Abstract

BACKGROUND:

Raltegravir is a potential treatment option for virologically suppressed HIV-1 infected patients on enfuvirtide with injection site reactions.

OBJECTIVES:

To characterize safety and efficacy of an enfuvirtide to raltegravir switch including changes in T-cells, quality of life, and residual viremia.

STUDY DESIGN:

In patients with viral load <50 copies/mL and injection site reactions, enfuvirtide was switched to raltegravir without additional changes to the antiretroviral regimen. Virologic failure was defined as a viral load >1000 copies/mL or two consecutive viral load measurements between 50 and 1000 copies/mL (low-level viremia). Over the 24 week study, we compared changes in T-cells, injection site reactions, quality of life, and residual viremia, as measured through the single-copy assay which can detect plasma virus down to a single copy, using paired t-tests.

RESULTS:

Fourteen patients with a median CD4+ T-cell count of 420 cells/microL were enrolled. After the switch, two patients experienced virologic failure due to confirmed low-level viremia. However, both patients subsequently were re-suppressed, one without any changes to his regimen. There was no change in CD4+ T-cell count. Injection site reactions resolved. However, there was little reported change in quality of life. The baseline median level of residual viremia was 6 copies/mL and did not change after the switch to raltegravir.

CONCLUSIONS:

A switch to raltegravir in virologically suppressed patients on enfuvirtide is effective in maintaining immunologic and virologic control at 24 weeks but did not result in a change in residual viremia.

Abstract 

Background

Adherence is crucial for public health program effectiveness, though the benefits of increasing adherence must ultimately be weighed against the associated costs. We sought to determine the relationship between investment in community health worker (CHW) home visits and increased attendance at cervical cancer screening appointments in Cape Town, South Africa.

Methodology/Principal Findings

We conducted an observational study of 5,258 CHW home visits made in 2003–4 as part of a community-based screening program. We estimated the functional relationship between spending on these visits and increased appointment attendance (adherence). Increased adherence was noted after each subsequent CHW visit. The costs of making the CHW visits was based on resource use including both personnel time and vehicle-related expenses valued in 2004 Rand. The CHW program cost R194,018, with 1,576 additional appointments attended. Adherence increased from 74% to 90%; 55% to 87%; 48% to 77%; and 56% to 80% for 6-, 12-, 24-, and 36-month appointments. Average per-woman costs increased by R14–R47. The majority of this increase occurred with the first 2 CHW visits (90%, 83%, 74%, and 77%; additional cost: R12–R26).

Conclusions/Significance

We found that study data can be used for program planning, identifying spending levels that achieve adherence targets given budgetary constraints. The results, derived from a single disease program, are retrospective, and should be prospectively replicated.

ABSTRACT

OBJECTIVE: To assess the health literacy of US parents and explore the role of health literacy in mediating child health disparities.

METHODS: A cross-sectional study was performed for a nationally representative sample of US parents from the 2003 National Assessment of Adult Literacy. Parent performance on 13 child health-related tasks was assessed by simple weighted analyses. Logistic regression analyses were performed to describe factors associated with low parent health literacy and to explore the relationship between health literacy and self-reported child health insurance status, difficulty understanding over-the-counter medication labeling, and use of food labels.

RESULTS: More than 6100 parents made up the sample (representing 72600098 US parents); 28.7% of the parents had below-basic/basic health literacy, 68.4% were unable to enter names and birth dates correctly on a health insurance form, 65.9% were unable to calculate the annual cost of a health insurance policy on the basis of family size, and 46.4% were unable to perform at least 1 of 2 medication-related tasks. Parents with below-basic health literacy were more likely to have a child without health insurance in their household (adjusted odds ratio: 2.4 [95% confidence interval: 1.1–4.9]) compared with parents with proficient health literacy. Parents with below-basic health literacy had 3.4 times the odds (95% confidence interval: 1.6–7.4) of reporting difficulty understanding over-the-counter medication labels. Parent health literacy was associated with nutrition label use in unadjusted analyses but did not retain significance in multivariate analyses. Health literacy accounted for some of the effect of education, racial/ethnic, immigrant-status, linguistic, and income-related disparities.

CONCLUSIONS: A large proportion of US parents have limited health-literacy skills. Decreasing literacy demands on parents, including simplification of health insurance and other medical forms, as well as medication and food labels, is needed to decrease health care access barriers for children and allow for informed parent decision-making. Addressing low parent health literacy may ameliorate existing child health disparities.

Abstract

Health literacy (HL) affects adult asthma management, yet less is known about how parent HL affects child asthma care.

OBJECTIVE:

To examine associations between parent HL and measures related to child asthma.

METHODS:

Parents of 499 school-age urban children with persistent asthma in Rochester, New York completed home interviews. Measures: the Rapid Estimate of Adult Literacy in Medicine (REALM) for parent HL; National Heart Lung and Blood Institute (NHLBI) criteria for asthma severity, and validated measures of asthma knowledge, beliefs, and experiences. Analyses: bivariate and multivariate analyses of associations between parent HL measures related to child asthma.

RESULTS:

Response rate: 72%, mean child age: 7.0 years. Thirty-two percent had a Hispanic parent; 88% had public insurance. Thirty-three percent had a parent with limited HL. Low parent HL was independently associated with greater parent worry, parent perception of greater asthma burden, and lower parent-reported quality of life. Measures of health care use (e.g., emergency care and preventive medicines) were not associated with parent HL.

CONCLUSIONS:

Parents with limited HL worried more and perceived greater overall burden from the child's asthma, even though reported health care use did not vary.

PRACTICE IMPLICATIONS:

Improved parent understanding and provider-parent communication about child asthma could reduce parent-perceived asthma burden, alleviate parent worry, and improve parent quality of life.

The nation's leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers.

Abstract

OBJECTIVE:

Concerns about the safety and efficacy of over-the-counter cold medications have led to a recent US Food and Drug Administration public health advisory against their use in children <2 years of age. Our goal was to examine caregiver understanding of the age indication of over-the-counter cold medication labels and identify factors, associated with caregiver understanding.

METHODS:

Caregivers of infant children (< or =1 year old) were recruited from clinics at 3 institutions. Questions were administered regarding the use of 4 previously common "infant" over-the-counter cold and cough medicines labeled to consult a physician if used in children <2 years of age. Literacy and numeracy skills were assessed with validated instruments.

RESULTS:

A total of 182 caregivers were recruited; 87% were the infants' mothers. Mean education level was 12.5 years, and 99% had adequate literacy skills, but only 17% had >9th-grade numeracy skills. When examining the front of the product label, 86% of the time parents thought these products were appropriate for use in children <2 years of age. More than 50% of the time, parents stated they would give these over-the-counter products to a 13-month-old child with cold symptoms. Common factors that influenced parental decisions included label saying "infant," graphics (eg, infants, teddy bears, droppers), and dosing directions. Caregivers were influenced by the dosing directions only 47% of the time. Caregivers with lower numeracy skills were more likely to provide inappropriate reasons for giving an over-the-counter medication.

CONCLUSIONS:

Misunderstanding of over-the-counter cold products is common and could result in harm if medications are given inappropriately. Label language and graphics seem to influence inappropriate interpretation of over-the-counter product age indications. Poorer parental numeracy skills may increase the misinterpretation of these products. Opportunities exist for the Food and Drug Administration and manufacturers to revise existing labels to improve parental comprehension and enhance child safety.

Objective

To determine whether eligible extremely-low-birth-weight children (<1000g) were enrolled in the federally enacted, state-coordinated Early Intervention (EI) program intended to help children with developmental delay or disability regardless of parental income, and the factors associated with enrollment.

Methods

Retrospective analysis of 884 EI-eligible ELBW children born in South Carolina with birth weight 401 to 999g, gestation ≥24 weeks, and survival for the first 120 days of life. We created a linked data set with data from Early Intervention (1996–2001), Vital Records (1996–1998), death certificates, and Medicaid. Each child was followed from birth to 3 years old, the program eligibility period.

Results

A total of 54% of ELBW children were enrolled in EI at any time from birth to 36 months. Even among children ever enrolled in Medicaid (83% of all ELBW children), only 63% were enrolled in EI. Being born in a multiple gestational birth, having heavier birth weight (750 to 999g), and having ever enrolled in Medicaid were positively associated with EI enrollment. Among Medicaid patients for whom perinatal data were available, additional risk adjustment showed that EI enrollment was more likely with birth in level 3 hospitals, birth weight 750 to 999g, Neonatal Medical Index severity level V (most severe), and longer initial length of hospital stay.

Conclusions

Only about half of eligible ELBW children in South Carolina were enrolled—much lower than reported elsewhere. Efforts are needed to understand why eligible infants are not being enrolled and to develop strategies to remedy the situation.

Abstract

PURPOSE OF REVIEW:

To provide a better understanding and summarize recent advances in the diagnosis and treatment of Mycobacterium tuberculosis (MTB) infection in solid organ transplant (SOT) candidates and recipients.

RECENT FINDINGS:

Despite advances in SOT medicine, MTB causes substantial morbidity and mortality in SOT recipients, with reported prevalence rates of 0.4-6%. The primary source of posttransplant MTB is reactivation of pretransplant latent MTB infection. The short-term mortality rate in SOT recipients with drug-susceptible active MTB is 30%. In immunocompromised persons with extensively drug-resistant MTB, the mortality rate approaches 100%. Clinical presentation is often atypical with more than half of SOT recipients presenting with extrapulmonary or disseminated disease. Pretransplant latent MTB infection screening and treatment is the cornerstone for preventing reactivation and dissemination of active MTB posttransplant. Treatment of active MTB in SOT recipients is problematic, given significant drug toxicity and interaction with immunosuppressive agents.

SUMMARY:

A high degree of suspicion for latent and active MTB infection in SOT candidates and recipients is warranted to establish a timely diagnosis and initiate life-saving appropriate therapy.

Mycobacterium tuberculosis (MTB) causes substantial morbidity and mortality in liver transplant recipients. We examined the efficacy of isoniazid latent Mycobacterium tuberculosis infection (LTBI) treatment in liver transplant recipients and reviewed systematically all cases of active MTB infection in this population. We found 7 studies that evaluated LTBI treatment and 139 cases of active MTB infection in liver transplant recipients. Isoniazid LTBI treatment was associated with reduced MTB reactivation in transplant patients with latent MTB risk factors (0.0% versus 8.2%, P = 0.02), and isoniazid-related hepatotoxicity occurred in 6% of treated patients, with no reported deaths. The prevalence of active MTB infection in transplant recipients was 1.3%. Nearly half of all recipients with active MTB infection had an identifiable pretransplant MTB risk factor. Among recipients who developed active MTB infection, extrapulmonary involvement was common (67%), including multiorgan disease (27%). The short-term mortality rate was 31%. Surviving patients were more likely to have received 3 or more drugs for MTB induction therapy (P = 0.003) and to have been diagnosed within 1 month of symptom onset (P = 0.01) and were less likely to have multiorgan disease (P = 0.01) or to have experienced episodes of acute transplant rejection (P = 0.02). Compared with the general population, liver transplant recipients have an 18-fold increase in the prevalence of active MTB infection and a 4-fold increase in the case-fatality rate. For high-risk transplant candidates, isoniazid appears safe and is probably effective at reducing MTB reactivation. All liver transplant candidates should receive a tuberculin skin test, and isoniazid LTBI treatment should be given to patients with a positive skin test result or MTB pretransplant risk factors, barring a specific contraindication.

The world of genomics is transforming medicine, and is likely to influence the future development of new drugs, diagnostics, and vaccines. To date, the greater focus of genomics and medicine has been on conditions affecting resourcewealthy settings, primarily involving scientists and companies in those settings. However, we believe that it is possible to expand genomics into a more global technology that can also focus on diseases of resource-limited settings. This goal can be achieved if genomics is made a global priority. We feel one way to move in this direction is through a comprehensive approach to infectious diseases-i.e., an Infectious Disease Genomics Project-that would mirror the Human Genome Project. Without an active, unified effort specifically focused on allowing actors at any level to participate in the genomics revolution, infectious diseases that primarily affect the poor will likely not achieve the same level of scientifici advancement as diseases affecting the wealthy.