RESUMO
HIV pre-exposure prophyalxis (PrEP) might lead individuals to view serodisclosure as unnecessary. We examined the prevalence of non-disclosure and lack of knowledge of partner status in a global cohort of men who have sex with men (MSM) and transgender women (TW) enrolled in the iPrEx Open Label Extension (OLE). We calculated prevalence ratios by fitting a logistic model and estimating predicted probabilities using marginal standardization. Prevalence of non-disclosure and lack of knowledge of partner status were highest in Thailand (73% and 74%, respectively) and lowest in the USA (23% and 37%, respectively). In adjusted analyses, PrEP use was not significantly associated with non-disclosure or lack of knowledge of partner status (p-values>0.05). We found that relationship characteristics were significantly associated with both outcomes. Non-disclosure was higher among casual (adjusted prevalence ratio [aPR] 1.54, [95% confidence interval 1.24-1.84]) and transactional sex partners (aPR 2.03, [1.44-2.62]), and among partners whom participants have known only minutes or hours before their first sexual encounter (aPR 1.62, [1.33-1.92]). Similarly, participants were less likely to know the HIV status of casual partners (aPR 1.50, [1.30-1.71]), transactional sex partners (aPR 1.62, [1.30-1.95]), and those they have known for only days or weeks (aPR 1.13, [0.99-1.27]) or minutes or hours (aPR 1.27, [1.11-1.42]). Our findings underscore the role of dyadic factors in influencing serodisclosure. Comprehensive risk reduction counseling provided in conjunction with PrEP that address relationship characteristics are needed to help patients navigate discussions around HIV status.
Assuntos
Infecções por HIV/prevenção & controle , Profilaxia Pré-Exposição/estatística & dados numéricos , Autorrevelação , Adulto , Idoso , Feminino , Infecções por HIV/diagnóstico , Homossexualidade Masculina , Humanos , Relações Interpessoais , Masculino , Pessoa de Meia-Idade , Parceiros Sexuais , África do Sul , América do Sul , Tailândia , Pessoas Transgênero , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: As pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine for the prevention of HIV infection is rolled out internationally, strategies to maintain effectiveness and to minimise adverse effects merit consideration. In this study, we aimed to assess reductions in renal function and predictors of renal toxicity in a large open-label study of PrEP. METHODS: As part of the iPrEx open-label extension (OLE) study, men who have sex with men or transgender women aged 18-70 years who were HIV negative and had participated in three previous PrEP trials from Brazil, Ecuador, Peru, South Africa, Thailand, and the USA were enrolled into an open-label PrEP study. There were no restrictions on current renal function for enrolment into iPrEx OLE, in which participants were given combination tablets of tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) and advised to take one tablet per day. At follow-up sessions every 12 weeks, participants' creatinine clearance on PrEP was estimated and in a subset of participants, hair samples were collected to measure tenofovir and emtricitabine concentrations (a measure of adherence and exposure) via liquid-chromatography-tandem-mass-spectrometry. Reductions in creatinine clearance from baseline were calculated and predictors of decline were identified by use of multivariate models. iPrEx is registered with ClinicalTrials.com, number NCT00458393. FINDINGS: Baseline characteristics were similar between all participants in iPrEx-OLE (1224 participants with 7475 person-visits) and those participating in the hair substudy (220 participants with 1114 person-visits). During a median of 72 weeks, the mean decline in creatinine clearance was -2·9% (95% CI -2·4 to -3·4; ptrend<0·0001), but declines were greater for those who started PrEP at older ages: participants aged 40-50 years at baseline had declines of -4·2% (95% CI -2·8 to -5·5) and participants older than 50 years at baseline had declines of -4·9% (-3·1 to -6·8). In multivariate models, age and baseline creatinine clearance less than 90 mL/min predicted declines in renal function. We identified a monotonic association between percentage decrease in creatinine clearance and the number of doses of tenofovir disoproxil fumarate and emtricitabine taken per week, as estimated by hair concentrations of tenofovir and emtricitabine (ptrend=0·008). INTERPRETATION: Our data suggest that the frequency of safety monitoring for PrEP might need to be different between age groups and that pharmacological measures can monitor for toxic effects as well as adherence. FUNDING: National Institutes of Health.
Assuntos
Fármacos Anti-HIV/efeitos adversos , Creatinina/sangue , Infecções por HIV/prevenção & controle , Profilaxia Pré-Exposição , Adulto , Fatores Etários , Fármacos Anti-HIV/análise , Fármacos Anti-HIV/uso terapêutico , Brasil/epidemiologia , Estudos de Coortes , Equador/epidemiologia , Emtricitabina/efeitos adversos , Emtricitabina/análise , Emtricitabina/uso terapêutico , Feminino , Infecções por HIV/virologia , Cabelo/química , Humanos , Testes de Função Renal , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Peru/epidemiologia , África do Sul , Tenofovir/efeitos adversos , Tenofovir/análise , Tenofovir/uso terapêutico , Tailândia/epidemiologiaAssuntos
Infecções por HIV , Profilaxia Pré-Exposição , Fármacos Anti-HIV , Brasil , Feminino , Humanos , Adesão à MedicaçãoRESUMO
OBJECTIVE: To determine the contemporary etiology, burden, and short-term outcomes of seizures in neonates monitored with continuous video-electroencephalogram (cEEG). STUDY DESIGN: We prospectively collected data from 426 consecutive neonates (56% male, 88% term) ≤44 weeks' postmenstrual age with clinically suspected seizures and/or electrographic seizures. Subjects were assessed between January 2013 and April 2015 at 7 US tertiary care pediatric centers following the guidelines of the American Clinical Neurophysiology Society for cEEG for at-risk neonates. Seizure etiology, burden, management, and outcome were determined by chart review by the use of a case report form designed at study onset. RESULTS: The most common seizure etiologies were hypoxic-ischemic encephalopathy (38%), ischemic stroke (18%), and intracranial hemorrhage (11%). Seizure burden was high, with 59% having ≥7 electrographic seizures and 16% having status epilepticus; 52% received ≥2 antiseizure medications. During the neonatal admission, 17% died; 49% of survivors had abnormal neurologic examination at hospital discharge. In an adjusted analysis, high seizure burden was a significant risk factor for mortality, length of hospital stay, and abnormal neurological examination at discharge. CONCLUSIONS: In this large contemporary profile of consecutively enrolled newborns with seizures treated at centers that use cEEG per the guidelines of the American Clinical Neurophysiology Society, about one-half had high seizure burden, received ≥2 antiseizure medications, and/or died or had abnormal examination at discharge. Greater seizure burden was associated with increased morbidity and mortality. These findings underscore the importance of accurate determination of neonatal seizure frequency and etiology and a potential for improved outcome if seizure burden is reduced.
Assuntos
Doenças do Prematuro/etiologia , Convulsões/etiologia , Anticonvulsivantes/uso terapêutico , Estudos de Coortes , Eletroencefalografia , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/tratamento farmacológico , Doenças do Prematuro/mortalidade , Tempo de Internação , Masculino , Avaliação de Resultados em Cuidados de Saúde , Convulsões/tratamento farmacológico , Convulsões/mortalidadeRESUMO
BACKGROUND: Pre-exposure prophylaxis (PrEP) with oral emtricitabine and tenofovir disoproxil fumarate is used to prevent the sexual acquisition of HIV in groups at high risk such as transgender women. We used data from the iPrEx study to assess PrEP efficacy, effectiveness, and adherence in transgender women. METHODS: The iPrEx trial was a randomised controlled trial of PrEP with oral emtricitabine plus tenofovir disoproxil fumarate compared with placebo in men who have sex with men (MSM) and transgender women, followed by an open-label extension. Drug concentrations were measured in blood by liquid chromatography and tandem mass spectroscopy. We did unplanned exploratory analyses to investigate differences in PrEP outcomes among transgender women and between transgender women and MSM. FINDINGS: Of the 2499 participants enrolled in the randomised controlled trial, 29 (1%) identified as women, 296 (12%) identified as trans, 14 (1%) identified as men but reported use of feminising hormones, such that 339 (14%) reported one or more characteristics and are classified as transgender women for the purpose of this study. Compared with MSM, transgender women more frequently reported transactional sex, receptive anal intercourse without a condom, or more than five partners in the past 3 months. Among transgender women, there were 11 HIV infections in the PrEP group and ten in the placebo group (hazard ratio 1·1, 95% CI 0·5-2·7). In the PrEP group, drug was detected in none of the transgender women at the seroconversion visit, six (18%) of 33 seronegative transgender women (p=0·31), and 58 (52%) of 111 seronegative MSM (p<0·0001). PrEP use was not linked to behavioural indicators of HIV risk among transgender women, whereas MSM at highest risk were more adherent. INTERPRETATION: PrEP seems to be effective in preventing HIV acquisition in transgender women when taken, but there seem to be barriers to adherence, particularly among those at the most risk. Studies of PrEP use in transgender women populations should be designed and tailored specifically for this population, rather than adapted from or subsumed into studies of MSM. FUNDING: US National Institutes of Health and the Bill & Melinda Gates Foundation.
Assuntos
Fármacos Anti-HIV/administração & dosagem , Preservativos/estatística & dados numéricos , Emtricitabina/administração & dosagem , Infecções por HIV/prevenção & controle , Adesão à Medicação/psicologia , Profilaxia Pré-Exposição , Tenofovir/administração & dosagem , Pessoas Transgênero , Adulto , Brasil/epidemiologia , Ensaios Clínicos Fase III como Assunto , Prestação Integrada de Cuidados de Saúde , Aconselhamento Diretivo/métodos , Equador/epidemiologia , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/psicologia , Homossexualidade Masculina , Humanos , Masculino , Adesão à Medicação/estatística & dados numéricos , Peru/epidemiologia , Parceiros Sexuais/psicologia , África do Sul/epidemiologia , Tailândia/epidemiologia , Pessoas Transgênero/psicologia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To determine the rate of magnetic resonance imaging (MRI)-detected noncystic white matter injury (WMI) in a prospective cohort of premature newborns, and to evaluate its associations with changes in clinical predictors of WMI over the study period. STUDY DESIGN: A prospective cohort of premature newborns (<33 weeks gestational age) was studied with MRI within 4 weeks of birth and near term-equivalent age. A pediatric neuroradiologist scored the severity of WMI on T1-weighted MRI according to published criteria. WMI was classified as none/mild or moderate/severe. Subjects with severe cystic WMI, periventricular hemorrhagic infarction, or motion artifact on MRI were excluded. Changes in clinical characteristics and predictors of WMI over the study period (1998-2011) were evaluated. Predictors of moderate/severe WMI, including birth year, were evaluated using multivariate logistic regression. RESULTS: Among 267 newborns, 45 (17%) had moderate/severe WMI. The rate of moderate/severe WMI decreased over the study period (P = .002, χ(2) test for trends). On multivariate logistic regression, the odds of moderate/severe WMI decreased by 11% for each birth year of the cohort (OR, 0.89; 95% CI, 0.81-0.98; P = .02). Prolonged exposure to indomethacin also was independently associated with reduced odds of moderate/severe WMI. CONCLUSION: The decreasing burden of MRI-detected moderate/severe noncystic WMI in our cohort of premature newborns is independent over time of changes in the known clinical predictors of WMI. Prolonged exposure to indomethacin is associated with reduced WMI.
Assuntos
Dano Encefálico Crônico/fisiopatologia , Recém-Nascido Prematuro , Imageamento por Ressonância Magnética/métodos , Substância Branca/lesões , Anti-Inflamatórios não Esteroides/administração & dosagem , Dano Encefálico Crônico/diagnóstico , Dano Encefálico Crônico/prevenção & controle , California , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Indometacina/administração & dosagem , Recém-Nascido , Modelos Logísticos , Masculino , Estudos Prospectivos , Fatores de Risco , Substância Branca/patologiaRESUMO
HIV-testing algorithms for preexposure prophylaxis (PrEP) should be optimized to minimize the risk of drug resistance, the time off PrEP required to evaluate false-positive screening results, and costs and to expedite the start of therapy for those confirmed to be infected. HIV rapid tests (RTs) for anti-HIV antibodies provide results in less than 1 h and can be conducted by nonlicensed staff at the point of care. In many regions, Western blot (WB) testing is required to confirm reactive RT results. WB testing, however, causes delays in diagnosis and adds expense. The iPrEx study evaluated the safety and efficacy of daily oral emtricitabine-tenofovir disoproxil fumarate among HIV-seronegative men and transgender women who have sex with men: HIV infection was assessed with two RTs plus WB confirmation, followed by HIV-1 plasma viral load testing. During the iPrEx study, there were 51,260 HIV status evaluations among 2,499 volunteers using RTs: 142 (0.28%) had concordant positive results (100% were eventually confirmed) and 19 (0.04%) had discordant results among 14 participants; 11 were eventually determined to be HIV infected. A streamlined approach using only one RT to screen and a second RT to confirm (without WB) would have had nearly the same accuracy. Discrepant RT results are best evaluated with nucleic acid testing, which would also increase sensitivity.
Assuntos
Infecções por HIV/diagnóstico , Infecções por HIV/virologia , HIV-1/classificação , Profilaxia Pré-Exposição , Adulto , Algoritmos , Fármacos Anti-HIV/uso terapêutico , Feminino , Seguimentos , Infecções por HIV/prevenção & controle , Humanos , Imunoensaio/métodos , Masculino , Reação em Cadeia da Polimerase , Pré-Medicação , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: To evaluate the concordance between adherence estimated by self-report (in-person interview or computer-assisted self-interview), in-clinic pill counts, and pharmacy dispensation records and drug detection among participants in a placebo-controlled pre-exposure prophylaxis HIV prevention trial (iPrEx). DESIGN: Cross-sectional evaluation of 510 participants who had drug concentration data and matched adherence assessments from their week-24 study visit. METHODS: Self-reported adherence collected through (1) interview and (2) computer-assisted self-interview surveys, (3) adherence estimated by pill count, and (4) medication possession ratio was contrasted to having a detectable level of drug concentrations [either tenofovir diphosphate (TFV-DP) or emtricitabine triphosphate (FTC-TP)], as well as to having evidence of consistent dosing (tenofovir diphosphate ≥ 16 fmol/106 cells), focusing on positive predictive values, overall and by research site. RESULTS: Overall, self-report and pharmacy records suggested high rates of product use (over 90% adherence); however, large discrepancies between these measures and drug detection were noted, which varied considerably between sites (positive predictive values from 34% to 62%). Measures of adherence performed generally well in the US sites but had poor accuracy in other research locations. Medication possession ratio outperformed other measures but still had relatively low discrimination. CONCLUSIONS: The sizable discrepancy between adherence measures and drug detection in certain regions highlights the potential contribution of factors that may have incentivized efforts to seem adherent. Understanding the processes driving adherence reporting in some settings, but not others, is essential for finding effective ways to increase accuracy in measurement of product use and may generalize to promotion efforts for open-label pre-exposure prophylaxis.
Assuntos
Fármacos Anti-HIV/administração & dosagem , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/prevenção & controle , Adesão à Medicação , Adulto , Fármacos Anti-HIV/sangue , Feminino , Saúde Global , Infecções por HIV/sangue , Humanos , Masculino , Pessoas Transgênero , Adulto JovemRESUMO
BACKGROUND: For maximum effect pre-exposure prophylaxis should be targeted to the subpopulations that account for the largest proportion of infections (population-attributable fraction [PAF]) and for whom the number needed to treat (NNT) to prevent infection is lowest. We aimed to estimate the PAF and NNT of participants in the iPrEx (Pre-Exposure Prophylaxis Initiative) trial. METHODS: The iPrEx study was a randomised controlled efficacy trial of pre-exposure prophylaxis with coformulated tenofovir disoproxil fumarate and emtricitabine in 2499 men who have sex with men (MSM) and transgender women. Participants aged 18 years or older who were male at birth were enrolled from 11 trial sites in Brazil, Ecuador, Peru, South Africa, Thailand, and the USA. Participants were randomly assigned (1:1) to receive either a pill with active pre-exposure prophylaxis or placebo, taken daily. We calculated the association between demographic and risk behaviour during screening and subsequent seroconversion among placebo recipients using a Poisson model, and we calculated the PAF and NNT for risk behaviour subgroups. The iPrEx trial is registered with ClinicalTrials.gov, NCT00458393. FINDINGS: Patients were enrolled between July 10, 2007, and Dec 17, 2009, and were followed up until Nov 21, 2010. Of the 2499 MSM and transgender women in the iPrEx trial, 1251 were assigned to pre-exposure prophylaxis and 1248 to placebo. 83 of 1248 patients in the placebo group became infected with HIV during follow-up. Participants reporting receptive anal intercourse without a condom seroconverted significantly more often than those reporting no anal sex without a condom (adjusted hazard ratio [AHR] 5·11, 95% CI 1·55-16·79). The overall PAF for MSM and transgender women reporting receptive anal intercourse without a condom was 64% (prevalence 60%). Most of this risk came from receptive anal intercourse without a condom with partners with unknown serostatus (PAF 53%, prevalence 54%, AHR 4·76, 95% CI 1·44-15·71); by contrast, the PAF for receptive anal intercourse without a condom with an HIV-positive partner was 1% (prevalence 1%, AHR 7·11, 95% CI 0·70-72·75). The overall NNT per year for the cohort was 62 (95% CI 44-147). NNTs were lowest for MSM and transgender women self-reporting receptive anal intercourse without a condom (NNT 36), cocaine use (12), or a sexually transmitted infection (41). Having one partner and insertive anal sex without a condom had the highest NNTs (100 and 77, respectively). INTERPRETATION: Pre-exposure prophylaxis may be most effective at a population level if targeted toward MSM and transgender women who report receptive anal intercourse without a condom, even if they perceive their partners to be HIV negative. Substance use history and testing for STIs should also inform individual decisions to start pre-exposure prophylaxis. Consideration of the PAF and NNT can aid in discussion of the benefits and risks of pre-exposure prophylaxis with MSM and transgender women. FUNDING: National Institute of Allergy and Infectious Diseases and the Bill & Melinda Gates Foundation.
Assuntos
Antivirais/administração & dosagem , Infecções por HIV/prevenção & controle , Homossexualidade Masculina/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/prevenção & controle , Pessoas Transgênero/estatística & dados numéricos , Adenina/administração & dosagem , Adenina/análogos & derivados , Adolescente , Adulto , Preservativos/estatística & dados numéricos , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Emtricitabina , Feminino , Soropositividade para HIV , Humanos , Masculino , Ácidos Fosforosos/administração & dosagem , Parceiros Sexuais , África do Sul , América do Sul , Tailândia , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To investigate the relationship between cerebellar hemorrhage in preterm infants seen on magnetic resonance imaging (MRI), but not on ultrasonography, and neurodevelopmental outcome. STUDY DESIGN: Images from a cohort study of MRI in preterm newborns were reviewed for cerebellar hemorrhage. The children were assessed at a mean age of 4.8 years with neurologic examination and developmental testing using the Wechsler Preschool and Primary Scale of Intelligence, Third Edition. RESULTS: Cerebellar hemorrhage was detected on both ultrasonography and MRI in 3 of the 131 preterm newborns evaluated, whereas smaller hemorrhages were seen only on MRI in 10 newborns (total incidence, 10%). Adjusting for gestational age at birth, intraventricular hemorrhage, and white matter injury, cerebellar hemorrhage detectable solely by MRI was associated with a 5-fold increased odds of abnormal neurologic examination compared with newborns without cerebellar hemorrhage (outcome data in 74%). No association with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition score was found. CONCLUSIONS: Cerebellar hemorrhage is not uncommon in preterm newborns. Although associated with neurologic abnormalities, hemorrhage seen only on MRI is associated with much more optimistic outcomes than that visible on ultrasonography.
Assuntos
Cerebelo/patologia , Hemorragia Cerebral/patologia , Deficiências do Desenvolvimento/etiologia , Recém-Nascido Prematuro , Imageamento por Ressonância Magnética/métodos , Estudos de Casos e Controles , Hemorragia Cerebral/complicações , Hemorragia Cerebral/diagnóstico por imagem , Pré-Escolar , Estudos de Coortes , Deficiências do Desenvolvimento/epidemiologia , Deficiências do Desenvolvimento/fisiopatologia , Feminino , Seguimentos , Humanos , Incidência , Lactente , Recém-Nascido , Testes de Inteligência , Modelos Lineares , Modelos Logísticos , Masculino , Exame Neurológico/métodos , Medição de Risco , Índice de Gravidade de Doença , Ultrassonografia DopplerRESUMO
OBJECTIVE: To hypothesize that detailed examination of early cerebellar volumes in time would distinguish differences in cerebellar growth associated with intraventricular hemorrhage (IVH) and white matter injury in preterm infants. STUDY DESIGN: Preterm newborns at the University of California San Francisco (n = 57) and the University of British Columbia (n = 115) were studied with serial magnetic resonance imaging scans near birth and again at near term-equivalent age. Interactive semi-automated tools were used to determine volumes of the cerebellar hemispheres. RESULTS: Adjusting for supratentorial brain injury, cerebellar hemorrhage, and study site, cerebellar volume increased 1.7 cm(3)/week postmenstrual age (95% CI, 1.6-1.7; P < .001). More severe supratentorial IVH was associated with slower growth of cerebellar volumes (P < .001). Volumes by 40 weeks were 1.4 cm(3) lower in premature infants with grade 1 to 2 IVH and 5.4 cm(3) lower in infants with grade 3 to 4 IVH. The same magnitude of decrease was found between ipsilateral and contralateral IVH. No association was found with severity of white matter injury (P = .3). CONCLUSIONS: Early effects of decreased cerebellar volume associated with supratentorial IVH in either hemisphere may be a result of concurrent cerebellar injury or direct effects of subarachnoid blood on cerebellar development.
Assuntos
Lesões Encefálicas/patologia , Cerebelo/crescimento & desenvolvimento , Ventrículos Cerebrais , Recém-Nascido Prematuro , Hemorragias Intracranianas/patologia , Leucoencefalopatias/patologia , Cerebelo/irrigação sanguínea , Cerebelo/lesões , Feminino , Humanos , Imageamento Tridimensional , Recém-Nascido , Estudos Longitudinais , Imageamento por Ressonância Magnética , Masculino , Tamanho do Órgão , Análise de RegressãoRESUMO
OBJECTIVE: To examine whether neonatal seizures are associated with neurodevelopmental outcomes in infants with hypoxia-ischemia independent of the presence and severity of brain injury seen on magnetic resonance imaging (MRI). STUDY DESIGN: We used multivariate regression to examine the independent effect of clinical neonatal seizures and their treatment on neurodevelopment in 77 term newborns at risk for hypoxic-ischemic brain injury. Clinical seizures were recorded prospectively, and high-resolution newborn MRI measured the severity of brain injury. The outcome measure was the Full-Scale Intelligence Quotient (FSIQ) of the Wechsler Preschool and Primary Scale of Intelligence-Revised and neuromotor score at age 4 years. RESULTS: After controlling for severity of injury on MRI, the children with neonatal seizures had worse motor and cognitive outcomes compared with those without seizures. The magnitude of effect varied with seizure severity; children with severe seizures had a lower FSIQ than those with mild/moderate seizures (P < .0001). CONCLUSIONS: Clinical neonatal seizures in the setting of birth asphyxia are associated with worse neurodevelopmental outcome, independent of the severity of hypoxic-ischemic brain injury. Randomized controlled trials are needed to determine whether differences in seizure treatment can improve outcome.
Assuntos
Asfixia Neonatal/epidemiologia , Lesões Encefálicas/diagnóstico , Lesões Encefálicas/epidemiologia , Deficiências do Desenvolvimento/epidemiologia , Hipóxia-Isquemia Encefálica/epidemiologia , Convulsões/epidemiologia , Causalidade , Pré-Escolar , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/epidemiologia , Comorbidade , Deficiências do Desenvolvimento/diagnóstico , Feminino , Seguimentos , Humanos , Hipóxia-Isquemia Encefálica/diagnóstico , Recém-Nascido , Imageamento por Ressonância Magnética , Masculino , Transtornos das Habilidades Motoras/diagnóstico , Transtornos das Habilidades Motoras/epidemiologia , Estudos Prospectivos , Testes Psicológicos , Medição de Risco , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: To assess antenatal and intrapartum risk factors for seizures occurring during the birth admission. STUDY DESIGN: Using multivariable logistic regression analysis, we evaluated the association between maternal characteristics and birth admission seizures in a cohort of 2.3 million California children born at >or=36 weeks' gestation between 1998 and 2002 using the California Office of Statewide Planning and Development database containing birth certificates linked to infant and maternal hospital discharge abstracts. RESULTS: The incidence of seizures during the birth admission was 0.95/1000 live births. In an adjusted analysis, infants of women age 40 years and older who were nulliparous; had diabetes mellitus, intrapartum fever, or infection or delivered at >or=42 weeks had an increased risk of seizures. Infants of Hispanic and Asian mothers had a lower risk compared with infants of Caucasian mothers. CONCLUSIONS: Several maternal antenatal and intrapartum factors increased the risk of seizures during the birth admission. Identifying and avoiding risks for neonatal seizures may lead to lower infant neurologic morbidity and mortality.
Assuntos
Convulsões/epidemiologia , California/epidemiologia , Corioamnionite/epidemiologia , Feminino , Humanos , Incidência , Recém-Nascido , Idade Materna , Complicações do Trabalho de Parto/epidemiologia , Gravidez , Gravidez em Diabéticas/epidemiologia , Fatores de Risco , Convulsões/etnologiaRESUMO
OBJECTIVE: To determine the neurodevelopmental outcome of prematurely born newborns with magnetic resonance imaging (MRI) abnormalities. STUDY DESIGN: A total of 89 prematurely born newborns (median age 28 weeks postgestation) were studied with MRI when stable for transport to MRI (median age, 32 weeks postgestation); 50 newborns were studied again near term age (median age, 37 weeks). Neurodevelopmental outcome was determined at 18 months adjusted age (median) using the Mental Development Index (Bayley Scales Infant Development II) and a standardized neurologic exam. RESULTS: Of 86 neonatal survivors, outcome was normal in 51 (59%), borderline in 22 (26%), and abnormal in 13 (15%). Moderate/severe MRI abnormalities were common on the first (37%) and second (32%) scans. Abnormal outcome was associated with increasing severity of white matter injury, ventriculomegaly, and intraventricular hemorrhage on MRI, as well as moderate/severe abnormalities on the first (relative risk [RR] = 5.6; P = .002) and second MRI studies (RR = 5.3; P = .03). Neuromotor abnormalities on neurologic examination near term age (RR = 6.5; P = .04) and postnatal infection (RR = 4.0; P = .01) also increased the risk for abnormal neurodevelopmental outcome. CONCLUSIONS: In premature newborns, brain abnormalities are common on MRI early in life and are associated with adverse neurodevelopmental outcome.
Assuntos
Lesões Encefálicas/diagnóstico , Transtornos Cerebrovasculares/diagnóstico , Deficiências do Desenvolvimento/epidemiologia , Recém-Nascido Prematuro , Imageamento por Ressonância Magnética , Lesões Encefálicas/patologia , Estudos de Casos e Controles , Transtornos Cerebrovasculares/patologia , Feminino , Humanos , Recém-Nascido , Modelos Logísticos , Masculino , Análise Multivariada , Prognóstico , Estudos Prospectivos , Risco , Índice de Gravidade de Doença , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To determine whether the pattern of brain injury in term neonatal encephalopathy is associated with distinct prenatal and perinatal factors and to determine whether the pattern of injury is associated with 30-month neurodevelopmental outcome. STUDY DESIGN: A total of 173 term newborns with neonatal encephalopathy from 2 centers underwent magnetic resonance imaging (MRI) at a median of 6 days of age (range, 1-24 days). Patterns of injury on MRI were defined on the basis of the predominant site of injury: watershed predominant, basal ganglia/thalamus predominant, and normal. RESULTS: The watershed pattern of injury was seen in 78 newborns (45%), the basal ganglia/thalamus pattern was seen in 44 newborns (25%), and normal MRI studies were seen in 51 newborns (30%). Antenatal conditions such as maternal substance use, gestational diabetes, premature rupture of membranes, pre-eclampsia, and intra-uterine growth restriction did not differ across patterns. The basal ganglia/thalamus pattern was associated with more severe neonatal signs, including more intensive resuscitation at birth ( P = .001), more severe encephalopathy ( P = .0001), and more severe seizures ( P = .0001). The basal ganglia/thalamus pattern was associated with the most impaired motor and cognitive outcome at 30 months. CONCLUSION: The patterns of brain injury in term neonatal encephalopathy are associated with different clinical presentations and neurodevelopmental outcomes. Measured prenatal risk factors did not predict the pattern of brain injury.
Assuntos
Encefalopatias/diagnóstico , Lesões Encefálicas/diagnóstico , Imageamento por Ressonância Magnética , Encefalopatias/complicações , Lesões Encefálicas/complicações , Feminino , Humanos , Recém-Nascido , MasculinoRESUMO
BACKGROUND: Although Latinos constitute the largest and fastest growing minority group in the United States, little is known about the prevalence of renal disease among different Latino subgroups. METHODS: We used data from the Hispanic Health and Nutrition Examination Survey (HHANES) to compare serum creatinine measurements among Mexican Americans, mainland Puerto Ricans, and Cuban Americans. We compared estimated creatinine clearance across Latino subgroups adjusted for demographic, clinical, and socioeconomic characteristics (including known predictors of chronic kidney disease) using survey logistic regression analysis. RESULTS: Cuban Americans had higher mean serum creatinine levels than the other groups across both gender and age categories. In multivariable analysis, Puerto Ricans [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.16 to 2.60] and Cuban Americans (OR 4.59, CI 2.53 to 8.31) were more likely than the referent category of Mexican Americans to have an estimated creatinine clearance < 60 mL/min/1.73 m2. CONCLUSION: Serum creatinine levels differ substantially among Latino subgroups, suggesting national origin needs to be taken into consideration in studies of renal disease in Latinos. In addition, our findings highlight the need for more contemporary studies directly comparing both incidence rates of end-stage renal disease and measured renal function among Latino subgroups, perhaps leading to subgroup-specific prediction equations.
Assuntos
Creatinina/sangue , Hispânico ou Latino/estatística & dados numéricos , Nefropatias/etnologia , Americanos Mexicanos/estatística & dados numéricos , Inquéritos Nutricionais , Adulto , Feminino , Taxa de Filtração Glomerular , Humanos , Nefropatias/sangue , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To determine if the incidence of sonographically detected cystic periventricular leukomalacia (PVL) and periventricular hemorrhagic infarction (PVHI) have changed over the past decade and to determine if a decline in cystic PVL was associated with a change in neurodevelopmental outcome. STUDY DESIGN: Premature newborn infants admitted to our intensive care nursery from 1992 to 2002 were identified in a comprehensive nursery database. Premature newborn infants had routine neurosonography by means of a standardized protocol. Infants weighing < or =1500 g at birth surviving to nursery discharge were enrolled in a nursery follow-up clinic. RESULTS: Adjusting for gestational age, there was a significant decrease in cystic PVL from 1992 to 2002 (P=.003) without a concurrent decrease in PVHI (P=0.5). Cystic PVL and PVHI accounted for only 9 of the 28 cases of cerebral palsy and 12 of 90 cases of abnormal Developmental Scores in infants weighing <1500 g at birth. The decline in cystic PVL was not associated with improved developmental outcome from 1992 to 2002. CONCLUSIONS: The incidence of cystic PVL declined significantly from 1992 to 2002 at our center. Cystic PVL was detected by ultrasound in a minority of infants with abnormal neurodevelopmental outcome, indicating that other forms of cerebral injury account for the majority of abnormal neurodevelopmental outcomes in premature newborn infants.