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Background: Atrial fibrillation (AF) is a prevalent cardiac condition characterized by irregular heart rhythm. Conventional non-invasive diagnostic techniques, while useful, have limitations in providing comprehensive information for treatment planning. To address this gap, electromechanical cycle length mapping (ECLM), a non-invasive echocardiography-based technique, has emerged as a promising approach. Electromechanical cycle length mapping offers quantitative and spatially specific insights into atrial electromechanical activation rate mapping, thereby enhancing our understanding of arrhythmia disease progression in AF patients. Case summary: In this case series, we present two patient cases demonstrating the potential utility of ECLM in monitoring and evaluating treatment responses in atrial arrhythmia. The 1st case involved a 61-year-old male with persistent AF who underwent multiple procedures, including direct current cardioversion (DCCV) and radiofrequency ablation. Over three different DCCV encounters, pre- and post-procedure ECLM scans were performed, and the results showed the localization and incomplete elimination of arrhythmic triggers post-DCCV, which were used as early indicators of AF recurrence. The 2nd case involved a 71-year-old male with paroxysmal AF who also underwent cardioversion and ablation procedures. Electromechanical cycle length mapping imaging demonstrated a progressive reduction and elimination of arrhythmia triggers after each encounter, resulting in long-term maintenance of sinus rhythm. Discussion: The findings from this case series highlight the potential of ECLM as a non-invasive imaging tool for long-term monitoring and evaluating immediate and long-term treatment responses in AF patients. The integration of ECLM with standard echocardiograms holds promise in guiding clinical decisions and improving patient outcomes in managing atrial fibrillation.
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Background: Inpatient behavioral health units (BHUs) had unique challenges in implementing interventions to mitigate coronavirus disease 2019 (COVID-19) transmission, in part due to socialization in BHU settings. The objective of this study was to identify the transmission routes and the efficacy of the mitigation strategies employed during a COVID-19 outbreak in an inpatient BHU during the Omicron surge from December 2021 to January 2022. Methods: An outbreak investigation was performed after identifying 2 COVID-19-positive BHU inpatients on December 16 and 20, 2021. Mitigation measures involved weekly point prevalence testing for all inpatients, healthcare workers (HCWs), and staff, followed by infection prevention mitigation measures and molecular surveillance. Whole-genome sequencing on a subset of COVID-19-positive individuals was performed to identify the outbreak source. Finally, an outbreak control sustainability plan was formulated for future BHU outbreak resurgences. Results: We identified 35 HCWs and 8 inpatients who tested positive in the BHU between December 16, 2021, and January 17, 2022. We generated severe acute respiratory coronavirus virus 2 (SARS-CoV-2) genomes from 15 HCWs and all inpatients. Phylogenetic analyses revealed 3 distinct but genetically related clusters: (1) an HCW and inpatient outbreak likely initiated by staff, (2) an HCW and inpatient outbreak likely initiated by an inpatient visitor, and (3) an HCW-only cluster initiated by staff. Conclusions: Distinct transmission clusters are consistent with multiple, independent SARS-CoV-2 introductions with further inpatient transmission occurring in communal settings. The implemented outbreak control plan comprised of enhanced personal protective equipment requirements, limited socialization, and molecular surveillance likely minimized disruptions to patient care as a model for future pandemics.
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HIV-associated wasting (HIVAW) is an underappreciated AIDS-defining illness, despite highly effective antiretroviral therapy (ART). We (a) assessed the association between incident HIVAW/low weight and all-cause mortality and (b) described virologic outcomes after people with HIV (PWH) experienced HIVAW/low weight while on ART. In the Observational Pharmaco-Epidemiology Research & Analysis (OPERA®) cohort, PWH without prior HIVAW/low weight who were active in care in 2016-2020 were followed through the first of the following censoring events: death, loss to follow-up, or study end (October 31, 2021). HIVAW/low weight was a diagnosis of wasting or low body mass index (BMI)/underweight or a BMI measurement <20 kg/m2. Hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between time-dependent HIVAW/low weight and mortality were estimated with extended Cox regression models. Over a median follow-up of 45 months (interquartile range: 27, 65), there were 4,755 (8%) cases of HIVAW/low weight and 1,354 (2%) deaths among 62,314 PWH. PWH who experienced HIVAW/low weight had a significantly higher risk of death than those who did not (HR: 1.96; 95% CI: 1.68, 2.27) after adjusting for age, race, ethnicity, and changes in viral load (VL) and Veterans Aging Cohort Study Mortality Index scores over follow-up. Among 4,572 PWH on ART at HIVAW/low weight, 68% were suppressed (VL of <200 copies/mL); subsequent virologic failure was uncommon (7%). Among viremic PWH, 70% and 60% achieved suppression and undetectability (VL of <50 copies/mL), respectively, over follow-up. HIVAW remains a challenge for some PWH. Particular attention needs to be paid to HIVAW/low weight and virologic control to restore health and potentially reduce the risk of death.
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Infecções por HIV , Síndrome de Emaciação por Infecção pelo HIV , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Síndrome de Emaciação por Infecção pelo HIV/epidemiologia , Síndrome de Emaciação por Infecção pelo HIV/mortalidade , Infecções por HIV/mortalidade , Infecções por HIV/tratamento farmacológico , Infecções por HIV/complicações , Terapia Antirretroviral de Alta Atividade , Carga Viral , Fármacos Anti-HIV/uso terapêutico , Fatores de Risco , Estudos de Coortes , Índice de Massa Corporal , IncidênciaRESUMO
BACKGROUND: Tuberculosis remains the leading cause of death by an infectious disease among people living with HIV (PLHIV). TB Preventive Treatment (TPT) is a cost-effective intervention known to reduce morbidity and mortality. We used data from ZIMPHIA 2020 to assess TPT uptake and factors associated with its use. METHODOLOGY: ZIMPHIA a cross-sectional household survey, estimated HIV treatment outcomes among PLHIV aged ≥15 years. Randomly selected participants provided demographic and clinical information. We applied multivariable logistic regression models using survey weights. Variances were estimated via the Jackknife series to determine factors associated with TPT uptake. RESULTS: The sample of 2419 PLHIV ≥15 years had 65% females, 44% had no primary education, and 29% lived in urban centers. Overall, 38% had ever taken TPT, including 15% currently taking TPT. Controlling for other variables, those screened for TB at last HIV-related visit, those who visited a TB clinic in the previous 12 months, and those who had HIV viral load suppression were more likely to take TPT. CONCLUSION: The findings show suboptimal TPT coverage among PLHIV. There is a need for targeted interventions and policies to address the barriers to TPT uptake, to reduce TB morbidity and mortality among PLHIV.
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Infecções por HIV , Tuberculose , Humanos , Feminino , Adulto , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Zimbábue/epidemiologia , Masculino , Estudos Transversais , Tuberculose/prevenção & controle , Tuberculose/epidemiologia , Pessoa de Meia-Idade , Adulto Jovem , Adolescente , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Antituberculosos/uso terapêuticoRESUMO
BACKGROUND: The American College of Surgeons Committee on Trauma (ACS-CoT) mandated that trauma centers have mental health screening and referral protocols in place by 2023. This study compares the Injured Trauma Survivor Screen (ITSS) and the Automated Electronic Medical Record (EMR) Screen to assess their performance in predicting risk for posttraumatic stress disorder (PTSD) within the same sample of trauma patients to inform trauma centers' decision when selecting a tool to best fit their current clinical practice. METHODS: This was a secondary analysis of three prospective cohort studies of traumatically injured patients (N = 255). The ITSS and Automated EMR Screen were compared using receiver operating characteristic curves to predict risk of subsequent PTSD development. PTSD diagnosis at 6-month follow-up was assessed using the Clinician Administered PTSD Scale for DSM-5. RESULTS: Just over half the sample screened positive on the ITSS (57.7%), while 67.8% screened positive on the Automated EMR Screen. The area under the curve (AUC) for the two screens was not significantly different (ITSS AUC = 0.745 versus Automated EMR Screen AUC = 0.694, p = 0.21), similar performance in PTSD risk predication within the same general trauma population. The ITSS and Automated EMR Screen had similar sensitivities (86.5%, 89.2%), and specificities (52.5%, 40.9%) respectively at their recommended cut-off points. CONCLUSION: Both screens are psychometrically comparable. Therefore, trauma centers considering screening tools for PTSD risk to comply with the ACS-CoT 2023 mandate should consider their local resources and patient population. Regardless of screen selection, screening must be accompanied by a referral process to address the identified risk.
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Transtornos de Estresse Pós-Traumáticos , Humanos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Estudos Prospectivos , Psicometria , Programas de Rastreamento/métodos , Curva ROCRESUMO
Effective services along the HIV continuum of care from HIV testing and counseling to linkage, and from linkage to antiretroviral therapy (ART) initiation and retention, are key to improved health outcomes of persons living with HIV. A comprehensive analysis of the costs and outcomes of cascade services is needed to help allocate and prioritize resources to achieve UNAIDS targets. We evaluated the costs and population-level impact of a community-wide, integrated scale-up of testing, linkage, and defaulter-tracing programs implemented in Bukoba Municipal Council, Tanzania. Costs per identified HIV-positive client for provider-initiated, and home- and venue-based testing and counseling were $92.64 United States dollars (USD), $256.33 USD, and $281.57 USD, respectively. Costs per patient linked to HIV care and ART were $47.69 USD and $74.12 USD, respectively, during all ART-eligibility periods combined. Costs per defaulter traced and returned to HIV care were $47.56 USD and $206.77 USD, respectively. The provider-initiated testing and counseling was the most cost-effective modality. Testing approaches targeted to populations groups and geographic location with high testing positivity rates may improve the overall efficiency of testing services. The expansion of ART eligibility criteria and high linkage rate also result in efficiency gains and economies of scale of linkage services.
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We aimed to describe the prevalence, incidence, and predictors of HIV-associated wasting (HIVAW)/low weight among people with HIV (PWH) in the United States. We conducted an observational, clinical cohort analysis, utilizing prospectively collected electronic health record data obtained from the Observational Pharmaco-Epidemiology Research & Analysis (OPERA®) cohort. HIVAW/low weight included a wasting or low body-mass index (BMI)/underweight diagnosis (ICD codes and title search) or BMI <20 kg/m2. Prevalence was estimated among adult PWH in care from 2012 to 2015 and 2016 to 2020. Incidence from January 1, 2016, to October 31, 2021, was estimated using univariate Poisson regression among eligible PWH without prior HIVAW/low weight. Demographic and clinical predictors of incident HIVAW/low weight were included in multivariable logistic regression models, stratified by antiretroviral therapy (ART) experience. The period prevalence of HIVAW/low weight was 12% in both 2012-2015 and 2016-2020. Among 67,119 PWH without any prior HIVAW/low weight, 7% experienced incident HIVAW/low weight a median 64 months from HIV diagnosis. In multivariable regression models, similar predictor patterns were observed among ART-naïve and ART-experienced PWH without any prior HIVAW/low weight: lower odds of HIVAW/low weight with older age, female sex, Black race, and Hispanic ethnicity and higher odds with Medicaid. Notably, there was a dose-response relationship between increasing Veterans Aging Cohort Study Mortality Index scores and incident HIVAW/low weight in both groups. Wasting/low weight remains a challenge for PWH and may be underappreciated by providers. Advanced HIV and comorbidities significantly predict incident HIVAW/low weight. Increasing awareness of HIVAW, especially among frailer PWH, could improve the care of affected PWH.
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Infecções por HIV , Adulto , Humanos , Feminino , Estados Unidos/epidemiologia , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , HIV , Estudos de Coortes , Magreza/complicações , Magreza/epidemiologia , ComorbidadeRESUMO
Due to its ability to spread quickly and result in tree mortality, Sphaerulina musiva (Septoria) is one of the most severe diseases impacting Populus. Previous studies have identified that Septoria infection induces differential expression of phenylpropanoid biosynthesis genes. However, more extensive characterization of changes to lignin in response to Septoria infection is lacking. To study the changes of lignin due to Septoria infection, four field grown, naturally variant Populus trichocarpa exhibiting visible signs of Septoria infection were sampled at health, infected, and reaction zone regions for cell wall characterization. Fourier transform infrared spectroscopy (FTIR), nuclear magnetic resonance (NMR), and acid hydrolysis were applied to identify changes to the cell wall, and especially lignin. FTIR and subsequent principal component analysis revealed that infected and reaction zone regions were similar and could be distinguished from the non-infected (healthy) region. NMR results indicated the general trend that infected region had a higher syringyl:guaiacyl ratio and lower p-hydroxybenzoate content than the healthy regions from the same genotype. Finally, Klason lignin content in the infected and/or reaction zone regions was shown to be higher than healthy region, which is consistent with previous observations of periderm development and metabolite profiling. These results provide insights on the response of Populus wood characteristics to Septoria infection, especially between healthy and infected region within the same genotype.
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BACKGROUND: Direct current cardioversion (DCCV) is an established treatment to acutely convert atrial fibrillation (AF) to normal sinus rhythm. Yet, more than 70% of patients revert to AF shortly thereafter. Electromechanical Cycle Length Mapping (ECLM) is a high framerate, spectral analysis technique shown to non-invasively characterize electromechanical activation in paced canines and re-entrant flutter patients. This study assesses ECLM feasibility to map and quantify atrial arrhythmic electromechanical activation rates and inform on 1-day and 1-month DCCV response. METHODS: Forty-five subjects (30 AF; 15 healthy sinus rhythm (SR) controls) underwent transthoracic ECLM in four standard apical 2D echocardiographic views. AF patients were imaged within 1 h pre- and post-DCCV. 3D-rendered atrial ECLM cycle length (CL) maps and spatial CL histograms were generated. CL dispersion and percentage of arrhythmic CLs≤333ms across the entire atrial myocardium were computed transmurally. ECLM results were subsequently used as indicators of DCCV success. RESULTS: ECLM successfully confirmed the electrical atrial activation rates in 100% of healthy subjects (R2=0.96). In AF, ECLM maps localized the irregular activation rates pre-DCCV and confirmed successful post-DCCV with immediate reduction or elimination. ECLM metrics successfully distinguished DCCV 1-day and 1-month responders from non-responders, while pre-DCCV ECLM values independently predicted AF recurrence within 1-month post-DCCV. CONCLUSIONS: ECLM can characterize electromechanical activation rates in AF, quantify their extent, and identify and predict short- and long-term AF recurrence. ELCM constitutes thus a noninvasive arrhythmia imaging modality that can aid clinicians in simultaneous AF severity quantification, prediction of AF DCCV response, and personalized treatment planning.
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Fibrilação Atrial , Cardioversão Elétrica , Animais , Cães , Cardioversão Elétrica/métodos , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/terapia , Átrios do Coração/diagnóstico por imagem , Ecocardiografia/métodos , Resultado do TratamentoRESUMO
Non-invasive monitoring of atherosclerosis remains challenging. Pulse Wave Imaging (PWI) is a non-invasive technique to measure the local stiffness at diastolic and end-systolic pressures and quantify the hemodynamics. The objective of this study is twofold, namely (1) to investigate the capability of (adaptive) PWI to assess progressive change in local stiffness and homogeneity of the carotid in a high-cholesterol swine model and (2) to assess the ability of PWI to monitor the change in hemodynamics and a corresponding change in stiffness. Nine (n=9) hypercholesterolemic swine were included in this study and followed for up to 9 months. A ligation in the left carotid was used to cause a hemodynamic disturbance. The carotids with detectable hemodynamic disturbance showed a reduction in wall shear stress immediately after ligation (2.12 ± 0.49 to 0.98 ± 0.47 Pa for 40-90% ligation (Group B) and 1.82 ± 0.25 to 0.49 ± 0.46 Pa for >90% ligation (Group C)). Histology revealed subsequent lesion formation after 8-9 months, and the type of lesion formation was dependent on the type of the induced ligation, with more complex plaques observed in the carotids with a more significant ligation (C: >90%). The compliance progression appears differed for groups B and C, with an increase in compliance to 2.09 ± 2.90×10-10 m2 Pa-1 for group C whereas the compliance of group B remained low at 8 months (0.95 ± 0.94×10-10 m2 Pa-1). In summary, PWI appeared capable of monitoring a change in wall shear stress and separating two distinct progression pathways resulting in distinct compliances.
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Aterosclerose , Placa Aterosclerótica , Animais , Suínos , Aterosclerose/diagnóstico por imagem , Aterosclerose/patologia , Placa Aterosclerótica/diagnóstico por imagem , Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/patologia , Diagnóstico por Imagem , Progressão da DoençaRESUMO
Zimbabwe introduced raltegravir (RAL) granules at 14 facilities providing point-of-care HIV birth testing, aiming to initiate all newborns with HIV on a RAL-based regimen. From June 2020 to July 2021, we tested 3172 of the 6989 (45%) newborns exposed to HIV; we diagnosed 59(2%) with HIV infection, of whom 27 (46%) initiated RAL. The SARS-CoV-2 coronavirus disease pandemic exacerbated supply chain and trained provider shortages, contributing to low birth testing, RAL uptake and 6-month viral load testing.
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Fármacos Anti-HIV , COVID-19 , Infecções por HIV , Humanos , Recém-Nascido , Feminino , Gravidez , Raltegravir Potássico/uso terapêutico , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Pandemias , Zimbábue/epidemiologia , SARS-CoV-2 , Carga Viral , Fármacos Anti-HIV/uso terapêuticoRESUMO
OBJECTIVES: Early in the COVID-19 pandemic, several outbreaks were linked with facilities employing essential workers, such as long-term care facilities and meat and poultry processing facilities. However, timely national data on which workplace settings were experiencing COVID-19 outbreaks were unavailable through routine surveillance systems. We estimated the number of US workplace outbreaks of COVID-19 and identified the types of workplace settings in which they occurred during August-October 2021. METHODS: The Centers for Disease Control and Prevention collected data from health departments on workplace COVID-19 outbreaks from August through October 2021: the number of workplace outbreaks, by workplace setting, and the total number of cases among workers linked to these outbreaks. Health departments also reported the number of workplaces they assisted for outbreak response, COVID-19 testing, vaccine distribution, or consultation on mitigation strategies. RESULTS: Twenty-three health departments reported a total of 12 660 workplace COVID-19 outbreaks. Among the 12 470 workplace types that were documented, 35.9% (n = 4474) of outbreaks occurred in health care settings, 33.4% (n = 4170) in educational settings, and 30.7% (n = 3826) in other work settings, including non-food manufacturing, correctional facilities, social services, retail trade, and food and beverage stores. Eleven health departments that reported 3859 workplace outbreaks provided information about workplace assistance: 3090 (80.1%) instances of assistance involved consultation on COVID-19 mitigation strategies, 1912 (49.5%) involved outbreak response, 436 (11.3%) involved COVID-19 testing, and 185 (4.8%) involved COVID-19 vaccine distribution. CONCLUSIONS: These findings underscore the continued impact of COVID-19 among workers, the potential for work-related transmission, and the need to apply layered prevention strategies recommended by public health officials.
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COVID-19 , Humanos , COVID-19/epidemiologia , Pandemias/prevenção & controle , Teste para COVID-19 , Vacinas contra COVID-19 , Local de Trabalho , Surtos de DoençasRESUMO
Myocardial elastography (ME) is a cardiac strain imaging technique that has been found capable of detecting a decrease in radial strain caused by ischemia or infarction in patients with coronary artery disease (CAD) as well as in a canine model. Prior studies have focused on rest imaging, but stress testing can reveal functional deficits caused by stenoses that are asymptomatic at rest. Therefore, it has been proposed that stress ME (S-ME) improves the detection of CAD. A novel strain difference (Δε) metric is presented and investigated in a canine model of induced ischemia, as well as in a study in human patients with CAD validated by myocardial perfusion imaging. In the canine model study, flow-limiting stenosis was induced by partial ligation in n = 2 canines, and stenosis was found to consistently reduce Δε in the affected myocardial regions compared with baseline, as well as compared to myocardial regions that are remote to the induced stenosis. In the clinical study, the median Δε was significantly lower (p < 0.05) in infarcted myocardial regions (-6.29%) than in those with normal perfusion (4.62%), with Δε in ischemic regions falling in between (-2.91%). The same trend was observed when considering radial strain during stress and, to a lesser degree, at rest alone. The results indicate that S-ME may be more sensitive to mild cases of CAD that are functionally asymptomatic at rest.
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Doença da Artéria Coronariana , Técnicas de Imagem por Elasticidade , Imagem de Perfusão do Miocárdio , Humanos , Animais , Cães , Constrição Patológica , Técnicas de Imagem por Elasticidade/métodos , Estudos de Viabilidade , Isquemia , Imagem de Perfusão do Miocárdio/métodos , Angiografia Coronária/métodosRESUMO
WSS measurement is challenging since it requires sensitive flow measurements at a distance close to the wall. The aim of this study is to develop an ultrasound imaging technique which combines vector flow imaging with an unsupervised data clustering approach that automatically detects the region close to the wall with optimally linear flow profile, to provide direct and robust WSS estimation. The proposed technique was evaluated in phantoms, mimicking normal and atherosclerotic vessels, and spatially registered Fluid Structure Interaction (FSI) simulations. A relative error of 6.7% and 19.8% was obtained for peak systolic (WSSPS) and end diastolic (WSSED) WSS in the straight phantom, while in the stenotic phantom, a good similarity was found between measured and simulated WSS distribution, with a correlation coefficient, R, of 0.89 and 0.85 for WSSPS and WSSED, respectively. Moreover, the feasibility of the technique to detect pre-clinical atherosclerosis was tested in an atherosclerotic swine model. Six swines were fed atherogenic diet, while their left carotid artery was ligated in order to disturb flow patterns. Ligated arterial segments that were exposed to low WSSPS and WSS characterized by high frequency oscillations at baseline, developed either moderately or highly stenotic plaques (p < 0.05). Finally, feasibility of the technique was demonstrated in normal and atherosclerotic human subjects. Atherosclerotic carotid arteries with low stenosis had lower WSSPS as compared to control subjects (p < 0.01), while in one subject with high stenosis, elevated WSS was found on an arterial segment, which coincided with plaque rupture site, as determined through histological examination.
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Aterosclerose , Placa Aterosclerótica , Humanos , Suínos , Animais , Constrição Patológica , Artérias Carótidas/diagnóstico por imagem , Placa Aterosclerótica/diagnóstico por imagem , Aterosclerose/diagnóstico por imagem , Estresse MecânicoRESUMO
Conventional biventricular (BiV) pacing cardiac resynchronization therapy (CRT) is an established treatment for heart failure patients. Recently, multiple novel CRT delivering technologies such as His-Bundle pacing have been investigated as alternative pacing strategies for optimal treatment benefit. Electromechanical Wave Imaging (EWI), a high frame-rate echocardiography-based modality, is capable of visualizing the change from dyssynchronous activation to resynchronized BiV-paced ventricles in 3D. This proof-of-concept study introduces a new EWI-based dispersion metric to further characterize ventricular activation. Patients with His-Bundle device implantation (n = 4), left-bundle branch block (n = 10), right-ventricular (RV) pacing (n = 10), or BiV pacing (n = 15) were imaged, as well as four volunteers in normal sinus rhythm (NSR). EWI successfully mapped the ventricular activation resulting from His-Bundle pacing. Additionally, very similar activation patterns were obtained in the NSR subjects, confirming recovery of physiological activation with His pacing. The dispersion metric was the most sensitive EWI-based metric that identified His pacing as the most efficient treatment (lowest activation time spread), followed by BiV and RV pacing. More specifically, the dispersion metric significantly (p < 0.005) distinguished His pacing from the other two pacing schemes as well as LBBB. The initial findings presented herein indicate that EWI and its new dispersion metric may provide a useful resynchronization evaluation clinical tool in CRT patients under both novel His-Bundle pacing and more conventional BiV pacing strategies.
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Terapia de Ressincronização Cardíaca , Humanos , Terapia de Ressincronização Cardíaca/métodos , Bloqueio de Ramo/diagnóstico por imagem , Bloqueio de Ramo/terapia , Ventrículos do Coração/diagnóstico por imagem , Ecocardiografia , Arritmias CardíacasRESUMO
[This corrects the article DOI: 10.1016/j.jscai.2022.100392.][This corrects the article DOI: 10.1016/j.jscai.2023.101051.].
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BACKGROUND: Sustained, routine care is vital to the health of people with HIV (PWH) and decreasing transmission of HIV. We evaluated whether the identification of PWH at-risk of falling out of care and prompts for outreach were effective in retaining PWH in care in the United States. METHODS: In this cluster randomized controlled trial, 20 AIDS Healthcare Foundation Healthcare Centers (HCCs) were randomized to the intervention (n = 10) or control (n = 10) arm; all maintained existing retention efforts. The intervention included daily automated flags in CHORUS™, a mobile app and web-based reporting solution utilizing electronic health record data, that identified PWH at-risk of falling out of care to clinic staff. Among flagged PWH, the association between the intervention and visits after a flag was assessed using logistic regression models fit with generalized estimating equations (independent correlation structure) to account for clustering. To adjust for differences between HCCs, models included geographic region, number of PWH at HCC, and proportions of PWH who self-identified as Hispanic or had the Ryan White Program as a payer. RESULTS: Of 15,875 PWH in care, 56% were flagged; 76% (intervention) and 75% (control) resulted in a visit, of which 76% were within 2 months of the flag. In adjusted analyses, flags had higher odds of being followed by a visit (odds ratio [OR]: 1.08, 95% confidence interval [CI]: 0.97, 1.21) or a visit within 2 months (OR: 1.07, 95% CI: 0.97, 1.17) at intervention than control HCCs. Among at-risk PWH with viral loads at baseline and study end, the proportion with < 50 copies/mL increased in both study arms, but more so at intervention (65% to 74%) than control (62% to 67%) HCCs. CONCLUSION: Despite challenges of the COVID-19 pandemic, adding an intervention to existing retention efforts, and the reality that behavior change takes time, PWH flagged as at-risk of falling out of care were marginally more likely to return for care at intervention than control HCCs and a greater proportion achieved undetectability. Sustained use of the retention module in CHORUS™ has the potential to streamline retention efforts, retain more PWH in care, and ultimately decrease transmission of HIV. TRIAL REGISTRATION: The study was first registered at Clinical Trials.gov (NCT04147832, https://clinicaltrials.gov/show/NCT04147832 ) on 01/11/2019.
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Continuidade da Assistência ao Paciente , Infecções por HIV , Retenção nos Cuidados , Humanos , Instituições de Assistência Ambulatorial , Carcinoma Hepatocelular , COVID-19/epidemiologia , Infecções por HIV/epidemiologia , Neoplasias Hepáticas , Pandemias , Estados Unidos/epidemiologia , Sistemas de Apoio a Decisões ClínicasRESUMO
BACKGROUND: In 2020, Zimbabwe adopted the WHO's recommendation to use raltegravir (RAL) granule-based regimens for treatment of neonates identified with HIV at the time of birth testing. This study explores the acceptability of RAL granules by caregivers and healthcare workers (HCWs). METHODS: Interviews were conducted with 15 caregivers and 12 HCWs from 8 health facilities in Zimbabwe participating in the introductory pilot of RAL granules treatment for newborns. Eligible caregivers included those who had administered RAL to their infant and attended either 8th or 28th day of life appointments. Caregivers of neonates recently initiated on RAL were selected through convenience sampling. Eligible HCWs who provided RAL preparation, administration instructions and support to caregivers of neonates on RAL for at least 3 months were recruited from the same facilities as the caregivers. Interview transcripts were coded and thematically analysed. RESULTS: Caregivers reported that their babies looked healthier after RAL initiation, with improved skin appearance and weight gain. Some caregivers wanted their child to remain on RAL beyond 28 days instead of switching regimens, as recommended by national guidelines. HCWs observed that RAL granules improved health outcomes compared with other regimens. HCWs reported challenges with caregivers understanding dosing instructions, measuring with a syringe, swirling and not shaking the medicine, discarding unused medication and following the changes in the dosing schedule and amount when RAL was initiated a few days after birth. HCWs stated that adequate counselling and repeat demonstrations were crucial to ensure that caregivers clearly understood RAL dosing and administration instructions. HCWs requested more standardised training targeting nurses with guidance on handling missed doses and clarification on mixing RAL granules with water and not breastmilk. CONCLUSION: While feedback from caregivers and HCWs on RAL implementation was positive, barriers were also noted. Adequate training and sufficient instruction and support for caregivers would help to ensure that RAL granules are prepared, dosed and administered correctly.