[Assessing the use of proton pump inhibitors in an internal medicine department]. / Evaluación del uso de los inhibidores de la bomba de protones en un servicio de medicina interna.

INTRODUCTION: proton pump inhibitors (PPIs) block the H+/K+ ATPase enzyme in gastric wall cells, leading to an inhibition of both baseline and stimulated acid secretion. Appropriate indications include: Gastroesophageal reflux, acute upper gastrointestinal bleeding, erosive gastritis or esophagitis, dyspepsia, NSAID-related gastropathy, and stress ulcer prophylaxis in high risk patients. The aims of this study were to review the current indications of PPIs, and to evaluate their use in Guadalajara s University Hospital. MATERIAL AND METHODS: a transversal, analytic, randomized study was carried out during 2003 in our internal medicine department. A total of 208 medical records for 832 patients receiving PPIs were reviewed (25%). Mean age was 67 years (range: 16-92), 46.2% were females, and most frequent conditions were HBP, COPD, and DM. RESULTS: 34.6% of patients took PPIs before admission, their use being inappropriate in 68.1% of them. Among hospitalized patients 73.03% used PPIs inappropriately, and most of them had no such indication at discharge. CONCLUSIONS: results are in accordance with the literature, with a high frequency of incorrect PPI use; a more accurate use of PPIs is to be recommended to avoid side effects and drug interactions, and to provide a more efficient medical care.

Multivariate model for predicting relapse in human brucellosis.

Demographic, clinical, and laboratory data from 200 consecutive patients with acute brucellosis were analysed with univariate and multivariate methods to identify correlates of relapse. A risk score for predicting relapse was then calculated by using Cox proportional hazard model. The independent predictors of relapse were temperature of 38.3 degrees C or higher, positive blood cultures at baseline, and the duration of symptoms before treatment <10 days. Stratification according to the risk score demonstrated that rates of relapse were significantly different between risk groups (P<0.0001). The low-risk group had a 4.5% probability (6 of 135) of relapse at 12 months. In contrast, relapse was present in 15 of 47 patients in the medium-risk group (P<0.0017); and in 12 of 18 patients in the high-risk group (P<0.0001). This study provides a rational basis for estimating the risk of relapse in patients with acute brucellosis, and may be helpful in deciding what subjects might benefit from extra attention.

[Primary double neoplasias (author's transl)]. / Neoplasias primitivas dobles.

Data of 22 patients with primary double tumors are reviewed, collected from a total of 39.000 clinical protocols of which 1.168 were malignant. All were histologically verified. Criteria were those established by Warren & Gates i.e. a) each tumor must present clear signs of malignancy, b) each tumor must be different from the other, c) all possibility that one tumor may be a metastasis of the other must be excluded. Twelve of the cases were male and 10 female, representing 1.88% of the total with malignancies. In 6 cases both tumors appeared simultaneously, while the time interval was between 1 and 43 years in the remaining 16. Hematologic neoplasias are predominant with 12/44, followed by digestive and urogenital ones with 8/44 in each sub-group. Association between double tumors is assessed and causal factors which may influence or favor the appearance of two or more neoplasias are discussed.

[Evaluation of 2 tuberculosis chemoprophylaxis regimens in patients infected with human immunodeficiency virus. The GECMEI Group]. / Evaluación de dos pautas de quimioprofilaxis tuberculosa en pacientes infectados por el virus de la inmunodeficiencia humana. Grupo GECMEI.

OBJECTIVE: To assess the compliance, tolerance and efficacy of a short chemoprophylaxis regimen (IR) for tuberculosis using isoniazid (INH) plus rifampin (RIF) during 3 months versus a standard regimen (I) of isoniazid during 12 months in HIV positive patients. MATERIAL AND METHODS: Prospective, comparative, randomized and open clinical trial in four general hospitals and one prison hospital of Castilla-La Mancha. Prophylaxis was administered to PPD-positive patients and to anergic patients according to the CDC recommendations (1991). Patients were randomized in two treatment groups: regimen IR, isoniazid 300 mg daily and rifampin 600 mg daily; regimen I, isoniazid 300 mg during 12 months. RESULTS: 133 patients were included, 64 to regimen I and 69 to regimen IR. Regimen IR had a better tolerance with a 28% of adverse effects versus 55% in regimen I. Hepatotoxicity was more frequent in regimen I with a RR = 2.2 (CI 95% 1.23-4.01). Severe hepatotoxicity leading to treatment withdrawal was related to drug administration time and was more frequent in the 12 months regimen group. Short regimen showed a better compliance, without significant differences. Tuberculosis incidence rate was a 4.23 cases/100 persons--year for regimen I and 2.08 in regimen IR, with a relative risk for developing tuberculosis with regimen IR group of 0.51 (CI 95% 0.09-2.8) versus regimen I group, without statistical significance. Prison stay was associated to a significant risk for tuberculosis, regardless of both regimens (RR = 9.2 CI 95%, 1.06-80.2). CONCLUSIONS: In HIV-infected patients with PPD(+) or anergic, regimen with IR is at least as effective as regimen I for preventing the development of tuberculous disease, and has less adverse effects.

The resident as teacher: Medical students' perception in a Spanish university. / El residente como docente: percepción de estudiantes de medicina de una universidad española.

BACKGROUND AND OBJECTIVES: Residents play an important but scanty assessed role in medical students teaching. The aim of this study was to assess the perception of medical students about residents' teaching activity. MATERIAL AND METHODS: Autofilled survey provided to medical students of the University of Alcalá (Spain) in the final year in their school of medicine. Student opinion about care and teaching abilities of residents and physicians was evaluated using a 5-point Likert scale. RESULTS: 104 surveys were collected. A 69,9% of students consider that as much as 50% of their knowledge came from rounds with residents. Students believe that resident teaching lacks enough academical acknowledgment (94.2%); they estimate necessary to acquire teaching skills during residency (82,7%), and they would like to provide tutoring other medical students (88,5%). Students rated residents better than physicians on relational and motivational abilities. CONCLUSIONS: There is a positive view about resident as a teacher among medical students, which suggests the need to improve the resident's teaching skills.

Incidence of tuberculosis in HIV-infected patients receiving HAART: interaction between TST and CD4 count.

BACKGROUND: There may be an interaction between the CD4 count and the tuberculin skin test (TST) for the development of tuberculosis (TB) in human immunodeficiency virus (HIV) infected patients receiving highly active antiretroviral therapy (HAART). METHODS: Observational, cohort study of patients treated with HAART during the course of HIV infection in whom TB was confirmed by a positive culture result. Patients were stratified by TST and CD4 count. Univariate and multivariate analyses were performed to identify risk factors associated with the development of TB. RESULTS: The study included 1824 patients starting HAART, 339 (18.6%) of whom were TST-positive. After a median 473 days, 45 cases of TB had developed (1.9 cases per 100 person-years, 95%CI 1.38-2.54). The risk of developing TB increased significantly among patients with a positive TST (2.81, 95%CI 1.11-7.15), and in individuals with > or < 200 cells/µ l (1.37, 95%CI 0.44-4.21). By contrast, in the TST-negative group, the risk was significantly higher in patients with < 200 cells/µ l (16.64, 95%CI 2.16-127.6). CONCLUSIONS: TST-positive patients are at high risk of developing TB, irrespective of CD4 count. However, among TST-negative patients only those with a CD4 count < 200 cells/µ l have an appreciable risk of developing the disease.

[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.

[Report of three cases of hyperlactacidemiae/lactic acidosis after treatment of hepatitis C with pegylated interferon and ribavirin in HIV coinfected patients]. / A propósito de tres casos de hiperlactacidemia/acidosis láctica tras el tratamiento de la hepatitis C con interferón pegilado y ribavirina en pacientes coinfectados por VIH.

The hepatitis C infection is highly prevalent among HIV-infected patients. As a direct consequence of the increased survival of these patients in the HAART era, liver disease and its long-term complications have became a genuine health problem in these patients. The treatment of chronic HCV hepatitis is associated with several secondary effects, hiperlactacidemiae/lactic acidosis is one of the most dangerous. It appears to be related with the association of ribavirin and ddI, d4T or AZT. These are three cases of hiperlactacidemiae/lactic acidosis collected during the first twelve months of treatment with pegylated interferon and ribavirin in University Hospital of Guadalajara.

Impaired activity of natural killer cells in patients with acute brucellosis.

Researchers have claimed that natural killer (NK) cells are involved in the mechanisms of defense of the host against infections. We have investigated the activity of NK cells in peripheral blood mononuclear cells (PBMNC) from 12 patients for whom acute brucellar infection has been diagnosed and from 14 healthy controls. The sera of eight of the patients were also analyzed 3 months after initiation of a 45-day course of antibiotic treatment, at which time they had no evidence of relapse. PBMNC from patients with acute brucellar infection showed a significantly depressed NK cell activity (P < .01) when compared with those from healthy controls; this depressed activity was not related to a deficient number of NK cells since the numbers of CD56+ and CD16+ cells present in PBMNC were similar in patients and controls. Incubation of PBMNC from patients with acute brucellar infection with recombinant interleukin-2, but not with interferon-gamma, can correct this impaired cytotoxic activity. In treated patients, there was a significant enhancement (P < .05) and normalization of the previously defective NK cell activity. It is concluded that acute brucellar infection is associated with a deficient cytotoxic activity of NK cells that can be overcome by in vitro incubation with interleukin-2 and that reverts to normal after antibiotic treatment.

Intracavitary prophylactic treatment with interferon alpha 2b of patients with superficial bladder cancer is associated with a systemic T-cell activation.

The activation and proliferation of peripheral blood mononuclear cells (PBMNCs) are complex processes involving several surface molecules, cell secretion and response to cytokines. This paper investigates the immunomodulatory effect of prophylactic treatment with interferon alpha 2b (IFN-alpha 2b) upon the blastogenic response of PBMNCs from patients with superficial transitional cell carcinoma (STCC) of the bladder to mitogenic signals that interact with surface molecules [phytohaemagglutinin, PHA and anti-CD3 monoclonal antibodies, (MAbs)]. PBMNCs from the patients were studied prior to the transurethral resection (TUR) of the tumour, during the second month of prophylactic intravesical instillation of IFN-alpha 2b and 3 and 6 months after finishing the instillation treatment. The [3H]thymidine uptake of PBMNCs from 17 patients with STCC of the bladder after 5 days of PHA and anti-CD3 MAb stimulus was found to be significantly lower than that of healthy controls (P < 0.05). The addition of interleukin 2 (IL-2) to the culture medium did not correct this defective proliferative response to PHA and the anti-CD3 MAb. There were no significant differences between IL-2 production in PBMNCs from STCC patients after stimulation with PHA and in PBMNCs from healthy controls (P > 0.05). Patients without evidence of recurrence showed a significantly enhanced proliferative response in PBMNC to PHA and anti-CD3 MAb after intravesical prophylactic treatment with interferon-alpha 2b in the follow-up examinations 3 and 6 months after treatment (P < 0.01). However, three patients had evidence of tumour recurrence, and they showed no enhancement of the PBMNC proliferative response to these mitogens in the same examinations. In conclusion, the prophylactic intracavitary treatment of STCC with IFN-alpha 2b may induce a systemic immunomodulatory effect which is associated to the clinical evolution of the disease.

[Brucellar sacroiliitis. A detailed review with an analysis of treatment efficacy]. / Sacroileítis brucelar. Una revisión detallada con análisis de la eficacia de los tratamientos.

All patients diagnosed of brucellosis in 4 regional hospitals during a period of nine years were reviewed, in an attempt to evaluate the efficacy of different antimicrobic regimens and also the clinical features. Evolution and complications of brucellar sacroiliitis. Of a total of 548 patients, 12% had been diagnosed of sacroiliitis and, of theme, 49 had complete data available with efficacy of different treatments, the time elapsed until fever and pain ceased was evaluated, together with initial therapeutic failures, relapses and length of hospital stay. Brucellar sacroiliitis is the most frequent osteoarthral complication of Brucella sp. in our setting. Keeping an stable incidence. It is predominant among young male (82%) population (mean age 25 +/- 12 years). The illness evolution is acute and less frequently subacute with a evolution mean-time before referral of 38 +/- 44 days (minimum 4 days, maximum 180 days). Fever (81%) and pain on gluteus and low lumbar localizations (100%) are the more frequent clinical features. Time elapsed until pain ceased was longer with doxycycline plus rifampicin (68 +/- 86) than with doxycycline plus streptomycin (28 +/- 43) (less than 0.05) and length of hospital stay was also longer with said treatment (p less than 0.05). There were no differences concerning time frame until fever ceased, initial therapy failures and relapses. Sequelae are infrequent and consist in persistency of pain. In resume response to treatment with usual regimens, doxycycline plus streptomycin of doxycycline rifampicin is good, being however time elapsed until pain ceases of mean length in hospital stay shorter in the group receiving doxycycline plus streptomycin. Control studies to confirm these data are need.

An extract of the fern Polypodium leucotomos inhibits human peripheral blood mononuclear cells proliferation in vitro.

An alcoholic extract of the fern polypodium leucotomos (PLE) has been empirically used as an immunosuppressor for the treatment of several autoimmune diseases. In this paper, we investigated the effects of PLE on activation and proliferative responses of peripheral blood mononuclear cells (PBMNC) from healthy donors to T lymphocyte polyclonal mitogens. PLE shows a significant inhibitory effect on the proliferative response of PBMNC to stimulation with phytohaemagglutinin (PHA) or anti CD3 monoclonal antibodies (p < 0.05). In contrast, PLE did not modify the proliferative response of PBMNC to phorbol esters (p > 0.05). The inhibitory effect of PLE upon mitogen induced PBMNC proliferation is time dependent and can be overcome by the exogenous addition of interleukin-2 to the culture medium (p < 0.05). The decreased proliferative response of PBMNC to PHA stimulation in the presence of PLE is not associated with a significant modification of expression of the alpha chain (CD25) of the IL-2 receptor (p > 0.05). In conclusion, PLE shows an inhibitory effect on the polyclonal proliferative response of PBMNC to T lymphocyte mitogens that interact with cytoplasmic membrane molecules.