An update on drug-drug interactions in older adults living with human immunodeficiency virus (HIV).

INTRODUCTION: People with HIV are living longer due to advances in antiretroviral therapy. With improved life expectancy comes an increased lifetime risk of comorbid conditions - such as cardiovascular disease and cancer - and polypharmacy. Older adults, particularly those living with HIV, are more vulnerable to drug interactions and adverse effects, resulting in negative health outcomes. AREA COVERED: Antiretrovirals are involved in many potential drug interactions with medications used to treat common comorbidities and geriatric conditions in an aging population of people with HIV. We review the mechanisms and management of significant drug-drug interactions involving antiretroviral medications and non-antiretroviral medications commonly used among older people living with HIV. The management of these interactions may require dose adjustments, medication switches to alternatives, enhanced monitoring, and considerations of patient- and disease-specific factors. EXPERT OPINION: Clinicians managing comorbid conditions among older people with HIV must be particularly vigilant to side effect profiles, drug-drug interactions, pill burden, and cost when optimizing treatment. To support healthier aging among people living with HIV, there is a growing need for antiretroviral stewardship, multidisciplinary care models, and advances that promote insight into the correlations between an individual, their conditions, and their medications.

The 1982 Medicaid Funding Cessation for Circumcision in California and Circumcision Rates.

We investigated California's 1982 decision to stop funding Medicaid neonatal circumcision. We examined male neonatal circumcision rates for those born 1977-1981 and 1983-1987 by region, race, and insurance status. Overall, West-Medicaid circumcision rates decreased from 56.5% in 1979-81 to 26.7% in 1983-85. California's 1982 decision to defund Medicaid circumcision coverage was associated with a 25.0-30.8% point decrease in West-Medicaid circumcision rates compared other groups, p < 0.01. This provides the earliest data to support that funding coverage for neonatal circumcision affects circumcision rates and magnifies healthcare disparities. Other states have since defunded Medicaid male neonatal circumcision. Circumcision have been associated with lower rates of sexually transmitted infections including HIV, and urinary tract infections. Lawmakers should consider re-funding Medicaid male neonatal circumcision.

RESUMEN: La cesación de financiamiento por Medicaid en 1982 para la circuncisión y el impacto de su tasa en California.Aquí investigamos la decisión del gobierno de California en 1982 de dejar de financiar la circuncisión neonatal por Medicaid. Examinamos las tasas de circuncisión neonatal masculina para los nacidos entre 1977 a 1981 y entre 1983 a 1987 por región, raza y estatus de seguro médico. En general, las tasas de circuncisión de West-Medicaid disminuyeron 56.5% en 1979-81 a 26.7% en 1983-85. La decisión de California en 1982 de desfinanciar la cobertura de circuncisión por Medicaid se asoció con una disminución de 25.0 a 30.8 puntos porcentuales en las tasas de circuncisión de West-Medicaid en comparación con otros grupos, p < 0.01. Esto provee los primeros datos que demuestra la cobertura de financiamiento para la circuncisión neonatal afecta las tasas de circuncisión y aumenta las disparidades en cuidado médico. Desde entonces, otros estados han desfinanciado la circuncisión neonatal masculina por Medicaid. La circuncisión se ha asociado con tasas más bajas de infecciones de transmisión sexual, incluyendo el VIH, e infecciones del tracto urinario. Los legisladores deberían considerar refinanciar la circuncisión neonatal masculina por Medicaid.

Practical methods for effective vancomycin-resistant enterococci (VRE) surveillance: experience in a liver transplant surgical intensive care unit.

OBJECTIVE: We evaluated the utility of vancomycin-resistant Enterococcus (VRE) surveillance by varying 2 parameters: admission versus weekly surveillance and perirectal swabbing versus stool sampling. DESIGN: Prospective, patient-level surveillance program of incident VRE colonization. SETTING: Liver transplant surgical intensive care unit (SICU) of a tertiary-care referral medical center with a high prevalence of VRE.PatientsAll patients admitted to the SICU from June to August 2015. METHODS: We conducted a point-prevalence estimate followed by admission and weekly surveillance by perirectal swabbing and/or stool sampling. Incident colonization was defined as a negative screen followed by positive surveillance. VRE was detected by culture on Remel Spectra VRE chromogenic agar. Microbiologically-confirmed VRE bloodstream infections (BSIs) were tracked for 2 months. Statistical analyses were calculated using the McNemar test, the Fisher exact test, the t test, and the χ2 test. RESULTS: In total, 91 patients underwent VRE surveillance testing. The point prevalence of VRE colonization was 60.9%; VRE prevalence on admission was 30.1%. Weekly surveillance identified an additional 7 of 28 patients (25.0%) with incident colonization. VRE BSIs were more common in VRE-colonized patients than in noncolonized patients (8 of 43 vs 2 of 48; P=.028). In a direct comparison, perirectal swabs were more sensitive than stool samples in detecting VRE (64 of 67 vs 56 of 67; P=.023). Compliance with perirectal swabbing was 89% (201 of 226) compared to 56% (127 of 226) for stool collection (P≤0.001). CONCLUSIONS: We recommend weekly VRE surveillance over admission-only screening in high-burden units such as liver transplant SICUs. Perirectal swabs had greater collection compliance and sensitivity than stool samples, making them the preferred methodology. Further work may have implications for antimicrobial stewardship and infection control.