The role of targeted viral load testing in diagnosing virological failure in children on antiretroviral therapy with immunological failure.

Objectives  To determine the improvement in positive predictive value of immunological failure criteria for identifying virological failure in HIV-infected children on antiretroviral therapy (ART) when a single targeted viral load measurement is performed in children identified as having immunological failure. Methods  Analysis of data from children (<16 years at ART initiation) at South African ART sites at which CD4 count/per cent and HIV-RNA monitoring are performed 6-monthly. Immunological failure was defined according to both WHO 2010 and United States Department of Health and Human Services (DHHS) 2008 criteria. Confirmed virological failure was defined as HIV-RNA >5000 copies/ml on two consecutive occasions <365 days apart in a child on ART for ≥18 months. Results  Among 2798 children on ART for ≥18 months [median (IQR) age 50 (21-84) months at ART initiation], the cumulative probability of confirmed virological failure by 42 months on ART was 6.3%. Using targeted viral load after meeting DHHS immunological failure criteria rather than DHHS immunological failure criteria alone increased positive predictive value from 28% to 82%. Targeted viral load improved the positive predictive value of WHO 2010 criteria for identifying confirmed virological failure from 49% to 82%. Conclusion  The addition of a single viral load measurement in children identified as failing immunologically will prevent most switches to second-line treatment in virologically suppressed children

Post-Operative Concurrent Chemoradiation with Mitomycin-C for Advanced Head and Neck Cancer

Purpose: Recent prospective randomized trials have shown concurrent chemo-radiation improves local-regional control in post-operative patients with squamous cell carcinomas of the head and neck (SCCHN) using cis-platinum based regimens. This report pools data from three randomized trials performed at Yale that employed mitomycin-C (MC), selecting those patients treated postoperatively, to evaluate the long term benefit of MC in the postoperative setting and to compare these results with other recently published randomized trials. Methods and Materials: Between 1980 and 1999, a total of 331 SCCHN patients from the three prospective trials were enrolled. Of those patients, 205 were post-operative of which 103 were randomized to receive mitomycin-C and radiation, while 102 received radiation alone or radiation with porfiromycin in the third trial. Patients were treated with daily radiotherapy to a total median dose of 60 Gy over 47 days. Patients who were randomized to MC received 15 milligrams per square meter (mg/M2) of mitomycin-C on days 5 and 47 (or last day). Results: The 5-year rate of local-regional control was higher in the MC arms (85.3% vs. 69.9%, p = .008). There was no statistically significant difference in overall survival or distant metastasis. Patients had a lower percentage of high risk factors in both arms of the study, compared to patients of the large prospective trials, including positive margins, 2 or more positive lymph nodes, or oropharynx primary. The gains in local-regional control realized with MC were similar to the improvements in the recently published randomized trials using cis-platinum. Conclusions: These results confirm significant gains in local-regional control using concurrent chemo-radiotherapy in the postoperative setting for patients with SCCHN. The lack of consensus over a benefit in overall survival and distant metastasis emphasizes the need for further prospective trials in the postoperative management of SCCHN

How many people living with HIV will be additionally eligible for antiretroviral treatment in Karnataka State, India as per the World Health Organization 2013 guidelines?

BACKGROUND: The National AIDS control programme (NACP) in India is currently following the World Health Organization (WHO) 2010 antiretroviral therapy (ART) guidelines. In 2013, the WHO revised its recommendations for initiating ART among people living with HIV (PLHIV) by increasing the threshold for ART initiation to a CD4 count ≤500 cells/uL. For certain patient groups, ART is recommended irrespective of CD4 count (PLHIV with active tuberculosis, hepatitis B virus infection, pregnant and breast feeding women, children aged under five years and those living in a sero-discordant relationship). In this operational research, we assess the effect of applying this recommendation on the number of PLHIV additionally eligible for ART. METHODS: This was a cross-sectional analysis of routinely collected programme data from all PLHIV registered in Karnataka State (population 60 million), India in 2012. RESULTS: Of 37,044 PLHIV, 27,074 (73%) were eligible for initiating ART as per WHO-2010 criteria. As per the WHO-2013 criteria (CD4 count ≤500 and all pregnant women and under-five children irrespective of CD4 count), an additional 5104 (14%) HIV-infected people would be eligible for initiating ART. There were no data to inform the additional patient load due to sero-discordance. CONCLUSION: Adopting the WHO-2013 guidelines for India has important resource implications. However, given the significant patient and programmatic benefits of adopting the new guidelines, this has been considered favourably by the NACP in India and steps are being planned to integrate ART care into the general health system to cope with the increased numbers of patients

Epidurals for liver transplantation – Where are we?

Thoracic epidural analgesia (TEA) has been used as a mode of postoperative pain relief for orthotopic liver transplants (OLT) in a selected group of patients. It is not widely practiced in view of the impaired haemostasis associated with end-stage liver disease and severe unpredictable intraoperative coagulopathy. TEA in OLT may not be the technique of choice for routine administration of postoperative analgesia, but can be considered in patients who have a normal coagulation profile preoperatively. Safe conduct of TEA in OLT involves anaesthetic expertise and stringent monitoring in the postoperative period. This review discusses the status of thoracic epidural analgesia in patients undergoing an orthotopic liver transplant

Intraoperative cardiovascular monitoring in hypertensive patients

Bacground and Purpose: Hypertensive patients are more prone to perioperative ischaemia, arrythmias and cardiovascular instability. Attention should be paid to the presence of target organ damage, such as coronary artery disease. Material and Method: Haemodynamically unstable patients undergoing major surgery require more complex haemodynamic monitoring. Multiple studies have demonstrated the favourable outcome achieved by goal-directed fluid management during the intraoperative period. Conclusion: The trend in intraoperative haemodynamic monitoring, a key feature of anaesthetic practice is towards less invasive systems that provide continuous information. A balance is needed between the hazards of an invasive approach and the desire for a continuous stream of accurate information that is robust enough to withstand the surgical and physiological challenges in hypertensive patients. In spite of its importance for anaesthetists, there is no consensus as to which system is best. This review examines the recent developments in haemodynamic monitoring

Myrin Library News, Vol. 7 No. 1, October 1993

This newsletter announces recent acquisitions of Myrin Library at Ursinus College and provides information and updates about recent projects, exhibits and events.https://digitalcommons.ursinus.edu/library_news/1034/thumbnail.jp

Retention in pre-antiretroviral treatment care in a district of Karnataka, India: how well are we doing?

Setting: Antiretroviral treatment (ART) Centre in Tumkur district of Karnataka State, India. There is no published information about pre-ART loss to follow-up from India. Objective: To assess the proportion lost to follow-up (defined as not visiting the ART Centre within 1 year of registration) and associated socio-demographic and immunological variables. Design: Retrospective cohort study involving a review of medical records of adult HIV-infected persons (aged ⩾15 years) registered in pre-ART care during January 2010–June 2012. Results: Of 3238 patients registered, 2519 (78%) were eligible for ART, while 719 (22%) were not. Four of the latter were transferred out; the remaining 715 individuals were enrolled in pre-ART care, of whom 290 (41%) were lost to follow-up. Factors associated with loss to follow-up on multivariate analysis included age group ⩾45 years, low educational level, not being married, World Health Organization Stage III or IV and rural residence. Conclusion: About four in 10 individuals in pre-ART care were lost to follow-up within 1 year of registration. This needs urgent attention. Routine cohort analysis in the national programme should include those in pre-ART care to enable improved review, monitoring and supervision. Further qualitative research to ascertain reasons for loss to follow-up is required to design future interventions

Rabies vaccine and neuraxial anaesthesia

This case report of neuraxial anaesthesia for emergency orthopaedic surgery serves to highlight the dilemma faced by anaesthetists when surgical intervention becomes necessary in a patient on anti-rabies vaccine. The two issues of importance are the possible reduction in the efficacy of vaccination by an immunosuppressive effect of anaesthesia and surgery, and the possible need to avoid local anaesthetics for the provision of postoperative analgesia to assist in the early detection of any neurological deficit.Keywords: rabies; vaccine; anaesthesia; neuraxial bloc