The rising U.S. obesity prevalence has disproportionately affected minority children. Previous studies have reported that among African American U.S.-born participants, those with foreign-born parents were significantly less likely to be obese than individuals with U.S.-born parents. Little is known about the children of Hispanic immigrants from Central and South America, and among 2-5 year olds in particular. The current study examined demographic characteristics of 307 children ages 2-5 year olds who participated in a randomized controlled obesity prevention intervention trial in 8 childcare centers in Miami, Florida. Anthropometric data collected included weight, height, waist circumference and body mass index (BMI). Overweight was defined as > 95th %ile for age and at- risk-for-overweight was defined as > 85th to <95th percentile, based on the Centers for Disease Control and Prevention (CDC) guidelines. Obese children were significantly more likely to be born in the US than another country (P<0.0001). Girls were equally as likely as boys to be overweight; 31% of the sample has a BMI percentile > 85th %ile. Children of Central American immigrants were significantly more likely than their Cuban or Caribbean immigrant parent counterparts to be obese (p< 0.01). Obesity prevention interventions need to target children as young as preschool age and should be tailored to the child’s ethnic background, particularly if the child was born in the US and the parents were not.

We evaluated the frequency of HIV testing across the Department of Veterans Affairs (VA), the largest provider of HIV care in the United States. An electronic survey was used to determine the volume and location of HIV screening, confirmatory testing, rapid testing and laboratory consent policies in VA medical centers between October 1, 2005, and September 30, 2006. One hundred thirty-five VA laboratories reported that 112,033 HIV screening tests were performed (81% outpatients vs. 19% inpatients, p<.0001). Overall HIV prevalence was 1.49% (1.62% in inpatients vs. 1.46% in outpatients, p=N.S., range=0.2-3.8%). Rapid testing was available in 67% of facilities, 60% of which took place in the clinical laboratory. Sixty-four percent of labs required a copy of the informed consent in order to perform testing. We estimate that fewer than 10% of VA inpatients and fewer than 5% of VA outpatients were tested for HIV during the survey period. Substantial opportunities for increasing routine HIV testing exist in this population.

Although HIV infection is more prevalent in people younger than age 45 years, a substantial number of infections occur in older persons. Recent guidelines recommend HIV screening in patients age 13 to 64 years. The cost-effectiveness of HIV screening in patients age 55 to 75 years is uncertain. OBJECTIVE: To examine the costs and benefits of HIV screening in patients age 55 to 75 years. DESIGN: Markov model. DATA SOURCES: Derived from the literature. TARGET POPULATION: Patients age 55 to 75 years with unknown HIV status. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTION: HIV screening program for patients age 55 to 75 years compared with current practice. OUTCOME MEASURES: Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: For a 65-year-old patient, HIV screening using traditional counseling costs $55,440 per QALY compared with current practice when the prevalence of HIV was 0.5% and the patient did not have a sexual partner at risk. In sexually active patients, the incremental cost-effectiveness ratio was $30,020 per QALY. At a prevalence of 0.1%, HIV screening cost less than $60,000 per QALY for patients younger than age 75 years with a partner at risk if less costly streamlined counseling is used. RESULTS OF SENSITIVITY ANALYSIS: Cost-effectiveness of HIV screening depended on HIV prevalence, age of the patient, counseling costs, and whether the patient was sexually active. Sensitivity analyses with other variables did not change the results substantially. LIMITATIONS: The effects of age on the toxicity and efficacy of highly active antiretroviral therapy and death from AIDS were uncertain. Sensitivity analyses exploring these variables did not qualitatively affect the results. CONCLUSION: If the tested population has an HIV prevalence of 0.1% or greater, HIV screening in persons from age 55 to 75 years reaches conventional levels of cost-effectiveness when counseling is streamlined and if the screened patient has a partner at risk. Screening patients with advanced age for HIV is economically attractive in many circumstances.

The American College of Physicians developed this guideline to present the available evidence on the pharmacologic management of the acute, continuation, and maintenance phases of major depressive disorder; dysthymia; subsyndromal depression; and accompanying symptoms, such as anxiety, insomnia, or neurovegetative symptoms, by using second-generation antidepressants.

METHODS: Published literature on this topic was identified by using MEDLINE, EMBASE, PsychLit, the Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts from 1980 to April 2007. Searches were limited to English-language studies in adults older than 19 years of age. Keywords for search included terms for depressive disorders and 12 specific second-generation antidepressants-bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine-and their specific trade names. This guideline grades the evidence and recommendations by using the American College of Physicians clinical practice guidelines grading system.

RECOMMENDATIONS

1. The American College of Physicians recommends that when clinicians choose pharmacologic therapy to treat patients with acute major depression, they select second-generation antidepressants on the basis of adverse effect profiles, cost, and patient preferences (Grade: strong recommendation; moderate-quality evidence).
2. The American College of Physicians recommends that clinicians assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within 1 to 2 weeks of initiation of therapy (Grade: strong recommendation; moderate-quality evidence).
3. The American College of Physicians recommends that clinicians modify treatment if the patient does not have an adequate response to pharmacotherapy within 6 to 8 weeks of the initiation of therapy for major depressive disorder (Grade: strong recommendation; moderate-quality evidence).
4. The American College of Physicians recommends that clinicians continue treatment for 4 to 9 months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had 2 or more episodes of depression, an even longer duration of therapy may be beneficial (Grade: strong recommendation; moderate-quality evidence).

Background: Although the number of infected people receiving highly active anti-retroviral therapy (HAART) in low- and middle- income countries increased dramatically, optimal disease management is not well defined.

Methods: We developed a model to compare the costs and benefits of three types of Human Immunodeficiency Virus monitoring strategies: symptom-based strategies, CD4-based strategies, and CD4 plus viral load strategies for starting, switching, and stopping HAART. We used clinical and cost data from southern Africa and performed a cost-effectiveness analysis. All assumptions were tested in sensitivity analyses.

Results: Compared to the symptom-based approaches, monitoring CD4 every 6 months and starting treatment at a threshold of 200 cells/μl was associated with a life expectancy gain of 6.5 months (61.9 vs. 68.4) and a discounted lifetime cost savings of $464 per person (4,069 vs. 3,605 discounted 2007 USD). CD4-based strategies where treatment was started at the higher threshold of 350 cells/μl provided an additional life expectancy gain of 5.3 months at a cost effectiveness of $107 per life-year gained compared to a threshold of 200 cells/μl. Monitoring viral load with CD4 was more expensive than monitoring CD4 alone, added 2.0 months of life, and had an incremental cost-effectiveness ratio of $5,414/life-year gained relative to monitoring CD4 counts. In sensitivity analyses, the cost-savings from CD4 monitoring compared to symptom-based approaches was sensitive to cost of inpatient care, and the cost-effectiveness of viral load monitoring was influenced by the per-test costs and rates of virologic failure.

Conclusions: Use of CD4 monitoring and early HAART initiation in southern Africa provides large health benefits relative to symptom-based approaches for HAART management. In southern African countries with relatively high costs of hospitalization, CD4 monitoring would likely reduce total health care expenditures. The cost-effectiveness of viral load monitoring depends on test prices and rates of virologic failure.