Guidelines for magnetic resonance imaging in axial spondyloarthritis: A Delphi study.

OBJECTIVE: The term axial spondyloarthritis refers to a group of chronic inflammatory rheumatic diseases with a common genetic basis that course with axial and peripheral involvement and enthesitis. Recently, the Assessment of SpondyloArthritis international Society (ASAS) established some diagnostic criteria, including for the first time magnetic resonance imaging (MRI) findings. Given the difficulties of obtaining MRI in some environments and the lack of experience with axial spondyloarthritis, a group of radiologists and rheumatologists sought to establish some practical guidelines to ensure the correct use of MRI in this disease. MATERIAL AND METHODS: Using the Delphi method, we used a questionnaire with 49 items stratified into 4 blocks to survey 46 experts in the MRI diagnosis of axial spondyloarthritis. RESULTS: The experts agreed on 82% of the items. The degree of agreement was 100% in the block "Importance of early diagnosis of axial spondyloarthritis", 69% in the block "Optimization of the use of MRI in the diagnosis of axial spondyloarthritis", 93% in the block "Use of MRI in axial spondyloarthritis: Technical aspects", and 57% in the block "Usefulness of MRI in the prognosis, follow-up, and evaluation of the response to treatment in axial spondyloarthritis". CONCLUSIONS: Despite the importance of MRI in the early diagnosis of axial spondyloarthritis, this study shows the need for standardization and points to relative disagreement about how to use MRI in the follow-up of the disease and evaluation of the response to treatment. The results of this study can help improve the use of MRI in axial spondyloarthritis.

Lack of short-term increase in serum mediators of fibrogenesis and in non-invasive markers of liver fibrosis in HIV/hepatitis C virus-coinfected patients starting maraviroc-based antiretroviral therapy.

The aim of this study was to analyze serum changes in mediators of fibrogenesis and in non-invasive markers of liver fibrosis among HIV/HCV-coinfected patients starting maraviroc (MVC)-based antiretroviral therapy. Patients included in this prospective pilot study met the following criteria: (1) HIV-infection, (2) detectable serum HCV-RNA, and ((3) started MVC. Transforming growth factor-ß1 (TGF-beta1), matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) were measured in serum samples at baseline and 6 months after starting MVC. AST-to-platelet ratio index (APRI) was assessed at the same time points. Twenty-four patients were analyzed. Median (IQR) serum levels at baseline and after 6 months on MVC of TGF-beta1 were 27,295 (20,562-36,844) and 33,753 (18,973-46,130) pg/mL (p=0.116), of MMP-2 were 216 (186-274) and 241 (194-306) ng/mL (p=0.247), and of TIMP-1 were 237 (170-284) and 216 (171-271) ng/mL (p=0.415). APRI levels were 0.99 (0.53-3.46) at baseline and 0.83 (0.48-2.34) at 6 months (p=0.16). Serum mediators of liver fibrogenesis and fibrosis do not change significantly in HIV/HCV-coinfected patients in the short-term after starting MVC. As TGF-beta1 levels have been shown to increase over time in HCV infection and liver fibrosis worsens rapidly in HIV/HCV coinfection, these parameters seem to evolve in a different way in MVC-treated patients.

Insulin resistance is associated with liver stiffness in HIV/HCV co-infected patients.

BACKGROUND: The factors that influence liver fibrosis progression in patients co-infected with human immunodeficiency virus/hepatitis C virus (HIV/HCV) are not completely understood. It is not known if insulin resistance (IR), a condition that promotes liver fibrosis in HCV mono-infected individuals, is one of these factors. OBJECTIVE: To evaluate the association between IR and liver stiffness (LS). DESIGN: Multicentre cross-sectional study. PATIENTS: 330 patients co-infected with HIV/HCV. METHODS: LS was assessed by transient elastography, which has shown a high accuracy to predict significant fibrosis in patients co-infected with HIV/HCV. The outcome variable of the study was LS. Patients with LS> or =9 kPa were considered as having significant fibrosis. IR was calculated using the HOMA method. RESULTS: LS was > or =9 kPa in 150 (45%) patients. HOMA correlated with LS (Spearman's rho correlation coefficient, 0.37; p<0.0001). The median (Q1-Q3) HOMA in patients with LS> or =9 kPa was 3.30 (2.17-5.16) while it was 2.09 (1.37-3.22) in patients with LS <9 kPa (p<0.0001). Ninety-six (39%) individuals with a HOMA <4 and 54 (63%) with a HOMA > or =4 showed LS> or =9 kPa (p<0.0001). Analyses after excluding patients with cirrhosis yielded similar results. After multivariate analyses, age > or =40 years (adjusted odds ratio (AOR), 1.85; 95% confidence interval (CI), 1.03 to 3.29; p = 0.03), CD4 cell count <200 cells/ml (AOR, 3.45; 95% CI, 1.67 to 7.11; p = 0.001), hepatitis B virus co-infection (AOR, 9.25; 95% CI, 2.42 to 35.31; p = 0.001), and HOMA > or =4 (AOR, 5.33; 95% CI, 2.70 to 10.49; p<0.0001) were the independent predictors of LS> or =9 kPa. CONCLUSION: IR is associated with LS in patients co-infected with HIV/HCV.

[Prevalence of hepatitis C virus among HIV-infected patients in Area 2 of Madrid]. / Prevalencia de hepatitis C en población infectada por el VIH en el Area 2 de Madrid.

INTRODUCTION: The evolution of HIV infection, a rapid and fatal illness not long time ago, has become a chronic disease due to the implementation of new antiretroviral treatment. Therefore it is essential to focus on the management of concurrent illnesses such as chronic hepatitis C infection, specially as they share common routes of transmission. METHODS: A cross sectional survey was done to determine the prevalence of HIV and HCV coinfection, measuring different HIV and HCV variables among 651 HIV infected patients of a health area in Madrid. RESULTS: 500 patients (76.8%) were male and 151 female (23%). HCV serology was performed in all the patients and resulted positive in 45.7% (298) most of them drug users (84.8%). The CD4 cell count was lower in patients HIV-HCV coinfected compared to those HCV negative (p < 0.001). CONCLUSION: This study shows a high prevalence of HIV-HCV coinfection, mainly due to parenteral transmission. We emphasize the low percentage of coinfected patients treated with interferon and ribavirine which probably will increase in the future.

[Treatment with interferon and ribavirin of chronic hepatitis C in HIV-infected patients]. / Tratamiento con interferón y ribavirina de la hepatitis crónica por virus C en pacientes con infección por VIH.

BACKGROUND: The rapid progression of chronic hepatitis C (CHC) in HIV-infected patients is now the most important cause of morbidity, mortality and hospital admissions. In order to avoid this evolution, the treatment of CHC is a major challenge in these patients. PATIENTS AND METHOD: The aim of this study is to evaluate the safety and efficacy of treatment of CHC in HIV-infected patients with subcutaneous IFN (3 MU 3 times a week) plus Ribavirin (RBV) administered per 200 mg dosage depending on their body weight, for 24 weeks for genotype 2 or 3 and 48 weeks for genotype 1 or 4. All the patients have a CD4 count over 150 cells/microl and HIV viral load < 50,000 copies/ml, with or without antiretroviral treatment. We defined sustained response as RNA-VHC below level of detection 24 weeks after the end of treatment. RESULTS: We included 28 patients in the study, with median age of 36.6 y.o. 82% of the patients were on antiretroviral treatment, with AZT in 60% of them. Genotype distribution was HCV-1 in 50%, HCV-3 in 35.7%, HCV-4 in 10.7% and HCV-2 in 3%. Liver biopsy was performed in all the patients. Adverse events leading to treatment discontinuation occurred in 5 patients (17.8%). The overall sustained response rate in the intent-to-treat analysis was 25.8% (50% for genotype 3 and 14% for genotype 1). CONCLUSION: This therapy provides cure in a rate significantly lower than that seen in HCV-monoinfected individuals, with a similar safety. The modern formulations of IFN (pegylated) will provide new expectatives in this group of patients.

[Treatment with interferon of chronic active hepatitis in patients with HIV infection]. / Tratamiento con interferón de la hepatitis crónica activa en pacientes con infección por VIH.

Clinical records of 14, CD4 cell counts > 400/mm3, mild symptoms or asymptomatic, HIV infected patients and with chronic active hepatitis (identified by hepatic biopsy) were under review. Four of them were infected with HBV, 8 with HCV, 1 with HDV and other one with HBV + HCV + HDV. They were treated with alpha interferon for 6 months. Effectiveness was evaluated. It was found that in 4 (50%) of HCV infected patients transaminases raised normal value two of them remained with normal values at the end of review (22 and 48 months of follow-up). All HBV infected patients (4) normalized transaminases. Three of them lost HBeAg, that persisted through 38 months of follow-up. It was found too, whose did not improved with 6 months treatment did not benefit with a longer treatment. Therefore, HIV infected patients uncompromised (CD4+ > 400/mm3) and with chronic active hepatitis were benefited by interferon treatment (57%). Reversal of HBeAg was remarkable.

[Descriptive study of 39 cases of hepatic abscess of pyogenic and amebic origin]. / Estudio descriptivo de 39 casos de abscesos hepáticos de origen piógeno (33) y amebiano (6).

Thirty nine cases of liver abscess--33 pyogenic (LAP) and 6 amebic (LAA)--attended in our hospital between 1980 and 1994, were reviewed. Mean patient age was 55.66 years (LAP) and 35.83 years (LAA), while the relation male/female was 2.3:1 and 5:1 respectively. The most usual underlying pathology in LAP was bile duct disease (39.39%). Four patients with LAA had travelled to endemic areas. Fever was the most frequent clinical finding (71.79%). Echography and/or CT scan confirmed the diagnosis in 32 patients (82.05%), with a sensitivity of 86.66 and 95.65% respectively. Positive cultures were found in 74.35% (39.13% polymicrobials), being E. Coli and K. Pneumoniae the most frequently isolated bacteria. In LAP pus cultures were positive in 73% and blood cultures in 55%. Diagnosis of LAA was made by wet mount smears/serology (3/3). Percutaneous drainage was performed in 41.02%, surgical drainage in 48.71 and 15.38% (all with LAP) received antibiotics exclusively. Four patients died (3 with LAP and 1 with LAA).

[Atrial fibrillation and cerebral infarct]. / Fibrilación auricular e infarto cerebral.

The importance of atrial fibrillation (AF) as a risk factor (RF) for cerebral infarction (CI) is well-known. It is probably caused by cardiac embolism but other explanations can also justify this association. Our aim was to analyse the features of the patients with CI and AF and sinus rhythm (SR), as well as to form hypotheses as regards the pathogenesis. 250 patients with CI, 204 in RS and 46 in AF (31 non-valvular and 15 associated to a valvular disease) were studied, analysing the prevalence of RF and initial blood tests. The group of patients with valvular AF of probably embolic mechanism had a minor prevalence of RF (hypertension, diabetes, smoking, alcoholism) but higher mortality. The group with non-valvular AF, had a lower RF prevalence compared to the SR group (non-embolic mechanism), without statistical significance and with a similar mortality rate. We concluded that the atherothrombotic mechanism can be the cause of a considerable proportion of CI in patients with non-valvular AF.

[Clinical trial comparing efficacy and safety of four highly active antiretroviral therapy (HAART) in antiretroviral-naive treatment with advanced HIV infection]. / Ensayo clínico comparativo de eficacia y seguridad de cuatro pautas de tratamiento antirretroviral de alta eficacia (TARGA) en pacientes naive con infección por VIH avanzada.

BACKGROUND: Comparison of efficacy and safety of four highly active antiretroviral therapy regimens (HAART) including two nucleoside analogues (NA) and a protease inhibitor (PI) in HIV positive patients with advanced infection and antiretroviral naive. PATIENTS AND METHODS: Multicenter, randomized and open labeled clinical trial in ten community hospitals of Castilla-La Mancha and Madrid. Regimen 1 contains zidovudine (AZT), lamivudine (3TC) and indinavir (IDV) regimen 2 includes AZT, 3TC and ritonavir (RTV), regimen 3 was didanosine (DDI), estavudine (D4T) and IDV, and regimen 4 included DDI, D4T and RTV. Decrease in viral load of HIV (VC) has been assessed as primary endpoint and as secondary one, the increase of the numbers of CD4 lymphocytes, percentage of disease progression, adverse reactions and adherence. Measurements were made at baseline visit and at 6, 12, 24, 36 and 48 weeks. RESULTS: A total of 98 patients with a mean baseline CD4 count of 122 x 10(6)/l (range of 5-340) and a baseline viral load of 5.1 log copies/ml were included. At 48 weeks, a mean increase of the CD4 and decrease of the viral load without significant difference between the 4 regimens (103 cells/2.62 log in regimen 1; 169 cells/2.86 log in regimen 2; 171 cells/2.56 log in regimen 3 and 141 cells/1.71 log in regimen 4) were observed in the analysis of the patients in treatment. Treatment was discontinued due to adverse reactions: 24% in regimen 1, 48% in regimen 2, 26% in regimen 3 and 32% in regimen 4, without significant difference. Analyzing by PI groups, 41% of the patients with RTV and 25% of those with IDV discontinued treatment due to adverse effects. There was withdrawal from treatment due to disease progression in 7% of the RTV patients and in 9% of IDV patients. CONCLUSIONS: In the HIV positive patients with advanced infection, efficacy between the four regimens of HAART is similar, but there is a tendency to require more withdrawal due to adverse effects in the RTV group than in those of IDV, the two used as single PI.

[Complaints and suggestion slips as a method of integrating users' viewpoints into primary health care. A comparison with professionals' perspective]. / Las reclamaciones y las hojas de sugerencias como método de incorporación de la opinión del usuario en atención primaria. Comparación con la perspectiva de los profesionales.

OBJECTIVE: To analyze consumer's opinions as a method of incorporating them in the programmes whose aim is to improve the Quality of Primary Health Care. To compare the problems the consumers found with those detected by professionals through the nominal group technique. DESIGN: Transversal descriptive. PLACE: Primary Health Care Center. Manises Health Centre. MEASUREMENTS AND MAIN RESULTS: Analyze the ideas included in the suggestions box during the 14 months since the programme was set up were analyzed. RESULTS: The 89 problems found by the consumers as well as the professionals are the following: accessibility, 37%; structure, 36%; organization, 13%; personal relationship, 6%; professional knowledge, 3%; information, 2%, and continuity, 2%. The most frequent problems were: difficulties in connecting with Health Center by telephone, loss of medical records in the visits, lack of continuous assistance by the same doctor, absence of a public telephone. CONCLUSIONS: The possibility to give ideas about how to improve the quality of the Health Center by using a suggestion box is used more often than the possibility of making a formal complaint. The ideas fundamentally refer to structural problems, organizational ones and accessibility. The nominal group technique is the best method for professionals to detected quality problems.

[Risk factors in cerebrovascular disease and their prognostic importance]. / Factores de riesgo en la enfermedad cerebrovascular y su importancia pronóstica.

The prevalence of cerebrovascular disease risk factors and their immediate mortality prognostic value together with the initial analytical parameters are evaluated. 250 cases of cerebral infarction (CI), 150 cases of intracerebral hemorrhage (ICH) and 60 cases of transitory ischemic events (TIE) were studied and compared to a control group. A higher prevalence of arterial hypertension, cardiopathy, previous cerebrovascular disease and elevated hematocrit was found in the CI group. In the TIE group there was an increased prevalence of cardiopathy, previous cerebrovascular disease and high hematocrit. In the ICH group an increased prevalence of hypertension and left ventricular hypertrophy was found. We have to point out the importance of a global approach of the risk factors. The intrahospital mortality due to CI was associated with old age, low hematocrit, leukocytosis and high blood sugar at admission. ICH was associated with a higher systolic arterial pressure leukocytosis and elevated blood glucose at admission.