Search

Objective: To lengthen the days between electroencephalogram electrode-related pressure injury (EERPI) to 100 EERPI-free days in 6 months of study implementation with a goal to maintain 200 EERPI-free days thereafter (≤1 EERPI event/year)., Methods: This quality improvement study took place in a level IV neonatal ICU over three epochs spanning 2 years: epoch 1 or baseline (January-June 2019), epoch 2 or implementation of intervention (July-December 2019), and epoch 3 or sustainment (January-December 2020). A daily electroencephalogram (EEG) skin assessment tool, introduction in practice of a flexible hydrogel EEG electrode, and successive rapid-cycle staff-education sessions were key interventions of the study., Results: Seventy-six infants were monitored for 214 continuous EEG (cEEG) days, of which six (13.2%) developed EERPI in epoch 1. Eighty infants were monitored for 193 cEEG days, of which two (2.5%) developed EERPI in epoch 2. One hundred thirty-nine infants were monitored for 338 cEEG days, and none developed EERPI in epoch 3. There was no statistical difference with respect to the median cEEG days among study epochs. A G-chart of EERPI-free days showed an increase in EERPI-free days from an average of 34 days in epoch 1 to 182 days in epoch 2 and 365 days (or zero harm) in epoch 3. Skin erythema from EEG electrodes was noted during the study., Conclusions: The structured study interventions eliminated EERPI events in infants monitored with cEEG. Preventive intervention at the cEEG-electrode level coupled with skin assessment successfully reduced EERPIs in neonates., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In antiretroviral (ARV) therapy, pill burden, dosing frequency, and regimen complexity adversely affect adherence. We sought to evaluate the effect of regimen simplification on maintenance of virologic suppression and treatment adherence., Method: In this 48-week, open-label, randomized study, 320 HIV-1-infected adult patients with a viral load of <50 copies/mL on a twice-daily or more frequent ARV regimen were either switched to a once-daily regimen of efavirenz, extended-release stavudine, and lamivudine (QD arm) or continued on existing therapy (BID+ arm). Medication Event Monitoring System (MEMS) caps, AIDS Clinical Trials Group (ACTG)-validated questionnaire, and pill counts were used to evaluate adherence. Treatment satisfaction and preference were also evaluated., Results: The QD arm was noninferior to the BID+ arm in the primary efficacy measure (proportion of patients who maintained virologic suppression at Week 48; QD arm, 80.0% vs. BID+ arm, 75.8%). Adherence and treatment satisfaction significantly favored the QD arm, in which 91.0% of patients preferred the simpler regimen. Overall, the majority of adverse events were mild to moderate in severity and resulted in a low rate of treatment discontinuations., Conclusions: Simplifying twice-daily or more frequent ARV therapy to a once-daily efavirenz-containing regimen in virologically suppressed HIV-1-infected patients maintains virologic suppression while improving adherence and patient satisfaction.

A high level of adherence to highly active antiretroviral therapy (HAART) is essential to minimize the risk of treatment failure and HIV disease progression. This cohort study evaluated the prevalence and predictors of long-term adherence with first-line HAART in a hospital-based unselected sample of HIV patients from central Italy, and examined the association between adherence and virological response or relapse. Between July 1996 and June 2004, 171 patients (67.3% males; mean age, 41.2 years) were followed for at least 24 weeks and up to 8 years. Adherence was measured by patient self-reports and confirmed using pharmacy records. The prevalence of high-level adherence (>or=90%) at 6 months was 88.3%; slightly less than 80% at 12 months. The incidence of adherence failure in the sample remained fairly stable until 24 months of follow-up, then it declined about 5% every 6 months. Cox analysis showed that compared to single/separated patients, homeless and married persons were, respectively, 1.95 times more likely and two times less likely to experience adherence failure (p < 0.05). The adjusted risk of adherence failure among patients who did not suffer drug-related toxicity was 0.57 (p < 0.05). Medication adherence was significantly associated with shorter time to virological response and longer time to relapse. Adherents were 1.69 times more likely to achieve viral suppression and nine times less likely to experience relapse than nonadherents (p < 0.01). Efforts at improving adherence should be prolonged for at least 24 months. A protective role of marriage for adherence failure is promising but requires confirmation in further research, that should also clarify the exact mechanisms determining the association.

Nevirapine associated rash has been well described in the Caucasian population. With increasing access to antiretroviral treatment--especially a fixed dose combination--by people living with HIV/AIDS in developing countries, there is a need to emphasize the lead in doses of nevirapine. We strongly recommend a warning label on the bottle advising patients on the lead-in period and the signs and symptoms of significant rash.

Over the past 10 years, highly active antiretroviral therapy that included a protease inhibitor has played a significant role in reducing morbidity and mortality among HIV-infected individuals. The early protease inhibitors were associated, however, with some significant limitations that posed major obstacles to their use--limited potency, difficult side effects, high regimen complexity and potential for cross-resistance. Important advances in the protease inhibitor class, including ritonavir boosting and the approval of two new protease inhibitors with the potential for once daily dosing, have led to simpler, better-tolerated protease-inhibitor therapy with the potential for improved efficacy, less toxicity and a reduced risk of the development of HIV resistance. Protease inhibitor characteristics and patient preferences should be considered in selecting the protease inhibitor that maximizes the opportunity for long-term efficacy and tolerability of highly active antiretroviral therapy.

Emergence of drug-resistant viral variants is a major reason why HIV-infected patients experience viral rebound during antiretroviral therapy. Although combination antiretroviral therapy substantially inhibits viral replication, replication-competent mutant virus remains. In addition, it is now clear that virologic failure is not necessarily caused by failure of all drugs in a regimen. The use of resistance-testing data can assist in understanding the reasons for failure of antiretroviral therapy. However, there is a need for additional trials to better define the role resistance testing may play in developing management approaches to mitigate or minimize emergence of resistant HIV.

The Maryland Division of Correction houses 24,000 inmates in 27 geographically disparate facilities. The inmate population increasingly includes a frail, elderly component, as well as many inmates with chronic or progressive diseases. The Division houses about 900 human immunodeficiency virus (HIV)-positive detainees, almost one quarter with an acquired immune deficiency syndrome (AIDS) diagnosis. A Ryan White Special Project of National Significance (SPNS) grant and the interest of a community hospice helped transform prison hospice from idea to reality. One site is operational and a second site is due to open in the future. Both facilities serve only male inmates, who comprise more than 95% of Maryland's incarcerated. "Medical parole" is still the preferred course for terminally ill inmates; a number have been sent to various local community inpatient hospices or released to the care of their families. There will always be some who cannot be medically paroled, for whom hospice is appropriate. Maryland's prison hospice program requires a prognosis of 6 months or less to live, a do-not-resuscitate (DNR) order and patient consent. At times, the latter two of these have been problematic. Maintaining the best balance between security requirements and hospice services to dying inmates takes continual communication, coordination and cooperation. Significant complications in some areas remain: visitation to dying inmates by family and fellow prisoners; meeting special dietary requirements; what role, if any, will be played by inmate volunteers. Hospice in Maryland's Division of Correction is a work in progress.