Participation in longitudinal research studies in resource-limited settings often involves frequent interactions with study staff and other participants, as well as receipt of incentives and ...transportation reimbursements. Social support-receipt of material and emotional resources from one's social network-has been linked to antiretroviral adherence in sub-Saharan Africa. The extent to which social support arises from study participation, its range and depth, and its implications for observational study conduct, have not been extensively described.
We conducted individual open-ended and semi-structured interviews with participants in a longitudinal, observational antiretroviral therapy adherence monitoring study in Mbarara, Uganda. Participants were asked about their experiences in the longitudinal study and their interactions with research staff. We also interviewed study research assistants (RAs). Deductive and inductive coding were used to identify content related to the experience of study participation. Codes were organized into themes, and relationships between themes were used to develop overarching categories.
Sixty longitudinal study participants and 6 RAs were interviewed. Instrumental and emotional social support emerged as pervasive and valued aspects of longitudinal study participation. Instrumental support that participants received consisted of enhanced linkage to medical care, health education, and direct and indirect material benefits. Emotional support consisted of perceptions of feeling "cared for" and social interactions that permitted escape from HIV-related stigma. Both instrumental and emotional support often arose through the close relationships participants formed with research staff and with each other. Study-derived social support motivated some participants to adhere to antiretroviral therapy-an unanticipated effect potentially influencing the longitudinal study's primary observational outcome.
Longitudinal study participation resulted in instrumental and emotional social support for participants. The depth of support participants experienced has implications for observational study design in resource-limited settings, including need to assess potential effects on study outcomes; consideration of social support during risk/benefit assessment in study ethics review and consent; and vigilance for consequences of social support loss when studies end.
Electronic adherence monitors (EAMs) record and report an array of health behaviors, ranging from taking daily medications to wearing medical devices. EAMs are utilized in research worldwide and are ...being investigated for clinical use. However, there is also growing popular concern about the extent to which electronic devices may be used to monitor individuals, including allegations in the media that EAMs represent a move towards “Big Brother” in medicine. Here, we highlight the unique benefits as well as the potential ethical challenges that electronic adherence monitoring generates. These challenges surround autonomy, privacy and confidentiality, trust, and ancillary care obligations. We describe key questions within each of these domains that warrant further investigation, and present potential solutions to many of the concerns raised.
Features of multisystem inflammatory syndrome in children (MIS-C) overlap with other febrile illnesses, hindering prompt and accurate diagnosis. The objectives of this study were to identify clinical ...and laboratory findings that distinguished MIS-C from febrile illnesses in which MIS-C was considered but ultimately excluded, and to examine the diseases that most often mimicked MIS-C in a tertiary medical centre.
We identified all children hospitalised with fever who were evaluated for MIS-C at our centre and compared clinical signs and symptoms, SARS-CoV-2 status and laboratory studies between those with and without MIS-C. Multivariable logistic LASSO (least absolute shrinkage and selection operator) regression was used to identify the most discriminative presenting features of MIS-C.
We identified 50 confirmed MIS-C cases (MIS-C
) and 68 children evaluated for, but ultimately not diagnosed with, MIS-C (MIS-C
). In univariable analysis, conjunctivitis, abdominal pain, fatigue, hypoxaemia, tachypnoea and hypotension at presentation were significantly more common among MIS-C
patients. MIS-C
and MIS-C
patients had similar elevations in C-reactive protein (CRP), but were differentiated by thrombocytopenia, lymphopenia, and elevated ferritin, neutrophil/lymphocyte ratio, BNP and troponin. In multivariable analysis, predictors of MIS-C included age, neutrophil/lymphocyte ratio, platelets, conjunctivitis, oral mucosa changes, abdominal pain and hypotension.
Among hospitalised children undergoing evaluation for MIS-C, children with MIS-C were older, more likely to present with conjunctivitis, oral mucosa changes, abdominal pain and hypotension, and had higher neutrophil/lymphocyte ratios and lower platelet counts. These data may be helpful for discrimination of MIS-C from other febrile illnesses, including bacterial lymphadenitis and acute viral infection, with overlapping features.
Tuberculosis (TB) preventive therapy (TPT) is increasingly recognized as the key to eliminating tuberculosis globally and is particularly critical for children with TB infection or who are in close ...contact with individuals with infectious TB. But many barriers currently impede successful scale-up to provide TPT to those at high risk of TB disease. The cascade of care in TB infection (and the related contact management cascade) is a conceptual framework to evaluate and improve the care of persons who are potential candidates for TPT. This review summarizes recent literature on barriers and solutions in the TB infection care cascade, focusing on children in both high- and low-burden settings, and drawing from studies on children and adults. Identifying and closing gaps in the care cascade will require the implementation of tools that are new (e.g. computer-assisted radiography) and old (e.g. efficient contact tracing), and will be aided by innovative implementation study designs, quality improvement methods, and shared clinical practice with primary care providers.
To characterize the socioeconomic and racial and/or ethnic disparities impacting the diagnosis and outcomes of multisystem inflammatory syndrome in children (MIS-C).
This multicenter retrospective ...case-control study was conducted at 3 academic centers from January 1 to September 1, 2020. Children with MIS-C were compared with 5 control groups: children with coronavirus disease 2019, children evaluated for MIS-C who did not meet case patient criteria, children hospitalized with febrile illness, children with Kawasaki disease, and children in Massachusetts based on US census data. Neighborhood socioeconomic status (SES) and social vulnerability index (SVI) were measured via a census-based scoring system. Multivariable logistic regression was used to examine associations between SES, SVI, race and ethnicity, and MIS-C diagnosis and clinical severity as outcomes.
Among 43 patients with MIS-C, 19 (44%) were Hispanic, 11 (26%) were Black, and 12 (28%) were white; 22 (51%) were in the lowest quartile SES, and 23 (53%) were in the highest quartile SVI. SES and SVI were similar between patients with MIS-C and coronavirus disease 2019. In multivariable analysis, lowest SES quartile (odds ratio 2.2 95% confidence interval 1.1-4.4), highest SVI quartile (odds ratio 2.8 95% confidence interval 1.5-5.1), and racial and/or ethnic minority background were associated with MIS-C diagnosis. Neither SES, SVI, race, nor ethnicity were associated with disease severity.
Lower SES or higher SVI, Hispanic ethnicity, and Black race independently increased risk for MIS-C. Additional studies are required to target interventions to improve health equity for children.
To identify subgroups likely to benefit from monoclonal antibody and antiviral therapy by evaluating the relationship between comorbidities and hospitalization among US adolescents with symptomatic ...coronavirus disease 2019 (COVID-19).
We analyzed the relationship between presence of comorbidities and need for hospitalization within 28 days of COVID-19 diagnosis for adolescents aged 12-17 years listed in the Pediatric COVID-19 US registry, a multicenter retrospective cohort of US pediatric patients with COVID-19. Comorbidities assessed included obesity, chronic kidney disease (CKD), diabetes, immunosuppressive disease or treatment, sickle cell disease (SCD), heart disease, neurologic disease/neurodevelopmental disorders, and pulmonary disease (excluding patients with mild asthma). We used multivariable logistic regression to determine race/ethnicity-adjusted associations between comorbidities and hospitalization.
A total of 1877 patients met our inclusion criteria, of whom 284 (15%) were hospitalized within 28 days of their COVID-19 diagnosis. In a race/ethnicity-adjusted model, the following comorbidities were independently associated with increased odds of hospitalization: SCD (aOR, 6.9; 95% CI, 3.0-15.9), immunocompromising condition (aOR, 6.4; 95% CI, 3.8-10.8), obesity (aOR, 3.2; 95% CI, 2.1-4.9), diabetes (aOR, 3.0; 95% CI, 1.4-6.2), neurologic disease (aOR, 2.8; 95% CI, 1.8-4.3), and pulmonary disease (excluding mild asthma) (aOR, 1.9; 95% CI, 1.2-3.1). Heart disease and CKD were not independently associated with hospitalization.
SCD, immunocompromising conditions, obesity, diabetes, neurologic disease, and pulmonary disease (excluding mild asthma) were associated with hospitalization for symptomatic COVID-19. Adolescents with acute COVID-19 and these comorbidities should be prioritized for consideration of therapy to avert hospitalization.
To examine the associations between race and ethnicity and length of stay (LOS) for US children with acute osteomyelitis.
Using the Kids’ Inpatient Database, we conducted a cross-sectional study of ...children <21 years old hospitalized in 2016 or 2019 with acute osteomyelitis. Using survey-weighted negative binomial regression, we modeled LOS by race and ethnicity, adjusting for clinical and hospital characteristics and socioeconomic status. Secondary outcomes included prolonged LOS, defined as LOS of >7 days (equivalent to LOS in the highest quartile).
We identified 2388 children discharged with acute osteomyelitis. The median LOS was 5 days (IQR, 3-7). Compared with White children, children of Black race (adjusted incidence rate ratio aIRR 1.15; 95% CI, 1.05-1.27), Hispanic ethnicity (aIRR 1.11; 95% CI, 1.02-1.21), and other race and ethnicity (aIRR 1.12; 95% CI, 1.01-1.23) had a significantly longer LOS. The odds of Black children experiencing prolonged LOS was 46% higher compared with White children (aOR, 1.46; 95% CI, 1.01-2.11).
Children of Black race, Hispanic ethnicity, and other race and ethnicity with acute osteomyelitis experienced longer LOS than White children. Elucidating the mechanisms underlying these race- and ethnicity-based differences, including social drivers such as access to care, structural racism, and bias in provision of inpatient care, may improve management and outcomes for children with acute osteomyelitis.
A total of 700 000 US children and adolescents are estimated to have latent tuberculosis (TB) infection. Identifying facilitators and barriers to engaging in TB infection care is critical to ...preventing pediatric TB disease. We explored families' and clinicians' perspectives on pediatric TB infection diagnosis and care.
We conducted individual interviews and small group discussions with primary care and subspecialty clinicians, and individual interviews with caregivers of children diagnosed with TB infection. We sought to elicit facilitators and barriers to TB infection care engagement. We used applied thematic analysis to elucidate themes relating to care engagement, and organized themes using a cascade-grounded pediatric TB infection care engagement framework.
We enrolled 19 caregivers and 24 clinicians. Key themes pertaining to facilitators and barriers to care emerged that variably affected engagement at different steps of care. Clinic and health system themes included the application of risk identification strategies and communication of risk; care ecosystem accessibility; programs to reduce cost-related barriers; and medication adherence support. Patient- and family-level themes included TB knowledge and beliefs; trust in clinicians, tests, and medical institutions; behavioral skills; child development and parenting; and family resources.
Risk identification, education techniques, trust, family resources, TB stigma, and care ecosystem accessibility enabled or impeded care cascade engagement. Our results delineate an integrated pediatric TB infection care engagement framework that can inform multilevel interventions to improve retention in the pediatric TB infection care cascade.
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