David M. Forrest

The Incidence and Spectrum of AIDS-Defining Illnesses in Persons Treated with Antiretroviral Drugs

The incidence and spectrum of primary AIDS-defining illnesses in human immunodeficiency virus-positive patients receiving antiretroviral drugs may have changed since the introduction of newer antiretroviral agents. We performed a retrospective analysis of patients enrolled in the British Columbia Drug Treatment Program who were ever prescribed antiretroviral drugs between 1 January 1994 and 31 December 1996. Rates were calculated on a 6-month basis. There were 344 AIDS cases diagnosed among 2,533 participants between 1994 and 1996. The incidence of primary AIDS diseases decreased from 1994 to 1996, with a sharp decline in 1995 and 1996. There was no statistically significant change in the incidence of primary AIDS diagnoses relative to one another, and Pneumocystis carinii pneumonia and Kaposis sarcoma remain the most common AIDS index diagnoses. In patients receiving antiretroviral therapy in the modern era, the incidence of AIDS-defining illnesses has decreased substantially, but the spectrum of AIDS-defining illnesses remains unchanged.

Implementation of a clinical practice guideline for stress ulcer prophylaxis increases appropriateness and decreases cost of care

AbstractObjective: To develop, implement and evaluate a practice guideline for stress ulcer prophylaxis. Design: Before-after study. Setting: Ten-bed Intensive Care Unit (ICU) and 4-bed Step-down Unit in a teaching hospital. Patients and participants: Fifty patients admitted during 1 year before and 50 patients admitted 3–6 months after introduction of the guideline. Intervention: Introduction of the practice guideline by dissemination of pocket cards, seminars and ‘academic detailing’. Measurements and results: Appropriateness (defined as proportion of days in which the prophylaxis met the criteria in the guideline), incidence of gastrointestinal bleeding and of ventilator-associated pneumonia, length of stay in ICU and in hospital, ventilator days, ICU mortality and medication costs for stress ulcer prophylaxis. After the introduction of the guideline, appropriateness increased from 75.8 % to 91.1 %, and medication costs decreased from C

Willingness to Take, Use of, and Indications for Pre-exposure Prophylaxis Among Men Who Have Sex With Men-20 US Cities, 2014.

2.50/day to C

Introduction of a Practice Guideline for Penicillin Skin Testing Improves the Appropriateness of Antibiotic Therapy

1.30/day. There were no differences in any clinical outcomes. Predictors of appropriate use or the withholding of prophylaxis were the introduction of the guideline, lack of an indication for prophylaxis and number of days studied. Conclusions: Introduction of this guideline was associated with an increase in appropriateness of prophylaxis and a decrease in medication costs.

Imaging features of pulmonary kaposi sarcoma-associated immune reconstitution syndrome

BACKGROUND Pre-exposure prophylaxis (PrEP) is an effective prevention tool for people at substantial risk of acquiring human immunodeficiency virus (HIV). To monitor the current state of PrEP use among men who have sex with men (MSM), we report on willingness to use PrEP and PrEP utilization. To assess whether the MSM subpopulations at highest risk for infection have indications for PrEP according to the 2014 clinical guidelines, we estimated indications for PrEP for MSM by demographics. METHODS We analyzed data from the 2014 cycle of the National HIV Behavioral Surveillance (NHBS) system among MSM who tested HIV negative in NHBS and were currently sexually active. Adjusted prevalence ratios and 95% confidence intervals were estimated from log-linked Poisson regression with generalized estimating equations to explore differences in willingness to take PrEP, PrEP use, and indications for PrEP. RESULTS Whereas over half of MSM said they were willing to take PrEP, only about 4% reported using PrEP. There was no difference in willingness to take PrEP between black and white MSM. PrEP use was higher among white compared with black MSM and among those with greater education and income levels. Young, black MSM were less likely to have indications for PrEP compared with young MSM of other races/ethnicities. CONCLUSIONS Young, black MSM, despite being at high risk of HIV acquisition, may not have indications for PrEP under the current guidelines. Clinicians may need to consider other factors besides risk behaviors such as HIV incidence and prevalence in subgroups of their communities when considering prescribing PrEP.

Management following resuscitation from cardiac arrest: recommendations from the 2003 Rocky Mountain Critical Care Conference.

We hypothesized that the introduction of a practice guideline for penicillin skin testing would increase the appropriateness of skin testing and reduce antibiotic costs for patients with a history of penicillin allergy who have infections caused by penicillin-susceptible pathogens. We measured the appropriateness of skin testing and daily antibiotic costs before and after the introduction of a guideline for penicillin skin testing. For patients who had negative results of skin testing and were subsequently treated with a penicillin instead of an alternative antibiotic, we calculated the difference between the actual costs and the projected costs of continuing alternative antibiotics without skin testing. After the guideline was introduced, appropriateness of skin testing increased from 17% to 64%, but daily antibiotic costs did not change. For patients who had negative results of skin testing and who were subsequently treated with a penicillin, there was no difference between actual costs and the projected costs if they had not been skin tested. We conclude that introduction of a guideline for penicillin skin testing increases the percentage of eligible patients who have a skin test, and it does so without increasing costs.

Volume expansion using pentastarch does not change gastric-arterial CO2 gradient or gastric intramucosal pH in patients who have sepsis syndrome.

OBJECTIVE The purpose of this study was to analyze the radiologic features of pulmonary Kaposi sarcoma-associated immune reconstitution syndrome. The syndrome is a phenomenon characterized by clinical deterioration of the condition of HIV-positive patients after initiation of highly active antiretroviral therapy. MATERIALS AND METHODS The study included four patients at our institution who fulfilled the diagnostic criteria for pulmonary Kaposi sarcoma-associated immune reconstitution syndrome from 2001 to 2006. All patients were men (mean age, 43 years; range, 31-59 years). Images reviewed included chest radiographs obtained before highly active antiretroviral therapy, radiographs and chest CT scans obtained at appearance of the symptoms of Kaposi sarcoma-associated immune reconstitution syndrome, and follow-up radiographs and chest CT scans during immune reconstitution syndrome. RESULTS The radiographic findings of Kaposi sarcoma-associated immune reconstitution syndrome included reticular and reticulonodular opacities (n = 4), areas of consolidation (n = 3), septal lines (n = 3), and pleural effusion (n = 3). The CT findings in all four patients were ill-defined pulmonary nodules and interlobular septal thickening. Three of the patients had a CT halo sign, areas of consolidation, ground-glass opacities, lymphadenopathy, and pleural effusion. The areas of consolidation in three subjects who did not receive chemotherapy increased markedly after 14-20 days. CT performed during the initial symptoms of immune reconstitution syndrome in these three subjects showed less than 5% parenchymal involvement. Follow-up CT showed 26-50% involvement in two patients and more than 50% involvement in one patient. CONCLUSION The radiologic findings of pulmonary Kaposi sarcoma-associated immune reconstitution syndrome are similar to the findings described in patients with Kaposi sarcoma without the syndrome, but the extent of abnormalities tends to increase with the development of the syndrome.

Conduite à tenir après la réanimation post-arrêt cardiaque: Recommandations de la conférence du Rocky mountain critical care 2003

PurposeTo propose a strategy for the management of patients admitted to critical care units after resuscitation from cardiac arrest.SourcePrior to the conference relevant studies were identified via literature searches and brief reviews circulated on the following topics: glucose and blood pressure management; therapeutic hypothermia; prearrest outcome prediction; post-arrest outcome prediction; and management of myocardial ischemia. Two days were devoted to assessing evidence and developing a management strategy at the conference. Consensus opinion of conference participants [intensive care unit (ICU) physicians] was used when high grade evidence was unavailable. Additional literature searches and data grading were performed post-conference.Principal findingsHigh grade evidence was lacking in most areas. Specific goals of treatment were proposed for: general care; neurologic care; respiratory care; cardiac care; and gastrointestinal care. There was adequate evidence to recommend therapeutic hypothermia for comatose patients who had witnessed ventricular fibrillation or ventricular tachycardia arrests. Conference participants supported extending therapeutic hypothermia to other presenting rhythms in selected circumstances. Additional goals included mean arterial pressure 80 to 100 mmHg, glucose 5 to 8 mmol·L-1 using insulin infusions, and PaO2 > 100 mmHg for the first 24 hr. Absent withdrawal to pain 72 hr after resuscitation should prompt consideration of palliative care. The level of evidence for other recommendations was low.ConclusionsThe proposed management strategy represents an approach to manage patients in the ICU following resuscitation from cardiac arrest. Most of the recommendations are based on low grade evidence. Additional research is needed to improve the evidence base. A standard post-arrest management strategy could help facilitate future research.RésuméObjectifProposer une stratégie de traitement à adopter avec les patients admis aux unités de soins intensifs (USI) après la réanimation post-arrêt cardiaque.SourceAvant la conférence, les études utiles ont été repérées dans les publications et de brèves revues ont circulé sur : le glucose et le traitement de la tension artérielle; l’hypothermie thérapeutique; la prédiction de l’évolution pré-arrêt; la prédiction des suites de l’arrêt cardiaque et le traitement de l’ischémie myocardique. Deux jours ont été alloués à l’évaluation de la preuve et au développement d’une approche thérapeutique à la conférence. L’opinion générale des par-ticipants, médecins intensivistes, a prévalu quand une preuve de haut niveau n’était pas assurée. Des recherches de documents et une clas-sification de données supplémentaires ont été faites après la con-férence.Constatations principalesUne preuve de haut niveau manquait dans la majorité des domaines. On a proposé des objectifs spécifiques de traitement pour : les soins généraux, neurologiques, respiratoires, cardiaques et gastro-intestinaux. Des preuves suffisantes ont permis de recommander l’hypothermie thérapeutique chez les patients comateux victimes d’arrêts cardiaques causés par une fibrillation ou une tachycardie ventriculaire. Les participants à la conférence ont appuyé l’extension de l’hypothermie thérapeutique aux rythmes présentés dans des circonstances choisies. D’autres objectifs incluent une tension artérielle moyenne de 80 à 100 mmHg, le glucose à 5 àObjectif Proposer une strategie de traitement a adopter avec les patients admis aux unites de soins intensifs (USI) apres la reanimation post-arret cardiaque.

Awareness, Willingness, and Use of Pre-exposure Prophylaxis among Men Who Have Sex with Men in Washington, DC and Miami-Dade County, FL: National HIV Behavioral Surveillance, 2011 and 2014

Objective In hypovolemic patients with sepsis syndrome, to determine the effects of colloid volume infusion using 10% pentastarch on abnormal gastric tonometer measurements (gastric intramucosal CO2 tension, gastric intramucosal-arterial Pco2 gradient, and gastric intramucosal pH [pHi]) and on cardiac index, global oxygen delivery, and hemoglobin. Design Prospective prepost intervention study. Setting Tertiary care, university-affiliated 15-bed general systems intensive care unit. Patients Patients were studied who had sepsis syndrome, who had pulmonary arterial catheters in place, who were hypovolemic (pulmonary arterial occlusion pressure [PAOP] <15 mm Hg), and who had a gastric arterial Pco2 gradient >10 mm Hg. Interventions Baseline measurements of gastric intramucosal CO2 tension, gastric intramucosal-arterial Pco2 gradient, and pHi, as well as arterial lactate, pulmonary arterial occlusion, central venous and systemic arterial pressures, thermodilution cardiac output, and temperature. Boluses of 500 mL pentastarch were administered to a total of 1000 mL or until PAOP was >18 mm Hg. Measurements were repeated at 30 mins and 120 mins postinfusion of pentastarch. Main Results Volume infusion using pentastarch did not change gastric Pco2, gastric-arterial Pco2 gradient, or pHi. Volume expansion with pentastarch significantly increased cardiac index, global oxygen delivery, and PAOP. Administration of pentastarch decreased hemoglobin and arterial lactate at 30 mins but not at 120 mins. Conclusions Volume expansion using a colloidal solution of 10% pentastarch does not change abnormal intramucosal CO2 tension, gastric-arterial Pco2 gradient, or pHi in critically ill hypovolemic patients who have sepsis syndrome despite increasing cardiac index, oxygen delivery, and pulmonary artery occlusion pressure.

Impact of acid-base disorders on individual organ systems

PurposeTo propose a strategy for the management of patients admitted to critical care units after resuscitation from cardiac arrest.SourcePrior to the conference relevant studies were identified via literature searches and brief reviews circulated on the following topics: glucose and blood pressure management; therapeutic hypothermia; prearrest outcome prediction; post-arrest outcome prediction; and management of myocardial ischemia. Two days were devoted to assessing evidence and developing a management strategy at the conference. Consensus opinion of conference participants [intensive care unit (ICU) physicians] was used when high grade evidence was unavailable. Additional literature searches and data grading were performed post-conference.Principal findingsHigh grade evidence was lacking in most areas. Specific goals of treatment were proposed for: general care; neurologic care; respiratory care; cardiac care; and gastrointestinal care. There was adequate evidence to recommend therapeutic hypothermia for comatose patients who had witnessed ventricular fibrillation or ventricular tachycardia arrests. Conference participants supported extending therapeutic hypothermia to other presenting rhythms in selected circumstances. Additional goals included mean arterial pressure 80 to 100 mmHg, glucose 5 to 8 mmol·L-1 using insulin infusions, and PaO2 > 100 mmHg for the first 24 hr. Absent withdrawal to pain 72 hr after resuscitation should prompt consideration of palliative care. The level of evidence for other recommendations was low.ConclusionsThe proposed management strategy represents an approach to manage patients in the ICU following resuscitation from cardiac arrest. Most of the recommendations are based on low grade evidence. Additional research is needed to improve the evidence base. A standard post-arrest management strategy could help facilitate future research.RésuméObjectifProposer une stratégie de traitement à adopter avec les patients admis aux unités de soins intensifs (USI) après la réanimation post-arrêt cardiaque.SourceAvant la conférence, les études utiles ont été repérées dans les publications et de brèves revues ont circulé sur : le glucose et le traitement de la tension artérielle; l’hypothermie thérapeutique; la prédiction de l’évolution pré-arrêt; la prédiction des suites de l’arrêt cardiaque et le traitement de l’ischémie myocardique. Deux jours ont été alloués à l’évaluation de la preuve et au développement d’une approche thérapeutique à la conférence. L’opinion générale des par-ticipants, médecins intensivistes, a prévalu quand une preuve de haut niveau n’était pas assurée. Des recherches de documents et une clas-sification de données supplémentaires ont été faites après la con-férence.Constatations principalesUne preuve de haut niveau manquait dans la majorité des domaines. On a proposé des objectifs spécifiques de traitement pour : les soins généraux, neurologiques, respiratoires, cardiaques et gastro-intestinaux. Des preuves suffisantes ont permis de recommander l’hypothermie thérapeutique chez les patients comateux victimes d’arrêts cardiaques causés par une fibrillation ou une tachycardie ventriculaire. Les participants à la conférence ont appuyé l’extension de l’hypothermie thérapeutique aux rythmes présentés dans des circonstances choisies. D’autres objectifs incluent une tension artérielle moyenne de 80 à 100 mmHg, le glucose à 5 àObjectif Proposer une strategie de traitement a adopter avec les patients admis aux unites de soins intensifs (USI) apres la reanimation post-arret cardiaque.