Characterizing the double-sided cascade of care for adolescents living with HIV transitioning to adulthood across Southern Africa

INTRODUCTION: As adolescents and young people living with HIV (AYLH) age, they face a "transition cascade," a series of steps associated with transitions in their care as they become responsible for their own healthcare. In high-income countries, this usually includes transfer from predominantly paediatric/adolescent to adult clinics. In sub-Saharan Africa, paediatric HIV care is mostly provided in decentralized, non-specialist primary care clinics, where "transition" may not necessarily include transfer of care but entails becoming more autonomous for one's HIV care. Using different age thresholds as proxies for when "transition" to autonomy might occur, we evaluated pre- and post-transition outcomes among AYLH. METHODS: We included AYLH aged <16 years at enrolment, receiving antiretroviral therapy (ART) within International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) sites (2004 to 2017) with no history of transferring care. Using the ages of 16, 18, 20 and 22 years as proxies for "transition to autonomy," we compared the outcomes: no gap in care (≥2 clinic visits) and viral suppression (HIV-RNA <400 copies/mL) in the 12 months before and after each age threshold. Using log-binomial regression, we examined factors associated with no gap in care (retention) in the 12 months post-transition. RESULTS: A total of 5516 AYLH from 16 sites were included at "transition" age 16 (transition-16y), 3864 at 18 (transition-18y), 1463 at 20 (transition-20y) and 440 at 22 years (transition-22y). At transition-18y, in the 12 months pre- and post-transition, 83% versus 74% of AYLH had no gap in care (difference 9.3 (95% confidence interval (CI) 7.8 to 10.9)); while 65% versus 62% were virally suppressed (difference 2.7 (-1.0 to 6.5%)). The strongest predictor of being retained post-transition was having no gap in the preceding year, across all transition age thresholds (transition-16y: adjusted risk ratio (aRR) 1.72; 95% CI (1.60 to 1.86); transition-18y: aRR 1.76 (1.61 to 1.92); transition-20y: aRR 1.75 (1.53 to 2.01); transition-22y: aRR 1.47; (1.21 to 1.78)). CONCLUSIONS: AYLH with gaps in care need targeted support to prevent non-retention as they take on greater responsibility for their healthcare. Interventions to increase virologic suppression rates are necessary for all AYLH ageing to adulthood

Spironolactone therapy in infants with congestive heart failure secondary to congenital heart disease.

The efficacy of treatment with spironolactone for congestive heart failure secondary to congenital heart disease was studied in 21 infants under 1 year of age. All received digoxin and chlorothiazide. In addition, group A (n = 10) was given supplements of potassium and group B (n = 11) received spironolactone. Daily clinical observations of vital signs, weight, hepatomegaly, and vomiting were recorded. Paired t test analysis showed significant reduction in liver size and weight (P less than 0.01) and respiratory rate (P less than 0.05) in group B, and less significant decreases in group A. The incidence of vomiting was slightly lower in group B. We conclude that the addition of spironolactone hastens and enhances the response to standard treatment with digoxin and chlorothiazide in infants with congestive heart failure

Conduction disturbances after surgical correction of ventricular septal defect by the atrial approach.

Conduction disturbances have been documented after correction of ventricular septal defects by the ventricular route. Recently, repair of the ventricular septal defect has been through the right atrium to overcome damage to the conduction system and a right ventriculotomy. Thirty-nine children with ventricular septal defects under the age of 5 years were operated upon by the atrial route (group 1). The incidence of conduction disturbances in this group was compared with that occurring in 19 children of comparable age with a ventricular septal defect repaired via a right ventriculotomy (group 2). Complete right bundle-branch block developed in 13 of 39 children (33.3%) in group 1, compared with 15 of 19 children (78.9%) in group 2. This was a statistically significant reduction in complete right bundle-branch block in group 1. The incidence of left axis deviation occurring with complete right bundle-branch block was similarly statistically reduced. Transient complete heart block and arrhythmias were not statistically different in the two groups. The atrial approach to the repair of the ventricular septal defect significantly reduced the incidence of complete right bundle-branch block alone and occurring with left axis deviation

Comparison of low-and high-altitude Doppler velocimetry in the peripheral and central circulations of normal fetuses

OBJECTIVE: Our aim was to test the hypothesis that Doppler velocimetry of the peripheral and central circulations in normal fetuses is not affected by moderately high altitude (Denver, Colo - 1609 m) compared with sea level (Milan, Italy - 40 m). STUDY DESIGN: One hundred nineteen patients with singleton pregnancies underwent Doppler waveform analysis of the following: umbilical artery, uterine artery, middle cerebral artery, ductus venosus, and the tricuspid and mitral valves. RESULTS: Birth weights were reduced at Denver's altitude (P < .001). The early/late diastolic inflow ratios of the atrioventricular valves increased with gestational age (P < .01), whereas systolic/diastolic ratios of the uterine and umbilical arteries decreased with gestational age (P < .01). There were no Doppler velocimetry differences in any vessel between Denver's and Milan's altitudes. CONCLUSIONS: Gestational age has the same effect on Doppler index at both high and low altitudes. Moderately high altitude does not affect uteroplacental or fetal vascular Doppler index and may reflect normal acclimatization in the smaller Denver fetuses

Reduction of subcutaneous mass, but not lean mass, in normal fetuses in Denver, Colorado

OBJECTIVE: To test the hypothesis that reduced birth weight in normal fetuses born at moderately high altitude (Denver), compared with the birth weight in normal fetuses born at sea level (Milan), is caused by a reduction in both lean mass and subcutaneous fat mass. STUDY DESIGN: Ninety-four normal singleton pregnancies (46 in Denver, 48 in Milan) had serial ultrasonographic axial images obtained to assess subcutaneous tissues of fetuses as a measure of body fat. The abdominal wall thickness and mid upper arm and mid thigh were examined. The equation was: Subcutaneous tissue equals total cross-sectional area minus bone and muscle area. Lean mass included the area of muscle and bone, head circumference, and femur length. RESULTS: Gestational age at delivery was similar between groups. Birth weight was less at Denver's altitude (2991 \ub1 79 g versus 3247 \ub1 96 g; P = .04). Abdominal wall thickness, mid upper arm, and mid thigh subcutaneous tissues measurements were significantly reduced at Denver's altitude and increased further in significance with advancing gestational age. Lean mass measurements were similar between groups. CONCLUSIONS: The reduced birth weight of the newborns in Denver was the result of a reduction in fetal subcutaneous fat tissue and not lean mass. Ultrasonography can be used to follow subcutaneous measurements longitudinally and to detect differences, and potentially disease processes, in study populations

Umbilical vein blood flow determination in the ovine fetus : Comparison of Doppler ultrasonographic and steady-state diffusion techniques

OBJECTIVE: This study was undertaken to assess the accuracy of triplex ultrasonographic measurement of venous umbilical blood flow in comparison with the steady-state diffusion technique and to determine the impact of cotyledon weight and number on umbilical blood flow. STUDY DESIGN: Six late- gestation ewes with long-term catheter placement were studied for venous umbilical blood flow with the ethanol steady-state diffusion technique and with triplex-mode ultrasonography (color Doppler, pulsed-wave Doppler, and real-time ultrasonography). At necropsy the number and weight of the cotyledons serving each umbilical vein were recorded. RESULTS: Umbilical blood flow determined by triplex-mode ultrasonography (207.5 \ub1 8.6 mL \ub7 kg-1 fetus \ub7 min-1) was virtually identical to that determined with the steady-state diffusion technique (208.1 \ub1 7.3 mL \ub7 kg-1 fetus \ub7 min-1; P = .9). When values were normalized for the weight or number of cotyledons serving each vein, there was no difference in umbilical blood flow between small and large umbilical veins in all the sheep. CONCLUSIONS: Our study validates the accuracy of the triplex ultrasonographic method and provides justification for its use in future human investigations. In absolute terms umbilical blood flow frequently differs between the 2 veins. When expressed per number or mass of cotyledons, however, the umbilical blood flows are similar