Impact of late presentation of HIV infection on short-, mid- and long-term mortality and causes of death in a multicenter national cohort: 2004–2013

SummaryObjectivesTo analyze the impact of late presentation (LP) on overall mortality and causes of death and describe LP trends and risk factors (2004–2013).MethodsCox models and logistic regression were used to analyze data from a nation-wide cohort in Spain. LP is defined as being diagnosed when CD4 < 350 cells/ml or AIDS.ResultsOf 7165 new HIV diagnoses, 46.9% (CI95%:45.7–48.0) were LP, 240 patients died.First-year mortality was the highest (aHRLP.vs.nLP = 10.3[CI95%:5.5–19.3]); between 1 and 4 years post-diagnosis, aHRLP.vs.nLP = 1.9(1.2–3.0); and >4 years, aHRLP.vs.nLP = 1.5(0.7–3.1).First-year's main cause of death was HIV/AIDS (73%); and malignancies among those surviving >4 years (32%). HIV/AIDS-related deaths were more likely in LP (59.2% vs. 25.0%; p < 0.001). LP declined from 55.9% (2004–05) to 39.4% (2012–13), and reduced in 46.1% in men who have sex with men (MSM) and 37.6% in heterosexual men, but increased in 22.6% in heterosexual women.Factors associated with LP: sex (ORMEN.vs.WOMEN = 1.4[1.2–1.7]); age (OR31–40.vs.<30 = 1.6[1.4–1.8], OR41–50.vs.<30 = 2.2[1.8–2.6], OR>50.vs.<30 = 3.6[2.9–4.4]); behavior (ORInjectedDrugUse.vs.MSM = 2.8[2.0–3.8]; ORHeterosexual.vs.MSM = 2.2[1.7–3.0]); education (ORPrimaryEducation.vs.University = 1.5[1.1–2.0], ORLowerSecondary.vs.University = 1.3[1.1–1.5]); and geographical origin (ORSub-Saharan.vs.Spain = 1.6[1.3–2.0], ORLatin-American.vs.Spain = 1.4[1.2–1.8]).ConclusionsLP is associated with higher mortality, especially short-term- and HIV/AIDS-related mortality. Mid-term-, but not long-term mortality, remained also higher in LP than nLP. LP decreased in MSM and heterosexual men, not in heterosexual women. The groups most affected by LP are low educated, non-Spanish and heterosexual women

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

The use of pulse pressure variation and stroke volume variation in spontaneously breathing patients to assess dynamic arterial elastance and to predict arterial pressure Response to Fluid Administration

BACKGROUND: Dynamic arterial elastance (Eadyn), defined as the pulse pressure variation (PPV) to stroke volume variation (SVV) ratio, has been suggested as a predictor of the arterial pressure response to fluid administration. In this study, we assessed the effectiveness of Eadyn to predict the arterial blood pressure response to a fluid challenge (FC) in preload-dependent, spontaneously breathing patients. METHODS: Patients admitted postoperatively and monitored with the Nexfin monitor (BMEYE, Amsterdam, The Netherlands) were enrolled in the study. Patients were included in the analysis if they were spontaneously breathing and had an increase in cardiac output ≥10% during an FC. Patients were classified according to the increase in mean arterial blood pressure (MAP) after FC into MAP-responders (MAP increase ≥10%) and MAP-nonresponders (MAP increase <10%). Eadyn was continuously calculated from the PPV and SVV values obtained from the monitor. RESULTS: Thirty-four FCs from 26 patients were studied. Seventeen FCs (50%) induced a positive MAP response. Preinfusion Eadyn was significantly higher in MAP-responders (1.39 ± 0.41 vs 0.85 ± 0.23; P = 0.0001). Preinfusion Eadyn predicted a positive MAP response to FC with an area under the receiver-operating characteristic curve of 0.92 ± 0.04 of standard error (95% confidence interval, 0.78-0.99; P < 0.0001). A preinfusion Eadyn value ≥1.06 (gray zone: 0.9-1.15) discriminated MAP-responders with a sensitivity and specificity of 88.2% (approximate 95% confidence interval, 64%-99%), respectively. CONCLUSIONS: Noninvasive Eadyn, defined as the PPV to SVV ratio, predicted the arterial blood pressure increase to fluid administration in spontaneously breathing, preload-dependent patients

El contenido de la EGB a través de sus textos

Se trata de analizar el contenido de la EGB, mediante la cuantificación de sus conceptos (censo, distribución y frecuencia del vocabulario escolar) en los textos más utilizados en la práctica educativa actual y ubicarlo en el conjunto de repertorios lexicográficos, de cara a elaborar un conjunto de datos y clasificaciones que sirvan de base a posteriores investigaciones. Los universos de trabajo son tres: 37242, 6674 y 10705 lexemas (unidades significativas distintas) correspondientes respectivamente al vocabulario textual (texto), epigráfico (encabezamiento) e iconográfico (pie de ilustraciones) de 112 textos de EGB. Para realizar los censos se establecieron normas lexicométricas: reducción morfológica, distinción semántica, verbalización de símbolos. Para estudiar la composición y distribución interna de los universos se consideró la variable 'categorías lingüísticas' (elementos fonéticos, útiles gramaticales, números, símbolos, nombres propios, términos, palabras no castellanas y sin clasificar). Para estudiar la frecuencia y distribución de cada lexema en los 112 textos se consideraron las variables nivel y áreas de estudio. La ubicación del vocabulario escolar en el conjunto de repertorios lexicográficos (variable dependiente) se realizó considerando las variables independientes de su extensión (número) y frecuencia de uso. Los resultados sólo se expresan mediante los datos cuantitativos de los censos y clasificaciones realizados, sin un análisis cualitativo. Sólo se publican los datos referidos a la composición relativa de cada universo por categorías lingüísticas y una muestra de 13 lexemas para ilustrar la frecuencia y especificidad por nivel y área de estudio de algunos vocablos. La clasificación de los lexemas en subcategorías lingüísticas no está todavía publicada. Para la ubicación del vocabulario escolar en el conjunto de repertorios lexicográficos sí aparecen resultados: La extensión del vocabulario escolar efectivo (una vez comprobada la relación inversa entre la extensión del vocabulario y su frecuencia de uso) es muy alta (de 32 a 63 millares), situándose dentro del nivel de consulta, por encima de los de iniciación y uso. Los censos y clasificaciones realizados, junto con los datos referidos a cada vocablo permiten una cuantificación del vocabulario escolar así como su ubicación respecto al resto de posible vocabulario. La investigación adquiere una importancia fundamental como creación de universos de trabajo que servirán de base a posteriores investigaciones , entre ellas la llevada a cabo por el mismo equipo investigador sobre el valor informativo y adaptativo en el contenido de la EGB.CantabriaES

A prospective cohort study of neurocognitive function in aviremic HIV-infected patients treated with 1 or 3 antiretrovirals

The evolution of neurocognitive performance in aviremic human immunodeficiency virus (HIV)– positive patients treated with <3 antiretrovirals is unknown. Methods. We prospectively included aviremic (≥1 year) HIV-positive patients, without concomitant major neurocognitive confounders, currently receiving boosted lopinavir or darunavir as monotherapy (n = 67) or triple antiretroviral therapy (ART) (n = 67) for ≥1 year. We evaluated neurocognitive function (7 domains) at baseline and after 1 year.We performed analysis of covariance to evaluate if 1 additional year of exposure tomonotherapy compared with triple ART had an effect on Global Deficit Score (GDS) changes after adjustment for potential confounders. We also compared the evolution of neurocognitive performance and impairment rates. Results. Intention-to-treat analysis showed that monotherapy did not influence 1-year GDS change after adjustment for significant confounders (age, ethnicity, duration of therapy, hepatitis C virus status, and HOMA-IR index); the adjusted effect was −0.04 (95% confidence interval, −.14 to .05; P = .38). Neurocognitive stability was observed with monotherapy and triple therapy (GDS crude mean change, −0.09 [95% confidence interval, −.16 to −.01] vs −0.08 [−.14 to −.02]), after 1 year of follow-up, similar proportions of patients changed neurocognitive status from impaired to unimpaired (monotherapy, 4 of 18 [22.2%]; triple therapy, 4 of 19 [21.1%]; P = .91) and vice versa (monotherapy, 5 of 44 [10.2%] and triple therapy, 3 of 45 [6.3%]; P = .48). Similar results were observed in an on-treatment analysis and with use of clinical ratings instead of GDS changes. Conclusions. The number of antiretrovirals included in the ART regimen does not seem to influence the evolution of neurocognitive function in HIV-infected patients with suppressed plasma viremia.8.886 JCR (2014) Q1, 9/148 Immunology, 2/78 Infectious diseases, 9/119 MicrobiologyUE

Dynamic arterial elastance as a predictor of arterial pressure response to fluid administration: a validation study.

INTRODUCTION: Functional assessment of arterial load by dynamic arterial elastance (Eadyn), defined as the ratio between pulse pressure variation (PPV) and stroke volume variation (SVV), has recently been shown to predict the arterial pressure response to volume expansion (VE) in hypotensive, preload-dependent patients. However, because both SVV and PPV were obtained from pulse pressure analysis, a mathematical coupling factor could not be excluded. We therefore designed this study to confirm whether Eadyn, obtained from two independent signals, allows the prediction of arterial pressure response to VE in fluid-responsive patients. METHODS: We analyzed the response of arterial pressure to an intravenous infusion of 500 ml of normal saline in 53 mechanically ventilated patients with acute circulatory failure and preserved preload dependence. Eadyn was calculated as the simultaneous ratio between PPV (obtained from an arterial line) and SVV (obtained by esophageal Doppler imaging). A total of 80 fluid challenges were performed (median, 1.5 per patient; interquartile range, 1 to 2). Patients were classified according to the increase in mean arterial pressure (MAP) after fluid administration in pressure responders (≥ 10%) and non-responders. RESULTS: Thirty-three fluid challenges (41.2%) significantly increased MAP. At baseline, Eadyn was higher in pressure responders (1.04 ± 0.28 versus 0.60 ± 0.14; P < 0.0001). Preinfusion Eadyn was related to changes in MAP after fluid administration (R (2) = 0.60; P < 0.0001). At baseline, Eadyn predicted the arterial pressure increase to volume expansion (area under the receiver operating characteristic curve, 0.94; 95% confidence interval (CI): 0.86 to 0.98; P < 0.0001). A preinfusion Eadyn value ≥ 0.73 (gray zone: 0.72 to 0.88) discriminated pressure responder patients with a sensitivity of 90.9% (95% CI: 75.6 to 98.1%) and a specificity of 91.5% (95% CI: 79.6 to 97.6%). CONCLUSIONS: Functional assessment of arterial load by Eadyn, obtained from two independent signals, enabled the prediction of arterial pressure response to fluid administration in mechanically ventilated, preload-dependent patients with acute circulatory failure

Fluid administration for acute circulatory dysfunction using basic monitoring:narrative review and expert panel recommendations from an ESICM task force

An international team of experts in the field of fluid resuscitation was invited by the ESICM to form a task force to systematically review the evidence concerning fluid administration using basic monitoring. The work included a particular emphasis on pre-ICU hospital settings and resource-limited settings. The work focused on four main questions: (1) What is the role of clinical assessment to guide fluid resuscitation in shock? (2) What basic monitoring is required to perform and interpret a fluid challenge? (3) What defines a fluid challenge in terms of fluid type, ranges of volume, and rate of administration? (4) What are the safety endpoints during a fluid challenge? The expert panel found insufficient evidence to provide recommendations according to the GRADE system, and was only able to make recommendations for basic interventions, based on the available evidence and expert opinion. The panel identified significant gaps in the scientific evidence on fluid administration outside the ICU (excluding the operating theater). Globally, scientific communities and health care systems should address these critical gaps in evidence through research on how basic fluid administration in resource-rich and resource-limited settings can be improved for the benefit of patients and societies worldwide.SCOPUS: re.jSCOPUS: er.jinfo:eu-repo/semantics/publishe