Diagnóstico tardío de la infección por VIH / Late diagnosis of HIV infection

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Efectos del VIH y otras variables sobre el resultado del tratamiento antituberculoso en España / Effects of HIV status and other variables on the outcome of tuberculosis treatment in Spain

Objetivo: Analizar el efecto del virus de la inmunodeficiencia humana (VIH) y otras variables sobre el resultado del tratamiento antituberculoso en España. Pacientes y métodos: Estudio multicéntrico de cohorte retrospectivo en 6 comunidades autónomas (de mayo de 1996 a abril de 1997). Se recogió información sobre el resultado del tratamiento en casos nuevos de tuberculosis siguiendo la normativa europea. Se realizó seguimiento de los casos hasta 3 meses después de la fecha prevista de finalización del tratamiento. Resultados: De los 4.899 pacientes incluidos, se observó un resultado satisfactorio en 3.417 (69,7%), 438 (8,9%) murieron antes o durante el tratamiento y 1.044 (21,4%) tuvieron un resultado potencialmente insatisfactorio. Estratificando por el estado de la infección por el VIH, las cifras fueron, respectivamente: para los que la presentaban, del 43,4, el 21,5 y el 35,1%; para los seronegativos, del 71, el 6,2 y el 22,8%, y para aquellos en quienes no constaba, del 74,3, el 7,5 y el 18,2%. El VIH modificaba el efecto de diversas variables sobre el resultado del tratamiento, por lo que se ajustaron modelos de regresión logística separados para cada categoría VIH. Entre los seropositivos, la mortalidad aumentó en enfermos con neoplasias y en usuarios de drogas por vías distintas de la parenteral, mientras que los resultados potencialmente insatisfactorios aumentaron en usuarios de drogas por vía intravenosa y en las mujeres. Conclusiones: En España, el resultado del tratamiento antituberculoso es mucho peor en enfermos infectados por el VIH. El uso de drogas y el hecho de padecer neoplasias tienen un papel importante sobre la mortalidad

Objective: To analyze the effect of human immunodeficiency virus (HIV) status and other variables on the outcome of tuberculosis treatment in Spain. Patients and Methods: Multicenter retrospective cohort study in 6 autonomous communities of Spain (from May 1996 to April 1997). Data on treatment outcome were collected for new cases of tuberculosis in accordance with European guidelines. Follow up of patients continued for 3 months after scheduled end of treatment. Results: Of the 4899 patients included, 3417 (69.7%) had a satisfactory outcome, 438 (8.9%) died before or during treatment, and 1044 (21.4%) had a potentially unsatisfactory outcome. On stratification by HIV status, satisfactory outcome, mortality, and potentially unsatisfactory outcome were reported for 43.4%, 21.5%, and 35.1%, respectively, of HIV-positive patients; 71%, 6.2%, and 22.8%, respectively, of HIV-negative patients; and 74.3%, 7.5%, and 18.2%, respectively, of patients with no HIV status available. HIV modified the effect of several variables on the outcome of treatment, and so separate logistic regression models for each HIV category were constructed. Among HIV-positive patients, mortality increased in patients with neoplastic disease and in users of drugs by nonintravenous routes of administration, whereas potentially unsatisfactory outcomes increased in intravenous drug users and in women. Conclusions: In Spain, the outcome of tuberculosis treatment is much worse in HIV-positive patients. Drug use and presence of neoplastic disease substantially affect mortality

[Results of anti-tuberculosis treatment in six autonomous regions in Spain]. / Resultados del tratamiento antituberculoso en seis comunidades autónomas españolas.

BACKGROUND: To analyze tuberculosis treatment outcome in Spain. PATIENTS AND METHOD: A retrospective cohort study was performed of 6 Autonomous Regions of Spain: Asturias, Catalonia, Galicia, La Rioja, Murcia and Basque Country. Study subjects were new cases of tuberculosis identified through the MPTR who were not in prison at the time of diagnosis (May 1996-April 1997). Information was gathered from the patients' clinical records. Guidelines issued for tuberculosis treatment outcome monitoring in Europe were followed. RESULTS: A total of 4,899 new cases of tuberculosis met the criteria for inclusion. Out of them, 4,240 (86.6%) had enough information on tuberculosis treatment outcome in their clinical record. Results showed that 3,417 cases (69.7%) had a satisfactory outcome, 438 (8.9%) died before or during treatment and 1,044 (21.4%) met the definition of a potentially unsatisfactory outcome. There were important differences in treatment outcome between regions. There were also variations by nationality, age group, HIV status, history of intravenous drug use, history of alcohol abuse and site of disease. CONCLUSIONS: According to the results of our study, the proportion of new cases of tuberculosis that had a satisfactory outcome at the end of treatment do not reach WHO recommended level to effectively control the disease. Therefore, it is necessary to analyze the situation and to propose measures to improve it.

[Effect of antiretroviral treatment and prophylaxis for opportunistic infections on survival of patients with AIDS]. / Efecto del tratamiento antirretrovírico y de la profilaxis para enfermedades oportunistas en la supervivencia de los pacientes con SIDA.

OBJECTIVE: To analyze the influence of anti-retroviral therapy (ART) and prophylaxis against opportunist disease on survival of patients with AIDS. PATIENTS AND METHODS: Study of AIDS patients diagnosed from January 1996 to October 1997 in a Madrid hospital. An analysis was made of demographic, clinical, and immunological data, as well as ART and prophylaxis against Pneumocystis carinii pneumonia (PCP) and tuberculosis (TB). Both univariate and multivariate analyses were performed, as well as Kaplan-Meier curves. RESULTS: A total of 205 patients were included in the study (83% male) with a median age of 34 years. ART, PCP prophylaxis, and TB prophylaxis were received by 147 (72%), 141 (69%) and 22 (11%) patients, respectively. Among individuals on ART, the likelihood of survival at 12 and 22 months since diagnosis of AIDS was made was 79% and 76%, respectively, and among non treated individuals 54% and 54%, respectively (p < 0.05). ART was associated with a 57% decrease in death risk, and regarding PCP prophylaxis, no benefit on survival was found. CONCLUSIONS: ART was significantly associated with a lower risk of death among AIDS patients. The survival rate was not increased with PCP prophylaxis.

Efecto del tratamiento antirretrovírico y de la profilaxis para enfermedades oportunistas en la supervivencia de los pacientes con SIDA / Effect of anti-retroviral therapy and prophylaxis against opportunistic diseases on survival of patients with AIDS

Objetivo. Analizar la influencia del tratamiento antirretrovírico (ARV) y de la profilaxis para enfermedades oportunistas en la supervivencia de pacientes con síndrome de la inmunodeficiencia adquirida (SIDA).Pacientes y métodos. Estudio de seguimiento de los casos de SIDA diagnosticados entre enero de 1996 y octubre de 1997 en un hospital de Madrid. Se analizaron datos demográficos, clínicos, inmunológicos, tratamiento ARV y profilaxis para neumonía por Pneumocystis carinii (NPC) y tuberculosis (TB). Se realizó un estudio univariado, multivariado y curvas de Kaplan-Meier. Resultados. Se incluyeron 205 pacientes (83 por ciento varones); mediana de edad: 34 años. Recibieron tratamiento ARV 147 (72 por ciento), profilaxis para NPC 141 (69 por ciento) y profilaxis para TB 22 (11 por ciento). En los pacientes con tratamiento ARV la probabilidad de supervivencia a los 12 y 22 meses del diagnóstico de SIDA fue de 79 por ciento y 76 por ciento, y en los no tratados de 54 por ciento y 54 por ciento, respectivamente (p < 0,05). El tratamiento ARV se asoció con una reducción del riesgo de muerte del 57 por ciento, sin encontrarse beneficio independiente en la supervivencia en relación con la profilaxis para NPC. Conclusiones. El tratamiento ARV se asocia significativamente con un menor riesgo de muerte en los pacientes con SIDA. La profilaxis para NPC no incrementó la supervivencia (AU)

Toxic oil syndrome mortality: the first 13 years.

BACKGROUND: The toxic oil syndrome (TOS) epidemic that occurred in Spain in the spring of 1981 caused approximately 20000 cases of a new illness. Overall mortality and mortality by cause in this cohort through 1994 are described for the first time in this report. METHODS: We contacted, via mail or telephone, almost every living member of the cohort and family members of those who were known to have died in order to identify all deaths from 1 May 1981 through 31 December 1994. Cause of death data were collected from death certificates and underlying causes of death were coded using the International Classification of Diseases, 9th Revision. RESULTS: We identified 1663 deaths between 1 May 1981 and 31 December 1994 among 19 754 TOS cohort members, for a crude mortality rate of 8.4%. Mortality was highest during 1981, with a standardized mortality ratio (SMR) of 4.92 (95% confidence interval [CI]: 4.39-5.50) compared with the Spanish population as a whole. The highest SMR, (20.41, 95% CI: 15.97-25.71) was seen among women aged 20-39 years during the period from 1 May 1981 through 31 December 1982. Women <40 years old, who were affected by TOS , were at greater risk for death in most time periods than their unaffected peers, while older women and men were not. Over the follow-up period, mortality of the cohort was less than expected when compared with mortality of the general Spanish population, or with mortality of the population of the 14 provinces where the epidemic occurred. We also found that, except for deaths attributed to external causes including TOS and deaths due to pulmonary hypertension, all causes of death were decreased in TOS patients compared to the Spanish population. The most frequent underlying causes of death were TOS, 350 (21.1%); circulatory disorders, 536 (32.3%); and malignancies, 310 (18.7%). CONCLUSIONS: We conclude that while on average people affected by toxic oil syndrome are not at greater risk for death over the 13-year study period than any of the comparison groups, women <40 years old were at greater risk of death.

Factors associated with pathogenicity of oils related to the toxic oil syndrome epidemic in Spain.

The toxic oil syndrome (TOS), which affected over 20,000 persons in Spain in 1981, has been linked to the consumption of aniline-denatured rapeseed oil, but the precise etiologic agent is still unknown. We attempted to validate the use of high concentrations of oleyl anilide as a marker for oils that contain (or contained) the causal agent. We compared the chemical compositions of oils obtained from ill (N = 59) and unaffected (N = 70) families in 1981. Case oils had higher concentrations of fatty acids and sterols in which rapeseed oil is particularly rich. In addition, case oils had more frequent and extensive contamination with oleyl anilide and other fatty acid anilides. We observed a dose-response effect; risk increased sharply with increasing concentrations of oleyl anilide, and no control oil had more than about 825 micrograms per liter of that compound. We conclude that high concentrations of oleyl anilide specifically mark oils that contain (or used to contain) the TOS etiologic agent.

Mortality among people affected by toxic oil syndrome.

The authors conducted a mailed questionnaire survey of a 5% sample of the cohort of 20,643 people officially recognized by the Spanish government as having had toxic oil syndrome, a previously undescribed illness that was epidemic in Spain in 1981. After three mailings of a letter and questionnaire, responses for only 66% of the sample had been received. Nevertheless, responses were obtained from virtually all remaining patients (or surrogates for them in the cases of patients that had died) when they were sought by telephone. In 1981, there was clear-cut excess mortality in the cohort (standardized mortality ratio [SMR] 6.51; 95% confidence interval [CI]: 3.92-10.17). During the period January 1982 through 7 March 1988, there was no statistically significant overall mortality excess except during the period 1982-1983 among people aged < 65 years (SMR 2.26; 95% CI: 1.03-4.29). Toxic oil syndrome substantially altered the patterns of mortality among affected people. Analysis of deaths by cause among the TOS cohort will be useful for further evaluation of the long-term impact of the TOS epidemic.

Toxic oil syndrome: a current clinical and epidemiologic summary, including comparisons with the eosinophilia-myalgia syndrome.

In the spring and summer of 1981, an epidemic of a new illness now referred to as the toxic oil syndrome occurred in central and northwestern Spain, resulting in some 20,000 cases, 12,000 hospital admissions and greater than 300 deaths in the 1st year of the epidemic. The initial onset of illness was usually acute, and patients presented primarily with a respiratory syndrome involving cough, fever, dyspnea, hypoxemia, pulmonary infiltrates and pleural effusions. While approximately 50% of patients recovered from this acute phase of the illness without apparent sequelae, the remaining patients developed an intermediate or chronic phase, or both, of illness involving severe myalgia, eosinophilia, peripheral nerve damage, sclerodermiform skin lesions, sicca syndrome, alopecia and joint contractures, among other findings. Epidemiologic and analytic chemical studies have clearly linked the toxic oil syndrome to the ingestion of oil mixtures containing rapeseed oil denatured with aniline. However, the precise identity of the etiologic agent within this oil has never been determined. Aniline itself did not cause the illness, but the causal agent may be a reaction product of aniline with some oil component. Although many aspects of disease activity in the involved patients have lessened with time, the ultimate consequences of their disease are not clear and are the subject of ongoing study. The recently described eosinophilia-myalgia syndrome in the United States clinically resembles the toxic oil syndrome.