Association Between Race, Depression, and Antiretroviral Therapy Adherence in a Low-Income Population with HIV Infection

Background

Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist.

Objective

To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients.

Design

Retrospective cohort study.

Setting

Multi-state Medicaid database (Thomson Reuters MarketScan®).

Participants

Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed.

Main Measures

Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables.

Key Results

In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63–0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12–3.29).

Conclusions

Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.KEY WORDS: HIV, adherence, depression, race, Medicaid     

Guideline-Based Antibiotics and Mortality in Healthcare-Associated Pneumonia

Background

Guidelines recommend administration of antibiotics with activity against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa for treatment of healthcare-associated pneumonia (HCAP). It is unclear if this therapy improves outcomes for patients with HCAP.

Objective

To determine if administration of guideline-similar therapy (GST) was associated with a reduction in 30-day mortality for HCAP.

Design

Multi-center retrospective study.

Participants

Thirteen hundred and eleven admissions for HCAP in six Veterans Affairs Medical Centers.

Interventions

Each admission was classified as receiving GST, anti-MRSA or anti-pseudomonal components of GST, or other non-HCAP therapy initiated within 48 hours of hospitalization. Association between 30-day mortality and GST was estimated with a logistic regression model that included GST, propensity to receive GST, probability of recovering an organism from culture resistant to antibiotics traditionally used to treat community-acquired pneumonia (CAP-resistance), and a GST by CAP-resistance probability interaction.

Main Measures

Odds ratios and 95% confidence intervals [OR (95% CI)] of 30-day mortality for patients treated with GST and predicted probability of recovering a CAP-resistant organism, and ratio of odds ratios [ROR (95% CI)] for treatment by CAP-resistance probability interaction.

Key Results

Receipt of GST was associated with increased odds of 30-day mortality [OR?=?2.11 (1.11, 4.04), P?=?0.02)] as was the predicted probability of recovering a CAP-resistant organism [OR?=?1.67 (1.26, 2.20), P?P?=?0.05].

Conclusions

For HCAP patients with high probability of CAP-resistant organisms, GST was associated with lower mortality. Consideration of the magnitude of patient-specific risk for CAP-resistant organisms should be considered when selecting HCAP therapy.     

The Medical Management of Pediatric Arrhythmias

OPINION STATEMENT: Arrhythmias are an important cause of morbidity and mortality in children. Despite recent technological advances in treatment, pharmacologic therapy remains the most common treatment modality for pediatric arrhythmias. The choice of antiarrhythmic agent, the duration of therapy, and the dosing schedule depend on multiple factors including the recurrence risk and the arrhythmia burden (the latter being determined by the hemodynamic effect of the arrhythmia), and the frequency and duration of episodes. As with all pediatric medications, consideration must be given to the drug formulation, palatability, adverse effects and adherence issues. There are very few randomized trials available to guide the choice of therapy for pediatric arrhythmias, and thus treatment options often reflect physician or institutional preferences. Although various classification schemes exist, we classify antiarrhythmic agents based on their primary site of action: atrial muscle/accessory pathway (class IA, IC, and III agents); the atrioventricular node (beta-blockers, calcium channel blockers, digoxin, and class III agents); or ventricular muscle (class I and III agents). This type of categorization assists in the approach to treatment required for each type of arrhythmia encountered.     

Role of the anesthesiologist in the wider governance of healthcare and health economics

Purpose

Healthcare resources will always be limited, and as a result, difficult decisions must be made about how to allocate limited resources across unlimited demands in order to maximize health gains per resource expended. Governments and hospitals now in severe financial deficits recognize that reengagement of physicians is central to their ability to contain the runaway healthcare costs. Health economic analysis provides tools and techniques to assess which investments in healthcare provide good value for money vs which options should be forgone. Robust decision-making in healthcare requires objective consideration of evidence in order to balance clinical and economic benefits vs risks.

Principal findings

Surveys of the literature reveal very few economic analyses related to anesthesia and perioperative medicine despite increasing recognition of the need. Now is an opportune time for anesthesiologists to become familiar with the tools and methodologies of health economics in order to facilitate and lead robust decision-making in quality-based procedures. For most technologies used in anesthesia and perioperative medicine, the responsibility to determine cost-effectiveness falls to those tasked with the governance and stewardship of limited resources for unlimited demands using best evidence plus economics at the local, regional, and national levels. Applicable cost-effectiveness, cost-utility, and cost-benefits in health economics are reviewed in this article with clinical examples in anesthesia.

Conclusions

Anesthesiologists can make a difference in the wider governance of healthcare and health economics if we advance our knowledge and skills beyond the technical to address the “other” dimensions of decision-making – most notably, the economic aspects in a value-based healthcare system.     

Relative potency of pregabalin, gabapentin, and morphine in a mouse model of visceral pain

Purpose

Pregabalin is probably more effective than prototype gabapentin in different kinds of pain treatments. This study was performed to compare the potency of gabapentin, pregabalin, and morphine in a well-established model of visceral pain.

Methods

The number of abdominal contractions was counted for 30 min in adult male mice that received different doses of pregabalin, gabapentin, morphine, or placebo intraperitoneally 30 min before receiving 0.6% acetic acid 10 mL·kg^?1.The antinociceptive effect of each drug dose was determined as a percentage of the reduction in the number of acetic acid-induced writhes. The effective doses, for 20%, 50%, and 80% response (ED₂₀, ED₅₀, and ED₈₀, respectively), of each drug were calculated using least squares linear regression analysis, and then dose-response curves were compared.

Results

Pregabalin, gabapentin, and morphine produced a linear dose-dependent antinociceptive effect (coefficient of determination [r²] > 0.9). No difference was observed between slopes of dose-response curves. The ED₅₀ estimates (95% confidence interval) for pregabalin, gabapentin, and morphine were 17.1 (12.9 to 22.1) mg·kg^?1, 87.1 (45.8 to 129.8) mg·kg^?1, and 0.2 (0.1 to 0.3) mg·kg^?1, respectively.

Conclusion

In this animal model of visceral pain, all three drugs exhibited parallel dose-response curves. Pregabalin had five times the potency of gabapentin and 1/85^th the potency of morphine. Similar potency ratios may apply in clinical practice. Despite some limitations of animal studies, this model could be useful for comparing new analgesics in visceral pain treatment.     

Wound healing potential of topical bacteriophage therapy on diabetic cutaneous wounds

Chronic wounds that fail to heal are a common complication of diabetes mellitus and the most common precipitating reason for nontraumatic lower limb amputation. Unfortunately, the bacterial species that cause these infections are becoming more resistant to antibiotics, making them increasingly difficult to treat. We assessed the feasibility of combating chronic bacterial infections with a topically delivered bacteriophage cocktail in two animal models of diabetes mellitus. Microbiological, planimetric, and histological parameters were compared in debrided infected wounds with or without topical bacteriophage treatment. We determined that bacteriophage treatment effectively decreased bacterial colony counts and improved wound healing, as indicated by smaller epithelial and dermal gaps, in Staphylococcus aureus and Pseudomonas aeruginosa infections but was not as effective against Acinetobacter baumannii. Although the improvements were more significant in the rodent model than in the porcine model, our results suggest that topically administered bacteriophage treatment may be effective in resolving chronic infections, especially when applied in conjunction with wound debridement. These findings have important implications for the feasibility of using topical antimicrobial therapies to safely treat chronic infections in diabetes mellitus patients.     

Leucine‐rich glioma inactivated 3 promotes HaCaT keratinocyte migration

Our finding that human skin expresses leucine‐rich glioma inactivated 3 (LGI3) raises the question of the function of this cytokine in keratinocytes. We have shown that LGI3 stimulates human HaCaT keratinocyte migration without affecting viability or proliferation. Western blot analysis showed that LGI3 induced focal adhesion kinase activation, Akt phosphorylation, and glycogen synthase kinase 3β (GSK3β) phosphorylation in these cells. Using the scratch wound assay and a modified Boyden chamber, we found that LY294002, a selective phosphatidylinositol 3‐kinase inhibitor, and LiCl, a selective GSK3β inhibitor, abolished LGI3‐induced cell migration. We tested β‐catenin levels after LGI3 treatment because the Akt‐GSK3β pathway regulates β‐catenin accumulation, and β‐catenin promotes cell migration. LGI3 treatment increased β‐catenin protein and nuclear localization, whereas LY294002 prevented LGI3‐induced focal adhesion kinase and Akt activation as well as β‐catenin accumulation. Overall, these data suggest that LGI3 stimulates HaCaT cell migration following β‐catenin accumulation through the Akt pathway.     

Clinical information systems in the intensive care unit

Clinical information systems (CIS) are used to help manage the large amount of data generated in an intensive care unit every day. Linkage to laboratories, monitoring and other systems simplifies acquisition and increases the accuracy of data entered into the patient record. Once data are in the CIS they can be viewed in different ways without re-entry to improve patient care. The addition of decision support gives another dimension to CIS. The concentration of data in one place simplifies audit, quality improvement and obtains management information more easily compared to paper notes. CIS are large complex systems with challenges and risks that differ from paper notes and need to be considered during introduction.     

Characteristics of emergency department transfers for hand surgery consultation

Background

The purpose of this study was to establish the characteristics of patients who are transferred from referring emergency departments (EDs) to two receiving institutions for hand-related emergencies. Our primary hypothesis was that many transferred patients would not require emergent specialty intervention. Our secondary hypotheses were that treatment would differ by day of presentation and type of insurance coverage.

Methods

We searched ED records for all hand-related cases over 1 year. We reviewed charts for demographics and treatment details. The main outcome measures were whether patients were seen by a hand surgeon or underwent surgery within 24 h of transfer.

Results

The study group comprised 296 patients. Ninety-two percent saw a specialty resident, and 48 % saw a hand surgeon. Thirty-nine percent of patients were taken to the operating room within 24 h of presentation. Of patients transferred on the weekends, 48 % saw a hand surgeon versus 61 % of those transferred on weekdays. Similarly, 51 % of patients transferred on a weekday were taken to the OR within 24 h, while 38 % of patients transferred on a weekend were taken to the OR in the same time frame.

Conclusions

More than half of transfers for hand emergencies did not result in examination by a hand surgeon, and nearly two thirds did not require a visit to the OR within 24 h. Patients transferred on the weekend were less likely to see a hand surgeon than those transferred on weekdays. Alternative methods of consultation might allow avoidance of transfer.     

Thrombolysis for stroke caused by infective endocarditis: an illustrative case and review of the literature

Infective endocarditis represents a classical contra-indication to thrombolysis for acute ischemic stroke due to a potential increased risk of intracranial hemorrhage. However, some case reports have suggested safety and potential efficacy of intravenous or intra-arterial thrombolysis in stroke related to infective endocarditis. We present a case of ischemic stroke related to infective endocarditis who was treated with intravenous tissue plasminogen activator within the first 3 h of symptoms onset and subsequently developed symptomatic multifocal intracerebral hemorrhages, and summarize currently available data on this issue.