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Biomedical subjects

H C Bucher

Publications and source records attributed to H C Bucher.

At least 19 recordsLinked to original sources
PubMed2006

Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection.

BACKGROUND: Pneumocystis jiroveci pneumonia (PCP) remains the most common opportunistic infection in patients infected with the human immunodeficiency virus (HIV). Among patients with HIV infection and PCP the mortality rate is 10 to 20% during the initial infection and increases substantially with the need for mechanical ventilation. It was suggested that in these patients corticosteroids adjunctive to standard treatment for PCP could prevent the need for mechanical ventilation and decrease mortality. OBJECTIVES: To assess the effects of adjunctive corticosteroids on overall mortality and the need for mechanical ventilation in HIV-infected patients with PCP and substantial hypoxemia (arterial oxygen partial pressure <70 mmHg or alveolar-arterial gradient >35 mmHg on room air). SEARCH STRATEGY: We searched Medline (January 1980-December 2004), EMBASE (January 1985-December 2004) and The Cochrane Library (Issue 4, 2004) without language restrictions to identify randomised controlled trials that compared adjunctive corticosteroids to control in HIV-infected patients with PCP. We further reviewed the reference lists from previously published overviews, we searched UptoDate version 2005 and Clinical Evidence Concise (Issue 12, 2004), contacted experts of the field, and searched reference lists of identified publications for citations of additional relevant articles. SELECTION CRITERIA: Trials were considered eligible for this review if they compared corticosteroids to placebo or usual care in HIV-infected patients with PCP in addition to baseline treatment with trimethoprim-sulfamethoxazole, pentamidine or dapsone-trimethoprim, used random allocation, and reported mortality data. We excluded trials in patients with no or mild hypoxemia (arterial oxygen partial pressure >70 mmHg or an alveolar-arterial gradient <35 mmHg on room air) and trials with a follow-up of less than 30 days. DATA COLLECTION AND ANALYSIS: Two teams of reviewers independently evaluated the methodology and extracted data from each primary study. We pooled treatment effects across studies and calculated a weighted average risk ratio of overall mortality in the treatment and control groups by using a random effects model. MAIN RESULTS: Six studies were included in the review and meta-analysis. Risk ratios for overall mortality for adjunctive corticosteroids were 0.56 (95% confidence interval [CI], 0.32-0.98) at 1 month and 0.68 (95% CI, 0.50-0.94) at 3-4 months of follow-up. To prevent 1 death, numbers needed to treat are 9 patients in a setting without highly active antiretroviral therapy (HAART) available, and 23 patients with HAART available. Only the 3 largest trials provided data on the need for mechanical ventilation with a risk ratio of 0.38 (95% CI, 0.20-0.73) in favour of adjunctive corticosteroids. AUTHORS' CONCLUSIONS: The number and size of trials investigating adjunctive corticosteroids for HIV-infected patients with PCP is small, but evidence from this review suggests a beneficial effect for patients with substantial hypoxemia.

AIDS-Related Opportunistic Infections↗
PubMed2006

Prevalence of risk factors for cardiovascular disease in HIV-infected patients over time: the Swiss HIV Cohort Study.

OBJECTIVE: Metabolic changes caused by antiretroviral therapy (ART) may increase the risk of coronary heart disease (CHD). We evaluated changes in the prevalence of cardiovascular risk factors (CVRFs) and 10-year risk of CHD in a large cohort of HIV-infected individuals. METHODS: All individuals from the Swiss HIV Cohort Study (SHCS) who completed at least one CVRF questionnaire and for whom laboratory data were available for the period February 2000 to February 2006 were included in the analysis. The presence of a risk factor was determined using cut-offs based on the guidelines of the National Cholesterol Education Program (NCEP ATP III), the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), the American Diabetes Association, and the Swiss Society for Cardiology. RESULTS: Overall, 8,033 individuals completed at least one CVRF questionnaire. The most common CVRFs in the first completed questionnaire were smoking (57.0%), low high-density lipoprotein (HDL) cholesterol (37.2%), high triglycerides (35.7%), and high blood pressure (26.1%). In total, 2.7 and 13.8% of patients were categorized as being at high (>20%) and moderate (10-20%) 10-year risk for CHD, respectively. Over 6 years the percentage of smokers decreased from 61.4 to 47.6% and the percentage of individuals with total cholesterol >6.2 mmol/L decreased from 21.1 to 12.3%. The prevalence of CVRFs and CHD risk was higher in patients currently on ART than in either pretreated or ART-naive patients. CONCLUSION: During the 6-year observation period, the prevalence of CVRFs remains high in the SHCS. Time trends indicate a decrease in the percentage of smokers and individuals with high cholesterol.

Adult↗
PubMed2004

Demographics and prevalent risk factors of chronic subdural haematoma: results of a large single-center cohort study.

Chronic subdural haematoma (CSDH) is a typical disease in elderly patients and encountered frequently in neurosurgical practice. With an increasing number of elderly people in the general population, there is a need to investigate risk factors (age, falls, anticoagulant or antithrombotic therapy) which could be pertinent to the development of this disease. We reviewed 354 patients undergoing surgery for CSDH over a period of 7 years (1996-2002), the occurrence being equally distributed over these years. CSDH occurred more often in elderly (> or = 65 years) than in younger people (69 vs 31%), and in men than in women (64 vs 36%). Falls were reported in 77% of patients. There was a trend towards a higher risk of falls in the elderly. Antithrombotic or anticoagulant therapy was present in 41% of patients, 32% of them having had falls. Overall postoperative mortality was 0% and overall recurrence rate 13.6%. CSDH in the elderly population, especially in men, is frequently associated with falls and anticoagulation or antithrombotic therapy. The indication for these medications, especially in elderly patients at risk for falls, should be carefully evaluated and controlled.

Accidental Falls↗
PubMed2002

Ritonavir plus saquinavir versus single protease inhibitor therapy in protease inhibitor-naive HIV-infected patients: the Swiss HIV Cohort Study.

OBJECTIVES: To compare the response to ritonavir (RTV) plus saquinavir (SQV) with single protease inhibitor (PI) therapies among PI-naive HIV-1 infected individuals. METHODS: Response to treatment was analysed according to the intent-to-treat principle in a prospective observational cohort study of 177 patients who between May 1995 and March 2000 started a double PI therapy with RTV and SQV (nonboosting dosages) plus at least one nucleoside reverse transcriptase inhibitor (NRTI) and 2,214 patients with a single PI therapy plus two NRTIs. We used survival analysis and Cox's proportional hazard regression methods. The primary endpoint was the time to a plasma viral load of < 400 copies/mL. Secondary endpoints were taken as a gain in the CD4 count of >100 cells/microL, and change of initial PI for any reason. RESULTS: Baseline characteristics in both treatment groups were balanced. Median follow-up in both groups was 10.4 months. Time to an HIV-1 viral load of < 400 copies/mL and an increase in the CD4 count of >100 x 10(6) cells/L was shorter for RTV plus SQV compared with single PI regimens (log rank test for each endpoint P < 0.05). The adjusted hazard ratios of RTV plus SQV compared with single PI regimens were 1.21 (95% confidence interval 0.99-1.47) for achieving an HIV-1 viral load of < 400 copies/mL, 1.12 (0.88-1.42) for an increase in the CD4 count of > 100 cells/microL, and 0.90 (0.73-1.11) for change of first PI regimen. CONCLUSIONS: Treatment with RTV plus SQV compared with single PI regimens appeared to give similar results for virological or immunological response.

Adolescent↗
PubMed2001

[Hospitalizations in a cohort of 175 severely drug-addicted patients of a medically managed opiate withdrawal project].

In this study we investigated a population of 175 seriously drug addicted patients. They were randomised in a controlled opiate maintenance program in Basel, Switzerland. We investigated hospitalizations in the time period three years before entry into the program and approximately 3.5 years after entry into this program. The mean age was 28.4 years, the mean drug injection time was 8.8 years. 82.6% of the patients were seropositive for HCV and 21.5% were HIV-infected. We observed 223 hospitalizations in 100/175 patients during the observation period of 6.5 years. Most commonly infections (n = 94), different diseases of internal medicine (n = 44) and surgical diseases (n = 41) led to hospitalization. Altogether, we found no decrease of the incidence of hospitalisations. However, there was a significant decrease of directly drug-induced diseases (p < 0.05). So far, hospitalizations did not diminish in this well-controlled opiate maintenance program. However, as shown in earlier studies, the incidence of HIV drastically dropped. Hence, it may be that a longer follow-up may prove beneficial regarding the incidence of hospitalisations.

Adult↗
PubMed2001

Response to first protease inhibitor- and efavirenz-containing antiretroviral combination therapy. The Swiss HIV Cohort Study.

OBJECTIVE: To compare the response to protease inhibitor (PI) and efavirenz-containing combination therapy among treatment-naive HIV-infected persons. DESIGN: Prospective observational cohort study. METHODS: Response to treatment was analysed according to the intent-to-treat principle among antiretroviral-naive patients who started either efavirenz (n = 89) or PI (n = 183) plus two nucleoside reverse transcriptase inhibitors between February 1999 and March 2000 using Kaplan-Meier and multivariable Cox proportional hazard regression methods. Primary endpoint was time to undetectable plasma viral load. Secondary endpoints included the number of CD4 cells gained, virological rebound, treatment change, and clinical progression. RESULTS: Patients on PI regimens had lower median CD4 counts (165 versus 216 x 5 106/l; P = 0.15) and were more likely to have AIDS at initiation of treatment (25% versus 15% P = 0.048) than patients starting efavirenz regimens. The probability of reaching plasma HIV-1 RNA < 400 copies/ml was higher with efavirenz- than with PI-containing regimens [adjusted hazard ratio, 1.75; 95% confidence interval (CI), 1.34-2.29]. Median times to undetectable viral load were 58 days (95% CI, 44-70 days) for efavirenz-treated and 88 days (95% CI, 79-98 days) for PI-treated patients. The median number of CD4 cells gained in the first 6 months (90 x 10(6) cells/l with efavirenz, 10(7) x 10(6) cells/l with PI; P = 0.63), time to and reasons for treatment change, time to viral rebound, drug intolerance and clinical progression rates were similar in the two treatment groups. CONCLUSIONS: Treatment with efavirenz-, compared with PI-based regimens, appeared to result in a superior virological response but no difference in immunological or clinical efficacy. The relevance of these observations remains to be determined in studies with longer follow-up.

Adult↗
PubMed2001

Onset and pattern of substance use in intravenous drug users of an opiate maintenance program.

OBJECTIVES: To assess the initiation of substance use of participants in an opiate maintenance program by a cross-sectional survey. METHOD: Participants (n=184) filled out a questionnaire assessing age at initial substance use and age at onset of regular drug use. RESULTS: Of 15 substances investigated, alcohol, nicotine, analgesics and marijuana were initiated and consumed regularly before the age of 18 years. Barbiturates, benzodiazepines, cocaine, and opiates were begun later. The time gap between initial and regular use varied depending on the substance. Regular use exceeded 50% for alcohol, benzodiazepines, cocaine, heroin, marijuana and nicotine. CONCLUSIONS: Specific knowledge about the age of onset and sequence of substances used by drug addicts may help to prevent substance use more age specifically.

Adult↗
PubMed2000

Long-term hydroxyurea in combination with didanosine and stavudine for the treatment of HIV-1 infection. Swiss HIV Cohort Study.

OBJECTIVE AND METHODS: In 1998 we reported on a randomized comparison between stavudine plus didanosine plus placebo versus stavudine plus didanosine plus hydroxyurea (HU), in patients with a CD4 count of 200-500 x 10(6) cells/l. After 3 months, the HU group had a higher proportion of patients with viral load < 200 x 10 cells/l. At the end of the 3 months blinded period, patients in the placebo group had the option to add HU if their viral load remained > 200 x 10(6) cells/l. We report results after 24 months. RESULTS: Seventy-two patients were randomized to the HU arm, and a further 30 elected to add HU after 12 weeks. Twenty-four months after the start of the trial, only 25% of the 72 patients originally randomized to HU, and 20% of the 30 who added HU after week 12, were still taking it. The reasons for stopping HU were: lack of efficacy (45%), adverse events (37%) and patient or physician preference (18%). Side effects were more frequent in the didanosine/stavudine/HU group than in the didanosine/stavudine group: neuropathy (35 versus 15%, P< 0.02), fatigue (22 versus 7%, P< 0.01), and nausea or vomiting (26 versus 9%, P< 0.01). Of those who had discontinued HU, 73% were taking three drugs including a protease inhibitor. Patients who had started HU were compared with similar patients who had started protease inhibitors in the Swiss cohort. The probability of stopping HU was higher than the probability of stopping nelfinavir or indinavir, and similar to the probability of stopping ritonavir. CONCLUSION: HU increased the antiviral effect of stavudine plus didanosine. However, side effects were more frequent, and after 24 months the majority of patients had switched to protease inhibitor regimens.

Anti-HIV Agents↗
PubMed2000

Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials.

OBJECTIVE: To determine whether percutaneous transluminal coronary angioplasty (angioplasty) is superior to medical treatment in non-acute coronary artery disease. DESIGN: Meta-analysis of randomised controlled trials. SETTING: Randomised controlled trials conducted worldwide and published between 1979 and 1998. PARTICIPANTS: 953 patients treated with angioplasty and 951 with medical treatment from six randomised controlled trials, three of which included patients with multivessel disease and pre-existing myocardial infarction. MAIN OUTCOME MEASURES: Angina, fatal and non-fatal myocardial infarction, death, repeated angioplasty, and coronary artery bypass grafting. RESULTS: In patients treated with angioplasty compared with medical treatment the risk ratios were 0. 70 (95% confidence interval 0.50 to 0.98; heterogeneity P<0.001) for angina; 1.42 (0.90 to 2.25) for fatal and non-fatal myocardial infarction, 1.32 (0.65 to 2.70) for death, 1.59 (1.09 to 2.32) for coronary artery bypass graft, and 1.29 (0.71 to 3.36; heterogeneity P<0.001) for repeated angioplasty. Differences in the methodological quality of the trials, in follow up, or in single versus multivessel disease did not explain the variability in study results in any analysis. CONCLUSIONS: Percutaneous transluminal coronary angioplasty may lead to a greater reduction in angina in patients with coronary heart disease than medical treatment but at the cost of more coronary artery bypass grafting. Trials have not included enough patients for informative estimates of the effect of angioplasty on myocardial infarction, death, or subsequent revascularisation, though trends so far do not favour angioplasty.

Angina Pectoris↗
PubMed1999

Cost effectiveness of highly active antiretroviral therapy in HIV-infected patients. Swiss HIV Cohort Study.

BACKGROUND: Highly active antiretroviral therapy (HAART) has become the most important strategy for treating HIV infection in developed countries; however, access to HAART might vary under different funding policies. The Swiss health care system provides unrestricted access to HAART for all patients who need these newer combination therapies. This study investigated the impact of this funding policy on the society and health care system. METHODS: A cost-effectiveness analysis with natural history data and productivity estimates was based on the Swiss HIV Cohort Study. A random sample of patient charts was used to estimate health care costs. In addition to a base-case scenario, a pessimistic and an optimistic scenario of natural disease history was developed. Costs were expressed in 1997 Swiss francs (100 CHF correspond to about US$67) and effects as projected years of life gained. RESULTS: In the analysis limited to health care costs, on the basis of projected survival in each scenario, the cost-effectiveness ratio was 33,000 CHF (base case), 14,000 CHF (optimistic), and 45,000 CHF (pessimistic) per year of life gained. When changes in productivity were included, cost savings occurred in the base-case and optimistic scenarios. The cost-effectiveness ratio was 11,000 CHF per year of life gained in the pessimistic scenario. CONCLUSIONS: HAART increases expected survival and health care costs. However, when productivity gains are included, society will probably save costs or pay a low price for substantial health benefits. The study provides strong arguments, from a societal perspective, to continue the current policy of providing unrestricted access to HAART in Switzerland. The presented results also suggest that this policy could be of interest for other developed countries. Decision makers in developed countries where access to HAART is limited should re-evaluate their policy for the benefit of the society at large.

Anti-HIV Agents↗