Risk of myocardial infarction among people living with HIV: an updated systematic review and meta-analysis.

OBJECTIVE: Cardiovascular disease (CVD) is one of the leading non-AIDS-defining causes of death among HIV-positive (HIV+) individuals. However, the evidence surrounding specific components of CVD risk remains inconclusive. We conducted a systematic review and meta-analysis to synthesise the available evidence and establish the risk of myocardial infarction (MI) among HIV+ compared with uninfected individuals. We also examined MI risk within subgroups of HIV+ individuals according to exposure to combination antiretroviral therapy (ART), ART class/regimen, CD4 cell count and plasma viral load (pVL) levels. DESIGN: Systematic review and meta-analysis. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews until 18 July 2018. Furthermore, we scanned recent HIV conference abstracts (CROI, IAS/AIDS) and bibliographies of relevant articles. ELIGIBILITY CRITERIA: Original studies published after December 1999 and reporting comparative data relating to the rate of MI among HIV+ individuals were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers working in duplicate, independently extracted data. Data were pooled using random-effects meta-analysis and reported as relative risk (RR) with 95% CI. RESULTS: Thirty-two of the 8130 identified records were included in the review. The pooled RR suggests that HIV+ individuals have a greater risk of MI compared with uninfected individuals (RR: 1.73; 95% CI 1.44 to 2.08). Depending on risk stratification, there was moderate variation according to ART uptake (RR, ART-treated=1.80; 95% CI 1.17 to 2.77; ART-untreated HIV+ individuals: 1.25; 95% CI 0.93 to 1.67, both relative to uninfected individuals). We found low CD4 count, high pVL and certain ART characteristics including cumulative ART exposure, any/cumulative use of protease inhibitors as a class, and exposure to specific ART drugs (eg, abacavir) to be importantly associated with a greater MI risk. CONCLUSIONS: Our results indicate that HIV infection, low CD4, high pVL, cumulative ART use in general including certain exposure to specific ART class/regimen are associated with increased risk of MI. The association with cumulative ART may be an index of the duration of HIV infection with its attendant inflammation, and not entirely the effect of cumulative exposure to ART per se. PROSPERO REGISTRATION NUMBER: CRD42014012977.

Access to Multidisciplinary Care for Pediatric Weight Management: Exploring Perspectives of the Health Care Team within Canada and the United States.

Background: In Canada and the United States, most families referred for pediatric weight management services do not start treatment. Of families who initiate care, many discontinue before the program ends. Parents and youth have reported difficulties in accessing services as an important barrier to starting or completing programming. The purpose of this study was to understand barriers and identify potential solutions related to access to care from the perspective of health care team members from Canada and the United States. Methods: Qualitative description method guided the study design. Participants were health care team members, purposefully recruited through Canadian and US-based pediatric weight management program registries. Telephone interviews were conducted with participants between February and May 2017. Interviews were transcribed verbatim and analyzed using content analysis. Results: Eighteen individuals from 16 sites participated (n = 8 Canada, n = 8 United States). Access barriers and potential solutions were related to: (1) referral and eligibility, (2) wait lists and program capacity, (3) logistics and costs, and (4) stigma and weight bias. Barriers were similar between Canadian and US sites, with the exception of cost-related barriers. Conclusions: Health care providers from Canada and the United States reported multiple societal, organizational, service, and family-level barriers to accessing multidisciplinary pediatric weight management care. Proposed solutions suggest that service providers can play a key role alongside families to improve access to appropriate care. Further research is needed to demonstrate the feasibility and effectiveness of proposed solutions.

Knowledge sharing between general and pediatric emergency departments: connections, barriers, and opportunities.

OBJECTIVE: Translating Emergency Knowledge for Kids (TREKK) is a national network aimed at improving emergency care for children by increasing collaborations and knowledge sharing between general and pediatric emergency departments (EDs). This study aimed to determine patterns of knowledge sharing within the network and to identify connections, barriers, and opportunities to obtaining pediatric information and training. METHODS: We conducted 22 semi-structured interviews with health care professionals working in general EDs, purposefully sampled to represent connected and disconnected sites, based on two previous internal quantitative social network analyses (SNA). Data were analyzed by two independent reviewers. RESULTS: Participants included physicians (59%) and nurses (41%) from 18 general EDs in urban (68%) and rural/remote (32%) Canada. Health care professionals sought information both formally and informally, by using guidelines, talking to colleagues, and attending pediatric related training sessions. Network structure and processes were found to increase connections, support practice change, and promote standards of care. Participants identified personal, organizational and system level barriers to information and skill acquisition, including resources and personal costs, geography, dissemination, and time. Providing easy access to information at the point of care was promoted through enhancing content visibility and by embedding resources into local systems. There remains a need to share successful methods of local dissemination and implementation across the network, and to leverage local professional champions such as clinical nurse liaisons. CONCLUSIONS: These findings reinforce the critical role of ongoing network evaluation to improve the design and delivery of knowledge mobilization initiatives.