Calcium Absorption in Infants and Small Children: Methods of Determination and Recent Findings

Determining calcium bioavailability is important in establishing dietary calcium requirements. In infants and small children, previously conducted mass balance studies have largely been replaced by stable isotope-based studies. The ability to assess calcium absorption using a relatively short 24-hour urine collection without the need for multiple blood samples or fecal collections is a major advantage to this technique. The results of these studies have demonstrated relatively small differences in calcium absorption efficiency between human milk and currently available cow milk-based infant formulas. In older children with a calcium intake typical of Western diets, calcium absorption is adequate to meet bone mineral accretion requirements

Event-level analyses of sex-risk and injection-risk behaviors among nonmedical prescription opioid users

Nonmedical prescription opioid use has been linked to hepatitis C virus (HCV) infection among people who inject drugs and with using high dead space syringes that retain more blood and transfer more HIV if shared. Little is known regarding its effects on sex risk behaviors

Engagement in Outpatient Care for Persons Living with HIV in the United States

Prior studies that have assessed engagement within the various stages of care for persons living with HIV (PLWH) studied patients receiving care in HIV medical care facilities. These data are not representative of care received throughout the United States, as not all PLWH receive care in HIV clinics. This study evaluated engagement in outpatient care and healthcare utilization for PLWH, beyond facilities that specialize in HIV. Cross-sectional data were from the 2009–2010 National Hospital Ambulatory Medical Care Survey. Levels of care included receiving any care, receiving HIV-related care, established in care, engaged in care, and prescribed antiretroviral therapy (ARV). Factors associated with ARV prescription were determined by logistic regression. We analyzed data for ∼2.6 million outpatient clinic visits for PLWH. Of these, 90% were receiving HIV-related care, 86% were established in care, 75% were engaged in care, and 65% were prescribed ARV. In stratified analysis, the proportion of PWLH who were engaged in care varied by race/ethnicity (p<0.001) and ARV prescription varied significantly across the three age groups (p=0.004). Clinic visits within the past year did not differ for those prescribed ARV vs. not prescribed ARV [median, IQR=3.3 visits (1.8–5.6) vs. 3.6 visits (1.3–5.9); p=0.7]. Seeing a physician was associated with ARV prescription (OR=0.27, 95% CI=0.15–0.51), whereas routine engagement in care was not associated with ARV prescription (OR=0.99, 95% CI=0.96–1.03). Given that non-ARV-treated PLWH utilized outpatient care services at rates similar to ARV-treated PLWH, these routine clinic visits are missed opportunities for increasing ARV prescription in untreated patients

Racial/Ethnic and Gender Gaps in the Use of and Adherence to Evidence-Based Preventive Therapies Among Elderly Medicare Part D Beneficiaries After Acute Myocardial Infarction

It is unclear whether gender and racial/ethnic gaps in the use of and patient adherence to β-blockers, angiotensin-converting-enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), and HMG-CoA reductase inhibitors (statins) post-acute myocardial infarction (AMI) have persisted following establishment of the Medicare Part D prescription program

Barriers to Hepatitis C Antiviral Therapy in HIV/HCV Co-Infected Patients in the United States: A Review

This review synthesized the literature for barriers to HCV antiviral treatment in persons with HIV/HCV co-infection. Searches of PubMed, Embase, CINAHL, and Web of Science were conducted to identify relevant articles. Articles were excluded based on the following criteria: study conducted outside of the United States, not original research, pediatric study population, experimental study design, non-HIV or non-HCV study population, and article published in a language other than English. Sixteen studies met criteria and varied widely in terms of study setting and design. Hepatic decompensation was the most commonly documented absolute/nonmodifiable medical barrier. Substance use was widely reported as a relative/modifiable medical barrier. Patient-level barriers included nonadherence to medical care, refusal of therapy, and social circumstances. Provider-level barriers included provider inexperience with antiviral treatment and/or reluctance of providers to refer patients for treatment. There are many ongoing challenges that are unique to managing this patient population effectively. Documenting and evaluating these obstacles are critical steps to managing and caring for these individuals in the future. In order to improve uptake of HCV therapy in persons with HIV/HCV co-infection, it is essential that barriers, both new and ongoing, are addressed, otherwise, treatment is of little benefit

Differences in outpatient care and treatment utilization for patients with HIV/HCV coinfection, HIV, and HCV monoinfection, a cross-sectional study

Background Few studies have explored how utilization of outpatient services differ for HIV/HCV coinfected patients compared to HIV or HCV monoinfected patients. The objectives of this study were to (1) compare annual outpatient clinic visit rates between coinfected and monoinfected patients, (2) to compare utilization of HIV and HCV therapies between coinfected and monoinfected patients, and (3) to identify factors associated with therapy utilization. Methods Data were from the 2005–2010 U.S. National Hospital Ambulatory Medical Care Surveys. Clinic visits with a primary or secondary ICD-9-CM codes for HIV or HCV were included. Coinfection included visits with codes for both HIV and HCV. Monoinfection only included codes for HIV or HCV, exclusively. Patients <15 years of age at time of visit were excluded. Predictors of HIV and HCV therapy were determined by logistic regressions. Visits were computed using survey weights. Results 3,021 visits (11,352,000 weighted visits) met study criteria for patients with HIV/HCV (8%), HIV (70%), or HCV (22%). The HCV subgroup was older in age and had the highest proportion of females and whites as compared to the HIV/HCV and HIV subgroups. Comorbidities varied significantly across the three subgroups (HIV/HCV, HIV, HCV): current tobacco use (40%, 27%, 30%), depression (32%, 23%, 24%), diabetes (9%, 10%, 17%), and chronic renal failure (<1%, 3%, 5%), (p < 0.001 for all variables). Annual visit rates were highest in those with HIV, followed by HIV/HCV, but consistently lower in those with HCV. HIV therapy utilization increased for both HIV/HCV and HIV subgroups. HCV therapy utilization remained low for both HIV/HCV and HCV subgroups for all years. Coinfection was an independent predictor of HIV therapy, but not of HCV therapy. Conclusion There is a critical need for system-level interventions that reduce barriers to outpatient care and improve uptake of HCV therapy for patients with HIV/HCV coinfection

Non-initiation of hepatitis C virus antiviral therapy in patients with human immunodeficiency virus/hepatitis C virus co-infection

AIM: To assess whether reasons for hepatitis C virus (HCV) therapy non-initiation differentially affect racial and ethnic minorities with human immunodeficiency virus (HIV)/HCV co-infection. METHODS: Analysis included co-infected HCV treatment- naïve patients in the University of North Carolina CFAR HIV Clinical Cohort (January 1, 2004 and December 31, 2011). Medical records were abstracted to document non-modifiable medical (e.g. , hepatic decompensation, advanced immunosuppression), potentially modifiable medical (e.g. , substance abuse, severe depression, psychiatric illness), and non-medical (e.g. , personal, social, and economic factors) reasons for non-initiation. Statistical differences in the prevalence of reasons for non-treatment between racial/ethnic groups were assessed using the two-tailed Fisher's exact test. Three separate regression models were fit for each reason category. Odds ratios and their 95%CIs (Wald's) were computed. RESULTS: One hundred and seventy-one patients with HIV/HCV co-infection within the cohort met study inclusion. The study sample was racially and ethnically diverse; most patients were African-American (74%), followed by Caucasian (19%), and Hispanic/other (7%). The median age was 46 years (interquartile range = 39-50) and most patients were male (74%). Among the 171 patients, reasons for non-treatment were common among all patients, regardless of race/ethnicity (50% with ≥ 1 non-modifiable medical reason, 66% with ≥ 1 potentially modifiable medical reason, and 66% with ≥ 1 non-medical reason). There were no significant differences by race/ethnicity. Compared to Caucasians, African-Americans did not have increased odds of nonmodifiable [adjusted odds ratio (aOR) = 1.47, 95%CI: 0.57-3.80], potentially modifiable (aOR = 0.72, 95%CI: 0.25-2.09) or non-medical (aOR = 0.90, 95%CI: 0.32-2.52) reasons for non-initiation. CONCLUSION: Race/ethnicity alone is not predictive of reasons for HCV therapy non-initiation. Targeted interventions are needed to improve access to therapy for all co-infected patients, including minorities

Adaptation of calcium absorption during treatment of nutritional rickets in Nigerian children

Nutritional rickets in Nigerian children has been effectively treated with Ca supplementation. High values of Ca absorption efficiency have been observed in untreated children, but whether Ca absorption efficiency changes during treatment with Ca is unknown. Our objective in conducting this study wits to identify the effect of Ca therapy on Ca absorptive efficiency in children with primary Ca-deficient nutritional rickets. Twelve children with radiographically active tickets, 2 to 14 years of age (median 39 months) participated in the study. We assessed dietary Ca intake via dietary recalls, and measured biochemical markers of Ca and vitamin D homeostasis. Fractional Ca absorption was measured using a dual tracer stable isotope method, before and after 2 weeks of treatment with 15.0 mmol elemental Ca daily. Ten children had adequate urine collection for inclusion in the analysis. Usual dietary Ca intake was 4.2 (SD 1.0) mmol/d. The median Ca absorption prior to treatment was 72% (range 52-97%) and decreased significantly to 57% (31-84%) (P=0.004) after 2 weeks Of Supplementation. We conclude that Nigerian children with rickets adapt to Ca Supplementation with a small decrease in Ca absorptive capacity, but retain very high absorptive levels during supplementation. Overall Ca absorption efficiency was comparable with that identified in other populations with low Ca intakes. These data demonstrate that although absorptive capacity is regulated by supplementation, recovery from rickets likely occurs through efficient use of both dietary and supplemental Ca

The electronic medication complete communication (EMC2) study: Rationale and methods for a randomized controlled trial of a strategy to promote medication safety in ambulatory care

AbstractBackgroundAdverse drug events (ADEs) affect millions of patients annually and place a significant burden on the healthcare system. The Food and Drug Administration (FDA) has developed patient safety information for high-risk medications that pose serious public health concerns. However, there are currently few assurances that patients receive this information or are able to identify or respond correctly to ADEs.ObjectiveTo evaluate the effectiveness of the Electronic Medication Complete Communication (EMC2) Strategy to promote safe medication use and reporting of ADEs in comparison to usual care.MethodsThe automated EMC2 Strategy consists of: 1) provider alerts to counsel patients on medication risks, 2) the delivery of patient-friendly medication information via the electronic health record, and 3) an automated telephone assessment to identify potential medication concerns or ADEs. The study will take place in two community health centers in Chicago, IL. Adult, English or Spanish-speaking patients (N=1200) who have been prescribed a high-risk medication will be enrolled and randomized to the intervention arm or usual care based upon practice location. The primary outcomes of the study are medication knowledge, proper medication use, and reporting of ADEs; these will be measured at baseline, 4weeks, and three months. Intervention fidelity as well as barriers and costs of implementation will be evaluated.ConclusionsThe EMC2 Strategy automates a patient-friendly risk communication and surveillance process to promote safe medication use while minimizing clinic burden. This trial seeks to evaluate the effectiveness and feasibility of this strategy in comparison to usual care

National trends in hospitalization and mortality rates for patients with HIV, HCV, or HIV/HCV coinfection from 1996–2010 in the United States: a cross-sectional study

Abstract Background The comparative impact of chronic viral monoinfection versus coinfection on inpatient outcomes and health care utilization is relatively unknown. This study examined trends, inpatient utilization, and hospital outcomes for patients with HIV, HCV, or HIV/HCV coinfection. Methods Data were from the 1996–2010 National Hospital Discharge Surveys. Hospitalizations with primary ICD-9-CM codes for HIV or HCV were included for HIV and HCV monoinfection, respectfully. Coinfection included both HIV and HCV codes. Demographic characteristics, select comorbidities, procedural interventions, average hospital length of stay (LOS), and discharge status were compared by infection status (HIV, HCV, HIV/HCV). Annual disease estimates and survey weights were used to generate hospitalization rates. Results ~6.6 million hospitalizations occurred in patients with HIV (39%), HCV (56%), or HIV/HCV (5%). The hospitalization rate (hospitalizations per 100 persons with infection) decreased in the HIV group (29.8 in 1996; 5.3 in 2010), decreased in the HIV/HCV group (2.0 in 1996; 1.5 in 2010), yet increased in the HCV group (0.2 in 1996; 0.9 in 2010). Median LOS from 1996 to 2010 (days, interquartile range) decreased in all groups: HIV, 6 (3–10) to 4 (3–8); HCV, 5 (3–9) to 4 (2–6); HIV/HCV, 6 (4–11) to 4 (2–7). Age-adjusted mortality rates decreased for all three groups. The rate of decline was least pronounced for those with HCV monoinfection. Conclusion Hospitalizations have declined more rapidly for patients with HIV infection (including HIV/HCV coinfection) than for patients with HCV infection. This growing disparity between HIV and HCV underscores the need to allocate more resources to HCV care in hopes that similar large-scale improvements can also be accomplished for patients with HCV