Data integration for infrastructure asset management in small to medium-sized water utilities

Water utilities collect, store and manage vast data sets using many information systems (IS). For infrastructure asset management (IAM) planning those data need to be processed and transformed into information. However, information management efficiency often falls short of desired results. This happens particularly in municipalities where management is structured according to local government models. Along with the existing IS at the utilities' disposal, engineers and managers take their decisions based on information that is often incomplete, inaccurate or out-of-date. One of the main challenges faced by asset managers is integrating the several, often conflicting, sources of information available on the infrastructure, its condition and performance, and the various predictive analyses that can assist in prioritizing projects or interventions. This paper presents an overview of the IS used by Portuguese water utilities and discusses how data from different IS can be integrated in order to support IAM.

Descriptive analyse of a case control study in Portugal: identify to prevent

Background

Prenatal exposure to environmental risk factors are one of the known causes of congenital anomalies (CA). In 2015, a cluster of anorectal anomalies, a rare malformation, in Setúbal district raised interest in researchers. The aim of study was to assess the impact of prenatal exposure of the mothers on the occurrence of CA in the offspring.

Methods

A Case-control study (1:2) was implemented between 2016-2019. Newborns with CA (cases) and newborns without CA (controls) are identified and recruited. Parents were personally interviewed by a health professional using a standardized questionnaire. A descriptive analyses was performed and cases and controls were described based on maternal residence during pregnancy. Chi-square test was used to compare cases and controls.

Results

97 cases and 194 controls were identified. There was a male predominance in the case group (60 vs. 34) and no difference in gestational age between case and control groups. The mean birth weight was similar (3115g in cases vs. 3221g in controls). There was no difference related to mean mother's age nor the presence of maternal chronic disease. Smoking had more expression in the case group (21,2% vs. 16,3%). Moita (37,8%) is the municipality with higher frequency of cases. Musculoskeletal anomalies were the most frequent (35.4%), followed by genital (22.2%) and other anomalies (11%). During the study period, five cases with anorectal anomalies were reported, 4 of them born at 2016 and in 3 the mothers residence place was Moita.

Conclusions

In this study, the high proportion of cases from Moita suggests a possible environmental exposure to a teratogenic agent. Also smoking during pregnancy could be a high risk to anorectal anomalies, as suggested in other studies. More investment in public health measures could protect population from harmful environments.

Key messages

Pprenatal exposure to environemental risk factors increase the risk of congenital anomalies. Mothers residence and place of work could be a risk factor to pregnancy.

Delays in the diagnosis of pulmonary tuberculosis in critical and non-critical areas in Portugal

Background

Delays in diagnosing tuberculosis lead to longer infectious periods, posing a challenge in tuberculosis control. This is particularly relevant in high incidence areas (critical). Thus, the objectives of this work were to characterize tuberculosis diagnosis delay and its components (patient delay and health delay) in incidence critical and non-critical areas in Portugal, as well as associated factors.

Methods

Notified cases of pulmonary tuberculosis diagnosed due to symptoms (passive screening) in the Portuguese Tuberculosis Surveillance System were analysed (2008-2017). Patient, health and overall delays were calculated. Factors associated with each delays' components were identified utilising Cox regression, while adjusting for sex, age and education level. Analyses were stratified by area type (critical and non-critical).

Results

Median (1st-3rd quartile - Q1-Q3) delays in patient, health and overall delay in critical areas were: 40 (Q1-Q3: 21-76), 8 (Q1-Q3:1-31), and 65 (Q1-Q3: 40-105) days, respectively; similar delays in non-critical areas were 32 (Q1-Q3:16-63); 9 (Q1-Q3: 1-34) and 58 (Q1-Q3: 35-98), respectively. More recent cases, adults younger than 65 years and alcoholic presented longer patient delays (both areas); healthcare professionals and patients with HIV infection presented shorter patient delays (only critical areas). Tuberculosis high-risk groups (males, alcohol dependency, homelessness, community residency) presented shorter health delays in both areas; drug use also presented shorter health delays but only in critical areas. Existing comorbidities was associated with longer health delays in both areas.

Conclusions

Patient delays increased between 2008 and 2017. Groups with longer/shorter delays differed between delay type and area type. Intervening in tuberculosis diagnosis delays requires different action for critical and non-critical areas, targeting health literacy from the general population and training of healthcare professionals.

Key messages

Delays in diagnosing in Portugal are mainly driven by delays in patient seeking care and are longer in areas of higher tuberculosis incidence. Intervening in tuberculosis diagnosis delays in Portugal requires different action in different areas, targeting health literacy in the general population and training of professionals.

Polarization-coded material classification in automotive LIDAR aiming at safer autonomous driving implementations

LIDAR sensors are one of the key enabling technologies for the wide acceptance of autonomous driving implementations. Target identification is a requisite in image processing, informing decision making in complex scenarios. The polarization from the backscattered signal provides an unambiguous signature for common metallic car paints and can serve as one-point measurement for target classification. This provides additional redundant information for sensor fusion and greatly alleviates hardware requirements for intensive morphological image processing. Industry decision makers should consider polarization-coded LIDAR implementations. Governmental policy makers should consider maximizing the potential for polarization-coded material classification by enforcing appropriate regulatory legislation. Both initiatives will contribute to faster (safer, cheaper, and more widely available) advanced driver-assistance systems and autonomous functions. Polarization-coded material classification in automotive applications stems from the characteristic signature of the source of LIDAR backscattering: specular components preserve the degree of polarization while diffuse contributions are predominantly depolarizing.

Use of extubation bundle including modified spontaneous breathing trial (SBT) to reduce the rate of reintubation, among preterm neonates ≤ 30 weeks

BACKGROUND

Respiratory support in the form of mechanical ventilation is a crucial intervention in premature neonates, with respiratory problems. However, prolonged mechanical ventilation and endotracheal intubation may be associated with major adverse effects. The ideal time for extubation is based on clinical and laboratory parameters assessed at the time of planned extubation. However, such parameters are not very objective, which makes extubation in NICUs a trial-and-error approach.

OBJECTIVE

This work was done to assess the use of extubation bundle including modified spontaneous breathing trial (SBT) (10 minutes) to reduce the rate of reintubation, among preterm neonates≤30 weeks who were mechanically ventilated and extubated to non-invasive ventilation in the NICU, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar.

METHODS

A prospective study based on the collection of data regarding preterm neonates≤30 weeks gestation admitted to the NICU, Women's Wellness and Research Center (WWRC), from January, 2015 to December, 2017, who were subjected to mechanical ventilation (MV) and extubation. When the clinical team decides a newborn is ready for extubation based on the extubation bundle, a modified SBT (10 min) is used.

RESULTS

This study included 465 premature babies from 24-≤30 weeks recruited in the NICU, Women's Wellness and Research Center (WWRC). Extubation bundle with modified SBT was able to predict success of extubation with 95% sensitivity and 90.4% Positive Predictive Value (PPV) in the gestational age (GA) group 24 -≤27 weeks (245) and 95.3% sensitivity and 90% PPV in the GA group > 27 -≤30 weeks (220). As expected, successfully extubated babies had a higher GA and weighed more at extubation, compared to babies who required re-intubation.

CONCLUSION

We recommend the extubation bundle with modified SBT prior to elective extubation to be used in predicting successful extubation in premature babies. Guidelines for extubation among premature babies are needed in order to reduce unnecessary exposure to adverse effects of mechanical ventilation.

475 A rare cause of right ventricular mass

Introduction

Intracardiac masses are always a challenging diagnosis, especially when it involves the right side of the heart. There are multiples etiologies that can be responsible for these masses, namely thrombosis, neoplasm or vegetations. Occasionally, these may be related to an autoimmune process not yet discovered.

Case Report

17-year-old male, with a previous history of genital ulcers, medicated with penicillin with complete resolution of symptoms.

In January 2019, he started an history of recurrent fever, associated with right anterior thoracalgia, weight loss and oral afthosis. He went to the emergency department several times, where he was medicated with antibiotic, with partial symptom relief.

Three months later, he returned to medical attention due to an episode of abundant hemoptysis, followed by hematemesis and cough. At hospital admission, he was hemodynamically stable, tachycardic (100/min) and with occasional episodes of cough. Cardiac and pulmonary auscultation were unremarkable. Thoracic CT revealed the presence of pulmonary thromboembolism (PTE) and a large mass in the right ventricle (RV). It was performed an echocardiogram (echo) that confirmed the presence of a large mass in the RV (50x53mm) from which a projecting hypermobile mass appeared to prolapse into the right atrium.

Taking into account the diagnosis of PTE and the presence of a right ventricular mass, the patient was hospitalized and started anticoagulation. The case was immediately discussed with cardiac surgery, that confirmed that there was no surgical indication. During hospitalization, there were no more episodes of hemoptysis or hematemesis.Consecutive echos were performed, that did not reveal a significant decrease in mass dimensions despite anticoagulation. Viral serologies and autoimmunity panel were all negative. Cardiac RMI was performed raising the suspicion of a possible mass covered with thrombus.

After discussion with rheumatology, and according to clinical signs, the hypothesis of vasculitis was placed, and the patient started treatment with steroids. This treatment had to be suspended after a few days due to an infectious intercurrence. After a course of antibiotic therapy, the patient started therapy with cyclophosphamide with good clinical and echocardiographic response (reduced mass dimensions).

It was admitted Behçet’s disease with cardiac complications, and the patient was referred to the rheumatology consultation.

Conclusion

Behçet’s disease is a multi-system, chronic disorder that behaves like vasculitis.There are some typical clinical manifestations associated with this disease, such as oral and genital afthosis, uveitis, arthritis, skin lesions and nervous system involvement.Presentations with cardiac symptoms are one of the extremely rare manifestations of this disease, posing a challenge for the treating physician.

Abstract 475 Figure. Right ventricular mass

P1808 The impact of valve type in morbimortality of patients with infectious endocarditis

Introduction

Infectious endocarditis (IE) represents one of the main causes of morbimortality in patients (pts) with valvular heart disease. Prosthetic valves infection is usually associated with worse outcomes.

Aim

To compare the clinical features and adverse outcomes of patients with native vs prosthetic valve IE.

Methods

We analysed a population with suspected/confirmed IE, according to Duke criteria, in the last 12 years (2006-2017). The clinical and imaging data were collected as well as complication rates and mortality data.

Results

174 pts, 75% males with mean age of 61 ± 16 years. Native valve EI occurred in 74,1%. of pts. 25,3% had heart failure (HF), 16,1% chronic kidney disease(7,1% on haemodialysis), 12,8% HIV infection, 9,3% active neoplasm and 7,1% were on immunosuppression. 16 pts with native valve disease had previous valvular disease: 1 congenital valve disease, 2 with rheumatic heart disease, 3 with previous IE and 10 with degenerative disease. At admission: 73,1% had fever, 53,2% murmur and 47,9% anemia. The majority (78,4%) had single valve IE and 15,8% had double valve involvement. Aortic valve (AoV) was affected in 54% of the cases and mitral valve involvement was seen in 43,7%. 13,3% had right valve disease. S. Aureus was the most frequent microrganism. Echocardiographic findings: 87,7% had vegetation, 21,2% valve destruction , 5,6% valve obstruction, 14,3% abscess, 3,7% valve aneurysm, 5,6% pseudoaneurysm and 5,6% fistula. Regurgitation was observed in 62,1%. The intrahospitalar mortality was 29,9%.

Comparing both groups, pts with prosthetic IE had more previous history of HF (40,5% vs 20,5% p = 0,009) and diabetes (31,7% vs 15,3% p = 0,020). No differences were found in what concerns microrganisms involved.

Echocardiographically, pts with prosthetic valve had predominantly AoV involvement (81,1% vs 45,5% p < 0,001), less vegetation (75% vs 91,8% p = 0,01) and less regurgitation (45% vs 67,8% p = 0,01). They had more local complications (61% vs 27,7% p> 0,001) like valve obstruction (12,5% vs 3,3% p = 0,043), abscess (32,5% vs 8,3% p> 0,001) or pseudoaneurysm (17,5% vs 1,7% p= 0,001).

In what concerns morbidity burden, developed more HF during hospitalization (56,1% vs 37,7% p= 0,037) as well as more isquemic and haemorragic stroke(85,7% vs 42,3%. P = 0,004 and 28,6% vs 2,4% p = 0,012, respectively). However there were no differences regarding the development of septic shock (p = 0,542) or overall embolization (p = 0,732). At last, no differences were found in intrahospitalar(IH) mortality (p = 0,085), relapse (p = 0,573) or overall survival between both groups (log rank: 1,5, p = 0,217).

Conclusion

Pts with prosthetic valve IE usually have worse outcomes. However,for this population,we conclude that besides having more HF and stroke, there were no differences in what concerns septic shock or overall embolization, as well as IH mortality and survival between both groups.

38 Ram sperm longevity after cryopreservation in extender containing L-carnitine

The cryopreservation process causes oxidative stress to the sperm cell, and the addition of antioxidants to the extender for semen freezing helps sperm protection. This study assessed the effect of L-carnitine (LC) concentrations (0, 5, or 10mM LC) on two ram semen extenders (Tris-egg yolk or the commercial optiXcell IMV medium (IMV Technologies)) for semen cryopreservation. Four Santa Inês rams were used during the breeding season. After semen collection, macroscopic and microscopic evaluations were performed, and a pool of semen was formed. The semen was diluted, and the final concentration was 100×106 per 0.25-mL straw. Cryopreservation was performed with a cooling rate of 0.25°C min−1 until 5°C, and the freezing rate used was 20°C min−1 from 5 to −120°C. After the freezing-thawing process and throughout incubation (38°C in 5% CO2) in Fert-Tyrode's albumin lactate pyruvate medium, every 1h for up to 3h, several parameters were evaluated: sperm kinetics, hypo-osmotic test, plasma membrane integrity, capacitation status, and lipid peroxidation level. We did not find any protective effect of LC on plasma membrane integrity, hypo-osmotic test, and capacitation status. The sperm kinetics values throughout incubation showed that Tris extender promoted better indices of staight-line velocity, linearity, wobble, and straightness than IMV extender along incubation, regardless of the presence of LC. There were no benefits of the LC addition throughout the incubation, and 10mM was deleterious to few parameters (amplitude of lateral head displacement, linearity, and wobble) compared with the control (0mM) in the Tris extender group. The plasma membrane integrity analysis revealed no differences (P>0.05) among the groups. The average number of intact cells (hypo-osmotic) was higher in Tris extender groups supplemented with 10mM LC at 1h and 5mM LC at 2h compared to the respective extender IMV groups. Regarding capacitation status, the Tris 5mM LC group had more acrosome-reacted cells when compared with the IMV 5mM LC group at 2h. At 3h, the percentage of acrosome-reacted cells was higher in the Tris 0-mM group when compared with the IMV 0-mM group. Regardless the presence of LC, IMV had higher (P<0.05) lipoperoxidation than the Tris treatments. In conclusion, LC supplementation in semen extender had no beneficial effect on freezing-thawing ram sperm and throughout incubation for up to 3h, with no difference in each time point evaluated. Under the conditions of this study, the use of Tris extender was superior to IMV extender for ram sperm. Financial support for this work came from the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (Young Scientist Program of Our State; E-26/203.168/2017).

Salt reduction in bread: Is it enough? Preliminary results of a HIA in Portugal

Issue

Health Impact Assessment (HIA) is a methodology that aims at assessing the impact of policies in health. A pilot HIA is in progress to kick off the implementation of this methodology in Portugal with the support of the World Health Organization (WHO). In this context, the impact of a nation-wide policy that intends to achieve a maximum of 1 g of salt/100 gr in bread is under assessment.

Description of the issue

In 2017, Portugal approved a protocol between the industry and other stakeholders to gradually decrease the amount of salt in bread, as this is the main source of salt intake. The purpose of this study was to assess the impact in blood pressure from current (1.4 gr) to 1 g (29% reduction) of salt in bread. Data from two different surveys regarding blood pressure and salt intake was gathered. We estimated the decrease in blood pressure with respect to current average values according to sex, age, education and region.

Results

It is expected that a reduction of 29% in salt intake through bread contributes to a general decrease in systolic pressure for normotensive people (from 120.4mmHg to 120.0mmHg, p = 0.85) and hypertensive people (from 151.0mmHg to 150.1mmHg, p = 0.68), although not statistically significant. Older hypertensive individuals (65 to 75 years) are the group with the largest benefit (152.8mmHg to 152.0mmHg) but no statistical difference was found. Disaggregation by sex, region and education also didn’t show any statistical difference.

Lessons

The impact in blood pressure from a 29% reduction in salt intake from bread seems very small. We found no statistical significance between the current and expected values in blood pressure either for total or group stratification. The absence of statistical effect might be due to sample size as our sources only allowed us to work with aggregated data.

Key messages

Quality and access to data is needed to assess impact of policies. to increase effects in blood pressure either salt reduction from bread must be larger or a wider range of products should be considered.

Knowledge and Attitude towards the Gradual Reduction of Salt in Bread – an Online Survey

Background

Bread is one of the main sources of salt intake in Portugal. Based on this evidence, a protocol signed between national Health Sector and the Associations of Industrial Bakeries, in 2017, established gradually decrease salt in bread until 2021. This measure also targets schools’ available bread, this should not exceed 1g salt, to end of 2018. A pilot Health Impact Assessment (HIA) aims to assess the potential impact on salt reduction in bread on the eating habits of children (6-18 years) and their families.

Methods

A questionnaire is being performed to assess the effect of this measure. The first version was designed by a panel of 11 experts (content validity), following the plain text principles. A external specialist revised it for facial validity. A pilot was tested. Thereafter, a REDCap online survey of “Knowledge and Attitude towards the Gradual Reduction of Salt in Bread” questionnaire was finalized. The target group is the parents or guardians of children and young persons, of School Clusters in the south of Portugal.

Results

Final online survey totalizes 33 items, divided into four blocks: 1.Knowledge and General literacy data, 2.Domestic Consumption, 3.Scholar consumption and 4.Sociodemographic. An adult responsible for the child/young person should answer the survey. Access is possible through a REDCap link, using computers available in the School Cluster, or other manner suitable for the purpose.

Conclusions

This survey will contribute to the identification of modifiable behaviors related with salt intake. Such evidence may eventually provide the opportunity for new strategies in this area.

Key messages

Health Impact Assessment as a procedure to assess the effects of measures and policies on human health. Questionnaires are a rapid tool to access perceptions, attitudes and knowledge.

Normas de reação para peso aos 365 e 550 dias de idade em bovinos Guzerá no Nordeste do Brasil

Objetivou-se avaliar o efeito da interação genótipo ambiente (IGA) sobre os pesos ajustados aos 365 (P365) e 550 (P550) dias de idade de bovinos Guzerá por meio de modelos hierárquicos Bayesianos de norma de reação. O banco de dados utilizado foi cedido pela Associação Brasileira dos Criadores de Zebu (ABCZ) e continha 15169 e 11183 registros para o P365 e P550, respectivamente. Ajustou-se um modelo animal (MA) e modelos hierárquicos de norma de reação com variâncias homogenias e heterogenias em um passo (MHNRHO1P e MHNRHE1P, respectivamente) e dois passos (MHNRHO2P e MHNRHE2P, respectivamente) para avaliar a existência e efeito da IGA. O MHNRHO1P foi o modelo de melhor ajuste. As estimativas de herdabilidade no MA foram de 0,37 e 0,29 para o P365 e P550, respectivamente. Foram obtidos valores de herdabilidade variando de 0,21 a 0,71 para o P365 e 0,06 a 0,93 para o P550 no MHNRHO1P ao longo do gradiente ambiental. As correlações de Spearman entre as classificações dos reprodutores para o P365 e P550 variaram de 0,26 a 0,99 e de -0,99 a 0,99, respectivamente, e as correlações genéticas variaram entre 0,70 a 1,00 e 0,40 a 1,00 para o P365 e P550, respectivamente. Existe IGA em bovinos da raça Guzerá no Nordeste do Brasil para o P365 e P550, sendo necessário considerar a possibilidade de inclusão deste efeito nas avaliações genéticas.

Lipid changes and tolerability in a cohort of adult HIV-infected patients who switched to rilpivirine/emtricitabine/tenofovir due to intolerance to previous combination ART: the PRO-STR study

Objectives

To analyse lipid changes and tolerability in a cohort of HIV-infected patients who switched their antiretroviral regimens to rilpivirine/emtricitabine/tenofovir (RPV/FTC/TDF) in a real-world setting.

Methods

PRO-STR is a 48 week prospective observational post-authorization study in 25 hospitals. Patients with a viral load <1000 copies/mL, receiving at least 12 months of combination ART (cART), with constant posology for at least the prior 3 months, were categorized according to previous treatment [NNRTI or ritonavir-boosted PI (PI/r)]. Analytical tests were performed at the baseline visit, between week 16 and week 32, and at week 48.

Results

A total of 303 patients were included (mean age 46.6 years; male 74.0%; previous treatment 74.7% NNRTI and 25.3% PI/r). Both groups exhibited significantly reduced lipid profiles, except for HDL cholesterol, for which a non-significant increase was observed. [NNRTI patients: total cholesterol (baseline: 195.5 ± 38.4 mg/dL; week 48: 171.0 ± 35.5 mg/dL), total cholesterol/HDL ratio (baseline: 4.2 ± 1.2; week 48: 4.0 ± 1.2), HDL (baseline: 49.1 ± 12.0 mg/dL; week 48: 49.2 ± 45.8 mg/dL), LDL (baseline: 119.2 ± 30.2 mg/dL; week 48: 114.2 ± 110.7 mg/dL), and triglycerides (baseline: 136.6 ± 86.8 mg/dL; week 48: 113.4 ± 67.8 mg/dL); PI/r patients: total cholesterol (baseline: 203.2 ± 48.8 mg/dL; week 48: 173.4 ± 36.9 mg/dL), total cholesterol/HDL ratio (baseline: 4.7 ± 1.6; week 48: 4.0 ± 1.2), HDL (baseline: 46.4 ± 12.5 mg/dL; week 48: 52.1 ± 54.4 mg/dL), LDL (baseline: 127.0 ± 36.3 mg/dL; week 48: 111.4 ± 35.8 mg/dL), and triglycerides (baseline: 167.6 ± 107.7 mg/dL; week 48: 122.7 ± 72.1 mg/dL)]. The most common intolerances were neuropsychiatric in the NNRTI patients and gastrointestinal and metabolic in the PI/r patients, and these intolerances were significantly reduced in both groups at week 48 [NNRTI: neuropsychiatric (baseline: 81.3%; week 48: 0.0%); PI/r: gastrointestinal (baseline: 48.7%; week 48: 0.0%) and metabolic (baseline: 42.1%; week 48: 0.0%)].

Conclusions

RPV/FTC/TDF improved the lipid profiles and reduced the intolerances after switching from NNRTI or PI-based regimens, in a cohort of HIV-infected patients.

Composition of fatty acids, tocopherols, tocotrienols and β-carotene content in oils of seeds of Brazilian Sapindaceae and Meliaceae species

This study analyzes the lipid composition and the oxidative stability of oils of Sapindaceae and Meliaceae seeds. The oil content ranged from 14.7% (Guarea guidonia) to 30.1% (Allophylus puberulus and Paullinia elegans). Ten fatty acids were identified in seed oils. Guarea guidonia seeds accumulated mainly oleic (44.9%) and linoleic (24.1%) acid, whereas the unusual gondoic and paullinic acids were identified in A. puberulus (15.8%; 8.9%) and P. elegans (14.4%; 44.2%), respectively. The oil of P. elegans had the highest oxidative stability (16.2 h.). Tocopherol predominated in A. puberulus (10.4 mg/100 g) and tocotrienol predominated in G. guidonea and P. elegans (2.6 mg/100 g). The vitamers α-tocopherol, γ-tocopherol, and γ-tocotrienol were found in the studied oils. β-carotene was predominantly detected in the oil of A. puberulus seeds (22.4 μg/g). Guarea guidonia seed oil has a high potential in food due to richness in essential fatty acids. In turn, A. puberulus and P. elegans oils could be suggested for other industrial purposes (e.g., biodiesel, varnishes, paints, soaps, or oleochemicals) due to their content of long-chain fatty acids.

Continued propagation of the CRF19_cpx variant among HIV-positive MSM patients in Spain

Objectives

The HIV-1 CRF19_cpx genetic form has been recently associated with greater pathogenicity. We used CoRIS, a national cohort of 31 reference hospitals in Spain, to investigate the current epidemiological situation of this variant in Spain.

Patients and methods

We analysed 4734 naive HIV-1-positive patients diagnosed during the 2007-15 period with an available pol gene sequence in the CoRIS resistance database. HIV-1 CRF19_cpx was ascribed through REGA3.0 and confirmed by a phylogenetic analysis. We analysed the presence of the transmission clusters of HIV-1 CRF19_cpx by maximum likelihood [with the randomized accelerated maximum likelihood (RAxML) program] and the time to the most recent common ancestor using Bayesian inference (BEAST, v. 1.7.5).

Results

Nineteen patients were infected with CRF19_cpx: all were male, they had a mean age of 42.9 years (95% CI: 36.4-52.5 years), the majority were MSM [n = 18 (95%)] and of Spanish nationality [n = 16 (84.2%)] and they had high CD4+ T cell counts (∼415 cells/mm3). Fifteen patients were grouped into four different transmission clusters: two clusters (two patients each) grouped the patients from Valencia and another cluster grouped one patient from Madrid and another from Seville. We found a larger cluster that grouped nine patients from southern Spain (Malaga and Seville), of which six presented mutation G190A. We estimated the origin of all the transmission clusters to take place between 2009 and 2010.

Conclusions

We demonstrate that this variant has spread in Spain in recent years among young HIV-positive MSM and we note a recent expansion in southern Spain in patients who carry mutation G190A. We alert healthcare managers to enhance preventive measures to prevent the continuous spread of HIV-1 CRF19_cpx.