Executive summary of the consensus document for the training and development of clinical ultrasound in Internal Medicine: Recommendations from the Clinical Ultrasound Working Group of the Spanish Society of Internal Medicine (GTECO-SEMI).

INTRODUCTION: Given the increasing adoption of clinical ultrasound in medicine, it is essential to standardize its application, training, and research. OBJECTIVES AND METHODS: The purpose of this document is to provide consensus recommendations to address questions about the practice and operation of clinical ultrasound units. Nineteen experts and leaders from advanced clinical ultrasound units participated. A modified Delphi consensus method was used. RESULTS: A total of 137 consensus statements, based on evidence and expert opinion, were considered. The statements were distributed across 10 areas, and 99 recommendations achieved consensus. CONCLUSIONS: This consensus defines the most important aspects of clinical ultrasound in the field of Internal Medicine, with the aim of standardizing and promoting this healthcare advancement in its various aspects. The document has been prepared by the Clinical Ultrasound Working Group and endorsed by the Spanish Society of Internal Medicine.

Point-of-Care Ultrasound (POCUS) as an Extension of the Physical Examination in Patients with Bacteremia or Candidemia.

BACKGROUND: In general, transthoracic echocardiography (TTE) is the first diagnostic test used for patients with bacteremia or candidemia and clinical signs of Infective Endocarditis (IE). Point-of-care ultrasound (POCUS) may be used in addition to physical examination for the detection of structural heart disease and valve abnormalities. OBJECTIVE: To determine the diagnostic accuracy of POCUS for the detection of signs suggestive of IE, including vegetation, valvular regurgitation, structural heart disease, hepatomegaly, splenomegaly and septic embolisms, in patients with bacteremia or candidemia. DESIGN: Observational, cross-sectional, multicenter study using convenience sampling. SETTING: Six Spanish academic hospitals. PATIENTS: Adult patients with bacteremia or candidemia between 1 February 2018 and 31 December 2020. MEASUREMENTS: The reference test, to evaluate vegetation, valvular regurgitation and structural heart disease, was transesophageal echocardiography (TEE). For patients who did not undergo TEE, transthoracic echocardiography (TTE) was considered the reference test. POCUS was performed by internists, while conventional echocardiography procedures were performed by cardiologists. RESULTS: In 258 patients, for the detection of valvular vegetation, POCUS had sensitivity, specificity, and positive and negative predictive values of 77%, 94%, 82% and 92%, respectively. For valvular regurgitation (more than mild), sensitivity was ≥76% and specificity ≥85%. Sensitivity values for the detection of hepatomegaly and splenomegaly were 92% and 92%, respectively, while those for specificity were 96% and 98%. CONCLUSION: POCUS could be a valuable tool, as a complement to physical examination, at the hospital bedside for patients with bacteremia or candidemia, helping to identify signs suggestive of IE.

[Positive urine pneumococcal antigen test and vaccination]. / Antigenuria positiva a neumococo y vacunación.

INTRODUCTION AND OBJECTIVE: Although urine pneumococcal antigen is an useful test, it has false positives such as pneumococcal vaccination. MATERIAL AND METHODS: Positive urine pneumococcal antigen in Hospital de Denia (January-February/2015). We studied epidemiological, radiological and microbiological variables as well as previous pneumococcal vaccination (neumo-23 and/or neumo-13). RESULTS: Urine pneumococcal antigen test was positive in 12.4% of 385 cases. Only 33.3% of positive cases had pneumonia in chest X-ray, and 35.4% of patients had previous pneumococcal vaccination. In most cases (87.5%), an antibiotic was prescribed. CONCLUSIONS: Pneumococcal vaccination can produce a false positive result in the urine pneumococcal antigen test in clinical practice, leading to an unnecessary prescription of antibiotics.

[Candidemias: multicentre analysis in 16 hospitals in Andalusia (Spain)]. / Candidemias: análisis multicéntrico en 16 hospitales andaluces.

INTRODUCTION: Candidemia is a nosocomial infection with high associated mortality. There have been changes in microbiology, epidemiology and treatment over the last few years, which has led us to analyse our own situation. MATERIAL AND METHODS: Prospective, multicentre and observational study. All episodes of candidemia in adult patients seen in 17 Andalusian hospitals from 1 October 2005 to 30 September 2006 were included. RESULTS: Were detected 220 cases, the incidence was 0.58 cases/1,000 hospital discharges. Candida albicans was the most frecuent species (53% of cases). The majority of isolates (89%) was susceptibility to fluconazole. Sepsis was the most frequent clinical manifestation (65.7%). The treatment was inadequate in 38.7% of cases. Overall mortality was 40%. On univarite analysis death was found to be significantly associated with: aged > 60 years, unknown candidemia focus, Pitt score ≥ 2, APACHE II, shock at onset, persistents positive second blood cultures, non-removal of the central venous catheter and Candida species different of C. parasilopsis, among others. In the multivariate analysis death was found to be significantly associated with: aged > 60 years, Pitt score ≥ 2, Candida species different of C.parasilopsis and inadequate treatment. CONCLUSIONS: The candidemia clinical epidemiology in our region is similar to other areas and receiving inadequate treatment is the only modifiable risk factor associated with higher odds of mortality. Therefore, this modifiable factor needs to be improved to reduce the mortality.

Old and new insights in the treatment of thyroid carcinoma.

Thyroid cancer is the endocrine tumor that bears the highest incidence with 33 550 new cases per year. It bears an excellent prognosis with a mortality of 1530 patients per year (Jemal et al.; 2007). We have been treating patients with thyroid carcinoma during many years without many innovations. Recently, we have assisted to the development of new agents for the treatment of this disease with unexpected good results. Here we present a review with the old and new methods for the treatment of this disease.

Efficacy of pegylated interferon plus ribavirin treatment in HIV/hepatitis C virus co-infected patients receiving abacavir plus lamivudine or tenofovir plus either lamivudine or emtricitabine as nucleoside analogue backbone.

OBJECTIVES: To compare the response to hepatitis C virus (HCV) therapy among human immunodeficiency virus (HIV)/HCV co-infected patients receiving a nucleos(t)ide reverse transcriptase inhibitor [N(t)RTI] backbone consisting of abacavir plus lamivudine with that observed in subjects who receive tenofovir plus lamivudine or emtricitabine. METHODS: A total of 256 subjects, enrolled in a cohort of 948 HIV-infected patients who received pegylated interferon and ribavirin from October 2001 to January 2006, were included in this study. All patients were taking one protease inhibitor or one non-nucleoside reverse transcriptase inhibitor and abacavir plus lamivudine or tenofovir plus lamivudine or emtricitabine as N(t)RTI backbone during HCV therapy. Sustained virological response (SVR) rates in both backbone groups were compared. RESULTS: In an intention-to-treat analysis, 20 out of 70 (29%) individuals under abacavir and 83 out of 186 (45%) under tenofovir showed SVR (P = 0.02). N(t)RTI backbone containing tenofovir was an independent predictor of SVR in the multivariate analysis [adjusted odds ratio (95% CI), 2.6 (1.05-6.9); P = 0.03]. The association between abacavir use and lower SVR was chiefly seen in patients with plasma HCV-RNA load higher than 600 000 IU/mL and genotype 1 or 4. Among patients treated with ribavirin dose <13.2 mg/kg/day, 3 (20%) of those under abacavir versus 22 (52%) under tenofovir reached SVR (P = 0.03), whereas the rates were 31% and 38% (P = 0.4), respectively, in those receiving >/=13.2 mg/kg/day. CONCLUSIONS: HIV-infected patients who receive abacavir plus lamivudine respond worse to pegylated interferon plus ribavirin than those who are given tenofovir plus lamivudine or emtricitabine as N(t)RTI backbone, especially in those receiving lower ribavirin doses.

Clinical findings, therapeutic approach, and outcome of brucellar vertebral osteomyelitis.

BACKGROUND: Osteoarticular complications are the most common focal complications of brucellosis. Although vertebral osteomyelitis is the most frequent location in adults >30 years of age, little information is available about this serious complication of brucellosis, and great confusion surrounds its prognosis and the most appropriate treatment. METHODS: We undertook a descriptive, retrospective, observational study of 96 patients who received a diagnosis of brucella vertebral osteomyelitis from September 1982 through December 2005 at a tertiary care hospital. All of the patients were treated for 3 months, after which they were followed up monthly for the first 3 months and then at 2-month intervals for the subsequent 6 months. RESULTS: The incidence of vertebral osteomyelitis was 10.4%. The mean diagnostic delay was 12.7 weeks. Inflammatory spinal pain (occurring in 94.8% of patients) and fever (91.7%) were the most relevant clinical characteristics. Eight patients (8.3%) had motor weakness or paralysis. Paravertebral masses, epidural masses, and psoas abscesses were detected in 45.8%, 27.1%, and 10.4% of patients, respectively. Sixty-three patients (65.6%) received medication only, and 33 (34.4%) required surgical therapy in addition to medication. Twenty percent of patients experienced therapeutic failure. Attributable mortality was 2.1%, and severe functional sequelae were apparent in 6.2% of the patients. No significant differences were seen between patients who were treated with doxycycline-streptomycin and those treated with doxycycline-rifampicin. CONCLUSIONS: Vertebral osteomyelitis is a serious complication of brucellosis. It generates a high rate of therapeutic failure and functional sequelae. In the absence of more-powerful controlled studies, the duration of treatment of brucellar vertebral osteomyelitis should be 3 months.

[Impact of demographic and psychosocial factors on adherence to antiretroviral treatment]. / Impacto de los factores demográficos y psicosociales en la no adherencia a los fármacos antirretrovirales.

BACKGROUND AND OBJECTIVE: Antiretroviral efficacy is closely related to the degree of adherence. The aim of this study is to assess the association between psychosocial and demographic variables and adherence to antiretroviral treatment. PATIENTS AND METHODS: A cross-sectional survey of 320 patients under antiretroviral treatment was conducted in four Andalusian hospitals, using a semi-structured questionnaire given by health care professionals. RESULTS: Median age was 39.7 years. Nearly 12% of the sample was considered non-compliant to antiretroviral treatment. An interaction was observed between psychological morbidity and mental health quality of life scores. Among patients who presented psychological morbidity, a higher mental quality of life score was associated with a lower risk of non-compliance (P = 0.04). This association was not found among patients without psychological morbidity. Older age, homosexual or bisexual status and the use of injecting drugs for a shorter period of time was associated with non-compliance. CONCLUSIONS: Demographic and psychological factors have an influence on adherence to antiretroviral treatment.

[Clinical status, adherence to HAART and quality of life in HIV-infected patients receiving antiretroviral treatment]. / Estado clínico, adherencia al TARGA y calidad de vida en pacientes con infección por el VIH tratados con antirretrovirales.

INTRODUCTION: Quality of life is one of the most frequently used subjective measures in chronic health problems. The aim of this study is to analyze the association between clinical and therapeutic parameters, and 11 quality of life domains in HIV-infected patients. METHODS: A cross-sectional survey of 320 patients on antiretroviral treatment was conducted in four Andalusian hospitals (Spain). A semi-structured questionnaire was administered by health care professionals. Health-related quality of life was assessed with the MOS-HIV questionnaire, an instrument designed specifically for HIV-infected patients. RESULTS: Almost three-quarters of the population were men (73.4%); 35.6% had developed aids, and 88.1% were considered adherent to treatment. Patients with greater viral load presented lower quality of life scores for all the domains, except cognitive functioning. Patients who had developed aids showed poorer quality of life for 10 of the 11 domains. Patients with adequate adherence to antiretroviral treatment showed better quality of life for 10 domains. No statistically significant differences in the domain scores except for quality of life were found between patients with a treatment regimen including protease inhibitors and those without. CONCLUSION: The patient's clinical status and adherence affect not only survival, but also quality of life.

Epidemiological, clinical, and prognostic differences between the diseases caused by Mycobacterium kansasii and Mycobacterium tuberculosis in patients infected with human immunodeficiency virus: a multicenter study.

A multicenter, comparative study was performed to determine the epidemiological, clinical, and prognostic differences between the diseases caused by Mycobacterium tuberculosis and Mycobacterium kansasii in human immunodeficiency virus (HIV)-infected patients. From 1 January 1995 through 31 December 1999, 25 HIV-infected patients received diagnoses of M. kansasii infection, and another 75 were selected as control subjects from among patients who had M. tuberculosis infection. Variables associated with M. tuberculosis disease in the multivariate analysis were previous intravenous drug use (odds ratio [OR], 8; 95% confidence interval [CI], 1.5-41.4) and interstitial radiologic pattern (OR, 12.7; 95% CI, 1.7-94.3). Variables associated with M. kansasii were previous diagnosis of acquired immunodeficiency syndrome (OR, 15.8; 95% CI, 4.2-59.6) and concomitant opportunistic infections (OR, 14.2; 95% CI, 2-105.7). Clinical and radiologic features were similar for both groups, but epidemiological characteristics and prognosis were different. M. kansasii disease was associated more closely with level of immunosuppression and progression of HIV infection than was disease caused by M. tuberculosis.