The COVID-19 pandemic and the right to health of people who use drugs

Context: According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) people who inject drugs (PWID) make up a significant part of the population that needs to be looked after to eliminate infectious diseases such as those caused by HIV and HCV. This situation has been exacerbated by the COVID-19 pandemic. As COVID-19 rapidly spread across the globe, governments implemented various prevention measures which not only caused an increase in problem drug use (PDU) because of their negative impact on mental health and socioeconomic conditions but also prompted a decrease in drug services provided. Therefore, new challenges appeared, such as increased demand for drugs and diversification of clients, and new needs. Nevertheless, in clear contradiction to what was needed, the EMCDDA’s initial reports suggested that there was a decline in European drug services both in providing treatment and harm reduction interventions. COVID-19 increased the need to access drug services, healthcare, and support services creating an increased demand for opioid substitution therapy and other medication. Thus, comprehensive, and sustainable policies are needed to combat the public health threats associated with these challenges and to ensure the continuity of care. Policy Options: The challenging circumstances brought by the COVID-19 pandemic require policymakers need to take action to build capacity and resiliency for those facing drug-related health and social problems. These should include the adoption of integrated strategies that combine drug consumption rooms, substance-specific therapies, provision of free needles and naloxone, primary healthcare, and social support. Recommendations: The creation of an integrated drug policy framework addressed to European Union member states is necessary to create robust drug services capable of surviving a crisis. This is guided by a relevant policy design and implementation framework, alongside tangible action principles in line with low-threshold service provision. &nbsp

Be Healthy in Pregnancy (BHIP): A Randomized Controlled Trial of Nutrition and Exercise Intervention from Early Pregnancy to Achieve Recommended Gestational Weight Gain

A randomized two-arm prospective superiority trial tested the efficacy of a novel structured and monitored nutrition (bi-weekly counselling for individualized energy and high dairy protein diet) and exercise program (walking goal of 10,000 steps/day) (intervention) compared to usual care (control) in pregnant women to achieve gestational weight gain (GWG) within current recommendations. Women recruited in communities in southern Ontario, Canada were randomized at 12–17 weeks gestation with stratification by site and pre-pregnancy BMI to intervention (n = 119) or control (n = 122). The primary outcome was the proportion of women who achieved GWG within the Institute of Medicine recommendations. Although the intervention compared to control group was more likely to achieve GWG within recommendations (OR = 1.51; 95% CI (0.81, 2.80)) and total GWG was lower by 1.45 kg (95% CI: (−11.9, 8.88)) neither reached statistical significance. The intervention group achieved significantly higher protein intake at 26–28 week (mean difference (MD); 15.0 g/day; 95% CI (8.1, 21.9)) and 36–38 week gestation (MD = 15.2 g/day; 95% CI (9.4, 21.1)) and higher healthy diet scores (22.5 ± 6.9 vs. 18.7 ± 8.5, p \u3c 0.005) but step counts were similar averaging 6335 steps/day. Pregnancy and infant birth outcomes were similar between groups. While the structured and monitored nutrition with counselling improved diet quality and protein intake and may have benefited GWG, the exercise goal of 10,000 steps/day was unachievable. The results can inform future recommendations for diet and physical activity in pregnancy

Can We Modify the Intrauterine Environment to Halt the Intergenerational Cycle of Obesity?

Child obesity is a global epidemic whose development is rooted in complex and multi-factorial interactions. Once established, obesity is difficult to reverse and epidemiological, animal model, and experimental studies have provided strong evidence implicating the intrauterine environment in downstream obesity. This review focuses on the interplay between maternal obesity, gestational weight gain and lifestyle behaviours, which may act independently or in combination, to perpetuate the intergenerational cycle of obesity. The gestational period, is a crucial time of growth, development and physiological change in mother and child. This provides a window of opportunity for intervention via maternal nutrition and/or physical activity that may induce beneficial physiological alternations in the fetus that are mediated through favourable adaptations to in utero environmental stimuli. Evidence in the emerging field of epigenetics suggests that chronic, sub-clinical perturbations during pregnancy may affect fetal phenotype and long-term human data from ongoing randomized controlled trials will further aid in establishing the science behind ones predisposition to positive energy balance

The COVID-19 pandemic and the right to health of people who use drugs

Context: According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) people who inject drugs (PWID) make up a significant part of the population that needs to be looked after to eliminate infectious diseases such as those caused by HIV and HCV. This situation has been exacerbated by the COVID-19 pandemic. As COVID-19 rapidly spread across the globe, governments implemented various prevention measures which not only caused an increase in problem drug use (PDU) because of their negative impact on mental health and socioeconomic conditions but also prompted a decrease in drug services provided. Therefore, new challenges appeared, such as increased demand for drugs and diversification of clients, and new needs. Nevertheless, in clear contradiction to what was needed, the EMCDDA’s initial reports suggested that there was a decline in European drug services both in providing treatment and harm reduction interventions. COVID-19 increased the need to access drug services, healthcare, and support services creating an increased demand for opioid substitution therapy and other medication. Thus, comprehensive, and sustainable policies are needed to combat the public health threats associated with these challenges and to ensure the continuity of care.   Policy Options: The challenging circumstances brought by the COVID-19 pandemic require policymakers need to take action to build capacity and resiliency for those facing drug-related health and social problems. These should include the adoption of integrated strategies that combine drug consumption rooms, substance-specific therapies, provision of free needles and naloxone, primary healthcare, and social support.   Recommendations: The creation of an integrated drug policy framework addressed to European Union member states is necessary to create robust drug services capable of surviving a crisis. This is guided by a relevant policy design and implementation framework, alongside tangible action principles in line with low-threshold service provision.   Acknowledgments: The authors would like to sincerely thank J. Neicun and K. Czabanowska for their support in preparing, editing, and revising the policy brief. Authors’ Contributions: All authors contributed equally to this work. Conflicts of Interest: None declared Funding: None declared &nbsp

Be Healthy in Pregnancy (BHIP): A Randomized Controlled Trial of Nutrition and Exercise Intervention from Early Pregnancy to Achieve Recommended Gestational Weight Gain

A randomized two-arm prospective superiority trial tested the efficacy of a novel structured and monitored nutrition (bi-weekly counselling for individualized energy and high dairy protein diet) and exercise program (walking goal of 10,000 steps/day) (intervention) compared to usual care (control) in pregnant women to achieve gestational weight gain (GWG) within current recommendations. Women recruited in communities in southern Ontario, Canada were randomized at 12–17 weeks gestation with stratification by site and pre-pregnancy BMI to intervention (n = 119) or control (n = 122). The primary outcome was the proportion of women who achieved GWG within the Institute of Medicine recommendations. Although the intervention compared to control group was more likely to achieve GWG within recommendations (OR = 1.51; 95% CI (0.81, 2.80)) and total GWG was lower by 1.45 kg (95% CI: (−11.9, 8.88)) neither reached statistical significance. The intervention group achieved significantly higher protein intake at 26–28 week (mean difference (MD); 15.0 g/day; 95% CI (8.1, 21.9)) and 36–38 week gestation (MD = 15.2 g/day; 95% CI (9.4, 21.1)) and higher healthy diet scores (22.5 ± 6.9 vs. 18.7 ± 8.5, p < 0.005) but step counts were similar averaging 6335 steps/day. Pregnancy and infant birth outcomes were similar between groups. While the structured and monitored nutrition with counselling improved diet quality and protein intake and may have benefited GWG, the exercise goal of 10,000 steps/day was unachievable. The results can inform future recommendations for diet and physical activity in pregnancy

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London