Seguimiento prospectivo de una población infectada por VIH con y sin posibilidades de terapia anti retroviral: impacto en sobrevida y complicaciones / Prospective follow up of HIV positive patients with and without access to antiretroviral therapy: survival and complications

Background: Three-drug antiretroviral therapy (ART-3) has reduced complications and improved survival in HIV+ patients. The Chilean Public Health System began dual therapy (ART-2) in 1997, covering approximately 40 percent of patients in need. Aim: To report the results of a follow-up of patients with and without access to ART in a Chilean public hospital. Patient and Methods: Prospective follow-up of patients with ART-2 and 3 (cases) and patients with no access to ART (controls). All patients needed ART but it was available to a minority of them. Selection for ART was at random. Follow-up was between 6-24 months (11/96 to 3/99). Basal and periodic clinical and laboratory parameters were determined. Mortality and occurrence of new AIDS-defining events (ADE) were compared statistically using chi square. Results: One hundred and fifty cases (106 ART2, 28 ART3 and 16 ART2 expanded to ART3) and 166 controls were studied. Basal parameters were similar except prior ART (32.7 and 18.7 percent in cases and controls respectively). Close to 1/3 patients had AIDS. Cases had a mean follow up of 527 days; controls, 478. Six cases (4 percent) (5 in ART-2) and 17 controls (10 percent) died. Mortality x 100/pts/yr was 2.7 in cases and 7.7 in controls, p <0.05. ADE per 100/pts/yr was 21 in cases (24.4 in ART2, 15.1 in TAR3) and 54.5 in controls, p <0.05. Cases had a reduction of: esophageal candidiasis (84 percent), tuberculosis (75 percent), cryptococcosis and toxoplasmosis (66 percent), P carinii pneumonia (55 percent) and bacterial pneumonia (46 percent) and they had fewer hospitalizations (73 percent). Late assessment: 70 of 101 ART-2 patients had changed to ART-3 (1 death); 22 of 101 kept original ART-2 (12 dead, 10 alive), 39 of 43 ART-3 patients were alive and 1 died. Conclusions: Short-term ART-2 and 3 significantly reduced mortality (60 percent and 73 percent) ADE (65 percent and 76 percent respectively) and hospitalizations. Benefits of ART-2 were short lived. Resource-constrained countries cannot depend on weaker than standard ART for proper care of people with HIV disease

Impacto de la terapia anti retroviral en la mortalidad de pacientes VIH+ chilenos: estudio caso control MORTAR / Impact of antiretroviral therapy in mortality of chilean HIV+ patients: a case control study

Background: Combined antiretroviral therapy (AVR) has shown a protective effect (PE) on morbidity and survival in HIV (+) patients of industrialised countries where triple-drug therapy (ARV-3) is standard. In Chile the public health system began providing double-drug therapy in 1997 (ARV-2) with 2 reverse transcriptase inhibitors. Aim: To assess the impact of ARV in morbimortality of HIV (+) patients in Chile after a year of follow up. Patients and methods: Retrospective case-control (1:1) study. Cases were 97 patients followed during 1997 for 6 or more months and dying during that period. Each case had a control of the same gender and CDC stage, similar age and CD4 count, but surviving a same period of follow up. A comparison of ARV before and during follow up (rate and type) was done. P carinii prophylaxis, pneumococcal immunization at baseline or follow up, frequency of hospital admissions and occurrence of opportunistic infections in both groups were assessed. Odds ratio (OR) for mortality, hospitalisation and opportunistic infections in ARV user, as well as treatment PE were calculated. Results: Twenty four (24.7 percent) cases and sixty six (68 percent) controls received ARV during follow up (p< 0.001), OR was 0.15 (CI 95 percent 0.08-0.3), p < 0.001, the PE was 6.6 for ARV users versus non users, among cases 19 patients received ARV-2 and five received ARV-3. Among controls, 41 patients received ARV-2 and 25 received ARV-3. These differences established an OR of 0.20 (CI 95 percent 0.09-0.04) and a PE of 5 for ARV-2 versus no ARV. For ARV-3 compared with no ARV the OR was 0.08 (CI 95 percent 0.003-0.26), and the PE 12.5. Fifty three (54.6 percent) cases and 13 (13.4 percent) controls required hospital admission, OR 0.49 (CI 95 percent 0.25-0.94), p=0.03, and PE of 2.04 of ARV versus no ARV; 82 (85.3 percent) cases and 50 (51 percent) controls had opportunistic infections, OR 0.5 (CI 95 percent 0.26-0.96), p=0.03 and PE of 2 for ARV versus no ARV. There were no significant differences in prior ARV, prophylaxis and immunisation between cases and controls. Conclusions: This study showed the high impact of ARV in short term morbimortality of HIV(+) patients and the need to implement antiretroviral therapy to all patients as an official health policy. This study did not answer the question of the role, if any, of weaker-than standard antiretroviral therapy

Experiencia en el tratamiento paliativo del cáncer esofágico / Experience in the palliative treatment of esophageal cancer

El cáncer de esófago es de mal pronóstico, porque habitualmente se pesquisa en estados muy avanzados y las terapias con intención curativa son posibles en no mas de 20-25 por ciento de los casos. Existe consenso en que las resecciones paliativas son las mas satisfactorias, pero siendo su indicación muy limitada hay que recurrir con mas frecuencia a cortocircuitos, endoprótesis, radioterapia, dilataciones o tunelizaciones con laser las que tienen resultados mas inciertos y transitorios. Se analiza la experiencia en nuestro servicio entre 1986 y 1990 comparándola con la del quinquenio anterior: de 47 pacientes tratados paliativamente se operan 41 y se irradian en forma exclusiva 6, todos con lesiones muy avanzadas. Se efectuan 12 esofagectomías (10 por stripping), 7 puentes, 11 prótesis y 11 exploraciones (6 con ostomías). La morbilidad postoperatoria es importante en los resecados, en los puentes y en las prótesis determinando una mortalidad global de 43,9 por ciento , que es alta en los simplemente explorados y en los con prótesis y que llega sólo a 16,6 por ciento en los resecados. La mayor sobrevida la obtuvimos en resecados y en ostomías mas irradiación. La mayor utilización de procedimientos no resectivos no ha significado mejores resultados, salvo en casos aislados, corroborando la experiencia mundial acerca de la dudosa utilidad de los puentes y no alcanzando aún los aceptables resultados que se obtienen en otros centros nacionales con las endoprótesis. Los mayores beneficios fueron logrados en pacientes seleccionados con cirugía resectiva sin toracotomía y en pacientes con radioterapia