HIV/STI co-infection among men who have sex with men in Spain.

In Spain, neither the HIV nor the STI national surveillance systems collect information on HIV/STI co-infection. However, there are two networks based on HIV/STI clinics which gather this data. We describe HIV prevalence in men who have sex with men (MSM) diagnosed with infectious syphilis and/or gonorrhoea in 15 STI clinics; and concurrent diagnoses of STI in MSM newly diagnosed with HIV in 19 HIV/STI clinics. In total, 572 MSM were diagnosed with infectious syphilis and 580 with gonorrhoea during 2005-2007. HIV prevalence among syphilis and gonorrhoea cases was 29.8% and 15.2% respectively. In the multivariate analysis, HIV/syphilis co-infection was associated with being Latin American; having a history of STI; reporting exclusively anal intercourse; and having sex with casual or several types of partners. HIV and gonorrhoea co-infection was associated with age older than 45 years; having no education or only primary education completed; and having a history of STI. In total, 1,462 HIV infections were newly diagnosed among MSM during 2003-2007. Of these, 31.0% were diagnosed with other STI at the same time. Factors associated with STI co-infection among new HIV cases in MSM were being Latin American; and having sex with casual partners or with both steady and casual partners. In Spain, a considerable proportion of MSM are co-infected with HIV and STI.

[HIV infection and cervical cancer: a note of caution for clinicians and health planners]. / Infección por VIH y cáncer de cérvix: una llamada de atención para clínicos y planificadores.

BACKGROUND: To estimate the association between HIV infection and cervical intraepithelial neoplasia (CIN). PATIENTS AND METHODS: Cross-sectional study based on data from 251 women from a Sexually Transmitted Diseases clinic. Patients with CIN were compared with those without CIN in terms of HIV infection and exposure to other risk factors, calculating the corresponding adjusted odds ratio (ORA) by logistic regression. RESULTS: HIV infection (ORA = 7.5; CI 95%: 2.5-22.1), having previous cytologies with cellular changes associated with human papillomavirus infection (ORA = 3.6; CI 95%: 1.3-10.2) and history of condylomas (ORA = 3.2; CI 95%: 1.2-8.4) were associated with CIN. CONCLUSIONS: The strong association observed between HIV and CIN, shows that it is necessary for health services planners and clinicians caring for HIV infected women to ensure that the latter receive the appropriate care to guarantee its early detection.

[Clinical and epidemiological characteristics of persons newly diagnosed of HIV infection]. / Características clinicoepidemiológicas de los nuevos diagnósticos de infección por el virus de la inmunodeficiencia humana.

BACKGROUND: We describe the characteristics of people with a recent diagnosis of HIV infection. PATIENTS AND METHOD: Series of 126 new cases of HIV infection diagnosed in an infectious diseases Service. RESULTS: Sexual transmission was the commonest form of infection (74%). Fifteen percent of individuals were aged over 50 years and 16% were immigrants. A late diagnosis (stage C) accounted for 36% of cases and it was associated with being more than 50 years old (OR: 5.1; 95% CI: 1.6-16.8). CONCLUSIONS: It is necessary to implement HIV infection surveillance systems and to improve preventive services.

[Is it necessary that some patients come to see us so often? Factors associated with primary care use in pediatrics]. / Es necesario que algunos pacientes nos visiten tan a menudo?: factores asociados con la utilización en pediatría de atención primaria.

OBJECTIVES: To analyze the relationship between pediatric patients morbidity and their level of primary health care services use; and to establish if the patients level of use affects the health promotion and immunization schedule completion. METHODS: All patients assigned to a pediatric practice of the Basque National Health Service in Astrabudua (Bizkaia, Spain) over a 6-year period were categorized into different utilization patterns according to their age and number of primary care visits (whose principal reason for encounter was different from health promotion activities). Bivariate and multivariate analyses were performed comparing three groups of subjects: 116 consistently high users, 115 consistently low users and 123 patients classified as consistently medium or erratic users. Ambulatory care Groups (ACGs) case-mix system was used to manage pathologies. RESULTS: High use patients experienced several morbidity types most frequently than low use ones: asthma (OR = 44.7; 95% CI = 5.5-206.1), diseases likely to recurr (OR = 33.5; 95% CI = 8.5-131.6), specialty unstable chronic conditions (OR = 10.8; 95% CI = 2.2-52.8), psychosocial conditions (OR = 5.7; 95% CI = 2.1-15.2), chronic medical stable conditions (OR = 4.0; 95% CI = 1.9-8.6), eye/dental diseases (OR = 3.5; 95% CI = 1.5-8.1). On the other hand, low users were more likely to be lacking completion of the immunization (OR = 3.0; 95% CI = 1.1-8.8) and the well-child care program visits schedules (OR = 4.3; 95% CI = 2.3-8.0). CONCLUSION: Our data confirm that high utilization, far from being inadequate behavior, is an adequate response to the higher health care needs showed by such patients. Primary care pediatricians should assess preventive care needs of the children who consult them infrequently.

Drug-resistant tuberculosis in Puerto Rico, 1987-1990.

We conducted a proportional morbidity study to determine the factors associated with, patterns of, and proportion of cases of tuberculosis with drug resistance in Puerto Rico. We abstracted data from 279 report forms of new cases of tuberculoses reported to the Puerto Rico Health Department between 1987 and 1990 in which isolates had been tested for drug susceptibility. Overall, 55 (19.7%) of the 279 cases of tuberculosis were resistant to at least one drug, and 27 (9.7%) were resistant to more than one drug. Among the 59 patients with previous tuberculosis therapy, 20 (33.9%) had isolates that were drug-resistant. Among the 220 without previous therapy, 35 (15.9%) had isolates that were drug-resistant. For all 279, resistance to isoniazid (INH) was most common (11.1%) followed by streptomycin (SM) (10%), rifampin (RIF) (4.3%), ethambutol (EMB) (2.2%), and pyrazidimide (PZA) (1.1%). A history of previous tuberculosis therapy (odds ratio [OR] = 2.71, 95% confidence interval [CI] = 1.34-5.48) and being born outside the United States and Puerto Rico (OR = 4.76, CI = 1.69-13.39) were independently associated with drug resistance. Because of the high proportion of drug-resistant tuberculosis in Puerto Rico we recommend (1) that all persons in Puerto Rico in whom tuberculosis is diagnosed should initially receive four-drug therapy (INH, RIF, EMB, and PZA), (2) that susceptibility testing be done on initial Mycobacterium tuberculosis isolates from all patients, and (3) that those with a history of previous tuberculosis therapy or those who are foreign-born have very careful clinical and microbiologic follow-up.

Prevention in routine general practice: activity patterns and potential promoting factors.

BACKGROUND: Primary care physicians have a unique opportunity to deliver preventive services, but a desired level of involvement is not always attained. METHODS: We analyzed self-reported preventive activity in a stratified random sample of 635 primary care physicians to determine how often they deliver effective interventions for the prevention of cardiovascular diseases, cancer, and acquired immunodeficiency syndrome as well as to assess factors associated with a greater implementation of preventive activity in routine practice. RESULTS: More than 63% reported to ask about tobacco use or alcohol consumption or to check blood pressure to most of their new patients. On the other hand, only 33% asked about intravenous drug use, 14% about sexually transmitted diseases, and 6% about the number of sexual partners and less than 33% reported to have an appropriate criterion for any periodic preventive activity in routine daily practice. Correlates of high preventive activity included group practice, specific register of preventive activities, participation in the Program of Preventive Activities of the Spanish Society of Community and Family Medicine, and specific nursing consultation. CONCLUSIONS: Organizational factors could be used to improve preventive activity which is far from being an adequate component of routine general practice especially with regard to human immunodeficiency virus infection and periodic preventive activity for chronic diseases.

Application of the ambulatory care groups in the primary care of a European national health care system: does it work?

BACKGROUND: Ambulatory Care Groups (ACGs), a US case-mix system that uses the patient as the unit of analysis, is particularly appropriate for health care systems in which physicians serve a defined list of patients. OBJECTIVE: To determine the extent to which the categorization of patients according to ACGs would account for the utilization of primary care services in a national health care system within the European Union. METHODS: Of all subjects continuously assigned to 9 physicians from public primary health care centers in Bizkaia, Basque Country (Spain) over a 12-month period, those visited at least once (n = 9,093) were included. According to the subject's age, sex, and ICD-9-CM diagnoses assigned during a year of patient-provider encounters, patients were classified by means of the ACGs system. RESULTS: Multiple linear regression analyses indicated that age and sex did not explain more than 7.1% of the variance in annual visits made by adults and 25.7% by children to primary care physicians. However, the r2 adjusted to the ACGs model was 50% and 48%, respectively, and even higher, that is 58% and 64% for another component of the system, the Ambulatory Diagnostic Groups (ADGs). CONCLUSIONS: Those results support the inadequacy of using the patient's age and sex alone to estimate physicians' workload in the primary health setting and the need to consider morbidity categories. The ACGs case-mix system is a useful tool for incorporating patients' morbidity in the explanation of the use of primary health care services in a European national health system.

¿Es necesario que algunos pacientes nos visiten tan a menudo?: factores asociados con la utilización en pediatría de atención primaria / Are such frequent visits really necessary? Factors associated with the use of primary-care pediatric services

Objetivos: Analizar la asociación entre la morbilidad que presentan los pacientes pediátricos y su grado de frecuentación de los servicios de atención primaria; y establecer si el nivel de frecuentación de los pacientes afecta al correcto cumplimiento de las pautas de promoción de la salud e inmunizaciones. Métodos: En función de su edad y número de visitas a atención primaria (excepto las motivadas por programas de salud) se categorizó en diferentes patrones de utilización a todos los pacientes asignados ininterrumpidamente durante seis años a una consulta de pediatría del Servicio Vasco de Salud ubicada en Astrabudúa (Bizkaia). Se realizaron análisis bivariados y multivariantes, comparando tres grupos de sujetos: 116 hiperutilizadores persistentes, 115 hipoutilizadores persistentes y 123 pacientes normoutilizadores o con otros patrones de utilización. Para el manejo de las patologías, se empleó el case-mix Ambulatory Care Groups (ACGs).Resultados: Los pacientes hiperutilizadores presentaron más frecuentemente que los hipoutilizadores diferentes tipos de morbilidad: asma (OR = 44,7; IC 95 por ciento = 5,5 - 206,1), patologías recurrentes (OR = 33,5; IC 95 por ciento = 8,5 - 131,6), patología crónica inestable propia de especialista (OR = 10,8; IC 95 por ciento = 2,2 - 52,8), patología psicosocial (OR = 5,7; IC 95 por ciento = 2,1 - 15,2), patología crónica estable (OR = 4,0; IC 95 por ciento = 1,9 - 8,6) y patología oftálmica/dental (OR = 3,5; IC 95 por ciento = 1,5 - 8,1). Por otra parte, los pacientes hipoutilizadores mostraron un peor cumplimento del calendario vacunal (OR = 3,0; IC 95 por ciento = 1,1 - 8,8) y del programa de control de niño sano (OR = 4,3; IC 95 por ciento = 2,3 - 8,0).Conclusión: Nuestros datos confirman que la hiperutilización persistente, lejos de ser un comportamiento inadecuado, es una respuesta apropiada a las mayores necesidades de cuidados sanitarios que presentan estos pacientes. Los pediatras de atención primaria deberían evaluar las necesidades de cuidados preventivos en aquellos de sus pacientes que raramente les visitan (AU)