Maraviroc: integration of a new antiretroviral drug class into clinical practice

Maraviroc (Pfizer's UK-427857, Selzentry or Celsentri outside the US) is the first agent in the new class of oral HIV-1 entry inhibitors to acquire FDA and EMEA approval. It is expected that this drug will be effective only in a subpopulation of HIV-1-infected people, namely those harbouring only the R5 virus. The wide use of this drug is currently hampered by the lack of a readily available R5 virus only determination test (tropism test) and by insufficient scientific insight into the dynamics of R5 and X4 viruses during infection. We discuss the challenges associated with the currently available assay, as well as the potential role of alternative assays

What is new in the prevention of ventilator-associated pneumonia?

Purpose of review: Ventilator-associated pneumonia (VAP) remains a frequent and severe complication in endotracheally intubated patients. Strict adherence to preventive measures reduces the risk of VAP. The objective of this paper is to review what has come forward in recent years in the nonpharmacological prevention of VAP. Recent findings: It seems advantageous to implement care bundles rather than single prevention measures. A solid basis of knowledge seems necessary to facilitate implementation and maintain a high adherence level. Continuous educational efforts have a beneficial effect on attitude toward VAP. Intermittent subglottic secretions drainage, continuous lateral rotation therapy, and polyurethane cuffed endotracheal tubes decrease the risk of pneumonia. In an in-vitro setting, an endotracheal tube with a taper-shaped cuff appears to better prevent fluid leakage compared to cylindrical polyurethane or polyvinylchloride cuffed tubes. Cuff pressure control by means of an automatic device and multimodality chest physiotherapy need further investigation, as do some aspects of oral hygiene. Summary: New devices and strategies have been developed to prevent VAP. Some of these are promising but need further study. In addition, more attention is being given to factors that might facilitate the implementation process and the challenge of achieving high adherence rates

What determines health-related quality of life among people living with HIV : an updated review of the literature

Background: As infection with the Human Immunodeficiency Virus (HIV) has evolved to a chronic disease, perceived health-related quality of life (HRQoL) is becoming a prominent and important patient-reported outcome measure in HIV care. Literature discusses different factors influencing HRQoL in this population, however, currently no consensus exists about the main determinants. In this review a clear, up-to-date overview of the determinants influencing HRQOL among people living with HIV is provided. Methods: All studies published before July 2013 that identified determinants of HRQoL among people living with HIV in high-income countries, were considered in this narrative review. PubMed, Web of Science and The Cochrane Library were consulted using the keywords ‘determinants’, ‘quality of life’, ‘HIV’ and ‘AIDS’. To be included, studies should have reported overall health and/or physical/mental health scores on a validated instrument and performed multivariable regression analyses to identify determinants that independently influence perceived HRQoL. Results: In total, 49 studies were included for further analysis and they used a variety of HRQoL instruments: Medical Outcomes Study Short Form-36 or variants, Medical Outcomes Study-HIV, HIV Cost and Services Utilization Study measure, Multidimensional Quality of Life Questionnaire, HIV targeted quality of life instrument, Functional Assessment of Human Immunodeficiency Virus Infection, HIV Overview of Problems Evaluation System, EuroQol, Fanning Quality of Life scale, Health Index and PROQOL-HIV. In this review, the discussed determinants were thematically divided into socio-demographic, clinical, psychological and behavioural factors. Employment, immunological status, presence of symptoms, depression, social support and adherence to antiretroviral therapy were most frequently and consistently reported to be associated with HRQoL among people living with HIV. Conclusions: HRQoL among people living with HIV is influenced by several determinants. These determinants independently, but simultaneously impact perceived HRQoL. Most HRQoL instruments do not capture all key determinants. We recommend that the choice for an instrument should depend on the purpose of the HRQoL assessment

Effects of chlorhexidine gluconate oral care on hospital mortality : a hospital-wide, observational cohort study

Chlorhexidine oral care is widely used in critically and non-critically ill hospitalized patients to maintain oral health. We investigated the effect of chlorhexidine oral care on mortality in a general hospitalized population. In this single-center, retrospective, hospital-wide, observational cohort study we included adult hospitalized patients (2012-2014). Mortality associated with chlorhexidine oral care was assessed by logistic regression analysis. A threshold cumulative dose of 300 mg served as a dichotomic proxy for chlorhexidine exposure. We adjusted for demographics, diagnostic category, and risk of mortality expressed in four categories (minor, moderate, major, and extreme). The study cohort included 82,274 patients of which 11,133 (14%) received chlorhexidine oral care. Low-level exposure to chlorhexidine oral care (ae 300 mg) was associated with increased risk of death [odds ratio (OR) 2.61; 95% confidence interval (CI) 2.32-2.92]. This association was stronger among patients with a lower risk of death: OR 5.50 (95% CI 4.51-6.71) with minor/moderate risk, OR 2.33 (95% CI 1.96-2.78) with a major risk, and a not significant OR 1.13 (95% CI 0.90-1.41) with an extreme risk of mortality. Similar observations were made for high-level exposure (> 300 mg). No harmful effect was observed in ventilated and non-ventilated ICU patients. Increased risk of death was observed in patients who did not receive mechanical ventilation and were not admitted to ICUs. The adjusted number of patients needed to be exposed to result in one additional fatality case was 47.1 (95% CI 45.2-49.1). These data argue against the indiscriminate widespread use of chlorhexidine oral care in hospitalized patients, in the absence of proven benefit in specific populations

Contrast-enhanced ultrasonography in hepatosplenic sarcoidosis

We report a case of a 38-year-old woman with atypical pain in the left lower hemi-abdomen. On abdominal B-mode ultrasonography the liver was normal; the spleen showed multiple subcentimetric hypoechoic nodules. A multidetector CT-examination revealed multiple small low-attenuation nodules in the liver and the spleen, suggestive for metastatic disease. Contrast-enhanced ultrasound (CEUS) revealed two hypoechoic nodules in the liver that were visible in the portal phase and disappeared in the late phase. The focal splenic lesions were visible as irregular hypo-enhancing nodules. An MRI examination, including T1, T2 and contrast-enhanced images, could not confirm the exact nature of the lesions. A core biopsy of a splenic nodule yielded non-caseating epithelioid cell granulomas. Different complementary examinations were normal and hepatosplenic sarcoidosis was diagnosed. The pain in the left lower hemi-abdomen was ascribed to irritable bowel syndrome

The rising problem of antimicrobial resistance in the intensive care unit

Mainly due to its extremely vulnerable population of critically ill patients, and the high use of (invasive) procedures, the intensive care unit (ICU) is the epicenter of infections. These infections are associated with an important rise in morbidity, mortality, and healthcare costs. The additional problem of multidrug-resistant pathogens boosts the adverse impact of infections in ICUs. Several factors influence the rapid spread of multidrug-resistant pathogens in the ICU, e.g., new mutations, selection of resistant strains, and suboptimal infection control. Among gram-positive organisms, the most important resistant microorganisms in the ICU are currently methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. In gram-negative bacteria, the resistance is mainly due to the rapid increase of extended-spectrum Beta-lactamases (ESBLs) in Klebsiella pneumonia, Escherichia coli, and Proteus species and high level third-generation cephalosporin Beta-lactamase resistance among Enterobacter spp. and Citrobacter spp., and multidrug resistance in Pseudomonas aeruginosa and Acinetobacter species. To conclude, additional efforts are needed in the future to slow down the emergence of antimicrobial resistance. Constant evaluation of current practice on basis of trends in MDR and antibiotic consumption patterns is essential to make progress in this problematic matter