Efectividad de los antivirales de acción directa de segunda generación en el tratamiento de la hepatitis C crónica / Effectiveness of second-generation direct-acting antivirals in chronic hepatitis C

Fundamento: Los antivirales de acción directa de segunda generación (AAD) han demostrado porcentajes elevados de respuesta viral sostenida (RVS) en el tratamiento de la hepatitis C crónica en ensayos clínicos. Este estudio tiene como objetivo estimar la efectividad de los AAD en el tratamiento de esta enfermedad. Material y métodos: Se estudiaron pacientes monoinfectados por el virus de la hepatitis C (VHC) y coinfectados por VHC y virus de la inmunodeficiencia humana (VIH) que iniciaron tratamientos libres de interferón con AAD durante 2015. La RVS se definió como una carga viral indetectable a las 12 semanas de finalizar el tratamiento, y fue el indicador principal de efectividad. Resultados: Se incluyeron 293 pacientes, 52 (17,7%) coinfectados por VIH. Los genotipos VHC más prevalentes fueron el 1b en monoinfectados (41,5%) y 1a en coinfectados (40,4%). La proporción de cirróticos fue superior en la población coinfectada (69,2% vs 41,1%; p<0,0001), en su mayoría Child-Pugh A. La cifra global de RVS fue del 96,9% (284/293) en un análisis por intención de tratar (IC 95%: 94,9-98,9%), siendo 4 los pacientes con fracaso virológico. Tanto pacientes naïve como pretratados tuvieron RVS superior al 95%, y en la mayoría de subgrupos establecidos según la presencia o no de cirrosis, la coinfección VIH y el genotipo, la efectividad se situó próxima o por encima del 90%. Conclusiones: Los AAD presentan una efectividad elevada, igual o superior a la descrita en los ensayos clínicos, e incluso en subpoblaciones difíciles de tratar (AU)

Background: Second-generation direct-acting antivirals (DAA) have shown high sustained virologic response (SVR) for the treatment of chronic hepatitis C in clinical trials. The objective of this study is to estimate DAA effectiveness in treatment of this disease. Methods: Hepatitis C virus (HCV) monoinfected patients and HCV-human immunodeficiency virus (HIV) coinfected patients who started interferon-free DAA based regimens during 2015 were included. The primary effectiveness outcome was SVR, defined as an undetectable viral load 12 weeks after the end of treatment. Results: A total of 293 patients were enrolled, and 52 (17.7%) were HIV coinfected. HCV 1b genotype was the most prevalent in monoinfected patients (41.5%) and 1a in HIV coinfected patients (40.4%). The proportion of cirrhosis was higher among HIV coinfected patients (69.2% vs 41.1%; p<0.0001), mostly Child-Pugh A. SVR was achieved by 96.9% of patients (284/293), in an intention-to-treat analysis (CI 95%: 94.9- 98.9), in which just 4 people had virologic failure. Both naïve and pretreated patients had SVR higher than 95%, and in most of subgroups, according to the presence of cirrhosis, HIV coinfection and HVC genotype, effectiveness rates were near or above 90%. Conclusions: DAA are highly effective, with similar or higher rates of SVR than that found in clinical trials, and even among difficult to treat populations (AU)

Diagnóstico tardío de la infección por el virus de la inmunodeficiencia humana: oportunidades diagnósticas perdidas / Late diagnosis of HIV infection: missed diagnostic opportunities

Fundamento: Analizar el porcentaje de pacientes con diagnóstico tardío (DT) de infección por VIH, sus factores de riesgo y las oportunidades perdidas para un diagnóstico más precoz. Material y métodos: Se incluyó a 165 pacientes diagnosticados de infección por VIH entre 2009 y 2013 en Navarra. Mediante regresión logística se estudiaron los factores asociados con DT (CD4 <350 células/mm3 o enfermedad definitoria de sida al diagnóstico). Se analizó la presencia de factores de riesgo e indicadores clínicos de una posible infección por VIH en los 5 años previos al diagnóstico. Resultados: La prevalencia global de DT fue del 55% (90/165). Este porcentaje fue mayor en los pacientes inmigrantes que en los españoles, y en aquellos sin serología realizada previamente. Se observó una interacción entre la edad y el origen del paciente. En los españoles el riesgo de DT aumentó con la edad a partir de los 40 años (OR: 3,72; IC95%: 1,52-9,12) pero esto no ocurrió en los inmigrantes. De los 132 pacientes con atención médica en los años previos al diagnóstico, 20 (15%) tenían factores de riesgo clásicos documentados en la historia, 14 (11%) procedían de regiones con alta prevalencia de VIH y 46 (35%) habían presentado indicadores clínicos sin la realización de la serología. Conclusiones: A pesar de los múltiples contactos con nuestro sistema sanitario, más de la mitad de los nuevos diagnósticos de infección por VIH se realizan tarde. Es necesario una mayor atención a los signos clínicos de la infección y, sobre todo, una mejor valoración del riesgo en pacientes asintomáticos (AU)

Background: To analyse the percentage of patients with a late diagnosis (LD) of HIV infection, their risk factors and the missed opportunities for an earlier diagnosis. Methods: One hundred and sixty-five patients diagnosed with HIV infection in Navarre between 2009 and 2013 were included. Logistic regression was used to study the factors associated with LD (CD4 <350 cells/ mm3 or AIDS defining disease at diagnosis). The presence of risk factors and clinical indicators of possible HIV infection in the 5 years preceding the diagnosis were analyzed. Results: The global prevalence of LD was 55% (90/165). This percentage was greater in immigrant patients than in Spanish patients, and in those without previous serology tests. An interaction was observed between the age and origin of patients. In Spaniards the risk of LD rose with age after 40 years (OR: 3.72; 95%CI: 1.52-9.12) but this did not occur in immigrant patients. Of the 132 patients who had received medical care in the years prior to diagnosis, 20 (15%) had classical risk factors recorded in their history, 14 (11%) proceeded from regions with a high prevalence of HIV, and 46 (35%) had presented clinical indicators without a serology test being realized. Conclusions: In spite of multiple contacts with our health system, over half of the new cases of HIV infection are diagnosed late. Greater attention to clinical signs is needed and, above all, a better evaluation of the risk in asymptomatic patients (AU)

[Late diagnosis of HIV infection: missed diagnostic opportunities]. / Diagnóstico tardío de la infección por el virus de la inmunodeficiencia humana: oportunidades diagnósticas perdidas.

BACKGROUND: To analyse the percentage of patients with a late diagnosis (LD) of HIV infection, their risk factors and the missed opportunities for an earlier diagnosis. METHODS: One hundred and sixty-five patients diagnosed with HIV infection in Navarre between 2009 and 2113 were included. Logistic regression was used to study the factors associated with LD (CD4 < 350 cells/mm3 or AIDS defining disease at diagnosis). The presence of risk factors and clinical indicators of possible HIV infection in the 5 years preceding the diagnosis were analyzed. RESULTS: The global prevalence of LD was 55% (90/165). This percentage was greater in immigrant patients than in Spanish patients, and in those without previous serology tests. An interaction was observed between the age and origin of patients. In Spaniards the risk of LD rose with age after 40 years (OR: 3.72; 95%CI: 1.52-9.12) but this did not occur in immigrant patients. Of the 132 patients who had received medical care in the years prior to diagnosis, 20 (15%) had classical risk factors recorded in their history, 14 (11%) proceeded from regions with a high prevalence of HIV, and 46 (35%) had presented clinical indicators (only 24 of them 1 year before diagnosis) without a serology test being realized. CONCLUSIONS: In spite of multiple contacts with our health system, over half of the new cases of HIV infection are diagnosed late. Greater attention to clinical signs is needed and, above all, a better evaluation of the risk in asymptomatic patients.

[Brain lesions in patients with acquired immunodeficiency syndrome]. / Lesiones cerebrales en pacientes con síndrome de inmunodeficiencia adquirida.

During a period of 3 years 14 patients with AIDS and CNS focal lesions documented by CT scan were evaluated. All patients received empirical treatment against Toxoplasma. The aim of the study was to determine the prevalence of the different etiologies of the neurologic lesions as well as to evaluate the usefulness of routine cerebral biopsy before establishing empiric antitoxoplasma treatment in a population of AIDS patients with a high incidence of drug addiction. Eleven patients developed histologic and clinical criteria of cerebral toxoplasmosis, one patient presented progressive multifocal leukoencephalopathy, and in the remaining two patients the etiologic diagnosis could not be established. Only one patient presented multiple etiologic lesions and in no cases the presence of mycobacteria or fungi could be demonstrated in the cerebral tissue. The overall percentage of responses to the empiric antitoxoplasma treatment was 42%. This percentage increased to 54% if patients with coma were not included in the analysis. Cumulated mortality of the entire group was 78.5%. It is concluded: 1) the predominance of Toxoplasma gondii as a cause of cerebral lesions in our AIDS population; 2) the acceptable percentage of response to empiric antitoxoplasma treatment in non-comatose patients, and 3) the high overall mortality rate in these patients. It is therefore suggested that routine cerebral biopsies will not be justified as initial diagnostic approach in HIV positive patients with focal CNS lesions.

[Mycosis fungoides associated with HIV infection]. / Micosis fungoide asociada a infección por VIH.

The increasing number of cases of HIV-infections made the pathology association wider. Between these pathologies, tumors and lymphoid neoplasias are the most frequent. Large series showed the association between B-cell non-hodgkin lymphomas, and HIV infection, but only exceptional cases of T-cell lymphomas were found. We present a case of T-cell cutaneous lymphoma (mycosis fungoides) in a patient with HIV-infection owing to the fact that very few: cases have been reported, the causal relationship is still unknown.

[Infectious complications in the orthoptic liver transplant]. / Complicaciones infecciosas del trasplante hepático ortotópico.

Orthotopic liver transplantation is a therapeutic option for selected patients with end-stage liver disease. Among the complications of orthotopic liver transplantation infectious problems are a major cause of mortality. In this report the different types of infection following orthotopic liver transplantation are reviewed. In addition, currently available data regarding to transmission of infectious agents from organ donor to transplant recipient are reported.