[Lipid profile in untreated HIV positive patients. HIV infection: cardiovascular risk factor?]. / Perfil lipídico en pacientes VIH (+) no tratados. Infección VIH: ¿factor de riesgo cardiovascular?

INTRODUCTION: Some cases of HIV+ patients with unexplained vascular disease have been reported and many studies are being performed to determine whether HIV infected individuals have an increased cardio-vascular risk (CVR). We propose: to describe lipid profile of untreated HIV+ patients and to compare it with the HIV- and to assess whether any of the lipid abnormalities influence in CVR estimation. MATERIAL AND METHODS: 407 homosexual males: 251 untreated HIV+ and 156 HIV-. Biochemistry parameters: Total cholesterol (CHOL), HDL-cholesterol (HDL), VLDL-cholesterol, LDL-cholesterol (LDL), triglycerides (TG), apolipoproteins A1 and B (ApoA1 y ApoB) and lipoprotein A. Atherogenic rates: CHOL/HDL, LDL/HDL and log (TG/HDL). HIV+ patients were classified into three groups according to CD4 lymphocytes number. RESULTS: HIV+ patients had lower CHOL, HDL, and ApoA1 and higher CVR rates. These differences showed also between each HIV+ group according to CD4 number and control group HIV-. 76% of the HIV+ patients showed low levels of HDL (less than 40 mg/dL) as compared with 31% of HIV- subjects. CONCLUSION: Untreated HIV+ patients' lipid profile is different from the HIV- subjects; one. There are decreases in HDL and ApoA1 from the beginning of the infection that persis along all the CD4 levels. HDL decrease in HIV infection multiplies global CVR in HIV infected individuals, independently of other risk factors.

[Tuberculosis epidemiological study in a third level hospital during 2001]. / Estudio epidemiológico de la tuberculosis en un hospital de tercer nivel en el año 2001.

OBJECTIVES: Estimate the incidence and epidemiological and clinical characteristics of Tuberculosis (TB), analyzing the influence of factors such as: HIV infection, immigration, chronic diseases and styles of life. MATERIAL AND METHODS: Retrospective study of patients who have diagnosed of active TB (microbiological results positive) and latent tuberculosis (Mantoux positive) during the year 2001 in the Gregorio Marañon Hospital. The variables include epidemiological, microbiological, clinical and therapeutic features. RESULTS: We registered 78 patients with TB at hospital, with estimated incidence in health area of 11, 14 cases per 100,000 habitants. The mean age of were 41.98 years; with 43.6% HIV infected patients and 9% immigrants. The sputum was the sample most used for the microbiological diagnosis, we detected resistance in 30% of samples analyzed. The HIV infected patients had more frequent TB from reactivation (p=0,016). The primary site of disease was pulmonary (78%). One pulmonary infiltrate was more frequent in the thoracic X-ray. The 56% of our HIV infected patients had normal thoracic X-ray (p <0,05). The treatment more common was with four drugs and the 75% of our patients fulfilled the treatment; the HIV infected patients leaves the treatment more frequent. The global mortality was 9%. CONCLUSIONS: Actually, in Madrid, the persons with HIV infection, injection drug abuse, immigration and elders in residential home were higher risk of infection for TB. For strict control of disease is need early diagnosis and supervision of treatment .

[The usefulness and limitations of adenosine deaminase in the diagnosis of tubercular pleurisy. A meta-analytical study]. / Utilidad y limitaciones de la adenosina desaminasa en el diagnóstico de la pleuresía tuberculosa. Estudio metaanalítico.

To assess the yield of adenosine deaminase (ADA) measurement in the diagnosis of tuberculous pleuritis and to afford parameters applicable to different populations and risk groups, a meta-analysis was performed in this study. National and anglo-saxon studies included in the Index Medicus from 1980 to march of 1990 were reviewed. The estimated incidence of tuberculous pleuritis in our medium was about 0.18 (confidence intervals for 95%-95% CI: 15-0.21). The diagnostic yield of ADA was as follows: sensitivity of 0.99 (95% CI: 0.98-0.99) and specificity of 0.93 (95% CI: 0.91-0.94). The quotients of probability (parameters that measure the predictive values of the tests at any given prevalence) were 14.31 and 0.004 for the positive and negative tests, respectively. In or medium the positive and negative predictive values were 0.74 (95% CI: 0.68-0.81) and 0.99 (95% CI: 0.98-0.99), respectively. An ADA value below the discriminative level nearly rules out the existence of tuberculous pleuritis, whereas at the contrary, and ADA value above the discriminative point offers a limited information about the etiology of the pleural effusion.

[Epidemiological and clinical study of patients diagnosed with tuberculosis in the northeastern area of Madrid]. / Estudio epidemiológico y clínico de los pacientes diagnosticados de tuberculosis en el área noroeste de Madrid.

OBJECTIVE: Estimate the incidence and the epidemiological and clinical characteristics of patients diagnosed with tuberculosis in a county hospital located in the north western area of the Autonomous Region of Madrid, to determine if there has been an increase due to immigration. MATERIAL AND METHODS: Tuberculosis cases from January, 1996 to June, 2001 were analysed, researched through the Microbiology and Pathologic Anatomy Laboratory, fetching information such as demographics, clinical studies and disease diagnostics from the different medical histories. RESULTS: A total of 66 tuberculosis cases were registered, ten of them among immigrants, with an incidence of 13/100,000 inhabitants in 1996, decreasing to a 7/100,000 incidence in 2000. The age average is 34 with double the incidence in males (31/100,000) than females (17/100,000). The main risk factor is alcoholism with 11 cases (16.7%). The most commonly used diagnostic tests were the thorax radiography (61/66, 92%) with 57 (93.4%) positive identifications, culture of esputo (47/66, 71%) with 32 (68%) positive ids, and the Mantoux test (28, 42%) with 20 (71.4%) positive ids. The location of the illness is mainly pleuro-pulmonar in 50 cases (75%). There were almost no atypical mycobacterium found (5 cases). Overall, response to treatment with 3 drugs (isoniacide, rifampicine, piracinamide) was good in 88% of patients, with the average treatment lasting 6.8 months (ED: 2.8). CONCLUSION: The incidence of tuberculosis in the north western area of Autonomous Community of Madrid is below that of the rest of our Community. It dipped in 1997 and has been stable around 9/100,000 inhabitants until 2000, even with the effect of immigration.

[Alterations of fibrinolysis in stroke]. / Alteraciones de la fibrinolisis en los ACVA.

The fibrinolytic system has an important role as a controller of the coagulation, since plasmin digests and dissolves the fibrin clot. In this way, they have described many alterations in this system that are responsible of the thromboembolic disease, moreover stroke. This study tries to show the incidence of these alterations in a group of patients suffering from stroke, and the difference of this incidence between men and women. We obtained that the fibrinogen, tissue plasminogen activator (tPA) and plasminogen activator inhibitor (PAI-1) levels are significantly increased (p < 0.01) in the group of patients, and in the same way, there are also differences (p < 0.01) between men and women, so in the control group as in the patients group; these differences should mean that women have a major risk for suffering an stroke, but it doesn't fits the fact that stroke is more frequent in men and that they are younger when they suffer from this disease.

[Maxillary sinus lymphoma associated with HIV infection]. / Linfoma de seno maxilar asociado a infección VIH.

We present the case of a patient with positive antibodies against the human immunodeficiency virus, erroneously diagnosed, on the basis of conventional radiology and clinical signs, as right maxillary sinusitis. CT showed a tumoral mass at the maxillary sinus, with histology of highly malignant Non-Hodgkin's Lymphoma (NHL). The chemotherapy (CHOP) resulted in clinical remission, but the appearance of acute myelodepression forced the staggering of cycles, resulting in recurrency of the disease. The addition of G-CSF allowed to continue chemotherapy at full doses, again with positive responses. The lymphoma located at the maxillary sinus is extremely rare in patients with AIDS. Chemotherapy is complicated by myelodepression and the frequent development of opportunistic infections. The use of stimulant factors of the hematopoietic growth facilitates the management of AIDS-associated neoplasias.

[HIV infection at the Central Military Hospital of Madrid]. / La infección por VIH en el Hospital Militar Central de Madrid.

UNLABELLED: We describe the infection by HIV observed in the scope of the Military Hospital and we evaluate the clinical usefulness of the current classification systems. We have retrospectively studied (1986-1993) 80 confirmed cases of infection by HIV: 21 women and 59 men (age range: 17-65 years). Quarterly clinico-biological controls. Initial and final classification according to CDC 87/93 systems. STATISTICAL ANALYSIS: RSIGMA. We have detected in 26% of the patients heterosexual contagion; in 55%, toxicomania and in 17%, homosexuality; 39% had less than 200 CD4/microL upon admission. During the follow-up, 35 patients fulfilled AIDS criteria (17% due to tuberculosis); 17 died (21%) and 30 gave up (37%). CONCLUSIONS: HIV infection is less frequent in the military sociofamiliar environment, with lower incidence of tuberculosis. There is a greater proportion of women, heterosexual transmission and asymptomatic patients. CDC-93 classification is the system best adapted to the natural history of the HIV infection.

[Peritoneal mesothelioma: long-course ascites as the only clinical manifestation]. / Mesotelioma peritoneal: ascitis de larga evolución como única manifestación clínca.

The mesothelioma is a rare tumor, especially in its peritoneal location (20%). Most of these cases are related to an exposition to asbestos long time age. We present a patient with long-evolution ascites and without any other clinical manifestations. The study of the ascitic fluid, the imaging techniques and the peritoneoscopy did not allow the diagnosis in the first place. Only after one year of follow-up and when the patient recalled, in a directed interrogation, her occupational contact with asbestos thirty years age, the diagnosis could be established.

[Adenosine deaminase in pleural effusions. Its usefulness in the diagnosis of tuberculous pleurisy]. / Adenosina desaminasa (ADA) en los derrames pleurales. Su utilidad en el diagnóstico de la pleuresia tuberculosa.

The activity of adenosine deaminase was determined in 79 pleural effusions in order to evaluate the utility and reliability in diagnosing tuberculous effusions. The effusions were grouped by the etiology: 26 were tuberculous (group I); 22 were neoplastic (group II); 11 were pneumonic (group III); 10 were non-infections exudates of different causes (group IV); and 10 transudates (group V). Group I presented the higher median value of AD (MED = 81.92; DE: 29.02) the difference being statistically significant (p less than 0.0001) compared with the results of the other groups. We found 2 cases of pleural tuberculosis histologically demonstrated with AD levels under the amount of 40 U/L. In our experience, AD determination had a sensitivity of 92% and specificity of 94%; with a predictive value of 89% and a negative predictive value of 96%, this being considered useful but non specific of tuberculosis.

[Adenosine deaminase (ADA) and beta 2-microglobulin (beta 2M) as discriminating serum markers of progression to AIDS]. / Adenosina desaminasa (ADA) y beta 2-microglobulina (beta 2 M) como marcadores séricos discriminantes de progresión al SIDA.

BACKGROUND: To establish the discriminatory value of ADA and beta 2M serum levels as markers of AIDS progression. METHODS: We have followed quarterly during two years a cohort of 24 patients with HIV infection; 103 clinical and laboratory evaluations were done (CDC/93 classification). In each of those blood samples we determined ADA, beta 2M, IgG, IgA, IgM, and CD4+ and CD8+ lymphocytes. RESULTS: 26 evaluations belong to cases that kept stable in the clinic category A or B, CDC/93, ("stables": ADA = 19.05 +/- 10.79 U/L; beta 2M = 2.95 +/- 1.1 mg/L); the remaining 77 evaluations are from patients who clinical progressed to AIDS ("progressors": ADA = 32.03 +/- 13.2 U/L; beta 2M = 4.74 +/- 1.94 mg/L). When we compared statistically (RSIGMA software) the ADA and beta 2M means of both groups (Student t) and the means of all the variables in a block (multivariate analysis: Hotelling T2), very significant differences were appreciated (p < 0.001). CONCLUSIONS: ADA and beta 2M are significantly increased in serum of HIV infected patients who clinical progress to AIDS. ADA and beta 2M can be used as serum markers of AIDS progression with a mistaken classification probability in the discriminatory analysis of 0.25; this probability decreases to 0.06 when immunoglobulins and lymphocytes subpopulations are evaluated too.

[Antiphospholipid antibodies in megakaryocytic thrombopenias]. / Anticuerpos antifosfolípidos en las trombopenias megacariocíticas.

We investigated the prevalence of antiphospholipid antibodies (APA) in megakaryocytic thrombopenias in order to establish their clinical significance and prognostic value. We studied 82 thrombopenic patients: 38 women and 44 men (age: 17-91 years). We assessed circulating lupus antibody (LA) through thromboplastin inhibition test (TIT), anticardiolipin antibodies (ACL) through ELISA and antiplatelet antibodies through flow cytometer. We conducted a statistical study RSIGMA, comparing patients with ACL + against ACL-. We found ACL positive in 21%, LA in 33% and antiplatelet antibodies in 42%. We observed a direct correlation (p < 0.05) between ACL and LA and between ACL and anticore antibodies, but not between ACL and antiplatelet antibodies. There was also a significant correlation between ACL and abortion, thrombosis and bleeding in thrombopenic patients. We conclude that APAs are present in 39% of the megakaryocytic thrombopenias and that they are not correlated with antiplatelet antibodies. Positivity of APA in thrombopenic patients is associated to poor prognosis and long term follow-up.

[Differences in laboratory parameters in clinical categories (CDC/93) of HIV infection]. / Diferencias en parámetros de laboratorio entre las categorías clínicas (CDC/93) de la infección por VIH.

OBJECTIVE: To establish the difference between the evolutive clinical categories (CDC/93) of the HIV infection, on the basis of diverse laboratory parameters. MATERIAL AND METHOD: 332 samples of blood, from 118 patients with HIV infection revised every three months from 1986, were studied. Determinations: haematologic, biochemical and immunologic study. Classification in each review by CDC/93 system. Statistical analysis (R-SIGMA) comparing by ANOVA and NEWMANN-KEULS the averages of the laboratory variables in the clinics categories ("A", "B" and "C"). RESULTS: There are very significant laboratory differences (p < 0.01) between the asymptomatic patients ("A") and the AIDS cases ("C"), with important decrease of hemoglobin, platelets, leukocytes, albumin, CD4+ and CD8+ T cells in the "C" category. On the contrary there is a marked increase of erythrocyte sedimentation, triglycerides, immunoglobulin A and beta 2-microglobulin in those patients with AIDS. CONCLUSION: AIDS patients present very significant differences in ten laboratory parameters, compared to the asymptomatic HIV infected patients. The follow up of these parameters may have prognostic value of AIDS evolution and be useful for the therapeutic decision making.

[Discriminative value for AIDS case of erythrocyte sedimentation rate, immunoglobulins IgA and IgM, and beta 2-microglobulin in combination with the CD4+ lymphocyte count]. / Valor discriminante para caso de sida de la velocidad de sedimentación globular (VSG), inmunoglobulinas (IgA e IgM) y beta 2-microglobulina (beta 2M) en combinación con el recuento de linfocitos CD4+.

OBJECTIVE: To establish the probability to discriminate the evolution to "AIDS case" in relation to the common laboratory parametres in the follow-up of the HIV infection. MATERIAL AND METHODS: We have studied a cohort of 118 patients (1986-95) with HIV infection, 14 of them (12%) had clinical criteria for AIDS (CDC/93) during the follow-up. Clinical evaluations and CD4+ and CD8+ lymphocytes, beta 2M, IgG, IgA, IgM and E.S.R determinations were done. Multivariate analysis (RSIGMA) was done. with the initial laboratory values, according to the clinical diagnostic (AIDS and NO AIDS) done during the follow-up. RESULTS: By multiple logistic regression those laboratory variables with more predictor value for "AIDS CASE" were selected. With the initial value of these variables (E.S.R., beta 2M, IgA, IgM and CD4+ lymphocytes) and the clinical diagnostic of AIDS done during the follow-up, we did the linear discriminatory analysis between two groups (AIDS, NO AIDS) obtaining generalized distance between both groups of 3,4609 and a probability of classification error of 4%. A very significant difference (p < 0.001) was obtaining when we compare the variables' mean of each of the clinical groups. CONCLUSION: In the HIV infection the values of ESR, beta 2M, IgA and IgM in combination with the absolute value of the CD4+ lymphocytes allows to discriminate those patients who will develop AIDS with a probability of classifications error of 4%. This has clinical interest in absence of viral load and helps to take therapeutical decisions.

[Megestrol in the treatment of AIDS associated cachexia. Evaluation by bioelectric impedance analysis of body composition]. / Megestrol en el tratamiento de la caquexia del SIDA. Valoración mediante análisis de composición corporal por impedancia bioeléctrica.

OBJECTIVE: To value the effects of megestrol acetate wer the weight and the body composition (fat, lean and body water) in patients with AIDS associated cachexia, by bioelectric impedance analysis. SUBJECTS: 25 patients between 23 and 57 years of age, with confirmed HIV infection and prior weight lost of 7.96 +/- 4.6 kg in relation to their habitual weight in the previous months. All the patients were under antiretroviral therapy. METHOD: Basal determination, before the beginning of the antianorexic treatment and at the end of it, using bioelectric impedance analysis by Maltron BF 905 analyzer, calculating fat, lean and total body water in relation to weight, height, age and sex. Oral administration of 320 mg/day megestrol acetate for three consecutive months. Statistical comparation (RSIGMA and SPSS) by paired t-test of the mean weight, body mass index, fat, lean and total body water. RESULTS: During the three months treatment the mean basal body weight of the patients increased 3.54 Kg (p < 0.001) at the expense of an increase of 2.24 kg in the total body lean (p < 0.01), while the increment of the body fat (1.2 kg) was not statistically significant. The total body water increased 1.48 L (p < 0.001) and the body mass index in 1.22 kg/m2 (p < 0.001). CONCLUSION: Treatment with megestrol acetate results in a substained and very significant increase of the weight and body mass index in patients with AIDS related cachexia. This increment in weight is at the expense of body lean.

[Ankle-brachial index testing is particularly indicated in patients with metabolic syndrome but without known arterial disease]. / La medida del índice tobillo-brazo: particularmente indicada en pacientes con síndrome metabólico sin enfermedad arterial conocida.

INTRODUCTION: The objective was to investigate the prevalence of metabolic syndrome (MetS), its cardiovascular disease (CVD) risk and its association with peripheral arterial disease, defined by a low ankle-brachial index (ABI) (< 0.90), in primary prevention. MATERIAL AND METHODS: Cross-sectional study performed in the primary care general population, aged 50-79 years. CVD risk and ABI were measured in persons without known arterial disease with MetS and in a control group. MetS was defined by Adult Treatment Panel III. CVD risk was estimated using the Systematic Coronary Risk Evaluation (SCORE). RESULTS: A total of 581 subjects were recruited. The prevalence of the metabolic syndrome was 30.8% (95% confidence interval [CI], 27.0-34.5). For the CVD risk and ABI studies 217 individuals were included (138 with MetS and 49 with diabetes). Average CVD risk was high (5%) on patients with MetS and twice as much as those without MetS. ABI was low (< 0.90) on 15 subjects [6.9% (95% CI), 3.5-10.2], with higher frequency in the MetS group: 14 patients (10.1%) vs 1 patient (1.3%). The frequency of low ABI in patients with and without diabetes was 18.3% and 3.6% respectively. Low ABI was associated to MetS, diabetes, inactivity, high risk of SCORE and less alcohol habit. In the multivariate analysis, the odds ratio for the association MetS/low ABI was 14.7 (95% CI, 1.7-123.6). CONCLUSION: MetS is related to asymptomatic peripheral arterial disease. Thus, the measure of ABI in those patients with this syndrome is recommended.

[Nutrition alterations in internal medicine. Body composition analysis with bioelectrical impedance]. / Alteraciones de la nutrición en Medicina Interna. Análisis de la composición corporal por impedancia bioeléctrica.

OBJECTIVES: To determine the prevalence of malnutrition in patients in Internal Medicine. To describe the changes of corporal composition depending on body mass index (BMI). To evaluate validity of the different screening tools for the estimation of body composition. MATERIAL AND METHODS: Prospective observational cross-sectional study of the prevalence of malnutrition in 300 patients (sample 1); these were chosen 136 patients (sample 2), classifying in four groups: BMI < 20: 30 patients; BMI = 20-25: 46 patients; BMI = 25-30: 30 patients, and BMI > 30: 30 patients. In the patients of sample 2, we carried out a protocol of nutritional evaluation with anthropometry, laboratory and bioelectrical impedance analysis. RESULTS: The prevalence of desnutrition was 9.3% and the obesity was 22.3%. In undernourished patients, the measure of body compartments with bioelectrical impedance, expressed in percentage of body weight, were: fat mass 20.5%, fat-free mass 79.4% and total body mater 58.3%. The body composition in obeses was: fat mass 40.1%, fat-free mass 60.6% and total body water 44.3%. The patients with normal BMI, the meta index (impedance at 50 kHz/BMI) was 25.9 +/- 5.21; in undernourished the index was higher (36.7) and obeses lower (15.5). The meta index (30-20) estimates desnutrition-obesity with high sensibility and specificity. The prevalence of desnutrition varies from 6% to 69% and obesity from 23% to 74%, using different methods and criterions for the estimation of body composition. CONCLUSIONS: In Internal Medicine, the overweight (BMI > 25) is the most prevalent nutritional alteration. The bioelectrical impedance analysis helps for estimation of body composition and meta index is a very useful indicator of malnutrition (desnutrition-obesity).

[Multidisciplinary management of elderly patients with heart failure in a day hospital]. / Manejo de la insuficiencia cardíaca en pacientes ancianos a través de la implantación de un hospital de día multidisciplinar.

INTRODUCTION: To evaluate the utility of a day hospital managed by a multidisciplinary heart failure (HF) team composed of nurses, geriatricians and internal physicians in the reduction of hospital readmission of elderly patients with HF who are not selected by their left ventricular ejection fraction (LVEF). MATERIAL AND METHODS: 182 patients with mean age of 76 years and decompensated HP who required admission in internal medicine and geriatric wards were included. A total of 51 patients were followed up in a day hospital, where education, phone access, drug titration and use of parenteral diuretics were performed. Readmission due to HF at 3 months post-hospitalization was measured. A bivariate analysis was performed in both groups using parametrics test (p < 0.05) and a Kaplan Meier analysis using log rank. RESULTS: A total of 61% were women. Mean NYHA class was 2.75 +/- 0.44. LVEF < 45% was found in 40%. Prescription rate of beta blockers was significantly higher in the intervention group (93% vs 24%; p < 0.001) as well as ACE-inhibitors and ARB prescription rates (96% vs 72%, p = 0.002). Readmission rate due to HF in the first 90 days after discharge was lower in the intervention group (11% vs 28%; p = 0.020). HF admission free time was longer for these patient than those managed with conventional care (85.12 days versus 76; log rank; p = 0.026). DISCUSSION: Multidisciplinary intervention carried out by generalist physicians and HF nurses in a day hospital is useful to reduce HF admission in elderly patients not selected by their LVEF.