Healthcare transition challenges faced by young adults with autism spectrum disorder.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that impacts communicative interactions, with patterns of repetitive and restricted behaviors, interests, and cognitive rigidity. Recent incidence rate estimates for ASD are 1 in 68, and primarily male (4:1). A major epidemiological issue in ASD is transitioning to independence in adulthood, particularly navigating the healthcare system. This commentary will focus on approaches healthcare providers can use to not overlook and support individuals with ASD.

Analysis of osteoporosis treatment patterns with bisphosphonates and outcomes among postmenopausal veterans.

PURPOSE: Adherence and persistence with bisphosphonates are frequently poor, and stopping, restarting, or switching bisphosphonates is common. We evaluated bisphosphonate change behaviors (switching, discontinuing, or reinitiating) over time, as well as fractures and costs, among a large, national cohort of postmenopausal veterans. METHODS: Female veterans aged 50+ treated with bisphosphonates during 2003-2011 were identified in Veterans Health Administration (VHA) datasets. Bisphosphonate change behaviors were characterized using pharmacy refill records. Patients' baseline disease severity was characterized based on age, T-score, and prior fracture. Cox Proportional Hazard analysis was used to evaluate characteristics associated with discontinuation and the relationship between change behaviors and fracture outcomes. Generalized estimating equations were used to evaluate the relationship between change behaviors and cost outcomes. RESULTS: A total of 35,650 patients met eligibility criteria. Over 6800 patients (19.1%) were non-switchers. The remaining patients were in the change cohort; at least half displayed more than one change behavior over time. A strong, significant predictor of discontinuation was ≥5 healthcare visits in the prior year (11-23% more likely to discontinue), and discontinuation risk decreased with increasing age. No change behaviors were associated with increased fracture risk. Total costs were significantly higher in patients with change behaviors (4.7-19.7% higher). Change-behavior patients mostly had significantly lower osteoporosis-related costs than non-switchers (22%-118% lower). CONCLUSIONS: Most bisphosphonate patients discontinue treatment at some point, which did not significantly increase the risk of fracture in this majority non-high risk population. Bisphosphonate change behaviors were associated with significantly lower osteoporosis costs, but significantly higher total costs.

Risk of hospitalized bacterial infections associated with biologic treatment among US veterans with rheumatoid arthritis.

OBJECTIVE: The comparative risk of infection associated with non-anti-tumor necrosis factor (anti-TNF) biologic agents is not well established. Our objective was to compare risk for hospitalized infections between anti-TNF and non-anti-TNF biologic agents in US veterans with rheumatoid arthritis (RA). METHODS: Using 1998-2011 data from the US Veterans Health Administration, we studied RA patients initiating rituximab, abatacept, or anti-TNF therapy. Exposure was based upon days supplied (injections) or usual dosing intervals (infusions). Treatment episodes were defined as new biologic agent use. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for hospitalization for a bacterial infection were estimated from Cox proportional hazards models, adjusting for potential confounders. RESULTS: Among 3,152 unique RA patients contributing 4,158 biologic treatment episodes to rituximab (n = 596), abatacept (n = 451), and anti-TNF agents (n = 3,111), the patient mean age was 60 years and 87% were male. The most common infections were pneumonia (37%), skin/soft tissue (22%), urinary tract (9%), and bacteremia/sepsis (7%). Hospitalized infection rates per 100 person-years were 4.4 (95% CI 3.1-6.4) for rituximab, 2.8 (95% CI 1.7-4.7) for abatacept, and 3.0 (95% CI 2.5-3.5) for anti-TNF. Compared to etanercept, the adjusted rate of hospitalized infection was not different for adalimumab (HR 1.4, 95% CI 0.9-2.2), abatacept (HR 1.1, 95% CI 0.6-2.1), or rituximab (HR 1.4, 0.8-2.6), although it was increased for infliximab (HR 2.3, 95% CI 1.3-4.0). Infection risk was greater for those taking prednisone >7.5 mg/day (HR 1.8, 95% CI 1.3-2.7) and in the highest quartile of C-reactive protein (HR 2.3, 95% CI 1.4-3.8) and erythrocyte sedimentation rate (HR 4.1, 95% CI 2.3-7.2) compared to the lowest quartile. CONCLUSION: In older, predominantly male US veterans with RA, the risk of hospitalized bacterial infections associated with rituximab or abatacept was similar to etanercept.

Patient and provider perspectives on implementation models of HIV counseling and testing for patients with TB.

SETTING: TB clinics in Kinshasa, Democratic Republic of Congo. OBJECTIVES: To identify an acceptable approach to human immunodeficiency virus (HIV) counseling and testing (CT) for patients with tuberculosis (TB) from health care worker (HCWs) and patient perspectives. DESIGN: A qualitative evaluation was conducted of three models of routine provider-initiated HIV CT: off-site referral to a freestanding voluntary counseling and testing (VCT) center, on-site referral for HIV CT at the primary health care center to which the TB clinic belongs and HIV CT by the TB nurse. RESULTS: Incorporating HIV CT into routine TB care was supported by HCWs (96%) and patients (99%). The trusting patient-provider relationship was a primary reason why most HCWs (74%) and patients (68%) preferred the HIV CT by TB nurse model. Patients also cited continuity of care and potential optimisation of the management of HIV co-infected patients as reasons. Some patients and HCWs were concerned about confidentiality issues (HIV status documentation and privacy of counseling) and the potential difficulty of refusing routine HIV CT when it was offered by TB nurses. Some HCWs also expressed worry about the increased workload. CONCLUSION: Qualitative data provided insight into reasons for the high uptake observed of routine HIV CT offered by TB nurses and identified potential concerns when implementing this model.

Randomized comparison of linezolid (PNU-100766) versus oxacillin-dicloxacillin for treatment of complicated skin and soft tissue infections.

This randomized, double-blind, multicenter trial compared the efficacy and safety of linezolid, an oxazolidinone, with those of oxacillin-dicloxacillin in patients with complicated skin and soft tissue infections. A total of 826 hospitalized adult patients were randomized to receive linezolid (600 mg intravenously [i.v.]) every 12 h or oxacillin (2 g i.v.) every 6 h; following sufficient clinical improvement, patients were switched to the respective oral agents (linezolid [600 mg orally] every 12 h or dicloxacillin [500 mg orally] every 6 hours). Primary efficacy variables were clinical cure rates in both the intent-to-treat (ITT) population and clinically evaluable (CE) patients and microbiological success rate in microbiologically evaluable (ME) patients. Safety and tolerability were evaluated in the ITT population. Demographics and baseline characteristics were similar across treatment groups in the 819 ITT patients. In the ITT population, the clinical cure rates were 69.8 and 64.9% in the linezolid and oxacillin-dicloxacillin groups, respectively (P = 0.141; 95% confidence interval -1.58 to 11. 25). In 298 CE linezolid-treated patients, the clinical cure rate was 88.6%, compared with a cure rate of 85.8% in 302 CE patients who received oxacillin-dicloxacillin. In 143 ME linezolid-treated patients, the microbiological success rate was 88.1%, compared with a success rate of 86.1% in 151 ME patients who received oxacillin-dicloxacillin. Both agents were well tolerated; most adverse events were of mild-to-moderate intensity. No serious drug-related adverse events were reported in the linezolid group. These data support the use of linezolid for the treatment of adults with complicated skin and soft tissue infections.

A screening level probabilistic risk assessment of mercury in Florida Everglades food webs.

A screening level probabilistic assessment of risks was performed on three species of piscivorous wildlife at the top of Everglades aquatic food webs: the American alligator (Alligator mississippiensis), the great egret (Egretta alba), and the raccoon (Procyon lotor varius). Ranges of dietary exposure concentrations (and probability distribution functions) were derived for two general areas of the Everglades: Shark Slough and the southcentral Everglades (highly contaminated with Hg), and the northern Everglades (a lower Hg contaminated area in and near Water Conservation Area 1). Ranges of toxicity reference values and probability distribution functions were derived from literature on the toxicity of dietary methyl Hg to birds and mammals. Probability distributions of risk estimates for each receptor were generated using Monte Carlo simulations and indicated that piscivorous wildlife feeding in the south-central region of the Everglades are at high risk from consumption of Hg-contaminated prey. Alligators had 100% exceedences of chronic risk thresholds, and great egrets had 99% exceedences. In the northern Everglades, exceedences of chronic risk thresholds were substantially lower but were still present (6-34% exceedences). Results support previous studies suggesting that top predators of the Everglades may be at risk from Hg contamination and indicate that Hg risks are location-dependent.

Allelic expression and genetic distance in hybrid macaque monkeys.

Levels of structural genic divergence at 21 loci encoding blood proteins were quantified in six macaque (Macaca) species, using standard techniques of starch-gel electrophoresis. Genetic distances between all pairs of species fall within a narrow range (0.080 less than or equal to D less than or equal to 0.250; D = 0.164) which is near the lower limit of genetic distances typically observed between other congeneric organisms. In an effort to measure levels of regulatory gene differences between these species, we have examined the patterns of allelic expression in their F1, F2, and backcross hybrids. Nine of the 21 loci examined encode allelic forms of the proteins with different electrophoretic mobilities in at least some of the individual parents of the hybrids. In all cases where expected, hybrids express fully both maternal and paternal allelic products, thus providing no strong evidence ofr a breakdown in the regulatory mechanisms responsible for proper expression of these genes. Results are compared to degrees of allelic repression previously observed in other hybrids, and are discussed within the context of current ideas about rates of regulatory gene evolution in mammals.

Paternity and status in a rhesus monkey group.

In the blood from 63 rhesus monkeys (Macaca mulatta), transferrin, 6-phosphogluconate dehydrogenase, carbonic anhydrase II, phosphohexose isomerase, NADH diaphorase and leucocyte antigens were polymorphic. On the basis of these traits, paternity eliminations were determined for 29 offspring of 26 females from an established breeding group containing 8 sexually mature males. The dominance of the males was assessed by the directionality of the agonistic encounters. After examination of the results for two breeding seasons it was found that (1) the alpha male did not do all, or even most, of the successful mating and (2) there was evidence demonstrating increased reproductive success for males as a function of relative agonistic rank for the second but not the first of the 2 years.