Mean CD4 cell count changes in patients failing a first-line antiretroviral therapy in resource-limited settings

Background Changes in CD4 cell counts are poorly documented in individuals with low or moderate-level viremia while on antiretroviral treatment (ART) in resource-limited settings. We assessed the impact of on-going HIV-RNA replication on CD4 cell count slopes in patients treated with a first-line combination ART. Method Naïve patients on a first-line ART regimen with at least two measures of HIV-RNA available after ART initiation were included in the study. The relationships between mean CD4 cell count change and HIV-RNA at 6 and 12 months after ART initiation (M6 and M12) were assessed by linear mixed models adjusted for gender, age, clinical stage and year of starting ART. Results 3,338 patients were included (14 cohorts, 64% female) and the group had the following characteristics: a median follow-up time of 1.6 years, a median age of 34 years, and a median CD4 cell count at ART initiation of 107 cells/μL. All patients with suppressed HIV-RNA at M12 had a continuous increase in CD4 cell count up to 18 months after treatment initiation. By contrast, any degree of HIV-RNA replication both at M6 and M12 was associated with a flat or a decreasing CD4 cell count slope. Multivariable analysis using HIV-RNA thresholds of 10,000 and 5,000 copies confirmed the significant effect of HIV-RNA on CD4 cell counts both at M6 and M12. Conclusion In routinely monitored patients on an NNRTI-based first-line ART, on-going low-level HIV-RNA replication was associated with a poor immune outcome in patients who had detectable levels of the virus after one year of ART.

Image and imaging an emergency department: expense and benefit of different quality assessment methods

Introduction. In this era of high-tech medicine, it is becoming increasingly important to assess patient satisfaction. There are several methods to do so, but these differ greatly in terms of cost, time, and labour and external validity. The aim of this study is to describe and compare the structure and implementation of different methods to assess the satisfaction of patients in an emergency department. Methods. The structure and implementation of the different methods to assess patient satisfaction were evaluated on the basis of a 90-minute standardised interview. Results. We identified a total of six different methods in six different hospitals. The average number of patients assessed was 5012, with a range from 230 (M5) to 20 000 patients (M2). In four methods (M1, M3, M5, and M6), the questionnaire was composed by a specialised external institute. In two methods, the questionnaire was created by the hospital itself (M2, M4).The median response rate was 58.4% (range 9-97.8%). With a reminder, the response rate increased by 60% (M3). Conclusion. The ideal method to assess patient satisfaction in the emergency department setting is to use a patient-based, in-emergency department-based assessment of patient satisfaction, planned and guided by expert personnel.

Oberflächenveränderung verschiedener zahnmedizinischer Werk-stoffe nach in-vitro Alterung

Susceptibility of different restorative materials to toothbrush abrasion and coffee staining Objective: The aim of this study was to evaluate the susceptibility of different restorative materials to surface alterations after an aging simulation. Methods: Specimens (n=15 per material) of five different restorative materials (CER: ceramic/Vita Mark II; EMP: composite/Empress Direct; LAV: CAD/CAM composite/Lava Ultimate; COM: prefabricated composite/Componeer; VEN: prefabricated composite/Venear) were produced. Whereas CER was glazed, EMP and LAV were polished with silicon polishers, and COM and VEN were left untreated. Mean roughness (Ra and Rz) and colorimetric parameters (L*a*b*), expressed as colour change (E), were measured. The specimens underwent an artificial aging procedure. After baseline measurements (M1), the specimens were successively immersed for 24 hours in coffee (M2), abraded in a toothbrushing simulator (M3), immersed in coffee (M4), abraded (M5) and repeatedly abraded (M6). After each aging procedure (M2-M6), surface roughness and colorimetric parameters were recorded. Differences between the materials regarding Ra/Rz and E were analysed with a nonparametric ANOVA analysis. The level of significance was set at α=0.05. Results: The lowest roughness values were obtained for CER. A significant increase in Ra was detected for EMP, COM and VEN compared to CER. The Ra/Rz values were found to be highly significantly different for the materials and measuring times (M) (p<0.0001). Regarding E most alterations were found for EMP and COM, whereas CER and LAV remained mostly stable. The E values were significantly different for the materials and M (p<0.0001). Conclusion: The ceramic and the CAD/CAM composite were the most stable materials with regard to roughness and colour change and the only materials that resulted in Ra values below 0.2 μm (the clinically relevant threshold). Venears and Componeers were more inert than the direct composite material and thus might be an alternative for extensive restorations in the aesthetic zone.

Infarction Distribution Pattern in Acute Stroke May Predict the Extent of Leptomeningeal Collaterals.

OBJECTIVE The aim of this study was to evaluate whether the distribution pattern of early ischemic changes in the initial MRI allows a practical method for estimating leptomeningeal collateralization in acute ischemic stroke (AIS). METHODS Seventy-four patients with AIS underwent MRI followed by conventional angiogram and mechanical thrombectomy. Diffusion restriction in Diffusion weighted imaging (DWI) and correlated T2-hyperintensity of the infarct were retrospectively analyzed and subdivided in accordance with Alberta Stroke Program Early CT score (ASPECTS). Patients were angiographically graded in collateralization groups according to the method of Higashida, and dichotomized in 2 groups: 29 subjects with collateralization grade 3 or 4 (well-collateralized group) and 45 subjects with grade 1 or 2 (poorly-collateralized group). Individual ASPECTS areas were compared among the groups. RESULTS Means for overall DWI-ASPECTS were 6.34 vs. 4.51 (well vs. poorly collateralized groups respectively), and for T2-ASPECTS 9.34 vs 8.96. A significant difference between groups was found for DWI-ASPECTS (p<0.001), but not for T2-ASPECTS (p = 0.088). Regarding the individual areas, only insula, M1-M4 and M6 showed significantly fewer infarctions in the well-collateralized group (p-values <0.001 to 0.015). 89% of patients in the well-collateralized group showed 0-2 infarctions in these six areas (44.8% with 0 infarctions), while 59.9% patients of the poor-collateralized group showed 3-6 infarctions. CONCLUSION Patients with poor leptomeningeal collateralization show more infarcts on the initial MRI, particularly in the ASPECTS areas M1 to M4, M6 and insula. Therefore DWI abnormalities in these areas may be a surrogate marker for poor leptomeningeal collaterals and may be useful for estimation of the collateral status in routine clinical evaluation.