Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

Although the pathogenesis of human immunodeficiency virus (HIV) infection and the general virologic and immunologic principles underlying the use of antiretroviral therapy are similar for all HIV-infected persons, there are unique considerations needed for HIV-infected infants, children, and adolescents, including; A acquisition of infection through perinatal exposure for many infected children, In utero, intrapartum, and/or postpartum neonatal exposure to zidovudine (ZDV) and other antiretroviral medications in most perinatally infected children, Requirement for use of HIV virologic tests to diagnose perinatal HIV infection in infants under age 15 to 18 months old, Age-specific differences in immunologic markers (i.e., CD4+ T cell count), Changes in pharmacokinetic parameters with age caused by the continuing development and maturation of organ systems involved in drug metabolism and clearance, Differences in the clinical and virologic manifestations of perinatal HIV infection secondary to the occurrence of primary infection in growing, immunologically immature persons, and Special considerations associated with adherence to antiretroviral treatment for infants, children and adolescents. This report addresses the pediatric-specific issues associated with antiretroviral treatment and provides guidelines to health care providers caring for infected infants, children, and adolescents. It is recognized that guidelines for antiretroviral use in pediatric patients are rapidly evolving. The Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children will review new data on an ongoing basis and provide regular updates to the guidelines

The Use of Health Service Areas for Measuring Provider Availability

Measurement of the availability of health care providers in a geographic area is a useful component in assessing access to health care. One of the problems associated with the county provider-to-population ratio as a measure of availability is that patients frequently travel outside their counties of residence for health care, especially those residing in non-metropolitan counties. Thus, in measuring the number of providers per capita, it is important that the geographic unit of analysis be a health service area. We have defined health care service areas for the coterminous United States, based on 1988 Medicare data on travel patterns between counties for routine hospital care. We used hierarchical cluster analysis to group counties into 802 service areas. More than one half of the service areas include only non-metropolitan counties. The service areas vary substantially in the availability of health care resources as measured by physicians and hospital beds per 100,000 population. For almost all of the service areas, the majority of hospital stays by area residents occur within the service area. In contrast, for 39 percent of counties, the majority of hospital stays by county residents occur outside the county. Thus, the service areas are a more appropriate georgraphic unit than the county for measuring the availability of health care

Routine use of patient reported outcome measures (PROMs) for improving treatment of common mental health disorders in adults

BACKGROUND: Routine outcome monitoring of common mental health disorders (CMHDs), using patient reported outcome measures (PROMs), has been promoted across primary care, psychological therapy and multidisciplinary mental health care settings, but is likely to be costly, given the high prevalence of CMHDs. There has been no systematic review of the use of PROMs in routine outcome monitoring of CMHDs across these three settings. OBJECTIVES: To assess the effects of routine measurement and feedback of the results of PROMs during the management of CMHDs in 1) improving the outcome of CMHDs; and 2) in changing the management of CMHDs. SEARCH METHODS: We searched the Cochrane Depression Anxiety and Neurosis group specialised controlled trials register (CCDANCTR-Studies and CCDANCTR-References), the Oxford University PROMS Bibliography (2002-5), Ovid PsycINFO, Web of Science, The Cochrane Library, and International trial registries, initially to 30 May 2014, and updated to 18 May 2015. SELECTION CRITERIA: We selected cluster and individually randomised controlled trials (RCTs) including participants with CMHDs aged 18 years and over, in which the results of PROMs were fed back to treating clinicians, or both clinicians and patients. We excluded RCTs in child and adolescent treatment settings, and those in which more than 10% of participants had diagnoses of eating disorders, psychoses, substance use disorders, learning disorders or dementia. DATA COLLECTION AND ANALYSIS: At least two authors independently identified eligible trials, assessed trial quality, and extracted data. We conducted meta-analysis across studies, pooling outcome measures which were sufficiently similar to each other to justify pooling. MAIN RESULTS: We included 17 studies involving 8787 participants: nine in multidisciplinary mental health care, six in psychological therapy settings, and two in primary care. Pooling of outcome data to provide a summary estimate of effect across studies was possible only for those studies using the compound Outcome Questionnaire (OQ-45) or Outcome Rating System (ORS) PROMs, which were all conducted in multidisciplinary mental health care or psychological therapy settings, because both primary care studies identified used single symptom outcome measures, which were not directly comparable to the OQ-45 or ORS.Meta-analysis of 12 studies including 3696 participants using these PROMs found no evidence of a difference in outcome in terms of symptoms, between feedback and no-feedback groups (standardised mean difference (SMD) -0.07, 95% confidence interval (CI) -0.16 to 0.01; P value = 0.10). The evidence for this comparison was graded as low quality however, as all included studies were considered at high risk of bias, in most cases due to inadequate blinding of assessors and significant attrition at follow-up.Quality of life was reported in only two studies, social functioning in one, and costs in none. Information on adverse events (thoughts of self-harm or suicide) was collected in one study, but differences between arms were not reported.It was not possible to pool data on changes in drug treatment or referrals as only two studies reported these. Meta-analysis of seven studies including 2608 participants found no evidence of a difference in management of CMHDs between feedback and no-feedback groups, in terms of the number of treatment sessions received (mean difference (MD) -0.02 sessions, 95% CI -0.42 to 0.39; P value = 0.93). However, the evidence for this comparison was also graded as low quality. AUTHORS' CONCLUSIONS: We found insufficient evidence to support the use of routine outcome monitoring using PROMs in the treatment of CMHDs, in terms of improving patient outcomes or in improving management. The findings are subject to considerable uncertainty however, due to the high risk of bias in the large majority of trials meeting the inclusion criteria, which means further research is very likely to have an important impact on the estimate of effect and is likely to change the estimate. More research of better quality is therefore required, particularly in primary care where most CMHDs are treated.Future research should address issues of blinding of assessors and attrition, and measure a range of relevant symptom outcomes, as well as possible harmful effects of monitoring, health-related quality of life, social functioning, and costs. Studies should include people treated with drugs as well as psychological therapies, and should follow them up for longer than six months

Restoration and compensation determination plan / environmental assessment for the Macalloy Corporation Site, Charleston,South Carolina

Under regulation guiding the Comprehensive Environmental Response, Compensation, and Liability Act, Federal and state natural resource agencies are designated to act as Trustees for the public. The Trustees are responsible for recovering damages for injury to natural resources caused by a release of hazardous substances.This Draft RCDP/EA is to provide the public with information on the natural resources injuries and service losses associated with the Macalloy Corporation Site; the restoration objectives that have guided the Trustees in developing this plan; the restoration alternatives that have been considered; the process used by the Trustees to identify preferred restoration alternatives; and the rationale for their selection

Intermediate Outcomes, Strategies, and Challenges of Eight Healthy Start Projects

Site visits were conducted for the evaluation of the national Healthy Start program to gain an understanding of how projects design and implement five service components (outreach, case management, health education, depression screening and interconceptional care) and four system components (consortium, coordination/collaboration, local health system action plan and sustainability) as well as program staff’s perceptions of these components’ influence on intermediate outcomes. Interviews with project directors, case managers, local evaluators, clinicians, consortium members, outreach/lay workers and other stakeholders were conducted during 3-day in-depth site visits with eight Healthy Start grantees. Grantees reported that both services and systems components were related to self-reported service achievements (e.g. earlier entry into prenatal care) and systems achievements (e.g. consumer involvement). Outreach, case management, and health education were perceived as the service components that contributed most to their achievements while consortia was perceived as the most influential systems component in reaching their goals. Furthermore, cultural competence and community voice were overarching project components that addressed racial/ethnic disparities. Finally, there was great variability across sites regarding the challenges they faced, with poor service availability and limited funding the two most frequently reported. Service provision and systems development are both critical for successful Healthy Start projects to achieve intermediate program outcomes. Unique contextual and community issues influence Healthy Start project design, implementation and reported accomplishments. All eight projects implement the required program components yet outreach, case management, and health education are cited most frequently for contributing to their perceived achievements

Geographic Differences in Use of Home Oxygen for Obstructive Lung Disease: A National Medicare Study

Rationale: Home oxygen is the most expensive equipment item that Medicare purchases ($1.7 billion/year). Objectives: To assess geographic differences in supplemental oxygen use. Methods: Retrospective cohort analysis of oxygen claims for a 20% random sample of Medicare patients hospitalized for obstructive lung disease in 1999 and alive at the end of 2000. Measurements and Main Results: While 33.7% of the 34,916 hospitalized patients used supplemental oxygen, there was more than a 4-fold difference between states and a greater than 6-fold difference between hospital referral regions with high/low utilization. Rocky Mountain States and Alaska had the highest utilization, while the District of Columbia and Louisiana had the lowest utilization. After adjusting for patient characteristics and elevation, high-utilization communities included low-lying areas in California, Florida, Michigan, Missouri, and Washington. Patients who were younger, male, white, and who had more comorbidities, more hospital admissions, and lived at higher altitudes and in areas of greater income also had higher odds of using supplemental oxygen. Residing in rural areas was associated with higher unadjusted oxygen use rates. After adjustment, patients living in large rural areas had higher odds of using oxygen than patients living in urban areas or in small rural areas. Conclusions: There is significant geographic variation in supplemental oxygen use, even after controlling for patient and contextual factors. The Centers for Medicare & Medicaid Services should examine these issues further and enact changes that ensure patient health and fiscal responsibility.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79291/1/j.1748-0361.2010.00275.x.pd

Characteristics, Access, Utilization, Satisfaction, and Outcomes of Healthy Start Participants in Eight Sites

To describe the characteristics, access, utilization, satisfaction, and outcomes of Healthy Start participants in eight selected sites, a survey of Healthy Start participants with infants ages 6–12-months-old at time of interview was conducted between October 2006 and January 2007. The response rate was 66% (n = 646), ranging from 37% in one site to >70% in seven sites. Healthy Start participants’ outcomes were compared to two national benchmarks. Healthy Start participants reported that they were satisfied with the program (>90% on five measures). Level of unmet need was 6% or less for most services, except for dental appointments (11%), housing (13%), and child care (11%). Infants had significantly better access to medical care than did their mothers, with higher rates of insurance coverage, medical homes, and checkups, and fewer unmet needs for health care. Healthy Start participants’ rates of ever breastfeeding (72%) and putting infants to sleep on their backs (70%) were at or near the Healthy People 2010 objectives, and considerably higher than rates among low-income mothers in the ECLS. The high rate of health education (>90%) may have contributed to these outcomes. Elimination of smoking among Healthy Start participants (46%) fell short of the Healthy People 2010 objective (99%). The low-birth weight (LBW) rate among Black Healthy Start participants (14%) was three times higher than the rate for Whites and Hispanics (5% each). Overall, the LBW rate in the eight sites (7.5%) was similar to the rate for low-income mothers in the ECLS, but both rates were above the Healthy People 2010 objective (5%). Challenges remain in reducing disparities in maternal and child health outcomes. Further attention to risk factors associated with LBW (especially smoking) may help close the gaps. The life course theory suggests that improved outcomes may require longer-term investments. Healthy Start’s emerging focus on interconception care has the potential to address longer-term needs of participants

Portion sizes of foods frequently consumed by the Korean elderly: Data from KNHANES IV-2

The purpose of this study was to define a one-portion size of food frequently consumed by the Koreans aged 65 years or over. From the original 8,631 people who took part in the Forth Korea National Health and Nutrition Examination Survey (KNHANES IV-2) 2008, we analyzed the data on 1,458 persons (16.9%) aged 65 and over, and selected food items consumed based on the intake frequency of 30 or more by all participant. A total of 158 varieties of food items were selected. The portion size of food items was set on the basis of the median amount (50 percentile) in a single intake by a single person. In the cereals category, 13 items were selected, of which the most frequently consumed item was well-polished rice with portion size of 75 g. Among legumes, 7 items were selected, of which the most frequent item was dried black soybean with a portion size of 6 g. Among the 16 groups, the most varied food group (49 items) was vegetables, and among these the most frequently occurring item was garlic (5 g), while among the fruit group, only 11 items were selected, as their intake frequency was low. Fish and shellfish were more frequently consumed by the elderly than meats. The most frequently consumed meat was pork loin, with a portion size of 30 g. In fish and shellfish, the most frequently consumed item was dried and boiled large anchovy with a portion size of 2 g. Portion sizes for food items consumed regularly by the elderly may be conveniently and effectively used in dietary planning and in nutritional education programs, and in assessing the diet intake status of the elderly

One portion size of foods frequently consumed by Korean adults

This study aimed to define a one portion size of food items frequently consumed for convenient use by Koreans in food selection, diet planning, and nutritional evaluation. We analyzed using the original data on 5,436 persons (60.87%) aged 20 ~ 64 years among 8,930 persons to whom NHANES 2005 and selected food items consumed by the intake frequency of 30 or higher among the 500 most frequently consumed food items. A total of 374 varieties of food items of regular use were selected. And the portion size of food items was set on the basis of the median (50th percentile) of the portion size for a single intake by a single person was analyzed. In cereals, the portion size of well polished rice was 80 g. In meats, the portion size of Korean beef cattle was 25 g. Among vegetable items, the portion size of Baechukimchi was 40 g. The portion size of the food items of regular use set in this study will be conveniently and effectively used by general consumers in selecting food items for a nutritionally balanced diet. In addition, these will be used as the basic data in setting the serving size in meal planning