Hepatocellular Carcinoma Surveillance in a Cohort of Chronic Hepatitis C Virus-Infected Patients with Cirrhosis.

BACKGROUND: Six-monthly hepatocellular carcinoma (HCC) screening in cirrhotic patients has been recommended since 2011. HCC prognosis is associated with diagnosis at an early stage. We examined the prevalence and correlates of 6-monthly HCC surveillance in a cohort of HCV-infected cirrhotic patients. METHODS: Data were obtained from the medical records of patients receiving care from four hospitals between January 2011 and December 2016. Frequencies and logistic regression were conducted. RESULTS: Of 2,933 HCV-infected cirrhotic patients, most were ≥ 60 years old (68.5%), male (62.2%), White (65.8%), and had compensated cirrhosis (74.2%). The median follow-up period was 3.5 years. Among these patients, 10.9% were consistently screened 6 monthly and 21.4% were never screened. Patients with a longer history of cirrhosis (AOR = 0.86, 95% CI = 0.80-0.93) were less likely to be screened 6 monthly while decompensated cirrhotic patients (AOR = 1.39, 95% CI = 1.06-1.81) and cirrhotic patients between 18 and 44 years (AOR = 2.01, 95% CI = 1.07-3.74) were more likely to be screened 6 monthly compared to compensated cirrhotic patients and patients 60 years and older respectively. There were no significant differences by race, gender, or insurance type. CONCLUSION: The prevalence of consistent HCC surveillance remains low despite formalized recommendations. One in five patients was never surveilled. Patients with a longer history of cirrhosis were less likely to be surveilled consistently despite their greater HCC risk. Improving providers' knowledge about current HCC surveillance guidelines, educating patients about the benefits of consistent HCC surveillance, and systemic interventions like clinical reminders and standing HCC surveillance protocols can improve guideline-concordant surveillance in clinical practice.

A randomised study of tailored toxicity-based dosage of fluorouracil-epirubicin-cyclophosphamide chemotherapy for early breast cancer (SBG 2000-1).

STUDY AIM: Retrospective studies have demonstrated a worse outcome in breast cancer patients not developing leukopenia during adjuvant chemotherapy. The SBG 2000-1 is the first randomised trial designed to compare individually dosed chemotherapy without G-CSF support based on grade of toxicity to standard-dosed chemotherapy based on body surface area (BSA). METHODS: Patients with early breast cancer were included and received the first cycle of standard FEC (fluorouracil 600 mg/m2, epirubicin 60 mg/m2, cyclophosphamide 600 mg/m2). Patients with nadir leukopenia grade 0-2 after first cycle were randomised between either 6 additional courses of tailored FEC with increased doses (E 75-90 mg/m2, C 900-1200 mg/m2) or fixed treatment with 6 standard FEC. Patients with grade 3-4 leukopenia were registered and treated with 6 standard FEC. Primary end-point was distant disease-free survival (DDFS). RESULTS: The study enrolled 1535 patients, of which 1052 patients were randomised to tailored FEC (N = 524) or standard FEC (N = 528), whereas 401 patients with leukopenia grade 3-4 continued standard FEC and formed the registered cohort. Dose escalation did not statistically significantly improve 10-year DDFS (79% and 77%, HR 0.87, CI 0.67-1.14, P = 0.32) or OS (82% and 78%, respectively, HR 0.89, CI 0.57-1.16, P = 0.38). Corresponding estimates for the registered group of patients were DDFS 79% and OS 82%, respectively. CONCLUSIONS: The SBG 2000-1 study failed to show a statistically significant improvement of escalated and tailored-dosed chemotherapy compared with standard BSA-based chemotherapy in patients with low haematological toxicity, although all efficacy parameters showed a numerical advantage for tailored treatment.

Impact of sustained virologic response on risk of type 2 diabetes among hepatitis C patients in the United States.

Data regarding the impact of hepatitis C (HCV) therapy on incidence of type 2 diabetes mellitus are limited. We used the data from the longitudinal Chronic Hepatitis Cohort Study-drawn from four large US health systems-to investigate how response to HCV treatment impacts the risk of subsequent diabetes. Among HCV patients without a history of type 2 diabetes mellitus or hepatitis B, we investigated the incidence of type 2 diabetes from 12 weeks post-HCV treatment through December 2015. Cox proportional hazards models were used to test the effect of treatment status (sustained virologic response [SVR] or treatment failure) and baseline risk factors on the development of diabetes, considering any possible risk factor-by-SVR interactions, and death as a competing risk. Among 5127 patients with an average follow-up of 3.7 years, diabetes incidence was significantly lower among patients who achieved SVR (231/3748; 6.2%) than among patients with treatment failure (299/1379; 21.7%; adjusted hazard ratio [aHR] = 0.79; 95% CI: 0.65-0.96). Risk of diabetes was higher among African American and Asian American patients than White patients (aHR = 1.82 and 1.75, respectively; P < .05), and among Hispanic patients than non-Hispanics (aHR = 1.86). Patients with BMI ≥ 30 and 25-30 (demonstrated higher risk of diabetes aHR = 3.62 and 1.72, respectively; P < .05) than those with BMI < 25; patients with cirrhosis at baseline had higher risk than those without cirrhosis (aHR = 1.47). Among a large US cohort of patients treated for HCV, patients who achieved SVR demonstrated a substantially lower risk for the development of type 2 diabetes mellitus than patients with treatment failure.

Diabetes and intracerebral hemorrhage: baseline characteristics and mortality.

BACKGROUND AND PURPOSE: Acknowledging the conflicting evidence for diabetes as a predictor of short- and long-term mortality following an intracerebral hemorrhage (ICH), we compared baseline characteristics and 30-day and long-term mortality between patients with and without diabetes after an ICH, paying special attention to differences between type 1 (T1D) and type 2 (T2D) diabetes. METHODS: Patients with a first-ever ICH were followed for a median of 2.3 years. Adjusting for demographics, comorbidities and documented ICH characteristics increasing mortality after ICH, logistic regression analysis assessed factors associated with case fatality and 1-year survival among the 30-day survivors. Diabetes was compared with patients without diabetes in separate models as (i) any diabetes and (ii) T1D or T2D. RESULTS: Of our 969 patients, 813 (83.9%) had no diabetes, 41 (4.2%) had T1D and 115 (11.9%) had T2D. Compared with patients without diabetes, those with diabetes were younger, more often men and more frequently had hypertension, coronary heart disease and chronic kidney disease, with similar ICH characteristics. Patients with T1D were younger, more often had chronic kidney disease and brainstem ICH, and less often had atrial fibrillation and lobar ICH, than did patients with T2D. Diabetes had no impact on case fatality. Any diabetes (odds ratio, 2.57; 1.19-5.52), T1D (odds ratio, 7.04; 1.14-43.48) and T2D (odds ratio, 2.32; 1.04-5.17) were independently associated with 1-year mortality. CONCLUSIONS: Patients with ICH with diabetes exhibited a distinct pattern of comorbidities and disease characteristics with specific differences between T1D and T2D. Despite their younger age, T1D seems to carry a substantially higher likelihood of long-term mortality after an ICH than does T2D.

Distribution of disease phase, treatment prescription and severe liver disease among 1598 patients with chronic hepatitis B in the Chronic Hepatitis Cohort Study, 2006-2013.

BACKGROUND: Limited information exists regarding the distribution of disease phases, treatment prescription and severe liver disease among patients with chronic hepatitis B (CHB) in US general healthcare settings. AIM: To determine the distribution of disease phases, treatment prescription and severe liver disease among patients with CHB in general US healthcare settings. METHODS: We analysed demographic and clinical data collected during 2006-2013 from patients with confirmed CHB in the Chronic Hepatitis Cohort Study, an observational cohort study involving patients from healthcare organisations in Michigan, Pennsylvania, Oregon and Hawaii. CHB phases were classified according to American Association for the Study of Liver Disease guidelines. RESULTS: Of 1598 CHB patients with ≥12 months of follow-up (median 6.3 years), 457 (29%) were immune active during follow-up [11% hepatitis B e antigen (HBeAg)-positive, 16% HBeAg-negative, and 2% HBeAg status unknown], 10 (0.6%) were immune tolerant, 112 (7%) were inactive through the duration of follow-up and 886 (55%) were phase indeterminate. Patients with cirrhosis were identified within each group (among 21% of immune active, 3% of inactive and 9% of indeterminate phase patients) except among those with immune-tolerant CHB. Prescription of treatment was 59% among immune active patients and 84% among patients with cirrhosis and hepatitis B virus (HBV) DNA >2000 IU/mL. CONCLUSIONS: Approximately, one-third of the cohort had active disease during follow-up; 60% of eligible patients were prescribed treatment. Our findings underscore the importance of ascertainment of fibrosis status in addition to regular assessment of ALT and HBV DNA levels.

Higher all-cause hospitalization among patients with chronic hepatitis C: the Chronic Hepatitis Cohort Study (CHeCS), 2006-2013.

In the United States, hospitalization among patients with chronic hepatitis C virus (HCV) infection is high. The healthcare burden associated with hospitalization is not clearly known. We analysed data from the Chronic Hepatitis Cohort Study, an observational cohort of patients receiving care at four integrated healthcare systems, collected from 2006 to 2013 to determine all-cause hospitalization rates of patients with chronic HCV infection and the other health system patients. To compare the hospitalization rates, we selected two health system patients for each chronic HCV patient using their propensity score (PS). Propensity score matching was conducted by site, gender, race, age and household income to minimize differences attributable to these characteristics. We also compared primary reason for hospitalization between chronic HCV patients and the other health system patients. Overall, 10 131 patients with chronic HCV infection and 20 262 health system patients were selected from the 1 867 802 health system patients and were matched by PS. All-cause hospitalization rates were 27.4 (27.0-27.8) and 7.4 (7.2-7.5) per 100 persons-year (PY) for chronic HCV patients and for the other health system patients, respectively. Compared to health system patients, hospitalization rates were significantly higher by site, gender, age group, race and household income among chronic HCV patients (P < 0.001). Compared to health system patients, chronic HCV patients were more likely to be hospitalized from liver-related conditions (RR = 24.8, P < 0.001). Hence, patients with chronic HCV infection had approximately 3.7-fold higher all-cause hospitalization rate than other health system patients. These findings highlight the incremental costs and healthcare burden of patients with chronic HCV infection associated with hospitalization.

APRI and FIB-4 are good predictors of the stage of liver fibrosis in chronic hepatitis B: the Chronic Hepatitis Cohort Study (CHeCS).

We aim to determine the predictive ability of APRI, FIB-4 and AST/ALT ratio for staging of liver fibrosis and to differentiate significant fibrosis (F2-F4) from none to minimal fibrosis (F0-F1) in chronic hepatitis B (CHB). Liver biopsy results were mapped to an F0-4 equivalent fibrosis stage. Mean APRI and FIB-4 scores were significantly higher for each successive fibrosis level from F1 to F4 (P < 0.05). Based on optimized cut-offs, the AUROCs in distinguishing F2-F4 from F0 to F1 were 0.81 (0.76-0.87) for APRI, 0.81 (0.75-0.86) for FIB-4 and 0.56 (0.49-0.64) for AST/ALT ratio. APRI and FIB-4 distinguished F2-F4 from F0 to F1 with good sensitivity and specificity and can be useful for treatment decisions and monitoring progression of fibrosis.

Improvement in the hospital organisation of CPR training and outcome after cardiac arrest in Sweden during a 10-year period.

AIM: To describe (a) changes in the organisation of training in cardiopulmonary resuscitation (CPR) and the treatment of cardiac arrest in hospital in Sweden and (b) the clinical achievement, i.e. survival and cerebral function, among survivors after in-hospital cardiac arrest (IHCA) in Sweden. METHODS: Aspects of CPR training among health care providers (HCPs) and treatment of IHCA in Sweden were evaluated in 3 national surveys (1999, 2003 and 2008). Patients with IHCA are recorded in a National Register covering two thirds of Swedish hospitals. RESULTS: The proportion of hospitals with a CPR coordinator increased from 45% in 1999 to 93% in 2008. The majority of co-ordinators are nurses. The proportions of hospitals with local guidelines for acceptable delays from cardiac arrest to the start of CPR and defibrillation increased from 48% in 1999 to 88% in 2008. The proportion of hospitals using local defibrillation outside intensive care units prior to arrival of rescue team increased from 55% in 1999 to 86% in 2008. During the past 4 years in Sweden, survival to hospital discharge has been 29%. Among survivors, 93% have a cerebral performance category (CPC) score of I or II, indicating acceptable cerebral function. CONCLUSION: During the last 10 years, there was a marked improvement in CPR training and treatment of IHCA in Sweden. During the past 4 years, survival after IHCA is high and the majority of survivors have acceptable cerebral function.

Is chronic hepatitis B being undertreated in the United States?

Chronic infection with the hepatitis B virus (HBV) is a major risk factor for development of end-stage liver disease, including cirrhosis, liver failure and primary liver cancer. There are now seven antiviral agents approved by the United States Food and Drug Administration (FDA) for the management of chronic HBV infection. Despite the fact that there are between 1.4 and 2 million chronic HBV infections in the United States, fewer than 50,000 people per year receive prescriptions for HBV antiviral medications. This report discusses possible explanations for the disparity between the number of people who are chronically infected and the number of people who receive treatment. Explanations for this incongruence include the potentially large number of infected persons who are unscreened and thus remain undiagnosed, and lack of access, including insurance, education and referral to appropriate medical care, particularly for disproportionately infected populations.

Passive leg raising during cardiopulmonary resuscitation in out-of-hospital cardiac arrest--does it improve circulation and outcome?

BACKGROUND: Passive leg raising (PLR), to augment the artificial circulation, was deleted from cardiopulmonary resuscitation (CPR) guidelines in 1992. Increases in end-tidal carbon dioxide (P(ET)CO(2)) during CPR have been associated with increased pulmonary blood flow reflecting cardiac output. Measurements of P(ET)CO(2) after PLR might therefore increase our understanding of its potential value in CPR. We also observed the alteration in P(ET)CO(2) in relation to the return of spontaneous circulation (ROSC) and no ROSC. METHODS AND RESULTS: The P(ET)CO(2) was measured, subsequent to intubation, in 126 patients suffering an out-of-hospital cardiac arrest (OHCA), during 15 min or until ROSC. Forty-four patients were selected by the study protocol to PLR 35 cm; 21 patients received manual chest compressions and 23 mechanical compressions. The PLR was initiated during uninterrupted CPR, 5 min from the start of P(ET)CO(2) measurements. During PLR, an increase in P(ET)CO(2) was found in all 44 patients within 15 s (p=0.003), 45 s (p=0.002) and 75 s (p=0.0001). Survival to hospital discharge was 7% among patients with PLR and 1% among those without PLR (p=0.12). Among patients experiencing ROSC (60 of 126), we found a marked increase in P(ET)CO(2) 1 min before the detection of a palpable pulse. CONCLUSION: Since PLR during CPR appears to increase P(ET)CO(2) after OHCA, larger studies are needed to evaluate its potential effects on survival. Further, the measurement of P(ET)CO(2) could help to minimise the hands-off periods and pulse checks.

Education in cardiopulmonary resuscitation in Sweden and its clinical consequences.

AIM: To describe the use of cardiopulmonary resuscitation (CPR) training programmes in Sweden for 25 years and relate those to changes in the percentage of patients with out of hospital cardiac arrest (OHCA) who receive bystander CPR. METHODS: Information was gathered from (a) the Swedish CPR training registry established in 1983 and includes most Swedish education programmes in CPR and (b) the Swedish Cardiac Arrest Register (SCAR) established in 1990 and currently covers about 70% of ambulance districts in Sweden. RESULTS: CPR education in Sweden functions according to a cascade principle (instructor-trainers who train instructors who then train rescuers in CPR). Since 1989, 5000 instructor-trainers have taught more than 50,000 instructors who have taught nearly 2 million of Sweden's 9 million inhabitants adult CPR. This is equivalent to one new rescuer per 100 inhabitants every year in Sweden. In addition, since 1989, there are 51,000 new rescuers in Advanced Life Support (ALS), since 1996, 41,000 new Basic Life Support (BLS) rescuers with Automated External Defibrillation (AED) training, and since 1998, there are 93,000 new rescuers in child CPR. As a result of this CPR training the number of bystander CPR attempts for OHCA in Sweden increased from 31% in 1992 to 55% in 2007. CONCLUSION: By using a cascade principle for CPR education nearly 2 million rescuers were educated in Sweden (9 million inhabitants) between 1989 and 2007. This resulted in a marked increase in bystander CPR attempts.

Extracapsular tumor spread and the risk of local, axillary and supraclavicular recurrence in node-positive, premenopausal patients with breast cancer.

BACKGROUND: Extracapsular tumor spread (ECS) has been identified as a possible risk factor for breast cancer recurrence, but controversy exists regarding its role in decision making for regional radiotherapy. This study evaluates ECS as a predictor of local, axillary, and supraclavicular recurrence. PATIENTS AND METHODS: International Breast Cancer Study Group Trial VI accrued 1475 eligible pre- and perimenopausal women with node-positive breast cancer who were randomly assigned to receive three to nine courses of classical combination chemotherapy with cyclophosphamide, methotrexate, and fluorouracil. ECS status was determined retrospectively in 933 patients based on review of pathology reports. Cumulative incidence and hazard ratios (HRs) were estimated using methods for competing risks analysis. Adjustment factors included treatment group and baseline patient and tumor characteristics. The median follow-up was 14 years. RESULTS: In univariable analysis, ECS was significantly associated with supraclavicular recurrence (HR = 1.96; 95% confidence interval 1.23-3.13; P = 0.005). HRs for local and axillary recurrence were 1.38 (P = 0.06) and 1.81 (P = 0.11), respectively. Following adjustment for number of lymph node metastases and other baseline prognostic factors, ECS was not significantly associated with any of the three recurrence types studied. CONCLUSIONS: Our results indicate that the decision for additional regional radiotherapy should not be based solely on the presence of ECS.

Survival and safety of exemestane versus tamoxifen after 2-3 years' tamoxifen treatment (Intergroup Exemestane Study): a randomised controlled trial.

BACKGROUND: Early improvements in disease-free survival have been noted when an aromatase inhibitor is given either instead of or sequentially after tamoxifen in postmenopausal women with oestrogen-receptor-positive early breast cancer. However, little information exists on the long-term effects of aromatase inhibitors after treatment, and whether these early improvements lead to real gains in survival. METHODS: 4724 postmenopausal patients with unilateral invasive, oestrogen-receptor-positive or oestrogen-receptor-unknown breast cancer who were disease-free on 2-3 years of tamoxifen, were randomly assigned to switch to exemestane (n=2352) or to continue tamoxifen (n=2372) for the remainder of a 5-year endocrine treatment period. The primary endpoint was disease-free survival; overall survival was a secondary endpoint. Efficacy analyses were intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN11883920. RESULTS: After a median follow-up of 55.7 months (range 0-89.7), 809 events contributing to the analysis of disease-free survival had been reported (354 exemestane, 455 tamoxifen); unadjusted hazard ratio 0.76 (95% CI 0.66-0.88, p=0.0001) in favour of exemestane, absolute benefit 3.3% (95% CI 1.6-4.9) by end of treatment (ie, 2.5 years after randomisation). 222 deaths occurred in the exemestane group compared with 261 deaths in the tamoxifen group; unadjusted hazard ratio 0.85 (95% CI 0.71-1.02, p=0.08), 0.83 (0.69-1.00, p=0.05) when 122 patients with oestrogen-receptor-negative disease were excluded. CONCLUSIONS: Our results suggest that early improvements in disease-free survival noted in patients who switch to exemestane after 2-3 years on tamoxifen persist after treatment, and translate into a modest improvement in overall survival.

Transradial coronary intervention without pre-screening for a dual palmar blood supply.

It is usual practice to determine the presence of collateral blood supply to the hand prior to radial artery cannulation. We propose that pre-screening for a dual palmar vascular supply is not necessary and the presence of a palpable radial pulse is sufficient to allow successful radial artery cannulation. We retrospectively analysed our interventional PTCA registry, including only patients who had a transradial procedure without being pre-screened with an Allen's test or plethysmography. We report our data including complications the day after the procedure and at 30 days, and provide an up to date discussion on the need to assess patients for a dual palmar blood supply prior to transradial intervention.

Characteristics and outcome amongst young adults suffering from out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation is attempted.

OBJECTIVES: Amongst patients suffering from out-of-hospital cardiac arrest, young adults represent a minority. However, these victims suffer from the catastrophe when they are in a very active phase of life and have a long life expectancy. This survey aims to describe young adults in Sweden who suffer from out-of-hospital cardiac arrest and in whom cardiopulmonary resuscitation (CPR) is attempted in terms of characteristics and outcome. DESIGN: Prospective and descriptive design. SUBJECTS AND METHODS: Young adults (18-35 years) who suffered from out-of-hospital cardiac arrest in whom CPR was attempted and who were included in the Swedish Cardiac Arrest Registry between 1990 and 2004. MAIN OUTCOME MEASURES: Survival to 1 month. RESULTS: In all, 1105 young adults (3.1% of all the patients in the registry) were included, of which 29% were females, 51% were nonwitnessed and 15% had a cardiac aetiology. Only 17% were found in ventricular fibrillation, 53% received bystander CPR. The overall survival to 1 month was 6.3%. High survival was found amongst patients found in ventricular fibrillation (20.8%) and those with a cardiac aetiology (14.8%). Ventricular fibrillation at the arrival of the rescue team remained an independent predictor of an increased chance of survival (odds ratio: 7.43; 95% confidence interval: 3.44-16.65). CONCLUSION: Amongst young adults suffering from out-of-hospital cardiac arrest and in whom CPR was attempted, a minority survived to 1 month. Subgroups with a higher survival could be defined (patients found in ventricular fibrillation and patients in whom there was a cardiac aetiology). However, only one independent predictor of an increased chance of survival could be demonstrated, i.e. ventricular fibrillation at the arrival of the rescue team.

Circuit parties: sexual behaviors and HIV disclosure practices among men who have sex with men at the White Party, Palm Springs, California, 2003.

The syphilis epidemic among men who have sex with men (MSM) in major US cities and concomitant increases in high-risk sexual behavior, have raised concerns of increased HIV transmission in this population. Therefore, to provide information for health promotion and disease awareness efforts, we investigated sexual behaviors, partner selection preferences and HIV serostatus disclosure practices of MSM at the White Party in Palm Springs, California. Circuit party attendees reported engaging in unprotected anal sex, however, a high proportion reported disclosing their HIV status. These findings suggest that some gay men are serosorting as a risk reduction strategy or implementing sexual risk reduction strategies to protect themselves and their partners. In our study, HIV-negative men were nine times more likely to report a preference for a seroconcordant sexual partner. The self-protecting attitudes of HIV-negative men in our sample outweighed the partner-protecting attitudes of HIV-positive men. This suggests that prevention interventions focusing on HIV-positive persons are warranted.

Knee injuries account for the sports-related increased risk of knee osteoarthritis.

Increased risk of osteoarthritis has been found among athletes active in different kinds of sports. Knee injury is an established risk factor for knee osteoarthritis. In this population-based case-control study we investigated the risk of knee osteoarthritis with respect to sports activity and previous knee injuries. A total of 825 cases with x-ray-verified femorotibial osteoarthritis were identified at six hospitals in southern Sweden. The cases were matched (age, sex and residential area) with 825 controls from the general population. Mailed questionnaire data on sports activity for more than 1 year after the age of 16, knee injuries and confounding variables (weight, height, heredity, smoking and occupation) were collected and analyzed using logistic regression models. The response frequency was 89%. Among men knee osteoarthritis was related to soccer (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.2), ice hockey (OR 1.9, 95% CI 1.2-3.0) and tennis (OR 2.0, 95% CI 1.1-3.8) but not to track and field sports, cross-country skiing, and orienteering. After adjustment for confounding variables soccer and ice hockey remained significantly related to knee osteoarthritis, but after adjustment for knee injuries no significant relation remained. The sports-related increased risk for knee osteoarthritis was explained by knee injuries.

Association between interval between call for ambulance and return of spontaneous circulation and survival in out-of-hospital cardiac arrest.

AIM: To describe the association between the interval between the call for ambulance and return of spontaneous circulation (ROSC) and survival in out-of-hospital cardiac arrest. PATIENTS: All patients suffering an out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was started, included in the Swedish Cardiac Arrest Registry (SCAR) for whom information about the time of calling for an ambulance and the time of ROSC was available. RESULTS: Among 26,192 patients who were included in SCAR and were not witnessed by the ambulance crew, information about the time of call for an ambulance and the time of ROSC was available in 4847 patients (19%). There was a very strong relationship between the interval between call for an ambulance and ROSC and survival to one month. If the interval was less than or equal to 5 min, 47% survived to one month. If the interval exceeded 30 min, only 5% (n = 35) survived to one month. The vast majority of the latter survivors had a shockable rhythm either on admission of the rescue team or at some time during resuscitation. CONCLUSION: Among patients who have ROSC after an out-of-hospital cardiac arrest, there is a very strong association between the interval between the call for ambulance and ROSC and survival to one month. However, even if this delay is very long (> 30 min after calling for an ambulance), a small percentage will ultimately survive; they are mainly patients who at some time during resuscitation have a shockable rhythm. The overall percentage of patients for whom CPR continued for more than 30 min who are alive one month later can be assumed to be extremely low.

Evaluation of hypophosphataemia in tenofovir disoproxil fumarate (TDF)-exposed and TDF-unexposed HIV-infected out-patients receiving highly active antiretroviral therapy.

OBJECTIVES: Cases of hypophosphataemia (often coincident with renal dysfunction) have been reported in HIV-infected patients taking tenofovir disoproxil fumarate (TDF), but randomized placebo-controlled trials of HIV-infected persons with normal baseline renal function have found a comparable incidence of hypophosphataemia in the TDF and placebo groups. We assessed the incidence of grade 2 and higher hypophosphataemia in the HIV Outpatient Study (HOPS). METHODS: We analysed a prospective cohort of patients who initiated either a TDF-containing highly active antiretroviral therapy (HAART) regimen [TDF-exposed (TDF+) group; n = 165] or a TDF-sparing HAART regimen [TDF-unexposed (TDF-) group; n = 90], and who had normal baseline phosphate and creatinine values. RESULTS: The TDF+ and TDF- groups had comparable median follow-up times (10.9 vs 8.8 months, respectively; P = 0.18) and number of phosphate measurements (median = 3 for both) and were similar on most clinical and demographic factors. During follow up, 12.7% of TDF+vs 6.7% of TDF-patients developed grade 2 hypophosphataemia (2.0-2.4 mg/dL), and 2.4% of TDF+ patients vs 0% of TDF-patients developed grade 3 hypophosphataemia (1.0-1.9 mg/dL); none developed grade 4 hypophosphataemia (<1.0 mg/dL). The incidence of grade 2 or higher hypophosphataemia was 16.7 per 100 person-years among TDF+ patients vs 8.0 per 100 person-years among TDF-patients (P = 0.11). CONCLUSIONS: The incidence of hypophosphataemia was somewhat elevated in HOPS patients who took TDF-containing HAART compared with those who took TDF-sparing HAART during the first 1 to 2 years of observation, but the difference was not statistically significant. Longer follow-up of a larger population is needed to determine if this trend towards an association achieves statistical significance and to evaluate the clinical consequences of hypophosphataemia.