cell count and high HIV viral load.

     

Cerebrospinal fluid HIV RNA in persons living with HIV

Objectives

Despite adequate suppression of plasma HIV RNA, viral escape in cerebrospinal fluid (CSF) is widely reported. Rates of CSF HIV RNA escape vary in the literature. In persons living with HIV (PLWH) undergoing lumbar puncture examination for clinical reasons, we assessed rates of CSF HIV RNA escape.

Methods

Persons living with HIV attending a designated HIV neurology service undergoing CSF assessment for clinical reasons between January 2015 and April 2017 were included in the study. CSF HIV RNA escape was defined as HIV RNA ≥ 0.5 log₁₀ HIV‐1 RNA copies/mL higher than plasma HIV RNA or detectable CSF HIV RNA when plasma HIV RNA was < 20 copies/mL. Clinical factors associated with CSF HIV RNA were assessed using logistic regression modelling.

Results

Of 38 individuals, 35 were receiving antiretroviral therapy, 30 were male and their mean age was 51 years. Clinical reasons for CSF assessment included investigation for cognitive decline (n = 25), early syphilis (n = 4) and other central nervous system (CNS) conditions (n = 9). HIV RNA was detectable in plasma and CSF in seven and six individuals, respectively, with two individuals (5.3%) meeting the definition of CSF escape. Detectable CSF HIV RNA was associated with a detectable plasma HIV RNA (P < 0.001) and a history of known antiretroviral drug resistance mutations (P = 0.021).

Conclusions

The prevalence of CSF viral escape in PLWH undergoing lumbar puncture examination for clinical reasons is lower than previously reported.

     

Weekly glucagon‐like peptide‐1 receptor agonist albiglutide as monotherapy improves glycemic parameters in Japanese patients with type 2 diabetes mellitus: A randomized,double‐blind,placebo‐controlled study

Aims/Introduction

The present phase 3, randomized, double‐blind 24‐week study with extension to 1 year assessed the efficacy and safety of albiglutide compared with placebo in Japanese patients with type 2 diabetes mellitus inadequately controlled by diet and exercise with or without a single oral antidiabetic drug.

Materials and Methods

Patients received weekly albiglutide 30 mg (n = 160), albiglutide 50 mg (n = 150) or a placebo switched to albiglutide 30 mg after 24 weeks (n = 77). Open‐label daily liraglutide 0.9 mg (n = 103) was included as a reference. Oral antidiabetic drug use was discontinued before baseline. The primary end‐point was 24‐week change from baseline in glycated hemoglobin (HbA1c). Secondary end‐points included fasting plasma glucose, bodyweight and adverse events.

Results

At 24 weeks, mean HbA1c changes from baseline were ?1.10, ?1.30, and 0.25% for albiglutide 30, 50 mg and placebo, respectively (P vs placebo <0.0001 for both albiglutide doses), ?1.19% for liraglutide. Decreases in HbA1c with albiglutide were sustained through the study. Mean fasting plasma glucose decreased by ≥20 mg/dL, and the mean change in bodyweight was ≤0.5 kg through 1 year across groups. Most commonly reported adverse events were nasopharyngitis, constipation and nausea. The incidence of adverse events was higher in active treatment groups than in the placebo group. Few hypoglycemia events were reported; no patient withdrew as a result of hypoglycemia. No new safety signals were detected.

Conclusions

Albiglutide monotherapy achieved clinically significant decreases in HbA1c and fasting plasma glucose with good tolerability in Japanese patients with type 2 diabetes mellitus inadequately controlled by diet and exercise with or without a single oral antidiabetic drug.

     

Community Program Improves Quality of Life and Self‐Management in Older Adults with Diabetes Mellitus and Comorbidity

Objectives

To compare the effect of a 6‐month community‐based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self‐efficacy, self‐management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM ) and 2 or more comorbidities.

Design

Multisite, single‐blind, parallel, pragmatic, randomized controlled trial.

Setting

Four communities in Ontario, Canada.

Participants

Community‐dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159).

Intervention

Client‐driven, customized self‐management program with up to 3 in‐home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation.

Measurements

Quality‐of‐life measures included the Physical Component Summary (PCS , primary outcome) and Mental Component Summary (MCS , secondary outcome) scores of the Medical Outcomes Study 12‐item Short‐Form Health Survey (SF ‐12). Other secondary outcome measures were the Generalized Anxiety Disorder Scale, Center for Epidemiologic Studies Depression Scale (CES ‐D‐10), Summary of Diabetes Self‐Care Activities (SDSCA ), Self‐Efficacy for Managing Chronic Disease, and healthcare costs.

Results

Morbidity burden was high (average of eight comorbidities). Intention‐to‐treat analyses using analysis of covariance showed a group difference favoring the intervention for the MCS (mean difference = 2.68, 95% confidence interval (CI ) = 0.28–5.09, P  = .03), SDSCA (mean difference = 3.79, 95% CI  = 1.02–6.56, P  = .01), and CES ‐D‐10 (mean difference = ?1.45, 95% CI  = ?0.13 to ?2.76, P  = .03). No group differences were seen in PCS score, anxiety, self‐efficacy, or total healthcare costs.

Conclusion

Participation in a 6‐month community‐based intervention improved quality of life and self‐management and reduced depressive symptoms in older adults with T2DM and comorbidity without increasing total healthcare costs.

     

Antiretroviral pill count and clinical outcomes in treatment‐naïve patients with HIV infection

Objectives

Treatment guidelines recommend single‐tablet regimens for patients with HIV infection starting antiretroviral therapy. These regimens might be as effective and cost less if taken as separate drugs. We assessed whether the one pill once a day combination of efavirenz, emtricitabine and tenofovir reduces the risk of disease progression compared with multiple‐pill formulations of the same regimen.

Methods

We selected treatment‐naïve patients starting one‐, two‐ or three‐pill formulations of this regimen in data from the Antiretroviral Therapy Cohort Collaboration. These patients were followed until an AIDS event or death or until they modified their regimen. We analysed these data using Cox regression models, then used our models to predict the potential consequences of exposing a future population to either a one‐pill regimen or a three‐pill regimen.

Results

Among 11 739 treatment‐naïve patients starting the regimen, there were 386 AIDS events and 87 deaths. Follow‐up often ended when patients switched to the same regimen with fewer pills. After the first month, two pills rather than one was associated with an increase in the risk of AIDS or death [hazard ratio (HR) 1.39; 95% confidence interval (CI) 1.01‐1.91], but three pills rather than two did not appreciably add to that increase (HR 1.19; 95% CI 0.84‐1.68). We estimate that 77 patients would need to be exposed to a one‐pill regimen rather than a three‐pill regimen for 1 year to avoid one additional AIDS event or death.

Conclusions

This particular single‐tablet regimen is associated with a modest decrease in the risk of AIDS or death relative to multiple‐pill formulations.

     

Screening for human papillomavirus,cervical cytological abnormalities and associated risk factors in HIV‐positive and HIV‐negative women in Rwanda

Objectives

Cervical cancer is the major cause of death from cancer in Africa. We wanted to assess the prevalence of human papillomavirus (HPV) infections and associated risk factors and to determine whether HPV testing could serve as a screening method for squamous intraepithelial lesions (SILs) in Rwanda. We also wanted to obtain a broader understanding of the underlying risk factors for the establishment of HPV infection in Rwanda.

Methods

A total of 206 HIV‐positive women, 172 HIV‐negative women and 22 women with unknown HIV status were recruited at the University Teaching Hospitals of Kigali (UTHK) and of Butare (UTHB) in Rwanda. Participants underwent an interview, cervical sampling for a Thinprep Pap test and a screening test analysing 37 HPV strains.

Results

Only 27% of HIV‐positive women and 7% of HIV‐negative women had been screened for cervical cancer before. HPV16 and HPV52 were the most common HPV strains. HIV‐positive women were more commonly infected with high‐risk (HR) HPV and multitype HPV than HIV‐negative women. The sensitivity was 78% and the specificity 87% to detect high‐grade SIL (HSIL) with HPV screening. Among HIV‐negative women, being divorced was positively associated with HR‐HPV infection, while hepatitis B, Trichomonas vaginalis infection and HR‐HPV infection were factors positively associated with SILs. Ever having had gonorrhoea was positively associated with HR‐HPV infection among HIV‐positive women. HR‐HPV infection and the number of live births were positively associated with SILs.

Conclusions

The currently used quadrivalent vaccine may be insufficient to give satisfactory HPV coverage in Rwanda. HPV Screening may be effective to identify women at risk of developing cervical cancer, particularly if provided to high‐risk patients.

     

Hospital‐based routine HIV testing in high‐income countries: a systematic literature review

Objectives

To produce a summary of the published evidence of the barriers and facilitators for hospital‐based routine HIV testing in high‐income countries.

Methods

Electronic databases were searched for studies, which described the offer of HIV testing to adults attending emergency departments (EDs) and acute medical units (AMUs) in the UK and US, published between 2006 and 2015. Other high‐income countries were not included, as their guidelines do not recommend routine testing for HIV. The main outcomes of interest were HIV testing uptake, HIV testing coverage, factors facilitating HIV screening and barriers to HIV testing. Fourteen studies met the pre‐defined inclusion criteria and critically appraised using mixed methods appraisal tool (MMAT).

Results

HIV testing coverage ranged from 9.7% to 38.3% and 18.7% to 26% while uptake levels were high (70.1–84% and 53–75.4%) in the UK and US, respectively. Operational barriers such as lack of time, the need for training and concerns about giving results and follow‐up of HIV positive results, were reported. Patient‐specific factors including female sex, old age and low risk perception correlated with refusal of HIV testing. Factors that facilitated the offer of HIV testing were venous sampling (vs. point‐of‐care tests), commitment of medical staff to HIV testing policy and support from local HIV specialist providers.

Conclusions

There are several barriers to routine HIV testing in EDs and AMUs. Many of these stem from staff fears about offering HIV testing due to the perceived lack of knowledge about HIV. Our systematic review highlights areas which can be targeted to increase coverage of routine HIV testing.

     

Food insecurity may lead to incomplete HIV viral suppression and less immune reconstitution among HIV/hepatitis C virus‐coinfected people

Objectives

The aim of this study was to determine the impact of food insecurity (FI) on HIV viral load and CD4 count among people coinfected with HIV and hepatitis C virus (HCV).

Methods

This study was conducted using data from the Food Security & HIV‐HCV Sub‐Study of the Canadian Co‐Infection Cohort study. FI was measured using the adult scale of Health Canada's Household Food Security Survey Module and was classified into three categories: food security, moderate food insecurity and severe food insecurity. The association between FI, HIV viral load, and CD4 count was assessed using a stabilized inverse probability weighted marginal structural model.

Results

A total of 725 HIV/HCV‐coinfected people with 1973 person‐visits over 3 years of follow‐up contributed to this study. At baseline, 23% of participants experienced moderate food insecurity and 34% experienced severe food insecurity. The proportion of people with undetectable HIV viral load was 75% and the median CD4 count was 460 [interquartile range (IQR): 300–665] cells/μL. People experiencing severe food insecurity had 1.47 times [95% confidence interval (CI): 1.14, 1.88] the risk of having detectable HIV viral load and a 0.91‐fold (95% CI: 0.84, 0.98) increase in CD4 count compared with people who were food secure.

Conclusions

These findings provide evidence of the negative impact of food insecurity on HIV viral load and CD4 count among HIV/HCV‐coinfected people.

     

The world‐wide incidence of Kaposi's sarcoma in the HIV/AIDS era

Objectives

Kaposi's sarcoma (KS) is a multicentric angioproliferative cancer of endothelial origin typically occurring in the context of immunosuppression or immunodeficiency. Consequently, KS is one of the most common cancers in HIV‐infected individuals and frequently occurs among transplant recipients. Nevertheless, its incidence in different populations is not well understood.

Methods

We searched online databases for publications on KS incidence. A random‐effect meta‐analysis was performed to combine the KS incidences and incidence rate ratios (IRRs) for associated risk factors.

Results

Seventy‐six eligible studies representing 71 time periods were included. For HIV‐infected people, the overall KS incidence was 481.54 per 100 000 person‐years with a 95% confidential interval (CI) of 342.36–677.32 per 100 000 person‐years. HIV‐infected men who have sex with men (MSM) had the highest incidence of KS (1397.11 per 100 000 person‐years; 95% CI 870.55–2242.18 per 100 000 person‐years). The incidence of KS was significantly lower in female than in male individuals (IRR 3.09; 95% CI 1.70–5.62). People receiving highly active antiretroviral therapy (HAART) had a lower incidence compared with people who had never received HAART (IRR 6.57; 95% CI 1.91–24.69). The incidence of KS was 68.59 (95% CI 31.39–149.86) per 100 000 person‐years in transplant recipients, 52.94 (95% CI 39.90–70.20) per 100 000 person‐years in children with HIV infection, and 1.53 (95% CI 0.33–7.08) per 100 000 person‐years in the general population.

Conclusions

Globally, a relatively high incidence of KS was found among HIV‐seropositive people and, in particular, in HIV‐infected MSM. The introduction of HAART has largely prevented the development of KS, but it has not entirely removed the challenge of KS. In Africa, in particular, KS imposes a very heavy disease burden, which can mainly be attributed to the high prevalence of KS‐associated herpesvirus and poor access to HAART.

     

Increasing incidence of HIV‐ associated tuberculosis in Romanian injecting drug users

Background

A high prevalence of tuberculosis (TB) among HIV‐positive injecting drug users (IDUs) may fuel the TB epidemic in the general population of Romania. We determined the frequency and characteristics of TB in HIV‐infected IDUs referred to a national centre.

Methods

Prospective observational cohort study of all newly‐diagnosed HIV‐positive IDUs admitted to Victor Babes Hospital, Bucharest, between January 2009 and December 2014. Socio‐demographics, clinical characteristics and outcomes of HIV/TB co‐infected IDUs were compared to HIV‐positive IDUs without TB.

Results

170/598 (28.5%) HIV‐infected IDUs were diagnosed with TB. The prevalence increased from 12.5% in 2009 to 32.1% in 2014 (P < 0.001). HIV/TB co‐infected individuals had lower median CD4 cell counts 75 (vs. 450/mm³, P < 0.0001) and higher median HIV viral loads 5.6 log₁₀ (vs. 4.9 log₁₀, P < 0.0001) when presenting to healthcare services. 103/170 (60.6%) HIV/TB co‐infected IDUs were diagnosed with pulmonary TB. Resistant Mycobacterium tuberculosis strains were common, with 18/105 (17.1%) of patients having Multi‐Drug Resistant (MDR) disease. Higher mortality rate was associated with TB co‐infection (P < 0.0001), extra‐pulmonary TB (P = 0.0026) and extensively drug resistant TB (P = 0.024).

Conclusions

Tuberculosis (TB) is an increasing problem in HIV‐infected IDUs in Romania. Presentation is often with advanced HIV, significant TB drug resistance and consequent outcomes are poor.

     

Sitagliptin improves beta‐cell function in patients with acute coronary syndromes and newly diagnosed glucose abnormalities–the BEGAMI study

Background

Newly detected impaired glucose tolerance (IGT) or type 2 diabetes mellitus (T2DM) are common in patients with acute coronary syndrome (ACS; i.e. unstable angina/myocardial infarction) and related to disturbed beta‐cell function. The aim of this study is to test the hypothesis that treatment with a dipeptidyl peptidase‐4 inhibitor initiated soon after a coronary event improves beta‐cell function.

Methods

Acute coronary syndromeACS patients with IGT or T2DM (n = 71), screened by oral glucose tolerance test (OGTT) 4–23 days (median 6 days) after hospital admission, were randomly assigned to sitagliptin 100 mg (n = 34) or placebo (n = 37) and treated for a duration of 12 weeks. All patients received lifestyle advice but no glucose‐lowering agents other than the study drug. The study end‐point was beta‐cell function assessed using the insulinogenic index (IGI = ΔInsulin₃₀/ΔGlucose₃₀), derived from an OGTT, and acute insulin response to glucose (AIRg) assessed by a frequently sampled intravenous glucose tolerance test.

Results

The IGI and AIRg did not differ at baseline between the sitagliptin and placebo groups (69.9 vs. 66.4 pmol mmol^?1 and 1394 vs. 1106 pmol L^?1 min^?1 respectively). After 12 weeks, the IGI was 85.0 in the sitagliptin and 58.1 pmol/mmol in the placebo group (P = 0.013) and AIRg was 1909 and 1043 pmol L^?1 min^?1 (P < 0.0001) in the sitagliptin and placebo groups respectively. Fasting glucose at baseline was 6.1 mmol L^?1 in sitagliptin‐treated patients and 6.0 mmol L^?1 in those who received placebo compared with 5.8 and 5.9 mmol L^?1 respectively, after 12 weeks of treatment. Post load glucose metabolism improved in significantly more sitagliptin‐treated patients compared with the placebo group (P = 0.003). Sitagliptin was well tolerated.

Conclusion

Sitagliptin improved beta‐cell function and glucose perturbations in patients with ACS and newly diagnosed glucose disturbances.

     

Rates of sustained virological response 12 weeks after the scheduled end of direct‐acting antiviral (DAA)‐based hepatitis C virus (HCV) therapy from the National German HCV registry: does HIV coinfection impair the response to DAA combination therapy?

Objectives

The European Association for the Study of the Liver (EASL) treatment recommendations for hepatitis C no longer discriminate between HIV/hepatitis C virus (HCV)‐coinfected and HCV‐monoinfected patients. However, recent data from Spain are questioning these recommendations on the basis of the findings of higher relapse rates and lower cure rates in HIV/HCV‐infected subjects. The aim of our study was to compare HCV cure rates in monoinfected and coinfected patients from Germany.

Methods

Data acquired from the Deutsches Hepatitis C‐Registry were analysed. A total of 5657 HCV‐monoinfected subjects and 488 HIV/HCV‐coinfected patients were included in the study. Rates of sustained virological response 12 weeks after the scheduled end of therapy (SVR12) were collected in both subgroups and in cirrhotic and noncirrhotic patients.

Results

HIV/HCV‐coinfected patients were more frequently male (84.6% vs. 56.4%, respectively; P < 0.001) and younger than HCV‐monoinfected subjects (46.5 ± 9 vs. 53.8 ± 12.5 years, respectively; P < 0.001). The CD4 blood cell count was > 350 cells/μL in 63.1% of HIV‐positive subjects and 88.7% were on antiretroviral therapy. SVR12 rates were 90.3% (5111 of 5657) in our HCV‐monoinfected cohort and 91.2% (445 of 488) in our coinfected patients. Liver cirrhosis was confirmed in 1667 of 5657 (29.5%) monoinfected patients and 84 of 488 (17.2%; P < 0.001) coinfected patients. SVR12 rates did not differ between HCV‐monoinfected and HIV/HCV‐coinfected patients with liver cirrhosis (87.8% vs. 89.3%, respectively; P = 0.864). A treatment duration of 8 weeks did not reduce the percentage of patients with SVR12 in either subgroup (93.7% in both groups).

Conclusions

We found high SVR12 rates in monoinfected as well as coinfected individuals. No differences were detected between the two subgroups regardless of whether there was accompanying liver cirrhosis or a shortened treatment duration.

     

Long‐term effectiveness of recommended boosted protease inhibitor‐based antiretroviral therapy in Europe

Objectives

The aim of the study was to evaluate the long‐term response to antiretroviral treatment (ART) based on atazanavir/ritonavir (ATZ/r)‐, darunavir/ritonavir (DRV/r)‐, and lopinavir/ritonavir (LPV/r)‐containing regimens.

Methods

Data were analysed for 5678 EuroSIDA‐enrolled patients starting a DRV/r‐, ATZ/r‐ or LPV/r‐containing regimen between 1 January 2000 and 30 June 2013. Separate analyses were performed for the following subgroups of patients: (1) ART‐naïve subjects (8%) at ritonavir‐boosted protease inhibitor (PI/r) initiation; (2) ART‐experienced individuals (44%) initiating the new PI/r with a viral load (VL) ≤500 HIV‐1 RNA copies/mL; and (3) ART‐experienced patients (48%) initiating the new PI/r with a VL >500 copies/mL. Virological failure (VF) was defined as two consecutive VL measurements >200 copies/mL ≥24 weeks after PI/r initiation. Kaplan–Meier and multivariable Cox models were used to compare risks of failure by PI/r‐based regimen. The main analysis was performed with intention‐to‐treat (ITT) ignoring treatment switches.

Results

The time to VF favoured DRV/r over ATZ/r, and both were superior to LPV/r (log‐rank test; P < 0.02) in all analyses. Nevertheless, the risk of VF in ART‐naïve patients was similar regardless of the PI/r initiated after controlling for potential confounders. The risk of VF in both treatment‐experienced groups was lower for DRV/r than for ATZ/r, which, in turn, was lower than for LPV/r‐based ART.

Conclusions

Although confounding by indication and calendar year cannot be completely ruled out, in ART‐experienced subjects the long‐term effectiveness of DRV/r‐containing regimens appears to be greater than that of ATZ/r and LPV/r.

     

CD4:CD8 ratio in children with perinatally acquired HIV‐1 infection

Objectives

In adults with horizontally acquired HIV infection, an inverted CD4:CD8 ratio is associated with persistent immune activation, size of HIV reservoir and predicts an increased risk of non‐AIDS‐defining adverse events. Normalization of this ratio with antiretroviral therapy (ART) is suboptimal in adults, despite viral suppression, and is less well described in paediatric populations. We investigated rates of CD4:CD8 ratio recovery in children with perinatally acquired HIV infection (PaHIV) on ART.

Methods

A cross‐sectional, retrospective analysis of routine clinical data in children with PaHIV (5–18 years old) attending a single UK centre was carried out.

Results

CD4:CD8 normalization was seen in 62% of children on suppressive ART. A negative correlation was found between current CD4:CD8 ratio and age at start of ART. Positive correlations were found between current CD4:CD8 ratio and total time with suppressed HIV viral load and nadir CD4 counts. Multiple linear regression analysis showed that age at start of ART was significantly associated with current CD4:CD8 ratio (standardized β = ?0.680; P < 0.001). Patient sex, ethnicity and antiretroviral regimen did not affect ratio recovery.

Conclusions

We found higher rates of CD4:CD8 ratio normalization compared with previous adult studies. Children who started ART at a younger age were more likely to recover a normal ratio. The current policy of universal treatment for all HIV‐positive adults and children will enhance immunological normalization.

     

Efficacy of a web‐based intervention with and without guidance for employees with risky drinking: results of a three‐arm randomized controlled trial

Aims

To test the efficacy of a web‐based alcohol intervention with and without guidance.

Design

Three parallel groups with primary end‐point after 6 weeks.

Setting

Open recruitment in the German working population.

Participants

Adults (178 males/256 females, mean age 47 years) consuming at least 21/14 weekly standard units of alcohol (SUA) and scoring ≥ 8/6 on the Alcohol Use Disorders Identification Test.

Intervention

Five web‐based modules including personalized normative feedback, motivational interviewing, goal setting, problem‐solving and emotion regulation during 5 weeks. One intervention group received an unguided self‐help version (n=146) and the second received additional adherence‐focused guidance by eCoaches (n=144). Controls were on a waiting list with full access to usual care (n=144).

Measurements

Primary outcome was weekly consumed SUA after 6 weeks. SUA after 6 months was examined as secondary outcome, next to numbers of participants drinking within the low‐risk range, and general and work‐specific mental health measures.

Findings

All groups showed reductions of mean weekly SUA after 6 weeks (unguided: ?8.0; guided: ?8.5; control: ?3.2). There was no significant difference between the unguided and guided intervention (P=0.324). Participants in the combined intervention group reported significantly fewer SUA than controls [B=?4.85, 95% confidence interval (CI)=?7.02 to ?2.68, P < 0.001]. The intervention groups also showed significant reductions in SUA consumption after 6 months (B=?5.72, 95% CI=?7.71 to ?3.73, P < 0.001) and improvements regarding general and work‐related mental health outcomes after 6 weeks and 6 months.

Conclusions

A web‐based alcohol intervention, administered with or without personal guidance, significantly reduced mean weekly alcohol consumption and improved mental health and work‐related outcomes in the German working population.

     

Pre‐exposure prophylaxis: awareness,acceptability and risk compensation behaviour among men who have sex with men and the transgender population

Objectives

This exploratory study examined the facilitators of and barriers to acceptance of pre‐exposure prophylaxis (PrEP) and potential risk compensation behaviour emerging from its use among men who have sex with men (MSM) and transgender individuals (TGs) in India.

Methods

A questionnaire was administered to 400 individuals registered with a targeted intervention programme. Logistic regression models were used to identify facilitators of and barriers to PrEP acceptance.

Results

The respondents consisted of 68% MSM and 32% TGs. Risk behaviour categorization identified 40% as low risk, 41% as medium risk and, 19% as high risk for HIV infection. About 93% of the respondents were unaware of PrEP, but once informed about it, 99% were willing to use PrEP. The facilitators of PrEP acceptance were some schooling [odds ratio (OR) 2.16; P = 0.51], being married or in a live‐in relationship (OR 2.08; P = 0.46), having a high calculated risk (OR 3.12; P = 0.33), and having a high self‐perceived risk (OR 1.8; P = 0.35). Increasing age (OR 2.12; P = 0.04) was a significant barrier. TGs had higher odds of acceptance of PrEP under conditions of additional cost (OR 2.12; P = 0.02) and once‐daily pill (OR 2.85; P = 0.04). Individuals identified as low risk for HIV infection showed lower odds of potential risk compensation, defined as more sexual partners (OR 0.8; P = 0.35), unsafe sex with new partners (OR 0.71; P = 0.16), and decreased condom use with regular partners (OR 0.95; P = 0.84), as compared with medium‐risk individuals. The associations, although not statistically significant, are nevertheless important for public health action given the limited scientific evidence on PrEP use among MSM and TGs in India.

Conclusions

With high acceptability and a low likelihood of risk compensation behaviour, PrEP can be considered as an effective prevention strategy for HIV infection among MSM and TGs in India.

     

Impact of ST‐segment resolution on clinical outcome in patients with ST‐segment elevation myocardial infarction and preserved left ventricular function

Background

Patients with successful reperfusion and preserved left ventricular ejection fraction (LVEF) after ST‐segment myocardial infarction (STEMI)have always been thought to have low risk for adverse events. Great interest is focused on finding simple, noninvasive tools to refine risk stratification among them.

Objectives

We hypothesized that degree of ST‐segment resolution (STR) after STEMI can identify high‐risk group among patients with LVEF ≥ 50% following STEMI.

Methods

During the period from January to July 2017, patients with successful reperfusion of STEMI and LVEF ≥ 50% were prospectively included. Patients were divided into two groups based on the percent of ST segment resolution using single lead STR method; group I (complete STR ≥ 70%) and group II (partial STR 50%–70%). The endpoint was a composite of cardiovascular mortality, re‐hospitalization for heart failure and urgent revascularization at 30‐day.

Results

After exclusion, 110 patients were left for final analysis. No significant differences in all baseline characteristics were found between both groups. The primary endpoint occurred in seven patients (12.7%) of group I versus 17 patients (30.9%) of group II (Relative risk = 2.43, 95%CI = 1.1–5.4, p = 0.021) driven by a significant reduction in rates of re‐hospitalization due to heart failure. A multivariate logistic regression analysis showed incomplete STR to be a significant independent predictor for 30‐dayMACEs (OR 3.25, 95% CI1.2–8.83, p = 0.02) even after adjustment for location of infarction.

Conclusion

Complete STR predicts 30‐day outcome in patients with preserved LVEF following successful reperfusion of STEMI.

     

The inflammatory biomarker YKL‐40 at admission is a strong predictor of overall mortality

Objectives

YKL‐40 is an inflammatory biomarker associated with disease activity and mortality in patients with diseases characterized by inflammation and tissue remodelling. The aim of this study was to describe the prognostic value of YKL‐40 in an unselected patient population.

Design

In consecutive patients admitted to hospital during a 1‐year period, blood was collected and information regarding final diagnosis and mortality was collected. Median follow‐up time was 11.5 years.

Setting

District hospital, Copenhagen, Denmark.

Patients

A total of 1407 patients >40 years of age were admitted acutely.

Main outcome measure

All‐cause mortality.

Results

Median YKL‐40 was increased in patients (157 μg L^?1, range 13–7704 μg L^?1) compared to healthy controls (40 μg L^?1, range 29–58 μg L^?1; P < 0.001). Patients with YKL‐40 in the highest quartile had a hazard ratio (HR) of 7.1 [95% confidence interval (CI) 4.2–12.0] for all‐cause mortality in the first year and 3.4 (95% CI 2.8–4.2) in the total study period, compared to those in the lowest quartile (HR = 1). The HR for death for all patients with YKL‐40 above the normal age‐corrected 95th percentile was 2.1 (95% CI 1.6–2.7) after 1 year and 1.5 (95% CI 1.3–1.7) during the total study period, compared to patients with YKL‐40 below the age‐corrected 95th percentile. The results of multivariable analysis showed that YKL‐40 was an independent biomarker of mortality; this was most significant in the first year. YKL‐40 was a marker of prognosis in all disease categories. The HR for death was increased in patients with YKL‐40 above the normal age‐corrected 95th percentile in healthy subjects independent of type of disease (all P < 0.001).

Conclusion

The level of YKL‐40 at admission is a strong predictor of overall mortality, independent of diagnosis and could be useful as a biomarker in the acute evaluation of all patients.