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Sound epidemiological data are a basic requirement for decision making on the allocation of health care resources. Unfortunately, this is not the case in Estonia, where the paucity of epidemiological data has impeded health care planning for rheumatic conditions. The current paper presents the first effort to explore the epidemiology of rheumatoid arthritis (RA) in Estonia. Electronic databases of all rheumatology units of Harju County, three national and one private, were searched for the records of RA (ICD-10 diagnoses M05 and M06.0) patients who had visited a rheumatologist during 2006 or 2007. Prevalence of RA was calculated for the age 20 years and older and for subsets according to age and gender, using the numbers from the patients' database in the numerator and the corresponding population numbers in the denominator. The total number of prevalent RA cases was 1,897, of which 85 % ( n = 1,605) were women. The overall crude period prevalence 2006-2007 of RA in Harju County for the age group 20 years and older was 0.46 %. RA prevalence for both sexes increased with age until the age of 70-79 years and decreased subsequently. Prevalence of RA was significantly higher for women compared with men in all age groups. The prevalence of RA among women and men 20 years and older was 0.70 % (6.68-7.37) and 0.16 % (1.42, 1.79), respectively. Age-standardized (European population) prevalence rate was 0.44 %. The results are concordant with epidemiological data on RA prevalence derived recently in other European countries. [ABSTRACT FROM AUTHOR]

AIM – to investigate the relationship between levels of social skills and drug use among 15–16-year-old students in Estonia. METHODS – A total of 2,460 Estonian schoolchildren, born in 1995, participated in the ESPAD study in 2011. Individual social skills levels were measured with questions on prosocial and antisocial behaviours assessing how children perform within their social milieu. The relationship between social skills levels and drug use was estimated using chi-squared tests and logistic regression analysis. Odds ratios (OR) were adjusted for gender, parents’ education and financial well-being, and 95% confidence intervals (CI) were used to estimate risks of drug use by social skills level. RESULTS – Students with lower social skills were at greater risk of starting smoking and smoking daily (50% risk increase). Students with low social skills had a higher risk of lifetime use of cannabis (OR=1.4; 95%CI 1.1–1.9), sedatives/tranquillisers without a prescription (OR=2.3; 1.4–3.9), and inhalants (OR=1.9; 1.2–3.0). The number of students with lower social skills was significantly higher among boys than girls: 35% vs 19%. CONCLUSIONS – Students’ social skill levels were related to their licit and illicit drug use. A low level of social skills can increase adolescents’ vulnerability to drug use. As boys’ social skills levels appeared much lower and their drug use higher than that of girls, we suggest that gender-related risk prevention programmes of social skills training could be beneficial in preventing drug use.

Abstract Background Both syringe exchange programs (SEPs) and pharmacy sales of syringes are available in Estonia, though the current high incidence and high prevalence of HIV among injection drug users (IDUs) in Tallinn, Estonia requires large-scale implementation of additional harm reduction programs as a matter of great urgency. The aims of this report were to compare risk behavior and HIV infection and to assess the prevention needs among IDUs who primarily use pharmacies as their source of sterile syringes with IDUs who primarily use SEPs in Tallinn. Methods A cross-sectional study using respondent-driven sampling was used to recruit 350 IDUs for an interviewer-administered survey and HIV testing. IDUs were categorized into two groups based on their self-reported main source for syringes within the last six months. Odds ratios with 95% CI were used to compare characteristics and risk factors between the groups. Results The main sources of sterile needles for injection drug users were SEP/SEP outreach (59%) and pharmacies (41%). There were no differences in age, age at injection drug use initiation, the main drug used or experiencing overdoses. Those IDUs using pharmacies as a main source of sterile needles had lower odds for being infected with either HIV (AOR 0.54 95% CI 0.33–0.87) or HCV (AOR 0.10 95% CI 0.02–0.50), had close to twice the odds of reporting more than one sexual partner within the previous 12 months (AOR 1.88 95% CI 1.17–3.04) and engaging in casual sexual relationships (AOR 2.09 95% CI 1.24–3.53) in the last six months. Conclusion The data suggest that the pharmacy users were at a less "advanced" stage of their injection career and had lower HIV prevalence than SEP users. This suggests that pharmacies could be utilized as a site for providing additional HIV prevention messages, services for IDUs and in linking IDUs with existing harm reduction services.

Objectives: To compare the treatment effectiveness of secukinumab in radiographic (r) versus non-radiographic (nr) axial spondyloarthritis (axSpA) patients treated in routine care across Europe., Methods: Prospectively collected data on secukinumab-treated axSpA patients with known radiographic status were pooled from nine countries.Remission rates based on patient-reported outcomes (PROs; Numeric Rating Scale (0-10), for example, pain ≤2/Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≤2 and Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease (ID) <1.3 after 6/12/24 months of secukinumab treatment were calculated.Remission and drug retention rates in r-axSpA versus nr-axSpA patients were compared by logistic and Cox regression models (unadjusted/adjusted for age+sex/adjusted for multiple confounders)., Results: Overall, 1161 secukinumab-treated patients were included (r-axSpA/nr-axSpA: 922/239). At baseline, r-axSpA patients had longer disease duration and higher C reactive protein, were more often male and HLA-B27 positive and had received fewer prior biological or targeted synthetic disease-modifying antirheumatic drugs compared with nr-axSpA patients, whereas PROs were largely similar.During follow-up, crude PRO remission rates were significantly higher in r-axSpA compared with nr-axSpA patients (6 months: pain≤2: 40%/28%, OR=1.7; BASDAI≤2: 37%/25%, OR=1.8), as were drug retention rates (24 months: 66%/58%, HR 0.73 (ref: r-axSpA)). Proportions of patients achieving ASDAS ID were low for both groups, particularly nr-axSpA (6 months: 11%/8%).However, when adjusting for age+sex, these differences diminished, and after adjusting for multiple confounders, no significant between-group differences remained for either remission or drug retention rates., Conclusion: Crude remission/drug retention rates in European secukinumab-treated patients were higher in r-axSpA compared with nr-axSpA patients. In adjusted analyses, secukinumab effectiveness was similar in both groups, suggesting that observed differences were related to factors other than radiographic status., Competing Interests: Competing interests: SNC: Speaker fees BMS and GE, Research grant from Novartis (paid to the employer). SHR: Research grant from Novartis (paid to the employer). MO: Speaker and/or consultancy fees from AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB. Research grants from AbbVie, BMS, Merck, Novartis and UCB. MP: Research grant from Novartis (paid to the employer). Speaker fees: Sandoz. Brigitte Michelsen: Consulting fees from Novartis. Research grant from Novartis (paid to employer). KP: Consultancy fees: AbbVie, UCB, Pfizer, Eli Lilly, Celltrion, MSD and Novartis. Catalin Codreanu: Speaker and consultancy fees from AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis, Pfizer. Adrian Ciurea: None. Bente Glintborg: Research grants from Pfizer, Abbvie, BMS, Sandoz. MJS: Speaker fees from AbbVie, AstraZeneca, Janssen, Lilly, Medac, Novartis, Pfizer. Ismail Sari: None. ZR: Speaker and consultancy fees from Abbvie, Novartis, Eli Lilly, Pfizer, Janssen, SOBI, Swixx BioPharma, AstraZeneca, Amgen, MSD, Medis, Biogen, Eli Lilly, Sanofi, Lek. BG: Speaker and consultancy fees from Novartis and Nordic-Pharma. GJM: Research grant from GSK. HR: Consulting and/or speaking fees from AbbVie, Celgene, Pfizer, UCB, Viatris. FI: None. Karin Laas: Speakers fees from AbbVie, Johnson and Johnson, Novartis, Pfizer. JKW: Speaker fees from AbbVie, Amgen. Research support from AbbVie, Amgen, Eli Lilly, Novartis, Pfizer. MvdS: Consultant for Novartis, AbbVie, Eli Lilly UCB, Speakers fee: Novartis, UCB, Janssen, Grant/research support: UCB, Janssen, Novartis, Eli Lilly. Sella Aarrestad Provan: Consultancy fees and Research grants from Boehringer Ingelheim. IC: Speaker and/or consultancy fees from BMS, Eli-Lilly, Galapagos, Gilead, Janssen, Novartis, MSD, Pfizer, GSK. JZ: Speakers fees from AbbVie, Elli-Lilly, Sandoz, Novartis, Egis, UCB, Sanofi, Astra Zeneca, Sobi. CM: None. MJN: Speaker and/or consultancy fees from AbbVie, Amgen, Eli Lilly, Janssens, Novartis, Pfizer. Research grants from Novartis and Pfizer. AGL: Speaking and/or consulting fees from AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, UCB. Research grant from Novartis. AB: Speaker and/or consultancy fees from AbbVie, Lilly, Janssen and Novartis. YE: None. Katja Perdan Pirkmajer: Speaker and/or consultancy fees from AbbVie, Novartis, MSD, Medis, Eli Lilly, Pfizer, Lek, Janssen and Boehringer Ingelheim. GG: None. GTJ: Speaker fee from Janssen. Research grants (paid to employer) from AbbVie, Pfizer, UCB, Amgen, GSK. A-MH: Grant/research support from MSD. MSC: None. SV: None. DdG: None. TKK: Speaker and/or consultancy fees from AbbVie, Amgen, Celltrion, Gilead, Novartis, Pfizer, Sandoz, UCB and Grünenthal. LO-V: None. IvdH-B: Speaker and/or consultancy fees from AbbVie, UCB, MSD, Novartis, Lilly. Unrestricted Grants received for investigator initiated studies from MSD, Pfizer, AbbVie, UCB. Fees received for Lectures from BMS, AbbVie, Pfizer, MSD, UCB. MLH: Advisory Board AbbVie (No personal income, paid to institution). Prev. chaired the steering committee of the Danish Rheumatology Quality Registry (DANBIO, DRQ), which receives public funding from the hospital owners and funding from pharmaceutical companies. Speaker for Pfizer, Medac, Sandoz (no personal income, institution). Research grants (institution) from AbbVie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Medac, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis, Nordforsk. LMO: Research grant from Novartis (paid to the employer)., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

IntroductionObtaining epidemiological data on chronic hepatitis C virus (HCV) infection is essential to monitor progress towards the hepatitis C elimination targets.AimWe aimed to estimate the prevalence of chronic HCV and the seroprevalence of HCV in the adult general population in Estonia.MethodsThis cross-sectional study, conducted between 12 July and 6 December 2022, included anonymised residual sera collected prospectively from patients 18 years and older visiting a general practitioner in all counties of Estonia. Specimens were considered HCV-seropositive if they tested positive for HCV antibodies by enzyme-linked immunoassay, confirmed by line-immunoblot assay. Chronic HCV infection was determined by positive RT-qPCR.ResultsWe tested a total of 4,217 specimens. The estimated HCV seroprevalence and prevalence of chronic HCV infection were 1.8% (95% CI: 1.4-2.2) and 0.8% (95% CI: 0.5-1.1), respectively, with ca 8,100 persons estimated to have chronic HCV infection in the general adult population of Estonia. No statistically significant differences in the prevalence of chronic HCV infection were observed between sexes, counties or age groups, with the highest prevalence rates observed in men (sex ratio: 1.7), Ida-Virumaa County (1.8%; 95% CI: 0.8-3.6) and the age group 40-49 years (1.7%; 95% CI: 0.9-2.9).ConclusionThis study found an overall low prevalence of chronic HCV infection in Estonia. Continued efforts should be made for the targeted screening, diagnosis and treatment of individuals with chronic HCV infection to achieve hepatitis elimination targets.

Objectives: This study aimed to (1) to describe trends of tranquilliser and sedative (TS) misuse in Estonia during 2003-2019 and (2) to analyse the associations between TS misuse and explanatory factors (perceived access to TS, medical use of TS, family-related, friends-related, school-related factors, risk behaviour and leisure time physical activity)., Design: A cross-sectional study., Setting: Data were collected from the European School Survey Project on Alcohol and Other Drugs (ESPAD) from 2003 to 2019 in Estonia., Participants: Estonian schoolchildren aged 15-16 years old (n=11 328), 48.6% were boys., Outcome Measures: Prevalence, crude and adjusted ORs with 95% CIs for TS misuse., Results: The prevalence of lifetime TS misuse significantly increased from 2003 (5.0% of boys and 12.6% of girls) to 2019 (11.3% and 17.5%, respectively) (p<0.001). Among boys, TS misuse increased significantly among those reporting medical use of TS from 21.1% to 41.4% in 2003-2019 (p=0.006). Medical use of TS multiplied the odds of misuse by 6.89 (95% CI 5.15 to 9.24) for boys and by 4.53 (95% CI 3.58 to 5.73) for girls. Perceived easy access to TS increased the odds of misuse by 6.57 (95% CI 4.13 to 10.46) times for boys and by 4.66 (95% CI 3.25 to 6.70) times for girls. Having many friends who misuse TS increased the odds of misuse by 3.27 (95% CI 2.16 to 4.95) times for boys and by 5.07 (95% CI 3.79 to 6.77) times for girls. Furthermore, higher odds of TS misuse were observed among adolescents who smoked cigarettes and engaged in less sports., Conclusions: TS misuse prevalence among Estonian adolescents increased significantly from 2003 to 2019. Misuse was strongly associated with medical use, perceived easy access and friends' TS misuse. These findings emphasise the need for targeted prevention strategies, including improving prescription practices, limiting TS access and promoting healthy behaviours and positive peer relationships among adolescents., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Excess all-cause mortality is a key indicator for assessing direct and indirect consequences of injection drug use and data are warranted to delineate sub-populations within people who inject drugs at higher risk of death. Our aim was to examine mortality and factors associated with mortality among people who inject drugs in Estonia., Methods: Retrospective cohort study using data from people who inject drugs recruited in the community with linkage to death records. Standardized mortality ratios were used to compare the cohort mortality to the general population and potential predictors of death were examined through survival analysis (Cox regression). The cohort include a total of 1399 people who inject drugs recruited for cross-sectional surveys using respondent driven sampling between 2013 and 2018 in Estonia. A cohort with follow-up through 2019 was formed with linkage to national causes of death registry., Results: Among 1399 participants with 4684 person-years of follow-up, 10% were deceased by 2019. The all-cause mortality rate in the cohort was 28.9 per 1000 person-years (95% confidence interval 25.3-35.3). Being HIV positive, injecting mainly opioids (fentanyl), living in the capital region and the main source of income other than work were associated with greater mortality risk., Conclusions: While low-threshold services have been available for a long time for people who inject drugs, there is still a need to widen the availability and integration of services, particularly the integration of HIV and opioid treatment., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Public Health Association.)

Objectives: In patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) initiating secukinumab, we aimed to assess and compare the proportion of patients achieving 6-, 12- and 24-month patient-reported outcomes (PRO) remission and the 24-month retention rates., Patients and Methods: Patients with axSpA or PsA from 16 European registries, who initiated secukinumab in routine care were included. PRO remission rates were defined as pain, fatigue, Patient Global Assessment (PGA) ≤2 (Numeric Rating Scale (NRS) 0-10) and Health Assessment Questionnaire (HAQ) ≤0.5, for both axSpA and PsA, and were calculated as crude values and adjusted for drug adherence (LUNDEX). Comparisons of axSpA and PsA remission rates were performed using logistic regression analyses (unadjusted and adjusted for multiple confounders). Kaplan-Meier plots with log-rank test and Cox regression analyses were conducted to assess and compare secukinumab retention rates., Results: We included 3087 axSpA and 3246 PsA patients initiating secukinumab. Crude pain, fatigue, PGA and HAQ remission rates were higher in axSpA than in PsA patients, whereas LUNDEX-adjusted remission rates were similar. No differences were found between the patient groups after adjustment for confounders. The 24-month retention rates were similar in axSpA vs. PsA in fully adjusted analyses (HR [95 %CI] = 0.92 [0.84-1.02])., Conclusion: In this large European real-world study of axSpA and PsA patients treated with secukinumab, we demonstrate for the first time a comparable effectiveness in PRO remission and treatment retention rates between these two conditions when adjusted for confounders., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sara Nysom Christiansen, Simon Horskjær Rasmussen, Lykke Midtbøll Ørnbjerg: research grant from Novartis; Marion Pons: research grant from Novartis and speaker fees from Sandoz; Brigitte Michelsen: research grant from Novartis and the centre for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY) is funded as a Centre for Clinical Treatment Research by The Research Council of Norway (project 328,657); Bente Glintborg: research grants from Pfizer, Abbvie, BMS, Sandoz; Bjorn Gudbjornsson: consulting fees from Novartis and speaker fees from Novartis, Nordic-Pharma; Gerdur Grondal: none; Jiri Vencovsky: research grant from Abbvie, consulting fees from Abbvie, Argenx, Boehringer, Eli Lilly, Gilead, Octapharma, Pfizer, UCB and speaker fees from Abbvie, Biogen, Boehringer, Eli Lilly, Gilead, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, Werfen; Anne Gitte Loft: research grant from Novartis andspeaking and/or consulting fees from AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, UCB, paid instructor from Pfizer; Ziga Rotar: consulting fees from Abbvie, Novartis, Eli Lilly, Pfizer, Janssen and speaker fees from Abbvie, Amgen, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek, Janssen; Katja Perdan Pirkmajer: consulting fees from Abbvie, Novartis, Medis, Eli Lilly, Pfizer, Boehringer Ingelheim and speaker fees from Abbvie, Novartis, MSD, Medis, Eli Lilly, Pfizer, Lek, Janssen; Michael J. Nissen: research grant from Pfizer andconsulting and/or speaker fees from Abbvie, Eli Lilly, Janssens, Novartis, Pfizer; Jana Baranova: none; Gary J. Macfarlane: research grant from GSK; Gareth T.Jones: research grants from Abbvie, Pfizer, UCB, Amgen, GSK and speaker fees from Janssen; Florenzo Iannone: research grant from BMS, Galapagos, Pfizer and consulting and/or speakers fees from Abbvie, Amgen, AstraZeneca, BMS, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB; Roberto Caporali: consulting and/or speaker fees from Abbvie, Amgen, AstraZeneca, BMS, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB; Karin Laas: research grant from Abbvie, Johnson and Johnson, Novartis, Pfizer; Sigrid Vorobjov: none; Daniella Di Giuseppe: none; Tor Olofsson: none; Sella Aarrestad Provan: Research grant from Boehringer Ingelheim and consulting fees from Boehringer Ingelheim; Karen Minde Fagerli: none; Isabel Castrejon: consulting and speaker fees from BMS, Eli-Lilly, Galapagos, Gilead, Janssen, Novartis, MSD, Pfizer, GSK; Lucia Otero-Varela: None; Marleen Van de Sande: research grants from UCB, Janssen, Novartis, Eli Lilly, consulting fees from Novartis, Abbvie, Eli Lilly UCB and speaker fees from Novartis, UCB, Janssen; Irene van der Horst-Bruinsma: Unrestricted Grants received for investigator initiated studies from MSD, Pfizer, AbbVie, UCB. Fees received for lectures from BMS, AbbVie, Pfizer, MSD, UCB, consulting fees from Abbvie, UCB, MSD, Novartis, Lilly and speaker fees from UCB; Dan Nordström: research grant from MSD, consulting fees from Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche, UCB, and speaker fees from Novartis, Pfizer, UCB; Laura Kuusalo: consulting fees from Gilead, Pfizer and speaker fees from Abbvie, Lilly, Medac, Orion, Pfizer, UCB; Miguel Bernades: none; Merete Lund Hetland: Research grants from Novartis, Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Medac, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis, Nordforsk, consulting fees from Abbvie, chaired the steering committee of the Danish Rheumatology Quality Registry (DANBIO, DRQ), which receives public funding from the hospital owners and funding from pharmaceutical companies and speaker fees from Pfizer, Medac, Sandoz; Mikkel Østergaard: Research grant from Abbvie, BMS, Merck, Novartis and UCB and consulting and/or speaker fees from Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB, (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Fear of coronavirus disease (COVID-19) has been associated with significant health effects., Objectives: To assess COVID-19 fear and investigate factors associated with higher fear among COVID-19 survivors over 6 months after infection., Methods: Cross-sectional study using multistage sampling (family practices within the highest 5th percentile of numbers of SARS-CoV-2 infected patients and random sample of patients within these practices) performed from March 15 to 17 July 2021. Adult patients with a laboratory-confirmed history of COVID-19 were recruited for a self-administered 79-item questionnaire including demographics, self-rated health, physical activity, COVID-19 characteristics, severity and the fear of COVID-19 Scale (FCV-19S). Comorbidity data were extracted from Estonian Health Insurance Fund. Logistic regression models were used to evaluate factors associated with COVID-19 fear., Results: Of 341 participants included, 60% were women, 24.2% were hospitalised due to COVID-19 and 22.2% had long COVID, 143 (42%) participants reported high levels of fear (cut-off FCV-19S >17.8). Higher fear was associated with being female (aOR 2.12, 95% CI 1.14-3.95), age ≥61 years (aOR 3.23, 95% CI 1.28-8.16), two-member-households (aOR 3.70, 95% CI 1.40-9.77) physical inactivity 6 months prior to COVID-19 (aOR 3.53, 95% CI 1.26-9.95), and symptom severity during acute COVID-19. Long COVID was not associated with higher COVID-19 fear (aOR 1.82 95% CI 0.91-3.63)., Conclusion: Almost half of participants reported COVID-19 fear more than 6 months after infection. Greater fear was associated with sociodemographic factors, physical activity prior to COVID-19 and COVID-19 symptom severity. There is a need to target this population to develop appropriate interventions.

Aims: We measured the association between a history of incarceration and HIV positivity among people who inject drugs (PWID) across Europe., Design, Setting and Participants: This was a cross-sectional, multi-site, multi-year propensity-score matched analysis conducted in Europe. Participants comprised community-recruited PWID who reported a recent injection (within the last 12 months)., Measurements: Data on incarceration history, demographics, substance use, sexual behavior and harm reduction service use originated from cross-sectional studies among PWID in Europe. Our primary outcome was HIV status. Generalized linear mixed models and propensity-score matching were used to compare HIV status between ever- and never-incarcerated PWID., Findings: Among 43 807 PWID from 82 studies surveyed (in 22 sites and 13 countries), 58.7% reported having ever been in prison and 7.16% (n = 3099) tested HIV-positive. Incarceration was associated with 30% higher odds of HIV infection [adjusted odds ratio (aOR) = 1.32, 95% confidence interval (CI) = 1.09-1.59]; the association between a history of incarceration and HIV infection was strongest among PWID, with the lowest estimated propensity-score for having a history of incarceration (aOR = 1.78, 95% CI = 1.47-2.16). Additionally, mainly injecting cocaine and/or opioids (aOR = 2.16, 95% CI = 1.33-3.53), increased duration of injecting drugs (per 8 years aOR = 1.31, 95% CI = 1.16-1.48), ever sharing needles/syringes (aOR = 1.91, 95% CI = 1.59-2.28) and increased income inequality among the general population (measured by the Gini index, aOR = 1.34, 95% CI = 1.18-1.51) were associated with a higher odds of HIV infection. Older age (per 8 years aOR = 0.84, 95% CI = 0.76-0.94), male sex (aOR = 0.77, 95% CI = 0.65-0.91) and reporting pharmacies as the main source of clean syringes (aOR = 0.72, 95% CI = 0.59-0.88) were associated with lower odds of HIV positivity., Conclusions: A history of incarceration appears to be independently associated with HIV infection among people who inject drugs (PWID) in Europe, with a stronger effect among PWID with lower probability of incarceration., (© 2023 Society for the Study of Addiction.)

This is the first report comparing EULAR and national treatment recommendations for PsA patients across Europe, and the first this decade to compare ASAS-EULAR and national treatment recommendations in axSpA patients. An electronic survey was completed from October 2021-April 2022 by rheumatologists in 15 European countries. One and four countries followed all EULAR and ASAS-EULAR recommendations, respectively. Five countries had no national treatment recommendations for PsA and/or axSpA, but followed other regulations. In several countries, national treatment recommendations predated the most recent EULAR/ASAS-EULAR recommendations. Entry criteria for starting biologic/targeted synthetic disease-modifying anti-rheumatic drugs varied considerably. In several countries, for PsA patients with significant skin involvement, interleukin-17 inhibitors were not given preference. The positioning of Janus Kinase inhibitors differed and Phosphodiesterase-4 inhibitors were not in use/reimbursed in most countries. This study may motivate European countries to update their national treatment recommendations, to align them better with the latest international recommendations., Competing Interests: BM, research grant from Novartis (for the present manuscript, paid to employer), Centre for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY) is funded as a Centre for Clinical Treatment Research by The Research Council of Norway (project 328657); MØ, Funding for the present manuscript from Novartis (paid to institution), The EuroSpA Research Collaboration Network was financially supported by Novartis Pharma AG, research grants from Abbvie, BMS, Merck, Novartis, UCB, consulting fees from Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, MEDAC, Merck, Novartis, Pfizer, Sandoz, UCB, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, MEDAC, Merck, Novartis, Pfizer, Sandoz, UCB, support for attending meetings and/or travel from UCB; MJN, grant from Novartis (payment to institution), consulting fees from AbbVie, Eli-Lilly, Janssen, Novartis, Pfizer (payment to institution), payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AbbVie, Eli-Lilly, Janssen, Novartis, Pfizer (payment to institution), support for attending meetings and/or travel from Janssen, UCB (payment to institution), participation on a Data Safety Monitoring Board or Advisory Board from Eli-Lilly, Janssen, Novartis, Pfizer (payment to institution), scientific member of the SCQM registry and the EuroSpA collaboration (unpaid), ASAS-EULAR taskforce member (unpaid); AC, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, Merck-Sharp & Dohme, Novartis; BMö, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, Janssen, Novartis, Pfizer, support for attending meetings and/or travel from Abbvie, Janssen, Novartis, Pfizer; LMØ, research grant from Novartis (for the present manuscript, paid to employer); JZ, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, Eli-Lilly, Sandoz, Novartis, Egis, UCB, Sanofi, Astra Zeneca, support for attending meetings and/or travel from Abbvie, Pfizer, Astra Zeneca, participation on a data safety monitoring board or advisory board from Abbvie, UCB, Sobi; BGli, Research grants from Pfizer, AbbVie, BMS (payments made to institution); AM; payment for work done in relation to research questions for this project from the University of Aberdeen, speakers fees for educational events from Galapagos; KL, Honoraria for lectures from Pfizer, Abbvie, Novartis, Janssen, support for attending meetings from Abbvie, Pfizer; DN, Consulting fees from BMS, Lilly, MSD, Novartis, Pfizer, UCB, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Pfizer, support for attending meetings and/or travel from Pfizer; BGu, consulting fees from Novartis, speaker bureaus from Novartis, Nordic Pharma; FI, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, BMS, Galapagos, Eli-Lilly, Pfizer, UCB, support for attending meetings and/or travel from Pfizer, UCB; PH, research grant (payments made to employer) from Novartis; TKK, consulting fees from AbbVie, Gilead, Janssen, Novartis, Pfizer, Sandoz, UCB, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Grünenthal, Janssen, Sandoz, participation on a data safety monitoring board or advisory board from Abbvie, grants or contracts from AbbVie, BMS, Galapagos, Novartis, Pfizer, UCB; AMR, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, Amgen, Novartis, support for attending meetings and/or travel from Amgen, Nordic, Theramex, grants or contracts from Novartis, Pfizer, Amgen, Astra Zeneca, Abbvie, MSD, Lilly, Boehringer Ingelheim; CC, None; ZR, Consulting fees from AbbVie, Janssen, Novartis, MSD and Lek Sandoz, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Eli Lilly, Janssen, Abbvie, Pfizer, Boehringer Ingelheim, support for attending meetings and/or travel from Gedeon Richter, Pfizer, SOBI (payments made to employer), participation on data safety monitoring board or advisory board from Abbvie, Pfizer, Astra Zeneca, Janssen, Eli Lilly, Novartis and Boehringer Ingelheim; ICF, consulting fees from Pfizer, Galapagos, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from BMS, Eli-Lilly, Gilead, Janssen, Novartis, MSD, Pfizer, GSK, support for attending meetings and/or travel from Pfizer, Eli-Lilly; JKW, Research support from Abbvie, Amgen, Eli Lilly, Novartis, Pfizer (unrelated to the present work, payment made to Lund University), speakers bureaus from Abbvie and Amgen (payed to Skåne University Hospital), acting co-chair of the Swedish Society for Rheumatology's working group annually updating Swedish treatment recommendations for axial spondyloarthritis and psoriatic arthritis (unpaid, fiduciary assignment); JV, support for the present manuscript from the Czech Ministry of Health–Conceptual Development of Research Organization 00023728 (Institute of Rheumatology), payment to institution, consulting fees from Eli Lilly, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, Biogen, Eli Lilly, Gilead, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, support for attending meetings and/or travel from Abbvie (payment to institution), participation on a data safety monitoring board or advisory board from Abbvie, Gilead, Pfizer, UCB, grants or contracts from Abbvie (payment to institution); AGL, Consulting fees from Jansen-Cilag A/S, Lilly Nordics, UCB, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Novartis Healthcare A/S, Pfizer, support for attending meetings and/or travel from Pfizer, UCB, participation on a data safety monitoring board or advisory board from Jansen-Cilag A/S, Lilly Nordics, UCB; MH; None; SV, None; AMH, Research grant from MSD, grant for attending meeting from Janssen, Pfizer, support for travel cost from Janssen; GG, None; MS, support for the present manuscript from Lilly and Boehringer-Ingelheim, payment or honoraria for lectures, presentations, speaker's bureaus, manuscript writing or educational events from Pfizer, Boehringer-Ingelheim, GSK, participation on data safety or advisory board from Janssen-Cilag, support for attending meetings and/or travel from Janssen-Cilag; MvdS, Research support/grant from UCB, Eli Lilly, Novartis, Janssen (payments made to institution, AMR Medical Research BV), consulting fees from Novartis, UCB, Abbvie (payments made to institution), payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Novartis, UCB, Janssen (payments made to institution), support for attending meetings and/or travel from UCB; EKK, None; MJS, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, Janssen, Lilly, Novartis, Pfizer, support for attending meetings and/or travel from Janssen, Viatris, Medac and receipt of equipment, materials, drugs, medical writing, gifts or other services from Vifor; CM, None; MT, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AbbVie, Amgen, Boehringer, Pfizer, Sanofi-Aventis, Roche, Lek-Sandoz, Janssen, Medis, Novartis, participation on data safety or advisory board from Astra Zeneca, Eli Lilly, Janssen, Boehringer, MSD, Novartis, Roche; FDG, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbvie, payment for expert testimony from Abbvie, Galapagos, Janssen, and support for attending meetings and/or travel from Pfizer, Astra Zeneca; DDG, None; MLH, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Pfizer, Medac, Sandoz, research grants from Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Foundation, MSD, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis, Nordstar (payment to institution). MLH has chaired the steering committee of the Danish Rheumatology Quality Registry (DANBIO, DRQ), which receives public funding from the hospital owners and funding from pharmaceutical companies. MLH co-chairs EuroSpA, which generates real-world evidence of treatment of psoriatic arthritis and axial spondyloarthritis based on secondary data and is partly funded by Novartis., (© 2023 The Author(s).)

Background: Hospital-acquired strains (HASs) and multiresistant strains in neonatal intensive care unit often harbour virulence and resistance mechanisms, carrying the risk of invasive infections. We describe colonisation with Enterobacteriaceae in neonates receiving early directed versus routine family-integrated care (FIC) within the first month of life., Methods: A prospective cohort study included neonates with a gestational age below 34 weeks. During the first period, neonates were admitted to an open bay unit with transfer to the single-family room if available; feeding with the mother's own breast milk (MOBM) was introduced within 24 hours, and skin-to-skin contact (SSC) within 5 days of life (the routine care group). During the second period, following a wash-in of 2 months, care in a single-family room within 48 hours, the introduction of MOBM within two and SSC in 48 hours were applied (the intervention group). Enterobacteriaceae isolated from neonatal stool, breast milk and parental skin swabs were genotyped, Simpson's Index of Diversity (SID) calculated, and extended-spectrum beta-lactamases (ESBL) detected., Results: In 64 neonate-parents' groups, 176 Enterobacteriaceae , 87 in routine care and 89 in the intervention group were isolated; 26 vs 18 were HAS and one vs three ESBL positive, respectively. In the intervention group compared with the routine care group, SSC and MOBM feeding was started significantly earlier (p<0.001); during the first week of life, time spent in SSC was longer (median hours per day 4.8 (4-5.1) vs 1.9 (1.4-2.6), p<0.001) and the proportion of MOBM in enteral feeds was higher (median (IQR) 97.8% (95.1-100) vs 95.1% (87.2-97.4), p=0.011). Compared with the routine care group, the intervention group had higher SID and a reduction of HAS by 33.1% (95% CI 24.4% to 42.4%) in time series analysis., Conclusions: Early implementation of FIC measures may hold the potential to increase diversity and reduce colonisation with HAS Enterobacteriaceae ., Competing Interests: Competing interests: No, there are no competing interests., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The aim of the study was to analyse health-related quality of life (HRQoL) among the Estonian general population and its socio-demographic and behavioural correlates during the COVID-19 pandemic. Longitudinal data on 1781 individuals from an Estonian rapid-assessment survey on COVID-19 were used. HRQoL was assessed with the EQ-5D-3L in June 2020 (baseline) and in May 2021 (follow-up). The HRQoL index score and its socio-demographic and behavioural variations were analysed using paired t -tests and Tobit regression modelling. Statistically significant declines in mean EQ-5D index scores were observed for all socio-demographic and behavioural variables considered. Most of these changes were due to increased reporting of problems in the pain/discomfort and anxiety/depression health domains. Older age, being unemployed or economically non-active and having financial difficulties were significantly associated with lower HRQoL in both baseline and follow-up measurements. In the follow-up data, women had significantly lower HRQoL compared to men, whereas higher education proved to be the only protective factor regarding HRQoL. Unhealthy dietary habits and low physical activity had a negative impact on the HRQoL score in the follow-up data. These results indicate that the COVID-19 pandemic has had a substantial impact on HRQoL in the Estonian population.

Objectives: The aims of the study were (1) to describe trends in the prevalence of monthly alcohol use from 2003 to 2015 and (2) to analyse the associations between alcohol use and family-related and school-related factors, risk behaviours and perceived alcohol availability in Estonia compared with Latvia, Lithuania, Finland and Sweden., Methods: The study used nationally representative data of 15-16-year-old adolescents from the European School Survey Project on Alcohol and Other Drugs. Data from Estonia, Latvia, Lithuania, Finland and Sweden collected in 2003, 2007, 2011 and 2015 were utilised (n=57 779). The prevalence of monthly alcohol use including light and strong alcohol use was calculated for each study year. A χ 2 test for trend was used to evaluate statistically significant changes in alcohol use over the study period. A multilevel logistic regression analysis was used for assessing the association between alcohol use and explanatory factors. Marginal ORs with 95% CIs for each country were calculated., Results: Monthly alcohol use decreased significantly among boys and girls in all countries from 2003 to 2015. In 2015, the prevalence of monthly alcohol use among boys was 36.1% in Estonia, 44.3% in Latvia, 32.4% in Lithuania, 32.3% in Finland and 22.4% in Sweden. Among girls, it was 39.1%, 45.9%, 35.6%, 31.8% and 29.1%, respectively. In all countries, higher odds of monthly alcohol use were observed among adolescents who skipped school, smoked cigarettes, used cannabis, perceived alcohol to be easy to access and had parents who did not know always/often about their child's whereabouts on Saturday nights. Compared with Estonia, associations between alcohol use and explanatory factors were similar in Latvia and Lithuania but different in Finland and Sweden., Conclusion: Results of cross-national comparison of alcohol use and explanatory factors could be effectively used to further decrease alcohol use among adolescents., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To study the population-level mental health responses during the first wave of coronavirus disease 2019 (COVID-19) outbreak in Estonia and analyze its socio-demographic, behavioral, and health-related variations among general population. Methods: This study used nationally representative data on 4,606 individuals, aged 18-79 years from a rapid-response cross-sectional survey conducted in April 2020. Point prevalence and mutually adjusted prevalence rate ratios for perceived stress from log-binomial regression analysis were presented for socio-demographic, behavioral, and health-related variables. Results: This study found that 52.2% of population aged 18-79 reported elevated stress levels in relation to COVID-19 outbreak. Higher levels of perceived stress were found in women, in younger age groups, in Estonians, and in those with higher self-perceived infection risk, presence of respiratory symptoms, and less than optimal health, according to self-reports. Conclusion: Although, the potential long-term health effects of the current crisis are yet unknown, the alarmingly high stress levels among people indicate that the COVID-19 pandemic might have had a widespread effect on people's mental health., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Reile, Kullamaa, Hallik, Innos, Kukk, Laidra, Nurk, Tamson and Vorobjov.)

Aims: (1) To describe the time trends of monthly cannabis use and (2) to analyse the association between the trends of monthly cannabis use and trends of different explanatory factors among adolescents in Estonia in 2003-2019., Methods: Nationally representative data from five waves of the cross-sectional European School Survey Project on Alcohol and Other Drugs (ESPAD) among 15-16-year-old adolescents ( n = 11,348) in Estonia were analysed. Tests for trends were used to assess significant changes in monthly cannabis use and explanatory variables over time. Logistic regression analysis was used to analyse the association between monthly cannabis use and perceived easiness of getting cannabis, perceived health risk of cannabis use, parental factors, risk behaviours, and leisure time activities. The model included interaction terms between the study year and each explanatory variable. Gender-adjusted odds ratios ( OR ) with 95% confidence intervals (CI) were calculated., Results: Monthly cannabis use increased from 5.3% in 2003 to 7.7% in 2015 and thereafter decreased to 6.6% in 2019 among adolescents in Estonia ( P = 0.007). The association between monthly cannabis use and alcohol use was significant over the study period and the interaction of alcohol use with study year indicated significantly increased effect of alcohol use over time ( P = 0.038). The association between monthly cannabis use and perceived easiness of obtaining cannabis, perceived low health risk from cannabis use and smoking was significant, but remained unchanged over the study period. The relationship between monthly cannabis use and low parental control was significant in two last study years but did not show any changes over time., Conclusions: The findings of this study demonstrate the need for the implementation of multi-component substance use prevention programmes among adolescents in Estonia that also pay attention to the factors associated with the cannabis use., Competing Interests: Declaration of conflicting interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: The spread of illicitly manufactured fentanyl has the potential to greatly increase the fatal overdoses in many places in the world. The purpose of this paper is to analyse the evolution of fentanyl use epidemic in Estonia., Methods: this scoping review is based on extensive review and synthesis of broad range of literature: research reports, newspaper, magazine, coverage of illicit fentanyl use; policy documents, position papers, reports released by government agencies, and surveillance data., Results: For an over a decade up to 2017, Estonia has had the highest overdose death mortality in Europe. The use of (injected) fentanyl is a major contributor to the Estonian overdose death epidemic. Shutting down a major producer and distributor of illicit fentanyl has been extremely effective in curbing the number of overdose deaths. Unfortunately, this supply-side intervention came ten years into the epidemic, and might be difficult to replicate in settings with decentralized production. In areas faced by fentanyl we would recommend large-scale implementation of opiate substitution treatment and naloxone distribution, syringe service programs to provide for safer injecting and link to other services (high frequencies of fentanyl injection create high risk for HIV and HCV transmission), and programs, such as "Break the Cycle," to reduce initiation into injecting drug use. Further, the means of responding to emerging substances should match the world in which different substances can be rapidly introduced, and where people who use drugs can change preferences based on market availability., Conclusion: Addressing illicitly manufactured fentanyl may serve as a public health learning experience for developing early detection and rapid response programs in rapidly changing drug use environments., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: It has been observed in an earlier study that the number of people who inject drugs (PWID) in Estonia is declining. We provide nationwide estimates of the number of PWID in Estonia for years 2010-2015 and compare different modelling strategies to minimise over-coverage-induced bias in capture-recapture estimates., Methods: We obtained data from the Estonian Causes of Death Registry (DR) for opioid-related deaths, the Estonian Health Insurance Fund (HIF) for opioid-related overdose and drug dependence treatment episodes, and the Estonian Police and Border Guard Board (PB) drug-related misdemeanours. Datasets were linked by identifier based on sex, date of birth, and initials; a capture-recapture method was used to estimate the number of PWID aged 15 or more, each year from 2010 to 2015. Log-linear regression maximum likelihood (ML) and Bayesian methods were used; over-coverage of police data was accounted for., Results: The annual population size estimates of the number of PWID (aged 15 and over) varied from 6000 to 17,300 (ML estimates not accounting for over-coverage of PB) to 1500-2300 (Bayesian estimates accounting for over-coverage). Bayesian estimates indicated a slight decrease in the number of PWID, and the median estimates were > 2000 in years 2010-2012 and < 1800 in years 2013-2015., Conclusions: Over-coverage of a registry can have a great impact on the estimates of the size of the target population. Bayesian estimates accounting for this over-coverage may provide better estimates of the target population size.

Background: Despite increasing contraceptive availability, unintended pregnancy remains a global problem. Developing strategies to reverse this trend and increasing occurrence of withdrawal syndrome among newborn children of females currently injecting drugs warrants special attention. The knowledge base on the uptake of effective contraception among females who inject drugs (FWID) is scant. We aimed to examine the prevalence of and factors associated with the use of non-condom contraceptives among sexually active FWID with the focus on effective contraception., Methods: In a series of cross-sectional studies (2007-2013), 265 current FWID were recruited through respondent-driven sampling (RDS), interviewed, and tested for HIV. RDS weights were used to estimate the prevalence of effective contraception (hormonal contraception, intrauterine device, sterilization) use in the last 6 months., Results: Of the sexually active women with main partners (n = 196) 4.8% (95% CI 2.3-9.7) were using effective contraception, 52.7% (95% CI 42.5-62.7) less-effective or no contraception. 42.5% (95% CI 32.7-52.9) relied on condoms for contraception. The odds for using effective contraception were higher among women with > 10 years of education (OR 7.29, 95% CI 1.4-38.8). None of the women lacking health insurance (n = 84) were using effective contraception., Conclusions: The very low coverage with effective contraception highlights the need to improve contraceptive services for FWID. Reproductive health service including contraception should be considered essential components of harm reduction and of comprehensive prevention and care for HIV among persons who use drugs.

Disclosure of injecting drug use and its associations with stigma have received very little research attention. This cross-sectional study examined the role of internalized HIV and drug stigma (i.e., self-stigmatization) in the disclosure of injecting drug use among people who inject drugs (PWID) self-reporting as HIV-positive (n = 312) in Kohtla-Järve, Estonia. The internalization of both stigmas was relatively high. On average, PWID disclosed to three disclosure targets out of seven. Disclosure was highest to close friends and health care workers and lowest to employers and casual sex partners. Internalized drug stigma was negatively associated with disclosure to other family members (AOR = 0.48; 95% CI 0.30-0.77) and health care workers (AOR = 0.46; 95% CI 0.25-0.87). Internalized HIV stigma was positively associated with disclosure to health care workers (AOR = 2.26; 95% CI 1.27-4.00). No interaction effect of internalized stigmas on disclosures emerged. We concluded that effects of internalized stigmas on disclosures are few and not uniform.

Introduction: New injectors / younger drug users are an important population to target for intervention because they are often at especially high risk of HIV and HCV infection. We examined HIV prevalence and gender differences in HIV prevalence and risk behavior among new injection-drug-users in Tallinn, Estonia., Methods: Respondent driven sampling (RDS) interview surveys and HIV testing were conducted in Tallinn in 2009, 2011 and 2013. We classified "new injectors" as persons who reported their first injection as occurring within three years of the study interview. Recruiting trees of the three individual RDS studies were joined to form one RDS dataset and RDS estimates for prevalence and means were derived. Bootstrap tests were used to compare data from men and women, HIV infected and uninfected., Results: Among 110 new injectors (34 women and 76 men) the mean age was 24.5 (SD 7.5) years; 63% reported injecting mainly fentanyl, 34% injecting mainly amphetamine, 36% sharing syringes, 89% were sexually active, and, of these, 88% did not always use condoms in the last 6 months. HIV prevalence was 18% (95%CI 8-28%) (41% (95%CI 19-63%) among female and 7% (95%CI 2-12%) among male new injectors). Based on self-reports, 8.1% of all new injectors (and 22% of female new injectors) were HIV positive before starting to inject drugs. 40% of HIV infected reported receiving antiretroviral therapy. In multivariable analysis, gender (male: OR 0.12, 95% CI 0.03-0.45), main drug injected (fentanyl: OR 6.7, 95% CI 1.3-35.7) and syringe sharing (distributive: OR 0.11, 95% CI 0.02-0.55; and receptive: OR 3.7, 95% CI 1.0-13.5) were associated with the HIV seropositivity., Conclusions: New injectors exhibit high-risk behavior and correspondingly high HIV prevalence. Sexual transmission of HIV infection, including before injection initiation, is likely to be a significant contributor to HIV risk among female new injectors. This highlights the need to identify and target new injectors and their partners with gender specific interventions in addition to interventions to reduce initiation into injecting and ensuring provision of ART to HIV positive new injectors., Competing Interests: The authors have declared that no competing interests exist.

Background: This study seeks to identify the prevalence of, and risk factors associated with, non-fatal overdose among people currently injecting drugs (PWID) in St. Petersburg (Russia) and in Kohtla-Järve (Estonia)., Methods: Five hundred eighty-eight study participants in Kohtla-Järve (in 2012) and 811 in St. Petersburg (in 2012-2013) were recruited using respondent driven sampling for interviewing and HIV testing., Results: Three-quarters (76%) of the current PWID were male. Participants from St. Petersburg were older (mean age 32.1 vs. 29.6 years, p < 0.0001) and reported a longer average duration of injecting drugs (mean duration: 13.3 vs. 10.9 years, p < 0.0001). Main drugs injected were opioids (fentanyl in Kohtla-Järve, heroin in St Petersburg). HIV prevalence was 63% (95% CI 59-67%) in Kohtla-Järve and 56% (95% CI 52-59%) in St. Petersburg. Two thirds of the PWID in Kohtla-Järve and St. Petersburg reported ever having experienced a drug overdose involving loss of consciousness or stopping breathing. In Kohtla-Järve, 28% (95% CI 24-31%) of participants and, in St Petersburg, 16% (95% CI 14-19%) of participants reported an overdose within the previous 12 months. Characteristics of injection drug use practice (longer duration of injection drug use, main drug injected), correlates of high-risk injection behaviour (higher injecting frequency, sharing), and problem alcohol use were associated with the risk of overdose within the previous 12 months. The significant factors effects did not differ between the sites., Conclusions: PWID are at high risk for overdose. Effective overdose prevention efforts at the public health scale are therefore warranted.

Background: Attempts to relate patellar cartilage involvement to anterior knee pain (AKP) have yielded conflicting results. We determined whether the condition of the cartilage of the patella at the time of knee replacement, as assessed by the OARSI score, correlates with postsurgical AKP., Patients and Methods: We prospectively studied 100 patients undergoing knee arthroplasty. At surgery, we photographed and biopsied the articular surface of the patella, leaving the patella unresurfaced. Following determination of the microscopic grade of the patellar cartilage lesion and the stage by analyzing the intraoperative photographs, we calculated the OARSI score. We interviewed the patients 1 year after knee arthroplasty using the HSS patella score for diagnosis of AKP., Results: 57 of 95 patients examined had AKP. The average OARSI score of painless patients was 13 (6-20) and that of patients with AKP was 15 (6-20) (p = 0.04). Patients with OARSI scores of 13-24 had 50% higher risk of AKP (prevalence ratio = 1.5, 95% CI: 1.0-2.3) than patients with OARSI scores of 0-12., Interpretation: The depth and extent of the cartilage lesion of the knee-cap should be considered when deciding between the various options for treatment of the patella during knee replacement.

Background and Objective: Anterior knee pain (AKP) may compromise the results of total knee arthroplasty in more than quarter of cases. The aim of the current work was to determine the prevalence of AKP and the severity of patellofemoral symptoms among patients who received a total knee arthroplasty with non-replaced patella in East-Tallinn Central Hospital from January 1, 2000 to December 31, 2009., Materials and Methods: We carried out a retrospective study involving 1778 consecutive total knee arthroplasties with non-replaced patella. Mean follow-up time was 68 months. We collected data by two patient-reported measures: the knee pain questionnaire and the Kujala score., Results: We diagnosed AKP among 20.2% of patients, 33.6% had pain in the knee from a source other than patellofemoral joint and 46.2% were pain free. In 87.3% of AKP cases the pain emerged within the first five years of knee replacement. AKP was more prevalent among patients with osteoarthritis compared to rheumatoid arthritis and among patients below 60 years. There was no difference in the prevalence of AKP in terms of gender or mobile and fixed bearing implants. The severity of patellofemoral symptoms in case of AKP was moderate., Conclusions: AKP is a frequent complication of total knee arthroplasty with non-replaced patella and patients undergoing this procedure should be apprised of the high probability of experiencing pain in the anterior part of the replaced knee., (Copyright © 2014 Lithuanian University of Health Sciences. Production and hosting by Elsevier Urban & Partner Sp. z o.o. All rights reserved.)

Aim: To explore socio-demographic factors, health risks and harms associated with early initiation of injecting (before age 16) among injecting drug users (IDUs) in Tallinn, Estonia., Methods: IDUs were recruited using respondent driven sampling methods for two cross-sectional interviewer-administered surveys (in 2007 and 2009). Bivariate and multivariate logistic regression analysis was used to identify factors associated with early initiation versus later initiation., Results: A total of 672 current IDUs reported the age when they started to inject drugs; the mean was 18 years, and about a quarter of the sample (n = 156) reported early initiation into injecting drugs. Factors significantly associated in multivariate analysis with early initiation were being female, having a lower educational level, being unemployed, shorter time between first drug use and injecting, high-risk injecting (sharing syringes and paraphernalia, injecting more than once a day), involvement in syringe exchange attendance and getting syringes from outreach workers, and two-fold higher risk of HIV seropositivity., Conclusions: Our results document significant adverse health consequences (including higher risk behaviour and HIV seropositivity) associated with early initiation into drug injecting and emphasize the need for comprehensive prevention programs and early intervention efforts targeting youth at risk. Our findings suggest that interventions designed to delay the age of starting drug use, including injecting drug use, can contribute to reducing risk behaviour and HIV prevalence among IDUs., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to develop a new radiographic measure, the patellar shift index (PSI), for the precise estimation of patellar position relative to the trochlea after a total knee replacement with an unresurfaced patella., Methods: This study included radiographs of 51 patients suffering from anterior knee pain following total knee arthroplasty. Patellofemoral axial radiographs were analyzed to compare the reliability of the PSI to the classical measures of patellofemoral congruence, the lateral patellar tilt (LPT) and patellar displacement (PD). Intra-rater reliability of the PSI, LPT and PD was estimated using the intraclass correlation coefficient (ICC) and the inter-rater reliability using Krippendorff's alpha (Kα). Agreement proportion of was calculated for the PD. Face validity of the PSI was also tested., Results: The PSI had excellent intra (mean ICC=0.91) and inter-rater (Kα=0.92) reliability, as did LPT (mean ICC=0.96; Kα=0.89). The calculation of PD caused a low level of agreement (47.1%) between evaluators in terms of which images could be measured. The exclusion of these radiographs resulted in a high PD intra (ICC=0.96) and inter-rater (Kα=0.97) reliability., Conclusion: The PSI appears to be a reliable and valid measure for patellofemoral congruence in a replaced knee joint with an unresurfaced patella. The superiority of the PSI is the result of its consideration of the geometry and size of the replaced knee joint and independence from radiographic magnification.

This study assesses relationships between drug administration routes and HIV serostatus, drug use, and sexual behaviors among current injecting drug users (IDUs) in Tallinn, Estonia. We recruited 350 IDUs for a cross-sectional risk behavior survey. Adjusted odds ratios (AORs) were calculated to explore injection risk behavior, sexual behavior, and HIV serostatus associated with multiple route use. Focus groups explored reasons why injectors might use non-injecting routes of administration. Those reporting multiple drug administration routes were less likely to be HIV seropositive (AOR = 0.49, 95% confidence interval [CI] = 0.25-0.97) and had almost twice the odds of having more than one sexual partner (AOR = 1.90, 95% CI = 1.01-3.60) and of reporting having sexually transmitted diseases (AOR = 2.38, 95% CI = 1.02-5.59). IDUs who engage in noninjecting drug use may be reducing their risk of acquiring HIV though sharing injection equipment, but if infected may be a critical group for sexual transmission of HIV to people who do not inject drugs., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Despite the high number of injecting drug users (IDUs) in Estonia, little is known about involving pharmacies into human immunodeficiency virus (HIV) prevention activities and potential barriers. Similarly, in other Eastern European countries, there is a need for additional sources for clean syringes besides syringe exchange programmes (SEPs), but data on current practices relating to pharmacists' role in harm reduction strategies is scant. Involving pharmacies is especially important for several reasons: they have extended hours of operation and convenient locations compared to SEPs, may provide access for IDUs who have avoided SEPs, and are a trusted health resource in the community. We conducted a series of focus groups with pharmacists and IDUs in Tallinn, Estonia, to explore their attitudes toward the role of pharmacists in HIV prevention activities for IDUs. Many, but not all, pharmacists reported a readiness to sell syringes to IDUs to help prevent HIV transmission. However, negative attitudes toward IDUs in general and syringe sales to them specifically were identified as important factors restricting such sales. The idea of free distribution of clean syringes or other injecting equipment and disposal of used syringes in pharmacies elicited strong resistance. IDUs stated that pharmacies were convenient for acquiring syringes due to their extended opening hours and local distribution. IDUs were positive toward pharmacies, although they were aware of stigma from pharmacists and other customers. They also emphasized the need for distilled water and other injection paraphernalia. In conclusion, there are no formal or legislative obstacles for providing HIV prevention services for IDUs at pharmacies. Addressing negative attitudes through educational courses and involving pharmacists willing to be public health educators in high drug use areas would improve access for HIV prevention services for IDUs.

Background: Both syringe exchange programs (SEPs) and pharmacy sales of syringes are available in Estonia, though the current high incidence and high prevalence of HIV among injection drug users (IDUs) in Tallinn, Estonia requires large-scale implementation of additional harm reduction programs as a matter of great urgency. The aims of this report were to compare risk behavior and HIV infection and to assess the prevention needs among IDUs who primarily use pharmacies as their source of sterile syringes with IDUs who primarily use SEPs in Tallinn., Methods: A cross-sectional study using respondent-driven sampling was used to recruit 350 IDUs for an interviewer-administered survey and HIV testing. IDUs were categorized into two groups based on their self-reported main source for syringes within the last six months. Odds ratios with 95% CI were used to compare characteristics and risk factors between the groups., Results: The main sources of sterile needles for injection drug users were SEP/SEP outreach (59%) and pharmacies (41%). There were no differences in age, age at injection drug use initiation, the main drug used or experiencing overdoses. Those IDUs using pharmacies as a main source of sterile needles had lower odds for being infected with either HIV (AOR 0.54 95% CI 0.33-0.87) or HCV (AOR 0.10 95% CI 0.02-0.50), had close to twice the odds of reporting more than one sexual partner within the previous 12 months (AOR 1.88 95% CI 1.17-3.04) and engaging in casual sexual relationships (AOR 2.09 95% CI 1.24-3.53) in the last six months., Conclusion: The data suggest that the pharmacy users were at a less "advanced" stage of their injection career and had lower HIV prevalence than SEP users. This suggests that pharmacies could be utilized as a site for providing additional HIV prevention messages, services for IDUs and in linking IDUs with existing harm reduction services.

Objective: To investigate treatment adherence and factors related to non-adherence in the Estonian postmenopausal hormone therapy (EPHT) trial., Methods: A total of 1823 postmenopausal women aged 50-64 years were recruited into the EPHT trial from 1999 to 2001. They were randomised into the blind group receiving continuous orally administered postmenopausal hormone therapy (PHT) or a placebo and to a non-blind group receiving open-label PHT or no drugs. A woman was classified as non-adherent, if she had stopped treatment for at least 6-month period in treatment arms or used PHT for at least 6-month period in the control group. Adherence was calculated by the Kaplan-Meier method, and factors affecting adherence were studied with Cox proportional hazard modelling., Results: The rate of adherent women declined approximately 50% during the first year in all treatment arms. Less than 10% of the control group women started taking prescribed PHT. Older women, with lower education, with only one birth, never used oral contraceptives (OC), with lower physical activity or who were dissatisfied with the information received from the trial staff, were more likely to discontinue. In treatment arms, the two most often cited reasons for non-adherence were side-effects and woman's loss of interest in participation. Control group women started PHT due to the menopausal symptoms or on doctor's recommendation., Conclusions: The adherence was similar to that found for PHT use in everyday life. Higher adherence was related to younger age, higher education, previous OC use, physical activity and satisfaction with received information.