Sunanda Gaur

Transmission from one child to another of human immunodeficiency virus type 1 with a zidovudine-resistance mutation.

BACKGROUND AND METHODS. We describe a child who apparently acquired human immunodeficiency virus type 1 (HIV-1) infection in the home setting. The suspected source of infection was a child with the acquired immunodeficiency syndrome who had received zidovudine and whose virus contained a mutation associated with in vitro zidovudine resistance. The children were born to different HIV-1-infected mothers, but they lived in the same home between the ages of two and five years. Child 1 was infected perinatally; Child 2 was not and was repeatedly found to be seronegative. Child 2 was examined because of acute lymphadenopathy and had seroconverted to HIV-1 positivity. HIV-1 proviral DNA was amplified from peripheral-blood mononuclear cells and subjected to sequence analysis. Sequences from Child 2 were compared with those from Child 2s mother, Child 1, and local HIV-1-infected control children.

Effect of the HIV-1 syncytium-inducing phenotype on disease stage in vertically-infected children

The syncytium‐inducing (SI) capability of HIV‐1 isolates from 48 HIV‐infected children was determined in order to examine the association of the SI phenotype with an AIDS diagnosis and/or with other clinical parameters in HIV‐infected children. In a retrospective cross‐sectional analysis, phenotypic data were linked to clinical and immunologic data from each patient. Multiple longitudinal samples were analyzed from 14 patients. Children with SI viruses were older than children with nonsyncytium‐inducing (NSI) strains. Twelve of 13 children less than 2 years old carried NSI viruses, seven of the 12 already had a diagnosis of AIDS. Two children under 2 years of age died within 1 month of NSI virus isolation. Although plasma p24 antigen levels tended to be higher in the NSI group, the difference appeared to reflect high p24 levels in children under 2 years old with AIDS. When children under 2 were omitted, differences in age, CD4+ cell counts, p24 antigenemia, and clinical parameters were not significant. The SI phenotype of HIV‐1 did not occur more frequently in children with an AIDS diagnosis. Four children remained stable with SI isolates over time periods of 16 to 31 months. Three childrens isolates converted from NSI to SI and 2 converted from SI to NSI. These data indicate that SI viruses do not play a significant role in progression to AIDS during the first 2 years of life. Furthermore, for children above the age of 2, the association between advanced disease stage and the SI phenotype in adults may not apply. J. Med. Virol. 55:56–63, 1998.

Health Care Practices of the Foreign Born Asian Indians in the United States. A Community Based Survey

Although successful utilization of medical and preventive care by members of the non-US born communities is an important public health concern, our knowledge regarding health practices of different ethnic subgroups is limited. In the present study, participants of the health fairs organized during South Asian cultural and religions events were asked anonymously to complete the South Asian Total Health Initiative (SATHI) health survey questionnaire to evaluate their health-related practices, self-health perception, and satisfaction with medical care. Among 1,250 surveyed, 1,016 foreign born Asian Indians adults that represented the fastest growing subgroups of the South Asian born nationals in the US were included in the analysis. We found that the majority reported healthy behavior (exercise activities and abstinence from alcohol or tobacco), high self-health perception, satisfaction with medical care, and compliance with annual routine medical examinations that was directly associated with the annual house income. Approximately 40% of women complied with breast and cervical cancer screenings and less than 20% of men complied with prostate cancer screening guidelines. Presence of chronic conditions (mostly cardiovascular pathology and/or diabetes) that were reported by approximately half of the participants negatively impacted their self-health perception. In conclusion, positive self-reported health perception and compliance with routine health examinations of the surveyed foreign born Asian Indians was reported along with an increased rate of chronic morbidity and underutilization of specific preventive services. Observed discrepancy between self-health perception and health status highlights the need to enhance utilization of preventive services among the non-US born Asian Indian community.

Poststreptococcal Reactive Arthritis in Children: A Retrospective Study:

The duration of treatment and appropriate guidelines for antibiotic prophylaxis for children with poststreptococcal reactive arthritis (PSRA) have not been determined. The authors performed a retrospective chart review of 40 children with PSRA and examined their clinical features at initial evaluation and at 6, 12, and 24months. At baseline, 18% (n = 7) had a finding noted on the echocardiogram. Although most patients developed cardiac findings early on in the course of their disease, 2 patients with a normal baseline echocardiogram may have developed findings after 12 months of follow-up. The mean duration of prophylaxis was 22 months. During the follow-up period, there was improvement in Physicians Global Assessment, number of patients with arthralgia, tender and swollen joints, erythrocyte sedimentation rate, anti—streptolysin O, and anti—DNAse B antibody titers. The authors conclude that marked improvement in clinical features and laboratory values was seen over time. Patients may benefit with long-term cardiac follow-up.

Adherence to antiretroviral therapy in pediatric patients with human immunodeficiency virus (HIV-1).

The evaluation of HIV treatment adherence is essential to manage the development of resistant mutations, treatment failure, and disease progression in patients with HIV-1 infection; however, none of the commonly used measures of treatment adherence have been found to be accurate. The objective of this study was to evaluate three treatment adherence measures (caregiver reports, pharmacy refill, and appointment maintenance data) in association with viral load suppression in pediatric patients with HIV-1 infection. Although viral suppression was not found to be significantly associated with adherence defined by any single measure, treatment adherence could be predicted if all three measures were in agreement.

Emergence of Drug Resistance Mutations in a Group of HIV-Infected Children Taking Nelfinavir-Containing Regimens

HIV-1-infected children are often treated with therapy regimens including protease inhibitors (PIs). We monitored the virologic response in a small group of pediatric patients undergoing therapy with regimens including the PI nelfinavir and determined whether new drug resistance mutations were present immediately after virologic failure. Seventeen reverse transcriptase inhibitor (RTI)-experienced children starting nelfinavir-containing therapy regimens were studied. After virologic failure, HIV-1 protease (PR) and RT sequences were examined for drug resistance mutations. Viral load levels decreased to <400 HIV RNA copies/ml in six patients and remained at <400 HIV RNA copies/ml in four patients. Three patients did not respond virologically; all three had mutations specific for one or more of their regimen drugs either before or soon after nelfinavir initiation. The virologic response was transient in eight patients whose viral loads did not decrease to <400 HIV RNA copies/ml. Genotypic data from seven of the eight patients revealed mutations specific for one or more of their regimen drugs after virologic rebound. PI resistance mutations occurred in eight patients: D30N in six, and L90M in three. In three patients, the only new mutation after failure was the RT mutation M184V. Despite virologic failure, sustained increases in CD4+ lymphocyte counts were noted in eight patients. We conclude that in this small group of pediatric patients, virologic failure occurred in all patients whose viral loads did not become undetectable after the switch to a nelfinavir-containing regimen. After failure, new drug resistance mutations were found in either PR or RT. Studies of larger cohorts are warranted to determine whether HIV-1 genotypic data can help in the formulation of effective salvage therapies in children.

Clinical Immunology and Infectious Diseases

Without the application of immunology, understanding of the pathogenesis and pathophysiology of infectious diseases would be severely retarded. The development new vaccines for the prevention of infectious diseases has been based on new immunologic findings. Immunodiagnostic modalities have provided for the growth of diagnostic techniques for infectious diseases. Clinical immunology also has laid the groundwork for immunotherapies using the old intravenous immunoglobulin preparations and the new monoclonal antibodies, cytokines, and interferons.

Clinical and cost burden of rotavirus infection before and after introduction of rotavirus vaccines among commercially and Medicaid insured children in the United States

This study aims to quantify clinical and economic burden of rotavirus (RV) infection pre- and post-vaccine introduction in commercially insured and Medicaid populations. Beneficiaries with continuous enrollment for ≥6 months while <5 years of age were identified separately in commercial (2000–2010) and Medicaid (2002–2009) claims databases. Commercial and Medicaid databases included 3 998 708 and 1 034 440 eligible children, respectively, observed from enrollment start date(s) to end of eligibility or 5-years-old. Rates of RV-coded and diarrhea-coded encounters and first RV episodes, and incremental cost of first RV episodes were calculated. In the post-vaccine period, rates per 10 000 person-years for RV-coded hospitalizations, outpatient visits and ER visits were 5.58 (95% CI, 5.37–5.80), 6.96 (95% CI, 6.75–7.20), and 4.85 (95% CI, 4.66–5.06), respectively (pre-vaccine, 16.67 [95% CI, 16.19–17.15], 13.20 [95% CI, 12.78–13.63], 11.26 [95% CI, 10.87–11.66], respectively), for commercially insured. In Medicaid the corresponding rates were 10.53 (95% CI, 9.60–11.56), 11.72 (95% CI, 10.73–12.80), and 9.11 (95% CI, 8.24–10.07) (pre-vaccine, 19.78 [95% CI, 19.14–20.45], 19.39 [95% CI, 18.75–20.05], 27.61 [95% CI, 26.84–28.40]). Incidence rate per 10 000 person-years for first RV episode pre- vs. post-vaccine were 27.03 (95% CI, 26.42–27.65) vs. 10.14 (95% CI, 9.86–10.44) in the commercially insured population and 37.71 (95% CI, 36.81–38.63) vs. 18.64 (95% CI, 17.37–19.99) in Medicaid. Incremental per-patient per-month cost of first RV episode was

Protease inhibitor associated mutations compromise the efficacy of therapy in human immunodeficiency virus – 1 (HIV-1) infected pediatric patients: a cross-sectional study

3363 (95% CI,

Adverse Outcomes Among Asian Indian Singleton Births in New Jersey, 2008-2011.

3308-