Impact of COVID-19 on the Care of Patients with HIV Infection.

The COVID-19 pandemic and associated lockdown measures have been associated with substantial disruptions to health care services, including screening for human immunodeficiency virus (HIV) and management of people living with HIV (PLWH). Data from 3265 patients were examined in a retrospective cohort study. We compared outpatient follow-up for PLWH, the number of new patients, treatment adherence, hospitalizations, and deaths during the "pandemic period" (March 2020 to February 2021), the "pre-pandemic period" (the equivalent time frame in 2019), and the "post-pandemic period" (March to September 2021). During the pandemic period, the number of new patients seen at the HIV clinic (116) as well as the requested viral load tests (2414) decreased significantly compared to the pre-pandemic (204 and 2831, respectively) and post-pandemic periods (146 and 2640, respectively) (p < 0.01 for all the comparisons). However, across the three study periods, the number of drug refills (1385, 1330, and 1411, respectively), the number of patients with undetectable viral loads (85%, 90%, and 93%, respectively), and the number of hospital admissions among PLWH remained constant. Despite the COVID-19 pandemic's impact, our findings show stability in the retention of clinical care, adherence to treatment, and viral suppression of PLWH, with no significant impact on hospitalization rates or all-cause mortality.

Predicting the evolution of neck pain episodes in routine clinical practice.

BACKGROUND: The objective of this study was to develop models for predicting the evolution of a neck pain (NP) episode. METHODS: Three thousand two hundred twenty-five acute and chronic patients seeking care for NP, were recruited consecutively in 47 health care centers. Data on 37 variables were gathered, including gender, age, employment status, duration of pain, intensity of NP and pain referred down to the arm (AP), disability, history of neck surgery, diagnostic procedures undertaken, imaging findings, clinical diagnosis, and treatments used. Three separate multivariable logistic regression models were developed for predicting a clinically relevant improvement in NP, AP and disability at 3 months. RESULTS: Three thousand one (93.5%%) patients attended follow-up. For all the models calibration was good. The area under the ROC curve was ≥0.717 for pain and 0.664 for disability. Factors associated with a better prognosis were: a) For all the outcomes: pain being acute (vs. chronic) and having received neuro-reflexotherapy. b) For NP: nonspecific pain (vs. pain caused by disc herniation or spinal stenosis), no signs of disc degeneration on imaging, staying at work, and being female. c) For AP: nonspecific NP and no signs of disc degeneration on imaging. d) For disability: staying at work and no signs of facet joint degeneration on imaging. CONCLUSIONS: A prospective registry can be used for developing valid predictive models to quantify the odds that a given patient with NP will experience a clinically relevant improvement.

Predicting outcomes of neuroreflexotherapy in patients with subacute or chronic neck or low back pain.

BACKGROUND CONTEXT: In the context of shared decision-making, a valid estimation of the probability that a given patient will improve after a specific treatment is valuable. PURPOSE: To develop models that predict the improvement of spinal pain, referred pain, and disability in patients with subacute or chronic neck or low back pain undergoing a conservative treatment. STUDY DESIGN AND SETTING: Analysis of data from a prospective registry in routine practice. PATIENT SAMPLE: All patients who had been discharged after receiving a conservative treatment within the Spanish National Health Service (SNHS) (n=8,778). OUTCOME MEASURES: Spinal pain, referred pain, and disability were assessed before the conservative treatment and at discharge by the use of previously validated methods. METHODS: Improvement in spinal pain, referred pain, and disability was defined as a reduction in score greater than the minimal clinically important change. A predictive model that included demographic, clinical, and work-related variables was developed for each outcome using multivariate logistic regression. Missing data were addressed using multiple imputation. Discrimination and calibration were assessed for each model. The models were validated by bootstrap, and nomograms were developed. RESULTS: The following variables showed a predictive value in the three models: baseline scores for pain and disability, pain duration, having undergone X-ray, having undergone spine surgery, and receiving financial assistance for neck or low back pain. Discrimination of the three models ranged from slight to moderate, and calibration was good. CONCLUSIONS: A registry in routine practice can be used to develop models that estimate the probability of improvement for each individual patient undergoing a specific form of treatment. Generalizing this approach to other treatments can be valuable for shared decision making.

Genital fistulas in female Crohn's disease patients.: clinical characteristics and response to therapy.

BACKGROUND: Genital fistulas (GF) can arise in the course of Crohn's disease (CD), are difficult to manage and determine a significant alteration of the quality of life. AIMS: To review the joint experience of the Inflammatory Bowel Disease Units in six University Hospitals in the management of GF in Crohn's disease on female patients. RESULTS: A total of 47 patients with GF were identified, affecting 3.8% of women with CD treated in our centers. A 47.5% of patients were smokers. The median of time from the diagnosis of CD reached 102 months. According to anatomical type, GF were classified as rectovaginal (74.5%), anovaginal/anovulvar (21.3%) and enterovaginal (4.3%). Main symptoms were vaginal discharge of fecal material (55.3%), vaginal passage of gas (40.4%), or both. Fistulas were treated with antibiotics in 59.6% of patients, without any lasting success. Thiopurines were used in 80.9% of cases, with 13.2% of complete and 23.7% of partial responses. Anti TNF-alpha therapy was applied in 63.8%, with a 16.7% of complete and a 30% of partial responses (all responding patients received infliximab). Surgery was indicated in 38.3% of patients, with a 22% of complete responses after a first operation and 38.8% after reintervention. In all, definitive closure after one or more of these therapies was achieved in only 31.9% of cases. CONCLUSION: Genital fistulas are a significant problem in female Crohn's disease patients. Therapy is not well defined and only partially effective (one in three cases). Surgical therapy stands out as the most effective treatment.

The correlation between pain, catastrophizing, and disability in subacute and chronic low back pain: a study in the routine clinical practice of the Spanish National Health Service.

STUDY DESIGN: Correlation between variables measured with previously validated instruments. OBJECTIVE: To explore the association between catastrophizing and disability in patients treated for subacute or chronic low back pain (LBP) within routine clinical practice in Spain. SUMMARY OF BACKGROUND DATA: The influence of psychological variables on LBP-related disability in Southern Europe is different to the one in the Anglo-Saxon and Northern European cultural environments. In Spanish LBP patients, the influence of fear avoidance beliefs on disability is negligible, and catastrophizing does not mediate the improvement of disability caused by active education. The association between catastrophizing and dis-ability is unknown. METHODS: Thirty-three clinicians working for the Spanish National Health Service in 6 primary care and 8 specialty centers, recruited 1461 patients seeking care for subacute and chronic LBP. Patients were assessed only once. A linear regression model was developed to assess the percentage of the variance of disability explained by gender, age, chronicity status, severity of LBP, severity of referred pain (referred pain down to the leg), catastrophizing, eligible for workers' compensation (yes/no), failed back surgery (yes/no), radiologic findings, and treatments. RESULTS: Correlations among LBP, referred pain down to the leg, disability, and catastrophizing were moderate, but significant. The strongest one was between disability and catastrophizing (r ∇ 0.520). Catastrophizing explained 28% of disability, whereas severity of LBP only 3%. Global adjusted R of the model was 0.387. There was an association between some radiologic findings and treatments, and slightly higher levels of disability. CONCLUSION: In Southern European subacute and chronic LBP patients, catastrophizing correlates with dis-ability and explains approximately one-fourth of its variance. Further studies should assess its value as a prognostic factor in subacute and chronic patients.

Neuro-reflexotherapy for the management of myofascial temporomandibular joint pain: a double-blind, placebo-controlled, randomized clinical trial.

PURPOSE: To assess the efficacy of neuro-reflexotherapy intervention (NRT) for treating temporomandibular joint dysfunction attributed to myofascial pain. Neuro-reflexotherapy intervention consists of the temporary implantation of epidermal devices in trigger points in the back and ear. It has shown efficacy, effectiveness, and cost-effectiveness in treating subacute and chronic common back pain. No study, however, has explored its efficacy in treating myofascial temporomandibular joint pain (MF/TMJP). PATIENTS AND METHODS: This was a randomized, double-blind, placebo-controlled trial. Patients with MF/TMJP for more than 3 months in spite of conservative treatment, and with no evidence of major structural damage in the joint, were recruited at the Maxillofacial Department of the Hospital Clínico Universitario, a teaching hospital in Madrid, Spain. Patients were randomly assigned to an intervention group and to a control group. Patients in the treated group underwent 2 NRTs, immediately after baseline assessment and 45 days later. Sham interventions in the control group consisted of placement of the same number of epidermal devices within a 5-cm radius of the target zones. In both groups, conservative treatment during follow-up was allowed and recorded. Patients underwent clinical evaluations on 4 occasions: 5 minutes before intervention, 5 minutes after intervention, and 45 and 90 days later. The preintervention assessment was performed by the physician at the hospital service who included the patient in the study. The 3 follow-up assessments were performed independently by 1 of 2 physicians who had no connection with the research team, and who were blinded to patients' assignments. The primary outcome variable was level of pain severity during jaw movements at the last assessment (90 days), and the key comparison of interest was change in pain over time (pain levels at baseline and at 90 days). Level of pain was measured using a visual analog scale (VAS). RESULTS: Fifty-one patients with MF/TMJP were recruited into the study. Random assignment allocated 27 patients to the intervention group, and 24 to the control group. Differences in pain severity in favor of the intervention group appeared immediately after the intervention, persisted for 45 days, and increased after the second intervention. Differences at last follow-up were highly clinically and statistically significant (4 to 5 points on the VAS, P = .000), allowing for patients in the intervention group to cease drug treatment (P = .005). There were no differences in the evolution of crepitus or clicking in the joint. There were no clinically relevant side effects associated with the intervention. CONCLUSIONS: For patients in whom conservative treatment has failed, NRT improves the chronic pain associated with MF/TMJP syndrome.

Prognostic factors for neuroreflexotherapy in the treatment of subacute and chronic neck and back pain: a study of predictors of clinical outcome in routine practice of the Spanish National Health Service.

STUDY DESIGN: Prospective cohort follow-up study. OBJECTIVES: To refine the indication criteria for neuroreflexotherapy (NRT) in the treatment of subacute and chronic neck (NP), thoracic (TP) and low back pain (LBP) in the Spanish National Health Service (SNHS), by identifying prognostic factors for clinical outcome. SUMMARY OF BACKGROUND DATA: NRT consists of the temporary subcutaneous implantation of surgical devices in trigger points. Previous randomized controlled trials have shown its efficacy, effectiveness, and cost-effectiveness for treating subacute and chronic LBP. Clinical audits in routine practice have shown similar results in NP, TP, and LBP patients. PATIENTS AND METHODS: All 1514 patients from the SNHS in the Balearic Islands in which a NRT intervention was performed and who were discharged between January 1, 2004, and December 31, 2005, were included in this study. Treatment failure was defined as a baseline score equivalent to or lower than the corresponding one at discharge for local pain, referred pain, or LBP-related disability. Multivariate logistic regression models were developed for each of those variables. Maximal models included reason for referral (NP, TP, or LBP), age, sex, baseline values for each variable, number of days in which the surgical devices used in NRT were left implanted, duration of the current episode, time elapsed since the first episode, and previous failed surgery for the current episode. Calibration of the models was assessed through the Hosmer-Lemeshow test, while discrimination was assessed through the area under the ROC curve and the Nagelkerke R test. RESULTS: When referred to NRT, patients' median (IQR) duration of the episode was 210 (90, 730) days. Failure rates ranged between 9.9% for local pain and 14.5% for disability. Variables associated with a worst prognosis for local pain, referred pain, and disability were surgical devices remaining implanted for a shorter duration and, especially, a longer pain duration. Patients referred for NP were more likely to improve than those referred for TP or LBP. Regarding the evolution of local and referred pain, lesser improvement was observed in the least severe complaint at baseline. Models showed a good calibration. The area under the ROC curve ranged between 0.719 and 0.804, and R ranged between 0.101 and 0.255. CONCLUSION: A longer duration of the current episode is the worst detected prognostic factor for response to NRT, but prognostic models are inaccurate for predicting the clinical outcome of a given patient. In order to improve the success rate of this technology, these results only support earlier referral for patients complying with current indication criteria.

Lumbar bone mineral density in renal transplant patients on neoral and tacrolimus: a four-year prospective study.

BACKGROUND: This prospective study was designed to investigate the long-term evolution of bone mineral density (BMD) in kidney transplant recipients. METHODS: In 86 patients with functioning grafts, 65 on tacrolimus-based immunosuppression and 21 on cyclosporine-based immunosuppression, laboratory parameters and BMD measurements in lumbar spine (L2-L4) and femoral neck (FN) were performed by DEXA in the first month after transplantation (baseline) and yearly thereafter up to the fourth year. RESULTS: BMD did not change at 12 months in lumbar spine nor in the FN. Detailed analysis identified three patterns of BMD in lumbar spine at 12 months: BMD remained stable in 27 patients (31.4%), decreased >2% in 31 (36.0%) and increased >2% in 28 (32.6%). Patients with no change or gain presented a parallel increase of BMD in FN (P<0.001 in both groups). On multivariate analysis, the variables associated with no change or lumbar BMD loss were total prednisone dose in grams at 12 months (OR 1.402; 95% CI 1.038-1.893; P=0.028), calcitriol levels at 12 months (OR 0.936; 95% CI 0.892-0.982; P=0.007) and lumbar BMD at baseline (OR 1.006; 95% CI 1.002-1.010; P=0.002). Late treatment with calcium supplements and calcitriol did not improve osteopenia. CONCLUSIONS: One third of patients had bone loss mainly during the first year of follow-up. Bone loss was associated to higher baseline BMD, high steroid dose, and lower calcitriol levels at 1 year. Late administration of calcitriol and calcium supplements did not improve posttransplant osteopenia. More than 50% of patients were osteopenic 4 years after transplantation.

The influence of fear avoidance beliefs on disability and quality of life is sparse in Spanish low back pain patients.

STUDY DESIGN: Correlation between previously validated questionnaires. OBJECTIVES: To assess the influence of fear avoidance beliefs (FAB) on disability and quality of life in Spanish low back pain (LBP) patients. SUMMARY OF BACKGROUND DATA: FAB has shown to be a major determinant of disability in LBP patients in Northern European and Anglo-Saxon cultural environments. There are no data on its influence on Latin-Mediterranean patients. METHODS: The study was done in 12 primary care and 9 hospital services from seven different regions of Spain, with 209 patients who were in a potentially active working situation and visited the National Health Service for LBP. None was excluded and the sample was balanced for acute, subacute, and chronic patients. On their first visit and 14 days later, patients were given two independent Visual Analogue Scales (VAS) for LBP and leg pain, as well as the validated Spanish versions of the Fear Avoidance Beliefs (FABQ), Roland-Morris (RMQ), and SF-12 questionnaires. RESULTS: Correlations between LBP, leg pain, FABQ, disability, and quality of life were moderate on day 1 (r = 0.320-0.564) and stronger on day 15 (r = 0.457-0.637). All of them were statistically highly significant (P = 0.000). Regression models showed that LBP severity explains 33% of disability on day 1 and 20% on day 15, while FAB only explains 6% on day 1 and 2% on day 15. FAB does not explain mental quality of life. It explains only 5% of physical quality of life on day 1 and 4% on day 15. There was no interaction between FAB and chronicity, and FABQ values on day 1 did not predict disability or quality of life at day 15. CONCLUSIONS: As opposed to what has been shown in other cultural settings, FAB have virtually no clinical relevance in Spanish LBP patients who are treated in the National Health Service and who are in a potentially active working situation. The influence of FAB on disability is minimal and much less than that of pain severity, and their contribution to the patient's quality of life is irrelevant. Further studies should explore the potential value of FAB in other Latin-Mediterranean countries.