Prevalence of peripheral artery disease (PAD) and factors associated: An epidemiological analysis from the population-based Screening PRE-diabetes and type 2 DIAbetes (SPREDIA-2) study.

AIM: To describe the prevalence of Peripheral Artery Disease (PAD) in a random population sample and to evaluate its relationship with Mediterranean diet and with other potential cardiovascular risk factors such as serum uric acid and pulse pressure in individuals ranged 45 to 74 years. METHODS: Cross-sectional analysis of 1568 subjects (mean age 6.5 years, 43% males), randomly selected from the population. A fasting blood sample was obtained to determine glucose, lipids, and HbA1C levels. An oral glucose tolerance test was performed in non-diabetic subjects. PAD was evaluated by ankle-brachial index and/or having a prior diagnosis. RESULTS: PAD prevalence was 3.81% (95% CI, 2.97-4.87) for all participants. In men, PAD prevalence was significantly higher than in women [5.17% (95% CI, 3.74-7.11) vs. 2.78% (95% CI, 1.89-4.07); p = 0.014]. Serum uric acid in the upper quartile was associated with the highest odds ratio (OR) of PAD (for uric acid > 6.1 mg/dl, OR = 4.31; 95% CI, 1.49-12.44). The remaining variables more strongly associated with PAD were: Heart rate >90 bpm (OR = 4.16; 95%CI, 1.62-10.65), pulse pressure in the upper quartile (≥ 54 mmHg) (OR = 3.82; 95%CI, 1.50-9.71), adherence to Mediterranean diet (OR = 2.73; 95% CI, 1.48-5.04), and former smoker status (OR = 2.04; 95%CI, 1.00-4.16). CONCLUSIONS: Our results show the existence of a low prevalence of peripheral artery disease in a population aged 45-74 years. Serum uric acid, pulse pressure and heart rate >90 bpm were strongly associated with peripheral artery disease. The direct association between Mediterranean diet and peripheral artery disease that we have found should be evaluated through a follow-up study under clinical practice conditions.

Introduction on health recommender systems.

People are looking for appropriate health information which they are concerned about. The Internet is a great resource of this kind of information, but we have to be careful if we don't want to get harmful info. Health recommender systems are becoming a new wave for apt health information as systems suggest the best data according to the patients' needs.The main goals of health recommender systems are to retrieve trusted health information from the Internet, to analyse which is suitable for the user profile and select the best that can be recommended, to adapt their selection methods according to the knowledge domain and to learn from the best recommendations.A brief definition of recommender systems will be given and an explanation of how are they incorporated in the health sector. A description of the main elementary recommender methods as well as their most important problems will also be made. And, to finish, the state of the art will be described.

Síndrome metabólico en pacientes con enfermedad arterial periférica / Metabolic syndrome in patients with peripheral arterial disease

Antecedentes y objetivos. La prevalencia del síndrome metabólico (SM) en pacientes con enfermedad arterial periférica (EAP) y arteriosclerosis de otros territorios está incrementada, pero se desconoce si también lo está en pacientes con EAP aislada. En pacientes con EAP, sin otra enfermedad aterosclerótica, hemos evaluado la prevalencia del SM y el grado de control de los factores de riesgo y fármacos cardiovasculares en comparación con enfermos sin SM. Pacientes y métodos. Estudio transversal multicéntrico, subestudio del PERIFÉRICA, realizado en consultas de atención primaria y especializada en 2009. Se incluyeron 3.934 pacientes, con ≥45 años y EAP documentada mediante el índice tobillo-brazo <0,9, amputación o revascularización arterial, sin antecedentes de enfermedad coronaria y/o cerebrovascular. Resultados. La edad media fue 67,6 años y el 73,8% eran varones. La prevalencia del SM fue del 63% (IC95% 61,5-64,3%). Los pacientes con SM tenían mayor prevalencia de factores de riesgo, mayor comorbilidad, una EAP más grave y utilizaban más frecuentemente fármacos cardiovasculares. Tras ajustar por factores de riesgo y comorbilidad, los bloqueadores del sistema renina-angiotensina, betabloqueantes, diuréticos y estatinas eran los fármacos utilizados con mayor frecuencia. Los objetivos de presión arterial (22% vs. 41,5%, p<0,001) y de HbA1c en pacientes diabéticos (44% vs. 53,1%, p<0,001) se alcanzaron menos frecuentemente en los pacientes con SM que en los que no tenían esta condición, sin que hubiera diferencias en cuanto al colesterol-LDL (29,8% vs. 39,1%, p=0,265). Conclusión. Cerca de dos tercios de los pacientes con EAP padecen el SM. A pesar de utilizar más fármacos cardiovasculares los objetivos terapéuticos se alcanzan en una menor proporción que en los pacientes sin SM (AU)

Background and objective. The prevalence of metabolic syndrome (MS) in patients with peripheral arterial disease (PAD) and coronary or cerebrovascular disease is increasing, but it is not known whether this association also exists in patients with isolated PAD. The aim of the current study was to assess the prevalence of MS in patients with PAD who had no coronary or cerebrovascular disease, the prescription rate of evidence-based cardiovascular therapies and the attainment of therapeutic goals in patients with PAD and with and without MS. Patients and methods. Multicenter, cross-sectional study of 3.934 patients aged ≥ 45 years with isolated PAD who were treated in primary care and specialized outpatient clinics during 2009. A diagnosis of PAD was reached for ankle brachial indices <0.9, a previous history of amputation or revascularization. Results. In the overall population, the mean age was 67.6 years, 73.8% were males and 63% had MS (95% CI 61.5-64.3%). Patients with MS had a higher prevalence of cardiovascular risk factors and comorbidities, more severe PAD and higher prescription rate of evidence-based cardiovascular therapies. After adjusting for risk factors and comorbidity, there was a more frequent use of renin-angiotensin system blockers, beta-blockers, diuretics and statins among the patients with MS. A lower percentage of patients with MS achieved the therapeutic goals for blood pressure (22% vs. 41.5%, p<0.001). Similarly, a lower percentage of patients with diabetes achieved the glycated hemoglobin goals (44% vs. 53.1%, p<0.001), with no differences in LDL-cholesterol levels (29.8% vs. 39.1%, p=0.265). Conclusion. Patients with PAD have a high prevalence of MS. Patients with MS do not attain therapeutic goals as frequently as those without, despite taking more cardiovascular drugs (AU)

Metabolic syndrome in patients with peripheral arterial disease. / Síndrome metabólico en pacientes con enfermedad arterial periférica.

BACKGROUND AND OBJECTIVE: The prevalence of metabolic syndrome (MS) in patients with peripheral arterial disease (PAD) and coronary or cerebrovascular disease is increasing, but it is not known whether this association also exists in patients with isolated PAD. The aim of the current study was to assess the prevalence of MS in patients with PAD who had no coronary or cerebrovascular disease, the prescription rate of evidence-based cardiovascular therapies and the attainment of therapeutic goals in patients with PAD and with and without MS. PATIENTS AND METHODS: Multicenter, cross-sectional study of 3.934 patients aged ≥ 45 years with isolated PAD who were treated in primary care and specialized outpatient clinics during 2009. A diagnosis of PAD was reached for ankle brachial indices <0.9, a previous history of amputation or revascularization. RESULTS: In the overall population, the mean age was 67.6 years, 73.8% were males and 63% had MS (95% CI 61.5-64.3%). Patients with MS had a higher prevalence of cardiovascular risk factors and comorbidities, more severe PAD and higher prescription rate of evidence-based cardiovascular therapies. After adjusting for risk factors and comorbidity, there was a more frequent use of renin-angiotensin system blockers, beta-blockers, diuretics and statins among the patients with MS. A lower percentage of patients with MS achieved the therapeutic goals for blood pressure (22% vs. 41.5%, p<0.001). Similarly, a lower percentage of patients with diabetes achieved the glycated hemoglobin goals (44% vs. 53.1%, p<0.001), with no differences in LDL-cholesterol levels (29.8% vs. 39.1%, p=0.265). CONCLUSION: Patients with PAD have a high prevalence of MS. Patients with MS do not attain therapeutic goals as frequently as those without, despite taking more cardiovascular drugs.

Evaluación de la calidad de las páginas webs de los hospitales del Sistema Sanitario Público de Andalucía / Evaluation of the Andalusia Public Health System hospital websites in the period 2010-2012

Objetivos: Evaluar la calidad, la accesibilidad y la presencia de herramientas 2.0 de las páginas webs de los hospitales del Sistema Sanitario Público de Andalucía. Métodos: Estudio observacional descriptivo durante el periodo 2010-2012. Las variables analizadas fueron: calidad, accesibilidad y presencia de herramientas 2.0. La calidad se evaluó mediante el cuestionario de Bermúdez-Tamayo, la accesibilidad con la herramienta Test de Accesibilidad Web y las herramientas 2.0 por observación directa. Resultados: Disponían de página web en 2010, 31 de los 45 hospitales (68,9%), incrementándose hasta 34 (75,5%) en 2012. La puntuación media + desviación estándar (DE) del cuestionario de calidad Bermúdez Tamayo fue de 11,1 + 3,8 puntos en 2010 y de 12,3 + 3,9 puntos en el año 2012, observándose una diferencia entre las medias de 0,25 (IC del 95%, 0,00 a 0,50) estadísticamente significativa (p = 0,007). En la evaluación de la accesibilidad, solo 7 páginas webs (n = 31) en 2010 y 10 (n = 34) en 2012 cumplían criterios legales de accesibilidad. El uso de herramientas 2.0 se incrementó a lo largo del estudio. En 2010 disponían de este tipo de herramientas el 19,4% (n = 6) de las páginas webs de los hospitales y en 2012 el 58,8% (n = 20). Conclusiones: La calidad evaluada con el cuestionario Bermúdez-Tamayo, en general, fue buena. Sin embargo, se observó un incumplimiento de la legislación en materia de accesibilidad, que debe ser revisada y adaptada a la normativa legal vigente. Se constató la incipiente utilización de los recursos web 2.0 como estrategias de educación y comunicación en materia de salud (AU)

Objectives: Evaluate the quality, accessibility and presence of Web 2.0 tools in the Andalusia Public Health System hospitals websites Methods: Observational, descriptive study carried out between 2010 and 2012. The variables analyzed were: quality, accessibility and innovation. The quality was evaluated using a Bermudez-Tamayo questionnaire. Accessibility was measured using the Web Accessibility Test (TAW) tool. Web 2.0 tools were identified by direct observation. Results: A total of 31 of the 45 hospitals (68.9%) had a website in the year 2010, increasing to 34 (75.5%) in 2012. The average score + standard deviation (SD) of the Bermudez-Tamayo quality questionnaire was 11.1 + 3.8 points in 2010, and 12.3 + 3.9 points in 2012, observing a statistically significant difference of 0.25 being observed between the means (P=.007), 95% CI; 0.00 to 0.50) In the accessibility evaluation only 7 websites (n = 31) in 2010, and 10 (n = 34) in 2012, fulfilled the legal criteria for accessibility. The use of Web 2.0 tools has increased throughout the study. In 2010, 19.4% (n = 6) of the hospital websites had this type of tool, in comparison to 58.8% (n = 20) in 2012. Conclusions: In general, the quality of the websites studied is good. However, current legislation regarding accessibility is not fulfilled and must be revised and adapted to the current legal rules. There is an incipient use of Web 2.0 resources as education and communication strategies with regard to health

[Evaluation of the Andalusia Public Health System hospital websites in the period 2010-2012]. / Evaluación de la calidad de las páginas webs de los hospitales del Sistema Sanitario Público de Andalucía.

OBJECTIVES: Evaluate the quality, accessibility and presence of Web 2.0 tools in the Andalusia Public Health System hospitals websites METHODS: Observational, descriptive study carried out between 2010 and 2012. The variables analyzed were: quality, accessibility and innovation. The quality was evaluated using a Bermudez-Tamayo questionnaire. Accessibility was measured using the Web Accessibility Test (TAW) tool. Web 2.0 tools were identified by direct observation. RESULTS: A total of 31 of the 45 hospitals (68.9%) had a website in the year 2010, increasing to 34 (75.5%) in 2012. The average score+standard deviation (SD) of the Bermudez-Tamayo quality questionnaire was 11.1+3.8 points in 2010, and 12.3+3.9 points in 2012, observing a statistically significant difference of 0.25 being observed between the means (P=.007), 95% CI; 0.00 to 0.50) In the accessibility evaluation only 7 websites (n=31) in 2010, and 10 (n=34) in 2012, fulfilled the legal criteria for accessibility. The use of Web 2.0 tools has increased throughout the study. In 2010, 19.4% (n=6) of the hospital websites had this type of tool, in comparison to 58.8% (n=20) in 2012. CONCLUSIONS: In general, the quality of the websites studied is good. However, current legislation regarding accessibility is not fulfilled and must be revised and adapted to the current legal rules. There is an incipient use of Web 2.0 resources as education and communication strategies with regard to health.

Treatment of leishmaniasis in HIV-positive patients

It presents study about treatment types's of leishmaniasis in HIV-positive patients. Document in PDF format, required Acrobat Reader.

[Ankle-brachial index in patients with diabetes mellitus: prevalence and risk factors]. / Indice tobillo-brazo en pacientes con diabetes mellitus: prevalencia y factores de riesgo.

INTRODUCTION: Diabetic patients have a high cardiovascular morbidity and mortality rate. Ankle brachial index (ABI) is an available, straightforward and reproducible method for the detection of peripheral vascular disease and for improving risk stratification in this population. The objective of our study was to evaluate the prevalence of a low and a pathological ABI in type 2 diabetics older than 60 years and to study the risk factors associated with its development. PATIENTS AND METHODS: 1,360 subjects between 60 and 79 years, 213 of them diabetics, without symptoms of intermittent claudication and who gave their consent to have an ABI measurement in their primary care center were included in the study. Cardiovascular risk factors were evaluated in all participants. An ABI < 0.9 was considered low and a value < 0.9, >or= 1.4 or non-compressible was considered pathological. RESULTS: Prevalence of a low ABI in subjects with or without diabetes was 11.3% and 4.3% and prevalence of a pathological ABI was 18.8% and 7%, respectively. Factor associated with a low or pathological ABI were gender, age, duration of diabetes, the type of antidiabetic treatment and the presence of vascular disease in another vascular bed. After multivariate adjustment, only age (OR: 1.15; 95% CI: 1.04-1.27) and duration of diabetes (OR: 1.05; 95% CI: 1.01-1.10) continue being significant. The prevalence of a pathological ABI did not differ between diabetics without vascular disease and non-diabetics with previous cardiovascular disease. CONCLUSION: The prevalence of a low or pathological ABI is elevated in diabetic subjects and relates with age, duration of diabetes and the presence of vascular disease in another vascular bed.

Índice tobillo-brazo en pacientes con diabetes mellitus: prevalencia y factores de riesgo / Ankle-brachial index in patients with diabetes mellitus: prevalence and risk factors

Introducción. Los pacientes diabéticos presentan una elevada morbimortalidad cardiovascular. El índice tobillo-brazo (ITB) es un método sencillo, barato y reproducible para detectar la existencia de enfermedad vascular periférica y mejorar la estratificación del riesgo cardiovascular en esta población. El objetivo de nuestro estudio fue evaluar la prevalencia de un ITB bajo y de un ITB patológico en pacientes diabéticos tipo 2 mayores de 60 años y conocer los factores que se asocian con su presencia. Pacientes y métodos. Fueron estudiados 1.360 sujetos de entre 60 y 79 años de edad, 213 de ellos diabéticos, sin clínica de claudicación intermitente, que accedieron de forma voluntaria a realizarse un ITB en su Centro de Salud. A todos ellos se les determinaron sus factores de riesgo cardiovascular. Se consideró un ITB bajo a un valor < 0,9 y un ITB patológico a un valor < 0,9, ≥ 1,4 o incompresible. Resultados. La prevalencia de un ITB bajo en pacientes con y sin diabetes fue del 11,3% y del 4,3% y la de un ITB patológico del 18,8% y del 7%, respectivamente. Los factores que se asociaron con un ITB bajo o patológico en la población diabética fueron el sexo, la edad, los años de evolución de la diabetes, el tratamiento antidiabético recibido y la presencia o no de enfermedad vascular en otro territorio. En el análisis multivariante sólo la edad (OR: 1,15; IC 95%: 1,04-1,27) y los años de evolución de la diabetes (OR: 1,05; IC 95%: 1,01-1,10) permanecieron significativos. La prevalencia de un ITB patológico fue similar en sujetos diabéticos sin enfermedad cardiovascular que en pacientes no diabéticos con enfermedad cardiovascular previa. Conclusión. La prevalencia de un ITB bajo o patológico es elevada en los pacientes diabéticos, siendo dependiente de la edad, los años de evolución de la diabetes y la presencia de enfermedad vascular a nivel coronario o cerebral (AU)

Introduction. Diabetic patients have a high cardiovascular morbidity and mortality rate. Ankle brachial index (ABI) is an available, straightforward and reproducible method for the detection of peripheral vascular disease and for improving risk stratification in this population. The objective of our study was to evaluate the prevalence of a low and a pathological ABI in type 2 diabetics older than 60 years and to study the risk factors associated with its development. Patients and methods. 1,360 subjects between 60 and 79 years, 213 of them diabetics, without symptoms of intermittent claudication and who gave their consent to have an ABI measurement in their primary care center were included in the study. Cardiovascular risk factors were evaluated in all participants. An ABI < 0.9 was considered low and a value < 0.9, ≥ 1.4 or non-compressible was considered pathological. Results. Prevalence of a low ABI in subjects with or without diabetes was 11.3% and 4.3% and prevalence of a pathological ABI was 18.8% and 7%, respectively. Factor associated with a low or pathological ABI were gender, age, duration of diabetes, the type of antidiabetic treatment and the presence of vascular disease in another vascular bed. After multivariate adjustment, only age (OR: 1.15; 95% CI: 1.04-1.27) and duration of diabetes (OR: 1.05; 95% CI: 1.01-1.10) continue being significant. The prevalence of a pathological ABI did not differ between diabetics without vascular disease and non-diabetics with previous cardiovascular disease. Conclusion. The prevalence of a low or pathological ABI is elevated in diabetic subjects and relates with age, duration of diabetes and the presence of vascular disease in another vascular bed (AU)

Índice tobillo-brazo y riesgo cardiovascular estimado mediante la función SCORE en sujetos no diabéticos en prevención primaria / Ankle/arm index and cardiovascular risk estimated by SCORE function in non-diabetic subjects in primary prevention

Introducción. El índice tobillo-brazo (ITB) es una prueba con alta sensibilidad y especificidad para la detección de enfermedad arterial periférica (EAP) y que, cuando es patológico, se asocia a un mayor riesgo de arteriosclerosis en otros territorios vasculares. Los objetivos de este estudio fueron evaluar la prevalencia de un ITB patológico en función del riesgo cardiovascular calculado mediante la función SCORE, estudiar las variables asociadas con un ITB patológico y determinar qué sujetos del grupo con riesgo intermedio presentan una mayor prevalencia de ITB patológico. Sujetos y métodos. Se ha estudiado a un total de 1.001 sujetos, con edades comprendidas entre los 60 y los 79 años, sin antecedentes de enfermedad cardiovascular o diabetes. A todos se les determinó el ITB y se valoró su riesgo cardiovascular utilizando las tablas del proyecto SCORE para poblaciones del sur de Europa. Resultados. El 6,4% de la población presentaba un ITB patológico. Un 17,5% de los participantes tenía un riesgo cardiovascular elevado (é 5% a 10 años), un 31,3% intermedio (3-4% a 10 años) y el resto bajo (< 3% a 10 años). El porcentaje de ITB patológico en estos 3 grupos fue del 11,9, 8,9 y 3,3%, respectivamente (p < 0,001). La edad, el consumo de tabaco, la hipertensión arterial, la glucemia y el colesterol unido a lipoproteínas de alta densidad (cHDL) (de forma inversa) se asociaron significativamente con un ITB patológico en el análisis multivariante. En el grupo con riesgo intermedio sólo aquellos sujetos con una glucemia é 110 mg/dl tenían un significativo mayor porcentaje de ITB patológico que aquellos con una glucemia menor (el 18,9 frente al 7,6%; p = 0,023). Conclusiones. La determinación del ITB en sujetos mayores de 60 años sin enfermedad cardiovascular ni diabetes obliga a cambios terapéuticos y a la búsqueda de arteriosclerosis en otros territorios vasculares en 1 de cada 8 sujetos con riesgo cardiovascular elevado, y en 1 de cada 11 con riesgo intermedio. En este último grupo es más eficiente la determinación en aquellos con una glucemia é 110 mg/dl (AU)

Introduction. The ankle/arm index (ABI) has high sensitivity and specificity in detecting peripheral artery disease (PAD). An abnormal ABI is associated with a high risk of arteriosclerosis in other vascular territories. The objectives of this study were to evaluate the prevalence of an abnormal ABI depending on cardiovascular risk (CVR) status calculated through the Systematic Coronary Risk Evaluation (SCORE) function, to study the variables associated with an abnormal ABI, and to determinate which subjects in the group with moderate risk have a high prevalence of abnormal ABI. Subjects and methods. A total of 1,001 subjects between the ages of 60 and 79 years, with no history of cardiovascular disease or diabetes were studied. ABI was measured and their cardiovascular disease risk status was calculated using the tables of the SCORE project for populations in southern Europe. Results. An abnormal ABI was found in 6.4% of the population. High CVR (10-year risk é 5%) was found in 17.5%, moderate CVR (10-year risk between 3-4%) was found in 31.1%, and low CVR (10-year risk 60 years without diabetes or cardiovascular disease indicates the need for therapeutic changes and investigation of arteriosclerosis in other vascular territories in 1 out of every 8 high risk subjects and in 1 out of every 11 moderate risk subjects. In the moderate risk group, ABI determination is more efficient in subjects with glucemia é 110 mg/dl (AU)

Visceral leishmaniasis in those infected with HIV: clinical aspects and other opportunistic infections.

Cases of visceral leishmaniasis (VL) in HIV-positive individuals have been reported from most areas of the world where the geographical distributions of the two infections overlap. The majority of the co-infected cases that have been recorded, however, live around the Mediterranean basin. In these subjects, the length of the incubation period of VL is presumably very short, particularly in those who have severe immunodepression. At diagnosis, almost all cases of VL/HIV co-infection have been found to have fewer than 200 CD4+ cells/microl blood, and about 50% meet the AIDS-defining criteria during their first episode of VL. The clinical manifestations of VL in HIV-infected individuals may be similar to those seen in HIV-negative cases; fever, pancytopenia and hepato-splenomegaly, for example, are found in 75% of all the HIV-positive cases. Following the dissemination of the parasites, however, the HIV-positive cases may develop unusual, multi-organ pathology. Almost all the cases of co-infection are very prone to VL relapses, even after carefully managed antileishmanial treatment. The opportunistic infections that are often seen in HIV-positives frequently develop during VL episodes, the signs and symptoms of the leishmaniasis then confusingly overlapping with those of the other infections.

Treatment of leishmaniasis in HIV-positive patients.

Although, in southern Europe, there has been considerable experience in the treatment of visceral leishmaniasis (VL) in HIV-positive patients, the optimal therapy has yet to be established. Pentavalent antimony salts, free amphotericin B deoxycholate (ABD) and lipidic formulations of amphotericin B are the drugs most commonly used. Treatment with pentavalent antimonials requires daily injections for 28 days, is not well tolerated and leads to initial clinical cure in only 66% of the co-infected cases. Free ABD has to be given, intravenously, for just as long, has significant toxicity and leads to initial clinical cure in even fewer cases (62%). In a prospective, comparative trial, treatment of co-infected cases with a pentavalent antimonial was found to have similar efficacy and toxicity to treatment with free ABD. The duration of treatment and the associated toxicity may both be reduced by the use of lipidic formulations of amphotericin B. Anecdotal evidence and the results of non-randomized trials indicate that treatment with liposomal amphotericin B is highly effective. In a comparative trial, amphotericin B lipid complex was found to be not only as effective as a pentavalent antimonial but also better tolerated. At the moment, however, such lipidic formulations have only been tested against VL/HIV cases in Europe, not elsewhere in the world, and they remain very expensive. However successful the treatment in terms of initial clinical cure, almost all VL/HIV cases develop VL relapses. Although the data available on secondary prophylaxis are limited and often inconclusive, it appears that regular treatment with a pentavalent antimonial drug, liposomal amphothericin B or amphotericin B lipid complex can reduce the incidence of leishmanial relapses in HIV-positive patients with VL. The development of new regimens, use of new oral drugs (such as miltefosine) and the development of new antileishmanial drugs could all improve the treatment of HIV-related VL in the future.

A nested polymerase chain reaction (Ln-PCR) for diagnosing and monitoring Leishmania infantum infection in patients co-infected with human immunodeficiency virus.

We investigated a Leishmania-specific nested polymerase chain reaction (Ln-PCR) for the diagnosis and treatment monitoring of L. infantum infections in patients co-infected with human immunodeficiency virus (HIV). Peripheral blood and bone marrow samples from 89 HIV patients in Spain suspected of having leishmaniasis were examined by different diagnostic techniques (Ln-PCR, microscopy, NNN culture and indirect fluorescent antibody test). The sensitivity of Ln-PCR compared with microscopy and culture of bone marrow was 95.45% using blood and 100% when using bone marrow. 38 of these patients with confirmed leishmaniasis were entered in a chemotherapy trial (reported elsewhere), and samples from them were collected before treatment, one month after treatment ended and during follow-up (1-20 months), and examined similarly. Ln-PCR was shown to be a good method for testing efficacy of treatment and for predicting relapses after treatment (relapses were predicted on average 5 months earlier than when using classical diagnostic techniques). We suggest that Ln-PCR (especially using peripheral blood) should be the technique of choice for diagnosis, monitoring the success of treatment, and predicting relapses in patients with HIV and suspected or confirmed L. infantum infection.

[Recommendation of GESIDA (AIDS Study Group)/National Plan on AIDS with respect to the anti-retroviral treatment in adult patients infected with the human immunodeficiency virus in the year 2000 (I)]. / Recomendaciones de GESIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretrovírico en pacientes adultos infectados por el virus de la inmunodeficiencia humana en el año 2000 (I).

OBJECTIVE: To update the recommendations for antiretroviral therapy in adult HIV-infected persons according to the new scientific advances and the existence of new antiretroviral drugs in the last two years. METHODS: The antiretroviral therapy recommendations have been condensed by a panel of experts from the Spanish AIDS Study Group (Grupo de Estudio de sida-GESIDA) of the Spanish Infectious Diseases and Clinical Microbiology Society (SEIMC) and from the Clinical Advisory Panel of the Secretariat of the Spanish National Plan on AIDS (SPNS) of the Ministry of Health. Three levels of evidence have been established depending if the data came from randomised and controlled studies, from cohort or case-control studies or from descriptive studies and expert opinions. For that purpose we have reviewed the advances in HIV pathophysiology and results of efficacy (clinical, virologic and immunologic) and security (toxicity) from clinical trials involving antiretroviral therapy lasting at least 12 months, from cohort studies and pharmacokinetic and security data of antiretroviral drugs, presented in international conferences or published in biomedical journals in the last two years. In each situation we have established either to recommend or to consider or not recommend antiretroviral therapy. RESULTS: Nowadays, antiretroviral therapy consisting of at least three drugs constitutes the election therapy for chronic HIV infection, since it delays clinical progression, increases significantly the survival and diminishes hospital admissions and associated costs. The decision to start antiretroviral therapy must be based upon three elements: presence or absence of symptoms, plasma viral load and CD4+ cells counts. Thus, in asymptomatic cases with a high CD4+ cells count (> 500/microL) and low viral load (< 10,000 copies/ml by branched DNA [bDNA] or < 20,000 copies/ml by reverse-transcription polymerase chain reaction [RT-PCR] or nucleic acid sequence based amplification [NASBA]) we recommend to delay antiretroviral therapy. In symptomatic patients we recommend to start it, and in asymptomatic patients, we could recommend or consider antiretroviral therapy initiation depending on the risk of progression, established by the viral load and the CD4+ cells count. In any case, if therapy is started, the objective must be to reach an undetectable viral load (< 50 copies/ml). The adherence to antiretroviral therapy plays a key role for its initial moment and for the duration of the antiviral response, antiretroviral therapy can achieve a restoration of cellular immunity in the advanced patients. There are few therapeutic options in failing patients due to cross-resistance. Resistance studies can be useful in this setting. The toxicity is a new and limiting factor of antiretroviral therapy which requires to look for new therapeutic options. Antiretroviral therapy criteria for acute infection, pregnancy, post-exposure prophylaxis and when to use resistance testing are discussed. CONCLUSIONS: In this moment, there is a more conservative attitude towards starting antiretroviral therapy than in previous recommendations in which a virus eradication was considered. On the other hand, the high number of disposable drugs, the more sensitive monitorization methods (plasma viral load) and the possibility of performing resistance studies make therapeutic strategies more dynamic and individualised for each patient and situation. In any case, it is mandatory to ensure a perfect adherence to antiretroviral therapy from the patients.

HIV--Leishmania infantum co-infection: humoral and cellular immune responses to the parasite after chemotherapy.

Specific serum antibodies, peripheral blood T-cell subsets, cellular response in vitro to soluble Leishmania antigens, phenotype of stimulated cells, and serum levels of tumour necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta 1 were studied in Spain in 17 patients co-infected with HIV and Leishmania infantum who had been previously treated with pentavalent antimony. Both humoral and cellular responses to Leishmania sp. appeared diminished, 8 out of 17 patients were positive by indirect immunofluorescence, and immunoblotting detected heterogeneous antibody-binding pattern in 11 out of 13 subjects. A blastogenesis test was positive in 4 cases; 2 of them presented proliferation of CD4+ cells while CD8+ cells proliferated in the other 2 patients. Serum levels of TNF-alpha were similar to those observed in patients infected with HIV only, while serum levels of TGF-beta 1 were significantly lower in the co-infected patients. The inability of antibody response to control the parasite and the absence of specific T-cell immunity to Leishmania sp. would explain the high frequency of relapses reported in these patients. The decreased levels of TGF-beta 1 could have an important role in the interaction between the 2 pathogens.

Diagnostic utility of a multiplex herpesvirus PCR assay performed with cerebrospinal fluid from human immunodeficiency virus-infected patients with neurological disorders.

We used a multiplex nested-PCR assay for the simultaneous detection in cerebrospinal fluid (CSF) of five human herpesviruses (HVs) (cytomegalovirus [CMV], Epstein-Barr virus [EBV], varicella-zoster virus [VZV], herpes simplex virus [HSV], and human herpesvirus 6 [HHV-6]) in a clinical evaluation of human immunodeficiency virus (HIV)-infected patients with neurological disorders. This method, which has the advantages of being rapid and economical, would be of particular interest for the diagnosis of neurological syndromes caused by more than one HV. We studied 251 CSF samples from 219 patients. HV DNA was demonstrated in 93 (37%) of the CSF samples (34% of the patients). CMV was the HV most frequently detected in our patients (25%), while EBV, VZV, HSV, and HHV-6 DNAs were present in significantly fewer cases (7, 4, 3, and 1%, respectively). When results were compared with the final etiological diagnoses of the patients, the multiplex HV PCR showed high specificity for the diagnosis of CMV and VZV neurological diseases and for cerebral lymphoma (0.95, 0.97, and 0.99, respectively). The sensitivity of the assay was high for CMV disease (0.87), was low for cerebral lymphoma (0.33), and was not evaluable for VZV disease due to the small number of patients with this diagnosis. Nevertheless, detection of VZV DNA had possible diagnostic value in four of the nine cases, and EBV DNA amplification always predicted the diagnosis of cerebral lymphoma in patients with cerebral masses. Detection of HSV DNA was frequently associated with CMV amplification and fatal encephalitis. HHV-6 was not considered to have a pathogenetic role in the three cases in which it was detected. This multiplex HV PCR assay is a specific and clinically useful method for the evaluation of HIV-infected patients with neurological disorders related to HV.

[The recommendations of GESIDA/SEFH/PNS for improving adherence to antiretroviral treatment. AIDS Study Group of the Spanish Society of Hospital Pharmacy and the National Plan on AIDS of the Minister of Health and Consumers]. / Recomendaciones GESIDA/SEFH/PNS para mejorar la adherencia al tratamiento antirretroviral. Grupo de Estudio de SIDA (GESIDA) de la SEIMC, por la Sociedad Española de Farmacia Hospitalaria (SEFH) y por el Plan Nacional sobre el SIDA (PNS) del Ministerio de Sanidad y Consumo (MSC).

The main objective of HAART is to achieve a complete suppression of the viral replication for long time. However, when the therapeutic drug levels are low, HIV can replicate and it can develop resistances. This fact can be the reason of treatment failure, HIV transmission of resistant strains and therefore an inappropriate use of the economical resources. In order to get the adequate therapeutic drug levels it is necessary to have a good adherence to the treatment. We review the factors that influence the adherence, the evaluation methods and we recommend the possible intervention strategies which should be given by a multidisciplinary team, integrated by physicians, pharmacists, nurses, psychologists and other personal support. To start HAART is not an emergency. For this reason is very important to prepare to the patient and to identify the non-adherence factors in order to correct it. Once the HAART is indicated it is very important to offer information during the medical prescription and when the drugs are dispensed. During the therapy is necessary to follow actively all patients on HAART. In order to make therapeutical decisions we need to know the patient drug adherence rate. We recommend to use several methods to calculate the drug adherence rate, being the most commonly used the patient interview, the patient questionnaire, the refill count, the pharmacy visits rate together with the viral load evolution of the patient. In order to get all this information it is necessary to have a very good communication between all the people involved in HIV infected patients care. If non-adherence is detected it is necessary to start the intervention strategies to correct it and if they fail it might be necessary in some cases to stop HAART. The potential benefits of the adherence programs can justify the economical spend in human and hospital facilities resources.