Experiencia de una unidad monográfica de tuberculosis: primeros 500 casos / Experience of a Monographic Tuberculosis Unit: The First 500 Cases

Introducción: La tuberculosis (TB) continúa siendo una enfermedad muy prevalente aunque desde el año 2002 el número de casos anuales muestra una tendencia decreciente en el mundo y también en nuestro país, donde la incidencia es muy variable entre comunidades autónomas. El objetivo principal de este estudio es describir la experiencia de una unidad monográfica de TB de un centro hospitalario de segundo nivel. Pacientes y métodos: Estudio descriptivo de los casos de TB diagnosticados en una unidad monográfica de un hospital secundario entre 2003 y 2011. Se recogieron datos demográficos, clínicos, epidemiológicos y microbiológicos para su análisis. Resultados: Se analizaron 500 casos de TB, encontrando una incidencia anual creciente en todos los subgrupos, incluyendo población autóctona e inmigrante. La mayoría (63,8%) eran varones, con una mediana de edad de 36 años (rango 8 meses-90 años). Un 39,8% de los pacientes era inmigrante. En un 11% de los casos existía coinfección con el virus de la inmunodeficiencia humana. La localización fue pulmonar en el 63,8% de los casos. La letalidad global fue del 5,8% sin encontrar diferencias significativas entre subgrupos (incluyendo población inmigrante y personas infectadas por el virus de la inmunodeficiencia humana). Conclusiones: A pesar de la tendencia descendente global en cuanto al número de casos de TB declarados, en nuestra serie esta es creciente en todos los subgrupos. La existencia de una unidad monográfica de TB junto con un exhaustivo programa de estudio de contactos podría explicar este hallazgo (AU)

Introduction: Tuberculosis (TB) remains a highly prevalent and potentially severe disease. However, since 2002 the annual incidence has been decreasing both worldwide and in Spain, where the incidence varies widely between regions. The main objective of this study is to describe the experience of a monographic TB unit in a second level hospital. Patients and methods: A descriptive study was carried out which included all cases of TB diagnosed in a monographic unit of a secondary hospital between 2003 and 2011. Demographic, clinical, epidemiological and microbiological data were recorded. Results: We analyzed 500 TB cases and found an increasing annual incidence in all subgroups, including native and immigrant populations. Most cases (63.8%) were male, with a median age of 36 years (range 8 months–90 years). In total, 39.8% of patients were foreign born. Coinfection with human immunodeficiency virus (HIV) was found in 11.0% of cases. The pulmonary form was most frequently diagnosed (63.8%). Overall mortality was 5.8% with no significant differences between groups (including foreign born and HIV positive patients). Conclusions: Although TB incidence is globally decreasing, in our study we found an increasing number of cases in recent years in all subgroups, which can be explained by this being a monographic unit with an intensive contact tracing program (AU)

Experience of a monographic tuberculosis unit: the first 500 cases.

INTRODUCTION: Tuberculosis (TB) remains a highly prevalent and potentially severe disease. However, since 2002 the annual incidence has been decreasing both worldwide and in Spain, where the incidence varies widely between regions. The main objective of this study is to describe the experience of a monographic TB unit in a second level hospital. PATIENTS AND METHODS: A descriptive study was carried out which included all cases of TB diagnosed in a monographic unit of a secondary hospital between 2003 and 2011. Demographic, clinical, epidemiological and microbiological data were recorded. RESULTS: We analyzed 500 TB cases and found an increasing annual incidence in all subgroups, including native and immigrant populations. Most cases (63.8%) were male, with a median age of 36 years (range 8 months-90 years). In total, 39.8% of patients were foreign born. Coinfection with human immunodeficiency virus was found in 11% of cases. The pulmonary form was most frequently diagnosed (63.8%). Overall mortality was 5.8% with no significant differences between groups (including foreign born and human immunodeficiency virus positive patients). CONCLUSIONS: Although TB incidence is globally decreasing, in our study we found an increasing number of cases in recent years in all subgroups, which can be explained by this being a monographic unit with an intensive contact tracing program.

Brote de gripe por virus pandémico (H1N1) 2009 en una residencia para personas discapacitadas psíquicas en las Islas Baleares / Outbreak of pandemic virus (H1N1) 2009 in a residence for mentally disable persons in balearic island, Spain

Fundamento: La temporada gripal 2009-2010 ha sido más corta y benigna de lo esperado. Desde enero de 2010 los sistemas de vigilancia de gripe indicaban unas tasas de incidencia muy bajas sin detección de circulación del virus. En este contexto, un hospital comunicó una sospecha de brote de enfermedad respiratoria grave, cuya etiología resultó ser gripe (H1N1) 2009. Describimos el brote y las actuaciones de Salud Pública para su control. Métodos: Estudio descriptivo de un brote epidémico por virus gripal pandémico en una residencia para discapacitados mentales. Establecimiento de vigilancia activa. La definición de caso de gripe fue muy sensible para detectar los nuevos casos al inicio, tratarlos precozmente y minimizar la transmisión. Se adoptaron medidas de contención de la infección por virus gripal. Resultados: De 38 casos detectados 7 (todos con factores de riesgo) sufrieron complicaciones graves. No hubo defunciones. La tasa global de ataque fue del 35,2%. Los primeros casos eran trabajadores. Los casos en residentes se acumularon en el pico del brote y entre trabajadores la presentación fue más dispersa. Ninguno de los trabajadores y sólo tres residentes habían sido vacunados. Conclusiones: El brote se inició en los trabajadores de la residencia, a partir de los cuales se difundió a las personas residentes. Destacamos la necesidad de cumplir las recomendaciones de vacunación, no sólo de las personas con factores de riesgo, sino también muy especialmente de los trabajadores en contacto con aquellos(AU)

Background: The flu season 2009-2010 has been shorter and less severe than expected. Since January 2010, influenza surveillance systems indicated rates of very low incidence of influenza without detection of virus circulation. In this context, a hospital reported a suspected outbreak of severe respiratory disease, the aetiology proved influenza A(H1N1)v. Wedescribe the outbreak and public health measures for their control. Methods: Descriptive study of an outbreak of pandemic influenza virus in a residency home for mentally disabled. Establishment of active surveillance. The case definition of influenza was very sensitive to detect new cases early, treated early and minimize transmission. Steps were taken to contain the influenza virus infection Results: Among 38 cases detected 7 had serious complica-tions(all of them with risk factors) . There were no deaths. The overall attack rate was 35.2%. The first cases were workers. The residents were ill at the peak of the outbreak, and among workers the presentation was more dispersed. None of the workers and only three of residents had been vaccinated. Conclusions: Workers possibly have initiated and contributed to the maintenance of transmission. We emphasize the need to comply with vaccination recommendations, not just those with risk factors, but particularly for workers in contact with those(AU)

Shoulder dislocation in patients older than 60 years of age.

PURPOSE: Recurrent anterior shoulder dislocation in elderly patients is a little studied condition. The goal of this paper is to clarify the role of associated injuries with respect to loss of function and recurrence of dislocation. MATERIALS AND METHODS: We have conducted a retrospective, descriptive study on 29 patients older than 60 years at the moment they suffered their first dislocation episode. All patients were assessed clinically (Constant test) and by imaging testing (X-ray, MRI). RESULTS: Nine (31.03%) out of 29 patients had a recurrent dislocation. Four of them required reconstructive surgery to maintain joint stability. Injury to the anterior support (anterior labrum, anterior glenoid rim) showed a statistically significant relation to the recurrence of dislocations. The occurrence or non-occurrence of a rotator cuff tear does have an impact on the shoulder function. The degree of rotator cuff involvement on the coronal plane does not significantly affect the shoulder's functional outcome. The tear extension on the sagittal plane does cause impairment on the Constant test. CONCLUSIONS: Labrum and/or anterior glenoid involvement should be suspected in elderly patients presenting with recurrent shoulder dislocation. Recurrence is due to an injury in the anterior support or both (anterior and posterior), even though shoulder function gets impaired when a rotation cuff tear occurs with anterior extension on the sagittal plane. Evidence level: IV Case series.

[Outbreak of pandemic virus (H1N1) 2009 in a residence for mentally disabled persons in Balearic Island, Spain]. / Brote de gripe por virus pandémico (H1N1) 2009 en una residencia para personas discapacitadas psíquicas en las Islas Baleares.

BACKGROUND: The flu season 2009-2010 has been shorter and less severe than expected. Since January 2010, influenza surveillance systems indicated rates of very low incidence of influenza without detection of virus circulation. In this context, a hospital reported a suspected outbreak of severe respiratory disease, the aetiology proved influenza A(H1N1)v. We describe the outbreak and public health measures for their control. METHODS: Descriptive study of an outbreak of pandemic influenza virus in a residency home for mentally disabled. Establishment of active surveillance. The case definition of influenza was very sensitive to detect new cases early, treated early and minimize transmission. Steps were taken to contain the influenza virus infection. RESULTS: Among 38 cases detected 7 had serious complications(all of them with risk factors). There were no deaths. The overall attack rate was 35.2%. The first cases were workers. The residents were ill at the peak of the outbreak, and among workers the presentation was more dispersed. None of the workers and only three of residents had been vaccinated. CONCLUSIONS: Workers possibly have initiated and contributed to the maintenance of transmission. We emphasize the need to comply with vaccination recommendations, not just those with risk factors, but particularly for workers in contact with those.

Fiabilidad diagnóstica de una consulta de teledermatología asíncrona / Diagnostic reliability of an asynchronous teledermatology consultation

Objetivo: Analizar el índice de concordancia diagnóstica entre atención primaria, una consulta de teledermatología asíncrona y una consulta de dermatología convencional.Diseño: Estudio prospectivo de concordancia no aleatorizado.Emplazamiento: Servicio de Dermatología del Hospital Son Llàtzer(Palma de Mallorca) ycentros de salud de Sóller y Arenal(Mallorca).Participantes: Se ha incluido a 158 pacientes entre diciembre de 2005 y julio de 2008 remitidos mediante teleconsulta.Mediciones principales: Análisis de los diagnósticos de atención primaria, de la consulta de teledermatología y de la consulta presencial en el periodo establecido. Cálculo delíndice kappa de concordancia.Resultados: Desde diciembre de 2005 hasta julio de 2008 se realizaron 158 teleconsultas: 94 (59,5%) mujeres y 64(40,5%) varones, de edades comprendidas entre 9 y 96 (media, 55)años. Agrupando los diagnósticos en categorías, la distribución fue: 48(37,2%) tumoresbenignos, 39 (30,2%)afecciones inflamatorias y de anejos, 15 (11,6%)enfermedades infecciosas, 14 (10,9%)tumores malignos y 13 (10,1%)tumores premalignos. En losdiagnósticos agrupados, la concordancia fue del 59,8% (intervalo de confianza[IC] del 95%, 50–70%) (p<0,0001) para atención primaria y del 94,7%(IC del 95%, 90–99%) (p<0,0001)para teledermatología.Conclusiones: La principal ventaja de la teledermatología asíncrona es la mejora en la calidad del cribado, que detecta lesiones malignas o sospechosas. Sin embargo, precisamos estudios metodológicamente comparables a mayor escala para evaluar tambiéninconvenientes (limitación de la técnica fotográfica, valoración de otras lesiones, aspectos legales, motivación de los profesionales, etc.)(AU)

Objective: To analyze the diagnostic agreement rate between primary care,anasynchronous teledermatology consultation, and a conventional dermatology consultation.Design: Prospective non-randomized concordance study.Setting: Dermatology Service in Hospital Son Llàtzer (Palma de Mallorca)and primary care centers of Sóller and Arenal(Mallorca).Participants: Patients have been included from December 2005 to July 2008, sent byteleconsultation (n = 158).Main measurements: Analysis of primary care, teledermatology consultation and face-to-face consultation diagnosis, in mentioned period of time. Calculation of kappa index of concordance.Results: 158 teleconsultations have been made from December 2005 to July 2008, 94 (59,5%) women, and 64(40,5%) men, aged from 9 to 96 years old (average, 55 year sold). After grouping the diagnosis in categories, the distribution was: 48 (37,2%) benigntumours, 39 (30,2%)inflammatory and appendages diseases, 15 (11,6%)infectious diseases, 14 (10,9%)malignant tumours, and 13 (10,1%)premalignant tumours. In grouped diagnosis, concordance was 59,8%(CI 95%, 50–70%) (P<0001) for general practitioner and 94,7% (CI 95%, 90–99%) (P<0001) forteledermatologist.Conclusions: The main advantage of asynchronous teledermatology is the improvement of the quality triage, allowing the detection of malignantor suspicious lesions. However, we need more comparable studies on a larger scale to evaluate the disadvantages(photographic technique limitation, evaluation of other lesions, legal aspects, professional motivation...)(AU)

[Clinical use of HIV-1 resistance genotyping. Predictive factors of poor virological evolution in salvage treatments]. / Utilización en la práctica clínica de los tests de resistencia genotípica al VIH-1. Factores predictivos de mala evolución virológica en tratamientos de rescate.

OBJECTIVES: To describe the use of genotype resistance testing (GRT) for virological failure in clinical practice, and the long-term clinical and virological evolution in patients for whom it is requested. To identify the predictive factors of virological failure in patients with antiretroviral (ARV) salvage therapy. METHODS: Observational study in HIV-infected patients for whom GRT was requested for virological failure (VF) in the period of 1 October 1999 to 31 December 2001. Logistic regression analysis was used to determine the predictive factors of virological progression. RESULTS: Over the period studied, 196 patients required GRT for VF (15%) among those monitored in specific units. GRT was mainly requested for patients who had been extensively pretreated for a mean of 5 years and with a median of 5 ARV combinations. Half the patients presented 3 or more mutations associated with thymidine analogs (TAMs), mutations associated with non-nucleoside analogs (NNRTIs), and 5 or more mutations associated with protease inhibitors (PIs). In 143 (74%) patients, the RTV regimen was changed on the basis of GRT results. In the intent-to-treat analysis, the percentage of patients with plasma VL < 400 cop/mL at 6, 12 and 18 months was 41%, 29% and 17%, respectively. In the on-treatment analysis, the results were 50%, 48% and 46%, respectively. Mean CD4 lymphocyte increase was 59.74 and 94 cells/mm 3. The variables predicting virological failure (plasma VL > 400 cop/mL) at 12 months were plasma VL > 30,000 cop/mL (OR 6, 1.8-19.5) and accumulation of 3 or more TAMs (OR 4.4, 1.3-15) at the start of ARV salvage therapy. CONCLUSION: Even though in clinical practice GRT is requested for patients with various treatment failures, when ART salvage treatment was started, plasma VL was undetectable and immunological response persisted in 40% of patients followed-up for 18 months. The factors best predicting virological evolution were VL and the number of baseline TAMs.

Utilización en la práctica clínica de los tests de resistencia genotípica al VIH-1. Factores predictivos de mala evolución virológica en tratamientos de rescate / Clinical use of HIV-1 resistance genotyping. Predictive factors of poor virological evolution in salvage treatments

Objetivos. Describir la utilización de los tests de resistencia genotípica (TRG) por fracaso virológico en la práctica clínica y la evolución clínica y virológica a largo plazo de los pacientes en los que se solicitaron. Establecer los factores predictivos de fracaso virológico con tratamientos antirretrovirales (TARV) de rescate. Métodos. Estudio observacional de los pacientes con infección por el virus de la inmunodeficiencia humana (VIH) a los que se solicitó TRG por fracaso virológico (FV) en el período comprendido entre el 1/10/1999 y 31/12/2001. Se determinaron los factores predictivos de mala evolución virológica mediante un análisis de regresión logística. Resultados. En el período de estudio, 196 pacientes precisaron TRG por FV (15%) de los seguidos en unas consultas específicas. Los TRG se solicitaron mayoritariamente a pacientes extensamente pretratados, con una media de 5 años y una mediana de cinco combinaciones TARV. La mitad de los pacientes presentaban tres o más mutaciones asociadas a análogos de la timidina (TAM), alguna mutación asociada a análogos no nucleósidos (ANNTI) y cinco o más mutaciones asociadas a inhibidores de proteasas (IP). En 143 (74%) se realizó un cambio de TARV en base al TRG recibido. En el análisis por intención de tratar, el porcentaje de pacientes con carga viral (CV) plasmática 400 cop./ml a los 12 meses, fueron tener una CV > 30.000 cop./ml odds ratio (OR) 6 (1,8-19,5) y haber acumulado tres o más TAM OR 4,4 (1,3-15) al iniciar el TARV de rescate. Conclusión. A pesar de que los TRG se solicitan en la práctica clínica en pacientes en multifracaso, al instaurar TARV de rescate se consiguen mantener la CV plasmática indetectables en el 40% de los pacientes en seguimiento a los 18 meses y con una respuesta inmunológica mantenida. Los factores que mejor predicen la evolución virológica son la CV plasmática y el número de TAMbasales (AU)

Objectives. To describe the use of genotype resistance testing (GRT) for virological failure in clinical practice, and the long-term clinical and virological evolution in patients for whom it is requested. To identify the predictive factors of virological failure in patients with antiretroviral (ARV) salvage therapy. Methods. Observational study in HIV-infected patients for whom GRT was requested for virological failure (VF) in the period of 1 October 1999 to 31 December 2001. Logistic regression analysis was used to determine the predictive factors of virological progression. Results. Over the period studied, 196 patients required GRT for VF (15%) among those monitored in specific units. GRT was mainly requested for patients who had been extensively pretreated for a mean of 5 years and with a median of 5 ARV combinations. Half the patients presented 3 or more mutations associated with thymidine analogs (TAMs), mutations associated with non-nucleoside analogs (NNRTIs), and 5 or more mutations associated with protease inhibitors (PIs). In 143 (74%) patients, the RTV regimen was changed on the basis of GRT results. In the intent-to-treat analysis, the percentage of patients with plasma VL 400 cop/mL) at 12 months were plasma VL > 30,000 cop/mL (OR 6, 1.8-19.5) and accumulation of 3 or more TAMs (OR 4.4, 1.3-15) at the start of ARV salvage therapy. Conclusion. Even though in clinical practice GRT is requested for patients with various treatment failures, when ART salvage treatment was started, plasma VL was undetectable and immunological response persisted in 40% of patients followed-up for 18 months. The factors best predicting virological evolution were VL and the number of baseline TAMs (AU)