Potentially inappropriate medications in older adults living with HIV.

OBJECTIVES: We assessed the prevalence of potentially inappropriate medication (PIM) among older (≥ 65 years) people living with HIV (O-PLWH) in the region of Madrid. METHODS: We analysed the dispensation registry of community and hospital pharmacies from the Madrid Regional Health Service (SERMAS) for the period between 1 January and 30 June 2017, looking specifically at PIMs according to the 2019 Beers criteria. Co-medications were classified according to the Anatomical Therapeutic Chemical (ATC) classification system. RESULTS: A total of 6 636 451 individuals received medications. Of these individuals, 22 945 received antiretrovirals (ARVs), and of these 1292 were O-PLWH. Overall, 1135 (87.8%) O-PLWH were taking at least one co-medication, and polypharmacy (at least five co-medications) was observed in 852 individuals (65.9%). A PIM was identified in 482 (37.3%) O-PLWH. Factors independently associated with PIM were polypharmacy [adjusted odds ratio (aOR) 7.08; 95% confidence interval (CI) 5.16-9.72] and female sex (aOR 1.75; 95% CI 1.30-2.35). The distribution of PIMs according to ATC drug class were nervous system drugs (n = 369; 28.6%), musculoskeletal system drugs (n = 140; 10.8%), gastrointestinal and metabolism drugs (n = 72; 5.6%), cardiovascular drugs (n = 61; 4.7%), respiratory system drugs (n = 13; 1.0%), antineoplastic and immunomodulating drugs (n = 10; 0.8%), and systemic anti-infectives (n = 2; 0.2%). Five drugs accounted for 84.8% of the 482O PLWH with PIMs: lorazepam (38.2%), ibuprofen (18.0%), diazepam (10.2%), metoclopramide (9.9%), and zolpidem (8.5%). CONCLUSIONS: Prescription of PIMs is highly prevalent in O-PLWH. Consistent with data in uninfected elderly people, the most frequently observed PIMs were benzodiazepines and nonsteroidal anti-inflammatory drugs . Targeted interventions are warranted to reduce inappropriate prescribing and polypharmacy in this vulnerable population.

Bacterial translocation and clinical progression of HCV-related cirrhosis in HIV-infected patients.

The aim of the study was to evaluate whether bacterial translocation (BT) predicts the clinical outcome in HIV/HCV-coinfected patients with compensated cirrhosis. A cohort of 282 HIV/HCV-coinfected patients with cirrhosis and no previous liver decompensation (LD) was recruited. Serum levels of the DNA sequences encoding the well-conserved 16S rRNA subunit (16S rDNA), the lipopolysaccharide (LPS) and soluble CD14 (sCD14) at diagnosis of cirrhosis were measured. Primary endpoint was the emergence of the first LD and/or death of any cause. Secondary endpoints were LD, liver-related death (LRD) and death of any cause. After a median (Q1-Q3) follow-up of 51 (27-72) months, 67 patients (24%; 95% CI: 19-29) developed their first LD or died during follow-up. Baseline levels of 16S rDNA, LPS and sCD14 were not associated with the probability of developing the primary endpoint of the study. The mean (SD) survival time free of LD and/or death according to levels of 16S rDNA (<83, 83-196, 197-355, >355 [copies/µL]) was 78 (5), 72 (5), 81 (4) and 82 (4) months, respectively (P = .5). The corresponding figures for LPS (<0.1, 0.1-0.6, 0.6-1.5, > 1.5 [IU/mL]) were 76 (5), 71 (5), 77 (5) and 81 (4) months, respectively (P = .4). Baseline levels of BT serum markers were not associated with any of the secondary endpoints analysed in the study. Thus, BT does not seem to be a relevant predictor of clinical outcome in HIV/HCV-coinfected patients with compensated cirrhosis.

Prevalence, antimicrobial susceptibility and molecular typing of Methicillin-Resistant Staphylococcus aureus (MRSA) in bulk tank milk from southern Italy.

This paper assesses the prevalence of MRSA in bulk tank milk (BTM) samples from southern Italy, and the relationship between the Coagulase Positive Staphylococci count (CPS) and MRSA prevalence. Of 486 BTM samples tested, 12 samples (2.5%) resulted positive for the presence of MRSA. Great genetic diversity was found among the isolates: ST1/t127 and t174/IVa, ST5/t688/V, ST8/t unknown/IVa/V, ST45/t015/IVa, ST71/t524/V, ST88/t786/Iva, ST398/t011 and t899/IVa/V and ST2781/t1730/V. All isolates were pvl-negative and icaA positive. The majority of strains (58%) carried the ses (sec, seh, seg, seo, sem and sen) genes. All tested strains resulted susceptible to amikacin, cephalotin, cloramphenicol, gentamycin, trimethoprim - sulfamethoxazole, tobramycin and vancomycin, and variably resistant to ampicillin, oxacillin and tetracycline. No statistical association between the CPS count and MRSA detection was found in the MRSA-positive samples. Although some of the spa-types and STs detected in our survey are known to cause human infections, raw milk from Italian herds in the considered area is not a common source of MRSA. Nonetheless, it is necessary to assess the risk of foodborne infection and the risk related to the handling of milk.

Demographic, clinical and microbiological characteristics of the first 30 human monkeypox confirmed cases attended in a tertiary hospital in Madrid (Spain), during the May-June 2022 international outbreak.

The present outbreak of Human Monkeypox (HMPX) that has begun in May 2022 and has spread across all continents in less than two months has qualitative and quantitative characteristics that make it different from the pattern of human disease previously caused by this virus. It has spread with enormous ease, affects almost exclusively adults, behaves as a sexually transmitted disease and focuses on very specific groups and transmission conditions. The high incidence in the city of Madrid in males that have sex with males (MSM) has allowed us to observe and report the experience with the first 30 cases diagnosed in our institution. Patients presented with febrile symptoms, genital and paragenital skin lesions reminiscent of smallpox, but less extensive and severe. The disease may also cause proctitis, pharyngitis and perioral lesions. The PCR test for diagnostic confirmation has been shown to be very sensitive and effective, not only in skin lesions but also in blood and other fluids such as pharyngeal, rectal exudates and blood. A very high proportion of patients with HMPX also have other sexually transmitted diseases that must be actively detected in this context. The spontaneous evolution of our patients has been good and hospitalization has been practically unnecessary. Transmission to non-sexual cohabitants and health personnel has been nonexistent and the lesions have disappeared in less than 30 days without leaving sequelae and no need for specific antiviral treatment.

Standard and new faecal indicators and pathogens in sewage treatment plants, microbiological parameters for improving the control of reclaimed water.

This study involved collaboration between three centres with expertise in viruses, bacteria and protozoa. The focus of the research was the study of the dissemination and removal of pathogens and faecal indicators in two sewage treatment plants (STP1 and STP2) using tertiary treatments. Samples were collected over a period of five months through the sewage treatment processes. Analysis of the samples revealed that the plants were not efficient at removing the faecal indicators and pathogens tested during the study. From entry point (raw sewage) to effluent level (tertiary treatment effluent water), the experimental results showed that the reduction ratios of human adenoviruses were 1.2 log10 in STP1 and 1.9 log10 in STP2. Whereas for Giardia spp. and Cryptosporidium spp. the reduction ratios were 2.3 log10 for both pathogens in STP1, and 3.0 and 1.7 log10 in STP2, respectively. Furthermore, the presence of faecal indicators and pathogens at different sampling points was evaluated revealing that the tested pathogens were present in reclaimed water. Human adenovirus and Arcobacter spp. showed positive results in infectivity assays for most of the tertiary effluent water samples that comply with current legislation in Spain. The pathogens detected must be evaluated using a risk assessment model, which will be essential for the development of improved guidelines for the re-use of reclaimed water.

Unresolved issues in the epidemiology and diagnosis of bacteremia: an opinion paper.

Bacteremia is an important cause of morbidity and mortality worldwide and, despite the diagnostic and therapeutic advances of the last decades, the evidence supporting many diagnostic aspects of bacteremia is scarce. Information on the epidemiological evolution of this entity is limited and many methodological aspects of blood culture collection and analysis are under discussion. Furthermore, the recommendations of the main scientific societies on many of these aspects are variable and, in many cases, have not been updated recently. In this scenario, we have arranged a series of questions on different aspects of bacteremia and reviewed the literature trying to find proper answers for them. We offer our opinion on the topics where the evidence was weak. The topics covered include epidemiological aspects of bacteremia, indications for blood culture extraction, methods for obtaining and incubating samples, or ways of transmitting results from the microbiology laboratory. We do not intend to summarize the current clinical practice guidelines, nor will we deal with the therapeutic management of this entity. The aim of this paper is to review the current perspective on the diagnosis of bacteremia with a critical approach, to point out the gaps in the literature, to offer the opinion of a team dedicated to infectious diseases and clinical microbiology, and to identify some areas of knowledge on which future studies should focus.

Low prevalence of Listeria monocytogenes in foods from Italy.

Listeria monocytogenes is an important foodborne pathogen that causes gastrointestinal disorders, and, especially in immunocompromised people, serious extraintestinal diseases, such as septicemia and meningitis, as well as abortion in pregnant women. Many foods, from both plant and animal origin, have been involved in listeriosis outbreaks. This article reports the results of a 12-year survey (1993 through 2004) on the presence of L. monocytogenes in several kinds of food marketed in Italy. Of 5,788 analyzed samples, 121 (2.1%) were contaminated with L. monocytogenes. The highest prevalence was found in smoked salmon (10.6%) and in poultry meat samples (8.5%) and the lowest in red meat (0.3%). L. monocytogenes was not found in 154 samples of fresh seafood products. Fifty-two isolates were also serotyped by the agglutination method. The most common serotypes detected in the 52 strains tested were 1/2a (36.5%), followed by 1/2c (32.8%), 1/2b (13.5%), 4b (11.5%), 3a (3.8%), and 3b (1.9%). The results of the present study showed low levels of L. monocytogenes in the analyzed samples. A total of 61.5% of the 52 L. monocytogenes strains analyzed belonged to serotypes 1/2a, 1/2b, and 4b, namely the serovars that are most commonly involved in extraintestinal human listeriosis outbreaks. In the ready-to-eat samples, these three serotypes were 40.0% (1/2a), 17.1% (1/2b), and 14.3% (4b). This finding highlights the need to implement strict hygienic measures during the production, distribution, and sale of foods to reduce the risk of foodborne listeriosis in humans to an acceptable level.

[Granulomatous amoebic meningoencephalitis by Balamuthia mandrillaris: case report and literature review]. / Meningoencefalitis granulomatosa por Balamuthia mandrillaris: reporte de un caso y revisión de la literatura.

The free-living amebas Naegleria and Acanthamoeba are recognized as causal agents of central nervous system infections. Recently a third free-living ameba, Balamuthia mandrillaris, was identified as the causal agent of granulomatous encephalitis in humans. We report a case of Balamuthia encephalitis in an immunocompetent school-age girl who presented cutaneous lesions that compromised the central portion of the face. The skin biopsy revealed granulomatous lesion with positive PCR for non-tuberculous Mycobacterium. We started treatment for atypical extrapulmonary mycobacteriosis. Nevertheless, the child was readmitted six months later, with progressive neurological involvement, dying about one year after the onset of cutaneous symptoms. The brain necropsy showed the presence of B. mandrillaris cysts and trophozoites. Balamuthia mandrillaris infection should be considered in the differential diagnosis of a patient with chronic granulomatous disease with neurologic symptoms.

Phenylpropanoids and tetrahydrofuran lignans from Piper solmsianum.

A tetrahydrofuran lignan as well as the known tetrahydrofuran lignan, (-)-grandisin, and five phenylpropanoid derivatives were isolated from Piper solmsianum. Their structures were determined by means of spectral analyses, including 2D NMR techniques such as NOE-DIFF and HMBC 3J(C-H).

Biosynthesis of friedelane and quinonemethide triterpenoids is compartmentalized in Maytenus aquifolium and Salacia campestris.

Maytenus aquifolium (Celastraceae) and Salacia campestris (Hippocrateaceae) species accumulate friedelane and quinonemethide triterpenoids in their leaves and root bark, respectively. Enzymatic extracts obtained from leaves displayed cyclase activity with conversion of the substrate oxidosqualene to the triterpenes, 3beta-friedelanol and friedelin. In addition, administration of (+/-)5-(3)H mevalonolactone in leaves of M. aquifolium seedlings produced radio labelled friedelin in the leaves, twigs and stems, while the root bark accumulated labelled maytenin and pristimerin. These experiments indicated that the triterpenes once biosynthesized in the leaves are translocated to the root bark and further transformed to the antitumoral quinonemethide triterpenoids.

Changes in superoxide dismutase activity and photosynthetic pigment content during growth of marine phytoplankters in batch-cultures.

The ability of phytoplankton to cope with oxidative stress is one of the main factors that influence its survival in the marine environment, when senescence conditions prevail. In a first attempt to investigate the antioxidant strategies of different phytoplanktonic groups face to oxidative stress, the superoxide dismutase (SOD; EC 1.15.1.1) activity and photosynthetic pigment content along the growth curves of the dinoflagellate Lingulodinium polyedrum (Stein) Dodge, the prasinophycean Tetraselmis gracilis (Kylin) Butcher and the diatom Minutocellus polymorphus (Hargraves and Guillard) Hasle, von Stosch and Syvertsen were evaluated in batch-cultures. Total SOD activity was determined by an indirect method involving the inhibition of cytochrome c reduction. The contents of photosynthetic pigments were analysed by HPLC using a reverse phase column (RP-18), based on a ternary gradient. A peak of total SOD activity was detected at the beginning of the T. gracilis and M. polymorphus exponential growth. In L. polyedrum and M. polymorphus, SOD activity increased approximately three times by day 17 of growth, compared to the values obtained on day 3 (exponential phase) of the growth curve. All three species of microalgae had reduced SOD activity at the end of their growth. The levels of peridinin in L. polyedrum increased about 60% by day 17 of growth compared to the values obtained at exponential phase. Tetraselmis gracilis exhibited a remarkable increase (approximately 85%) in beta-carotene concentration after 10-14 days of growth whereas the beta-carotene levels in M. polymorphus decreased about 85% along its growth curve. These findings suggest that the antioxidant response during senescence in batch-cultures differ according to the species. Induction of SOD activity may occur either in the early exponential or stationary growth phases, which is important to prevent oxidative stress triggered by a number of factors that affects growth, such as nutrient and light availability.

[Antineutrophil cytoplasmic antibodies and Wegener's granulomatosis]. / Anticuerpos anticitoplasma de neutrófilo y granulomatosis de Wegener.

In the presented case are described the clinic demonstrations, analytical and evolutionary in a diagnosed patient of Wegener Granulomatosis (WG). The biopsies practiced in the injuries of the nasal mucous and oral cavity demonstrated a necrotizing granulomatous vasculitis. The antineutrophil cytoplasmic antibodies with standard cytoplasmic (AANC-C) determined by immunofluorescence indirect were positive with a seric initial of 1:160 in the making negative to the sixty treatment days. The administration of the treatment coincided with an improvement meaningful clinic. We emphasize the scarce demonstration of the WG in the oral cavity as well as of the presentation histological described. Finally, we emphasize the growing importance of the AANC-C not only in the diagnosis of the disease but as specific marker of its activity.

A practical guide to health care antitrust issues.

This article provides a brief overview of antitrust principles that are applicable to the health care industry, and applies those principles to some major antitrust issues that hospitals currently face.

Hand transplantation: is it an ethical decision, a bioethical one, or both?

Essays by Seigler and Emmanuel define some criteria and requirements when doing an innovative procedure such as hand transplantation to determine whether it is possible to conduct clinical research. These criteria and requirements take into account the patient, the medical team, and society. However, we think that there are still other considerations that have not been given sufficient emphasis to justify an innovative procedure and are mainly determined by the patient and his environment, along with other quality-of-life issues, including social acceptance (according to cultural norms), appearance (body image), and function. There should be a balance between the patient, the medical team, and societal considerations in the decision process. Progressive societies are responsible for the distribution of the necessary resources to perform innovative procedures while controlling the costs of integral treatment and ensuring related investigations, thus facilitating the evaluation and advancement of innovative surgery. If these factors are taken into account along with the criteria already outlined involving the patient's cultural dimensions and the involved costs a decision can be made whether to proceed with hand transplantation. Being a difficult complex decision, it is imperative that it be made not only by an individual or group, either the patient or the medical team (ethical decision), but in conjunction with public discussion (bioethical decision) that not only takes into account the risks, benefits, and costs, but by including all criteria must also be at least technical, human, and social.

Potential of a hand transplantation program in Colombia.

The protocols and published results on hand transplantation show acceptable results of this technology. None of the registered groups, however has a sufficient number of patients to allow continuity of the process. In Colombia the main problems are violence, drug traffic, and guerrillas. Thanks to the profitability of drug traffic, guerrillas, who initially were created based on ideologic differences, have become terrorist groups whose main source of income is drug traffic. From that interest comes the use of landmines to protect illicit crops. Colombia is the most mined country in the world, followed by Cambodia and Afghanistan, and the only country in Latin America where there are still landmines. The mines, violence, and trauma produce a large number of people with disabilities and amputations. From 1990 to 2006, the number of victims rose from 21 to 1,041 per year. In Colombia, amputations are more frequently due to trauma than to disease. The fact that 88% of the victims are children and people of working age, affects the political and economic development. These alarming numbers generate a challenge for government, which has led to the creation of policies and laws aimed at comprehensive action against mines. This program under the Presidency has among its objectives assistance to victims, including integrated treatment, prostheses, and other procedures, financed entirely by the government. The number, type of victims, and their motivation to be transplanted, along with government programs directed to their attention, are key factors that we think will enable the continuity of our hand transplantation program at the Fundación Santa Fe de Bogotá, giving Colombia the unfortunate privilege of having the largest number of potential patients for transplantation.

Surveillance of antibiotic resistance in Neisseria gonorrhoeae in the WHO Western Pacific and South East Asian regions, 2007-2008.

Long-term surveillance of antimicrobial resistance in Neisseria gonorrhoeae has been conducted in the World Health Organization (WHO) Western Pacific Region (WPR) to optimise antibiotic treatment of gonococcal disease since 1992. In 2007 and 2008, this Gonococcal Antimicrobial Surveillance Programme (GASP) was enhanced by the inclusion of data from the South East Asian Region (SEAR) and recruitment of additional centres within the WPR. Approximately 17,450 N. gonorrhoeae were examined for their susceptibility to one or more antibiotics used for the treatment of gonorrhoea by external quality controlled methods in 24 reporting centres in 20 countries and/or jurisdictions. A high proportion of penicillin and/or quinolone resistance was again detected amongst isolates tested in North Asia and the WHO SEAR, but much lower rates of penicillin resistance and little quinolone resistance was present in most of the Pacific Island countries. The proportion of gonococci reported as 'resistant', 'less susceptible' or 'non-susceptible' gonococci to the third-generation cephalosporin antibiotic ceftriaxone lay in a wide range, but no major changes were evident in cephalosporin minimal inhibitory concentration (MIC) patterns in 2007-2008. Altered cephalosporin susceptibility was associated with treatment failures following therapy with oral third-generation cephalosporins. There is a need for revision and clarification of some of the in vitro criteria that are currently used to categorise the clinical importance of gonococci with different ceftriaxone and oral cephalosporin MIC levels. The number of instances of spectinomycin resistance remained low. A high proportion of strains tested continued to exhibit a form of plasmid mediated high level resistance to tetracyclines. The continuing emergence and spread of antibiotic resistant gonococci in and from the WHO WPR and SEAR supports the need for gonococcal antimicrobial resistance surveillance programs such as GASP to be maintained and potentially expanded.