Ayesha Mirza

A Double-Blind Taste Comparison of Pediatric Antibiotic Suspensions

This study examined the palatability of 22 antimicrobial suspensions by using five independent categories for scoring: appearance, smell, texture, taste, and aftertaste. The likely overall influence on patient compliance was also evaluated. Drugs were compared within their respective classes. The only antibiotics judged to be so unpalatable as to potentiallyjeopardize compliance were dicloxacillin, oxacillin, erythromycin/sulfisoxazole, and cefpodoxime. Among the penicillins, amoxicillin and ampicillin were preferred. Azithromycin was slightly superior to erythromycin and clarithromycin within the macrolide class. Many cephalosporins were ranked quite high, the best being loracarbef, cefadroxyl, cefprozil, and cefixime.

Continuous improvement in the immune system of HIV-infected children on prolonged antiretroviral therapy

Background: The goal of HAART is to promote reconstitution of CD4+ T cells and other immune responses. We evaluated the extent and the kinetics of immune reconstitution in HIV-infected children over 144 weeks of successful HAART. Methods: Thirty-seven children receiving their first HAART regimen had plasma HIV RNA; T cells and subpopulations; T-cell rearrangement excision circles (TREC) DNA; candida, HIVCD4 and HIVCD8 enzyme-linked immunospot measured at regular intervals. Results: Plasma HIV RNA became undetectable in 81% of patients at 24 weeks and remained undetectable in 77% at 144 weeks. In contrast, CD4+% continuously increased. Distribution of T-cell subpopulations changed rapidly during the first 48 weeks of HAART and more slowly thereafter. At 144 weeks, total, naive and activated CD4+% and naive CD8+% of HIV-infected children were not significantly different from those of healthy age-matched controls, whereas total and activated CD8+% remained elevated. CD4+ and CD8+ TREC content increased only during the first 48 weeks of HAART. They positively correlated with each other and with total CD4+%, naive CD4+% and naive CD8+%. Candida and HIVCD4 enzyme-linked immunospot increased over time reaching peak values at 48 weeks and 144 weeks, respectively. HIVCD8 enzyme-linked immunospot decreased in magnitude over 144 weeks of HAART but retained its breadth. Baseline CD4+% positively correlated with CD4+% and with functional immune reconstitution at week 144, whereas baseline TREC correlated with TREC at week 144. Conclusion: HIV-infected children acquired normal distribution of CD4+ T cells and other subpopulations and recovered CD4-mediated HIV immunity after 144 weeks of HAART.

Influenza vaccine: Awareness and barriers to immunization in families of children with chronic medical conditions other than asthma

Objectives: Children with chronic medical conditions (CMCs) are considered to be at increased risk for influenza and its related complications. Despite this, influenza immunization rates in the United States for children with CMCs in the primary care setting remain between 7–10%. This was a survey study looking at the barriers to influenza immunization among children with CMCs other than asthma. We examined caregiver knowledge and perceptions regarding influenza vaccine in addition to assessing other barriers, such as availability and perceived safety of the vaccine. Methods: The study was conducted during the fall-winter influenza seasons of 2002–2003 and 2003–2004 at five academic institutions across the southeastern US. Convenience samples of 100–150 families attending pediatric subspecialty clinics were surveyed. Results: A total of 794 surveys were completed. Controlling for disease, failure to recommend vaccination was significantly associated with failure to get the vaccine (P < 0.0001). Of the children who did not receive the vaccine, 61% of their parents believed that the vaccine itself could give influenza, 54% cited other safety concerns, and 30% thought it did not work. Among vaccine recipients, 163 (43%) reported that the primary care provider had given the vaccine, whereas 171 (45%) reported that the vaccine had been given at the subspecialty clinic. Conclusion: This study highlights the importance of physician recommendation, as well as parental education, as some of the key elements crucial to the receipt of influenza vaccination in children with CMCs.

Throat Culture Is Necessary After Negative Rapid Antigen Detection Tests

This study was conducted to determine if culture confirmation is needed for a negative rapid antigen detection test. Data on 18 509 tests done in patients younger than 18 years old were reviewed. Of the 14 167 (76.5%) that were negative, 968 (6.8%) were associated with positive cultures. No significant seasonal variation was noted. Significant differences were found between hospital and pediatric practices in the percentage of patients with a negative rapid antigen detection test who actually had group A β-hemolytic streptococcus (3.5% to 9.8%). This study supports the recommendation of culture confirmation of a negative rapid antigen detection test and validation of results within an individual practice if confirmatory cultures are not being performed. This study showed a high false-negative rate of the negative rapid antigen detection test and variation among hospital and pediatric practices for rates of positive culture after a negative rapid antigen detection test.

Psychiatric symptoms and antiretroviral nonadherence in US youth with perinatal HIV: a longitudinal study.

Objectives:The relationship of specific psychiatric conditions to adherence has not been examined in longitudinal studies of youth with perinatal HIV infection (PHIV). We examined associations between psychiatric conditions and antiretroviral nonadherence over 2 years. Design:Longitudinal study in 294 PHIV youth, 6–17 years old, in the United States and Puerto Rico. Methods:We annually assessed three nonadherence outcomes: missed above 5% of doses in the past 3 days, missed a dose within the past month, and unsuppressed viral load (>400 copies/ml). We fit multivariable logistic models for nonadherence using Generalized Estimating Equations, and evaluated associations of psychiatric conditions (attention deficit hyperactivity disorder, disruptive behavior, depression, anxiety) at entry with incident nonadherence using multivariable logistic regression. Results:Nonadherence prevalence at study entry was 14% (3-day recall), 32% (past month nonadherence), and 38% (unsuppressed viral load), remaining similar over time. At entry, 38% met symptom cut-off criteria for at least one psychiatric condition. Greater odds of 3-day recall nonadherence were observed at week 96 for those with depression [adjusted odds ratio (aOR) 4.14, 95% confidence interval (CI) 1.11–15.42] or disruptive behavior (aOR 3.36, 95% CI 1.02–11.10], but not at entry. Those with vs. without attention deficit hyperactivity disorder had elevated odds of unsuppressed viral load at weeks 48 (aOR 2.46, 95% CI 1.27–4.78) and 96 (aOR 2.35, 95% CI 1.01–5.45), but not at entry. Among 232 youth adherent at entry, 16% reported incident 3-day recall nonadherence. Disruptive behavior conditions at entry were associated with incident 3-day recall nonadherence (aOR 3.01, 95% CI 1.24–7.31). Conclusion:In PHIV youth, comprehensive adherence interventions that address psychiatric conditions throughout the transition to adult care are needed.

Human Immunodeficiency Virus and the Central Nervous System

Human immunodeficiency virus (HIV) continues to infect large numbers of people, including children, worldwide. The virus produces much of its clinical impact by infecting cellular components of the immune system. However, HIV also has the propensity to infect the brain, where it can induce substantial pathology and impair brain function. Highly active antiretroviral therapy has reduced the severity and prevalence of HIV-associated neurocognitive disorders. Nevertheless, substantial morbidity and mortality continue to stem from HIV infection of the nervous system. This article reviews the pathogenesis of HIV-induced central nervous system disease, the pathological and clinical effects of HIV infection within the brain, and the controversies and challenges of the use of highly active antiretroviral therapy for prevention and treatment of HIV-induced central nervous system dysfunction.

Primary Amebic Meningoencephalitis A Case Report and Literature Review

Abstract Primary amebic meningoencephalitis (PAM) is a rare but nearly always fatal disease caused by infection with Naegleria fowleri, a thermophilic, free-living ameba found in freshwater environments. Cases of N. fowleri infection have been reported from many of the southern-tier states in the United States, with Florida and Texas disproportionately represented among them. Primary amebic meningoencephalitis presents clinically in a fashion that may be indistinguishable from bacterial and viral meningitis. Unfortunately, because the disease is so rare, PAM is often excluded from the differential diagnosis of children with meningitis resulting in delayed diagnostic and therapeutic efforts. Pediatric acute care practitioners in emergency departments, general pediatric wards, and critical care units, especially those practicing in the southern United States, should be familiar with the risk factors for acquisition of PAM, its clinical presentation, and the fact that common empiric treatment of bacterial meningitis will not treat N. fowleri. Herein, we present the case of an adolescent who died of PAM and review the (a) epidemiology, (b) pathophysiology, (c) available diagnostic modalities, (d) treatment options, and (e) outcomes of patients treated for N. fowleri infection of the central nervous system.

Growth at 2 years of age in HIV-exposed uninfected children in the United States by trimester of maternal antiretroviral initiation

Background: Abnormal childhood growth may affect future health. Maternal tenofovir (TFV) use was associated with lower body length and head circumference at 1 year of age in HIV-exposed uninfected (HEU) US children. Methods: We studied 509 HEU children in the US-based Surveillance Monitoring of Antiretroviral Therapy Toxicities cohort whose HIV-infected mothers were not using antiretrovirals at the last menstrual period and began combination antiretroviral therapy (cART) in pregnancy (cART initiators). We examined adjusted associations between antiretrovirals and Centers for Disease Control 2000 growth Z scores at 2 years of age within trimester of cART initiation: weight (weight Z score), length (length Z score), weight-for-length [weight-for-length Z score (WFLZ)], triceps skinfold Z score (TSFZ) and head circumference (head circumference Z score). Results: Mothers mean age was 28.6 years; 57% were black non-Hispanic and 19% delivered at <37 weeks gestation. At 2 years, mean weight Z score, length Z score, WFLZ and head circumference Z score were above average (P < 0.05), whereas TSFZ (P = 0.57) did not differ from average. WFLZ was >1.64 standard deviation (SD) (>95th percentile) in 13%. Among children of first-trimester cART initiators, TFV+emtricitabine–exposed children had slightly higher mean WFLZ (0.45 SD; 95% confidence interval: −0.10 to 1.00) and lower TSFZ (−0.55 SD; 95% confidence interval: −1.07 to −0.02) compared with zidovudine+lamivudine–exposed children. TSFZ was lower in those exposed to boosted protease inhibitors. In contrast, growth in children of second trimester cART initiators did not differ by antiretroviral exposures. Conclusion: Growth was above average in HEU; 13% were obese. Maternal TFV use was not associated with lower length or head circumference at 2 years of age, as hypothesized, but may be related to greater weight among those exposed to cART early in pregnancy.

Elevated aspartate aminotransferase-to-platelet ratio index in perinatally HIV-infected children in the United States

Elevated aspartate aminotransferase-to-platelet ratio index may signal liver fibrosis. Among 397 US children with perinatal HIV infection, at baseline was >1.5 in 0.8% [95% confidence interval (CI), 0.2–2.2%) and >0.5 in 6.5% (95% CI, 4.3–9.4%); incidence on study was 0.5 (95% CI, 0.2–1.2) and 6.4 (95% CI, 4.8–8.3) per 100 person-years, respectively. Long-term liver outcomes after perinatal HIV infection warrant further study.

Immunization Update IV

The CDC recommends at least 1 dose of mumps, measles, and rubella (MMR) vaccine for children between the ages of 6 and 11 months who will be traveling outside theUnited States. Children12months and older, are considered immuneas long as they have received 2 doses of MMR vaccine. If any child received the first dose before 12months of age, that dose should not be counted and the child should receive 2 doses after 12months of agewith the second dose at least 28 days apart.