Nationwide Impact of Centralization, Neoadjuvant Therapy, Minimally Invasive Surgery, and Standardized Pathology Reporting on R0 Resection and Overall Survival in Pancreatoduodenectomy for Pancreatic Cancer.

BACKGROUND: Surgeons aim for R0 resection in patients with pancreatic cancer to improve overall survival. However, it is unclear whether recent changes in pancreatic cancer care such as centralization, increased use of neoadjuvant therapy, minimally invasive surgery, and standardized pathology reporting have influenced R0 resections and whether R0 resection remains associated with overall survival. METHODS: This nationwide retrospective cohort study included consecutive patients after pancreatoduodenectomy (PD) for pancreatic cancer from the Netherlands Cancer Registry and the Dutch Nationwide Pathology Database (2009-2019). R0 resection was defined as > 1 mm tumor clearance at the pancreatic, posterior, and vascular resection margins. Completeness of pathology reporting was scored on the basis of six elements: histological diagnosis, tumor origin, radicality, tumor size, extent of invasion, and lymph node examination. RESULTS: Among 2955 patients after PD for pancreatic cancer, the R0 resection rate was 49%. The R0 resection rate decreased from 68 to 43% (2009-2019, P < 0.001). The extent of resections in high-volume hospitals, minimally invasive surgery, neoadjuvant therapy, and complete pathology reports all significantly increased over time. Only complete pathology reporting was independently associated with lower R0 rates (OR 0.76, 95% CI 0.69-0.83, P < 0.001). Higher hospital volume, neoadjuvant therapy, and minimally invasive surgery were not associated with R0. R0 resection remained independently associated with improved overall survival (HR 0.72, 95% CI 0.66-0.79, P < 0.001), as well as in the 214 patients after neoadjuvant treatment (HR 0.61, 95% CI 0.42-0.87, P = 0.007). CONCLUSIONS: The nationwide rate of R0 resections after PD for pancreatic cancer decreased over time, mostly related to more complete pathology reporting. R0 resection remained associated with overall survival.

Clinical implications of chyle leakage following esophagectomy.

The clinical consequences of chyle leakage following esophagectomy are underexposed. The aim of this study was to investigate the clinical implications of chyle leakage following esophagectomy. This retrospective study of prospectively collected data included patients who underwent transthoracic esophagectomy in 2017-2020. Routinely, the thoracic duct was resected en bloc as part of the mediastinal lymphadenectomy. Chyle leakage was defined as milky drain fluid for which specific treatment was initiated and/or a triglyceride level in drain fluid of ≥1.13 mmol/L, according to the Esophagectomy Complications Consensus Group (ECCG) classification. Primary endpoints were the clinical characteristics of chyle leakage (type, severity and treatment). Secondary endpoints were the impact of chyle leakage on duration of thoracic drainage and hospital stay. Chyle leakage was present in 43/314 patients (14%), of whom 24 (56%) were classified as severity A and 19 (44%) as severity B. All patients were successfully treated with either medium chain triglyceride diet (98%) or total parental nutrition (2%). There were no re-interventions for chyle leakage during initial admission, although one patient needed additional pleural drainage during readmission. Patients with chyle leakage had 3 days longer duration of thoracic drainage (bias corrected accelerated (BCa) 95%CI:0.46-0.76) and 3 days longer hospital stay (BCa 95%CI:0.07-0.36), independently of the presence of other complications. Chyle leakage is a relatively frequent complication following esophagectomy. Postoperative chyle leakage was associated with a significant longer duration of thoracic drainage and hospital admission. Nonsurgical treatment was successful in all patients with chyle leakage.

Feasibility of a sub-3-minute imaging strategy for ungated quiescent interval slice-selective MRA of the extracranial carotid arteries using radial k-space sampling and deep learning-based image processing.

PURPOSE: To develop and test the feasibility of a sub-3-minute imaging strategy for non-contrast evaluation of the extracranial carotid arteries using ungated quiescent interval slice-selective (QISS) MRA, combining single-shot radial sampling with deep neural network-based image processing to optimize image quality. METHODS: The extracranial carotid arteries of 12 human subjects were imaged at 3 T using ungated QISS MRA. In 7 healthy volunteers, the effects of radial and Cartesian k-space sampling, single-shot and multishot image acquisition (1.1-3.3 seconds/slice, 141-423 seconds/volume), and deep learning-based image processing were evaluated using segmental image quality scoring, arterial temporal SNR, arterial-to-background contrast and apparent contrast-to-noise ratio, and structural similarity index. Comparison of deep learning-based image processing was made with block matching and 3D filtering denoising. RESULTS: Compared with Cartesian sampling, radial k-space sampling increased arterial temporal SNR 107% (P < .001) and improved image quality during 1-shot imaging (P < .05). The carotid arteries were depicted with similar image quality on the rapid 1-shot and much lengthier 3-shot radial QISS protocols (P = not significant), which was corroborated in patient studies. Deep learning-based image processing outperformed block matching and 3D filtering denoising in terms of structural similarity index (P < .001). Compared with original QISS source images, deep learning image processing provided 24% and 195% increases in arterial-to-background contrast (P < .001) and apparent contrast-to-noise ratio (P < .001), and provided source images that were preferred by radiologists (P < .001). CONCLUSION: Rapid, sub-3-minute evaluation of the extracranial carotid arteries is feasible with ungated single-shot radial QISS, and benefits from the use of deep learning-based image processing to enhance source image quality.

High spatial resolution whole-neck MR angiography using thin-slab stack-of-stars quiescent interval slice-selective acquisition.

PURPOSE: To report a 3D multi-echo thin-slab stack-of-stars (tsSOS) quiescent-interval slice-selective (QISS) strategy for high-resolution magnetic resonance angiography (MRA) of the entire neck in under seven minutes. METHODS: The neck arteries of eight subjects were imaged at 3 Tesla. Multi-echo 3D tsSOS QISS using a FLASH readout was compared with 3D tsSOS FLASH, 2D QISS, 2D TOF, and 3D TOF. A root-mean-square (RMS) combination of echo time images was tested. Evaluation metrics included arterial signal-to-noise ratio (SNR), arterial-to-muscle contrast-to-noise ratio (CNR), and image quality. RESULTS: 3D multi-echo tsSOS QISS using a RMS combination of echo time images increased SNR and CNR by 60% and 63% with respect to the reconstruction obtained with the shortest echo time. 3D tsSOS QISS showed superior CNR with respect to 3D tsSOS FLASH imaging, and more than 3-fold higher SNR and CNR with respect to 2D radial QISS when normalized for voxel size. 3D tsSOS QISS provided good to excellent image quality that exceeded the image quality of 2D QISS, 2D TOF, and 3D TOF (P < .05). CONCLUSION: Whole-neck high-resolution nonenhanced MRA is feasible using 3D tsSOS QISS, and produced image quality that exceeded those of competing nonenhanced MRA protocols at 3 Tesla.

Accelerated, free-breathing, noncontrast, electrocardiograph-triggered, thoracic MR angiography with stack-of-stars k-space sampling and GRASP reconstruction.

PURPOSE: To develop an accelerated, free-breathing, noncontrast, electrocardiograph-triggered, thoracic MR angiography (NC-MRA) pulse sequence capable of achieving high spatial resolution at clinically acceptable scan time and test whether it produces clinically acceptable image quality in patients with suspected aortic disease. METHODS: We modified a "coronary" MRA pulse sequence to use a stack-of-stars k-space sampling pattern and combined it with golden-angle radial sparse parallel (GRASP reconstruction to enable self-navigation of respiratory motion and high data acceleration. The performance of the proposed NC-MRA was evaluated in 13 patients, where clinical standard contrast-enhanced MRA (CE-MRA) was used as control. For visual analysis, two readers graded the conspicuity of vessel lumen, artifacts, and noise level on a 5-point scale (overall score index = sum of three scores). The aortic diameters were measured at seven standardized locations. The mean visual scores, inter-observer variability, and vessel diameters were compared using appropriate statistical tests. RESULTS: The overall mean visual score index (12.1 ± 1.7 for CE-MRA versus 12.1 ± 1.0 for NC-MRA) scores were not significantly different (P > 0.16). The two readers' scores were significantly different for CE-MRA (P = 0.01) but not for NC-MRA (P = 0.21). The mean vessel diameters were not significantly different, except at the proximal aortic arch (P < 0.03). The mean diameters were strongly correlated (R2 ≥ 0.96) and in good agreement (absolute mean difference ≤ 0.01 cm and 95% confidence interval ≤ 0.62 cm). CONCLUSION: This study shows that the proposed NC-MRA produces clinically acceptable image quality in patients at high spatial resolution (1.5 mm × 1.5 mm × 1.5 mm) and clinically acceptable scan time (~6 min).

Accelerated, first-pass cardiac perfusion pulse sequence with radial k-space sampling, compressed sensing, and k-space weighted image contrast reconstruction tailored for visual analysis and quantification of myocardial blood flow.

PURPOSE: To develop an accelerated cardiac perfusion pulse sequence and test whether it is capable of increasing spatial coverage, generating high-quality images, and enabling quantification of myocardial blood flow (MBF). METHODS: We implemented an accelerated first-pass cardiac perfusion pulse sequence by combining radial k-space sampling, compressed sensing (CS), and k-space weighted image contrast (KWIC) filtering. The proposed and clinical standard pulse sequences were evaluated in a randomized order in 13 patients at rest. For visual analysis, 3 readers graded the conspicuity of wall enhancement, artifact, and noise level on a 5-point Likert scale (overall score index = sum of 3 individual scores). Resting MBF was calculated using a Fermi function model with and without KWIC filtering. Mean visual scores and MBF values were compared between sequences using appropriate statistical tests. RESULTS: The proposed pulse sequence produced greater spatial coverage (6-8 slices) with higher spatial resolution (1.6 × 1.6 × 8 mm3 ) and shorter readout duration (78 ms) compared to clinical standard (3-4 slices, 3 × 3 × 8 mm3 , 128 ms, respectively). The overall image score index between accelerated (11.1 ± 1.3) and clinical standard (11.2 ± 1.3) was not significantly different (P = 0.64). Mean resting MBF values with KWIC filtering (0.9-1.2 mL/g/min across different slices) were significantly lower (P < 0.0001) than those without KWIC filtering (3.1-4.3 mL/g/min) and agreed better with values reported in literature. CONCLUSION: An accelerated, first-pass cardiac perfusion pulse sequence with radial k-space sampling, CS, and KWIC filtering is capable of increasing spatial coverage, generating high-quality images, and enabling quantification of MBF.

Evaluation of the Quality of ED Management for Patients with COPD.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is associated with exacerbations and high risk of serious outcomes. Our goal was to determine the appropriateness of the ED management of COPD exacerbations. METHODS: This observational cohort study incorporated a health records review and included COPD exacerbation cases seen at two large academic EDs. We included all patients with the primary diagnosis of COPD exacerbation. From the electronic medical record, demographic and clinical data were abstracted, and the Ottawa COPD Risk Score (OCRS) was calculated for each. Short-term serious outcomes (SSO) included ICU admission, intubation, myocardial infarction, non-invasive positive pressure ventilation (NIV), and death at 30 days. Cases were judged for appropriateness of treatment according to explicit indications and standards developed a priori. RESULTS: We enrolled 500 cases with mean age 71.9, female 51.2%, admitted 50.2%, and death 4.4%. The calculated OCRS score was >2 for 70.8% of patients. The treatments provided were inhaled beta-agonists (82.6%), inhaled anticholinergics (76.6%), corticosteroids (75.2%), antibiotics (71.0%), oxygen (63.8%), NIV (8.8%) and intubation (0.6%). Overall, 50.0% of cases were judged to have had inadequate management due to missing treatments. Specifically, the proportion of missing treatments were inhaled beta agonist (17.0%), inhaled anticholinergic (22.6%), corticosteroids (24.4%), antibiotics (12.8%), and NIV (2.0%). CONCLUSIONS: Adequate treatment of COPD exacerbation was lacking in 50.0% of patients in these two large academic EDs. Concerning were the number of patients not receiving corticosteroids or antibiotics. Implementation of explicit treatment standards should lead to improved patient care of this common and serious condition.

"I Was Worshiped and in Control": Sugar Arrangements Involving Transactional Sex from the Perspective of Both Sugar Babies and Sugar Benefactors.

Sugar dating arrangements involve an older partner ("sugar daddy/mommy") who provides financial support to a younger partner ("sugar baby") in exchange for intimacy. The current study recruited a U.S. and Canadian sample of sugar babies (n = 45) and sugar benefactors (n = 32) through social media sources to survey them about perceived power in their sugar arrangement, gender roles, and stigma. Sugar benefactors did not differ in perceived power from sugar babies, nor in endorsement of traditional gender roles or stigma. Directed content analysis analyzing open-ended responses about associated outcomes indicated that both partners placed strong emphasis on companionship despite the importance of sex within arrangements. Sugar babies reported that money drives participation, although arrangements fulfill other needs, such as pleasure. Other benefits include having an arrangement with clear boundaries and expectations. Disadvantages include concerns for safety, that being physical safety for babies, and reputation and being used for money for daddies. Notably, both groups perceived sugar babies as having equal or more power than sugar benefactors, although this was often attributed to sugar babies' attractiveness and youth. Findings include insights from both babies and benefactors, and support perspectives that sugar dating is distinct from traditional sex work.

Incidence, clinical management and prognosis of patients with small intestinal adenocarcinomas from 1999 through 2019: A nationwide Dutch cohort study.

BACKGROUND: Small intestinal adenocarcinomas (SIAs) are rare. Hence, randomized controlled trials are lacking and understanding of the disease features is limited. This nationwide cohort investigates incidence, treatment and prognosis of SIA patients, to improve disease outcome. PATIENTS AND METHODS: Data of 2697 SIA patients diagnosed from January 1999 through December 2019 were retrieved from the Netherlands Cancer Registry and Pathology Archive. Incidence was calculated using the revised European Standardized Rate. The influence of patient and tumor characteristics on overall survival (OS) was studied using survival analyses. RESULTS: The age-standardized incidence rate almost doubled from 0.58 to 1.06 per 100,000 person-years, exclusively caused by an increase in duodenal adenocarcinomas. OS did not improve over time. Independent factors for a better OS were a younger age, jejunal tumors, Lynch syndrome and systemic therapy. Only 13.8% of resected patients was treated with adjuvant chemotherapy, which improved OS compared to surgery alone in stage III disease (HR 0.47 (0.35-0.61)), but not in the limited group of deficient mismatch repair (MMR) patients (n = 53, HR 0.93 (0.25-3.47)). In the first-line setting, CAPOX was associated with improved OS compared to FOLFOX (HR 0.51 (0.36-0.72)). For oligometastatic patients, a metastasectomy significantly improved OS (HR 0.54 (0.36-0.80)). CONCLUSIONS: The incidence of SIAs almost doubled in the past 20 years, with no improvement in OS. This retrospective non-randomized study suggests the use of adjuvant chemotherapy for stage III disease and first-line CAPOX for metastatic patients. For selected oligometastatic patients, a metastasectomy may be considered. MMR-status testing could aid in clinical decision-making.

Equivalence testing in microarray analysis: similarities in the transcriptome of human atherosclerotic and nonatherosclerotic macrophages.

We focus on similarities in the transcriptome of human Kupffer cells and alveolar, splenic, and atherosclerotic plaque-residing macrophages. We hypothesized that these macrophages share a common expression signature. We performed microarray analysis on mRNA from these subsets (4 patients) and developed a novel statistical method to identify genes with significantly similar expression levels. Phenotypic and functional diversity between macrophage subpopulations reflects their plasticity to respond to microenvironmental signals. Apart from detecting differences in expression profiles, the comparison of the transcriptomes of different macrophage populations may also allow the definition of molecular similarities between these subsets. This new method calculates the maximum difference in gene expression level, based on the estimated confidence interval on that gene's expression variance. We listed the genes by equivalence ranking relative to expression level. FDR estimation was used to determine significance. We identified 500 genes with significantly equivalent expression levels in the macrophage subsets at 5.5% FDR using a confidence level of α = 0.05 for equivalence. Among these are the established macrophage marker CD68, IL1 receptor antagonist, and MHC-related CD1C. These 500 genes were submitted to IPA and GO clustering using DAVID. Additionally, hierarchical clustering of these genes in the Novartis human gene expression atlas revealed a subset of 200 genes specifically expressed in macrophages. Equivalently expressed genes, identified by this new method, may not only help to dissect common molecular mechanisms, but also to identify cell- or condition-specific sets of marker genes that can be used for drug targeting and molecular imaging.

Mitochondria, endoplasmic reticulum and innate immune dysfunction in mood disorders: Do Mitochondria-Associated Membranes (MAMs) play a role?

Mood disorders like major depression and bipolar disorder (BD) are among the most prevalent forms of mental illness. Current knowledge of the neurobiology and pathophysiology of these disorders is still modest and clear biological markers are still missing. Thus, a better understanding of the underlying pathophysiological mechanisms to identify potential therapeutic targets is a prerequisite for the design of new drugs as well as to develop biomarkers that help in a more accurate and earlier diagnosis. Multiple pieces of evidence including genetic and neuro-imaging studies suggest that mood disorders are associated with abnormalities in endoplasmic-reticulum (ER)-related stress responses, mitochondrial function and calcium signalling. Furthermore, deregulation of the innate immune response has been described in patients diagnosed with mood disorders, including depression and BD. These disease-related events are associated with functions localized to a subdomain of the ER, known as Mitochondria-Associated Membranes (MAMs), which are lipid rafts-like domains that connect mitochondria and ER, both physically and biochemically. This review will outline the current understanding of the role of mitochondria and ER dysfunction under pathological brain conditions, particularly in major depressive disorder (MDD) and BD, that support the hypothesis that MAMs can act in these mood disorders as the link connecting ER-related stress response and mitochondrial impairment, as well as a mechanisms behind sterile inflammation arising from deregulation of innate immune responses. The role of MAMs in the pathophysiology of these pathologies and its potential relevance as a potential therapeutic target will be discussed.

Prevalence and incidence of multiple sclerosis in Panama (2000-2005).

BACKGROUND: The first cases of multiple sclerosis (MS) in Panama were notified in the 1980s and it was considered a low-risk region for this disease. Between 2000 and 2005, a prevalence study was conducted to characterize MS in Panama. METHODS: An instrument was developed to gather information from clinical files and interviews with previous informed consent. The diagnosis was confirmed by neurologists applying the Poser and McDonald criteria as per the inclusion period. RESULTS: 178 patients from the public and private health sectors were captured between 1970 and 2005. The prevalence rate was 5.24/100,000 inhabitants, and the incidence was between 0.28 and 0.61/100,000 inhabitants. The disease was predominant among women, the mean age +/- SD being 34.76 +/- 10.909 years (1st crisis), and the average number of crises was 2.88. The most common clinical findings were motor, optic neuritis, sensitive and cerebellous. 52.4% presented monosymptomatic manifestations, 71.6% were clinically defined according to Poser's criteria and 55.6% had MS according to McDonald's criteria. 77.8% had their debut with the relapsing-remitting type and presented an Expanded Disability Status Scale score of 2.7 after the first crisis. CONCLUSION: MS is in Panama a neurological pathology with a low prevalence and the results of this investigation improved early treatment and diagnosis of this disease.

[Obstructive sleep apnoea]. / Obstructieve slaapapneu.

Obstructive sleep apnoea Obstructive sleep apnoea (OSA) is a complex condition with many different phenotypes. Historically, OSA has been defined using the apnoea-hypopnoea index (AHI). However, because there is no clear relationship between the AHI and the severity of symptoms and comorbidities the degree of hypoxia is increasingly being used to define OSA severity. To reach a diagnosis of obstructive sleep apnoea syndrome (OSAS), it has to be shown that symptoms improve with therapy. The treatment of first choice for patients with severe OSA is continuous positive airway pressure (CPAP) therapy. The indication for other therapies depends upon the patient's characteristics and preferences. Treatment with a position trainer and implantation of a hypoglossal nerve stimulator are relatively new therapies. OSA is a cardiovascular risk factor, but the effect of OSA treatment on cardiovascular outcome measures and mortality has not been shown in clinical trials.

Remission of acromegaly following long-term therapy with cabergoline: report of two cases.

Dopamine agonists are effective in some patients with acromegaly and in this condition treatment is considered to be chronic. We describe two acromegalic patients who responded adequately to the long-acting dopamine agonist cabergoline, but surprisingly maintained normal GH and IGF-I levels once therapy was discontinued after 42 and 76 months because of possibly related side effects. A 32-year-old woman with mild acromegaly (IGF-I: 423 microg/l, GH after OGTT: 2.5 microg/l, adenoma 4 mm) was treated with cabergoline as primary therapy and reached safe GH levels (2 microg/l or less) and normal IGF-I levels with 3.5 mg cabergoline weekly. After 42 months of therapy the patient experienced a progressive decrease of libido, which she attributed to the intake of cabergoline. After stopping medication, serum levels of GH and IGF-I remained normal during the following 2.5 years. A 53-year-old man with moderate acromegaly (serum IGF-I: 547 microg/l, GH after OGTT: 5.9 microg/l, adenoma 7 mm) preferred cabergoline as primary therapy. Serum GH levels below 2 microg/l and normal levels of IGF-I were obtained with 3.5 mg cabergoline weekly. When the patient experienced severe stomach pains after 76 months of treatment, cabergoline was held responsible and discontinued. Serum GH and IGF-I did not increase again and stayed at the same level during a follow-up of 5.5 years. These two cases demonstrate that acromegalic patients with a good response to cabergoline may occasionally remain in remission after stopping therapy. This phenomenon has previously only been described in patients with a prolactinoma.

Dead or alive: gene expression profiles of advanced atherosclerotic plaques from autopsy and surgery.

Since inclusion of atherosclerotic tissues from different sources is often indispensable to study the full atherogenic spectrum, we investigated to what extent the expression profiles of advanced, stable atherosclerotic lesions obtained during autopsy and surgery are comparable. The gene expression profiles of human carotids with advanced atherosclerosis obtained at autopsy and at vascular surgery were studied by microarray analysis. Expression analysis was performed both at the single gene (Rosetta, Gene Ontology) and at the pathway level using Ingenuity and Gene Set Enrichment Analysis. In addition, mRNA and protein expression levels were validated using quantitative (q) RT-PCR and immunohistochemistry on unrelated advanced carotid lesions from autopsy and surgery. Microarray analysis indicated that the 97.2% of genes showed similar expression levels in advanced atherosclerotic lesions from autopsy and surgery. While the expression data revealed no differences in common atherosclerotic related pathways such as lipid metabolism and inflammation, the differentially expressed genes were mainly involved in basal cell metabolism and hypoxia driven pathways. qRT-PCR confirmed the differential expression of hypoxia-driven genes VEGF-A (2.3-fold upward arrow), glucose transporter (GLUT)-1 (2.5-fold upward arrow), GLUT3 (8.3-fold upward arrow), and hexokinase 1 (2.4-fold upward arrow) in autopsy vs. surgical specimens. Immunohistochemistry revealed that the transcriptional differences in these hypoxia-related genes were not reflected at the protein level. The gene expression profiles of advanced atherosclerotic lesions from autopsy and surgery are largely similar. However, >500 genes, mostly involved in basal cell metabolism and hypoxia were differentially expressed at mRNA, but not at the protein level.

Health risks of lipodystrophy and abdominal fat accumulation: therapeutic possibilities with leptin and human growth hormone.

Lipodystrophy (LD) is a well-recognised clinical syndrome of peripheral fat atrophy and central adiposity, often associated with laboratory abnormalities such as dyslipidemia and glucose intolerance, and probably linked to insulin resistance. The long-term consequences of LD and its potential association with cardiovascular disease remain unknown. The visceral fat accumulation is characterised by the increased, abundant secretion of a number of peptides such as leptin, insulin-like growth factor (IGF), adiponectin and the recently reported resistin and visfatin hormones. Elevated resistin and tumour necrosis factor (TNF-alpha) levels and low levels of adiponectin secretion may have implications for the risk of development of type 2 diabetes and cardiovascular disease. LD is observed not only in rare autosomal syndromes, but also in patients positive for the human immunodeficiency virus (HIV) who have been treated with protease inhibitors. Both the origin of LD and its treatment deserve more attention and further research in clinical settings.

Risk behaviors and STI prevalence among people with HIV in El Salvador.

To date, there are no studies from El Salvador among people with HIV to inform prevention programs. We conducted a study in El Salvador in 2008 among people with HIV using audio computer-assisted interviews on risk behaviors and access to health care. Blood was tested for syphilis and herpes simplex type 2 (HSV-2). Active syphilis was defined as RPR titer ≥1:8. Genital specimens were tested for other sexually transmitted infections (STI) by PCR. We evaluated factors associated with unprotected sex with last stable partner of HIV-negative or unknown status among those reporting a stable partner. A total of 811 HIV-positive individuals participated: 413 men and 398 women. Prevalence of Chlamydia and gonorrhea was low (≤1%), while prevalence of other STI was high: Mycoplasma genitalium (14%), syphilis (15% seropositivity, active syphilis 3%) and HSV-2 (85%). In multivariate analysis, disclosing HIV status to partner (OR 0.2, 95% CI: 0.1-0.3, p<0.001), participation in HIV support groups (OR 0.3, 95% CI: 0.1-0.8, p=0.01), easy access to condoms (OR 0.4, 95% CI: 0.2-0.9, p=0.04) were protective factors for unprotected sex. Reporting a casual partner in the last 12 months (OR 3.6, 95% CI: 1.5-8.5, p=0.004). and having an STI (OR 2.6, 95% CI:1.3-5.5, p=0.02) were associated with an increased odds of unprotected sex. Prevention interventions among HIV-positives in El Salvador should focus on increasing condom access, promoting HIV disclosure and couples testing and reducing the number of partners. The positive role of support groups should be used to enhance behavioral change.