Abstract INTRODUCTION: The mortality due to cardiogenic shock complicating acute myocardial infarction (AMI) is high even in patients with early revascularization. Infusion of low dose recombinant human brain natriuretic peptide (rhBNP) at the time of AMI is well tolerated and could improve cardiac function. OBJECTIVE: The objective of this study was to evaluate the hemodynamic effects of rhBNP in AMI patients revascularized by emergency percutaneous coronary intervention (PCI) who developed cardiogenic shock. METHODS: A total of 48 patients with acute ST segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock and whose hemodynamic status was improved following emergency PCI were enrolled. Patients were randomly assigned to rhBNP (n=25) and control (n=23) groups. In addition to standard therapy, study group individuals received rhBNP by continuous infusion at 0.005 µg kg−1 min−1 for 72 hours. RESULTS: Baseline characteristics, medications, and peak of cardiac troponin I (cTnI) were similar between both groups. rhBNP treatment resulted in consistently improved pulmonary capillary wedge pressure (PCWP) compared to the control group. Respectively, 7 and 9 patients died in experimental and control groups. No drug-related serious adverse events occurred in either group. CONCLUSION: When added to standard care in stable patients with cardiogenic shock complicating anterior STEMI, low dose rhBNP improves PCWP and is well tolerated.

BACKGROUND: Faith-based organisations have expanded antiretroviral therapy (ART) in community clinics across South Africa. Loss to follow-up (LTFU), however, limits the potential individual and population treatment benefits and optimal care. OBJECTIVE: To identify patient characteristics associated with LTFU 6 months after starting ART in a large community clinic. METHODS: Patients initiating ART between April 2004 and October 2006 in one South African Catholic Bishops' Conference HIV treatment clinic who had at least one follow-up visit were included and routinely monitored every 6 months after ART initiation. Standardised instruments were used to collect data. Rates of LTFU over time were estimated by the Kaplan-Meier method. The Cox proportional hazard regression examined the impact of age, baseline CD4 count, baseline HIV RNA, gender and pregnancy status on LTFU. RESULTS: Data from 925 patients (age >14 years, median age 36 years, 70% female, of whom 16% were pregnant) were included: 51 (6%) were lost to follow-up 6 months after ART initiation. Younger age (<30 years) (hazard ratio (HR) 2.14, 95% confidence interval (CI) 1.05 - 4.38) and pregnancy for women (HR 3.75, 95% CI 1.53 - 9.16) were significantly associated with higher LTFU rates. When stratified by baseline CD4 count, gender and pregnancy status, pregnant women with lower baseline CD4 counts (<200 cells/µl) had 6.06 times the hazard (95% CI 2.20 - 16.71) of LTFU at 6 months compared with men. CONCLUSIONS: HIV-infected pregnant women initiating ART were significantly more likely to be lost to follow-up in a community clinic in South Africa. Urgent interventions to successfully retain pregnant women in care are needed.

OBJECTIVE: To identify predictors of mortality in patients initiating antiretroviral therapy (ART) in Durban, South Africa. DESIGN: We conducted a retrospective cohort study analysing data on patients who presented to McCord Hospital, Durban, and started ART between 1 January 1999 and 29 February 2004. We performed univariate and multivariate analysis and constructed Kaplan-Meier curves to assess predictors. RESULTS: Three hundred and nine patients were included. Forty-nine (16%) had died by the conclusion of the study. In univariate analysis, the strongest predictors of mortality were a CD4 cell count <50/µl (hazard ratio (HR) 3.70, 95% confidence interval (CI) 1.96 - 7.14), a haemoglobin concentration <8 g/dl (HR 1.23, 95% CI 1.08 - 1.40), a history of oral candidiasis (HR 3.17, 95% CI 1.70 - 5.87) and a history of cryptococcal meningitis (HR 2.76, 95% CI 1.80 - 19.2). A CD4 cell count <50/µl (HR 3.08, 95% CI 1.54 - 5.88) and a history of oral candidiasis (HR 2.58, 95% CI 1.37 - 4.88) remained significant in multivariate analysis. A history of tuberculosis was not a significant predictor of mortality. CONCLUSIONS: Simple clinical and laboratory data independently predict mortality and allow for risk stratification in patients initiating ART in South Africa. Interventions enabling patients to be identified before they develop these clinical markers and earlier initiation of ART will help to ensure maximum benefits of therapy.