Depression and suicidal ideation in Mexican medical students during COVID-19 outbreak. A longitudinal study.

INTRODUCTION: The COVID-19 pandemic has been particularly difficult for populations at risk for mental health problems, such as healthcare professionals and medical students. In the present study, we evaluated the effect of the pandemic on mental health in a sample of Mexican medical students with and without a mental health diagnosis. METHOD: Longitudinal and descriptive study based on scales of suicidal ideation, depressive symptoms and risk of alcohol consumption, conducted in April and December 2020. RESULTS: Sample includes 247 medical students, 64.4% are women. Prevalence of depression increased between April and December from 19.84% to 40.08%. In the case of women from 23.67% to 42.60% (χ2 = 0.000) and in men from 11.54% to 34.62% (χ2 = 0.001). In April 16.92% of healthy students presented some sign of depression and in December the percentage increased to 40.80% (χ2 = 0.000). Regarding medicated students, the prevalence in April was 32.61% and in December it was 36.96% (χ2 = 0.662). In April, the medicated students with risk of suicidal ideation were 17 out of 46 (36.96%), compared to the students without a diagnosis of psychiatric illness were 29 out of 201 (13.43%) (χ2 = 0.000). For December, the non-medicated students at risk of suicidal ideation were 34 out of 201 (16.91%), and the medicated students were 12 out of 46 (26.09%) (χ2 = 0.149). CONCLUSIONS: The pandemic has increase the rate of depression in medical students, being more severe in women. Students under psychiatric treatment showed a higher prevalence of depression; however, the fact of being under treatment resulted in a protective factor for the increase in the prevalence of depression. It is important to deepen the understanding of the causes of depression and to disseminate among the university community the benefits of early detection and treatment of people with socio-emotional disorders.

Liver stiffness change with HCV cure in HIV-infected patients on non-nucleoside analogues.

BACKGROUND: Liver stiffness (LS) at sustained viral response (SVR) is strongly associated with a lower incidence of subsequent hepatic events. HIV NNRTIs may have a beneficial impact on fibrogenesis. OBJECTIVES: Our aim was to analyse the influence of NNRTI-based therapy on the change in LS from starting direct-acting antiviral (DAA) therapy to achieving SVR in HIV/HCV-coinfected patients. METHODS: Three hundred and thirteen HIV/HCV-coinfected patients who fulfilled the following criteria were included: (i) had achieved SVR with an IFN-free, DAA-including regimen; (ii) LS ≥9.5 kPa before therapy; (iii) LS measurement available at SVR; (iv) seronegative for HBsAg; and (v) ART containing 2 NRTIs plus either 1 NNRTI or 1 integrase inhibitor (INI) or 1-2 NRTIs plus 1 PI. LS changes were assessed. RESULTS: Seventy-four patients received NNRTI-based combinations [53 (71.6%) rilpivirine and 16 (21.6%) efavirenz] and 239 patients received other regimens. At baseline, the median (IQR) LS was 16.7 kPa (11.8-25.6) in the NNRTI group and 17.3 kPa (11.9-27.4) in the non-NNRTI group (P = 0.278). The median (IQR) percentage of LS decrease from baseline to SVR was 35.2% (18.2%-52.3%) for NNRTI-based therapy and 29.5% (10%-45.9%) for PI- or INI-based therapy (P = 0.018). In multivariate analysis, adjusted for sex, age, HCV genotype, NRTI backbone and propensity score for HIV therapy, NNRTI-based regimen use was associated with a higher LS decrease [ß = 11.088 (95% CI = 1.67-20.51); P = 0.021]. CONCLUSIONS: Treatment with NNRTI plus 2 NRTI combinations is associated with a higher LS decline than other ART combinations in HIV/HCV-coinfected patients receiving DAA-based therapy.

Incidence of recently acquired hepatitis C virus infection among HIV-infected patients in southern Spain.

OBJECTIVES: Spain is close to HCV microelimination, so rates of recently acquired HCV infection (RAHC) should decrease. Nowadays, men who have sex with men (MSM) carry the highest risk of HCV acquisition. Our aim was to estimate the incidence of and the factors associated with RAHC, together with reinfection rates, among patients sexually infected by HIV. METHODS: Primary RAHC infection was diagnosed when anti-HCV antibody seroconversion was documented. In anti-HCV positive patients, initially without HCV viraemia, a diagnosis of reinfection was established if plasma HCV RNA was detected. RESULTS: All 350 patients tested negative for anti-HCV at baseline and had at least one follow-up visit. Among them, there were 16 RAHC cases from 2016 to 2019. RAHC incidence rates [IR (95% confidence interval, CI)] per 100 person-years were 3.77 (0.5-12.9) in 2016, 1.85 (0.6-4.3) in 2017, 1.49 (0.4-3.8) in 2018 and 1.98 (0.6-4.5) in 2019. Only previous sexually transmitted infections [incidence rate ratio (IRR) = 18.23, 95% CI: 1.93-172.1; P = 0.011], male sex (IRR = 8.33, 95% CI: 1.38-54.15; P = 0.026) and sharing chem-sex drugs (IRR: 4.93, 95% CI: 1.17-20.76; P = 0.030), were independently associated with RAHC. Four out of 42 (9.5%) patients became reinfected. CONCLUSIONS: The incidence of RAHC among HIV-infected patients showed a decrease after 2016, although a lower but steady incidence of residual cases still remains. HCV reinfections showed a similar pattern. New infections were associated with sharing chem-sex drugs among MSM.

Liver Stiffness at the Time of Sustained Virological Response Predicts the Clinical Outcome in People Living With Human Immunodeficiency Virus and Hepatitis C Virus With Advanced Fibrosis Treated With Direct-acting Antivirals.

BACKGROUND: Some people living with hepatitis C virus (HCV) with sustained virological response (SVR) develop hepatic complications. Liver stiffness (LS) predicts clinical outcome in people living with human immunodeficiency virus (HIV) with active HCV coinfection, but information after SVR is lacking. We aimed to analyze the predictive ability of LS at SVR for liver complications in people living with HIV/HCV with advanced fibrosis treated with direct-acting antivirals (DAA). METHODS: In sum, 640 people living with HIV/HCV fulfilling the following criteria were included: (i) Achieved SVR with DAA-including regimen; (ii) LS ≥ 9.5 kPa before therapy; and (iii) LS measurement available at SVR. The primary endpoint was the occurrence of a liver complication-hepatic decompensation or hepatocellular carcinoma (HCC)-or requiring liver transplant after SVR. RESULTS: During a median (Q1-Q3) follow-up of 31.6 (22.7-36.6) months, 19 (3%) patients reached the primary endpoint. In the multivariate analysis, variables (subhazard ratio [SHR] [95% confidence interval]) associated with developing clinical outcomes were: prior hepatic decompensations (3.42 [1.28-9.12]), pretreatment CPT class B or C (62.5 [3.08-1246.42]) and MELD scores (1.37 [1.03-1.82]), CPT class B or C at SVR (10.71 [1.32-87.01]), CD4 cell counts <200/µL at SVR time-point (4.42 [1.49-13.15]), FIB-4 index at SVR (1.39 [1.13-1.70]), and LS at SVR (1.05 [1.02-1.08] for 1 kPa increase). None of the 374 patients with LS <14kPa at SVR time-point developed a liver complication or required hepatic transplant. CONCLUSIONS: LS at the time of SVR after DAA therapy predicts the clinical outcome of people living with HIV/HCV with advanced fibrosis. These results suggest that LS measurement may be helpful to select candidates to be withdrawn from surveillance programs.

Parenteral drug use as the main barrier to hepatitis C treatment uptake in HIV-infected patients.

OBJECTIVES: Our objective was to identify patient factors associated with being untreated for hepatitis C virus (HCV) infection in HIV-coinfected patients. METHODS: A prospective longitudinal study was carried out. HIV-infected patients with active chronic HCV infection included in the HERACLES cohort (NCT02511496) constituted the study population. The main study outcome was receipt of HCV direct-acting antiviral (DAA) treatment from 1 May 2015 to 1 May 2017. The population was divided into patients who were receiving HCV treatment during follow-up and those who were not. RESULTS: Of the 15 556 HIV-infected patients in care, 3075 (19.7%) presented with chronic HCV infection and constituted the study population. At the end of the follow-up, 1957 patients initiated HCV therapy (63.6%). Age < 50 years, absence of or minimal liver fibrosis, being treatment-naïve, HCV genotype 3 infection, being in the category of people who inject drugs using opioid substitutive therapy (OST-PWID), and being in the category of recent PWID were identified as significant independent risk factors associated with low odds of DAA implementation. When a multivariate analysis was performed including only the PWID population, both OST-PWID [odds ratio (OR) 0.552; 95% confidence interval (CI) 0.409-0.746) and recent PWID (OR 0.019; 95% CI 0.004-0.087) were identified as independent factors associated with low odds of treatment implementation. CONCLUSIONS: We identified factors, which did not include prioritization of a DAA uptake strategy, that limited access to HCV therapy. The low treatment uptake in several populations seriously jeopardizes the elimination of HCV infection in the coming years.

Public insurance program impact on catastrophic health expenditure on acute myocardial infarction.

OBJECTIVE: ST-segment elevation myocardial infarction (STEMI) has an important economic burden that poised the urgent need to evaluate its catastrophic medical expense. This study evaluates the first 5 years of the national health initiative called Popular Insurance (PI) at the National Institute of Cardiology in Mexico. STUDY DESIGN: Retrospective data analysis. METHODS: STEMI patients with (n=317) and without (n=260) PI were selected. Analysed variables included socio-economical context, management care, cost evaluation and three outcomes (mortality, hospital readmission and therapeutic adherence). Descriptive statistical analyses, Kaplan-Meier survival and Support Vector Machine models were used accordingly. RESULTS: Treatment costs were higher for PI-covered individuals (P=0.022) and only 1.89% of them remained in debt, in contrast to 16.15% of those without PI. Statistically significant differences were found in relation to days in hospital wards (P<0.001), imaging studies (P<0.001) and surgical materials (P=0.04). Survival analysis (P=0.44) and therapeutic adherence (P=0.38) showed no differences. Hospital readmission was predicted with an 81.97% accuracy. The most important predictive variables included were stent type, number of days at the coronary care unit and hospital wards. CONCLUSIONS: The PI has proven to be a successful program where no differences were found in terms of health care and survival, whereas it provides timely financial support for families facing catastrophic health challenging events.

Impact of interferon-free regimens on the glomerular filtration rate during treatment of chronic hepatitis C in a real-life cohort.

Little data are available on renal toxicity exerted by direct-acting antivirals (DAAs) in real life. The aim of this study was to assess the impact of direct-acting antivirals against hepatitis C virus infection currently used in Spain and Portugal on the estimated glomerular filtration rate (eGFR) in clinical practise. From an international, prospective multicohort study, patients treated with DAAs for at least 12 weeks and with eGFR ≥30 mL/min per 1.73 m2 at baseline were selected. eGFR was determined using the CKD-EPI formula. A total of 1131 patients were included; 658 (58%) were HIV/HCV-coinfected patients. Among the 901 patients treated for 12 weeks, median (interquartile range) eGFR was 100 (87-107) at baseline vs 97 (85-105) mL/min per 1.73 m2 at week 12 of follow-up (FU12) post-treatment (P < .001). For HIV-coinfected subjects who received tenofovir plus a ritonavir-boosted HIV protease inhibitor (PI/r), baseline vs FU12 eGFR were 104 (86-109) vs 104 (91-110) mL/min per 1.73 m2 (P = .913). Among subjects receiving ombitasvir/paritaprevir with or without dasabuvir, eGFR did not show any significant change. Of 1100 subjects with eGFR >60 mL/min per 1.73 m2 at baseline, 22 (2%) had eGFR <60 mL/min per 1.73 m2 at FU12, but none presented with eGFR <30 mL/min per 1.73 m2 . In conclusion, eGFR slightly declines during therapy with all-oral DAAs and this effect persists up to 12 weeks after stopping treatment in subjects with normal to moderately impaired renal function, regardless of HIV status. Concomitant use of tenofovir plus PI/r does not seem to have an impact on eGFR.

Validación de cinco pulsioxímetros / Validation of five pulse oximeters

Resumen: ANTECEDENTES: la pulsioxímetria estima la saturación arterial de oxígeno mediante la absorción de un haz de luz infrarroja por la oxihemoglobina. OBJETIVO: determinar la validez y la confiabilidad interinstrumento de cinco pulsioxímetros comúnmente usados en la práctica clínica. MATERIAL Y MÉTODO: estudio transversal, analítico, realizado del 1 de enero de 2015 al 30 de octubre de 2016, en el que se incluyeron pacientes mayores de 18 años de edad, con línea arterial para toma de gasometría y se midió simultáneamente la saturación de oxígeno con cinco pulsioxímetros de uso habitual. Se determinaron medianas y porcentajes de los cinco pulsioxímetros entre sí mediante prueba de Friedman. RESULTADOS: se incluyeron 101 pacientes, 63 hombres y 38 mujeres. Se encontró similitud en las mediciones realizadas por cada pulsioxímetro con p = 0.08; todos los oxímetros se correlacionaron de manera positiva contra la prueba patrón de referencia (correlación de Pearson). Oxímetro 1: r = 0.90; oxímetro 2: r = 0.64; oxímetro 3: r = 0.57; oxímetro 4: r = 0.84 y oxímetro 5: r = 0.89; el área bajo la curva mostró oxímetro 1 (0.89), oxímetro 2 (0.88), oxímetro 3 (0.87), oxímetro 4 (0.83), oxímetro 5 (0.85) con p < 0.05. CONCLUSIONES: el pulsioxímetro número 1 muestra el mejor rendimiento comparado con la gasometría. Al comparar los oxímetros entre sí el rendimiento es igual.

Abstract: BACKGROUND: Pulse oximetry estimates the arterial oxygen saturation by absorption of an infrared light beam by oxyhemoglobin. OBJECTIVE: To determine the intraclass validity and reliability of five pulse oximeters commonly used in clinical practice. MATERIAL AND METHOD: A cross-sectional analytical study was done from January 1st 2015 to October 30 2016, including patients over 18 years old, with arterial line for blood gas sample and simultaneously oxygen saturation was measured with 5 pulse oximeters commonly used. Medians and percentages of the 5 pulse oximeters were determined by Friedman's test RESULTS: There were included 101 patients, 63 men and 38 women, with similarity in the measurements performed by each pulse oximeter with p = 0.08; all oximeters were positively correlated against the standard gold test (Pearson's correlation). Oximeter 1: r = 0.90; oximeter 2: r = 0.64; oximeter 3: r = 0.57; oximeter 4: r = 0.84 and oximeter 5: r = 0.89. The area under the curve showed oximeter 1 (0.89), oximeter 2 (0.88), oximeter 3 (0.87), oximeter 4 (0.83), oximeter 5 (0.85) with p < 0.05. CONCLUSIONS: The pulse oximeter number 1 shows a better performance when compared to the gasometry. When the oximeters are compared to each other the performance is the same.

Week 4 response predicts sustained virological response to all-oral direct-acting antiviral-based therapy in cirrhotic patients with hepatitis C virus genotype 3 infection.

OBJECTIVE: The aim of this study was to determine the predictive capacity of response at treatment week (TW) 4 for the achievement of sustained virological response 12 weeks after the scheduled end of therapy date (SVR12) to treatment against hepatitis C virus (HCV) genotype 3 (GT3) infection with all-oral direct-acting antiviral (DAA) -based regimens. PATIENTS AND METHODS: From a prospective multicohort study, HCV GT3-infected patients who completed a course of currently recommended DAA-based therapy at 33 Spanish hospitals and who had reached the SVR12 evaluation time-point were selected. TW4 HCV-RNA levels were categorized as target-not-detected (TND), below the lower limit of quantification (LLOQTD) and ≥LLOQ. RESULTS: A total of 123 patients were included, 86 (70%) received sofosbuvir/ daclatasvir±ribavirin, 27 (22%) received sofosbuvir/ ledipasvir/ ribavirin and 10 (8.1%) received sofosbuvir/ ribavirin, respectively. In all, 114 (92.7%) of the 123 patients presented SVR12 in an on-treatment approach, but nine (7.3%) patients relapsed, all of them had presented cirrhosis at baseline. In those who achieved TND, LLOQTD and ≥LLOQ, SVR12 was observed in 81/83 (98%; 95% CI 91.5%-99.7%), 24/28 (85.7%; 95% CI 67.3%-96%) and 9/12 (75%; 95% CI 42.8%-94.5%), respectively; p(linear association) 0.001. Corresponding numbers for subjects with cirrhosis were: 52/54 (96.3%; 95% CI 87.3%-95.5%), 14/18 (77.8%; 95% CI 52.4%-93.6%) and 7/10 (70%; 95% CI 34.8%-93.3%); p 0.004. CONCLUSIONS: TW4-response indicates the probability of achieving SVR12 to currently used DAA-based therapy in HCV genotype 3-infected individuals with cirrhosis. This finding may be useful to tailor treatment strategy in this setting.

Fat mass and obesity-associated gene variations are related to fatty liver disease in HIV-infected patients.

OBJECTIVES: Fatty liver disease (FLD) is frequently observed in HIV-infected patients. Obesity and type 2 diabetes mellitus (T2DM) are strongly associated with FLD. Because genetic variants within the fat mass and obesity-associated (FTO) gene have been associated with both pathologies, our aim was to evaluate the association of single nucleotide polymorphisms (SNPs) within the FTO, previously related to obesity or T2DM, with FLD in HIV-infected patients. METHODS: FLD was defined as a value of the controlled attenuation parameter (CAP) ≥ 238 dB/m, obtained by transient elastography. Four SNPs within FTO intron 1 (rs11642841, rs8050136, rs9939609 and rs9940128) were genotyped in 421 individuals using a custom Golden Gate protocol. The results were replicated in a validation sample consisting of a further 206 HIV-infected patients. Multivariate logistic regression analyses were conducted in the entire population. RESULTS: Three SNPs (rs8050136, rs9939609 and rs9940128) were associated with FLD, with rs9940128 showing the strongest association. This polymorphism also showed an association with FLD in the validation sample. In total, rs9940128 was genotyped in 627 HIV-infected patients, including 267 (42.6%) FLD-diagnosed individuals. The frequency of FLD among rs9940128 AA carriers was 55.7% (63 of 113 individuals) and that in patients without this genotype was 39.7% (204 of 514 individuals) [P = 0.009; adjusted odds ratio 1.88; 95% confidence interval (CI) 1.17-3.01]. CONCLUSIONS: Variations within FTO may be predictors of FLD in HIV-infected patients independently of metabolic factors.

Impact of universal access to hepatitis C therapy on HIV-infected patients: implementation of the Spanish national hepatitis C strategy.

In April 2015, the Spanish National Health System (SNHS) developed a national strategic plan for the diagnosis, treatment, and management of hepatitis C virus (HCV). Our aim was to analyze the impact of this on human immunodeficiency virus (HIV)-infected patients included in the HERACLES cohort during the first 6 months of its implementation. The HERACLES cohort (NCT02511496) was set up in March 2015 to evaluate the status and follow-up of chronic HCV infection in patients co-infected with HIV in the south of Spain. In September 2015, the data were analyzed to identify clinical events (death, liver decompensation, and liver fibrosis progression) and rate of treatment implementation in this population. The study population comprised a total of 3474 HIV/HCV co-infected patients. The distribution according to liver fibrosis stage was: 1152 F0-F1 (33.2 %); 513 F2 (14.4 %); 641 F3 (18.2 %); 761 F4 (21.9 %); and 407 whose liver fibrosis was not measured (12.3 %). During follow-up, 248 patients progressed by at least one fibrosis stage [7.1 %; 95 % confidence interval (CI): 6.3-8 %]. Among cirrhotic patients, 52 (6.8 %; 95 % CI: 5.2-8.9 %) developed hepatic decompensation. In the overall population, 50 patients died (1.4 %; 95 % CI: 1.1-1.9 %). Eight hundred and nineteen patients (23.56 %) initiated interferon (IFN)-free treatment during follow-up, of which 47.8 % were cirrhotic. In our study, during 6 months of follow-up, 23.56 % of HIV/HCV co-infected patients included in our cohort received HCV treatment. However, we observed a high incidence of negative short-term outcomes in our population.

Clinical, virological and phylogenetic characterization of a multiresistant HIV-1 strain outbreak in naive patients in southern Spain.

BACKGROUND: We describe the characteristics of an HIV-1 strain with six viral reverse transcriptase mutations (D67N, T69N/D, V118I, V179D, T215S and K219Q), which we have called the Malaga strain. This strain was detected in treatment-naive patients from southern Spain. METHODS: The study was undertaken at the Virgen de la Victoria Hospital, Malaga, a reference centre for the study of HIV-1 genotype resistance in Andalusia (the 'Costa del Sol'), Spain. Genotypic resistance testing was done in an automated sequencer. Phylogenetic analysis was performed using a 630 bp region of the reverse transcriptase with the mutations mentioned. RESULTS: Between 2007 and 2014, we detected the Malaga strain in 30 treatment-naive patients. All were MSM, seen at five hospitals on the Costa del Sol. In all cases, the HIV-1 was subtype B with viral tropism R5. Phylogenetic analysis based on the reverse transcriptase sequence showed consistent grouping (with a bootstrap value of the common node of 100%) of the isolates that shared the mutation pattern mentioned. This strain has not been detected elsewhere or in previously treated patients. All of the patients treated with first-line combination ART responded. CONCLUSIONS: We report a cluster of an HIV-1 strain with multiple resistance mutations that was transmitted over a period of >8 years, affecting 30 naive patients from the same geographical area. The strain was susceptible to first-line combination ART.

Dimension of chronic hepatitis C virus in HIV-infected patients in the interferon-free era: an overview from south Spain.

The implementation of hepatitis C (HCV) direct-acting antiviral drugs is prioritized in several populations in which its application provides the most immediate and impactful benefit. In this scenario, a precise knowledge of the situation of human immunodeficiency virus (HIV)/HCV chronic co-infection is required to adequately address this disease. This cross-sectional study was performed in 21 hospitals in Andalusia (Spain). The study population consisted of HIV-infected patients with an active HCV chronic infection who were not receiving HCV treatment at the time of inclusion. A total of 13,506 HIV-infected patients were included in the study. Of them, 2561 (18.9 %) presented chronic HCV infection. The majority of the patients included were on highly active antiretroviral therapy (HAART; 96.2 %), showed plasma levels with an undetectable HIV viral load (92.5 %), and had a good immunological status (median CD4+ cell count of 486 cells/mL). The HCV genotype distribution was as follows: 58.1 % were genotype 1, 1.1 % were genotype 2, 16.1 % were genotype 3, and 22.1 % were genotype 4 (2.6 % were missing data). In total, 24.8 % of the patients showed liver fibrosis stage F0-F1, 27.9 % showed stage F2, 16.7 % showed stage F3, and 21 % showed stage F4 (9.6 % were missing data). With regards to previous HCV treatment experiences, 68.05 % of the patients were naïve and 31.95 % had failed to respond to a previous treatment. The burden of HCV/HIV co-infected patients in our population was reported as one in five HIV-infected patients requiring HCV treatment. The implementation of extra resources to face this important health challenge is mandatory.

Efficacy of and risk of bleeding during pegylated interferon plus ribavirin treatment in HIV/HCV-coinfected patients with pretreatment thrombocytopenia.

The aim of this study was to assess the efficacy of and the risk of major bleeding during pegylated interferon (peg-IFN)/ribavirin (RBV) treatment among human immunodeficiency virus (HIV)/hepatitis C virus (HCV)-coinfected patients according to the pretreatment platelet count. Two hundred and seventy-four HCV/HIV-coinfected, previously naïve individuals with compensated cirrhosis enrolled in one Spanish prospective cohort who received peg-IFN/RBV were included in this study. The frequency of severe bleeding and sustained virological response (SVR) rate were compared between patients with a pretreatment platelet count ≤70,000/mm(3) and >70,000/mm(3), respectively. Sixty-one (22 %) patients had a baseline platelet count ≤70,000/mm(3). The median (Q1-Q3) pretreatment platelet count was 58,000 (49,000-65,000) cells/mm(3) in the platelet ≤70,000 group and 129,000 (102,500-166,000) cells/mm(3) in the platelet >70,000 group (p < 0.0001). Seventeen (28 %) subjects of the platelet ≤70,000 group and 71 (33 %) patients of the platelet >70,000 group achieved SVR (p = 0.4). Only 2 (3.2 %) patients in the platelet ≤70,000 group developed a severe hemorrhagic event, specifically esophageal variceal bleeding. The efficacy of therapy with peg-IFN/RBV in HIV/HCV-coinfected patients with low pretreatment platelet counts is comparable to that found in the overall subset of subjects with compensated cirrhosis. The frequency of severe hemorrhagic events related with this therapy is low in this population.

Epidemiology and clinical features of community-acquired, healthcare-associated and nosocomial bloodstream infections in tertiary-care and community hospitals.

Classification of bloodstream infections (BSIs) as community-acquired (CA), healthcare-associated (HCA) and hospital-acquired (HA) has been proposed. The epidemiology and clinical features of BSI according to that classification in tertiary-care (TH) and community (CH) hospitals were investigated in a prospective cohort of 821 BSI episodes from 15 hospitals (ten TH and five CH hospitals) in Andalucía, Spain. Eighteen percent were CA, 24% were HCA and 58% were HA. The incidence of CA and HCA BSI was higher in CH than in TH (CA: 3.9 episodes per 1000 admissions vs. 2.2, p <0.01; HCA: 5.0 vs. 2.9, p <0.01), whereas the incidence of HA BSI was lower (7.7 vs. 8.7, p <0.01). In CA and HCA BSI, the respiratory tract was more frequently the source in CH than in TH (CA: 30% vs. 15%; HCA: 20% vs. 9%, p ≤0.03). In HCA BSI, chronic renal insufficiency and tunnelled catheters were less frequent in CH than in TH (11% vs. 26% and 7% vs. 19%, p ≤0.03), although chronic ulcers were more frequent (22% vs. 8%, p 0.008). BSIs as a result of methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa were very rare in CA episodes, although extended-spectrum b-lactamase-producing Escherichia coli (ESBLEC) caused a similar proportion of all BSIs in CA, HCA and HA episodes. Multivariate analysis revealed no significant difference in mortality rates in CH and TH. HCA infections should be considered as a separate class of BSI in both TH and CH, although differences between hospitals must be considered. CA BSIs were not caused by multidrug-resistant pathogens, except for ESBLEC.

Bacteriemia, espondilodiscitis y artritis por estreptococo del grupo G en un paciente sin inmunodeficiencia conocida / Bacteriemia, spondylodiscitis and group B streptococcus arthritis in an adult without known immunodeficiency

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[Non-convulsive epileptic status associated with Lafora disease: two case reports]. / Estado epiléptico no convulsivo asociado a enfermedad de Lafora: presentación de dos casos.

INTRODUCTION: Lafora s disease is a type of progressive myoclonic epilepsy with poor prognosis, is characterized by myoclonic crisis, tonic clonic seizures, absence or partial complex seizures and other neurological manifestations with a progressive course and a poor response to the treatment. It has not been considered as a cause of epileptic status. CASE REPORTS: Two women without important past medical history with normal psychomotor development before their suffering, with manifestations of 2 years of evolution the first one and 8 years on the second case characterized by myoclonic generalized, partial complex seizures and progressive deterioration of the mental functions that joined to our institution in a non convulsive epileptic status and they featured with a different evolution. The first patient with favorable control of the event with a single medication and functionality recover later, the second one with torpid evolution complicated with an epileptic status convulsive widespread condition and a prolonged permanency in the unit of intensive therapy. In both patients the diagnosis of Lafora s disease was established based in the findings of the skin axilar biopsy. DISCUSSION AND CONCLUSION: We believe that Lafora s disease must be suspected as a probable cause of non convulsive epileptic status in patients with myoclonic epilepsy associated with other neurological manifestations and a refractary response to the medical treatment. The evolution and clinical response will depend on the evolutionary stage of the disease.

Estado epiléptico no convulsivo asociado a enfermedad de Lafora: presentación de dos casos / Non-convulsive epileptic status associated with lafora disease: two case report

Introducción. La enfermedad de Lafora (EL) es una forma de epilepsia mioclónica progresiva con un pronóstico fatal; se asocia a la presencia de crisis mioclónicas, tonicoclónicas, de ausencia o parciales complejas, asociadas a otras manifestaciones neurológicas, con un curso progresivo y una mala respuesta al tratamiento. No se considera una causa de estado epiléptico (EE). Casos clínicos. Dos mujeres sin antecedentes perinatales ni personales de importancia, con un desarrollo psicomotor normal hasta antes de su padecimiento, con manifestaciones de dos años de evolución la primera y ocho años la segunda, caracterizadas por mioclonías generalizadas, crisis parciales complejas y deterioro progresivo de las funciones mentales, que ingresaron en nuestra institución en EE no convulsivo y presentaron diferente evolución. La primera paciente, con un adecuado control del evento con un sólo fármaco y funcionalidad completa posterior; la segunda, con evolución tórpida complicada con un estado convulsivo generalizado y permanencia prolongada en la Unidad de Terapia Intensiva. En las dos pacientes se estableció el diagnóstico de EL con base en los hallazgos de la biopsia de músculo esquelético y de piel axilar. Discusión. Consideramos que la EL debe sospecharse como probable causa de EE no convulsivo en pacientes con epilepsia mioclónica asociada a otras manifestaciones neurológicas y mala respuesta al tratamiento médico. La evolución y respuesta clínica dependerán de la etapa evolutiva de la enfermedad (AU)

Introduction. Lafora’s disease is a type of progressive myoclonic epilepsy with poor prognosis, is characterized by myoclonic crisis, tonic-clonic seizures, absence or partial complex seizures and other neurological manifestations with a progressive course and a poor response to the treatment. It has not been considered as a cause of epileptic status. Case reports. Two women without important past medical history with normal psychomotor development before their suffering, with manifestations of 2 years of evolution the first one and 8 years on the second case characterized by myoclonic generalized, partial complex seizures and progressive deterioration of the mental functions that joined to our institution in a non convulsive epileptic status and they featured with a different evolution. The first patient with favorable control of the event with a single medication and functionality recover later, the second one with torpid evolution complicated with an epileptic status convulsive widespread condition and a prolonged permanency in the unit of intensive therapy. In both patients the diagnosis of Lafora’s disease was established based in the findings of the skin axilar biopsy. Discussion and conclusion. We believe that Lafora’s disease must be suspected as a probable cause of non convulsive epileptic status in patients with myoclonic epilepsy associated with other neurological manifestations and a refractary response to the medical treatment. The evolution and clinical response will depend on the evolutionary stage of the disease (AU)