The cost of antiretroviral drug resistance in HIV-positive patients.

INTRODUCTION: Antiretroviral (ARV) drug resistance limits treatment choices, often necessitating the selection of drugs with less desirable pill burdens, toxicity profiles, drug interactions and dosing schedules, and may increase cost. We examine the impact of resistance on the cost of HIV care. METHODS: All adult HIV-positive individuals newly referred for HIV care from 1 January 2007 to 1 January 2011 and followed until 31 December 2011 at the Southern Alberta Clinic, Calgary, AB, Canada, were included. We determined the cost of all ARV drugs, and HIV-related outpatient and inpatient care, reported as mean per patient per month (PPPM) costs in 2011 Canadian dollars (CDN). RESULTS: Overall, 78% of patients received genotypic antiretroviral resistance testing (GART); 57% among ARV-naive patients, 21% after suspected viral failure, and 20% during a treatment interruption. Resistance was detected in 6%, 49% and 21% of all tests respectively. The total mean PPPM cost for patients with GART was CDN 1,179. Patients with primary resistance had mean total PPPM costs of CDN 956. Patients with no resistance had mean PPPM costs of CDN 1,058, by contrast with the CDN 1,291 costs of patients with secondary/acquired resistance. Mean costs for one, two or three ARV class resistance was CDN 1,278, 1,337 and 1,801, respectively. Mean PPPM costs increased by 31% from CDN 1,068 to 1,396, respectively, before and after a positive resistance test. CONCLUSIONS: Transmission of resistant virus as well as emergence of resistance during ARV therapy leads to increased costs. Mean costs increased by number of resistant classes. Routine GART and optimizing ARV regimens to avoid resistance might minimize the long-term costs of HIV care.

The clinical implications of high rates of intimate partner violence against HIV-positive women.

INTRODUCTION: Intimate partner violence (IPV) is associated with increased risk of HIV infection among women, however, whether IPV affects outcomes after HIV infection is uncertain. We assess the impact of IPV on HIV-positive women. METHODS: All HIV-positive women who received outpatient HIV care in southern Alberta between March 2009 and January 2012 were screened for IPV. The associations with IPV of sociodemographic factors, health-related quality of life, clinical status, and hospitalizations were obtained from a regional database and evaluated with multivariable regression analysis. RESULTS: Of 339 women screened, 137 (40.4%) reported experiencing IPV. Those disclosing IPV had higher rates of smoking [adjusted prevalence ratio (APR) = 5.07; 95% confidence interval (CI): 2.72 to 9.43]; illicit drug use (APR = 7.58; CI: 2.45 to 23.26); a history of incarceration (APR = 4.84, CI: 1.85 to 12.68); depression (APR = 2.50, CI: 1.15 to 5.46); and anxiety disorders (APR = 5.75, CI: 2.10 to 15.63). Health-related quality of life was diminished with IPV (APR = 2.94, CI: 1.40 to 6.16) for poor/fair versus very good/excellent. IPV-exposed women were hospitalized 256 times per 1000 patient-years compared to 166/1000 patient-years among IPV-unexposed (P < 0.001) women. The relative risk was increased for HIV-unrelated hospitalizations (APR = 1.42, CI: 1.16 to 1.73) and for HIV-related hospitalizations after outpatient HIV care was initiated (APR = 2.19, CI: 1.01 to 4.85). Modifiable contributors to the poor outcomes included decreased use of antiretroviral therapy (APR = 0.55, CI: 0.34 to 0.91) and additional interruptions in care longer than 1 year (APR = 1.90, CI: 1.07 to 3.39). CONCLUSIONS: IPV is associated with deleterious HIV-related and HIV-unrelated health outcomes, of which, suboptimal engagement in care is a contributor. To improve outcomes, practitioners should aim to increase engagement in care of these women in particular.

Risk factors for posttraumatic vasospasm.

OBJECT: Posttraumatic vasospasm (PTV) is an underrecognized cause of ischemic damage after severe traumatic brain injury (TBI) that independently predicts poor outcome. There are, however, no guidelines for PTV screening and management, partly due to limited understanding of its pathogenesis and risk factors. METHODS: A database review of 46 consecutive cases of severe TBI in pediatric and adult patients was conducted to identify risk factors for the development of PTV. Univariate analysis was performed to identify potential risk factors for PTV, which were subsequently analyzed using a multivariate logistic regression model to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Fever on admission was an independent risk factor for development of PTV (OR 22.2, 95% CI 1.9-256.8), and patients with hypothermia on admission did not develop clinically significant vasospasm during their hospital stay. The presence of small parenchymal contusions was also an independent risk factor for PTV (OR 7.8, 95% CI 0.9-69.5), whereas the presence of subarachnoid hemorrhage or other patterns of intracranial injury were not. Other variables, such as age, sex, ethnicity, degree of TBI severity, or admission laboratory values, were not independent predictors for the development of clinically significant PTV. CONCLUSIONS: Independent risk factors for PTV include parenchymal contusions and fever. These results suggest that diffuse mechanical injury and activation of inflammatory pathways may be underlying mechanisms for the development of PTV, and that a subset of patients with these risk factors may be an appropriate population for aggressive screening. Further studies are needed to determine if treatments targeting fever and inflammation may be effective in reducing the incidence of vasospasm following severe TBI.

Antipyretic efficacy and safety of ibuprofen and acetaminophen in children.

OBJECTIVE: To evaluate the antipyretic effects and safety of ibuprofen compared with acetaminophen in febrile children. DATA SOURCES: Searches of MEDLINE (1966-November 2003) and EMBASE (1988-November 2003) were conducted using the terms ibuprofen and acetaminophen. Bibliographies of selected articles were reviewed. DATA SYNTHESIS: Ibuprofen was significantly more effective than acetaminophen in reducing fever after a single dose. Ibuprofen was found to be more effective after 6 hours, but not after a longer period of time. Studies with multiple doses have also failed to show that one drug is better than the other. CONCLUSIONS: The efficacy and effectiveness of acetaminophen and ibuprofen in their recommended dosages are similar, with slightly more beneficial effects shown with ibuprofen.