Use of Doxycycline to Prevent Sexually Transmitted Infections According to Provider Characteristics.

Use of doxycycline to prevent sexually transmitted infections (STIs) may lead to antimicrobial resistance. We analyzed attitudes toward this practice between US providers who commonly and less commonly treat STIs. Providers who more commonly treat STIs are more likely to prescribe prophylactic doxycycline and believe that benefits outweigh potential for increased antimicrobial resistance.

Evaluating the impact of point-of-care HIV viral load assessment on linkage to care in Baltimore, MD: a randomized controlled trial.

BACKGROUND: Integration of a sensitive point-of-care (POC) HIV viral load (VL) test into screening algorithms may help detect acute HIV infection earlier, identify people with HIV (PWH) who are not virally suppressed, and facilitate earlier referral to antiretroviral therapy (ART), or evaluation for pre-exposure prophylaxis (PrEP). This report describes a randomized clinical trial sponsored by the Centers for Disease Control and Prevention (CDC): "Ending the HIV Epidemic Through Point-of-Care Technologies" (EHPOC). The study's primary aim is to evaluate the use of a POC HIV VL test as part of a testing approach and assess the impact on time to linkage to ART or PrEP. The study will recruit people in Baltimore, Maryland, including patients attending a hospital emergency department, patients attending an infectious disease clinic, and people recruited via community outreach. The secondary aim is to evaluate the performance characteristics of two rapid HIV antibody tests approved by the United States Food and Drug Administration (FDA). METHODS: The study will recruit people 18 years or older who have risk factors for HIV acquisition and are not on PrEP, or PWH who are not taking ART. Participants will be randomly assigned to either the control arm or the intervention arm. Participants randomized to the control arm will only receive the standard-of-care (SOC) HIV screening tests. Intervention arm participants will receive a POC HIV VL test in addition to the SOC HIV diagnostic screening tests. Follow up will consist of an interim phone survey conducted at week-4 and an in-person week-12 visit. Demographic and behavioral information, and oral fluid and blood specimens will be collected at enrollment and at week-12. Survey data will be captured in a Research Electronic Data Capture (REDCap) database. Participants in both arms will be referred for either ART or PrEP based on their HIV test results. DISCUSSION: The EHPOC trial will explore a novel HIV diagnostic technology that can be performed at the POC and provide viral assessment. The study may help inform HIV testing algorithms and contribute to the evidence to support same day ART and PrEP recommendations. TRIAL REGISTRATION: NIH ClinicalTrials.gov NCT04793750. Date: 11 March 2021.

HIV Testing Preferences and Characteristics of Those Who Have Never Tested for HIV in the United States.

BACKGROUND: The initial phase of the federal Ending the HIV Epidemic in the U.S. (EHE) initiative prioritized efforts in 57 geographic areas. The US Centers for Disease Control and Prevention recommends persons aged 13 to 64 years be tested for HIV at least once as part of routine health care; however, it is unclear how effectively these testing recommendations have been implemented in EHE priority areas. METHODS: In 2021 to 2022, we analyzed data from a Web-based, nationally representative survey of adults fielded in 2021. HIV testing preferences were compared by testing history, demographic characteristics, behaviors, and geography. RESULTS: An estimated 72.5% of US adults had never tested for HIV. Never testing was most prevalent among those aged 18 to 29 or those 50 years or older, non-Hispanic White persons, and those living in the Midwest. Among persons living in EHE priority areas and persons reporting at least one behavior that increases risk of HIV transmission, 69.1% and 48.0%, respectively, had never tested for HIV. The top 3 HIV testing preferences among never testers were as follows: testing for HIV during a routine health care visit (41.2%), testing at an urgent care or walk-in clinic (9.6%), and self-testing (8.1%). CONCLUSIONS: Most adults had not been tested for HIV, confirming that US Centers for Disease Control and Prevention recommendations are not being fully implemented, even in EHE priority areas. Moreover, most adults who never tested preferred testing in clinical settings, highlighting missed opportunities. As the EHE initiative continues to advance, it is critical to leverage preferred HIV testing modalities, such as routine testing in clinical settings or HIV self-testing.

Variable Response to Antifibrinolytics Correlates with Blood-loss and Transfusion in Posterior Spinal Fusion.

PURPOSE: Posterior spinal fusion (PSF) activates the fibrinolytic protease plasmin, which is implicated in blood loss and transfusion. While antifibrinolytic drugs have improved blood loss and reduced transfusion, variable blood loss has been observed in similar PSF procedures treated with the same dose of antifibrinolytics. However, both the cause of this and the appropriate measures to determine antifibrinolytic efficacy during high-blood-loss spine surgery are unknown, making clinical trials to optimize antifibrinolytic dosing in PSF difficult. We hypothesized that patients undergoing PSF respond differently to antifibrinolytic dosing, resulting in variable blood loss, and that specific diagnostic markers of plasmin activity will accurately measure the efficacy of antifibrinolytics in PSF. METHODS: A prospective study of 17 patients undergoing elective PSF with the same dosing regimen of TXA was conducted. Surgery-induced plasmin activity was exhaustively analyzed in perioperative blood samples and correlated to measures of inflammation, bleeding, and transfusion. RESULTS: While markers of in vivo plasmin activation (PAP and D-dimer) suggested significant breakthrough plasmin activation and fibrinolysis (P < 0.01), in vitro plasmin assays, including TEG, did not detect plasmin activation. In vivo measures of breakthrough plasmin activation correlated with blood loss (R2 = 0.400, 0.264; P < 0.01), transfusions (R2 = 0.388; P < 0.01), and complement activation (R2 = 0.346, P < 0.05). CONCLUSIONS: Despite all patients receiving a high dose of TXA, its efficacy among patients was variable, indicated by notable intra-operative plasmin activity. Markers of in vivo plasmin activation best correlated with clinical outcomes. These findings suggest that the efficacy of antifibrinolytic therapy to inhibit plasmin in PSF surgery should be determined by markers of in vivo plasmin activation in future studies. LEVEL OF EVIDENCE: Level II-diagnostic.

A public health based vision for the management and regulation of opioids.

Prohibition of the possession of opioids for non-medical purposes and medical/pharmaceutical commercialization of opioids are important contributors to the current opioid overdose epidemic. A new model of regulation is urgently required. Within the context of a public health framework, we explore supply control, demand reduction, health promotion, and harm reduction and describe an alternative regulatory model that includes access for medical and non-medical purposes. Oversight of this proposed new system would include a control structure with an explicit public health mandate to minimize harms and maximize benefits of opioids. Medical access would be achieved through multi-disciplinary teams who would prescribe a range of opioids for 1) pain, 2) treatment for patients who develop opioid use disorder, and 3) other medical indications. Non-medical access could be achieved through models that would allow adults to purchase and use opioids for either supervised or take-home use. We describe three possible models to support jurisdiction specific discussions around the world. The first includes education and training that could result in certification with a basic or advanced license or a purchase authorization card. The second includes mandatory training that allows general access to opioids, but excludes people with problematic opioid use. The third model has optional training and excludes people with problematic opioid use. Allowing for inclusion of people dependent on the current illegal market during transition is highlighted. With any of these models, this approach, while attending to illegal market drivers, would result in a greatly reduced illegal opioid market and its attendant toxic products, reduced violence and corruption, and at the same time, provide a sharper focus for medical use with more appropriate prescribing and indications.

Anaphylaxis secondary to albumin infusion during posterior spinal fusion for pediatric scoliosis.

STUDY DESIGN: Case report. OBJECTIVES: To describe intraoperative administration of albumin as a cause of immunoglobulin E (IgE)-mediated anaphylaxis and cardiac arrest in an adolescent with adolescent idiopathic scoliosis. BACKGROUND: Albumin is considered the reference intraoperative colloidal solution, and is used commonly as a volume expander for treating hypovolemia. Albumin rarely causes an anaphylactic reaction, with a documented rate of only 0.099%. METHOD: An adolescent with scoliosis experienced acute, intraoperative hypotension during exposure for planned T5-L4 posterior spinal fusion shortly after infusion of albumin. She was treated rapidly and successfully with CPR and epinephrine. RESULTS: Intraoperative transesophageal echocardiogram, chest radiograph, and serum histamine, serum tryptase, and urine N-methyl-histamine laboratory tests confirmed albumin anaphylaxis to be the etiology of the intraoperative event. Further postoperative complications were avoided as a result of the rapid diagnosis and treatment. CONCLUSIONS: Although rare, IgE-mediated anaphylaxis to albumin, if administered, must be considered a possible cause of acute, intraoperative hypotension. Rapid management of anaphylaxis with communication between the surgeon, anesthesia team, and operative staff are essential if additional complications are to be avoided.

A Public-Health-Based Vision for the Management and Regulation of Psychedelics.

The Health Officers Council of British Columbia has proposed post-prohibition regulatory models for currently illegal drugs based on public health principles, and this article continues this work by proposing a model for the regulation and management of psychedelics. This article outlines recent research on psychedelic substances and the key determinants of benefit and harm from their use. It then describes a public-health-based model for the regulation of psychedelics, which includes governance, supervision, set and setting controls, youth access, supply control, demand limitation, and evaluation.

A common public health-oriented policy framework for cannabis, alcohol and tobacco in Canada?

Support for a public health approach to cannabis policy as an alternative to prohibition and criminalization is gaining momentum. Recent drug policy changes in the United States suggest growing political feasibility for legal regulation of cannabis in other North American jurisdictions. This commentary discusses the outcomes of an interdisciplinary policy meeting with Canadian experts and knowledge users in the area of substance use interventions. The meeting explored possibilities for applying cross-substance learning on policy interventions for alcohol, tobacco and cannabis, towards the goal of advancing a public health framework for reducing harms associated with substance use in Canada. The meeting also explored how the shift in approach to cannabis policy can provide an opportunity to explore potential changes in substance use policy more generally, especially in relation to tobacco and alcohol as legally regulated substances associated with a heavy burden of illness. Drawing from the contributions and debates arising from the policy meeting, this commentary identifies underlying principles and opportunities for learning from policy interventions across tobacco, alcohol and cannabis, as well as research gaps that need to be addressed before a public health framework can be effectively pursued across these substances.

Comparison of 4th-Generation HIV Antigen/Antibody Combination Assay With 3rd-Generation HIV Antibody Assays for the Occurrence of False-Positive and False-Negative Results.

OBJECTIVE: To assess the false-positive and false-negative rates of a 4th-generation human immunodeficiency virus (HIV) assay, the Abbott ARCHITECT, vs 2 HIV 3rd-generation assays, the Siemens Centaur and the Ortho-Clinical Diagnostics Vitros. METHODS: We examined 123 patient specimens. In the first phase of the study, we compared 99 specimens that had a positive screening result via the 3rd-generation Vitros assay (10 positive, 82 negative, and 7 indeterminate via confirmatory immunofluorescent assay [IFA]/Western blot [WB] testing). In the second phase, we assessed 24 HIV-1 RNA-positive (positive result via the nuclear acid amplification test [NAAT] and negative/indeterminate results via the WB test) specimens harboring acute HIV infection. RESULTS: The 4th-generation ARCHITECT assay yielded fewer false-positive results (n = 2) than the 3rd-generation Centaur (n = 9; P = .02) and Vitros (n = 82; P <.001) assays. One confirmed positive case had a false-negative result via the Centaur assay. When specimens from the 24 patients with acute HIV-1 infection were tested, the ARCHITECT assay yielded fewer false-negative results (n = 5) than the Centaur (n = 10) (P = .13) and the other 3rd-generation tests (n = 16) (P = .002). CONCLUSIONS: This study indicates that the 4th-generation ARCHITECT HIV assay yields fewer false-positive and false-negative results than the 3rd-generation HIV assays we tested.

Detection of acute HIV-1 infections utilizing NAAT technology in Dallas, Texas.

BACKGROUND: The detection of an acute human immunodeficiency virus infection (AHI) is vital in the fight against the spread of HIV to uninfected partners. Detection early after transmission is critical because the virus is replicating at a high level and is undetectable by serological markers. Nucleic acid amplification testing can detect HIV-1 RNA 10-12 days after exposure. OBJECTIVE: Provide Dallas County Public Health Department the ability to detect an AHI and maintain a three day turn-around-time for a reactive specimen. STUDY DESIGN: The population includes patients requesting HIV testing at various clinics throughout the state of Texas. Analyze various pool sizes for the pooling of specimens with the Aptima HIV-1 RNA qualitative assay to detect an acute HIV infection. Modify the HIV testing algorithm to include the detection of an acute HIV infection without delaying reporting results to original submitters. Perform a study to compare the detection of HIV in various HIV assays (3rd generation EIA assay, 4th generation EIA assay, HIV-1 RNA NAAT). Perform public health follow-up on patients who are confirmed to have an acute HIV infection with a goal of preventing the spread to uninfected partners. RESULTS: A pooling protocol was validated and performed concurrently with the EIA to maintain a reactive result released after three days of collection. Of the 148,888 (2009-2012) specimens screened for HIV, 161 AHIs were detected and the public health follow-up identified an additional 13 new HIV infections that had been a contact to one of the AHIs. CONCLUSION: Without the advancement in technology, patients could have received a negative or indeterminate test prior to implementing the NAAT, resulting in a delay in diagnosis and potential spread to uninfected partners. Improving the detection of an AHI is crucial in preventing the spread of the virus.

The obesity paradox and cardiorespiratory fitness.

Cardiorespiratory fitness as an explanation for the obesity paradox warrants further examination. We evaluated independent and joint associations of cardiorespiratory fitness and adiposity with all-cause mortality in 811 middle-aged (age, 53.3 ± 7.2 years) male never smokers without documented cardiopulmonary disease or diabetes from the Veterans Exercise Testing Study (VETS). Cardiorespiratory fitness was quantified in metabolic equivalents (METs) using final treadmill speed and grade achieved on a maximal exercise test. Subjects were grouped for analysis by METs: unfit (lowest third) and fit (upper two-thirds); and by body mass index (kg/m(2)): nonobese (18.5-29.9) and obese (≥30.0). Associations of baseline fitness and adiposity measures with all-cause mortality were determined by Cox proportional hazards analysis adjusted for age, ethnicity, hypertension, hypercholesterolemia, family history of coronary artery disease, and cardiovascular medication use. In multivariate analysis, mortality risk for obese/fit men did not differ significantly from the nonobese/fit reference group. However, compared to the reference group, nonobese and obese unfit men were 2.2 (P = 0.01) and 1.9 (P = 0.03) times more likely to die, respectively. Cardiorespiratory fitness altered the obesity paradox such that mortality risk was lower for both obese and nonobese men who were fit.

Obesity paradox and cardiorespiratory fitness in 12,417 male veterans aged 40 to 70 years.

OBJECTIVE: To evaluate the influence of cardiorespiratory fitness (fitness) on the obesity paradox in middle-aged men with known or suspected coronary artery disease. PATIENTS AND METHODS: This study consists of 12,417 men aged 40 to 70 years (44% African American) who were referred for exercise testing at the Veterans Affairs Medical Centers in Washington, DC, or Palo Alto, CA (between January 1, 1983, and June 30, 2007). Fitness was quantified as metabolic equivalents achieved during a maximal exercise test and was categorized for analysis as low, moderate, and high (defined as <5, 5-10, and >10 metabolic equivalents, respectively). Adiposity was defined by body mass index (BMI) according to standard clinical guidelines. Separate and combined associations of fitness and adiposity with all-cause mortality were assessed by Cox proportional hazards analyses. RESULTS: We recorded 2801 deaths during a mean+/-SD follow-up of 7.7+/-5.3 years. Multivariate hazard ratios (95% confidence interval) for all-cause mortality, with normal weight (BMI, 18.5-24.9 kg/m2) used as the reference group, were 1.9 (1.5-2.3), 0.7 (0.7-0.8), 0.7 (0.6-0.7), and 1.0 (0.8-1.1) for BMIs of less than 18.5, 25.0 to 29.9, 30.0 to 34.9, and 35.0 or more kg/m2, respectively. Compared with highly fit normal-weight men, underweight men with low fitness had the highest (4.5 [3.1-6.6]) and highly fit overweight men the lowest (0.4 [0.3-0.6]) mortality risk of any subgroup. Overweight and obese men with moderate fitness had mortality rates similar to those of the highly fit normal-weight reference group. CONCLUSION: Fitness altered the obesity paradox. Overweight and obese men had increased longevity only if they registered high fitness.

Cardiorespiratory fitness and mortality in diabetic men with and without cardiovascular disease.

We assessed joint associations of cardiorespiratory fitness and diabetes, cardiovascular disease (CVD), or both with all-cause mortality. High-fitness eliminated mortality risk in diabetes (P<0.001) and halved risk of death in diabetes/CVD (P<0.001). Fitness was a potent effect modifier in the association of diabetes and CVD to mortality.