Review of literature and clinical practice experience for the therapeutic management of Morgellons disease.

Morgellons disease (MD) is a rare and contentious health condition characterized by dermatological symptoms including slow-healing skin lesions 'attributed' to fibres emerging from or under the skin. Patients also report sensations of crawling, biting and infestation with inanimate objects. This review examines the aetiology, patient characteristics, epidemiology, historical context, correlation with Lyme disease, role of internet, impact on quality of life and treatment approaches for MD. Despite ongoing debate, MD is not officially recognized in medical classifications, with differing views on its aetiology. Some link MD to Lyme disease, while others view it as a variant of delusional infestation. The literature suggests both psychiatric and environmental factors may contribute. The manuscript explores the association with substance abuse, psychiatric comorbidities, infectious agents and the role of internet communities in shaping perceptions. MD's impact on quality of life is significant, yet often overlooked. Treatment approaches are varied due to limited evidence, with low-dose antipsychotics being considered effective, but patient beliefs may influence adherence. A patient-centred, multidisciplinary approach is emphasized, considering both the physical and psychological dimensions of MD. Addressing the controversies surrounding MD while focusing on patient well-being remains a critical challenge for healthcare professionals.

Identification of 2 Distinct Boundaries Distinguishes Critical From Noncritical Isthmuses in Ablating Atypical Atrial Flutter.

BACKGROUND: Atypical atrial flutters often involve complex circuits. Classic methods of identifying ablation targets, including detailed electroanatomical mapping and entrainment within a well-defined isthmus, may not always be sufficient to allow the critical isthmus to be delineated and ablated, with flutter termination and prevention of reinduction. OBJECTIVES: This study sought a systematic method to classify conduction barriers and isthmuses as critical or noncritical that would improve understanding and ablation success. We also sought a construct unifying single- and dual-loop re-entry. Re-entrant circuits are bounded on 2 sides, although these are not consistently identified. We hypothesized 2 distinct critical boundaries, and a critical isthmus could be consistently defined without requiring entrainment, and ablation connecting these 2 boundaries would terminate tachycardia. METHODS: Activation maps were created electroanatomically. Conduction barriers were classified as noncritical barriers or critical boundaries. Critical boundaries showed sequential activation around the barrier, spanning ≥90% of the cycle length. Noncritical barriers showed nonsequential, parallel, or colliding activation or <90% of the cycle length. Only tissue separating the 2 critical boundaries defined a critical isthmus (CI); all others were considered noncritical. The effect of ablation across a CI was assessed. RESULTS: Complete maps were obtained in 128 cases in 121 patients (28 atypical right atrial, 100 left atrial). In all cases, 2 distinct critical boundaries were identified. Ablation across a CI connecting these critical boundaries terminated tachycardia in 123 of 128 cases (96.1%). Failures were due to inability to achieve block across the isthmus. CONCLUSIONS: Activation mapping of atypical atrial flutter allows consistent identification of 2 critical boundaries. Successful ablation connecting the 2 critical boundaries reliably results in termination of atypical atrial flutter.

Acceptance and timeliness of post-exposure vaccination against mpox in high-risk contacts, Amsterdam, the Netherlands, May-July 2022.

BACKGROUND: May 2022, several countries reported mpox outbreaks among men-who-have-sex-with-men. In the Netherlands, high-risk contacts were offered the third-generation smallpox vaccine as post-exposure-prophylaxis (PEP) within 4 but maximum 14 days after exposure. We investigated their PEP acceptance, timeliness of uptake and development of mpox for the region of the Public Health Service (PHS) Amsterdam. METHODS: High-risk contacts identified during 20 May-22 July 2022 were included. Contacts were followed-up 21 days after exposure and classified as: no patient (no mpox symptoms or orthopoxvirus PCR-negative) or mpox patient (clinically suspected mpox or orthopoxvirus PCR-positive). We calculated time intervals between date of last exposure and first PHS consultation, PEP administration, and symptom onset. RESULTS: Two-hundred-ninety contacts were at high-risk of mpox predominantly due to sexual and/or direct skin-skin contact (212/290, 73 %). First PHS consultation was a median of 5 (IQR 3, 7) days after exposure, at which point 26/290 (9 %) contacts were ineligible for PEP. 84 % (223/264) of contacts eligible for PEP, received PEP within a median of 6 (IQR 3, 8) days after exposure. Of 282 contacts (missing outcome n = 8) 38 (14 %) developed mpox a median of 7 (IQR 5, 12) days after exposure, of whom 50 % (19/38) developed mpox before their first PHS consultation. Among contacts eligible for PEP, 2/38 (5 %) unvaccinated and 16/218 (7 %) vaccinated contact developed mpox. CONCLUSIONS: PEP acceptance among contacts of mpox patients was high. However, PEP timeliness was inadequate. Half of contacts received PEP 6 or more days after exposure, and half of contacts who developed mpox had an onset prior to their first PHS consultation. Estimating PEP vaccine effectiveness is problematic due to the timeliness of PEP and the time it takes to generate vaccine-induced immunity. It is important to assess how PEP timeliness may improve and to promote pre-exposure vaccination to control mpox outbreaks.

Steps towards implementation of protocolized dose reduction of adalimumab, etanercept and ustekinumab for psoriasis in daily practice.

BACKGROUND: Dose reduction (DR) of adalimumab, etanercept and ustekinumab has proven to be (cost-)effective in psoriasis patients with low disease activity. Further implementation is needed to establish application of DR for eligible patients. OBJECTIVES: To evaluate the implementation of protocolized biologic DR in daily practice. METHODS: A pilot implementation study was performed in 3 hospitals during 6 months. By combining education and protocol development, involved healthcare providers (HCPs) were directed toward the adoption of protocolized DR. DR of adalimumab, etanercept, and ustekinumab was achieved by stepwise injection interval prolongation. Implementation outcomes (fidelity, feasibility) were assessed. Factors for optimizing implementation were explored in interviews with HCPs. Uptake was measured in patients by chart review. RESULTS: The implementation strategy was executed as planned. Implementation fidelity was less than 100% as not all provided tools were used across study sites. HCPs indicated the feasibility of implementing protocolized DR, although time investment was needed. Identified additional factors for successful implementation included support for patients, uptake of DR into guidelines, and supportive electronic health record systems. During the 6 months intervention period, 52 patients were eligible for DR of whom 26 (50%) started DR. The proposed DR protocol was followed in 22/26 patients (85%) on DR. CONCLUSION: Additional staff for support, extra time during consultations, education on DR for HCPs and patients, and effective tools such as a feasible protocol can lead to more patients on biologic DR.

Recreation reduces tick density through fine-scale risk effects on deer space-use.

Altered interactions between pathogens, their hosts and vectors have potential consequences for human disease risk. Notably, tick-borne pathogens, many of which are associated with growing deer abundance, show global increasing prevalence and pose increasing challenges for disease prevention. Human activities can largely affect the patterns of deer space-use and can therefore be potential management tools to alleviate human-wildlife conflicts. Here, we tested how deer space-use patterns are influenced by human recreational activities, and how this in turn affects the spatial distribution of the sheep tick (Ixodes ricinus), a relevant disease vector of zoonoses such as Lyme borrelioses. We compared deer dropping and questing tick density on transects near (20 m) and further away from (100 m) forest trails that were either frequently used (open for recreation) or infrequently used (closed for recreation, but used by park managers). In contrast to infrequently used trails, deer dropping density was 31% lower near (20 m) than further away from (100 m) frequently used trails. Similarly, ticks were 62% less abundant near (20 m) frequently used trails compared to further away from (100 m) these trails, while this decline in tick numbers was only 14% near infrequently used trails. The avoidance by deer of areas close to human-used trails was thus associated with a similar reduction in questing tick density near these trails. As tick abundance generally correlates to pathogen prevalence, the use of trails for recreation may reduce tick-borne disease risk for humans on and near these trails. Our study reveals an unexplored effect of human activities on ecosystems and how this knowledge could be potentially used to mitigate zoonotic disease risk.

Management and outcome of middle ear adenomatous neuroendocrine tumours: A systematic review.

Middle ear adenomatous neuroendocrine tumours (MEANTs) are rare, unpredictable tumours. Although most MEANTs are characterized by a benign biological behaviour and indolent growth pattern, some studies have reported locally invasive and metastastic disease. Currently, the optimal management strategy for MEANTs remains subject of debate. The aim of this study is to review the literature on MEANTs with focus on its clinical characteristics, treatment strategies and outcome. A systematic review was conducted using PubMed, Embase and Cochrane databases. A total of 111 studies comprising 198 patients with MEANT were included. Treatment modalities comprised surgery (90%), surgery with adjuvant radiotherapy (9%) and palliative (chemo)radiotherapy in (1%). Local recurrence was observed in 25% of the patients and 7% of the patients developed metastasis, over a median period of 5.7 years (range 7 months - 32 years). Twelve of 13 patients (92%) who developed metastases had a local recurrence. Four patients (2%) died of MEANT: three due to distant metastases and one due to extensive local recurrence. Reliable histopathologic predictors of outcome could not be identified. These findings indicate that the clinical presentations of MEANT vary substantially, the overall recurrence rate is considerable and initial local tumour control is paramount. Because of the unpredictable clinical course, prolonged follow-up is warranted.

Exploring the directionality in the relationship between descriptive and injunctive parental and peer norms and snacking behavior in a three-year-cross-lagged study.

BACKGROUND: People's eating behavior is assumed to be influenced by what other people do (perceived descriptive norms) and what others approve of (perceived injunctive norms). It has been suggested that adolescents are more susceptible to peer norms than parental norms, because they experience a strong need for group acceptance that leads to conforming to peer group norms. The current study examined changes in snacking behavior and four types of social norms (i.e., parental and peer descriptive and injunctive norms) that promoted fruit and vegetable intake among adolescents. This study was the first to examine whether snacking behavior also influenced norm perceptions by testing the directionality of these associations. METHODS: The study consisted of 819 participants (M [SD] age = 11.19 [1.36]; 46.1% boys), collected at three time points (T1 = 2016, T2 = 2017 and T3 = 2018) during the MyMovez project. Self-reported frequency of snack consumption, perceived parental and peer descriptive and injunctive norms were assessed. The primary analysis consisted of a series of cross-lagged autoregressive models specified in a structural equation modeling framework. RESULTS: Model comparisons testing the descriptive and injunctive norms in separate models and in an additional combined model revealed evidence for bi-directional associations between norms and snacking behavior. Descriptive peer and parent norms were not found to have an effect on subsequent snacking behaviors. Perceived injunctive parental norms were positively associated with healthy snack food intake and negatively associated with unhealthy snack intake (forward direction). Injunctive peer norms were negatively associated with healthy snack food intake. In addition, higher unhealthy snack food intake was negatively associated with the perception of descriptive and injunctive parental norms 1 year later (reversed direction). We did not find peer norms to be more closely associated with changes in snacking behaviors compared to parental norms. CONCLUSIONS: Parents expecting their children to snack healthy had a positive influence on healthy snacking behavior whereas only acting as a healthy role model did not. Future research should address the possible interaction between descriptive and injunctive norms. Research should also take into account the bi-directional relations between eating behaviors and normative perceptions.

The effect of added fat on the accuracy of Cobb angle measurements in CT SPR images: A phantom study.

INTRODUCTION: Adolescent idiopathic scoliosis (AIS) is a spinal deformity that mostly affects females aged between 10 and 17 years old. Cobb's method is the gold standard for assessing AIS. Being overweight is a common characteristic in AIS patients; therefore, the aim of this study is to investigate the effect fat mass has on the accuracy of Cobb angle measurements in 10-year-old female AIS patients. METHODS: A purpose-built phantom representing an AIS patient was scanned after adding several thicknesses of lard fat (0,2,4 and 8 cm). The phantom was scanned in an antero-posterior position using the scout mode of the CT scanner. 18 observers performed Cobb angle measurements on the images. RESULTS: The average Cobb angle at 0 cm of fat was 10.83° (SD = 3.06), at 2 cm it was 10.90° (SD = 3.16), at 4 cm it was 10.64° (SD = 3.06) and at 8 cm it was 10.88° (SD = 3.02). No significant difference was observed between the measurements at these thicknesses. CONCLUSION: Cobb angle measurements are not affected by the presence of fat. IMPLICATIONS FOR PRACTICE: When assessing overweight AIS patients, it not necessary to manipulate the acquisition parameters, which could lead to increased patient dose, in order to get more accurate Cobb angle measurement.

Wolff-Parkinson-White, Brugada phenocopy, and flecainide toxicity: All in one patient.

Accessory pathway Wolff-Parkinson-white is sometimes not manifested till later in life, as the conduction properties of AV node become slower, other mechanisms are also possible. Brugada pattern on EKG can be associated with various underlying clinical conditions, such as mechanical compression of RVOT by tumors. It is essential to have high index of suspicion for flecainide toxicity when encountering arrhythmias in patients taking the drug.

Correction: Experienced sitting-related problems and association with personal, lesion and wheelchair characteristics in persons with long-standing paraplegia and tetraplegia.

A correction to this paper has been published and can be accessed via a link at the top of the paper.

Experienced sitting-related problems and association with personal, lesion and wheelchair characteristics in persons with long-standing paraplegia and tetraplegia.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To describe experienced sitting-related health and stability problems among persons with paraplegia (PP) or tetraplegia (TP) and to investigate associations with personal, lesion and wheelchair characteristics as well as satisfaction with sitting posture. SETTING: Dutch community. METHODS: A self-report questionnaire on seating was developed and completed by wheelchair-users living with Spinal Cord Injury (SCI) for ≥10 years (N = 264). Sitting-related problems and satisfaction with sitting posture were compared between participants with PP and TP using Chi-square and t-tests. Logistic regression analyses were performed to investigate associated characteristics. RESULTS: Reported sitting-related problems comprised: sitting to be tiring (regularly to always) (33%), sitting to be painful (28%), pressure ulcers in the last three months (29%), instability while sitting (8%) and instability during reaching (33%). Except for instability during reaching, no differences in occurrence of sitting-problems were found between lesion-group. Persons with TP were more dissatisfied with their sitting posture than persons with PP: 51% vs 36% (p = 0.022) and 51% and 47% respectively thought their sitting posture could be improved (p = 0.670). 'Experienced lack of support in the wheelchair' was associated with most sitting-problems. Pain and instability were associated with dissatisfaction with sitting posture. CONCLUSION: Sitting-related problems and dissatisfaction with sitting posture were frequently reported by persons with long-standing SCI. Sitting problems appeared to associate with lacking support in the wheelchair/seating. A comprehensive feedback from the wheelchair user and a stability check (reach task), as part of the wheelchair/seating-user fitting, may contribute to prevention of sitting-related problems.

Release of syngnathia by anticlockwise rotation and mandibular advancement using bilateral alloplastic temporomandibular joint prostheses: a new approach.

We describe a new approach to the planning of treatment and subsequent operation on a patient with syngnathia and severe mandibular retrognathism. To facilitate a large mandibular advancement we applied alloplastic temporomandibular joint (TMJ) prostheses to the coronoid processes after anticlockwise rotation of the mandible. To the best of our knowledge this is the first documented case of its kind.

Management of drug interactions with direct-acting antivirals in Dutch HIV/hepatitis C virus-coinfected patients: adequate but not perfect.

OBJECTIVES: Direct-acting antivirals (DAAs) for treatment of chronic hepatitis C virus (HCV) infection can cause drug-drug interactions (DDIs) with combination antiretroviral therapy (cART) and non-cART co-medication. We mapped how physicians manage DDIs between DAAs and co-medication and analysed treatment outcomes. METHODS: Data were prospectively collected as part of the ATHENA HIV observational cohort and retrospectively analysed. Dutch patients with HIV/HCV coinfection who initiated treatment with DAAs between January 2015 and May 2016 were included. Co-medication 3 months prior to and during DAA therapy was identified. Potential DDIs with the DAAs were checked using http://hep-druginteractions.org. DDIs were categorized as: (1) no interaction expected; (2) potential interaction; (3) contra-indication; (4) no recommendation. These categories were used to determine which patients switched or had a DDI during DAA therapy with co-medication. RESULTS: A total of 423 patients were treated with DAAs, of whom 418 (99%) used cART and 251 (59%) used non-cART co-medication. Before commencing DAA treatment, in 17 of 84 (20%) patients the non-cART co-medication which could result in a category 2/3 DDI was discontinued before DAA initiation, including two of six (33%) prescriptions of category 3 drugs. A total of 196 of 418 (47%) patients had a category 2/3 DDI between their DAA regimen and cART. Category 2/3 DDIs were prevented by switching cART in 78 of 147 (53%) and 47 of 49 (98%) patients. Overall, 367 of 423 (87%) patients have achieved a sustained virological response (33 in follow-up). CONCLUSIONS: Prescription patterns suggest that physicians are aware of potential DDIs between co-medication and DAAs, in particular potential DDIs with cART. Greater awareness is needed concerning category 3 interactions between non-cART co-medication and DAAs.

[Patients also have responsibility for prevention]. / Preventie, ook ons patiëntenpakkie an!

Patient organisations should be more visible in the societal debate about prevention, alongside fulfilling their more traditional tasks such as education, peer support and lobbying for their interests. Despite appreciating the medical care he received, the author also personally experienced a lack of attention for life-style interventions (e.g. a salt-free diet, exercise) in the care provided. Since 2012, awareness among European patient groups is rising about the importance of nutrition, which is evolving from being considered as a simple necessity to being an essential component of disease management. EU patient groups are participating in the EU-wide national 'Optimal Nutritional Care for All' campaigns. They perceive prevention as a way to decrease lifestyle diseases in the long term, and to economise on health-care costs. Dedicated, enthusiastic politicians are required if this transformation is to take place; they also need reduce the socio-economic differences in society that negatively impact on health and life-expectancy.

High prevalence of abnormalities on CT and MR imaging in children with unilateral sensorineural hearing loss irrespective of age or degree of hearing loss.

OBJECTIVE: Evaluation of causal abnormalities identified on CT and MR imaging in children with unilateral sensorineural hearing loss (USNHL), and the association with age and severity of hearing loss. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral otology/audiology center. PATIENTS AND DIAGNOSTIC INTERVENTIONS: 102 children diagnosed with USNHL between 2006 and 2016 were included. They underwent CT and/or MR imaging for the evaluation of the etiology of their hearing loss. MAIN OUTCOME MEASURES: Radiologic abnormalities of the inner ear and brain associated with USNHL. RESULTS: Using CT and/or MR imaging, causal abnormalities were identified in 49%, which is higher than previously reported (25-40%). The most frequently affected site was the labyrinth (29%), followed by the cochlear nerve (9%) and brain (7%). No significant difference in the number or type of abnormalities was found for the degree of hearing loss or age categories. CONCLUSIONS: Imaging is essential in the etiologic analysis of USNHL because of the high prevalence of causative abnormalities that can be identified with radiology, irrespective of the patients' age or degree of hearing loss. CT and MR imaging are complementary imaging options. The ideal imaging algorithm is controversial. Based on our findings, we conclude that there is limited additional diagnostic value of simultaneous dual modality imaging over sequential diagnostics. We therefore perform a stepwise radiological workup in order to maximize the diagnostic yield while minimizing impact and costs. If the primary imaging modality does not identify a cause for USNHL, performing the alternative imaging modality should be considered. LEVEL OF EVIDENCE: Retrospective cohort study 2b.

Factors associated with time to achieve an undetectable HIV RNA viral load after start of antiretroviral treatment in HIV-1-infected pregnant women.

OBJECTIVE: To identify factors associated with the time to viral suppression in women starting antiretroviral treatment (ART) during pregnancy. Knowledge on duration of viral load (VL) decline could help deciding the timing of treatment initiation. METHODS: Highly active antiretroviral treatment (HAART)-naive pregnant women over 18 years of age who started treatment during pregnancy were included. The time to viral suppression was calculated and compared between subgroups. RESULTS: A total of 227 pregnancies matched our inclusion criteria. In 84.6% of these an undetectable VL was reached at the time of delivery. The median time to undetectable VL after initiation of treatment was 60 days (12-168 days). Only baseline VL <10,000 copies/mL showed an independent association with time to viral suppression in multivariate Cox regression analysis, with a mean time to reach a VL <50 HIV-1 copies/mL of 49 days (95% CI 44-53). No difference in time to undetectable VL was found between protease inhibitor and non-nucleoside reverse transcriptase inhibitor-based regimens. Integrase inhibitors were not part of any treatment regimen. CONCLUSION: Our results suggest that in patients with baseline HIV RNA <10,000 copies/mL ART initiation might be postponed up to the twentieth week of pregnancy, thus minimising the risk of possible drug-related teratogenicity and toxicity.

Impact of health problems secondary to SCI one and five years after first inpatient rehabilitation.

STUDY DESIGN: This is a multicenter prospective cohort study. OBJECTIVES: The objective of this study was to describe and compare the impact of health problems secondary to spinal cord injury (SCI) on functioning at home and on social activities at 1 and 5 years after discharge from first inpatient rehabilitation. SETTING: The study was conducted in a Dutch community. METHODS: Participants with SCI who use a wheelchair for everyday mobility (N=110) completed a self-report questionnaire as part of a larger cohort study including four items on extra time needed (body care, bladder and bowel regulation, 'organization' and transportation) and impact of 10 health problems on functioning at home and on social activities. The 10 health problems include secondary health conditions (bladder regulation, bowel regulation, decubitus, pain, spasticity, gain in body weight and edema), psychosocial problems (sexuality, having difficulty with being dependent on help from others) and handicap management. RESULTS: Median extra time needed for self-management and transportation was not significantly higher 1 year after discharge (16 (IQR 13.5) h per week) compared with 5 years after discharge (13 (IQR 17) h per week) (P=0.925). Participants reported slightly less impact, comparing the severity sum-score (range 10-50) of the 10 health problems on functioning at home and in social activities, 5 years post discharge (20 and 17, respectively) than 1 year post discharge (21 and 18, respectively; P<0.05). Most frequently mentioned health problems were handicap management, being dependent on help from others, bladder regulation, bowel regulation, pain and sexuality. CONCLUSIONS: The impact of health problems after SCI is considerable and hardly diminishes over time. These results emphasize the need for structured long-term care for people with SCI.

Evidence for and cost-effectiveness of physiotherapy in haemophilia: a Dutch perspective.

INTRODUCTION: Musculoskeletal impact of haemophilia justifies physiotherapy throughout life. Recently the Dutch Health Care Institute constrained their 'list of chronic conditions', and withdrew financial coverage of physiotherapy for elderly persons with haemophilia (PWH). This decision was based on lack of scientific evidence and not being in accordance with 'state of science and practice'. METHODS: In general, evidence regarding physiotherapy is limited, and especially in rare diseases like haemophilia. 'Evidence based medicine' classifies and recommends evidence based on meta-analyses, systematic reviews and randomized controlled trials, but also means integrating evidence with individual clinical expertise. For the evaluation of physiotherapy - usually individualized treatment - case studies, observational studies and Case Based Reasoning may be more beneficial. RESULTS: Overall annual treatment costs for haemophilia care in the Netherlands are estimated over 100 million Euros, of which 95% is covered by clotting factor concentrates. The cost for physiotherapy assessments in all seven Dutch HTCs (seven centres for adult PWH and seven centres for children) is limited at approximately 500 000 Euros annually. Costs of the actual physiotherapy sessions, carried out in our Dutch first-line care system, will also not exceed 500 000 Euros. Thus, implementation of physiotherapy in haemophilia care the Netherlands in a most optimal way would cost less than 1% of the total budget. AIM: The present paper describes the role of physiotherapy in haemophilia care including available evidence and providing suggestions regarding generation of evidence. Establishing the effectiveness and cost-effectiveness of physiotherapy in haemophilia care is a major topic for the next decennium.

Virological and Social Outcomes of HIV-Infected Adolescents and Young Adults in The Netherlands Before and After Transition to Adult Care.

BACKGROUND: As a result of effective combination antiretroviral therapy (cART) and advanced supportive healthcare, a growing number of human immunodeficiency virus (HIV)-infected children survive into adulthood. The period of transition to adult care is often associated with impaired adherence to treatment and discontinuity of care. We aimed to evaluate virological and social outcomes of HIV-infected adolescents and young adults (AYAs) before and after transition, and explore which factors are associated with virological failure. METHODS: We included 59 HIV-infected AYAs from the Netherlands who had entered into pediatric care and transitioned from pediatric to adult healthcare. We used HIV RNA load and cART data from the Dutch Stichting HIV Monitoring database (1996-2014), and collected social and treatment data from patients' medical records from all Dutch pediatric HIV treatment centers and 14 Dutch adult treatment centers involved. We evaluated risk factors for virological failure (VF) in a logistic regression model adjusted for repeated measurements. RESULTS: HIV VF occurred frequently during the study period (14%-36%). During the transition period (from 18 to 19 years of age) there was a significant increase in VF compared with the reference group of children aged 12-13 years (odds ratio, 4.26 [95% confidence interval, 1.12-16.28]; P = .03). Characteristics significantly associated with VF were low educational attainment and lack of autonomy regarding medication adherence at transition. CONCLUSIONS: HIV-infected AYAs are vulnerable to VF, especially during the transition period. Identification of HIV-infected adolescents at high risk for VF might help to improve treatment success in this group.