Long-term hydroxyurea in combination with didanosine and stavudine for the treatment of HIV-1 infection

Objective and methods: In 1998 we reported on a randomized comparison between stavudine plus didanosine plus placebo versus stavudine plus didanosine plus hydroxyurea (HU), in patients with a CD4 count of 200±500 3 10 6 cells/l. After 3 months, the HU group had a higher proportion of patients with viral load , 200 3 10 6 cells/l. At the end of the 3 months blinded period, patients in the placebo group had the option to add HU if their viral load remained . 200 3 10 6 cells/l. We report results after 24 months. Results: Seventy-two patients were randomized to the HU arm, and a further 30 elected to add HU after 12 weeks. Twenty-four months after the start of the trial, only 25% of the 72 patients originally randomized to HU, and 20% of the 30 who added HU after week 12, were still taking it. The reasons for stopping HU were: lack of ef®cacy (45%), adverse events (37%) and patient or physician preference (18%). Side effects were more frequent in the didanosine/stavudine/HU group than in the didanosine/stavudine group: neuropathy (35 versus 15%, P , 0.02), fatigue (22 versus 7%, P , 0.01), and nausea or vomiting (26 versus 9%, P ,0.01). Of those who had discontinued HU, 73% were taking three drugs including a protease inhibitor. Patients who had started HU were compared with similar patients who had started protease inhibitors in the Swiss cohort. The probability of stopping HU was higher than the probability of stopping nel®navir or indinavir, and similar to the probability of stopping ritonavir. Conclusion: HU increased the antiviral effect of stavudine plus didanosine. However, side effects were more frequent, and after 24 months the majority of patients had switched to protease inhibitor regimens

Should pulmonary embolism be suspected in exacerbation of chronic obstructive pulmonary disease?

BACKGROUND: The cause of acute exacerbation of chronic obstructive pulmonary disease (COPD) is often difficult to determine. Pulmonary embolism may be a trigger of acute dyspnoea in patients with COPD. AIM: To determine the prevalence of pulmonary embolism in patients with acute exacerbation of COPD. METHODS: 123 consecutive patients admitted to the emergency departments of two academic teaching hospitals for acute exacerbation of moderate to very severe COPD were included. Pulmonary embolism was investigated in all patients (whether or not clinically suspected) following a standardised algorithm based on d-dimer testing, lower-limb venous ultrasonography and multidetector helical computed tomography scan. RESULTS: Pulmonary embolism was ruled out by a d-dimer value <500 microg/l in 28 (23%) patients and a by negative chest computed tomography scan in 91 (74%). Computed tomography scan showed pulmonary embolism in four patients (3.3%, 95% confidence interval (CI), 1.2% to 8%), including three lobar and one sub-segmental embolisms. The prevalence of pulmonary embolism was 6.2% (n = 3; 95% CI, 2.3% to 16.9%) in the 48 patients who had a clinical suspicion of pulmonary embolism and 1.3% (n = 1; 95% CI, 0.3% to 7.1%) in those not suspected. In two cases with positive computed tomography scan, the venous ultrasonography also showed a proximal deep-vein thrombosis. No other patient was diagnosed with venous thrombosis. CONCLUSIONS: The prevalence of unsuspected pulmonary embolism is very low in patients admitted in the emergency department for an acute exacerbation of their COPD. These results argue against a systematic examination for pulmonary embolism in this population

Impact of a patient-flow physician coordinator on waiting times and length of stay in an emergency department: A before-after cohort study.

OBJECTIVE:Overcrowding is common in most emergency departments (ED). Despite the use of validated triage systems, some patients are at risk of delayed medical evaluation. The objective of this study was to assess the impact of a patient-flow physician coordinator (PFPC) on the proportion of patients offered medical evaluation within time limits imposed by the Swiss Emergency Triage Scale (SETS) and on patient flow within the emergency department of a teaching urban hospital. METHODS:In this before-after retrospective cohort study, we compared the proportions of patients who received their first medical contact within SETS-imposed time limits, mean waiting times before first medical consultation, mean length of stay, and number of patients who left without being seen by a physician, between two periods before and after introducing a PFPC. The PFPC was a senior physician charged with quickly assessing in the waiting area patients who could not immediately be seen and managing patient flow within the department. RESULTS:Before introducing the PFPC position, 33,605 patients were admitted, versus 36,288 after. Introducing a PFPC enabled the department to increase the proportion of patients seen within the SETS-imposed time limits from 60.1% to 69.0% (p <0.0001). Waiting times until first medical consultation were reduced on average by 27.7 minutes (95% confidence interval [95% CI]: 25.9-29.5, p < .0001). No significant differences were observed as to length of stay or number of patients who left without being seen between the two study periods. CONCLUSIONS:Introducing a physician dedicated to managing patient flow enabled waiting times until first medical consultation to be reduced, yet had no significant benefit for patient flow within the ED, nor did it reduce the number of patients who left without being seen

Immunization and MS: a summary of published evidence and recommendations

To review the risk of MS exacerbations after infectious episodes potentially preventable by vaccination, and the risks and benefits of immunizing patients with MS. The authors searched MEDLINE (1966 to January 2001; U.S. National Library of Medicine, Bethesda, MD), HealthSTAR, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) database (Cinahl Information Systems, Glendale, CA) for English-language articles. Each study was summarized and rated for quality of evidence. Then feasible data were pooled and analyzed in meta-analysis. The risk of contracting common infectious diseases in patients with MS is not well established. There is strong evidence for an increased risk of MS exacerbations during weeks around an infectious episode. There is strong evidence against an increased risk of MS exacerbation after influenza immunization. There is no evidence that hepatitis B, varicella, tetanus, or Bacille Calmette-Guerin vaccines increase the risk of MS exacerbations. Insufficient evidence was found for other vaccines. Evidence supports 1) strategies to minimize the risk of acquiring infectious diseases that may trigger exacerbations of MS; and 2) the safety of using influenza, hepatitis B, varicella, tetanus, and Bacille Calmette-Guerin (BCG) vaccines in patients with MS

Concomitant leukocytosis and lymphopenia predict significant pathology at CT of acute abdomen: a case-control study

Abstract Background Acute abdominal pain accounts for about 10% of emergency department visits and has progressively become the primary indication for CT scanning in most centers. The goal of our study is to identify biological or clinical variables able to predict or rule out significant pathology (conditions requiring urgent medical or surgical treatment) on abdominal CT in patients presenting to an emergency department with acute abdominal pain. Methods This was a retrospective cohort study performed in the emergency department of an academic center with an annual census of 60′000 patients. One hundred and-nine consecutive patients presenting with an acute non-traumatic abdominal pain, not suspected of appendicitis or renal colic, during the first semester of 2013, who underwent an abdominal CT were included. Two medical students, completing their last year of medical school, extracted the data from patients’ electronic health record. Ambiguities in the formulations of clinical symptoms and signs in the patients’ records were solved by consulting a board certified emergency physician. Nine clinical and biological variables were extracted: shock index, peritonism, abnormal bowel sounds, fever (> 38 °C), intensity and duration of the pain, leukocytosis (white blood cell count >11G/L), relative lymphopenia (< 15% of total leukocytes), and C-reactive Protein (CRP). These variables were compared to the CT results (reference standard) to determine their ability to predict a significant pathology. Results Significant pathology was detected on CT in 71 (65%) patients. Only leukocytosis (odds ratio 3.3, p = 0.008) and relative lymphopenia (odds ratio 3.8, p = 0.002) were associated with significant pathology on CT. The joint presence of these two anomalies was strongly associated with significant pathology on CT (odds ratio 8.2, p = 0.033). Leukocytosis with relative lymphopenia had a specificity of 89% (33/37) and sensitivity of 48% (33/69) for the detection of significant pathology on CT. Conclusion The high specificity of the association between leukocytosis and relative lymphopenia amongst the study population suggests that these parameters would be sufficient to justify an emergency CT. However, none of the parameters could be used to rule out a significant pathology