Relationship of pertussis immunization to the onset of neurologic disorders: a retrospective epidemiologic study

A retrospective epidemiologic study examining the relationship of the time of onset of neurologic disorders with the time of pertussis immunization in two cohorts of children who received pertussis immunization at different ages is reported. Before April 1970, children in Denmark were vaccinated with diphtheria and tetanus toxoids with pertussis vaccine at 5, 6, 7, and 15 months of age. Since 1970, children were given monovalent pertussis vaccine at 5 and 9 weeks and at 10 months of age. A total of 554 cases of epilepsy with onset between 28 days and 24 months of age were reviewed, 286 from the 1967-1968 period and 268 from the 1972-1973 period. There was no relationship between the age of onset of epilepsy and the scheduled age of administration of pertussis vaccine. A total of 2199 children with febrile seizures were reviewed, 830 from the 1967-1968 period and 1369 from the 1972-1973 period. There was a statistical association between first febrile seizures and the scheduled age of administration of pertussis vaccine (p = 0.004). No relationship between pertussis immunization and the occurrence of central nervous system infections was noted.     

Support to the Safe Motherhood Programme in Nepal: an integrated approach

Evidence gathered from 1997 to 2006 indicates progress in reducing maternal mortality in Nepal, but public health services are still constrained by resource and staff shortages, especially in rural areas. The five-year Support to the Safe Motherhood Programme builds on the experience of the Nepal Safer Motherhood Project (1997-2004). It is working with the Government of Nepal to build capacity to institute a minimum package of essential maternity services, linking evidence-based policy development with health system strengthening. It has supported long-term planning, working towards skilled attendance at every birth, safe blood supplies, staff training, building management capacity, improving monitoring systems and use of process indicators, promoting dialogue between women and providers on quality of care, and increasing equity and access at district level. An incentives scheme finances transport costs to a health facility for all pregnant women and incentives to health workers attending deliveries, with free services and subsidies to facilities in the poorest 25 districts. Despite bureaucracy, frequent transfer of key government staff and political instability, there has been progress in policy development, and public health sector expenditure has increased. For the future, a human resources strategy with career paths that encourage skilled staff to stay in the government service is key.     

Fisetin for COVID-19 in skilled nursing facilities: Senolytic trials in the COVID era

The burden of senescent cells (SnCs), which do not divide but are metabolically active and resistant to death by apoptosis, is increased in older adults and those with chronic diseases. These individuals are also at the greatest risk for morbidity and mortality from SARS-CoV-2 infection. SARS-CoV-2 complications include cytokine storm and multiorgan failure mediated by the same factors as often produced by SnCs through their senescence-associated secretory phenotype (SASP). The SASP can be amplified by infection-related pathogen-associated molecular profile factors. Senolytic agents, such as Fisetin, selectively eliminate SnCs and delay, prevent, or alleviate multiple disorders in aged experimental animals and animal models of human chronic diseases, including obesity, diabetes, and respiratory diseases. Senolytics are now in clinical trials for multiple conditions linked to SnCs, including frailty; obesity/diabetes; osteoporosis; and cardiovascular, kidney, and lung diseases, which are also risk factors for SARS-CoV-2 morbidity and mortality. A clinical trial is underway to test if senolytics decrease SARS-CoV-2 progression and morbidity in hospitalized older adults. We describe here a National Institutes of Health-funded, multicenter, placebo-controlled clinical trial of Fisetin for older adult skilled nursing facility (SNF) residents who have been, or become, SARS-CoV-2 rtPCR-positive, including the rationale for targeting fundamental aging mechanisms in such patients. We consider logistic challenges of conducting trials in long-term care settings in the SARS-CoV-2 era, including restricted access, consent procedures, methods for obtaining biospecimens and clinical data, staffing, investigational product administration issues, and potential solutions for these challenges. We propose developing a national network of SNFs engaged in interventional clinical trials.     

Guardianship: A medicolegal review for clinicians

Guardianship may pose an ethical dilemma for physicians, who must balance protecting vulnerable patients from potential safety concerns with respecting their autonomy. Older adults with dementia are particularly susceptible to loss of independence and the ability to participate in medical decision making. To have the capacity for medical decision making, individuals must understand relevant information, appreciate their circumstances, demonstrate reasoning, and express a consistent choice free from coercion. Although capacity assessments are usually task-specific, geriatricians and other specialists may be asked to comment on capacity more globally. These determinations may be used to support a Petition for the Appointment of a Guardian of a Legally Incapacitated Adult, the legal process of pursuing guardianship in probate court. Assigned guardians may be known to the incapacitated individual (e.g., a family member or friend) or may be professional guardians with no prior relationship to the ward. Guardians are encouraged to use substituted decision-making, taking into account the ward's previously expressed values and preferences. Although a number of viable alternatives to guardianship exist, numerous systemic barriers may prevent these from being fully explored. The ongoing need for guardianship should be periodically revisited and reassessed. Data about guardians and wards is shockingly sparse, as there are no centralized databases. Laws and regulations for guardianships vary significantly between states. Physicians can serve as important allies and advocates for patients with cognitive impairment at risk of incapacity, can help preserve their autonomy for as long as possible, and ensure appropriate protections are in place if the patient does lose their decision-making ability.     

The Role of Stigma and Medical Mistrust in the Routine Health Care Engagement of Black Men Who Have Sex With Men

Objectives. We assessed how health care–related stigma, global medical mistrust, and personal trust in one’s health care provider relate to engaging in medical care among Black men who have sex with men (MSM).Methods. In 2012, we surveyed 544 Black MSM attending a community event. We completed generalized linear modeling and mediation analyses in 2013.Results. Twenty-nine percent of participants reported experiencing racial and sexual orientation stigma from heath care providers and 48% reported mistrust of medical establishments. We found that, among HIV-negative Black MSM, those who experienced greater stigma and global medical mistrust had longer gaps in time since their last medical exam. Furthermore, global medical mistrust mediated the relationship between stigma and engagement in care. Among HIV-positive Black MSM, experiencing stigma from health care providers was associated with longer gaps in time since last HIV care appointment.Conclusions. Interventions focusing on health care settings that support the development of greater awareness of stigma and mistrust are urgently needed. Failure to address psychosocial deterrents will stymie progress in biomedical prevention and cripple the ability to implement effective prevention and treatment strategies.The HIV epidemic is one of the most critical public health issues facing the United States today. Although HIV infections are documented among all racial/ethnic and sexual risk groups, Black men who have sex with men (Black MSM) are the most affected by HIV in the United States.1 Forty-four percent of new HIV infections are among Blacks, and the rate of HIV infection among this group is 7.9 times higher than is the rate of HIV infections among Whites. Black MSM, in particular, are diagnosed with HIV at a rate 6.0 times higher than that of White MSM, and they are 3.8 times more likely to be living with HIV than are White MSM.2 The remarkable HIV-related race/ethnicity and sexual orientation disparities observed among Black MSM require urgent attention.Although surveillance regarding HIV infection highlights increases in HIV transmission among Black MSM, in particular young Black MSM, there is considerable promise in emerging and available HIV prevention and treatment options (e.g., microbicides,3 preexposure prophylaxis,4 and treatment as prevention5). However, these approaches to HIV prevention require engagement in routine medical care and HIV treatment–related care. The use of biomedical technologies in preventing the spread of HIV will fail if those in need are not connected to care that can facilitate access to and monitor the use of these strategies.6,7Within the current HIV prevention and treatment health care landscape, it is well understood that HIV-positive Black MSM who are without engagement in care suffer worse morbidities and greater mortality than do those in care and that overall rates of engagement in care must be improved.8–10 Likewise, we know very little about the routine health care of HIV-negative Black MSM.11,12 Limited previous research has found that Black MSM describe their experiences of engaging in health care as fragmented and their health care services offered as subpar.13 The inadequate screening and treatment of sexually transmitted infection and HIV are observed even for routine sexually transmitted infection and HIV care among HIV-negative Black MSM.14 Consequently, failure to engage HIV-negative Black MSM in care results in missed opportunities to provide them with prevention options.Theoretically, there are multiple factors to consider when examining the limited retention to care that we observe among Black MSM.15–18 Notably, being uninsured or underinsured, limitations because of location and transportation, and lack of available qualified health professionals are factors directly related to access.19 However, psychosocial deterrents to care are equally important and impede health care access as well.20–23 For instance, stigma, described as the social devaluation or discrediting associated with a specific characteristic or attribute,24 and trust in health care providers and medical establishments are linked to health care behaviors.25 We focused on these psychosocial factors.Research in the area of psychosocial-related deterrents to seeking health care has highlighted the need to better understand the role of stigma in health care access26–28—in particular, the role of enacted stigma (or experiences of discrimination) in health care settings. Institutions that are mandated to protect the well-being of Black MSM are in many instances perceived as threatening to them as a result of experiencing health care provider sexual-orientation and HIV-status discrimination.29,30 Furthermore, in a review of stigma and the HIV epidemic, Mahajan et al. highlight the lack of data on measuring the effects of overlapping stigmas (in the case of Black MSM, being part of a racial and sexual orientation minority) on accessing health care.25 Not only can stigma undermine access to care, but it is also associated with longer breaks in care among those who have been linked.6,9,10 Therefore, previous research warrants an assessment of the extent to which Black MSM experience enacted stigmas and how these experiences are related to accessing medical care.Medical mistrust among Black adults has also been identified as a barrier to engaging in routine health care. Beliefs regarding mistrust in the treatment of HIV in particular are especially damaging to clinicians’ abilities to engage those in need of care.31,32 Trust in health care providers has been directly linked to health outcomes such as antiretroviral adherence and good mental health.32 However, few studies have investigated the role of medical mistrust among MSM, and limited data on Black MSM exist on this topic.33 The available literature generally presents 2 focus assessments when assessing medical mistrust: (1) a system focus assessment, that is, general trust in medical establishments; and (2) an individual focus assessment, that is, trust in a provider’s ability to offer adequate care.34–37 These concepts are thought to affect one’s likelihood of seeking out (system focus) and staying in (individual focus) care. However, research on these areas is limited and exploratory in nature.We sought to understand how experiences of health care–enacted stigma relate to accessing routine medical care among HIV-negative and HIV-positive Black MSM attending a community event in Atlanta, Georgia. Furthermore, we examined the association of this relationship with global medical mistrust and personal trust in one’s health care provider. We hypothesized that experiences of enacted health care stigma would predict routine care and that this relationship would be mediated by perceptions of medical mistrust among HIV-positive and -negative Black MSM.