Compliance with national guidelines for HIV treatment and its association with mortality and treatment outcome: a study in a Spanish cohort.

OBJECTIVES: The aim of the study was to assess the adequacy of initial antiretroviral therapy (ART), in terms of its timing and the choice of regimens, according to the Spanish national treatment guidelines [Spanish AIDS Study Group-National Plan for AIDS (GeSIDA-PNS) Guidelines] for treatment-naïve HIV-infected patients. METHODS: A prospective cohort study of HIV-positive ART-naïve subjects attending 27 centres in Spain from 2004 to 2010 was carried out. Regimens were classified as recommended, alternative or nonrecommended according to the guidelines. Delayed start of treatment was defined as starting treatment later than 12 months after the patient had fulfilled the treatment criteria. Multivariate logistic and Cox regression analyses were performed. RESULTS: A total of 6225 ART-naïve patients were included in the study. Of 4516 patients who started treatment, 91.5% started with a recommended or alternative treatment. The use of a nonrecommended treatment was associated with a CD4 count > 500 cells/µL [odds ratio (OR) 2.03; 95% confidence interval (CI) 1.14-3.59], hepatitis B (OR 2.23; 95% CI 1.50-3.33), treatment in a hospital with < 500 beds, and starting treatment in the years 2004-2006. Fourteen per cent of the patients had a delayed initiation of treatment. Delayed initiation of treatment was more likely in injecting drug users, patients with hepatitis C, patients with higher CD4 counts and during the years 2004-2006, and it was less likely in patients with viral loads > 5 log HIV-1 RNA copies/ml. The use of a nonrecommended regimen was significantly associated with mortality [hazard ratio (HR) 1.61; 95% CI 1.03-2.52; P = 0.035] and lack of virological response. CONCLUSIONS: Compliance with the recommendations of Spanish national guidelines was high with respect to the timing and choice of initial ART. The use of nonrecommended regimens was associated with a lack of virological response and higher mortality.

Differential characteristics of bacteraemias according to age in a community hospital. / Características diferenciales en las bacteriemias según la edad en un hospital comunitario.

OBJECTIVE: To describe the characteristics of bacteraemias, according to age, in a community hospital. MATERIAL AND METHOD: A prospective study of bacteraemias was conducted in 2011. The patients were classified into 3 age groups: younger than 65 years, 65 to 79, and 80 or older. The study collected variables on the patients and episodes. RESULTS: The study analysed 233 bacteraemias in 227 patients (23.8% in those younger than 65 years; 38.3% in the 65 to 79 age group; and 37.9% in the 80 years or older group). The most common underlying disease in all the groups was diabetes mellitus. In the most elderly patients, the Charlson index was highest, there was a lower proportion of exogenous factors, and almost 25% were severely dependent (Barthel index<20). Escherichia coli was the most common germ, and the main focus was urological. The patients aged 80 years or older had predominantly healthcare-associated infections, less severe symptoms (sepsis) (66.3%) and higher mortality (29.1%) compared with the younger patients. CONCLUSIONS: The very elderly patients with bacteraemia presented fewer exogenous factors, greater comorbidity and a poorer functional situation. The most common focus was urological and the origin was healthcare related. Despite their less severe clinical presentation, these patients' mortality was greater, and their degree of dependence was a highly relevant independent risk factor.

[Resistance of Mycobacterium tuberculosis in Zaragoza, Spain (1993-1997) and related factors]. / Resistencia de Mycobacterium tuberculosis en Zaragoza (1993-1997) y factores asociados.

BACKGROUND: To know the frequency of resistance of Mycobacterium tuberculosis in a general hospital and the related factors. PATIENTS AND METHOD: Transversal study of the sensitivity of Mycobacterium tuberculosis in the Hospital Miguel Servet (Zaragoza, Spain) between 1993-1997; the proportions method was used to study the susceptibility. Statistical analysis of conventional tests and significance level at p < 0.05 were performed. RESULTS: Four hundred and twenty height patients with culture-positive to Mycobacterium tuberculosis were studied; 136 (31.8%) were HIV+, 121 (28.3%) were HIV and in 171 (39.9%) this situation was unknown. In 47 patients (10.9%) the strains isolated were resistant at least to one drug. Primary resistance was 5.9% (22 patients) and acquired resistance was 42.4% (25 patients). Primary resistance in HIV+ patients was 9. 2% and in HIV patients was 7.5%; acquired resistance in HIV+ patients was greater than in HIV patients (51.8% vs 42.8%). When we compared the resistances between both HIV+ and HIV patients we did not find significant differences. Twenty isolates (4.7%) were resistant to more than one drug and 10 (2.3%) were resistant to at least isoniazid and rifampin. The risk factors for acquired resistance were alcohol (odds ratio [OR] = 2.65; 95% CI, 1.24-5.65), drugs users (OR = 2.33; 95% CI, 1.05-5.17), previous episodes of tuberculosis (OR = 109.40; 95% CI, 15.02-796.43) and homeless (OR = 3.75; 95% CI, 1.26-11.17); we did not find significant differences between the different risk factors according to primary resistance. CONCLUSIONS: On one study, the resistance of M. tuberculosis is similar to other described in Spain. We haven't found significant differences between both seropositive and seronegative patients. The risk factors for acquired resistance were alcoholism, drug users, previous episodes of tuberculosis and homeless.

[Malignant fibrous histiocytoma of soft tissue: description of 10 cases]. / Histiocitoma fibroso maligno de partes blandas: descripción de 10 casos.

We analyze the clinical and histological features of 10 cases of malignant fibrous histiocytoma of soft tissue. Nine belonged to the pleomorphic-verticillate variety and one was myxoid. The initial clinical feature was a palpable mass in all cases except three with retroperitoneal localization, where constitutional symptoms predominated. After therapy (surgery in all, associated with radiotherapy in four), seven patients had local relapse and two had distant metastases. 50% died, with a mean survival of 13 months. We discuss the prognostic factors and the therapeutic approach, with emphasis on aggressive therapy and the need for radical surgery and postoperative adjuvant therapy.

[Rol of thallium-201/gallium-67 cerebral tomogammography in the differential diagnosis of cerebral space occupying lesions]. / Valor de la tomogammagrafía cerebral Talio-201/Galio-67 en el diagnóstico diferencial de las lesiones cerebrales ocupantes de espacio.

INTRODUCTION: Central nervous system (CNS) neoplasms are 10% of all tumors. A metastasis of an unknown primary neoplasm should be suspected in an adult with a cerebral tumor. In this location, the origin of most of metastases (62%) is lung, breast, skin and kidney. However, a differentiation of CNS focal infection and brain tumor, based on clinical status and morphologic imaging, may be difficult. A positive Tl-201 next to a negative Ga-67 SPECT brain scans is entirely in accord with brain metastatic tumor. CLINICAL CASE: A 72-year-old man, with history of excised bladder cancer, was admitted for neurological symptoms associated with a left occipital mass demonstrated by cranial CT and brain MRI. Clinicoradiological findings suggested a neoplastic process. Two cerebral biopsies just showed inflammatory cells. Tl-201 and Ga-67 SPECT brain scans were performed and their findings, an abnormal uptake of Tl-201 in the left occipital cortex and a negative Ga-67 scan, favored a neoplastic process. Radical exeresis of the lesion showed a metastatic adenosquamous carcinoma of probably lung origin. CONCLUSION: Tl-201 in addition to Ga-67 brain SPECT scans are a valuable tool for differential diagnosis between cerebral infection and brain tumour in patients with a sole cerebral mass lesion, especially when clinicoradiological findings and biopsy results are conflicting.

[Brucellosis with nervous system involvement]. / Brucelosis con afectación del sistema nervioso.

Cases of brucellosis with involvement of the nervous system which was diagnosed in the Miguel Servet Hospital during the period 1985-1987 are retrospectively studied. The total quantity of affected patients of brucellosis was 132. Of this quantity, 9 patients (6.8%) had neurological complications under the following clinical forms: epidural abscess (2), meningoencephalitis (1), meningitis (2), encephalitis (1), myelitis (1) and polyradiculitis (2). The most important epidemiological and clinical characteristics are analysed, pointing out the diagnostic difficulties we found when the neurological manifestations are predominant in the brucella infection.

[Spleen abscess]. / Absceso esplénico.

3 cases of splenic abscess (SA), all of them with similar clinical findings; abdominal pain, liver and splenic enlargement and leukocytosis, are presented. The diagnosis was suspected by abdominal ultrasound and confirmed by CTR. We focused the interest on the etiopathogenesis, diagnosis and the rareness of the bacteria isolated: Salmonella group D (two cases) and Bacteroides Fragilis.

Tuberculosis in a cohort of HIV-positive patients: epidemiology, clinical practice and treatment outcomes.

OBJECTIVE: To describe tuberculosis (TB) incidence, risk factors, clinical presentation, disease management and outcomes in human immunodeficiency virus (HIV) infected patients from the CoRIS cohort, Spain, 2004-2010. DESIGN: Open multicentre cohort of antiretroviral treatment (ART) naïve patients at entry. Incidence and risk factors were evaluated using multivariate Poisson regression. RESULTS: Among 6811 patients, 271 were eligible for the study and 198 for the estimation of the incidence rate; TB incidence ranged from 12.1 to 14.1/1000 person-years. TB was associated with low education level (rate ratio [RR] 2.65, 95%CI 1.73-4.07), being sub-Saharan African (RR 3.14, 95%CI 1.81-5.45), heterosexual (RR 2.01, 95%CI 1.22-3.29) or an injecting drug user (RR 2.11, 95%CI 1.20-3.69), not undergoing ART (RR 3.33, 95%CI 2.22-4.76), CD4 <200 cells/mm(3) (RR 5.20, 95%CI 3.25-8.33) and log-viral load of 4-5 (RR 5.44, 95%CI 3.28-9.02) or >5 (RR 13.10, 95%CI 8.27-20.76). Overall, 87% were new cases and 13% were previously treated cases; 175 (65%) were bacteriologically confirmed. Drug susceptibility testing was performed in 146 (83%) patients: resistance to first-line drugs was 11.1% in new and 36.4% in previously treated cases. Standard anti-tuberculosis treatment with four or three drugs was prescribed in respectively 55% and 36% of cases. Treatment default was 11%, and was higher among previously treated cases; 80% received ART during anti-tuberculosis treatment, 80% of new and 50% of previously treated cases were cured or completed treatment, and 18 (6.6%) died. CONCLUSION: TB incidence in HIV-infected patients remains high. Interventions should include early HIV diagnosis and access to ART, enhanced bacteriological confirmation, wider use of four-drug regimens and reduction in treatment default.

Características diferenciales en las bacteriemias según la edad en un hospital comunitario / Differential characteristics of bacteraemias according to age in a community hospital

Objetivo. Describir las características de las bacteriemias, según la edad, en un hospital comunitario. Material y método. Estudio prospectivo de las bacteriemias en el año 2011. Los pacientes se clasificaron en 3 grupos de edad: menos de 65, de 65 a 79 y 80 o más años. Se recogieron variables de los pacientes y de los episodios. Resultados. Se analizaron 233 bacteriemias en 227 pacientes (23,8% en<65; 38,3% entre 65 y 79; y 37,9% en≥80 años). La enfermedad de base más frecuente en todos los grupos fue la diabetes mellitus. En los pacientes muy ancianos el índice de Charlson fue mayor, hubo una menor proporción de factores exógenos y casi un 25% eran dependientes graves (índice de Barthel<20). Escherichia coli fue el germen más frecuente y el foco principal fue el urológico. En los pacientes≥80 años predominó el origen de la infección asociado a cuidados sanitarios, la expresividad clínica menos grave (sepsis) (66,3%) y la mortalidad más elevada (29,1%), respecto a los de menor edad. Conclusiones. Los pacientes muy ancianos con bacteriemia presentaron menos factores exógenos, más comorbilidad y una situación funcional peor; el foco más frecuente fue el urológico y el origen el asociado a cuidados sanitarios. A pesar de que su presentación clínica fue menos grave, su mortalidad fue superior, siendo el grado de dependencia una variable de riesgo independiente muy relevante (AU)

Objective. To describe the characteristics of bacteraemias, according to age, in a community hospital. Material and method. A prospective study of bacteraemias was conducted in 2011. The patients were classified into 3 age groups: younger than 65 years, 65 to 79, and 80 or older. The study collected variables on the patients and episodes. Results. The study analysed 233 bacteraemias in 227 patients (23.8% in those younger than 65 years; 38.3% in the 65 to 79 age group; and 37.9% in the 80 years or older group). The most common underlying disease in all the groups was diabetes mellitus. In the most elderly patients, the Charlson index was highest, there was a lower proportion of exogenous factors, and almost 25% were severely dependent (Barthel index<20). Escherichia coli was the most common germ, and the main focus was urological. The patients aged 80 years or older had predominantly healthcare-associated infections, less severe symptoms (sepsis) (66.3%) and higher mortality (29.1%) compared with the younger patients. Conclusions. The very elderly patients with bacteraemia presented fewer exogenous factors, greater comorbidity and a poorer functional situation. The most common focus was urological and the origin was healthcare related. Despite their less severe clinical presentation, these patients’ mortality was greater, and their degree of dependence was a highly relevant independent risk factor (AU)

Critical role of ribavirin for the achievement of early virological response to HCV therapy in HCV/HIV-coinfected patients.

The response to hepatitis C virus (HCV) therapy seems to be lower in HCV/HIV-coinfected patients than in HCV-monoinfected individuals. Given that most pivotal trials conducted in coinfected patients have used the combination of pegylated interferon (pegIFN) along with fixed low doses (800 mg/day) of ribavirin (RBV), it is unclear whether HIV itself and/or suboptimal RBV exposure could explain this poorer outcome. Two well-defined end points of early virological response were evaluated in Peginterferon Ribavirina España Coinfección (PRESCO), a multicentre trial in which the combination of pegIFN plus RBV (1000 mg if body weight <75 kg and 1200 mg if >75 kg) was prescribed to coinfected patients. For comparisons, we used unpublished data from early kinetics in two other large trials, one performed in HIV-negative patients [Pegasys International Study Group (PISG)] in which RBV 1000-1200 mg/day was used and another [AIDS Pegasys Ribavirin Coinfection Trial (APRICOT)] in which HIV-positive patients received fixed low RBV doses (800 mg/day). A total of 348 HCV/HIV-coinfected patients from the PRESCO trial were analysed as well as all patients treated with pegIFN plus RBV, who completed 12 weeks of therapy in the comparative studies (435 in PISG and 268 in APRICOT). Negative serum HCV-RNA at week 4 (which has the highest positive predictive value of sustained virological response, SVR) was attained in 33.3%, 31.2% and 13% of treated patients with HCV genotype 1, respectively, in PRESCO, PISG and APRICOT. For HCV genotypes 2/3, responses were 83.7%, 84.2% and 37%, respectively. A decline lower than 2 log(10) at week 12 (which has the highest negative predictive value of SVR) was seen in 25.5%, 19.5% and 37% of HCV genotype-1-infected patients, and in 2.1%, 2.9% and 12% of genotypes-2/3-infected patients, respectively. Prescription of high RBV doses enhances the early virological response to HCV therapy in HCV/HIV-coinfected patients, with results approaching those seen in HCV-monoinfected patients.

[Ulcerative colitis and HIV infection]. / Colitis ulcerosa e infección por VIH.

UNLABELLED: FUNDAMENTAL: The difficulties to raise to a correct diagnosis in patients with human immunodeficiency virus infection and diarrhea, and the few cases reported of ulcerative colitis in the context of HIV infection. OBJECTIVE: Description of 2 cases of ulcerative colitis in patients with HIV infection and the possibility of immunopathogenic relationship between them. MATERIAL AND METHODS: The clinic history of the patients, the anatomopathological diagnosis after the colon biopsy and the determination of CD4 cells. RESULTS: In case 1 the low level of CD4 cells didn't stop the aggressivity of ulcerative colitis. However, in both cases there was a good evolution of colitis after treatment although AIDS. CONCLUSION: It is necessary to study more cases of inflammatory bowel disease in patients with HIV infection to determine the influence of the level of CD4 cells in the enteropathy's evolution.

[An epidemiological and social study of 127 patients with AIDS IN Aragon]. / Estudio epidemiológico y social de 127 pacientes con sida en Aragón.

OBJECTIVE: To evaluate the profile epidemiology and social of the patient with AIDS in our environment and the direct relation with primary care. DESIGN: A descriptive, analytic and retrospective study. SETTING: The study was carried out in the Miguel Servet Hospital in Zaragoza. PARTICIPANTS: Patients with AIDS between January 1991 and june 1993 and who fulfilled the requisite diagnostic criteria. MEASUREMENTS AND MAIN RESULTS: Out of the 127 patients studied, 74.8% were male and the age was 20 to 30 years old. The transmission mechanism was blood way in drug addicts in 63.8% and heterosexual way in 14.8%. It was socioeconomic problems in 40.94%, and 69.23% of them were drug addicts. The familiar support were proved in 29.13% and had relation with primary care only 15.74%. CONCLUSIONS: An increase of the incidence of AIDS is observed, prevailing men between 31-40 years old. The heterosexual way transmission is increasing, but the blood way in drug addicts is more frequently. The majority presents socioeconomic problems and they haven't familiar support.

[Sclerosing cholangitis and AIDS]. / Colangitis esclerosante y SIDA.

Bile tract pathology in AIDS has been described as an incomplete biliary obstructive syndrome and acalculous cholecystitis. Most reported cases have been associated to bile ducts infection by Cytomegalovirus (CMV) and/or Cryptosporidium. We present a case of sclerosing cholangitis and acalculous cholecystitis in an AIDS patient in whom Cryptosporidium was identified in the cholecystectomy sample and this same agent together with Candida Albicans in bile. We highlight the need to suspect this pathology in HIV infected patients who present a bile obstruction picture and/or cholecystitis, the possible etiological role of Candida Albicans, which has not been previously described, as well as the increasing association of bile pathology and AIDS.

[Pneumonia diagnosed with bronchoscopy in HIV-positive patients]. / Neumonías diagnosticadas por broncoscopia en pacientes HIV-positivos.

BACKGROUND: The object of our research is to analyse the microbiological results of the samples which have been obtained by means of fibronchoscopy (FB) from HIV positive patients from 1991 until 1993. METHODS: Sixty fibrobronchoscopies were carried out on fifty-seven HIV positive patients. In every case, samples of bronchoaspirate (BAS), bronchoalveolar lavage (BAL) and telescoping plugged catheter (TPC) were cultured; the last two in a quantitative way. Pneumocystis carinii was investigated in BAL by means of immunofluorescence with monoclonal antibodies. RESULTS: Some microorganisms were isolated in forty-seven bronchoscopies. Thirteen episodes resulted negative. The most frequent etiologic agent was Pneumocystis carinii (seventeen cases). The etiology of fifteen episodes was polymicrobial. The intersticial radiological pattern was the predominant one. It was observed in twenty-seven cases. With regard to immunity, 91% of the patients showed CD4 < 200. CONCLUSIONS: In our research work, the samples that have been obtained by means of FB showed a high percentage of diagnoses; that is the reason why we regard this technique as very useful for the diagnosis of pneumonia in patients with AIDS. Due to the large number of bacterian pneumonia, we consider necessary not only the use of BAL, but also that of TPC in these processes.

Ceftriaxone monotherapy for severe bacteremic infections. Spanish Ceftriaxone Study Group.

We tested the efficacy of a single daily dose of ceftriaxone (active ingredient of Rocephin) for the treatment of severe bacteremic infections in 125 non-neutropenic adult patients. A single daily dose of ceftriaxone ranging from 1 to 4 g was given. Surgical procedures were performed if needed. Seventy-six (60.8%) were males and bacteremia was nosocomially acquired in 45 (36%). Microbiologically proven bacteremia was demonstrated in all patients. The most common microorganisms isolated were Escherichia coli (46 episodes), Streptococcus pneumoniae (17 episodes), Klebsiella pneumoniae, and Haemophilus influenzae, Serratia marcescens, Salmonella sp., and Staphylococcus aureus (9, 7, 6, 6, respectively). The urinary tract was the source of the bacteremia in 45 cases (36%), and the lower respiratory tract in 33 (26.4%). Mean duration of treatment was 10.8 days (range 3-21 days). One hundred and six patients (84.8%) recovered completely, 11 (8.8%) improved, but needed an alternative antibiotic treatment. An alternative treatment was also given to a patient whose condition had initially deteriorated. Seven patients (5.6%) died. Death was directly related to the infection in 2 cases. Three patients (2.4%) developed a superinfection, and 5 (4%) a severe (1 case) or mild (4 cases) adverse effect. In summary, a single daily dose of ceftriaxone proved to be useful for the treatment of selected severe bacteremic infections.

[Brucellosis at a tertiary hospital. Retrospective epidemiologic study of 166 cases]. / La brucelosis en un hospital terciario. Estudio epidemiológico retrospectivo de 166 casos.

The epidemiologic polls concerning 166 cases of brucellosis are retrospectively analyzed; the cases are registered by the Preventive Medicine Service of Miguel Servet Hospital for five years (1980-1985). Most of our cases are of recent evolution, although 55% began to give symptoms more of 2 weeks ago and 30% more of 1 month ago. A clear annual increase of the number of cases, fundamentally of the male sex and patients coming from the rural areas, is observed. The percentage of cases in men (73.5%) is almost three times as those in women (26.5%), and the most numerous groups are the 20-29 interval age group and olders above 60. There is a small percentage of people with a professional risk factor (30.1%), which rise, slightly, for the ones who told of contact with cattle (39.2%) and rose up to 53.6% for the ones who consumed non controlled dairy products. However, in 23% of men and 40.9% of women the existence of some risk factors was unknown.