Analysis of antiretroviral therapy interruption in people living with HIV during the 2010-2021 Period

OBJECTIVE

In the context of the advancement of antiretroviral therapy and, as the characteristics of people living with HIV progress toward an aging population, understanding the causes of treatment interruption becomes crucial. The aim of the study was to determine the change in reasons for antiretroviral treatment discontinuation for 12 years. Secondarily, compare annual antiretroviral regimen discontinuation rate and factors associated.

METHODS

We conducted an analysis using data from people living with HIV who were receiving antiretroviral therapy and discontinued it for any reason. The study included people with HIV infection who visited an outpatient hospital pharmacy clinic from January 2010 to December 2021. Two periods were differentiated for the analysis: 2010-2015 and 2016-2021. The reasons for antiretroviral treatment discontinuation followed classification described by Swiss cohort. In the context of this study, it is pertinent to note that the term 'interruption' will be consistently used in this article to refer to the act of switching or stopping antiretroviral treatment. To examine factors associated with antiretroviral therapy discontinuation, we utilized Kaplan-Meier methods and Cox proportional models.

RESULTS

We included 789 people living with HIV, predominantly male (81,5%). The main reason for discontinuation was clinical decision (50.2%) followed by adverse effects (37.9%). Focusing on clinical decision, we observed a trend change that went from antiretroviral treatment simplification regimen (56.1%) in the first part of the period analyzed to the therapeutic optimization (53.6%) in the second half. Furthermore, factors that were statistically significantly associated with antiretroviral treatment discontinuation were people with HIV ≥50 years (HR 1.60; 95%CI 1.25-2.04), post-discontinuation single-tablet regimen (HR 1.49; 95%CI 1.06-2.11) and antiretroviral drug classes.

CONCLUSIONS

Over the 12 years there has been a change in the main cause of antiretroviral treatment discontinuation, currently therapeutic optimization being the main reason. Integrase inhibitors-based regimens and singletablet regimen strategies were less likely to be discontinued than others antiretroviral drug classes, allowing for better clinical management due to the efficacy profile, especially in people living with HIV ≥50 years with comorbidities.

Analysis of antiretroviral therapy interruption in people living with HIV during the 2010-2021 period

INTRODUCTION

In the context of the advancement of antiretroviral therapy and as the characteristics of people living with HIV progress toward an ageing population, understanding the causes of treatment interruption becomes crucial. The aim of the study was to determine the change in reasons for antiretroviral treatment discontinuation for 12 years. Secondarily, compare annual antiretroviral regimen discontinuation rate and factors associated.

METHODS

We conducted an analysis using data from people living with HIV who were receiving antiretroviral therapy and discontinued it for any reason. The study included people with HIV infection who visited an outpatient hospital pharmacy clinic from January 2010 to December 2021. Two periods were differentiated for the analysis: 2010-2015 and 2016-2021. The reasons for antiretroviral treatment discontinuation followed classification described by Swiss cohort. In the context of this study, it is pertinent to note that the term "discontinuation" is employed synonymously with "interruption". The term "discontinuation" will be consistently used in this article to refer to the act of switching or stopping antiretroviral treatment. To examine factors associated with antiretroviral therapy discontinuation, we utilised Kaplan-Meier methods and Cox proportional models.

RESULTS

We included 789 people living with HIV, predominantly male (81.5%). The main reason for discontinuation was clinical decision (50.2%) followed by adverse effects (37.9%). Focusing on clinical decision, we observed a trend change that went from antiretroviral treatment simplification regimen (56.1%) in the first part of the period analysed to the therapeutic optimisation (53.6%) in the second half. Furthermore, factors that were statistically significantly associated with antiretroviral treatment discontinuation were people with HIV≥50 years (HR 1.60; 95%CI 1.25-2.04), post-discontinuation single-tablet regimen (HR 1.49; 95%CI 1.06-2.11) and antiretroviral drug classes.

CONCLUSION

Over the 12 years, there has been a change in the main cause of antiretroviral treatment discontinuation, currently therapeutic optimisation being the main reason. Integrase inhibitors-based regimens and single-tablet regimen strategies were less likely to be discontinued than others antiretroviral drug classes, allowing for better clinical management due to the efficacy profile, especially in people living with HIV≥50 years with comorbidities.

Multidisciplinary Outpatient Clinic of Neurocutaneous Diseases: Five-year Experience of a Pediatric Tertiary Hospital in Portugal

INTRODUCTION

Neurocutaneous syndromes (NCS) are a heterogeneous group of conditions with multiorgan involvement and diverse manifestations, evolving throughout life with significant morbidity. A multidisciplinary approach to NCS patients has been advocated, although a specific model is not yet established. The aim of this study was 1) to describe the organization of the recently created Multidisciplinary Outpatient Clinic of Neurocutaneous Diseases (MOCND) at a Portuguese pediatric tertiary hospital; 2) to share our institutional experience focusing on the most common conditions, neurofibromatosis type 1 (NF1) and tuberous sclerosis complex (TSC); 3) to analyze the advantages of a multidisciplinary center and approach in NCS.

METHODS

Retrospective analysis of 281 patients enrolled in the MOCND over the first five years of activity (October 2016 to December 2021), reviewing genetics, family history, clinical features, complications, and therapeutic strategies for NF1 and TSC.

RESULTS

The clinic works weekly with a core team of pediatricians and pediatric neurologists supported by other specialties as needed. Of the 281 patients enrolled, 224 (79.7%) had identifiable syndromes such as NF1 (n = 105), TSC (n = 35), hypomelanosis of Ito (n = 11), Sturge-Weber syndrome (n = 5), and others. In NF1 patients, 41.0% had a positive family history, all manifested café-au-lait macules, 38.1% neurofibromas with 45.0% being large plexiform neurofibromas. Sixteen were under treatment with selumetinib. Genetic testing was performed in 82.9% of TSC patients with pathogenic variants found in TSC2 gene in 72.4% patients (82.7% if considered contiguous gene syndrome). Family history was positive in 31.4%. All TSC patients presented hypomelanotic macules and fulfilled diagnostic criteria. Fourteen patients were being treated with mTOR inhibitors.

CONCLUSION

Offering a systematic and multidisciplinary approach to NCS patients enables timely diagnosis, promotes a structured follow-up, and encourages discussion to outline management plans for optimal care to every patient, with significant impact on the quality of life of patients and families.

Development of a novel dynamic nosocomial infection risk management method for COVID-19 in outpatient settings

BACKGROUND

Application of accumulated experience and management measures in the prevention and control of coronavirus disease 2019 (COVID-19) has generally depended on the subjective judgment of epidemic intensity, with the quality of prevention and control management being uneven. The present study was designed to develop a novel risk management system for COVID-19 infection in outpatients, with the ability to provide accurate and hierarchical control based on estimated risk of infection.

METHODS

Infection risk was estimated using an auto regressive integrated moving average model (ARIMA). Weekly surveillance data on influenza-like-illness (ILI) among outpatients at Xuanwu Hospital Capital Medical University and Baidu search data downloaded from the Baidu Index in 2021 and 22 were used to fit the ARIMA model. The ability of this model to estimate infection risk was evaluated by determining the mean absolute percentage error (MAPE), with a Delphi process used to build consensus on hierarchical infection control measures. COVID-19 control measures were selected by reviewing published regulations, papers and guidelines. Recommendations for surface sterilization and personal protection were determined for low and high risk periods, with these recommendations implemented based on predicted results.

RESULTS

The ARIMA model produced exact estimates for both the ILI and search engine data. The MAPEs of 20-week rolling forecasts for these datasets were 13.65% and 8.04%, respectively. Based on these two risk levels, the hierarchical infection prevention methods provided guidelines for personal protection and disinfection. Criteria were also established for upgrading or downgrading infection prevention strategies based on ARIMA results.

CONCLUSION

These innovative methods, along with the ARIMA model, showed efficient infection protection for healthcare workers in close contact with COVID-19 infected patients, saving nearly 41% of the cost of maintaining high-level infection prevention measures and enhancing control of respiratory infections.

Information on antibiotics in an Indonesian hospital outpatient setting: What is provided by pharmacy staff and recalled by patients?

Background:

The provision of information by pharmacy staff is a key factor to ensure patients’ understanding and quality use of medications, including antibiotics. However, little is known regarding the transmission of information between pharmacy staff and patients in Indonesia.

Objective:

This study aimed to identify information on antibiotics provided by pharmacy staff and recalled by patients in an Indonesian outpatient setting.

Methods:

The study was conducted in a hospital outpatient clinic in Malang, Indonesia, in 2019. A checklist was used to obtain the data on information provided by pharmacy staff, while interviews were conducted to determine information recalled by patients (only presenting patients were included); a total of 15 information items – i.e. 14 essential and one secondary – were observed. Descriptive analysis was used to summarise data on the checklists (‘given’ versus ‘not given’) as well as responses from the interviews (‘recalled’ versus ‘missed’).

Results:

Eleven pharmacy staff (two pharmacists and nine pharmacy technicians) were involved in providing information for patients obtaining oral antibiotics during the study period. Of 14 essential information items, only about half was given by pharmacy staff, with pharmacists significantly providing on average more information items than pharmacy technicians (7.96 versus 7.67 respectively; p<0.001). The most frequently information items provided (>90%) included “antibiotic identification”, “indication”, administration directions (i.e. “dosage”, “frequency”, “hour of administration”, “administration before/after meal”, “route of administration”), and “duration of use”. A total of 230 patients consented to the study, giving 79.9% response rate. The average number of information items recalled by patients was 7.09 (SD 1.45). Almost all patients could recall information on administration directions [i.e. “route of administration” (97.0%), “frequency” (95.2%), “dosage” (92.6%), “hour of administration” (85.7%), “administration before/after meal” (89.1%)] and “duration of use” (90.9%). Fewer patients were able to recall “antibiotic identification” (76.5%) and “indication” (77.0%).

Conclusions:

Pharmacy staff provided antibiotic information in a limited fashion, while patients showed adequate ability to recall the information given to them. Further study is needed to better understand the effective process of information transmission between pharmacy staff and patients, especially if more information was provided, to better optimise the use of antibiotics in outpatient settings in Indonesia.

Demographic factors associated with loss to follow up in the management of chronic otitis media: case-control study

OBJECTIVE

The likelihood of a patient attending regular follow up can affect decision making when planning and performing tympanomastoid surgery. This study investigated whether demographic factors were associated with loss to follow up.

METHODS

A database of patients who had been investigated and treated for chronic otitis media was searched. Patients lost to follow up and a matching sample of patients who were formally discharged were identified. The demographic factors of age, sex and postcode were compared between the two groups. The information collected was also used to provide measures of deprivation.

RESULTS

Fifty patients in each group were identified. Patients lost to follow up were significantly younger than patients formally discharged (p < 0.02), and were more likely to live in an area of education and training deprivation (p < 0.05).

CONCLUSION

Younger patient age, and living in an area of education and training deprivation, are associated with a higher incidence of loss to follow up.

Use of Medical Resources by Preterm Infants Born at Less than 33 Weeks' Gestation Following Discharge from the Neonatal Intensive Care Unit in Korea

This study was aimed to provide data on the use of medical resources by preterm infants following discharge from the neonatal intensive care unit (NICU). The cohort included preterm infants (n=2,351) born at 22-32 weeks' gestation who were discharged from the NICUs of 44 Korean hospitals between April 2009 to March 2010. Mean duration of post-discharge follow-up was 425±237 days. After discharge from the NICU, 94.5% of total infants visited a pediatric outpatient clinic (11.5±9.8 mean visits), 42.9% visited a pediatric clinic for respiratory problems irregularly (4.9±6.6 mean visits), and 31.1% utilized emergency center at least once. Among all visits to the emergency center, 24.7% resulted in readmission and 50.8% of those visits were due to respiratory problems. At least one episode of readmission was required by 33.6% (788/2,346) of total infants, and 18.4% (431/2,346) of total infants were readmitted with respiratory problems at least once. Among all infants readmitted for respiratory problems, 16.2% (70/341) were diagnosed with respiratory syncytial virus infection which accounted for 30.3% of viral etiologies confirmed by laboratory testing. Infants born at <30 weeks' gestation had more frequent total readmission and respiratory readmission than those ≥30 weeks' gestation (2±1.7 vs. 1.7±1.2, P=0.009, 1.8±1.2 vs. 1.5±1.1, 0.027, respectively). Overall, use of medical resources is common, and respiratory problems are the leading cause of use of medical resources. Total readmissions and respiratory readmissions are more frequent in more immature infants.

Evidence-based history taking under "time constraint"

Physicians all through the world visit patients under time limitations. The most important troubled clinical skill under "time constraint" is the diagnostic approach. In this situation, clinicians need some diagnostic approaches to reduce both diagnostic time and errors. It seems that highly experienced physicians utilize some special tactics in this regard. Evidence-based medicine (EBM) as a relatively new paradigm for clinical practice stresses on using research evidences in diagnostic evaluations. The authors aimed to evaluate experts' strategies and assess what EBM can add to these tactics. They reviewed diagnostic strategies of some veteran internists in their busy outpatient clinics and proposed an evidence-based diagnostic model engaging clinical experience and research evidence. It appears that every clinician utilizes a set of "key pointer" questions for decision-making. In addition to use of evidence-based resources for making differential diagnosis and estimating utility of various diseases, clinicians should use "key pointers" with significant likelihood ratios and from independent systems to reduce time and errors of history taking. Clinical trainees can improve their practice by constructing their own set of pointers from valid research evidences. Using this diagnostic model, EBM can help physicians to struggle against their "time constraint".