Missed Opportunities for Preventing Perinatal Transmission of Human Immunodeficiency Virus, Florida, 2007-2014.

OBJECTIVES: Despite declining numbers of perinatally exposed infants, an increase in perinatal human immunodeficiency virus (HIV) infections from 2011 to 2013 prompted this study to identify missed perinatal HIV prevention opportunities. METHODS: Deidentified records of children born from 2007 through 2014, exposed to HIV perinatally, and reported to the Florida Department of Health were obtained. Crude relative risks (RRs) and 95% confidence intervals (CIs) for factors associated with perinatal transmission, nondiagnosis of maternal HIV infection, and nonreceipt of antiretroviral medication were calculated. RESULTS: Of the 4337 known singleton births exposed to maternal HIV infection, 70 (1.6%) were perinatally infected. Among perinatal transmission cases, more than one-third of mothers used illegal drugs or acquired a sexually transmitted infection during pregnancy. Perinatal transmission was most strongly associated with maternal HIV diagnosis during labor and delivery (RR 5.66, 95% CI 2.31-13.91) or after birth (RR 26.50, 95% CI 15.44-45.49) compared with antenatally or prenatally. Among the 29 women whose infection was not known before pregnancy and whose child was perinatally infected, 18 were not diagnosed during pregnancy; 12 had evidence of an acute HIV infection, and 6 had no prenatal care. CONCLUSIONS: Late diagnosis of maternal HIV infection appeared to be primarily the result of acute maternal infections and inadequate prenatal care. In Florida, effective programs to improve utilization of prenatal care and detection and primary prevention of prenatal acute infection are needed.

Risk factors for alcohol relapse following orthotopic liver transplantation: a systematic review.

BACKGROUND: Each year, 5000-6000 individuals undergo orthotopic liver transplantation (OLT) in the United States, and of these, nearly 18% have alcoholic liver disease. Relapse to alcohol occurs in more than 40% of patients with OLT for alcoholic liver disease. OBJECTIVES: We sought to identify factors that predict relapse to alcohol or medication nonadherence following OLT in patients with alcoholic liver disease and to review what randomized clinical interventions have addressed these factors following OLT. Our hypothesis was that there would be factors before and after OLT that predict relapse to alcohol following OLT, and that these, if targeted, might improve sobriety and associated outcomes of adherence with medications and appointments. METHODS: We performed a review (focusing on articles published since 2004) with PubMed and MEDLINE searches using the following search terms: liver transplantation, recidivism, alcohol relapse, and predictors of alcohol relapse. We supplemented the online searches with manual reviews of article reference lists and selected relevant articles for further review by author consensus. RESULTS: In largely white populations, prospective studies document that shorter length of pretransplantation sobriety is a significant predictor of time to first drink and time to binge use. Presence of psychiatric comorbidity, high score on standardized High-risk Alcoholism Relapse Scale, and diagnosis of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) alcohol dependence are predictive of posttransplantation alcohol relapse. Pretransplantation alcohol use history variables (e.g., family history of alcoholism) reliably discriminate between complete abstainers and those who drink, while medical and psychosocial characteristics at early post-liver transplantation period (e.g., more bodily pain) maximally discriminate patterns of alcohol use. Alcoholic individuals with early-onset, rapidly accelerating moderate use and early-onset, continuously increasing heavy use have more than double the prevalence of steatohepatitis or rejection on biopsy and graft failure and more frequent mortality resulting from recurrent alcoholic liver disease than late-onset (i.e., peak of heaviest drinking at 6y posttransplantation) alcohol users do. Fortunately, pretransplantation screening combined with a structured pretransplantation management program and a 12-step program attendance reduced recidivism. No randomized clinical trials have been performed that target pretransplantation risk factors in individuals with alcoholic liver disease before or after OLT to improve post-OLT outcomes. CONCLUSIONS: Recent research findings suggest that screening can reveal individuals who are vulnerable to alcohol relapse and targeted intervention can prevent their relapse to alcohol. Based on existing addiction treatments (e.g., relapse prevention plan construction), randomized clinical trials tailored to post-OLT patients should be conducted to improve their survival and quality of life.

Factors associated with the prescribing of olanzapine, quetiapine, and risperidone in patients with bipolar and related affective disorders.

STUDY OBJECTIVE: To identify the factors associated with newly prescribed, first-line, second-generation antipsychotics (SgAs) associated with weight gain-olanzapine, risperidone, and quetiapine. DESIGN: Retrospective medical record review. SETTING: Outpatient and inpatient psychiatry services at a tertiary care, academic medical center. PATIENTS: Three hundred forty consecutive adults who had major depressive disorder with psychotic features, bipolar I, bipolar II, bipolar not otherwise specified, or schizoaffective disorder over two time periods (August 30-October 30, 2009, and April 1-May 31, 2010). MEASUREMENTS AND MAIN RESULTS: Clinical and sociodemographic variables associated with newly prescribed olanzapine, risperidone, and quetiapine were identified by using univariate and multivariate logistic regression. Several clinical factors were individually associated with initiation of these SgAs: mania (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.2-10.8, p=0.02), psychosis (OR 3.3, 95% CI 1.5-6.9, p=0.002), and inpatient treatment (OR 3.8, 95% CI 1.8-7.9, p=0.0005). Prevalent use of lithium (OR 0.3, 95% CI 0.1-0.9, p=0.03) and being married (OR 0.3, 95% CI 0.1-0.8, p=0.02) were inversely associated with new use of an SgA. Mania, psychosis, married status, and lithium use remained independently associated on multivariate analysis. Factors related to metabolic or vascular risk were not associated with SgA initiation. CONCLUSION: Psychiatric clinicians were influenced heavily by clinical features related to mental status and acuity when determining whether to prescribe SgAs. However, factors related to vascular risk were not associated. Future observational studies should consider current clinical status as an important factor in determining propensity to receive antipsychotics or other short-term treatments for bipolar and related disorders.

Mania and mortality: why the excess cardiovascular risk in bipolar disorder?

Individuals with bipolar disorder experience twice the cardiovascular mortality expected from general population estimates. The metabolic syndrome is more common in those with bipolar disorder, with a prevalence ratio of 1.6, and includes many traditional cardiovascular risk factors, which may explain much of the elevated risk. Manic symptom burden also predicts cardiovascular mortality, begging questions regarding other explanations for elevated cardiovascular risk. Ultimately, the mechanisms that lead to elevated cardiovascular risk in bipolar disorder are complex and potentially involve behavior, treatment, access to quality health care, and underlying pathophysiology. Much remains unknown about the etiology of any mechanisms inherent to illness or, for that matter, treatment effects. Addressing access and health behaviors can mitigate risk for individuals with bipolar disorder. Recent evidence indicates that psychiatrists are becoming aware of the vascular risk associated with bipolar disorder, although further education will improve monitoring and subsequent outcomes.