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The optimal time to initiate combined antiretroviral therapy (cART) in HIV infection continues to be debated. In models that used pooled data from 12 large observational cohorts, initiating cART when the CD4 cell count decreased below 0.500 × 109 cells/L resulted in longer AIDS-free survival than delaying treatment until they decreased below 0.350 or 0.200 × 109 cells/L. However, mortality did not differ among these strategies. Randomized, controlled trials are needed to better define the timing of initiation of HIV therapy that results in the optimal balance of benefits, harms, and costs.
Although recombinant factor VIIa (rFVIIa) is approved only for treatment of bleeding in patients with hemophilia, physicians use it to prevent or treat bleeding in other situations. Investigators examined 12 644 discharge records of patients who received rFVIIa at U.S. hospitals from 2000 to 2008. Off-label use of rFVIIa increased more than 140-fold during this time, whereas use for hemophilia increased less than 4-fold. In 2008, 97% of the in-hospital use of rFVIIa was for off-label indications, including cardiovascular surgery, trauma, and intracranial hemorrhage. These patterns raise concern about the application of rFVIIa to conditions that lack strong supporting evidence.
Little is known about the characteristics and short-term prognosis of perioperative myocardial infarction (MI) in the setting of noncardiac surgery. In this multinational study of 8351 patients undergoing noncardiac surgery, 5% of patients had a perioperative MI, and the 30-day mortality rate was higher for patients who had an MI (12%) than for those who did not (2%). Of the patients who had an MI, 65% did not have ischemic symptoms, and the mortality rate was similar between those who did and did not have symptoms. The authors conclude that clinicians should routinely monitor for MI when at-risk patients have noncardiac surgery.
This comparative effectiveness review evaluated the benefits and harms of in-hospital use of rFVIIa in adults for 5 off-label indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. Evidence from 17 randomized trials and 56 observational studies suggests no mortality reduction with rFVIIa use for any of these indications. Use of rFVIIa increased risk for thromboembolism when used for some indications.
This systematic review summarized trials that compared lower versus higher blood pressure targets in adults with chronic kidney disease and focused on proteinuria as an effect modifier. Trials did not show that a blood pressure target of less than 125/75 to 130/80 mm Hg is more beneficial than one less than 140/90 mm Hg. Lower-quality evidence suggests that a low target may be beneficial in subgroups with proteinuria greater than 300 to 1000 mg/d. However, participants in the low target groups needed more antihypertensive medications and had a slightly higher rate of adverse events.
This Update summarizes studies published in 2010 that the author considers highly relevant to the practice of cardiology. Topics include statins and primary prevention, treatment of stable coronary artery disease, transcatheter aortic valve implants, genetics, and the appropriate use of cardiac imaging studies.
Patients with type 2 diabetes mellitus have an increased risk for atherosclerotic cardiovascular disease and microvascular complications. The authors propose a framework for individualizing glycemic targets according to patient age, disease stage, and propensity for hypoglycemia. In addition, targets should consider each patient's psychosocioeconomic status and preferences.
Physicians' increased use of social media, combined with the ease of finding information online, poses new considerations for physician professionalism in the information age. The authors discuss this and describe a professional approach to maintain confidentiality, honesty, and trust in the medical profession, which includes actively managing one's online presence and making informed choices about disclosure.
The study by the HIV-CAUSAL Collaboration in this issue addresses the optimal time to initiate cART. The editorialists discuss the findings and limitations of this and other cohort studies. They conclude that the HIV-CAUSAL Collaboration study supports the presence of a graded benefit of cART even when risk for AIDS is low. They emphasize, however, that uncertainty remains regarding the cumulative benefits of treating everyone who has HIV infection.
In this issue, the analysis by Logan and colleagues and systematic review by Yank and coworkers examine off-label use of rFVIIa in hospitalized patients. The editorialists discuss the articles' findings and conclude that they can serve as a model for many other rational therapy decisions that face physicians, patients, and policymakers.
I traveled to Port-au-Prince in March 2010, just over 2 months after the earthquake, and spent a week helping to staff a field hospital run by Project Medishare. Taking a step back, it's clear that the present health situation in Haiti after the earthquake resembles quite strikingly the health situation in Haiti before the earthquake.