Publications by authors named "Monica Desai"

62 Publications

The characteristics of people who inject drugs in the United Kingdom: changes in age, duration, and incidence of injecting, 1980-2019, using evidence from repeated cross-sectional surveys.

Addiction 2022 May 12. Epub 2022 May 12.

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK.

Background And Aims: Mortality and drug treatment data suggest that the median age of people who inject drugs is increasing. We aimed to describe changes in the characteristics of people injecting drugs in the United Kingdom (UK).

Design: Repeat cross-sectional surveys and modelling.

Setting: Low-threshold services in the United Kingdom such as needle and syringe programmes.

Participants: A total of 79 900 people who recently injected psychoactive drugs in the United Kingdom, recruited as part of the Unlinked Anonymous Monitoring Survey (England, Wales, Northern Ireland, 1990-2019) and Needle Exchange Surveillance Initiative (Scotland, 2008-2019).

Measurements: Age of people currently injecting, age at first injection, duration of injecting (each 1990-2019) and estimates of new people who started injecting (1980-2019).

Findings: In England, Wales and Northern Ireland between 1990 and 2019, the median age of people injecting increased from 27 (interquartile range [IQR], 24-31) to 40 (IQR, 34-46); median age at first injection increased from 22 (IQR, 19-25) to 33 (IQR, 28-39); and median years of injecting increased from 7 (IQR, 3-11) to 18 (IQR, 9-23). Values in Scotland and England were similar after 2008. The estimated number that started injecting annually in England increased from 5470 (95% prediction interval [PrI] 3120-6940) in 1980 to a peak of 10 270 (95% PrI, 8980-12 780) in 1998, and then decreased to 2420 (95% PrI, 1320-5580) in 2019. The number in Scotland followed a similar pattern, increasing from 1220 (95% PrI, 740-2430) in 1980 to a peak of 3080 (95% PrI, 2160-3350) in 1998, then decreased to a 270 (95% PrI, 130-600) in 2018. The timing of the peak differed between regions, with earlier peaks in London and the North West of England.

Conclusions: In the United Kingdom, large cohorts started injecting psychoactive drugs in the 1980s and 1990s and many still inject today. Relatively few people started in more recent years. This has led to changes in the population injecting drugs, including an older average age and longer injecting histories.
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http://dx.doi.org/10.1111/add.15911DOI Listing
May 2022

Optic Perineuritis in Waldenström Macroglobulinemia-Related Cryoglobulinemic Vasculitis.

J Neuroophthalmol 2022 Mar 18;42(1):e306-e309. Epub 2021 Aug 18.

Department of Ophthalmology (SR, PWM, PC-B, RK, AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Genomic Medicine (PC-B), Houston Methodist Hospital, Houston, Texas; Department of Pathology and Laboratory Medicine, and Ophthalmology (PC-B, RK), Weill Medical College of Cornell University, New York, New York; Department of Ophthalmology (PC-B), Baylor College of Medicine, Houston, Texas; Department of Pathology and Laboratory Medicine (PC-B), The University of Texas M.D. Anderson Cancer Center, Houston, Texas; Retina Consultants of Texas (RK), Houston, Texas; Department of Oncology/Hematology (MD), Houston Methodist Cancer Center, Houston, Texas; Departments of Ophthalmology, Neurology, and Neurosurgery (AGL), Weill Cornell Medicine, New York, New York; Department of Ophthalmology (AGL), University of Texas Medical Branch, Galveston, Texas; University of Texas MD Anderson Cancer Center (AGL), Houston, Texas; Texas A and M College of Medicine (AGL), Bryan, Texas; and Department of Ophthalmology (AGL), The University of Iowa Hospitals and Clinics, Iowa City, Iowa.

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http://dx.doi.org/10.1097/WNO.0000000000001406DOI Listing
March 2022

Epidemiology of HIV infection and associated behaviours among people who inject drugs in England, Wales, and Northern Ireland: Nearly 40 years on.

HIV Med 2022 Mar 30. Epub 2022 Mar 30.

UK Health Security Agency, London, UK.

Introduction: People who inject drugs are at high risk of blood-borne infections. We describe the epidemiology of HIV among people who inject drugs in England, Wales, and Northern Ireland (EW&NI) since 1981.

Methods: National HIV surveillance data were used to describe trends in diagnoses (1981-2019), prevalence (1990-2019), and behaviours (1990-2019) among people who inject drugs aged ≥15 years in EW&NI. HIV care and treatment uptake were assessed among those attending in 2019.

Results: Over the past four decades, the prevalence of HIV among people who inject drugs in EW&NI remained low (range: 0.64%-1.81%). Overall, 4978 people who inject drugs were diagnosed with HIV (3.2% of cases). Diagnoses peaked at 234 in 1987, decreasing to 78 in 2019; the majority were among white men born in the UK/Europe (90%), though the epidemic diversified over time. Late diagnosis (CD4 <350 cells/µl) was common (2010-2019: 52% [429/832]). Of those who last attended for HIV care in 2019, 97% (1503/1550) were receiving HIV treatment and 90% (1375/1520) had a suppressed viral load (<200 copies/ml). HIV testing uptake has steadily increased among people who inject drugs (32% since 1990). However, in 2019, 18% (246/1404) of those currently injecting reported never testing. The proportion of people currently injecting reporting sharing needles/syringes decreased from 1999 to 2012, before increasing to 20% (288/1426) in 2019, with sharing of any injecting equipment at 37% (523/1429).

Conclusion: The HIV epidemic among people who inject drugs in EW&NI has remained relatively contained compared with in other countries, most likely because of the prompt implementation of an effective national harm reduction programme. However, risk behaviours and varied access to preventive interventions among people who inject drugs indicate the potential for HIV outbreaks.
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http://dx.doi.org/10.1111/hiv.13297DOI Listing
March 2022

The effectiveness of low dead space syringes for reducing the risk of hepatitis C virus acquisition among people who inject drugs - findings from a national survey in England, Wales, and Northern Ireland.

Clin Infect Dis 2022 Feb 20. Epub 2022 Feb 20.

Population Health Sciences, University of Bristol, Bristol, UK.

Syringes with attached needles (termed fixed low dead space syringes [LDSS]) retain less blood following injection than syringes with detachable needles, but evidence on them reducing blood borne virus transmission among people who inject drugs (PWID) is lacking. Utilising the UK Unlinked Anonymous Monitoring cross-sectional bio-behavioural surveys among PWID for 2016/18/19 (n=1429), we showed that always using fixed LDSS was associated with 76% lower likelihood (adjusted Odds Ratio=0.24, 95%CI: 0.08-0.67) of recent hepatitis C virus infection (RNA-positive and antibody-negative) among antibody-negative PWID compared to using any syringes with detachable needles.
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http://dx.doi.org/10.1093/cid/ciac140DOI Listing
February 2022

Perceptions and Practicalities Influencing Pre-exposure Prophylaxis Adherence Among Men Who Have Sex with Men in England.

AIDS Behav 2022 Feb 19. Epub 2022 Feb 19.

Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Kepple Street, London, WC1E 7HT, UK.

PrEP is highly effective for HIV prevention but requires adequate adherence. In this paper we use the perceptions and practicalities approach (PAPA) to identify factors that influenced PrEP adherence using qualitative data from the PROUD study. From February 2014 to January 2016, we interviewed 41 gay, bisexual and other men-who-have-sex-with-men and one trans woman who were enrolled in the study. We purposively recruited participants for interview based on trial arm allocation, adherence and sexual risk behaviours. The interviews were conducted in English, audio-recorded, transcribed, coded and analysed using framework analysis. Participants in general were highly motivated to use and adhere to PrEP, and this was linked to strong perceptions of personal necessity for PrEP as they felt at risk of HIV and viewed PrEP as highly effective. On the other hand, concerns about side effects and HIV resistance did inhibit PrEP initiation and adherence although this was uncommon. Practical factors such as daily routine, existing habitual pill-taking and pill storage impacted adherence. Drug and alcohol use rarely caused participants to miss doses. These findings indicate that using the principals of PAPA to unpick influencers of PrEP use, could help tailor adherence support in PrEP programmes.
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http://dx.doi.org/10.1007/s10461-022-03624-6DOI Listing
February 2022

Research news in clinical context.

Sex Transm Infect 2022 03;98(2):159-160

MRC Clinical Trials Unit at UCL, London, UK.

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http://dx.doi.org/10.1136/sextrans-2021-055334DOI Listing
March 2022

Perceived availability and carriage of take-home naloxone and factors associated with carriage among people who inject drugs in England, Wales and Northern Ireland.

Int J Drug Policy 2022 04 13;102:103615. Epub 2022 Feb 13.

Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK. Electronic address:

Background: In 2019-2020, record-high numbers of overdoses have been reported across the UK. We estimated perceived availability to and carriage of naloxone and explored factors associated with carriage among people who inject drugs (PWID) engaged with services in England, Wales, and Northern Ireland.

Methods: Participants were PWID enrolled in the Unlinked Anonymous Monitoring Survey in 2019 who reported past-year injection drug use (n = 2,139). Recruitment occurred through specialist and community drug agencies located across the UK, excluding Scotland. Socio-demographic, behavioural and service use characteristics were self-reported. Participants were asked whether they carry naloxone (timeframe unspecified). If they answered "no", they were further asked whether it is available in their area. Perceived naloxone availability and carriage were estimated by requirement region, classified using the Nomenclature of Territorial Units for Statistics 1. We used the Gelberg-Andersen Model of healthcare access to explore predisposing, enabling and need factors associated with regionally-aggregated naloxone carriage.

Results: Perceived naloxone availability was ≥95% in all 11 regions; naloxone carriage varied (mean: 61.1; range: 48%-71%; P<0.01). Among predisposing factors, female gender (adjusted odds ratio (AOR): 1.52; 95% confidence interval (CI): 1.21-1.91) was positively associated with naloxone carriage, whilst recruitment in Yorkshire and the Humber-relative to London-was negatively associated (AOR: 0.55; 95%CI: 0.37-0.82). Among enabling factors, past-year contact with needle and syringe programmes (AOR: 1.74; 95%CI: 1.39-2.18) and currently receiving treatment for drug use (AOR: 1.75; 95%CI: 1.24-2.46) were positively associated with naloxone carriage. Among need characteristics, past-month heroin injection, with or without past-month high-risk drinking or benzodiazepine use, was positively associated with carriage relative to no heroin injection (range of AORs: 1.71-2.58).

Conclusion: Perceived naloxone availability is very high among PWID attending services in England, Wales, and Northern Ireland. Naloxone carriage is moderately high and varying across regions, and appears improved through recent engagement with harm-reduction programs.
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http://dx.doi.org/10.1016/j.drugpo.2022.103615DOI Listing
April 2022

Point of Care Ultrasound in the Diagnosis of Necrotizing Fasciitis.

Am J Emerg Med 2022 Jan 29;51:397-400. Epub 2021 Oct 29.

University of California Irvine, Department of Emergency Medicine, United States.

Background: Necrotizing fasciitis (NF) is a severe, life-threatening soft tissue infection requiring prompt diagnosis and immediate surgical debridement. Imaging, including a computed tomography (CT) scan, can often aid in the diagnosis, though it can prolong time to treatment and diagnosis. Point-of-care ultrasound (POCUS) is often used in the ED to identify soft tissue infections. The objective of this study is to evaluate the use of POCUS to identify NF in patients presenting to the emergency department.

Methods: We prospectively enrolled patients who presented to the emergency department (ED) with suspected soft tissue infection who received a computed tomography and/or surgical consult. POCUS images of the suspected site of infection were obtained by the emergency medicine physician and interpreted based on sonographic findings of NF. These findings were compared with CT scan or surgical impression.

Results: We enrolled 64 patients in this study. Eight were determined to be at high risk of having NF based on CT scan and/or surgical impression. All of these patients also had POCUS images interpreted as concerning for NF. Furthermore, 56 patients were classified as being low risk for having NF based on CT scan and/or surgical impression. All but one of these patients had POCUS images interpreted as not concerning for NF.

Conclusions: Our data indicates that POCUS can be used to identify NF with a high sensitivity and specificity.
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http://dx.doi.org/10.1016/j.ajem.2021.10.033DOI Listing
January 2022

Genetic Counseling and Testing in African American Patients With Breast Cancer: A Nationwide Survey of US Breast Oncologists.

J Clin Oncol 2021 12 18;39(36):4020-4028. Epub 2021 Oct 18.

Department of Psychiatry, Washington University School of Medicine, St Louis, MO.

Purpose: To determine if physicians' self-reported knowledge, attitudes, and practices regarding genetic counseling and testing (GCT) vary by patients' race.

Methods: We conducted a nationwide 49-item survey among breast oncology physicians in the United States. We queried respondents about their own demographics, clinical characteristics, knowledge, attitudes, practices, and perceived barriers in providing GCT to patients with breast cancer.

Results: Our survey included responses from 277 physicians (females, 58.8%; medical oncologists, 75.1%; academic physicians, 61.7%; and Whites, 67.1%). Only 1.8% indicated that they were more likely to refer a White patient than refer an African American patient for GCT, and 66.9% believed that African American women with breast cancer have lower rates of GCT than White women. Regarding perceived barriers to GCT, 63.4% of respondents indicated that African American women face more barriers than White women do and 21% felt that African American women require more information and guidance during the GCT decision-making process than White women. Although 32% of respondents indicated that lack of trust was a barrier to GCT in all patients, 58.1% felt that this was a greater barrier for African American women ( < .0001). Only 13.9% believed that noncompliance with GCT is a barrier for all patients, whereas 30.6% believed that African American women are more likely than White women to be noncompliant ( < .0001).

Conclusion: We demonstrated that racial differences exist in oncology physicians' perceived barriers to GCT for patients with breast cancer. This nationwide survey will serve as a basis for understanding physicians' determinants of GCT for African American women and highlights the necessity of education and interventions to address bias among physicians. Awareness of such physician biases can enable further work to address inequities, ultimately leading to improved GCT equity for African American women with breast cancer.
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http://dx.doi.org/10.1200/JCO.21.01426DOI Listing
December 2021

Research news in clinical context.

Sex Transm Infect 2021 08;97(5):321-322

Sexual Health Department, St Helens and Knowsley NHS Trusts, St Helens Hospital, St Helens, UK.

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http://dx.doi.org/10.1136/sextrans-2020-054857DOI Listing
August 2021

Postmastectomy radiation therapy following pathologic complete nodal response to neoadjuvant chemotherapy: A prelude to NSABP B-51?

Radiother Oncol 2021 09 29;162:52-59. Epub 2021 Jun 29.

Department of Radiation Oncology, Houston Methodist Hospital, United States.

Purpose: The utility of post-mastectomy radiotherapy (PMRT) in women with a nodal complete response (CRn) to neoadjuvant chemotherapy (NAC) is unknown. The NSABP B-51 trial is evaluating this question, but has not reported results thus far. Therefore, we sought to answer this question with the National Cancer Database.

Methods: The National Cancer Database was queried for women with cT1-4N1-3M0 breast cancer who had undergone NAC and were ypN0 upon mastectomy. Statistics included multivariable logistic regression, Kaplan-Meier overall survival (OS) analysis, Cox proportional hazards modeling, and construction of forest plots.

Results: Of 14,690 women, 10,092 (69%) underwent adjuvant PMRT and 4598 (31%) did not. The median follow-up was 55.6 months. In all patients, the 10-year OS was 76.3% for PMRT and 78.6% without (p = 0.412). There were no notable effects of PMRT on OS based on age or the axillary management (number of nodes removed). Specifically, in the NSABP B-51 population of cT1-3 cN1 patients, the 10-year OS was 82.6% for PMRT and 80.0% without (p = 0.250). PMRT benefitted women with increasing cT stage (i.e. cT3-4), increasing ypT stages (with the exception of ypT4 potentially owing to small sample sizes), and cN3 cases (p < 0.05 for all).

Conclusions: In the absence of published results from NSABP B-51, this assessment of over 14,000 women from a contemporary US database revealed that PMRT may be most useful for a "moderately-high" risk group - women with more advanced primary and/or nodal disease at diagnosis, yet with tumor biology favorable enough that the disease does not progress or remain stable after NAC. The OS findings notwithstanding, this study cannot exclude potential differences between groups in recurrence-free survival, which is the primary endpoint of NSABP B-51, While the results of the NSABP B-51 will confirm optimal management for patients with limited nodal disease having a CRn following NAC, the present results suggest PMRT should remain the standard of care for more advanced disease than NSABP B-51 eligibility criteria.
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http://dx.doi.org/10.1016/j.radonc.2021.06.032DOI Listing
September 2021

The cost-effectiveness of case-finding strategies for achieving hepatitis C elimination among men who have sex with men in the UK.

J Viral Hepat 2021 06 1;28(6):897-908. Epub 2021 Apr 1.

Population Health Sciences, University of Bristol, Bristol, UK.

Modelling suggests hepatitis C virus (HCV) elimination is possible among men who have sex with men (MSM), with key screening groups including HIV-diagnosed MSM and MSM using pre-exposure prophylaxis (PrEP). Mathematical modelling was used to determine the cost-effectiveness of HCV case-finding strategies among MSM from the provider perspective, and to determine which interventions could achieve a 90% reduction in HCV incidence over 2015-2030. At baseline, we assumed symptomatic screening in HIV-negative MSM (including PrEP users) and 12-monthly screening among HIV-diagnosed MSM. Improved case-finding strategies included screening alongside HIV testing in HIV-negative MSM not using PrEP (PrEP non-users); 12/6/3-monthly screening in PrEP users; and 6-monthly screening in HIV-diagnosed MSM, with the cost-effectiveness being compared incrementally. Costs (GBP) and quality-adjusted life years (QALYs) were assessed to estimate the mean incremental cost-effectiveness ratio (ICER) with a time horizon to 2050, compared to a willingness-to-pay threshold of £20,000/QALY. From the baseline, the most incrementally cost-effective strategy is to firstly undertake: (1) 12-monthly HCV screening of PrEP users (gaining 6715 QALYs with ICER £1760/QALY), followed by (2) HCV screening among PrEP non-users alongside HIV testing (gaining 7048 QALYs with ICER £4972/QALY). Compared to the baseline, this combined strategy would cost £46.9 (95%CrI £25.3-£66.9) million and achieve the HCV elimination target in 100% of model runs. Additional screening incurs ICERs >£20,000/QALY compared to this combined strategy. In conclusion, HCV elimination can be achieved cost-effectively among UK MSM. Policymakers should consider scaling-up HCV screening in HIV-negative MSM, especially PrEP users, for achieving this target.
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http://dx.doi.org/10.1111/jvh.13503DOI Listing
June 2021

Research news in clinical context.

Sex Transm Infect 2021 03;97(2):79-80

National Center for STD Control, Nanjing, China.

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http://dx.doi.org/10.1136/sextrans-2020-054854DOI Listing
March 2021

Overnight Caloric Restriction Prior to Cardiac Arrest and Resuscitation Leads to Improved Survival and Neurological Outcome in a Rodent Model.

Front Neurosci 2020 12;14:609670. Epub 2021 Jan 12.

Department of Neurology, School of Medicine, University of California, Irvine, Irvine, CA, United States.

While interest toward caloric restriction (CR) in various models of brain injury has increased in recent decades, studies have predominantly focused on the benefits of chronic or intermittent CR. The effects of ultra-short, including overnight, CR on acute ischemic brain injury are not well studied. Here, we show that overnight caloric restriction (75% over 14 h) prior to asphyxial cardiac arrest and resuscitation (CA) improves survival and neurological recovery as measured by, behavioral testing on neurological deficit scores, faster recovery of quantitative electroencephalography (EEG) burst suppression ratio, and complete prevention of neurodegeneration in multiple regions of the brain. We also show that overnight CR normalizes stress-induced hyperglycemia, while significantly decreasing insulin and glucagon production and increasing corticosterone and ketone body production. The benefits seen with ultra-short CR appear independent of Sirtuin 1 (SIRT-1) and brain-derived neurotrophic factor (BDNF) expression, which have been strongly linked to neuroprotective benefits seen in chronic CR. Mechanisms underlying neuroprotective effects remain to be defined, and may reveal targets for providing protection pre-CA or therapeutic interventions post-CA. These findings are also of high importance to basic sciences research as we demonstrate that minor, often-overlooked alterations to pre-experimental dietary procedures can significantly affect results, and by extension, research homogeneity and reproducibility, especially in acute ischemic brain injury models.
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http://dx.doi.org/10.3389/fnins.2020.609670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835645PMC
January 2021

The NICE COVID-19 rapid guideline on haematopoietic stem cell transplantation: development, implementation and impact.

Br J Haematol 2021 02 20;192(3):467-473. Epub 2021 Jan 20.

Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK.

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http://dx.doi.org/10.1111/bjh.17280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898641PMC
February 2021

Research news in clinical context.

Sex Transm Infect 2021 02;97(1):1-2

Psychology, University of Southampton, Southampton, UK.

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http://dx.doi.org/10.1136/sextrans-2020-054654DOI Listing
February 2021

NICE public health guidance update.

J Public Health (Oxf) 2021 04;43(1):e107-e109

National Institute for Health and Care Excellence, Level 1A City Tower, Piccadilly Plaza, Manchester M1 4BT, United Kingdom.

This article introduces the recently published National Institute for Health and Care Excellence (NICE) Guidance on 'Behaviour change: digital and mobile health interventions'. It provides an insight into the supporting evidence base, some of the key recommendations and issues that the NICE committee faced in guideline development. Particular focus is given to the impact on health inequalities.
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http://dx.doi.org/10.1093/pubmed/fdaa244DOI Listing
April 2021

A Durable Response With the Combination of Nivolumab and Cabozantinib in a Patient With Metastatic Paraganglioma: A Case Report and Review of the Current Literature.

Front Endocrinol (Lausanne) 2020 27;11:594264. Epub 2020 Nov 27.

Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.

Introduction: Pheochromocytomas and sympathetic paragangliomas (PPGL) are neuroendocrine catecholamine-secreting tumors that are usually localized. Metastatic disease is rare and systemic treatment consists of conventional chemotherapy and high-specific-activity iodine-131-MIBG which was approved by the FDA in 2018. Although chemotherapy combinations still have value in specific settings, the debilitating side effects of treatment with only modest benefit have limited their use. With the introduction of a new generation of targeted therapy and immunotherapy patients with metastatic PPGL may have improved therapeutic options.

Areas Covered: The current paper presents a case of a patient with metastatic PPGL who received multiple lines of systemic treatment. Despite progression on previous single agent cabozantinib and single agent pembrolizumab on separate clinical trials, the patient has exhibited a major response to the combination of cabozantinib and nivolumab for the past 22 months. In addition, we will review the available therapies for metastatic PPGL and discuss novel agents under clinical development.

Conclusion: Newer targeted therapies and immunotherapy options are under clinical development with promising results for patients with PPGL.
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http://dx.doi.org/10.3389/fendo.2020.594264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731902PMC
May 2021

Spotlight on COVID-19 rapid guidance: NICE's experience of producing rapid guidelines during the pandemic.

J Public Health (Oxf) 2021 04;43(1):e103-e106

National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT, United Kingdom.

This article highlights recent guidance from the National Institute for Health and Care Excellence (NICE). It provides an overview of the COVID-19 rapid guidance produced since March 2020, along with an account of how the organization adapted during the pandemic, developing resources to guide practice with the limited time and evidence available. The growing COVID-19 evidence base is also considered, with reference to international initiatives supporting production of the best possible information to guide the global pandemic response.

What’s New?: Since March 2020, the NICE has developed 21 rapid guidelines with NHS England and NHS Improvement (NHSE&I) and a cross-speciality clinical group, supported by specialist societies and royal colleges. The 21 guidelines can be summarized into three groups-managing symptoms and complications, managing conditions that increase risk, and providing services during the pandemic. The rapid guidelines are part of a suite of rapid resources, including innovative technology briefings, shared learning examples and rapid evidence summaries, such as that for Vitamin D in COVID-19 (ES28).
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http://dx.doi.org/10.1093/pubmed/fdaa184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665661PMC
April 2021

NICE public health guidance update.

J Public Health (Oxf) 2020 11;42(4):799-800

NICE, UK.

This article covers recent National Institute for Health and Care Excellence (NICE) guidance relevant to public health, with a focus on indoor air quality. It introduces the evidence behind this guideline, and the actions that need to be taken by a wide range of stakeholders to implement the guidance and help people to achieve good air quality in their homes. It also highlights the inequalities in exposure to poor quality indoor air and identifies groups that are more vulnerable to health impacts.
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http://dx.doi.org/10.1093/pubmed/fdaa045DOI Listing
November 2020

Scaling up screening and treatment for elimination of hepatitis C among men who have sex with men in the era of HIV pre-exposure prophylaxis.

EClinicalMedicine 2020 Feb 19;19:100217. Epub 2019 Dec 19.

University of Bristol, Oakfield House, Oakfield Grove BS8 2BN, UK.

Background: Routine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown.

Methods: An HCV/HIV transmission model was calibrated to UK prevalence of HIV among MSM (4·7%) and chronic HCV infection among HIV-positive MSM (9·9%) and HIV-negative MSM (1.2%). Assuming 12·5% coverage of PrEP among HIV-negative MSM, we evaluated the relative reduction in overall HCV incidence by 2030 (compared to 2018 levels) of HCV screening every 12/6-months (alongside completing direct acting antiviral treatment within 6-months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We estimated the additional screening required among HIV-negative non-PrEP users to reduce overall incidence by 90% by 2030. The effect of 50% reduction in condom use among PrEP users (risk compensation) was estimated.

Results: Screening and treating PrEP users for HCV every 12 or 6-months decreases HCV incidence by 67·3% (uncertainty range 52·7-79·2%) or 70·2% (57·1-80·8%), respectively, increasing to 75·4% (59·0-88·6%) or 78·8% (63·9-90·4%) if HIV-diagnosed MSM are also screened at same frequencies. Risk compensation reduces these latter projections by <10%. To reduce HCV incidence by 90% by 2030 without risk compensation, HIV-negative non-PrEP users require screening every 5·6 (3·8-9·2) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, shortening to 4·4 (3·1-6·6) years with risk compensation. For 25·0% PrEP coverage, the HCV elimination target can be reached without screening HIV-negative MSM not on PrEP, irrespective of risk compensation.

Interpretation: At low PrEP coverage, increased screening of all MSM is required to achieve the WHO HCV-elimination targets for MSM in the UK, whereas at higher PrEP coverage this is possible through just screening HIV-diagnosed MSM and PrEP users.
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http://dx.doi.org/10.1016/j.eclinm.2019.11.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7046521PMC
February 2020

Research news in clinical context.

Sex Transm Infect 2020 03 22;96(2):157-158. Epub 2020 Jan 22.

Institute for Global Health, University College London, London, UK.

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http://dx.doi.org/10.1136/sextrans-2019-054270DOI Listing
March 2020

Chemsex is not a barrier to self-reported daily PrEP adherence among PROUD study participants.

Int J Drug Policy 2019 12 15;74:246-254. Epub 2019 Nov 15.

LSHTM, Faculty of Public Health and Policy, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom. Electronic address:

Background: Pre-exposure prophylaxis (PrEP) is a novel HIV prevention method whereby HIV-negative individuals take the drugs tenofovir and emtricitabine to prevent HIV acquisition. Optimal adherence is critical for PrEP efficacy. Chemsex describes sexual activity under the influence of psychoactive drugs, in the UK typically; crystal methamphetamine, gamma-hydroxybutyrate(GHB) and/or mephedrone. Chemsex drug use has been associated with increased HIV transmission risk among gay, bisexual and other men who have sex with men (GBM) and poor ART adherence among people living with HIV. This study assessed whether self-reported chemsex events affected self-reported daily PrEP adherence among PROUD study participants.

Methods: The PROUD study was an open-label, randomised controlled trial, conducted in thirteen English sexual health clinics, assessing effectiveness of Truvada-PrEP among 544 HIV-negative GBM. The study reported an 86% risk-reduction of HIV from daily PrEP. Participants were asked about chemsex engagement at follow-up visits. Monthly self-reports of missed PrEP tablets were aggregated to assess adherence between visits. Univariable and multivariable regression analyses were performed to test for associations between chemsex and reporting less than seven out of seven intended doses(<7/7ID) in the 7 days before and/or after last condomless anal intercourse(CAI).

Results: 1479 follow-up visit forms and 2260 monthly adherence forms from 388 participants were included in the analyses, with 38.5% visit forms reporting chemsex since last visit and 29.9% follow-up periods reporting <7/7ID. No statistically significant associations were observed between reporting <7/7ID and chemsex (aOR=1.29 [95% CI 0.90-1.87], p = 0.168). Statistically significant associations were seen between reporting <7/7ID and participants perceiving that they would miss PrEP doses during the trial, Asian ethnicity, and reporting unemployment at baseline.

Conclusions: These analyses suggest PrEP remains a feasible and effective HIV prevention method for GBM engaging in chemsex, a practise which is prevalent in this group and has been associated with increased HIV transmission risk.
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http://dx.doi.org/10.1016/j.drugpo.2019.10.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913514PMC
December 2019

NICE public health guidance update.

J Public Health (Oxf) 2019 Sep;41(3):642-644

Deputy Chief Executive, National Institute for Health and Care Excellence.

This article covers recent NICE guidance relevant to public health and has a focus on healthy ageing. The article contextualizes NICE guidance on increasing personal capacity, creating supportive environments and developing longer term strategies to reduce chronic disease and disability through primary prevention.
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http://dx.doi.org/10.1093/pubmed/fdz087DOI Listing
September 2019

Reaching a shared understanding of shared decision making in health care: NICE's experience of scoping the shared decision making guideline.

J Eval Clin Pract 2019 Dec 10;25(6):1027-1029. Epub 2019 Jul 10.

Centre for Guidelines, National Institute for Health and Care Excellence, London, UK.

NICE's guideline on shared decision making, currently under development, endeavours to support shared decision making as part of routine health care practice. In this article, we summarize our learning to date, gained through the scoping of the guideline, on the key challenges that need to be addressed in the guideline. The production of a scope is the first stage in the development of a NICE guideline, setting the parameters for what will be considered in the guideline. The process for scoping the shared decision making guideline involved discussion with early recruited committee members and engagement with registered stakeholders, through both a workshop and formal consultation. Important, and sometimes divergent, viewpoints about shared decision making were revealed through this process. The key challenges centred on the issues of a need for a common definition of shared decision making, measurability, opportunities, barriers to implementation, and feasibility. Recognizing these challenges aided the refinement of the scope in terms of what the guideline will cover, draft questions and main outcomes for consideration.
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http://dx.doi.org/10.1111/jep.13221DOI Listing
December 2019

Phase II trial of levocetirizine with capecitabine and bevacizumab to overcome the resistance of antiangiogenic therapies in refractory metastatic colorectal cancer.

J Gastrointest Oncol 2019 Jun;10(3):412-420

Division of Oncology, University of Miami Miller School of Medicine, Miami, FL, USA.

Background: Despite the clinical success of vascular endothelial growth factor (VEGF) blockade in metastatic colorectal cancers (mCRC), resistance to anti-angiogenic drugs invariably develops. IL-8 and other cytokines have been implicated in development of resistance to anti-angiogenic therapy. Levocetirizine is a second generation H1 antihistamine with anti-inflammatory and IL-8 suppression properties. We conducted a phase II trial combining levocetirizine with capecitabine and bevacizumab to potentially overcome anti-angiogenic therapy resistance in patients with refractory mCRC.

Methods: This was a single-center open-label prospective trial in refractory mCRC patients. Treatment consisted of oral capecitabine 850 mg/m twice daily administered as 7 days on and 7 days off, intravenous (IV) bevacizumab 5 mg/kg every 14 days and oral levocetirizine 5 mg daily. The primary end point was progression free survival (PFS) and secondary endpoints included objective response rate (ORR) and tolerability. An exploratory endpoint included correlation of PFS with cytokine levels. A sample size of 36 evaluable patients could identify a median PFS of 3.4 months at a 0.05 significance level. To examine cytokine changes related to levocetirizine treatment, patients were randomized to Arm A where levocetirizine was started 7 days after starting chemotherapy and to Arm B where levocetirizine was started 7 days prior to chemotherapy. Cytokine levels were measured at baseline and with each cycle of chemotherapy (up to three cycles).

Results: Forty-seven patients were enrolled in the trial to have 36 evaluable patients. Arm A enrolled 23 patients and Arm B enrolled 24 patients. Fifty percent of patients had progressive disease and 62% of patients had stable disease in each arm as best response. There was no demonstrable difference in PFS between the two arms (log-rank test P=0.83). Median time to progression was 3.4 months in Arm A and 3.5 months in Arm B.

Conclusions: Median PFS in the trial was comparable to and appeared to be better than other regimens used in the refractory setting (e.g., median PFS of 1.9 months for regorafenib). Cytokine measurement with IL-8 levels did not show any correlation with progression free survival but patients with stable disease showed overall lower levels of IL-8 as compared to patients with progressive disease in the cytokine analysis.
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http://dx.doi.org/10.21037/jgo.2019.02.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534727PMC
June 2019

Preparing for PrEP: estimating the size of the population eligible for HIV pre-exposure prophylaxis among men who have sex with men in England.

Sex Transm Infect 2019 11 22;95(7):484-487. Epub 2019 Apr 22.

Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK.

Objectives: The size of the population of men who have sex with men (MSM) who may be eligible for HIV pre-exposure prophylaxis (HIV-PrEP) in England remains unknown. To plan for a national PrEP implementation trial, we estimated the number of MSM attending sexual health clinics (SHCs) that may be eligible for HIV-PrEP in England.

Methods: Sexually transmitted infection (STI) surveillance data from 2010 to 2015 from the GUMCAD surveillance system were used to estimate the annual number of HIV-negative MSM who may be eligible for HIV-PrEP in England. Based on national eligibility criteria, we identified HIV-negative MSM attending SHCs with a HIV-negative test in the past year and used diagnosed bacterial STI (past year) in this group as a proxy for condomless sex and eligibility for HIV-PrEP. We estimated HIV incidence per 100 person-years (py) in these groups in 2014.

Results: During 2010-2015, the number of HIV-negative MSM attending SHCs with a HIV-negative test in the past year doubled from 14 643 to 29 023, and HIV incidence in this group was 1.9 (95% CI 1.6 to 2.2) per 100 py in 2014. In the same period, the subgroup with a bacterial STI diagnosis (past year), and therefore considered potentially eligible for HIV-PrEP in this analysis, increased from 4365 (30%) to 10 276 (35%). HIV incidence in this subgroup was 3.3 (95% CI 2.7 to 4.0) per 100 py in 2014.

Conclusions: In 2015, approximately 10 000 HIV-negative MSM were considered potentially eligible for HIV-PrEP based on clinic history in GUMCAD. These data were used to inform the initial recruitment target for the PrEP Impact Trial and will inform future evaluations at a population level.
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http://dx.doi.org/10.1136/sextrans-2019-054009DOI Listing
November 2019

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

Euro Surveill 2019 Mar;24(13)

Authors contributed equally to the work and share last authorship.

Background: In 2015, Bristol (South West England) experienced a large increase in cases of meticillin-resistant (MRSA) infection in people who inject drugs (PWID).

Aim: We aimed to characterise and estimate the prevalence of MRSA colonisation among PWID in Bristol and test evidence of a clonal outbreak.

Methods: PWID recruited through an unlinked-anonymous community survey during 2016 completed behavioural questionnaires and were screened for MRSA. Univariable logistic regression examined associations with MRSA colonisation. Whole-genome sequencing used lineage-matched MRSA isolates, comparing PWID (screening and retrospective bacteraemia samples from 2012-2017) with non-PWID (Bristol screening) in Bristol and national reference laboratory database samples.

Results: The MRSA colonisation prevalence was 8.7% (13/149) and was associated with frequently injecting in public places (odds ratio (OR): 5.5; 95% confidence interval (CI):1.34-22.70), recent healthcare contact (OR: 4.3; 95% CI: 1.34-13.80) and injecting in groups of three or more (OR: 15.8; 95% CI: 2.51-99.28). People reporting any one of: injecting in public places, injection site skin and soft tissue infection or hospital contact accounted for 12/13 MRSA positive cases (sensitivity 92.3%; specificity 51.5%). Phylogenetic analysis identified a dominant clade associated with infection and colonisation among PWID in Bristol belonging to ST5-SCCmecIVg.

Conclusions: MRSA colonisation in Bristol PWID is substantially elevated compared with general population estimates and there is evidence of clonal expansion, community-based transmission and increased infection risk related to the colonising strain. Targeted interventions, including community screening and suppression therapy, education and basic infection control are needed to reduce MRSA infections in PWID.
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http://dx.doi.org/10.2807/1560-7917.ES.2019.24.13.1800124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6446509PMC
March 2019

Predictive factors for HIV infection among men who have sex with men and who are seeking PrEP: a secondary analysis of the PROUD trial.

Sex Transm Infect 2019 09 27;95(6):449-454. Epub 2019 Mar 27.

Medical Research Council Clinical Trials Unit at University College London, London, UK.

Objectives: Pre-exposure prophylaxis (PrEP) is a highly effective method of HIV prevention for men who have sex with men (MSM). However, uncertainty remains around the optimal eligibility criteria for PrEP, specifically whether there are subgroups at low risk of HIV for whom PrEP might not be warranted.

Methods: PROUD was an open-label waitlist trial design that randomised MSM attending participating sexual health centres in England to receive PrEP immediately (IMM) or after a deferral period of 1 year (DEF). This analysis is based on participants who were randomised to the deferred arm, when they did not have access to PrEP. HIV incidence was compared between subgroups defined by baseline characteristics.

Results: Overall, 21 participants acquired HIV infection over 239.3 person-years (PY) follow-up, yielding an incidence rate of 8.8/100 PY (95% CI 5.4 to 13.4). Two highly significant predictors for HIV acquisition were identified. Men with a self-reported diagnosis of syphilis, rectal chlamydia (CT) or rectal gonorrhoea (GC) in the previous 12 months had an incidence of 17.2/100 PY (95% CI 9.7 to 28.5); those reporting receptive anal intercourse without a condom (ncRAI) with two or more partners in the previous 3 months had an incidence of 13.6/100 PY (95% CI 7.9 to 21.7). The incidence rate among participants lacking both of these risk factors was 1.1/100 PY (1/87.6, 95% CI 0.03 to 6.4).

Conclusions: The high HIV incidence in PROUD suggests that most participants appropriately judged their need for PrEP. Eligibility criteria for a PrEP programme can therefore be broad, as in the current guidelines. However, a recent history of syphilis or rectal CT/GC, or multiple ncRAI partners indicates a high imminent risk of HIV infection. MSM with any of these characteristics should be offered PrEP as a matter of urgency.
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http://dx.doi.org/10.1136/sextrans-2018-053808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824743PMC
September 2019
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