RESUMEN
OBJECTIVES: Early initiation of antiretroviral therapy (ART) during acute HIV infection is associated with favourable clinical and epidemiological outcomes. Barriers to prompt treatment initiation limit the benefits of universal access to ART in Mexico. We sought to create an algorithm for the immediate detection and treatment of patients with acute HIV infection. METHODS: A nationwide cohort of patients with acute HIV infection was created in 2015. In order to identify cases and treat them promptly at our centre, an interdisciplinary group coordinated through an instant-messaging tool using smart phones was established. When a probable case was detected, a discussion was initiated to confirm the diagnosis and facilitate the administrative processes to initiate ART as soon as possible. We compared time to ART initiation with that in a comparison group of patients with chronic HIV infection enrolled during the same period (May 2015 to February 2017) through routine care, using survival analysis estimators and log-rank tests. RESULTS: We recruited 29 patients with acute HIV infection. The median time to ART initiation was 2 days in these patients, in contrast to 21 days for patients with chronic infection. There were no significant differences in the percentages of patients engaged in care, on treatment or virologically suppressed at 1 year of follow-up. CONCLUSIONS: Implementing immediate ART initiation programmes is feasible in Mexico, in spite of the substantial administrative barriers that exist in the country. More extensive replication of this model in other centres and in patients with chronic infection is warranted to evaluate its effect on the continuum of care.
Asunto(s)
Fármacos Anti-VIH/administración & dosificación , Infecciones por VIH/tratamiento farmacológico , Adulto , Algoritmos , Fármacos Anti-VIH/uso terapéutico , Estudios de Cohortes , Femenino , Humanos , Masculino , México , Persona de Mediana Edad , Relaciones Médico-Paciente , Teléfono Inteligente , Análisis de Supervivencia , Centros de Atención Terciaria , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
We aimed to quantify the proportion of people receiving care for HIV-infection that are 50 years or older (older HIV patients) in Latin America and the Caribbean between 2000 and 2015 and to estimate the contribution to the growth of this population of people enrolled before (<50yo) and after 50 years old (yo) (⩾50yo). We used a series of repeated, cross-sectional measurements over time in the Caribbean, Central and South American network (CCASAnet) cohort. We estimated the percentage of patients retained in care each year that were older HIV patients. For every calendar year, we divided patients into two groups: those who enrolled before age 50 and after age 50. We used logistic regression models to estimate the change in the proportion of older HIV patients between 2000 and 2015. The percentage of CCASAnet HIV patients over 50 years had a threefold increase (8% to 24%) between 2000 and 2015. Most of the growth of this population can be explained by the increasing proportion of people that enrolled before 50 years and aged in care. These changes will impact needs of care for people living with HIV, due to multiple comorbidities and high risk of disability associated with aging.
Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Adulto , Distribución por Edad , Región del Caribe , Demografía/tendencias , Femenino , Humanos , América Latina , Masculino , Persona de Mediana EdadRESUMEN
PURPOSE: We investigated the effects of maraviroc, the first approved CC-chemokine receptor 5 (CCR5) antagonist, on blood lipids in a post hoc analysis of the phase 3 MERIT study in treatment-naïve patients. METHODS: Patients received maraviroc 300 mg twice daily (n = 360) or efavirenz 600 mg once daily (n = 361), both in combination with zidovudine/lamivudine, for up to 96 weeks. Baseline and on- treatment lipid profiles were analyzed according to National Cholesterol Education Program (NCEP) thresholds. RESULTS: Baseline characteristics and lipid profiles were comparable between groups. Among patients with total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-c) below NCEP treatment thresholds at baseline, significantly more efavirenz- than maraviroc-treated patients exceeded those thresholds at 96 weeks (TC: 35% [74/209] vs 11% [20/188], P < .0001; LDL-c: 23% [47/197] vs 8% [15/183], P < .0001). Among patients exceeding NCEP thresholds at baseline, significantly more efavirenz- than maraviroc-treated patients exceeded the thresholds at 96 weeks (TC: 83% [24/29] vs 50% [17/34], P = .0084; LDL-c: 86% [19/22] vs 55% [16/29], P = .0314). Of those with baseline high- density lipoprotein cholesterol (HDL-c) < 40 mg/dL, 43% (56/130) of maravirocand 62% (86/139) of efavirenz-treated patients achieved HDL-c≥40 mg/dL at 96 weeks (P = .0020). CONCLUSIONS: Maraviroc was not associated with elevations in TC, LDL-c, or triglycerides and showed beneficial effects on lipid profiles of dyslipidemic patients.
Asunto(s)
Fármacos Anti-VIH/administración & dosificación , Benzoxazinas/administración & dosificación , Ciclohexanos/administración & dosificación , Dislipidemias/tratamiento farmacológico , Dislipidemias/virología , Infecciones por VIH/sangre , VIH-1/aislamiento & purificación , Triazoles/administración & dosificación , Adulto , Alquinos , Antagonistas de los Receptores CCR5 , Distribución de Chi-Cuadrado , Colesterol/sangre , Ciclopropanos , Dislipidemias/sangre , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/virología , Humanos , Metabolismo de los Lípidos/efectos de los fármacos , Masculino , Maraviroc , Receptores CCR5/metabolismo , Triglicéridos/sangreRESUMEN
Blood monocytes from patients with active pulmonary tuberculosis and age-matched healthy purified protein derivative-reactive donors were infected with human immunodeficiency virus type 1 (HIV-1)JR-FL in vitro to assess their susceptibility to productive infection by HIV-1. HIV-1 p24 levels (enzyme-linked immunosorbent assay) in supernatants of infected cells from patients with tuberculosis, albeit variable, were significantly higher at days 10-20 of culture; the maximum levels of p24 antigen were greater in supernatants of HIV-1-infected monocytes from patients than maximum levels for controls (p < 0.05). The maximum increment in p24 levels for patients also exceeded that for controls (p < 0.05). Entry of HIV-1 and/or initiation of reverse transcription, measured by polymerase chain reaction using HIV-1 R/U5 primer pairs, was variable and low in infected monocytes from both patients and controls, and did not correlate with HIV-1 p24 levels. The frequency of infected cells as assessed by endpoint dilution viral cultures was similar for both groups. Therefore, blood monocytes from patients with active tuberculosis can develop a highly productive infection with HIV-1 that does not appear to be due to enhanced HIV entry or higher frequency of infected cells. The enhanced susceptibility may result directly from activation of monocytes by exposure to Mycobacterium tuberculosis and its products in situ.
Asunto(s)
VIH-1/fisiología , Monocitos/microbiología , Tuberculosis Pulmonar/inmunología , Adulto , Secuencia de Bases , Células Cultivadas , ADN de Cadena Simple , ADN Viral/biosíntesis , Susceptibilidad a Enfermedades , Humanos , Persona de Mediana Edad , Datos de Secuencia Molecular , Monocitos/metabolismo , Tuberculosis Pulmonar/sangreRESUMEN
BACKGROUND: The function reported after arm transplantation is deemed beneficial relative to the marked disability that upper arm amputation causes. OBJECTIVE: We report a 51-year-old man with a Disabilities of the Arm, Shoulder and Hand (DASH) score of 75.83 who underwent bilateral arm transplantation in October 2015. PROCEDURE: The right arm was transplanted at the glenohumeral joint level, including transplantation of the humeral head, joint capsule, and rotator cuff ligaments and tendons. Additionally, neurorrhaphies were performed at the origin of the terminal branches of the brachial plexus, including the axillary and musculocutaneous nerves. Therefore, this was considered a total arm transplantation. The left arm was transplanted at the transhumeral level, with complete transplantation of the biceps and triceps brachii, and terminolateral neurorrhaphy of the donor musculocutaneous nerve to the receptor radial nerve. A maintenance triple immunosuppression scheme was administered, with tacrolimus levels kept at 10 ng/mL. RESULTS: At 18 months post-transplantation, the intrinsic musculature in the left hand showed electrical registry, DASH score was 67.5, Carroll test score was 28 in both extremities, Hand Transplant Score System was 67.5 in the right extremity and 77.5 in the left extremity, and Short Form-36 score was 96.1. The patient was healthy, with restored body integrity. He could lift medium-sized weightless objects, eat and go to the bathroom by himself, drink liquids with bimanual grasp, swim, dress almost independently, and drive. CONCLUSION: The functional evolution of the patient was similar to previously reported transplanted arms, even though the right arm transplant involved the glenohumeral joint and axillary and musculocutaneous nerve repair.
Asunto(s)
Brazo/trasplante , Evaluación de la Discapacidad , Músculo Esquelético/trasplante , Actividades Cotidianas , Amputación Quirúrgica/métodos , Brazo/inervación , Plexo Braquial/cirugía , Humanos , Masculino , Persona de Mediana Edad , Músculo Esquelético/fisiología , Trasplante de Órganos/métodos , Periodo Posoperatorio , Recuperación de la Función , Hombro/fisiopatología , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the efficacy of thalidomide in treating wasting syndrome in patients with advanced HIV disease, and to assess the effects of thalidomide on circulating CD4+ T cells, and on HIV viral burden in peripheral blood mononuclear cells (PBMC). DESIGN: Randomized, double-blind placebo-controlled clinical trial. SETTING: Public tertiary care hospital in Mexico City. PATIENTS: Twenty-eight adults with advanced HIV disease being treated with antiretroviral therapy, and who had received antiretrovirals for at least 6 months, who did not have an active opportunistic infection, and who had 10% weight loss in the previous 6 months. INTERVENTIONS: Patients received thalidomide (100 mg by mouth, four times daily) or a matching placebo for the duration of the study (12 weeks). MAIN OUTCOME MEASURES: The main clinical endpoint for efficacy of thalidomide was weight gain or no progression of wasting. Secondary endpoints were Karnofsky performance status, CD4+ cell counts, and HIV viral burden in PBMC. RESULTS: Both groups were comparable in their baseline status. Therapeutic failure occurred in 10 out of 14 patients from the placebo group and in three out of 14 from the thalidomide group (P = 0.021). Weight gain occurred in one patient on placebo and in eight given thalidomide. The Karnofsky index was significantly higher by the end of the study in the thalidomide group (P = 0.003). Mild and transient somnolence and erythematous macular skin lesions were significantly more common in the thalidomide group. CD4+ T cell counts and HIV viral burden in PBMC did not change in either group. CONCLUSIONS: Results suggest that thalidomide not only impeded but also reverted the wasting syndrome, preserving the Karnofsky index in patients with advanced HIV disease. Thalidomide, at the dosage used in this study, had no effect on peripheral CD4+ T cells nor on HIV viral burden in PBMC.
Asunto(s)
Infecciones por VIH/tratamiento farmacológico , Talidomida/uso terapéutico , Síndrome Debilitante/tratamiento farmacológico , Adulto , Recuento de Linfocito CD4 , Células Cultivadas , Método Doble Ciego , Femenino , Estudios de Seguimiento , Infecciones por VIH/complicaciones , Infecciones por VIH/inmunología , Infecciones por VIH/virología , Humanos , Estado de Ejecución de Karnofsky , Leucocitos Mononucleares/citología , Leucocitos Mononucleares/inmunología , Leucocitos Mononucleares/virología , Masculino , Talidomida/efectos adversos , Resultado del Tratamiento , Síndrome Debilitante/complicaciones , Síndrome Debilitante/inmunología , Síndrome Debilitante/virología , Pérdida de PesoRESUMEN
We describe a newborn patient with herpes simplex infection localized to the central nervous system. The diagnosis was suspected on clinical grounds and it was corroborated by tissue culture isolation of the virus and by herpes simplex glycoprotein B DNA detection by PCR in cerebrospinal fluid. We describe the clinical manifestations of this patient and we present some considerations regarding pathogenesis, diagnosis, prognosis and treatment of this viral infection in the newborn period.
Asunto(s)
Encefalitis Viral/congénito , Herpes Simple/congénito , Aciclovir/uso terapéutico , Adulto , Antivirales/uso terapéutico , Encefalitis Viral/complicaciones , Encefalitis Viral/diagnóstico , Encefalitis Viral/tratamiento farmacológico , Femenino , Herpes Genital , Herpes Simple/complicaciones , Herpes Simple/diagnóstico , Herpes Simple/tratamiento farmacológico , Herpes Simple/transmisión , Humanos , Recién Nacido , Embarazo , Complicaciones Infecciosas del EmbarazoRESUMEN
We conducted a survey of the prescription of antibiotics among the outpatient clinics of the Instituto Nacional de la Nutrición "Salvador Zubirán", a third level hospital in México City. We made an auditory of the medical record and prescriptions given to every patient treated for an infectious episode, accounting for at least six questions to evaluate the quality of the prescription: 1) if the patient should had received antibiotics; 2) if the antibiotic prescribed was adequate; 3) if the dose was sufficient; 4) if the frequency of administration was correct; 5) if the route of administration was adequate; and 6) if the length of the treatment was sufficient. We validated the concordance among two evaluators and found that it was 89% for the whole questionnaire. In the evaluation we found that the patients should had received antibiotic 94% of the time: the antibiotic selected was a right choice 80% of the time; the dose was adequate 45% of the time; the frequency of administration was adequate 70% of the time; the route of administration was adequate 79% of the time; and the length of treatment was adequate 38% of the time. The worst findings were seen in two of the most important issues of antibiotic prescription which directly affect the appearance of antibiotic resistance.
Asunto(s)
Antibacterianos/administración & dosificación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Utilización de Medicamentos , Femenino , Humanos , Masculino , Errores de Medicación , México , Persona de Mediana Edad , Servicio Ambulatorio en HospitalAsunto(s)
Vacunas contra la Influenza , Gripe Humana/prevención & control , Animales , Anticuerpos Antivirales/inmunología , Variación Antigénica , Antígenos Virales/inmunología , Antivirales/uso terapéutico , Antígenos del Núcleo de la Hepatitis B/inmunología , Humanos , Virus de la Influenza A/inmunología , Virus de la Influenza A/aislamiento & purificación , Gripe Humana/tratamiento farmacológico , Pulmón/virología , Ratones , Fragmentos de Péptidos/inmunología , Proteínas Recombinantes de Fusión/inmunología , Vacunas Atenuadas , Proteínas de la Matriz Viral/inmunologíaAsunto(s)
Enfermedades Óseas Metabólicas/etiología , Granuloma de Células Gigantes/etiología , Hiperparatiroidismo Secundario/complicaciones , Síndromes de Malabsorción/etiología , Esclerodermia Sistémica/complicaciones , Adulto , Calcio/metabolismo , Femenino , Humanos , Húmero/patología , Hipocalcemia/etiología , Síndromes de Malabsorción/metabolismoRESUMEN
Early medical intervention in patients with HIV infection is beneficial even in asymptomatic individuals. Medical care in these patients consists of the use of antiretroviral drugs, drugs to prevent opportunistic infections, vaccines and comprehensive psychosocial support. It is important to determine the stage of the natural history of the disease at any given moment. Besides clinical data, the determination of CD4+ T-lymphocytes is useful to make decisions related to the institution of antiretroviral drugs and preventive therapy for opportunistic infections. Present evidence shows a clear benefit of starting antiretroviral drugs in every patient with AIDS or AIDS related complex and also supports the use of these drugs in early stages of the disease. Preventive therapy against Pneumocystis carinii has to be instituted in every patient with CD4 lymphocyte counts below 200/mm3. Prophylactic therapy may also be necessary to prevent tuberculosis, toxoplasmosis and M. avium. It is likely that future studies will show some benefit with the use of additional preventive strategies for other frequent infections such as Cytomegalovirus and Cryptosporidium.
Asunto(s)
Infecciones por VIH/terapia , VIH-1 , Infecciones Oportunistas Relacionadas con el SIDA/prevención & control , Antivirales/uso terapéutico , Vacunas Bacterianas/inmunología , Infecciones por VIH/diagnóstico , Humanos , Vacunas contra la Influenza/inmunología , Streptococcus pneumoniae/inmunologíaRESUMEN
A group of staphylococcal isolates for which oxacillin MICs were intermediate (1 to 4 micrograms/ml) were studied to establish the role of beta-lactamase in this phenomenon. MICs and MBCs of oxacillin and penicillin with and without clavulanic acid or sulbactam (4 or 16 micrograms/ml, respectively) were determined for 11 Staphylococcus aureus and 2 coagulase-negative Staphylococcus isolates for which oxacillin MICs were 1 to 4 micrograms/ml. The susceptibility studies were done with incubation at 35 and 30 degrees C, and the MICs were read at 24 and 48 h. Of the 13 isolates, 4 became resistant when longer incubation or 30 degrees C incubation was used, and the MICs for 9 remained in the intermediate range. Only three of these strains were susceptible to penicillin, and beta-lactamase was not detected. For 6 of 10 beta-lactamase-positive strains, there was a greater-than-twofold-dilution reduction in oxacillin MICs with the addition of clavulanic acid or sulbactam. Of the four strains that became resistant with incubation at the lower temperature, a clavulanic acid effect was observed in three but only at 35 degrees C. The oxacillin MIC for one of the beta-lactamase-negative strains was also reduced with clavulanic acid; however, this strain was inhibited by 1 microgram of clavulanic acid per ml alone. Bactericidal activity was observed with two or four times the oxacillin MIC in eight strains tested at both temperatures, and the combination with clavulanic acid was bactericidal at higher than four times the MIC in five of the strains at 30 degrees C. Our results suggest that oxacillin intermediate MICs for staphylococcal isolates are due not only to beta-lactamase hyperproduction but also some other unidentified factor. The reduction in oxacillin MIC observed when clavulanic acid was added to one strain was probably due to the intrinsic inhibitory activity of clavulanic acid.
Asunto(s)
Oxacilina/farmacología , Penicilinas/farmacología , Staphylococcus/efectos de los fármacos , beta-Lactamasas/metabolismo , Ácidos Clavulánicos/farmacología , Pruebas de Sensibilidad Microbiana , Resistencia a las Penicilinas , Staphylococcus/metabolismoRESUMEN
Inactivation of penicillin and gentamicin in cultures was achieved by using monoclonal antibodies against these antibiotics. A viridans group streptococcus (penicillin MIC, less than or equal to 0.06 micrograms/ml) and Escherichia coli ATCC 35218 (gentamicin MIC, less than or equal to 1 microgram/ml) were able to grow in broth containing 0.25 micrograms of penicillin per ml and 4 micrograms of gentamicin per ml, respectively, when the specific antibodies were added. This procedure may be useful to increase the yield of bacteria from body fluid specimens that contain antibiotics.
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Antibacterianos/inmunología , Anticuerpos Monoclonales/inmunología , Bacterias/aislamiento & purificación , Antibacterianos/farmacología , Bacterias/efectos de los fármacos , Bacterias/crecimiento & desarrollo , Escherichia coli/efectos de los fármacos , Escherichia coli/crecimiento & desarrollo , Escherichia coli/aislamiento & purificación , Gentamicinas/inmunología , Gentamicinas/farmacología , Penicilina G/inmunología , Penicilina G/farmacología , Streptococcus/efectos de los fármacos , Streptococcus/crecimiento & desarrollo , Streptococcus/aislamiento & purificaciónRESUMEN
The mechanism of uptake of human immunodeficiency virus-1 (HIV-1) into alveolar macrophages (AM), freshly isolated blood monocytes (MN), and cultured MN (CM) was investigated focusing on the role of CD4 and of surfactant-associated protein A (SP-A). By radioimmunoassay which obviated the problems of auto- and nonspecific fluorescence of more differentiated macrophages, each of the macrophage populations studied expressed CD4. Semiquantitative polymerase chain reaction was performed to assess uptake of HIV-1(JR-FL) into cells. OKT4a (directed against CD4) blocked uptake of HIV-1 into CM, AM, and MN by 67 to 100%. OKT4 (directed against another epitope of CD4) had a smaller and less consistent effect (0-90%), and control antibodies showed minimal effects and only at supersaturating concentrations. SP-A had no effect on uptake of HIV-1 into AM. SP-A also had no consistent effect on production of HIV-1(JR-FL) by AM infected in vitro (p24 antigen ELISA). Thus CD4 is the major receptor for HIV-1 in mononuclear phagocytes, including AM, and SP-A does not modulate entry.
Asunto(s)
Antígenos CD4/inmunología , VIH-1/fisiología , Macrófagos Alveolares/virología , Fusión de Membrana/inmunología , Proteolípidos/fisiología , Surfactantes Pulmonares/fisiología , Adulto , Anticuerpos/inmunología , Femenino , Humanos , Masculino , Monocitos/virología , Fagocitos/inmunología , Proteína A Asociada a Surfactante Pulmonar , Proteínas Asociadas a Surfactante PulmonarRESUMEN
The level of human immunodeficiency virus type 1 (HIV-1) in lymphocytes and mononuclear phagocytes (MP) from the blood and pulmonary alveoli from 14 HIV-1-infected subjects during early (asymptomatic) and late (AIDS) stages of disease and the relationship between virus burden in MP and cytokine expression were assessed. Among asymptomatic subjects, HIV-1 was undetectable or low in both blood monocytes and alveolar macrophages (AM). Among subjects with AIDS, there was a significant increase of HIV-1 in AM but not monocytes. The level of HIV-1 in blood lymphocytes was higher than in either monocytes or AM. AM (but not monocytes) expressed increased levels of lipopolysaccharide-stimulated cytokine mRNA (tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6) during both early and late stages of HIV-1 infection regardless of virus load. AM thus may serve as a reservoir for virus in late stages of disease yet contribute to the immunopathogenesis of lung disease in both early and late stages through increased cytokine expression.
Asunto(s)
Citocinas/biosíntesis , Infecciones por VIH/inmunología , VIH-1/inmunología , Macrófagos Alveolares/microbiología , Síndrome de Inmunodeficiencia Adquirida , Adulto , Secuencia de Bases , Northern Blotting , Citocinas/genética , Cartilla de ADN/química , ADN Viral/aislamiento & purificación , Regulación Viral de la Expresión Génica , Gliceraldehído-3-Fosfato Deshidrogenasas/biosíntesis , Infecciones por VIH/metabolismo , Infecciones por VIH/microbiología , Humanos , Interleucina-1/biosíntesis , Interleucina-1/genética , Interleucina-6/biosíntesis , Interleucina-6/genética , Macrófagos Alveolares/metabolismo , Masculino , Datos de Secuencia Molecular , Monocitos/metabolismo , Monocitos/microbiología , Alveolos Pulmonares/patología , ARN Mensajero/biosíntesis , ARN Viral/aislamiento & purificación , Linfocitos T/metabolismo , Linfocitos T/microbiología , Factor de Necrosis Tumoral alfa/biosíntesis , Factor de Necrosis Tumoral alfa/genéticaRESUMEN
A double-blind, randomized, placebo-controlled clinical trial was performed in Mexico City to evaluate the efficacy of thalidomide in treating oral recurrent aphthae in human immunodeficiency virus (HIV)-infected subjects. Sixteen HIV-infected patients with clinical and histological diagnosis of oral recurrent aphthous ulcerations received randomly an 8-week course of either thalidomide or placebo, with an initial oral dosage of 400 mg/d for 1 week, followed by 200 mg/d for 7 weeks. Ten subjects received thalidomide and six received placebo. At 8 weeks, nine subjects (90%) in the thalidomide group had complete healing of their ulcers, compared with two (33.3%) of the six patients in the placebo group (P = .03). There was a significant reduction in largest ulcer diameter in the thalidomide group. Rash was observed in 80% of the thalidomide patients. Although thalidomide demonstrated an unquestionable benefit in treatment of oral ulcers in HIV patients, caution must be taken given the frequent occurrence of side effects.