Aged Residential Care Health Utilisation Study (ARCHUS): a randomised controlled trial to reduce acute hospitalisations from residential aged care

ABSTRACT: BACKGROUND: For residents of long term care, hospitalisations can cause distress and disruption, and often result in further medical complications. Multi-disciplinary team interventions have been shown to improve the health of Residential Aged Care (RAC) residents, decreasing the need for acute hospitalisation, yet there are few randomised controlled trials of these complex interventions. This paper describes a randomised controlled trial of a structured multi-disciplinary team and gerontology nurse specialist (GNS) intervention aiming to reduce residents' avoidable hospitalisations. METHODS: This Aged Residential Care Healthcare Utilisation Study (ARCHUS) is a cluster- randomised controlled trial (n = 1700 residents) of a complex multi-disciplinary team intervention in long-term care facilities. Eligible facilities certified for residential care were selected from those identified as at moderate or higher risk of resident potentially avoidable hospitalisations by statistical modelling. The facilities were all located in the Auckland region, New Zealand and were stratified by District Health Board (DHB).InterventionThe intervention provided a structured GNS intervention including a baseline facility needs assessment, quality indicator benchmarking, a staff education programme and care coordination. Alongside this, three multi-disciplinary team (MDT) meetings were held involving a geriatrician, facility GP, pharmacist, GNS and senior nursing staff.OutcomesHospitalisations are recorded from routinely-collected acute admissions during the 9-month intervention period followed by a 5-month follow-up period. ICD diagnosis codes are used in a pre-specified definition of potentially reducible admissions. DISCUSSION: This randomised-controlled trial will evaluate a complex intervention to increase early identification and intervention to improve the health of residents of long term care. The results of this trial are expected in early 2013.Trial registrationAustralian New Zealand Clinical Trials Registry: ACTRN 12611000187943.     

Assessment,prevalence, and correlates of frailty among middle-aged adults with HIV in rural Uganda

Journal of NeuroVirology - We investigated the prevalence and risk factors for frailty among people with HIV (PWH) in rural Uganda (n = 55, 47% male, mean age 44 years)....     

Changes in Condom Use During the First Year of HIV Treatment in Uganda and the Relationship to Depression

Purpose

We examined the effect of antiretroviral therapy (ART), and the predictive role of depression, on condom use with primary partners.

Methods

Data from three studies in Uganda were combined into a sample of 750 patients with a primary sex partner, with 502 starting ART and 248 entering HIV care, and followed for 12 months. Random-effects logistic regression models were used to examine the impact of ART, and the influence of baseline level and change in depression, on condom use with primary partners.

Results

At month 12, 61 % ART and 67 % non-ART patients were consistent condom users, compared to 44 and 41 % at baseline, respectively. Multivariate analysis revealed that consistent condom use increased similarly for ART and non-ART patients, and that minor depression at baseline and increased depression over time predicted inconsistent condom use.

Conclusions

Improved depression diagnosis and treatment could benefit HIV prevention.     

Predictors of neurocognitive outcomes on antiretroviral therapy after cryptococcal meningitis: a prospective cohort study

Cryptococcal meningitis is the most common cause of adult meningitis in Africa, yet neurocognitive outcomes are unknown. We investigated the incidence and predictors of neurologic impairment among cryptococcal survivors. HIV-infected, antiretroviral-naive Ugandans with cryptococcal meningitis underwent standardized neuropsychological testing at 1, 3, 6, and 12 months. A quantitative neurocognitive performance z-score (QNPZ) was calculated based on population z-scores from HIV-negative Ugandans (n?=?100). Comparison was made with an HIV-infected, non-meningitis cohort (n?=?110). Among 78 cryptococcal meningitis survivors with median CD4 count of 13 cells/μL (interquartile range: 6–44), decreased global cognitive function occurred through 12 months compared with the HIV-infected, non-cryptococcosis cohort (QNPZ-6 at 12 months, P?=?0.036). Tests of performance in eight cognitive domains was impaired 1 month after cryptococcal diagnosis; however, cryptococcal meningitis survivors improved their global neurocognitive function over 12 months with residual impairment (mean z-scores?<?-1), only in domains of motor speed, gross motor and executive function at 12 months. There was no evidence that neurocognitive outcome was associated with initial demographics, HIV parameters, or meningitis severity. Paradoxically, persons with sterile CSF cultures after 14 days of induction amphotericin therapy had worse neurocognitive outcomes than those still culture-positive at 14 days (P?=?0.002). Cryptococcal meningitis survivors have significant short-term neurocognitive impairment with marked improvement over the first 12 months. Few characteristics related to severity of cryptococcosis, including Cryptococcus burden, were associated with neurocognitive outcome.     

The Veterans Aging Cohort Study Index is not associated with HIV-associated neurocognitive disorders in Uganda

Journal of NeuroVirology - The Veterans Aging Cohort Study (VACS) Index has been associated with HIV-associated neurocognitive disorder (HAND) in some populations but has not been studied in...     

Human immunodeficiency virus neurological complications: an overview of the Ugandan experience

Sub-Saharan Africa, which has about 12% of the global population, is home to almost 70% of individuals infected with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). A recent survey by the Ugandan Ministry of Health has found the HIV prevalence rate to be approximately 7% in sexually active adults. The predominant HIV subtypes present in Uganda are A and D. Health care resources are well planned but often lack human and fiscal resources. Uganda has adopted the World Health Organization (WHO) "3 by 5" global strategy for the introduction of antiretroviral therapy and has surpassed the target. Neurological complications of the HIV virus are common and often have devastating consequences. A recent study in Kampala found the rate of HIV dementia and peripheral neuropathy at 31% and 47%, respectively. Further studies are urgently required to determine the natural history and treatment outcomes of both these common HIV complications.     

Fatal Incidents in Australia’s Older Farmers (2001–2015)

Objectives: This study assesses nonintentional injury deaths of older farmers and the causal agents associated with these fatalities in Australia (2001–2015). It also explores approaches based on the hierarchy of risk controls to reduce fatalities and injuries in this cohort. Methods: Data on farm-related incidents were sourced from the National Coroners Information System (NCIS) for the study period and coded. Rates were calculated and regression analyses completed to assess trends over time. Results: Those in the 50+ years category (n = 610) accounted for 49.8% of all on-farm nonintentional injury deaths, with males (n = 566) dominating the cases. The annual mean was 40.66 cases (SD = 8.08) and the average rate 36/100,000. Trend analysis revealed a nonstatistically significant (P < 0.05) increase in cases over the period. Farm vehicles and machinery were responsible for almost two thirds of the fatal cases. Conclusion: Nonintentional fatality rates for older farmers have remained relatively unchanged for a significant period in Australia. There is a need to examine additional approaches that not only maintain the benefits of work activity for older farmers but also balance this against a safety perspective.     

Vitamin D is not associated with HIV-associated neurocognitive disorder in Rakai,Uganda

Journal of NeuroVirology - We investigated whether vitamin D is associated with HIV-associated neurocognitive disorder (HAND). HIV-infected (HIV+) antiretroviral therapy (ART)-naïve adults in...     

Immunometabolic Reprogramming in Response to HIV Infection Is Not Fully Normalized by Suppressive Antiretroviral Therapy

Background: HIV infection results in immunometabolic reprogramming. While we are beginning to understand how this metabolic reprogramming regulates the immune response to HIV infection, we do not currently understand the impact of ART on immunometabolism in people with HIV (PWH). Methods: Serum obtained from HIV-infected (n = 278) and geographically matched HIV seronegative control subjects (n = 300) from Rakai Uganda were used in this study. Serum was obtained before and ~2 years following the initiation of ART from HIV-infected individuals. We conducted metabolomics profiling of the serum and focused our analysis on metabolic substrates and pathways assocaited with immunometabolism. Results: HIV infection was associated with metabolic adaptations that implicated hyperactive glycolysis, enhanced formation of lactate, increased activity of the pentose phosphate pathway (PPP), decreased β-oxidation of long-chain fatty acids, increased utilization of medium-chain fatty acids, and enhanced amino acid catabolism. Following ART, serum levels of ketone bodies, carnitine, and amino acid metabolism were normalized, however glycolysis, PPP, lactate production, and β-oxidation of long-chain fatty acids remained abnormal. Conclusion: Our findings suggest that HIV infection is associated with an increased immunometabolic demand that is satisfied through the utilization of alternative energetic substrates, including fatty acids and amino acids. ART alone was insufficient to completely restore this metabolic reprogramming to HIV infection, suggesting that a sustained impairment of immunometabolism may contribute to chronic immune activation and comorbid conditions in virally suppressed PWH.