Parálisis del nervio interóseo posterior secundario a lipoma profundo / Posterior interosseous nerve palsy secondary to deep lipoma

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Resonancia magnética en espondiloartritis axial: estudio Delphi sobre pautas de actuación y realización / Guidelines for magnetic resonance imaging in axial spondyloarthritis: a Delphi study

Objetivo. La espondiloartritis axial (EspA) pertenece a un grupo de enfermedades reumáticas inflamatorias crónicas que cursan con afectación axial, periférica y de entesis y tienen bases genéticas comunes. Recientemente, la Assessment of SpondyloArthritis International Society (ASAS) ha establecido unos criterios diagnósticos, incluyendo por primera vez la resonancia magnética (RM). Al ser esta una técnica de difícil acceso en determinados medios y ante la falta de experiencia con esta enfermedad, un grupo de radiólogos y reumatólogos propuso buscar recomendaciones prácticas para usarla correctamente. Material y métodos. Encuesta realizada (método Delphi) a 46 expertos sobre el diagnóstico de EspA mediante RM, con 49 ítems estratificados en 4 bloques. Resultados. Se consensuó el 82% de los ítems. El grado de consenso fue del 100% en el bloque «Importancia del diagnóstico precoz de la EspA», del 69% en la «Optimización del uso de la RM en el diagnóstico de la EspA», del 93% en el «Uso de la RM en la EspA: cuestiones técnicas», y del 57% en la «Utilidad de la RM en el pronóstico, seguimiento y valoración del tratamiento de la EspA». Conclusiones. A pesar de la importancia de la RM para diagnosticar precozmente la EspA, este trabajo refleja la necesidad de estandarizarla, y pone de manifiesto una falta de consenso relativa sobre cómo usarla para seguir la enfermedad y valorar la respuesta al tratamiento. Se aportan recomendaciones para mejorar el uso de la RM para diagnosticar la EspA (AU)

Objective. The term axial spondyloarthritis refers to a group of chronic inflammatory rheumatic diseases with a common genetic basis that course with axial and peripheral involvement and enthesitis. Recently, the Assessment of SpondyloArthritis international Society (ASAS) established some diagnostic criteria, including for the first time magnetic resonance imaging (MRI) findings. Given the difficulties of obtaining MRI in some environments and the lack of experience with axial spondyloarthritis, a group of radiologists and rheumatologists sought to establish some practical guidelines to ensure the correct use of MRI in this disease. Material and methods. Using the Delphi method, we used a questionnaire with 49 items stratified into 4 blocks to survey 46 experts in the MRI diagnosis of axial spondyloarthritis. Results. The experts agreed on 82% of the items. The degree of agreement was 100% in the block “Importance of early diagnosis of axial spondyloarthritis”, 69% in the block “Optimization of the use of MRI in the diagnosis of axial spondyloarthritis”, 93% in the block “Use of MRI in axial spondyloarthritis: Technical aspects”, and 57% in the block “Usefulness of MRI in the prognosis, follow-up, and evaluation of the response to treatment in axial spondyloarthritis”. Conclusions. Despite the importance of MRI in the early diagnosis of axial spondyloarthritis, this study shows the need for standardization and points to relative disagreement about how to use MRI in the follow-up of the disease and evaluation of the response to treatment. The results of this study can help improve the use of MRI in axial spondyloarthritis (AU)

Guidelines for magnetic resonance imaging in axial spondyloarthritis: A Delphi study.

OBJECTIVE: The term axial spondyloarthritis refers to a group of chronic inflammatory rheumatic diseases with a common genetic basis that course with axial and peripheral involvement and enthesitis. Recently, the Assessment of SpondyloArthritis international Society (ASAS) established some diagnostic criteria, including for the first time magnetic resonance imaging (MRI) findings. Given the difficulties of obtaining MRI in some environments and the lack of experience with axial spondyloarthritis, a group of radiologists and rheumatologists sought to establish some practical guidelines to ensure the correct use of MRI in this disease. MATERIAL AND METHODS: Using the Delphi method, we used a questionnaire with 49 items stratified into 4 blocks to survey 46 experts in the MRI diagnosis of axial spondyloarthritis. RESULTS: The experts agreed on 82% of the items. The degree of agreement was 100% in the block "Importance of early diagnosis of axial spondyloarthritis", 69% in the block "Optimization of the use of MRI in the diagnosis of axial spondyloarthritis", 93% in the block "Use of MRI in axial spondyloarthritis: Technical aspects", and 57% in the block "Usefulness of MRI in the prognosis, follow-up, and evaluation of the response to treatment in axial spondyloarthritis". CONCLUSIONS: Despite the importance of MRI in the early diagnosis of axial spondyloarthritis, this study shows the need for standardization and points to relative disagreement about how to use MRI in the follow-up of the disease and evaluation of the response to treatment. The results of this study can help improve the use of MRI in axial spondyloarthritis.

Lack of short-term increase in serum mediators of fibrogenesis and in non-invasive markers of liver fibrosis in HIV/hepatitis C virus-coinfected patients starting maraviroc-based antiretroviral therapy.

The aim of this study was to analyze serum changes in mediators of fibrogenesis and in non-invasive markers of liver fibrosis among HIV/HCV-coinfected patients starting maraviroc (MVC)-based antiretroviral therapy. Patients included in this prospective pilot study met the following criteria: (1) HIV-infection, (2) detectable serum HCV-RNA, and ((3) started MVC. Transforming growth factor-ß1 (TGF-beta1), matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) were measured in serum samples at baseline and 6 months after starting MVC. AST-to-platelet ratio index (APRI) was assessed at the same time points. Twenty-four patients were analyzed. Median (IQR) serum levels at baseline and after 6 months on MVC of TGF-beta1 were 27,295 (20,562-36,844) and 33,753 (18,973-46,130) pg/mL (p=0.116), of MMP-2 were 216 (186-274) and 241 (194-306) ng/mL (p=0.247), and of TIMP-1 were 237 (170-284) and 216 (171-271) ng/mL (p=0.415). APRI levels were 0.99 (0.53-3.46) at baseline and 0.83 (0.48-2.34) at 6 months (p=0.16). Serum mediators of liver fibrogenesis and fibrosis do not change significantly in HIV/HCV-coinfected patients in the short-term after starting MVC. As TGF-beta1 levels have been shown to increase over time in HCV infection and liver fibrosis worsens rapidly in HIV/HCV coinfection, these parameters seem to evolve in a different way in MVC-treated patients.

Insulin resistance is associated with liver stiffness in HIV/HCV co-infected patients.

BACKGROUND: The factors that influence liver fibrosis progression in patients co-infected with human immunodeficiency virus/hepatitis C virus (HIV/HCV) are not completely understood. It is not known if insulin resistance (IR), a condition that promotes liver fibrosis in HCV mono-infected individuals, is one of these factors. OBJECTIVE: To evaluate the association between IR and liver stiffness (LS). DESIGN: Multicentre cross-sectional study. PATIENTS: 330 patients co-infected with HIV/HCV. METHODS: LS was assessed by transient elastography, which has shown a high accuracy to predict significant fibrosis in patients co-infected with HIV/HCV. The outcome variable of the study was LS. Patients with LS> or =9 kPa were considered as having significant fibrosis. IR was calculated using the HOMA method. RESULTS: LS was > or =9 kPa in 150 (45%) patients. HOMA correlated with LS (Spearman's rho correlation coefficient, 0.37; p<0.0001). The median (Q1-Q3) HOMA in patients with LS> or =9 kPa was 3.30 (2.17-5.16) while it was 2.09 (1.37-3.22) in patients with LS <9 kPa (p<0.0001). Ninety-six (39%) individuals with a HOMA <4 and 54 (63%) with a HOMA > or =4 showed LS> or =9 kPa (p<0.0001). Analyses after excluding patients with cirrhosis yielded similar results. After multivariate analyses, age > or =40 years (adjusted odds ratio (AOR), 1.85; 95% confidence interval (CI), 1.03 to 3.29; p = 0.03), CD4 cell count <200 cells/ml (AOR, 3.45; 95% CI, 1.67 to 7.11; p = 0.001), hepatitis B virus co-infection (AOR, 9.25; 95% CI, 2.42 to 35.31; p = 0.001), and HOMA > or =4 (AOR, 5.33; 95% CI, 2.70 to 10.49; p<0.0001) were the independent predictors of LS> or =9 kPa. CONCLUSION: IR is associated with LS in patients co-infected with HIV/HCV.

[Prevalence of hepatitis C virus among HIV-infected patients in Area 2 of Madrid]. / Prevalencia de hepatitis C en población infectada por el VIH en el Area 2 de Madrid.

INTRODUCTION: The evolution of HIV infection, a rapid and fatal illness not long time ago, has become a chronic disease due to the implementation of new antiretroviral treatment. Therefore it is essential to focus on the management of concurrent illnesses such as chronic hepatitis C infection, specially as they share common routes of transmission. METHODS: A cross sectional survey was done to determine the prevalence of HIV and HCV coinfection, measuring different HIV and HCV variables among 651 HIV infected patients of a health area in Madrid. RESULTS: 500 patients (76.8%) were male and 151 female (23%). HCV serology was performed in all the patients and resulted positive in 45.7% (298) most of them drug users (84.8%). The CD4 cell count was lower in patients HIV-HCV coinfected compared to those HCV negative (p < 0.001). CONCLUSION: This study shows a high prevalence of HIV-HCV coinfection, mainly due to parenteral transmission. We emphasize the low percentage of coinfected patients treated with interferon and ribavirine which probably will increase in the future.

[Clinical trial comparing efficacy and safety of four highly active antiretroviral therapy (HAART) in antiretroviral-naive treatment with advanced HIV infection]. / Ensayo clínico comparativo de eficacia y seguridad de cuatro pautas de tratamiento antirretroviral de alta eficacia (TARGA) en pacientes naive con infección por VIH avanzada.

BACKGROUND: Comparison of efficacy and safety of four highly active antiretroviral therapy regimens (HAART) including two nucleoside analogues (NA) and a protease inhibitor (PI) in HIV positive patients with advanced infection and antiretroviral naive. PATIENTS AND METHODS: Multicenter, randomized and open labeled clinical trial in ten community hospitals of Castilla-La Mancha and Madrid. Regimen 1 contains zidovudine (AZT), lamivudine (3TC) and indinavir (IDV) regimen 2 includes AZT, 3TC and ritonavir (RTV), regimen 3 was didanosine (DDI), estavudine (D4T) and IDV, and regimen 4 included DDI, D4T and RTV. Decrease in viral load of HIV (VC) has been assessed as primary endpoint and as secondary one, the increase of the numbers of CD4 lymphocytes, percentage of disease progression, adverse reactions and adherence. Measurements were made at baseline visit and at 6, 12, 24, 36 and 48 weeks. RESULTS: A total of 98 patients with a mean baseline CD4 count of 122 x 10(6)/l (range of 5-340) and a baseline viral load of 5.1 log copies/ml were included. At 48 weeks, a mean increase of the CD4 and decrease of the viral load without significant difference between the 4 regimens (103 cells/2.62 log in regimen 1; 169 cells/2.86 log in regimen 2; 171 cells/2.56 log in regimen 3 and 141 cells/1.71 log in regimen 4) were observed in the analysis of the patients in treatment. Treatment was discontinued due to adverse reactions: 24% in regimen 1, 48% in regimen 2, 26% in regimen 3 and 32% in regimen 4, without significant difference. Analyzing by PI groups, 41% of the patients with RTV and 25% of those with IDV discontinued treatment due to adverse effects. There was withdrawal from treatment due to disease progression in 7% of the RTV patients and in 9% of IDV patients. CONCLUSIONS: In the HIV positive patients with advanced infection, efficacy between the four regimens of HAART is similar, but there is a tendency to require more withdrawal due to adverse effects in the RTV group than in those of IDV, the two used as single PI.

Prevalencia de hepatitis C en población infectada por el VIH en el Área 2 de Madrid / Prevalence of hepatitis C virus among HIV-infected patients in Madrid

Introducción: La evolución de la infección por VIH, antes inexorablemente fatal, se ha visto alterada por la introducción de nuevos fármacos antirretrovirales hasta convertirse en un proceso crónico. Por ello en el manejo del paciente VIH+ cobra especial importancia la presencia de otros procesos que a largo plazo puedan influir en la evolución de la enfermedad como es el caso de la infección por VHC, más aún compartiendo ambos virus similares vías de transmisión. Métodos: Para determinar la prevalencia de la coinfección por VIH-VHC realizamos un estudio transversal analizando diversos parámetros referentes al VIH y al VHC en 651 pacientes VIH+ en el Área 2 de Madrid. Resultados: El número de pacientes varones fue de 500 (76,8%) y el de mujeres 151 (23,2%). Se realizó serología para VHC en el 100% de los pacientes y se obtuvo resultado positivo en el 45,7% (298 pacientes), con un marcado predominio de ADVP dentro de este subgrupo (84,8%). El número de CD4 era significativamente menor en pacientes coinfectados comparados con pacientes no infectados por VHC (p < 0,001). Conclusión: Nuestro estudio muestra un alto índice de coinfección por VHC, referido fundamentalmente a la vía de transmisión parenteral y es de destacar el escaso porcentaje de pacientes tratados con interferón y ribavirina, que con seguridad va a aumentar en los próximos años

Introduction: The evolution of HIV infection, a rapid and fatal illness not long time ago, has become a chronic disease due to the implementation of new antiretroviral treatment. Therefore it is essential to focus on the management of concurrent illnesses such as chronic hepatitis C infection, specially as they share common routes of transmission. Methods: A cross sectional survey was done to determine the prevalence of HIV and HCV coinfection, measuring different HIV and HCV variables among 651 HIV infected patients of a health area in Madrid. Results: 500 patients (76,8%) were male and 151 female (23%). HCV serology was performed in all the patients and resulted positive in 45.7% (298) most of them drug users (84.8%). The CD4 cell count was lower in patients HIV-HCV coinfected compared to those HCV negative (p < 0.001). Conclusion: This study shows a high prevalence of HIV-HCV coinfection, mainly due to parenteral transmission. We emphasize the low percentage of coinfected patients treated with interferon and ribavirine which probably will increase in the future

Ensayo clínico comparativo de eficacia y seguridad de cuatro pautas de tratamiento antirretroviral de alta eficacia (TARGA) en pacientes naive con infección por VIH avanzada / Clinical trial comparing efficacy and safety of four highly active antiretroviral therapy (HAART) in antiretroviral-naive treatment with advanced HIV infection

Introducción. Comparación de la eficacia y seguridad de cuatro pautas de terapia antirretroviral de gran actividad (TARGA) incluyendo dos análogos de nucleósidos (AN) y un inhibidor de proteasa (IP) en pacientes con el virus de la inmunodeficiencia humana (VIH) con infección avanzada y naive a antirretrovirales. Pacientes y método. Ensayo clínico, multicéntrico, randomizado y abierto en diez hospitales comunitarios de Castilla-La Mancha y Madrid. La pauta 1 contenía zidovudina (ZDV), lamivudina (3TC) e indinavir (IDV); la pauta 2 incluía ZDV, 3TC y ritonavir (RTV); la pauta 3 era didanosina (DDI), estavudina (D4T) e IDV, y la pauta 4 incluía DDI, D4T y RTV. Se ha valorado como variable principal de respuesta el descenso de la carga viral del VIH (CV), y como variables secundarias: el aumento del número de linfocitos CD4, el porcentaje de progresión de la enfermedad, las reacciones adversas y la adherencia. Las determinaciones se realizaron en la visita basal y a las 6, 12, 24, 36 y 48 semanas. Resultados. Se incluyeron 98 pacientes con una media de CD4 basal de 122 x 106/l (rango de 5-340) y una carga viral basal de 5,1 log copias/ml. A las 48 semanas, en el análisis de los pacientes en tratamiento se observó un incremento medio de los CD4 y una disminución de la carga viral sin diferencia significativa entre las 4 pautas (103 células/2,62 log en la pauta 1, 169 células/ 2,86 log en la pauta 2, 171 células/2,56 log en la pauta 3 y 141 células/1,71 log en la pauta 4). Interrumpieron el tratamiento por reacciones adversas: el 24% en la pauta 1, el 48% en la pauta 2, el 26% en la pauta 3 y el 32% en la pauta 4, sin diferencias significativas. Analizando por grupos de IP el 41% de los pacientes con RTV y el 25% de los pacientes con IDV suspendieron el tratamiento por efectos adversos. Se produjo retirada del tratamiento por progresión de la enfermedad en el 7% de los pacientes con RTV y en el 9% de los pacientes con IDV. Conclusiones. En los pacientes VIH positivos con infección avanzada la eficacia entre cuatro pautas de TARGA es similar, pero existe una tendencia a precisar mayor retirada por efectos adversos en los grupos de RTV que en los de IDV, los dos usados como IP único

Background. Comparison of efficacy and safety of four highly active antiretroviral therapy regimens (HAART) including two nucleoside analogues (NA) and a protease inhibitor (PI) in HIV positive patients with advanced infection and antiretroviral naive. Patients and methods. Multicenter, randomized and open labeled clinical trial in ten community hospitals of Castilla-La Mancha and Madrid. Regimen 1 contains zidovudine (AZT), lamivudine (3TC) and indinavir (IDV) regimen 2 includes AZT, 3TC and ritonavir (RTV), regimen 3 was didanosine (DDI), estavudine (D4T) and IDV, and regimen 4 included DDI, D4T and RTV. Decrease in viral load of HIV (VC) has been assessed as primary endpoint and as secondary one, the increase of the numbers of CD4 lymphocytes, percentage of disease progression, adverse reactions and adherence. Measurements were made at baseline visit and at 6, 12, 24, 36 and 48 weeks. Results. A total of 98 patients with a mean baseline CD4 count of 122 x 106/l (range of 5-340) and a baseline viral load of 5.1 log copies/ml were included. At 48 weeks, a mean increase of the CD4 and decrease of the viral load without significant difference between the 4 regimens (103 cells/2.62 log in regimen 1; 169 cells/2.86 log in regimen 2; 171 cells/2.56 log in regimen 3 and 141 cells/1.71 log in regimen 4) were observed in the analysis of the patients in treatment. Treatment was discontinued due to adverse reactions: 24% in regimen 1, 48% in regimen 2, 26% in regimen 3 and 32% in regimen 4, without significant difference. Analyzing by PI groups, 41% of the patients with RTV and 25% of those with IDV discontinued treatment due to adverse effects. There was withdrawal from treatment due to disease progression in 7% of the RTV patients and in 9% of IDV patients. Conclusions. In the HIV positive patients with advanced infection, efficacy between the four regimens of HAART is similar, but there is a tendency to require more withdrawal due to adverse effects in the RTV group than in those of IDV, the two used as single PI

Dolor e impotencia funcional de ambas caderas / Pain and functional impotence of both hips

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[Treatment with interferon and ribavirin of chronic hepatitis C in HIV-infected patients]. / Tratamiento con interferón y ribavirina de la hepatitis crónica por virus C en pacientes con infección por VIH.

BACKGROUND: The rapid progression of chronic hepatitis C (CHC) in HIV-infected patients is now the most important cause of morbidity, mortality and hospital admissions. In order to avoid this evolution, the treatment of CHC is a major challenge in these patients. PATIENTS AND METHOD: The aim of this study is to evaluate the safety and efficacy of treatment of CHC in HIV-infected patients with subcutaneous IFN (3 MU 3 times a week) plus Ribavirin (RBV) administered per 200 mg dosage depending on their body weight, for 24 weeks for genotype 2 or 3 and 48 weeks for genotype 1 or 4. All the patients have a CD4 count over 150 cells/microl and HIV viral load < 50,000 copies/ml, with or without antiretroviral treatment. We defined sustained response as RNA-VHC below level of detection 24 weeks after the end of treatment. RESULTS: We included 28 patients in the study, with median age of 36.6 y.o. 82% of the patients were on antiretroviral treatment, with AZT in 60% of them. Genotype distribution was HCV-1 in 50%, HCV-3 in 35.7%, HCV-4 in 10.7% and HCV-2 in 3%. Liver biopsy was performed in all the patients. Adverse events leading to treatment discontinuation occurred in 5 patients (17.8%). The overall sustained response rate in the intent-to-treat analysis was 25.8% (50% for genotype 3 and 14% for genotype 1). CONCLUSION: This therapy provides cure in a rate significantly lower than that seen in HCV-monoinfected individuals, with a similar safety. The modern formulations of IFN (pegylated) will provide new expectatives in this group of patients.

Tratamiento con interferón y ribavirina de la hepatitis crónica por virus C en pacientes con infección por VIH / Treatment whith interferon and ribavirin of chronic hepatits C in HIV-infected patients

Introducción: Actualmente, las complicaciones de la hepatitis crónica por virus C en pacientes infectados por el VIH son la causa más importante de morbilidad, mortalidad e ingreso hospitalario en estos pacientes. Estos hechos han conducido a que cada vez sea más prioritario el tratamiento de la hepatitis crónica en este tipo de pacientes. Pacientes y método: Hemos evaluado la eficacia y seguridad del tratamiento de la hepatitis crónica por VHC en pacientes infectados por VIH, con interferón (IFN) 3 MU 3 veces por semana por vía subcutánea y ribavirina (RBV) en comprimidos de 200 mg en dosis dependiente del peso, durante 24 semanas para genotipo 2 ó 3 y 48 semanas para genotipo 1 ó 4. Todos los pacientes tenían más de 150 CD4/µl y carga viral de VIH <50.000 copias/ml, con o sin tratamiento antirretroviral. Se consideró respuesta sostenida si el ARN-VHC era indetectable 24 semanas después de finalizar el tratamiento. Resultados: Hemos incluido 28 pacientes infectados por ambos virus, con edad media de 36,6 años. El 82 por ciento estaban con tratamiento antirretroviral que incluía AZT en el 60 por ciento. La distribución por genotipos fue: 1 en 14 (50 por ciento), 3 en 10 (35,7 por ciento), 4 en 3 (10,7 por ciento) y 2 en 1 (3 por ciento). Todos los pacientes tenían realizada biopsia hepática. Hubo 5 abandonos de tratamiento (17,8 por ciento) debido a efectos adversos. Se observó respuesta sostenida "por intención de tratamiento" en el 25,8 por ciento de los pacientes (50 por ciento para genotipo 3 y 14 por ciento para genotipo 1). Discusión: La eficacia del tratamiento combinado con IFN y RBV en la hepatitis crónica de los pacientes coinfectados por VHC y VIH es menor que la descrita para pacientes VIH negativos, aunque la tolerancia y seguridad son similares. Las nuevas formas de IFN (pegilado) abren una nueva posibilidad para optimizar el tratamiento de estos pacientes (AU)

Linfocitopenia T CD4+ idiopática asociada a criptococosis diseminada / Idiopathic CD4+ T-cell lymphocytopenia associated with disseminated cryptococcosis

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Fiebre prolongada en paciente con lesiones ocupantes de espacio hepáticas de larga evolución / Fever in a patient with spatial hepatic lesions of large evolution

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