[Mortality and survival in a cohort of 1,115 HIV-infected patients (1989-97)]. / Estudio de la mortalidad y supervivencia en una cohorte de 1,115 pacientes con infección VIH (1989-97).

BACKGROUND: To study survival and HIV/AIDS-related mortality from 1989 through 1997. To analyze the effect of antiretroviral treatment and prophylaxis against P. carinii pneumonia (PCP-prophylaxis). PATIENTS AND METHODS: We retrospectively studied a cohort of 1,115 HIV (+) outpatients (331 with AIDS-defining criteria) seen in our specific HIV hospital unit from January 1989 through May 1997. We analyzed the effect of different antiretroviral treatments on annual mortality rate. In survival studies we used Cox regression analysis to analyze survival over time as well as the effect of different opportunistic events, adherence and changes in treatment during follow up. RESULTS: Mortality rate was 13.7 per 100 person-years in 1994. It went down to 4.2 during the first half of 1997 (p=0.001). Mortality rate decreased depending on treatment received: 53% (CI 95=34-65%) with monotherapy, 68% (CI 95=38-84%) with bitherapy, 86% (CI 95=40-96%) with triple therapy, and 49% (CI =29-64%) with PCP-prophylaxis. Patients with more than 100 CD4 had an increasing survival over time (p=0.002). In AIDS patients good adherence to antiretroviral treatment and PCP-prophylaxis were associated with a lower risk of death (RR=0.88; CI 95=0.63-1.22 and RR=0.72; CI 95=0.55-0.95 respectively). CONCLUSIONS: In recent years PCP-prophylaxis and antiretroviral treatment (especially combined therapy) have contributed to a decrease in AIDS-related mortality. Adherence to treatments relates to risk of death and survival.

Estudio de la mortalidad y supervivencia en una cohorte de 1.115 pacientes con infección VIH (1989-97) / Mortality and survival in a cohort of 1,115 HIV-infected patients (1989-97)

Fundamento: Analizar la supervivencia y mortalidad por VIH/sida entre 1989 y 1997, y evaluar el impacto que sobre ellas han tenido el tratamiento antirretroviral y la profilaxis frente al Pneumocystis carinii (anti-NPC). Pacientes y métodos: Estudio de una cohorte retrospectiva de 1.115 pacientes (331 con sida) seguidos en una Unidad hospitalaria de VIH en Madrid entre enero de 1989 y mayo de 1997. Se analizó tasa anual de mortalidad y el efecto en la misma del régimen de tratamiento antirretroviral. La regresión de Cox fue utilizada en los estudios de supervivencia para analizar su evolución, la influencia de los distintos eventos oportunistas, el efecto de la adherencia a los tratamientos y del cambio de tratamiento antirretroviral durante el seguimiento. Resultados: La tasa de mortalidad fue de 13,7 por 100 personas-año en 1994 y descendió hasta 4,2 en el primer semestre del 1997 (p=0,001).La monoterapia se asoció a una disminución de la mortalidad del 53 por ciento [IC95=34 por ciento-65 por ciento], la biterapia del 68 por ciento [IC95=38 por ciento-84 por ciento], la triple terapia del 86 por ciento [IC95=40-96 por ciento] y la profilaxis anti-NPC del 49 por ciento [IC95=29 por ciento-64 por ciento]. En los pacientes con CD4>100/mm3la supervivencia mejoró a lo largo del tiempo (p=0,002). En los pacientes con sida, el buen cumplimiento del tratamiento antirretroviral y de la profilaxis antiNPC se asociaron con una disminución del riesgo de muerte (RR=0,88; IC95=0,63-1,22 y RR=0,72; IC95=0,55-0,95 respectivamente). Conclusiones: La profilaxis anti-NPC y el tratamiento antirretroviral, en especial la terapia combinada, han contribuido a disminuir la mortalidad por sida en los últimos años. El grado de adherencia a los tratamientos se relaciona con el riesgo de morir y la supervivencia (AU)

[Prognostic factors of mortality during the episode of pneumonia due to Pneumocystis carinii in patients with HIV infection]. / Factores pronósticos de mortalidad durante el episodio de neumonía por Pneumocystis carinii en pacientes con infección por VIH.

BACKGROUND: Despite a steady decrease in its incidence, pneumonia caused by Pneumocystis carinii (PCP) are still diagnosed, and they occur frequently in patients unaware of being infected with the human immunodeficiency virus (HIV). Since it is a disease with a high mortality risk, its early diagnosis and therapy would allow these patients to benefit from the advantages afforded Pneumocystis carinii, neumonía, infecciones oportunistas relacionadas con el sida, pronóstico.by anti-retroviral therapy. PATIENTS AND METHODS: Retrospective study, in which all adult HIV infected patients with microbiologically demonstrated PCP diagnosed at two tertiary-level hospitals in our country between 1985 and 1996 were included. The clinical records of patients were used as information source. The relative risks (RR) of death were estimated by the multivariant logistic regression. RESULTS: PCP was the first AIDS indicating disease in approximately 70 % of cases. Thirteen percent of patients died during the episode. Patients aged over 45 years had a death RR during the episode of 3.15 (95 % CI from 0.8 to 12.2); patients previously diagnosed of AIDS had a death RR of 3.4 (95 % CI from 1.3 to 9), and those with an alveolar-arterial oxygen gradient (pA-aO2) > 50 mmHg, a death RR of 3 (95% CI from 1.1 to 8). CONCLUSIONS: Factors independently related to survival to the PCP episode are age below 45 years, not to have had another AIDS indicating disease, and to have a pA-aO2 below 50 mmHg at diagnosis.

Factores pronósticos de mortalidad durante el episodio de neumonía por Pneumocystis carinii en pacientes con infección por VIH / Prognostic factors of mortality during the episode of pneumonia due to Pneumocystis carinii in patients with HIV infection

Fundamento. A pesar de un claro descenso en su incidencia, se siguen diagnosticando neumonías por Pneumocystis carinii (NPC), presentándose con frecuencia en pacientes que ignoran su situación de infectados por el VIH. Puesto que se trata de una enfermedad con un riesgo elevado de mortalidad, su rápido reconocimiento y tratamiento les permitirá beneficiarse a posteriori de las ventajas aportadas por el tratamiento antirretrovírico. Pacientes y métodos. Estudio retrospectivo en el que se incluyeron todos los pacientes adultos con infección por VIH y NPC confirmada microbiológicamente, diagnosticados en dos hospitales terciarios de nuestro país entre 1985 y 1996. Las historias clínicas de los pacientes se utilizaron como fuente de información. Los riesgos relativos (RR) de muerte se estimaron mediante regresión logística multivariable. Resultados. La NPC fue la primera enfermedad indicadora de sida en aproximadamente el 70 por ciento de los casos. Un 13 por ciento de los pacientes fallecieron durante el episodio. Los pacientes mayores de 45 años tienen un RR de muerte durante el episodio de 3,15 (índice de confianza [IC] 95 por ciento: 0,8, 12,2); aquellos que habían sido previamente diagnosticados de sida tienen un RR de muerte de 3,4 (índice de confianza [IC] 95 por ciento: 1,3, 9) y los que presentan un gradiente alveolo-arterial de oxígeno (pA-a O2) > 50 mmHg, un RR de muerte de 3 (IC 95 por ciento: 1,1,8).Conclusiones. Los factores relacionados de forma independiente con la supervivencia al episodio de NPC son la edad menor de 45 años, el no haber tenido con anterioridad otra enfermedad indicadora de sida y presentar en el momento del diagnóstico un pA-a O2 inferior a 50 mmHg. (AU)

[Diastolic dysfunction in human immunodeficiency virus infection]. / Disfunción diastólica en la infección por el virus de la inmunodeficiencia humana.

AIMS: We sought to determine the prevalence and characteristics of echocardiographic abnormalities (systolic and/or diastolic dysfunction, pericardial effusion) in patients with human immunodeficiency virus infection (HIV) with no symptoms or previous history of cardiac disease, and compare them with a healthy control group. PATIENTS AND METHOD: Transthoracic echocardiography was performed in 125 patients (73% male, mean age 33.2 +/- 6.6 years) with HIV infection without cardiac involvement and 47 age and sex-matched healthy volunteers (78% male, 31.6 +/- 7.3 years). The immunologic situation was determined by CD4 lymphocyte counts. RESULTS: Abnormal left ventricular relaxation and filling patterns (E/A relation 1.31 +/- 0.35 in HIV group, 1.66 +/- 0.38 in control group, p < 0.001; pressure half-time 57.5 +/- 13 in HIV group, 50.6 +/- 6.6 in control group, p < 0.001), segmental wall-motion abnormalities (15%) and pericardial effusion (7.2%) were found in patients with HIV infection. Systolic function (EF 64.8 +/- 8.3) and left ventricular dimension (diastolic diameter 4.94 +/- 0.55, systolic diameter 3.17 +/- 0.51) showed normal patterns and did not significantly differ from those of the control group. CONCLUSIONS: Silent echocardiographic abnormalities in patients with HIV infection are frequent suggesting a direct myocardial effect of the virus. The development of diastolic dysfunction is directly related to a worse immunologic situation. Prospective studies are needed to clarify the clinical prognosis of these asymptomatic abnormalities.

[Efficacy and safety of zidovudine in monotherapy in patients with HIV infection]. / Eficacia y tolerancia del tratamiento con zidovudina (ZDV) en monoterapia en pacientes con infección VIH.

BACKGROUND: To study the efficacy and the tolerance of the zidovudine (ZDV) in monotherapy for the treatment of a cohort of patients with HIV infection, most of them injection-drug users (IDU). METHODS: Retrospective study of a historic cohort of 350 patients, from January 1988 to December 1994. The clinic progression, the immunologic deterioriation and the survival after the ZDV administration were evaluated, like the toxicity of the drug. RESULTS: The estimated progression time to AIDS for the 25% of the cohort was 29 months for the initially asymptomatic patients and 22 months for the subjects who showed symptoms. After 26 months half of the patients showed CD4 cell counts less to 50% of the basals. The cumulative survival probability after a year was 99%, 97% and 85% for the groups A, B y C of the CDC classification, and 94%, 87% and 58% after two years for these groups. The predictive factors associated with the survival were the clinic and immunologic status, ESR, LDH, and beta 2-microglobulin levels at the beginning of the treatment. The 35% of the patients suffered adverse events, mainly hematologic effects, although they only forced to suspend the treatment in the 5% of the cases. The only predictive factor associated with the toxicity was a neutrophile count less than 1.500 cells/mm3 previous to the treatment (p < 0.001). CONCLUSION: The ZDV use in monotherapy in a cohort of patients majority IDU shows the same efficacy and safety as the treatment in other patients with HIV infection.

[Past, present and future of zidovudine, the first antiretroviral drug]. / Pasado, presente y futuro de la zidovudina, el primer antirretroviral.

The zidovudine (ZDV) was the first drug approved to treat the VIH infection. The ZDV prescriptions have been changing throughout the years. Actually it's known that its efficacy is limited over time, and same substances have been discovered which inhibtes more strongly the VIH replication. However the ZDV appears in majority the combined therapy regimens as a first line drug. Even in same special situations there is no existence of another antiretroviral drugs which have showed utility. In this essay it s revised the mainly studies which have provided new knowledge about the ZDV treatment and it s also considered the possibilities of this drug in the more new therapies against the VIH.

[Predictive factors of non-compliance with anti-tuberculosis treatment in patients infected with the human immunodeficiency virus]. / Factores predictivos del abandono del tratamiento antituberculoso en pacientes infectados por el virus de la inmunodeficiencia humana.

A study was conducted to know the rate of non-compliance of antituberculosis therapy among HIV-infected patients, the factors associated with non-compliance and the evolution of these patients. The therapy compliance in 276 tuberculous HIV infected patients diagnosed in two Madrid hospitals was analyzed. Fifty-one patients (18%) were not included in the analysis (6 died without therapy, 6 were lost and 39 died during therapy). Out of the 225 evaluable patients, 36 (16%, 95% CI, 11.6-21.6) did not comply with therapy. The only factor associated with a higher therapy non-compliance was the antecedent of drug use (20% of non-compliance; relative risk: 10, 95% CI, 1.4-71). Patients using drugs at tuberculosis diagnosis had higher risk for non-compliance (31%; RR, 3.1; 95% CI, 1.6-6.3). The incidence of tuberculosis reactivation after leaving therapy was 78.8/100 patient-years. Therapy non-compliance increased death risk associated with tuberculosis (RR, 9.8; 95% CI, 4.6-21). Programs for controlling antituberculous therapy should give priority to active drug users, as this is the group with the highest risk for non-compliance.

[Study of hypercholesterolemia among the child population of Valdemoro]. / Estudio de la hipercolesterolemia en la población infantil de Valdemoro.

We studied 99 children with ages ranging from 0 to 14 years, randomly selected from the census of Valdemoro (Madrid) and stratified by sex and age. The clinical records of all the children were completed and the levels of total serum cholesterol were assessed. The average cholesterol level for the total sample was 159 +/- 31 mg/dl (m +/- sd). Twenty-six children (26.3%) had values above 175 mg/dl [75th percentile of the Lipid Research Clinics Program(LRCP)], with no significant differences between the values of such percentile in both studies. Ten per cent of the children showed cholesterolemias greater than 200 mg/dl. The average cholesterol level in children whose mothers had high education levels was 125 +/- 16 mg/dl (m +/- sd), versus 161 +/- 21 mg/dl (m +/- sd); p = 0.005; (CI 95% of the difference 12 to 62 mg/dl) in children whose mothers had low-medium education levels. Cholesterol in children with family history of hypercholesterolemia (HC) showed a non-significant trend towards higher levels than in children without such antecedents (164 mg/dl vs 155 mg/dl; p = 0.19; NS). Neither the differences were significant when comparing children with or without family history of early cardiovascular disease (ECDV) (162 md/dl vs 158 md/dl; p = 0.49). Using both familiar antecedents as misleading method, just 72% of the children were diagnosed of HC (cholesterol greater than 175 md/dl). The absence of both antecedents (negative VP) would discard the presence of HC in 83% of the children in such situation (CI 95%, 67% to 92%).

[Reactivity of serologic tests for the detection of syphilis in patients infected with the human immunodeficiency virus]. / Reactividad de las pruebas serológicas para detección de sífilis en pacientes infectados por el virus de la inmunodeficiencia humana.

BACKGROUND: The coexistence of syphilis and infection by the human immunodeficiency virus (HIV) appears to modify the natural history of both diseases. The aim of this study was to know the prevalence of syphilis in a population of patients with HIV infection, the possible association with certain risk practices and the validity of the reaginic test in such patients. METHODS: Three hundred sixty-seven patients with HIV infection who went for the first time to a monographic clinic of a university hospital were studied. Syphilis serology was carried out: rapid plasma reaginic (RPR) and hemagglutination (MHA-TP) tests. RESULTS: Out of all the patients 26 (7.1%) had positive MHA-TP. The proportion of homosexuals was greater among those who had a positive treponemic test (69%) than among those who were negative (6.4%; odds ratio [OR] = 32.6; confidence interval 95%: 16.2-65.4). The positivity of MHA-TP was more frequent among those presenting criteria of the acquired immunodeficiency syndrome (AIDS) at the diagnosis (18% versus 5.6%; OR = 3.6 [1,5-8,9]). Seventy-four false positive reactions were observed with the RPR (20%) corresponding almost exclusively (96%) to intravenous drug users who presented false positivity in 25% of the cases. CONCLUSIONS: The prevalence of syphilis detected by treponemic serology among subjects with infection by the human immunodeficiency virus is related with homosexuality as the principal practice of risk. One quarter of the intravenous drug users with infection by the human immunodeficiency virus presented false positive results to the reaginic test thus leading to the recommendation that therapeutic measures should not be initiated without confirmation with a treponemic test.

[Epidemiology of primary biliary cirrhosis in southern Madrid]. / Epidemiología de la cirrosis biliar primaria en Madrid sur.

This study reports the epidemiologic features of primary biliary cirrhosis in patients admitted to the 12 de Octubre Hospital in Madrid between 1974 and 1988. Among the 54 patients recruited, 45 lived in the hospital surroundings. Ninety-three percent were women with a mean age of 53.7 +/- 15.1 years (range 25 to 76 years). The maximal incidence of the disorder occurred in patients above 60 years. At the time of diagnosis 37.8% were asymptomatic and the mean time to symptoms was 20.1 +/- 18.1 months. The year incidence was maximal in 1982, being the mean year rate of 7.45 +/- 4.9 cases/10(6) inhabitants. This rate was lower in women above 25 years (13.9 +/- 8 cases/10(6) inh/yr). A comparable incidence has been reported in Catalonia and Asturias but it was higher in Navarre. During the study period the prevalence of the illness has increased. By december 1988 the mean incidence for the whole group was 45.5 cases/10(6) inh/yr, whereas it reached 134.1 cases/10(6) ihn/yr in women above 25 years. Environmental, genetic or personal factors contributing to the development of the illness have not been encountered. There was, however, a relationship between the mortality and morbidity rates with the severity of the symptoms and with the degree of histological damage.