Peter J. Dunbar

Peer support and pager messaging to promote antiretroviral modifying therapy in Seattle: a randomized controlled trial.

Objective:To determine the relative efficacy of peer support and pager messaging strategies versus usual care to improve medication adherence and clinical outcomes among HIV-positive outpatients initiating or switching to a new highly active antiretroviral therapy regimen. Design:A 2 × 2 factorial randomized controlled trial of a 3-month intervention with computer-assisted self-interviews and blood draws administered at baseline, 3, 6, and 9 months. Methods:HIV-positive patients at a public HIV specialty clinic in Seattle, WA (N = 224) were randomly assigned to peer support, pager messaging, both strategies, or usual care. The main outcomes were adherence according to self-report and electronic drug monitoring, CD4 count, and HIV-1 RNA viral load. Results:Intent-to-treat analyses suggested the peer intervention was associated with greater self-reported adherence at immediate postintervention. However, these effects were not maintained at follow-up assessment; nor were there significant differences in biological outcomes. The pager intervention, on the other hand, was not associated with greater adherence but was associated with improved biological outcomes at postintervention that were sustained at follow-up. Conclusions:Analyses indicate the potential efficacy of peer support and pager messaging to promote antiretroviral adherence and biological outcomes, respectively. More potent strategies still are needed.

Key Concepts for Estimating the Burden of Surgical Conditions and the Unmet Need for Surgical Care

BackgroundSurgical care is emerging as a crucial issue in global public health. Methodology is needed to assess the impact of surgical care from a public health perspective.Method sA consensus opinion of a group of surgeons, anesthesiologists, and public health experts was established regarding the methodology for estimating the burden of surgical conditions and the unmet need for surgical care.Result sFor purposes of analysis, we define surgical conditions as any disease state requiring the expertise of a surgically trained provider. Abnormalities resulting from a surgical condition or its treatment are termed surgical sequelae. Surgical care is defined as any measure that reduces the rates of physical disability or premature death associated with a surgical condition. To measure the burden of surgical conditions and unmet need for surgical care we propose using cumulative disability-adjusted life-year (DALY) curves generated from age-specific population-based data. This conceptual framework is based on the premise that surgically associated disability and death is determined by the incidence of surgical conditions and the quantity and quality of surgical care. The burden of surgical conditions is defined as the total disability and premature deaths that would occur in a population should there be no surgical care; the unmet need for surgical care is defined as the potentially treatable disability and premature deaths due to surgical conditions. Burden of surgical conditions should be expressed as DALYs and unmet need as potential DALYs avertable.ConclusionsMethodology is described for estimating the burden of surgical conditions and unmet need for surgical care. Using this approach it will be feasible to estimate the global burden of surgical conditions and help clarify where surgery fits among other global health priorities. These methods need to be validated using population-based data.

A Two-way Messaging System to Enhance Antiretroviral Adherence

Failure to adhere to complex antiretroviral regimens can lead to resistance and treatment failure among HIV-positive persons. In this study of the feasibility of an automated two-way messaging system to improve adherence, participants received multiple short daily messages designed to remind, educate, encourage adherence, and solicit responses concerning side effects and self-reported adherence. Twenty-five participants remained in the study for a median of 208 days, receiving 17,440 messages and replying to 14,677 (84%). Participants reported missing one or more doses on 36% of 743 queries and reported medication side effects on 26% of 729 queries. Participants expressed high satisfaction with the messaging system and reported that it helped with medication adherence. The study suggests that it is feasible to use an automated wireless two-way messaging system to communicate with HIV-positive patients over an extended period of time.

Coagulopathy Predicts Poor Outcome Following Head Injury in Children Less Than 16 Years of Age

The authors examined the relationship between fibrin degradation products (FDP) and outcome in children with isolated head injury by reviewing the records of 69 children who met the following criteria: (1) less than 16 years of age; (2) diagnosis of isolated head injury and (3) FDP levels. Outcome was evaluated using the following Glasgow Outcome Scale (GOS): 1 = death; 2 = vegetative state; 3 = functionally impaired; 4 = minimal dysfunction; 5 = premorbid level of functioning. Poor outcome was defined as GOS 1–3. Twenty-nine of 33 patients with FDP > 1000 (g/mL had GOS scores < 4 compared to 4/36 patients (11%) with FDP < 1000 &mgr;g/mL (Fishers Exact Probability Test P < .0001). When stratified by GCS, no other prognosticator of outcome was needed when GCS was < 7 and > 12. In patients with GCS 7–12, however, 4/6 with FDP >1000 &mgr;g/mL had a poor outcome and all 12 patients with FDP < 1000 &mgr;g/mL had a good outcome (P = .004). The authors conclude that FDP > 1000 &mgr;g/mL predicts poor outcome in children with isolated head injury. Fibrin degradation products are a strong independent prognosticator of outcome in children when GCS is between 7 and 12.

Population Health Metrics for Surgery: Effective Coverage of Surgical Services in Low-Income and Middle-Income Countries

BackgroundAccess to surgical services is emerging as a crucial issue in global public health. “Effective coverage” is a health metric used to evaluate essential health services in low- and middle-income countries. It measures the fraction of potential health gained that is actually realized for a given intervention by integrating the concepts of need, use, and quality.MethodsThis study applies the concept of effective coverage to surgical services by considering injuries and obstetric complications as high-priority surgical conditions in low- and middle-income countries.ResultsEffective coverage for both is poor, but it is less well defined for traumatic conditions compared to obstetric conditions owing to a lack of data.ConclusionsMore primary and secondary data are critical to measure effective coverage and to estimate the resources required to improve access to surgical services in low- and middle-income countries.

Two-Way Text Messaging for Health Behavior Change Among Human Immunodeficiency Virus–Positive Individuals

BACKGROUND text-messaging systems have been used to promote a range of health behaviors, including medication adherence among human immunodeficiency virus-positive individuals. However, little is currently known about the specific characteristics of messaging systems that promote user engagement. OBJECTIVE using data from a randomized controlled trial involving a pager-based text messaging system, this study sought to examine the overall usability of the system, user evaluation of the system, demographic and psychosocial correlates of usability, and its performance as an adherence assessment tool. MATERIALS AND METHODS the messaging system consisted of an alphanumeric pager capable of sending and receiving individualized text messages and the software necessary to program and track communication. The system was evaluated using behavioral outcomes (pager message response rate), self-report survey responses, focus group discussions, and data from electronic medication monitoring pill bottles. RESULTS Although the majority of participants reported that the system was effective in reminding them to take medication doses, the overall response rate to system messages was relatively low (42.8%) and dropped significantly over the course of the 3-month intervention period. In addition, user engagement did not differ significantly by most demographic and psychosocial variables. CONCLUSIONS the pager-based text messaging system was received well by participants and appears to be applicable to a broad population; however, the system did not actively engage all participants over the course of the trial. Future research should determine whether systems customized to personal preference in notification style, frequency, and user device can increase use and provide further assistance to achieve optimal medication adherence.

Trauma, critical care, and emergency care anesthesiology: A new paradigm for the "Acute Care" anesthesiologist?

1668 www.anesthesia-analgesia.org December 2015 • Volume 121 • Number 6 Copyright