Caregivers' and Health Care Providers' Cultural Perceptions of and Experiences With Latino Patients With Dementia.

Background and Objectives: The prevalence of Alzheimer dementia in the US Latino population in 2060 is projected to increase 7-fold, the highest among any other major ethnic/racial group. One vital question is how clinicians can tailor their care for Latinos. Given this rapidly growing prevalence, we sought to characterize the experiences and perspectives of Latino caregivers by analyzing interview data from both caregivers and experienced providers that specifically work with Latino populations. In this study, we present 6 themes that emerged along with tailored solutions and recommendations to implement in clinical practice to improve patient care and outcomes. Methods: This qualitative analysis uses coded interview transcripts from 2 studies, one in Southern California and another in Washington State. The combined dataset included interview transcripts with 51 caregivers and 20 providers. A thematic analysis was performed on the coded interview transcripts to identify themes related to tailoring care for Latino populations. Results: Six themes emerged from the analysis: (1) multiple caregivers involved within a family-oriented Latino household; (2) need for encouragement in advocating for loved ones in the clinician's office; (3) challenges in reaching and communicating with the Latino population; (4) increasing use of technology by patients and caregivers despite some challenges; (5) stigma associated with mental health issues within the Latino culture; and (6) limited understating of dementia leading to a delay in care in the Latino population. Discussion: Many Latino households have a strong sense of familism, thus care coordination with multiple caregivers is essential to high-quality care. Improved shared decision-making strategies tailored to a population that may be culturally deferential to authoritative figures can aid caregiver understanding and engagement with the provider. These interactions can often be more authentic when communicating with a member of the care team in Spanish. A cultural stigma of mental illness was also identified; clinicians can work toward normalizing discussion of mental illness and its treatment by openly discussing mental health during annual visits. Through these themes, we demonstrate some of the strengths and weaknesses of the current care delivery model within a sociocultural context to improve patient care and outcomes for Latino families caring for individuals living with dementia.

Longitudinal analysis of CSF HIV RNA in untreated people with HIV: Identification of CSF controllers.

Interindividual variation of human immunodeficiency virus (HIV) RNA setpoint in cerebrospinal fluid (CSF) and its determinants are poorly understood, but relevant for HIV neuropathology, brain reservoirs, viral escape, and reseeding after antiretroviral interruptions. Longitudinal multicentric study on demographic, clinical, and laboratory correlates of CSF HIV RNA in 2000 follow-up visits from 597 people with HIV (PWH) off antiretroviral therapy (ART) and with plasma HIV RNA > the lower limit of quantification (LLQ). Factors associated with CSF control (CSFC; CSF HIV RNA < LLQ while plasma HIV RNA > LLQ) and with CSF/plasma discordance (CSF > plasma HIV RNA > LLQ) were also assessed through mixed-effects models. Posthoc and sensitivity analyses were performed for persistent CSFC and ART-naïve participants, respectively. Over a median follow-up of 2.1 years, CSF HIV RNA was associated with CD4+ and CD8+ T cells, CSF leukocytes, blood-brain barrier (BBB) integrity, biomarkers of iron and lipid metabolism, serum globulins, past exposure to lamivudine, and plasma HIV RNA (model p < 0.0001). CSFC (persistent in 7.7% over 3 years) and CSF/plasma discordance (persistent in <0.01% over 1 year) were variably associated with the same parameters (model p < 0.001). Sensitivity analyses confirmed most of the previous associations in participants never exposed to ART. Persistent CSFC was associated with higher CD4+ T-cell count nadir (p < 0.001), lower serum globulins (p = 0.003), and lower CSF leukocytes (p < 0.001). Without ART, one in 13 PWH had persistently undetectable CSF HIV RNA, while persistent CSF/plasma discordance was extremely rare over years. Immune responses, inflammation, BBB permeability, and iron and lipid metabolism were all associated with HIV replication in CSF.

A Multidisciplinary Pediatric Neurology Clinic for Systematic Follow-up of Children with Neurologic Sequelae of COVID-19.

Clinical guidance on outpatient follow-up of children hospitalized with acute neurologic complications of SARS-CoV2 infection is needed. We describe the clinical infrastructure of our pediatric neurology post-Covid clinic, including our clinical evaluation and cognitive testing battery specific to this patient population, and a case series of our initial patient cohort. Our findings demonstrate cognitive sequelae in all 4 of our patients months following acute SARS-CoV2 infection with neurologic complications including acute disseminated encephalomyelitis, posterior reversible encephalopathy syndrome, viral encephalitis, and gait difficulties. Verbal and executive function domains were predominantly affected in our cohort, even in patients who did not endorse symptomatic or academic complaints at follow-up. Our recommendations include systematic clinical follow-up for children following hospitalization with SARS-CoV2 infection with a comprehensive cognitive battery to monitor for cognitive sequalae and to assist with developing an individualized education plan for the child as they return to school.

Physical function and fatigue recovery at 6 months after hospitalization for COVID-19.

INTRODUCTION: There are an increasing number of individuals with long-term symptoms of coronavirus-19 disease (COVID-19); however, the prognosis for recovery of physical function and fatigue after COVID-19 is uncertain. OBJECTIVE: To report the changes in functional recovery between 1 and 6 months after hospitalization of adults hospitalized for COVID-19 and explore the baseline factors associated with physical function recovery. DESIGN: A prospective cohort study. SETTING: Tertiary care hospital. PARTICIPANTS: U.S. adult COVID-19 survivors. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Telephone interviews assessed three outcome domains: basic and instrumental activities of daily living (ADLs) performance, fatigue, and general physical function (Health Assessment Questionnaire [HAQ]). RESULTS: The age of participants (n = 92) ranged from 22 to 95 years (54.3 ± 17.2). Across outcome domains, a majority (63%-67%) of participants developed new ADL impairment, fatigue, or worsening HAQ severity by 1 month. Of those, 50%-79% partially or fully recovered by 6 months, but 21%-50% did not recover at least partially. Fifteen to 30% developed new impairment between 1 and 6 months. For those without any improvement in ADL impairments at 6 months, lower socioeconomic status was significantly more common (p = .01) and age ≥ 65 (p = .06), trending toward being more common. CONCLUSION: In this cohort, a substantial proportion of the participants who developed new ADL impairment, worsening fatigue, or HAQ severity after hospitalization for COVID-19 did not recover at least partially by 6 months after discharge. Evaluating functional status 1 month after discharge may be important in understanding functional prognosis and recovery after hospitalization for COVID-19.

Pediatric Nirmatrelvir/Ritonavir Prescribing Patterns During the COVID-19 Pandemic.

Objective: This study was conducted to identify rates of pediatric nirmatrelvir/ritonavir (Paxlovid) prescriptions overall and by patient characteristics. Methods: Patients up to 23 years old with a clinical encounter and a nirmatrelvir/ritonavir (Paxlovid, n/r) prescription in a PEDSnet-affiliated institution between December 1, 2021 and September 14, 2022 were identified using electronic health record (EHR) data. Results: Of the 1,496,621 patients with clinical encounters during the study period, 920 received a nirmatrelvir/ritonavir prescription (mean age 17.2 years; SD 2.76 years). 40% (367/920) of prescriptions were provided to individuals aged 18-23, and 91% (838/920) of prescriptions occurred after April 1, 2022. The majority of patients (70%; 648/920) had received at least one COVID-19 vaccine dose at least 28 days before nirmatrelvir/ritonavir prescription. Only 40% (371/920) of individuals had documented COVID-19 within the 0 to 6 days prior to receiving a nirmatrelvir/ritonavir prescription. 53% (485/920) had no documented COVID-19 infection in the EHR. Among nirmatrelvir/ritonavir prescription recipients, 64% (586/920) had chronic or complex chronic disease and 9% (80/920) had malignant disease. 38/920 (4.5%) were hospitalized within 30 days of receiving nirmatrelvir/ritonavir. Conclusion: Clinicians prescribe nirmatrelvir/ritonavir infrequently to children. While individuals receiving nirmatrelvir/ritonavir generally have significant chronic disease burden, a majority are receiving nirmatrelvir/ritonavir prescriptions without an EHR-recorded COVID-19 positive test or diagnosis. Development and implementation of concerted pediatric nirmatrelvir/ritonavir prescribing workflows can help better capture COVID-19 presentation, response, and adverse events at the population level.

Neuropathogenesis of severe acute respiratory syndrome coronavirus 2.

PURPOSE OF REVIEW: The purpose of this review is to address our current understanding of the pathophysiology of neurologic injury resulting from severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection on the developing nervous system. RECENT FINDINGS: SARS-CoV2 may enter the brain through three potential mechanisms: transsynaptic spread from the olfactory bulb following intranasal exposure, migration across the blood-brain barrier through endothelial cell infection, and migration following disruption of the blood-brain barrier from resulting inflammation. SARS-CoV2 does not appear to directly infect neurons but rather may produce an inflammatory cascade that results in neuronal injury. Additionally, autoantibodies targeting neuronal tissue resulting from the immune response to SARS-CoV2 are present in select patients and may contribute to central nervous system (CNS) injury. SUMMARY: These findings suggest that neuronal injury during SARS-CoV2 infection is immune mediated rather than through direct viral invasion. Further multimodal studies evaluating the pathophysiology of neurologic conditions in pediatric patients specifically following SARS-CoV2 infection are needed to improve our understanding of mechanisms driving neurologic injury and to identify potential treatment options.

Behavioral impairment and cognition in Thai adolescents affected by HIV.

BACKGROUND: Cognitive and behavioral impairment are common in children living with perinatally acquired HIV (pHIV) and children exposed to HIV in utero but uninfected (HEU). METHODS: We sought to determine the prevalence of adverse behavioral symptomatology using a Thai-translated and validated version of the SNAP-IV questionnaire and assess cognitive function utilizing the Children's Color Trails Test, Delis-Kaplan Executive Function System, and the Wechsler Intelligence Scales, in our cohort of Thai adolescents (10-20 years old) with well-controlled pHIV compared to HEU and HIV-unexposed, uninfected youth. We then evaluated the interaction between HIV status, behavioral impairment, and executive function outcomes independent of demographic variables. RESULTS: After controlling for demographic factors of age and household income, adolescents with pHIV had higher inattentive symptomatology and poorer neuropsychological test scores compared to uninfected controls. Significant interactions were found between inattention and executive function across multiple neurocognitive tests. CONCLUSIONS: Behavioral impairment and poor executive functioning are present in adolescents with well-controlled pHIV compared to HIV-uninfected matched peers. The SNAP-IV questionnaire may be a useful tool to identify those with attentional impairment who may benefit from further cognitive testing in resource-limited settings.

Trajectory Analysis of Cognitive Outcomes in Children With Perinatal HIV.

BACKGROUND: Children with perinatal HIV (pHIV) may display distinct long-term cognitive phenotypes. We used group-based trajectory modeling to identify clusters of children with pHIV after similar developmental trajectories and predictors of belonging to select cognitive trajectory groups. METHODS: Participants included children, 4-17 years of age, with pHIV in Thailand and Cambodia. Cognitive measures included translated versions of Intelligence Quotient tests, Color Trails Tests and Beery-Buktenica Developmental Test of Visual-Motor Integration conducted semiannually over 3-6 years. The best fit of trajectory groups was determined using maximum likelihood estimation. Multivariate logistic regression identified baseline factors associated with belonging to the lowest scoring trajectory group. RESULTS: Group-based trajectory analyses revealed a 3-cluster classification for each cognitive test, labeled as high, medium and low scoring groups. Most trajectory group scores remained stable across age. Verbal IQ declined in all 3 trajectory groups and the high scoring group for Children's Color Trails Test 1 and 2 showed an increase in scores across age. Children in the lowest scoring trajectory group were more likely to present at an older age and report lower household income. CONCLUSIONS: Group-based trajectory modeling succinctly classifies cohort heterogeneity in cognitive outcomes in pHIV. Most trajectories remained stable across age suggesting that cognitive potential is likely determined at an early age with the exception of a small subgroup of children who displayed developmental gains in select cognitive domains and may represent those with better cognitive reserve. Poverty and longer duration of untreated HIV may predispose children with pHIV to suboptimal cognitive development.

Sociodemographic Factors Associated With Hospital Care for Pediatric Migraine: A National Study Using the Kids' Inpatient Dataset.

BACKGROUND: Although migraine often starts in childhood or adolescence, hospital care for migraine in children is not well described. We examined patient and hospital characteristics associated with hospital care for migraine among children in the United States. METHODS: We queried the Kids' Inpatient Database (2003 to 2009) for hospitalizations of children aged 3-20. Sociodemographic and hospital characteristics were compared between hospitalizations for migraine and for other common medical conditions. Multivariate logistic regression models estimated the associations between patient, hospital, and socioeconomic characteristics and inpatient migraine care. RESULTS: We identified 11,696 pediatric migraine hospitalizations, the majority (68.7%) occurring at teaching hospitals, involving a female (68.8%) child, ages 13-20 (71%, mean age: 14.6 years). As compared to the overall inpatient sample, migraine hospitalizations were less likely to involve children who were Black (adjusted odds ratio [AOR] 0.54, 95% confidence interval [CI] 0.49 to 0.60), Hispanic (AOR = 0.58, 95% CI 0.50 to 0.68), or Asian (AOR = 0.42, 95% CI 0.32 to 0.55), and more likely to involve females (AOR = 1.49, 95% CI 1.40 to 1.59). Migraine inpatients were more likely to live in higher income postal ZIP code areas (versus lowest ZIP code income quartile: AOR = 1.32, 95% CI 1.18 to 1.48). The average length of stay for migraine was 2.54 (SEM 0.6) days. CONCLUSIONS: Children who are hospitalized for migraines have distinct sociodemographic characteristics and a short length of stay. Understanding the reasons for these variations will inform the design of interventions aimed at reducing the need for pediatric migraine hospitalization.

Global Health Neurology: HIV/AIDS.

With the advent of combination antiretroviral therapies, the mortality rate from HIV has declined, while the prevalence of long-term HIV-related neurologic complications continues to rise. Thirty-six million individuals are living with HIV around the world, many of whom reside in resource-limited settings. The majority of studies have focused on individuals residing in the developed world, while the impact of HIV disproportionately affects people living in developing countries. This review focuses on recent domestic and international studies regarding neurologic complications related to HIV, including opportunistic infections, peripheral neuropathy, cerebrovascular disease, and HIV-associated neurocognitive disorders, in light of the growing population affected by these conditions.