Today's antiretroviral combination regimens can induce significant and sustained decreases in human immunodeficiency virus (HIV)-RNA levels, allowing the immune system to recover. To what extent ...immune reconstitution is possible and what factors determine the outcome have thus far not been resolved. We studied 19 subjects, treated for 2 years with protease inhibitor-containing triple therapy, who had a strong suppression of HIV-RNA levels. CD4+ T-cell numbers increased from medians of 170 to 420x106 cells/L, but in a number of subjects T-cell numbers did not further increase after week 72, without having reached normal values. Long-term CD4+ T-cell change was mainly caused by a slow but continuous increase in naive CD4+ T cells (CD45RA+CD62L+) and was predicted by the baseline number of these cells. Our data indicate that long-term immunological recovery is gradual, even during strong suppression of viral replication, not always complete, and dependent on the preexisting level of naive CD4+ T cells.
Peripheral oxygen saturation (SpO
) measured by pulse oximetry is an unreliable surrogate marker for arterial oxygenation (SaO
) in critically ill patients. We hypothesized that a higher perfusion ...index (PFI) would be associated with better accuracy of SpO
measurement. We retrospectively collected SaO
, SpO
, and PFI data for each arterial blood gas (ABG) analysis in a cohort of intensive care unit patients. PFI was categorised as low (PFI < 1.0), intermediate (1.0 ≤ PFI ≤ 2.5), or high (PFI > 2.5). The correlation between SpO
and SaO
was studied using Pearson's correlation. The Bland-Altman plot was used to analyse the agreement between SpO
and SaO
. Furthermore, the correlation between the (SpO
-SaO
) difference and PFI was assessed. The level of (dis)agreement was calculated for the three PFI categories separately. Overall, 281 patients and 1281 data points were analysed. There was a significant correlation between SaO
and SpO
(r = 0.69, p < 0.01). The Bland-Altman analysis revealed a mean difference between SaO
and SpO
of 0.2% with limits of agreement of ± 6% (SD ± 2%). The correlation between the PFI and the (SpO
-SaO
) difference was low; the (SpO
-SaO
) difference improved only marginally with higher PFI values. The accuracy of pulse oximetry for estimating arterial oxygenation was moderate and improved little with increasing PFI values. Thus, the additive value of PFI in clinical decision making is limited. Therefore, we advise performing an ABG before adjusting fraction of inspired oxygen (FiO
) settings.
In a retrospective study the data concerning 40 patients, with primary operable breast cancer were analysed. The mean follow-up of the patient group was 29 months. All patients received tamoxifen ...only. 17 (43%) reached remission and there was stable disease in 16 (40%). 7 (18%) showed progression, although they have had stable disease for at least 18 months. There were 1 local, 1 distant and 5 local plus distant progressions. 3 patients required salvage mastectomy. The mean progression-free interval was 33 months. Death was attributable to breast carcinoma in only 6 patients (15%). The 3-year survival was 47.2%. We conclude that primary treatment with tamoxifen as a sole therapy is acceptable in operable breast carcinoma for those patients for whom surgery is contraindicated or who refuse surgery.
Intravenously administered iodine-containing contrast medium (CM) is associated with the development of contrast-induced nephropathy (CIN). Data on the effectiveness of sodium bicarbonate therapy in ...the prevention of CIN are controversial. Furthermore, the incidence of and risk factors for CIN in intensive care unit (ICU) patients are poorly defined. We investigated the effectiveness of sodium bicarbonate prophylaxis and the incidence of and risk factors for CIN in a heterogeneous ICU population.
This retrospective cohort study included patients admitted to the ICU in 2009-2011 who received CM for computed tomography (CT).
Two hundred eleven CT scans with CM, performed in 170 patients, were included in the study. Contrast prophylaxis with sodium bicarbonate was administered in 48 of the 211 cases. CIN developed in 19 of the 48 cases receiving prophylaxis and in 39 of 163 cases not receiving prophylaxis (p = 0.03). In 115 CTs performed in patients with a glomerular filtration rate (GFR) >60 mL/min, prophylaxis was administered 15 times (13 %) and no prophylaxis was administered 100 times (87 %). CIN developed in 12 and 13 % of these cases, respectively (NS). In 96 CTs in patients with a GFR <60 mL/min, 17 of 33 (51.5 %) cases receiving prophylaxis developed CIN and 27 of 63 (42.9 %) cases not receiving prophylaxis developed CIN (NS). Prophylactic sodium bicarbonate therapy did not prevent CIN in our patients, irrespective of pre-existing renal failure. Pre-existing renal impairment (odds ratio 4.41), an elevated Acute Physiology and Chronic Health Evaluation (APACHE) IV score (odds ratio 1.02), and higher haemoglobin levels (odds ratio 0.64) were significant and independent risk factors associated with the development of CIN.
Prophylactic isotonic sodium bicarbonate was not associated with a decreased incidence of CIN in ICU patients. Current sodium bicarbonate prophylaxis guidelines cannot be generalized to a heterogeneous ICU population. Pre-existing renal impairment was associated with the highest CIN risk.
Abstract Objective We prospectively studied the effect of methylene blue (MB) infusion on gastric mucosal metabolism perfusion ratio, assessed by gastric tonometry, and on mucosal cell damage, ...assessed by urinary levels of intestinal fatty acid binding protein, in septic shock patients. Methods Methylene blue (MB) infusion (1 mg/kg per hour) during 4 hours in 10 consecutive patients with a proven or suspected bacterial infection and with severe vasodilatory shock, defined as a mean arterial pressure 70 mm Hg or lower for at least 1 hour despite adequate volume resuscitation and norepinephrine infusion at a rate ≥0.2 μ g/kg per minute. Results Methylene blue infusion did not significantly change the P(g-a)CO2 gradient ( P = .16). Post hoc analysis of the subgroup of patients with an elevated baseline P(g-a)CO2 gradient, defined as ≥20 mm Hg, showed that the median P(g-a)CO2 gradient (interquartile range IQR) decreased from 45 (41-56) mm Hg before infusion to 41 (28-52) at the end of the 4-hour infusion and decreased further to 32 (26-36) mm Hg 2 hours after cessation of MB infusion ( P = .012). The median urinary intestinal fatty acid binding protein concentration at baseline was elevated (210 79-437 pg/ μ mol creatinine) and did not change significantly after 24 hours (116 53-601 pg/ μ mol creatinine, P = .15). The median mean arterial blood pressure (IQR) increased from 70 (69-71) mm Hg at baseline to 77 (67-83) mm Hg after 1 hour ( P = .04), the norepinephrine dose did not change significantly. The median (IQR) cardiac index decreased from 4.4 (3.2-5.5) L min-1 m-2 at baseline to 3.6 (3.3-4.7) L min-1 m-2 after 2 h, returning back to baseline values after cessation of MB infusion P = .02). Conclusion Although MB infusion in patients with septic shock and advanced multi-organ failure increases mean arterial blood pressure and decreases cardiac index, it does not compromise the gastric mucosal perfusion metabolism ratio as indicated by tonometry, and by the release of a mucosal cellular injury marker.
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