Epidemiological and clinical characteristics of HIV infection in the Spanish VACH Cohort: a descriptive study

BACKGROUND

knowledge of the present features of the HIV epidemic is relevant, especially to develop management programmes directed to poorly controlled patients.

OBJECTIVES

to describe the epidemiological and clinical features of HIV infection in a large multicentre cohort.

DESIGN

cross-sectional study.

SETTING AND PARTICIPANTS

data of the Spanish VACH Cohort of HIV infected patients.

MAIN OUTCOME MEASURES

a total of 53 variables were included. Descriptive statistics were used to report the results. Bivariable statistics were used to assess variation along time on prescribed antiretroviral treatment and on causes of death.

RESULTS

a total of 30,843 patients belonging to most regions of Spain were included: 23,682 (76.78%) were male, mean and standard deviation of age of all patients was 34.03 ± 9.55 years in their first visit and 43.68 ± 10.52 years in their last visit; 12,677 (41.10%) were smokers, 3,521 (11.42%) had diabetes mellitus, 15,351 (49.77%) had acquired HIV via sexual route and 12,714 (41,22%) via parenteral route, 16,057 (52.06%) had positive hepatitis C virus serology. Their median and interquartile range of CD4 lymphocyte count, per cubic millimetre, were: lowest available 198 (79-337) and last available 510 (299-745). Last available HIV viral load was suppressed (<200 RNA copies per mL) in 23,485 (76.14%). Modalities of prescribed antiretroviral treatment varied substantially over time, with integrase inhibitor combinations predominating the last years. Causes of death changed from AIDS defining conditions early in the epidemic to non-AIDS defining conditions more recently.

CONCLUSIONS

patients in the Spanish HIV VACH Cohort are predominantly middle-aged men. They acquired HIV via sexual or parenteral routes in similar proportions. Most of them are taking antiretroviral treatment and have their HIV infection properly controlled.

Assessment of Drug Interactions with Online Electronic Checkers in Multi-Pathological Patients

INTRODUCTION

Multi-pathological patients are at high risk of drug interactions and side effects. We aimed to assess the usefulness of 3 online drug interaction checkers.

METHODS

In a cross-sectional study, carried out in the Medicine Department of Hospital General of Castellon, Spain, in February 2020, we assessed drug interaction detection with 3 online electronic checkers, Drugs.com, Lexicomp®, and Medscape, and compared results obtained with the 3 tools. From every hospitalized patient, we obtained the list of drugs he or she had been taking until admission. Bivariable tests were used for analysis. p values <0.05 were considered significant.

RESULTS

We included data from 134 patients; 68 (51%) were male; median (and interquartile range) of their age was 82 (76-88) years. A total of 1,082 substance drugs were entered in the checkers. The number of highest grade interactions found with every program was Drugs.com 85, Lexicomp® 33, and Medscape 67. Positive correlations were found between age and number of drug substances prescribed (p = 0.009) and between number of drug substances prescribed and interactions found with any of the 3 checkers (p < 0.001 in all 3 cases). Regarding highest grade interactions, agreement among all 3 checkers was poor.

CONCLUSIONS

The 3 online checkers we assessed found a large number of interactions. The 3 programs gave very discrepant results. Impact on Practice Statements: The analyzed programs, Drugs.com, Lexicomp®, and Medscape Interactions, found a large number of drug interactions in the studied patients. The 3 programs gave very discrepant results among them.

eGFR-EPI changes among HIV patients who switch from F/TDF to F/TAF while maintaining the same third agent in the Spanish VACH cohort

Background: Evidence from clinical practice on the effects of switching from emtricitabine/tenofovir disoproxil fumarate (F/TDF) to emtricitabine/tenofovir alafenamide (F/TAF)-based triple-therapy (TT) regimens on renal parameters is limited.Objective: This retrospective analysis evaluated the effects on renal function of switching from F/TDF to F/TAF-based TT regimens with no change in third agent among people living with HIV (PLWH).Methods: Data were from a multicenter Spanish PLWH cohort. Patients with a baseline estimated glomerular filtration rate (eGFR-EPI) measurement, ≥1 follow-up measurement, ≥30 days treatment with F/TAF, and who switched from F/TDF to F/TAF with no change in third agent were included. Multivariate mixed linear models were used to evaluate change from baseline over time in eGFR-EPI. eGFR-EPI changes before and after switch were analyzed in a matched patient subgroup.Results: Overall, 340 patients were included. Mean (95% CI) eGFR-EPI in patients with baseline eGFR-EPI <90 ml/min/1.73m² (n = 125) was 79.6 (78.0; 81.2) ml/min/1.73m² at baseline and 81.3 (79.9; 82.7) ml/min/1.73m² at 12 months after switch. In the patient-matched subgroup (n = 175), median annual eGFR-EPI declined -4.24 ml/min/1.73m² while on F/TDF and increased +0.93 ml/min/1.73m² after switch to F/TAF (P < 0.0001). In patients with baseline eGFR-EPI <90 ml/min/1.73m², median annual eGFR-EPI increased +4.19 mL/min/1.73m² after switch (P < 0.0001).Conclusion: Switching from F/TDF to F/TAF-based TT regimens while maintaining the same third agent numerically improved eGFR-EPI in PLWH with baseline eGFR-EPI <90 mL/min/1.73m². eGFR-EPI improved significantly when comparing progression while on F/TDF vs progression after switch, confirming beneficial renal effects of switching to F/TAF in a clinical practice setting.

Real world effectiveness of standard of care triple therapy versus two-drug combinations for treatment of people living with HIV

Background

Since 1996, the standard of care (SOC) therapy for HIV treatment has consisted of a backbone of two nucleoside analogue reverse transcriptase inhibitors (NRTI) paired with a third agent. Use of two-drug combinations (2DC) has been considered for selected patients to avoid toxicities associated with the use of NRTIs. This study aimed to compare the real-world outcomes of integrase strand transfer inhibitor (INSTI)-containing triple therapy (TT) to dolutegravir- (DTG) and/or boosted protease inhibitor (bPI)-based 2DC in a large Spanish cohort of HIV patients.

Methods

A retrospective analysis was performed using data from the VACH cohort, a prospective multicentre Spanish cohort of adult HIV patients. All treatment experienced patients initiating a TT of an INSTI combined with two NRTIs or a 2DC-containing DTG and/or a bPI between 01/01/2012 and 01/06/2017 were included. The unit of analysis was patient-regimens. The overall sample analysis was complemented with two sub-analyses. The first sub-analysis focused on patients treated with a backbone plus DTG compared to those treated with DTG+ one other antiretroviral. The second sub-analysis focused on patients with HIV RNA<50 copies/mL at baseline, irrespective of the regimen used. The following endpoints were assessed: time to discontinuation for any reason, time to switch due to virologic failure, and time to switch due to toxicity (reasons for discontinuation according to clinician report in the database). Time-to-event analyses were conducted using Kaplan–Meier survival curves and Cox regression models.

Results

Overall 7,481 patients were included in the analysis, contributing to 9,243 patient-regimens. Patient characteristics at baseline differed among groups, with the 2DC group being significantly older and having a higher proportion of women, a longer time on ART and a higher number of previous virologic failures. Median (95% Confidence Interval [C.I.]) time to switch was 2.5 years (2.3, 2.7) in 2DC group versus 2.9 years (2.7, 3.0) in TT. Adjusted hazard ratios (95% C.I.) for discontinuation due to any reason, virologic failure and toxicity in the 2DC vs TT group were 1.29 (1.15; 1.44), 2.06 (1.54; 2.77) and 1.18 (0.94; 1.48), respectively. Results were consistent in the two sub-analyses.

Conclusion

In this analysis, time to discontinuation and probability of remaining free of virologic failure were significantly higher in patients on INSTI-based TT compared to DTG- and/or bPI-containing 2DC, with no differences in toxicity.

Factors Associated with Nonsuppression of HIV Infection in the Spanish VACH Cohort

We aim to determine the prevalence of HIV nonsuppression and factors associated with it. This is a cross-sectional multicenter study carried out in January 2016 with data of the VACH Cohort, a registry participated by 23 hospitals from most regions of Spain. The prevalence of HIV nonsuppression, defined as HIV RNA ≥200 copies/mL, is documented. The possible association of HIV nonsuppression with sociodemographic and clinical variables is assessed with a logistic regression analysis. A total of 30,843 adult patients are included; 7,358 of them (23.86%) have nonsuppressed HIV. An association is found between nonsuppression of HIV and the following variables: lower body mass index, lower age of patients in their last registered visit, lower number of visits carried out during follow-up, lower last available CD4 cell count, higher age of patients at the time of their HIV infection diagnosis, higher lowest available CD4 cell count, higher highest available HIV RNA, enrolment in the Cohort in first years of the HIV epidemic, region of Spain where the patient is attended other than Andalusia, HIV risk factor other than sexual, occurrence of death during follow-up, hepatitis C coinfection, being a smoker, pertaining to groups A1 or A2 of the CDC groups classification, and not taking antiretroviral treatment, p < .001 in all cases. HIV nonsuppression is still common with the effective antiretroviral treatment nowadays available. HIV nonsuppression is associated with HIV risk factor other than sexual, hepatitis C coinfection, and being a smoker, among other factors.

Cervical cancer risk in women living with HIV across four continents: A multicohort study

We compared invasive cervical cancer (ICC) incidence rates in Europe, South Africa, Latin and North America among women living with HIV who initiated antiretroviral therapy (ART) between 1996 and 2014. We analyzed cohort data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) and the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord. We used flexible parametric survival models to determine regional ICC rates and risk factors for incident ICC. We included 64,231 women from 45 countries. During 320,141 person-years (pys), 356 incident ICC cases were diagnosed (Europe 164, South Africa 156, North America 19 and Latin America 17). Raw ICC incidence rates per 100,000 pys were 447 in South Africa (95% confidence interval [CI]: 382-523), 136 in Latin America (95% CI: 85-219), 76 in North America (95% CI: 48-119) and 66 in Europe (95% CI: 57-77). Compared to European women ICC rates at 5 years after ART initiation were more than double in Latin America (adjusted hazard ratio [aHR]: 2.43, 95% CI: 1.27-4.68) and 11 times higher in South Africa (aHR: 10.66, 95% CI: 6.73-16.88), but similar in North America (aHR: 0.79, 95% CI: 0.37-1.71). Overall, ICC rates increased with age (>50 years vs. 16-30 years, aHR: 1.57, 95% CI: 1.03-2.40) and lower CD4 cell counts at ART initiation (per 100 cell/μl decrease, aHR: 1.25, 95% CI: 1.15-1.36). Improving access to early ART initiation and effective cervical cancer screening in women living with HIV should be key parts of global efforts to reduce cancer-related health inequities.

Palliative Sedation in Patients Hospitalized in Internal Medicine Departments

CONTEXT

Palliative sedation is used to relieve end-of-life refractory symptoms.

OBJECTIVE

The objective of this study was to describe the use of palliative sedation in patients who die in internal medicine departments.

METHODS

An observational, cross-sectional, retrospective, and multicenter clinical audit study was conducted in 145 hospitals in Spain and Argentina. Each hospital included the first 10 patients who died in the internal medicine department, starting on December 1, 2015.

RESULTS

We included 1447 patients, and palliative sedation was administered to 701 patients (48.4%). Having a terminal illness (odds ratio [OR] 2.469, 95% CI 1.971-3.093, P < 0.001) and the length of hospital stay (OR 1.011, 95% CI 1.002-1.021, P = 0.017) were independently associated with the use of palliative sedation. Consent was granted by the families of 582 (83%) patients. The most common refractory symptom was dyspnea, and the most commonly used drugs for sedation were midazolam (77%) and morphine (89.7%). An induction dose was administered in 25.7% of the patients. Rescue doses were scheduled for 70% of the patients, and hydration was maintained in 49.5%. Pain was more common in patients with cancer, whereas dyspnea was more common in those without cancer. Rescue doses were used more often for the patients with cancer (77.8% vs. 67.7%, P = 0.015). Monitoring the palliative sedation with a scale was more frequent in the patients with cancer (23.7% vs. 14.3%, P = 0.008).

CONCLUSIONS

Palliative sedation is used more often for terminal patients. There are differences in the administration of palliative sedation between patients with and without cancer.

Within subject variability of HDL-cholesterol in HIV-infected patients

Background and objective: Within-subject variability of cardiovascular risk factors may influence the development of cardiovascular disease. We aimed to improve knowledge on HDL-cholesterol variability and its clinical significance in HIV-infected patients, a population at high risk of cardiovascular disease.Methods: This was a cohort study to quantify the variability of HDL-cholesterol between two consecutive visits and to determine factors associated with such variability, in a group of HIV-infected patients.Results: A total of 307 patients were included, mean ± standard deviation of their age was 45.1 ± 8.5 years, and 225 of them (73.3%) were male. The absolute difference (after squaring and root squaring) of serum HDL-cholesterol level between the first and the second visit was 12.1 ± 9.2 mg/dL. In 65 patients (21.2%) the absolute value of the difference between both serum HDL-cholesterol level results were 20 mg/dL or higher. In a multivariable analysis the number of cigarettes smoked per day showed a significant, negative, correlation with the absolute difference in serum HDL-cholesterol level between the two visits (P = 0,009).Conclusions: Within-subject variability of HDL-cholesterol was substantial among our HIV-infected patients. Smoking was inversely correlated with such variability.

Typhlitis as a complication of influenza in a patient with advanced HIV infection

The authors report the case of an HIV-infected patient who presented with typhlitis as a complication of typical influenza. To the best of their knowledge, this is the first case reported in the literature with such an association of clinical conditions.

Punctate inner choroidopathy complicated with exudative neurosensory detachment: A favourable response to treatment with systemic corticosteroids and intravitreal ranibizumab

CASE REPORT

Punctate inner choroidopathy (PIC) is a variant of multifocal choroiditis that principally affects young and healthy women. A case of this condition is described in a woman who presented with a scotoma as the main complaint. Four months after the diagnosis of PIC, she developed an exudative neurosensory detachment associated with an active focus of juxtafoveal choroiditis. Finally, with systemic corticosteroids and intravitreal ranibizumab, she made excellent progress.

DISCUSSION

Intravitreal ranibizumab, associated with systemic corticosteroids, may be an effective treatment for exudative neurosensory detachment complicating PIC.

The new oral anticoagulants: Reasonable alternatives to warfarin

Dabigatran (a direct thrombin inhibitor) and rivaroxaban, apixaban, and edoxaban (direct activated factor X inhibitors) are increasingly being used in clinical practice. Compared with vitamin K antagonists, they are more convenient, do not require laboratory monitoring, have limited drug and food interactions, and have fixed dosages suitable for most patients. But the shortcomings of these agents can jeopardize their efficacy and increase the risk of bleeding. Their future role in preventing and treating thromboembolic disease will depend on building clinical experience, but current evidence indicates that they are reasonable alternatives to vitamin K antagonists.

Reference curves for CD4 T-cell count response to combination antiretroviral therapy in HIV-1-infected treatment-naïve patients

OBJECTIVES

The aim of this work was to provide a reference for the CD4 T-cell count response in the early months after the initiation of combination antiretroviral therapy (cART) in HIV-1-infected patients.

METHODS

All patients in the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) cohort who were aged ≥ 18 years and started cART for the first time between 1 January 2005 and 1 January 2010 and who had at least one available measurement of CD4 count and a viral load ≤ 50 HIV-1 RNA copies/mL at 6 months (± 3 months) after cART initiation were included in the study. Unadjusted and adjusted references curves and predictions were obtained using quantile regressions.

RESULTS

A total of 28 992 patients were included in the study. The median CD4 T-cell count at treatment initiation was 249 [interquartile range (IQR) 150, 336] cells/μL. The median observed CD4 counts at 6, 9 and 12 months were 382 (IQR 256, 515), 402 (IQR 274, 543) and 420 (IQR 293, 565) cells/μL. The two main factors explaining the variation of CD4 count at 6 months were AIDS stage and CD4 count at cART initiation. A CD4 count increase of ≥ 100 cells/mL is generally required in order that patients stay 'on track' (i.e. with a CD4 count at the same percentile as when they started), with slightly higher gains required for those starting with CD4 counts in the higher percentiles. Individual predictions adjusted for factors influencing CD4 count were more precise.

CONCLUSIONS

Reference curves aid the evaluation of the immune response early after antiretroviral therapy initiation that leads to viral control.

Increased homocysteine plasma level is associated with shortened prothrombin time in HIV-infected patients

OBJECTIVE

To find factors associated with increased homocysteine plasma level in HIV-infected patients.

METHODS

Cross-sectional study, carried out as a supplementary task to the standard care of HIV-infected patients. The possible association of increased homocysteine plasma level with blood analyses results was assessed with a multiple linear regression analysis, using the automatic linear modeling available in SPSS version 22.

RESULTS

A total of 145 patients were included. Creatinine was higher than normal in 7 patients (5%), prothrombin time was shortened in 36 patients (25%), and a monoclonal gammopathy was detected in 2 patients (1%). In the regression analysis, an association was found between high homocysteine plasma level and the following variables: low prothrombin time (β coefficient -0.286, confidence interval -1.1854 to -0.754, p < 0.001), high creatinine (coefficient 9.926, confidence interval 6.351-15.246, p < 0.001), low folic acid (coefficient -0.331, confidence interval -0-483 to -0.187, p < 0.001), and low vitamin B12 (coefficient -0.007, confidence interval -0.01 to -0.001, p = 0.005).

CONCLUSION

An association was found between increased homocysteine plasma level and shortened prothrombin time.

Very low level viraemia and risk of virological failure in treated HIV-1-infected patients

OBJECTIVES

The aim of the study was to investigate whether very low level viraemia (VLLV) (20-50 HIV-1 RNA copies/mL) was associated with increased risk of virological failure (VF) as compared with persistent full suppression (< 20 copies/mL).

METHODS

From the VACH Cohort database, we selected those patients who started antiretroviral therapy (ART) after January 1997 and who achieved effective viral suppression [two consecutive viral loads (VLs) < 50 copies/mL] followed by full suppression (at least one VL <20 copies/mL). We carried out survival analyses to investigate whether the occurrence of VLLV rather than maintaining full suppression at < 20 copies/mL was associated with virological failure (two consecutive VLs > 200 copies/mL or one VL > 200 copies/mL followed by a change of ART regimen, administrative censoring or loss to follow-up), adjusted for nadir CD4 cell count, sex, age, ethnicity, transmission group, type of ART and time on effective suppression at < 50 copies/mL.

RESULTS

Of 21 480 patients who started ART, 13 674 (63.7%) achieved effective suppression at < 50 copies/mL, of whom 4289 (31.4%) further achieved full suppression at < 20 copies/mL after May 2009. A total of 2623 patients (61.1%) remained fully suppressed thereafter, while 1666 had one or more episodes of VL detection > 20 copies/mL (excluding virological failure). A total of 824 patients had VLLV after suppression at < 20 copies/mL. VLLV was not associated with virological failure as compared with persistent full suppression [hazard ratio (HR) 0.67; 95% confidence interval (CI) 0.44-1.00], independently of the number of blips recorded (from one to 18).

CONCLUSIONS

In our population of HIV-infected patients on ART who achieved viral suppression at < 20 copies/mL, the risk of virological failure was no different for patients who remained fully suppressed compared with those who experienced subsequent episodes of VLLV.

Improved darunavir genotypic mutation score predicting treatment response for patients infected with HIV-1 subtype B and non-subtype B receiving a salvage regimen

OBJECTIVES

The objective of this study was to improve the prediction of the impact of HIV-1 protease mutations in different viral subtypes on virological response to darunavir.

METHODS

Darunavir-containing treatment change episodes (TCEs) in patients previously failing PIs were selected from large European databases. HIV-1 subtype B-infected patients were used as the derivation dataset and HIV-1 non-B-infected patients were used as the validation dataset. The adjusted association of each mutation with week 8 HIV RNA change from baseline was analysed by linear regression. A prediction model was derived based on best subset least squares estimation with mutational weights corresponding to regression coefficients. Virological outcome prediction accuracy was compared with that from existing genotypic resistance interpretation systems (GISs) (ANRS 2013, Rega 9.1.0 and HIVdb 7.0).

RESULTS

TCEs were selected from 681 subtype B-infected and 199 non-B-infected adults. Accompanying drugs were NRTIs in 87%, NNRTIs in 27% and raltegravir or maraviroc or enfuvirtide in 53%. The prediction model included weighted protease mutations, HIV RNA, CD4 and activity of accompanying drugs. The model's association with week 8 HIV RNA change in the subtype B (derivation) set was R(2) = 0.47 [average squared error (ASE) = 0.67, P < 10(-6)]; in the non-B (validation) set, ASE was 0.91. Accuracy investigated by means of area under the receiver operating characteristic curves with a binary response (above the threshold value of HIV RNA reduction) showed that our final model outperformed models with existing interpretation systems in both training and validation sets.

CONCLUSIONS

A model with a new darunavir-weighted mutation score outperformed existing GISs in both B and non-B subtypes in predicting virological response to darunavir.

Alkaptonuria Presenting with Impressive Osteoarticular Changes and Severe Aortic Stenosis

Alkaptonuria, or ochronosis, a rare autosomal recessive metabolic disorder, causes an excess of homogentisic acid that results in dark pigmentation, calcification, and inflammation of cartilaginous and other tissues. Cardiovascular complications are also typical of the disease. We report the case of a 78-year-old male who presented with impressive osteoarticular changes and aortic stenosis associated with alkaptonuria.

Admissions for imported and non-imported parasitic diseases at a General Hospital in Spain: A retrospective analysis

OBJECTIVE

To analyze imported and non-imported parasitic diseases as a cause of admission to a general hospital.

METHODS

A retrospective analysis of hospital admissions for parasitic diseases between 2004 and 2013 performed by means of hospital information systems at a public hospital in the city of Castellón (Spain).

RESULTS

During the period covered in this study, there were 204,349 admissions, 213 of which were for parasitic diseases (prevalence: 1.04/1000 admission). 129 were neglected parasitic tropical diseases and 61 were imported parasitic diseases. The main parasitic diseases were hydatidosis (24.9%), visceral leishmaniasis (22.5%) and malaria (12.2%). There was a decrease in admissions for visceral leishmaniasis in the 2004-2008 period from 27.7% to 15.9% in the 2009-2013 period (p < 0.001), and an increase in admissions for malaria from 5.0% to 21.3% (p < 0.001). 38 (20.3%) of the 187 patients with parasitic diseases were HIV infected. HIV infection was more common in patients with toxoplasmosis (94.1%; p < 0.001), cryptosporidiosis (66.7%; p < 0.02) and visceral leishmaniasis (46.4%; p = 0.003). There were 34 (18.2%) children with parasitic diseases. Twelve of the 28 patients with visceral leishmaniasis (42.9%; p < 0.001), and 11 of the 17 patients with soil-transmitted diseases were children (64.7%; p < 0.001). The cause of death in eight patients was parasitic disease related (mortality rate: 4.3%). The mortality rate for visceral leishmaniasis was significantly higher (14.3%; p = 0.01).

CONCLUSION

The main cause is endemic parasitic diseases such as hydatidosis. Visceral leishmaniasis decreased during the period covered by the study, but malaria increased.

Acute prostatitis probably due to Listeria monocytogenes in an HIV-infected patient

We report a unique case of acute bacterial prostatitis probably caused by Listeria monocytogenes in an HIV-infected patient. For the best of our knowledge, this is the first case reported of a patient with this association. Our case illustrates the protean clinical presentations that L. monocytogenes infections may adopt, particularly in immunocompromised patients.

Pandemic H1N1 influenza-associated myocarditis in a patient with Castleman’s disease

We report on a patient with longstanding multicentric Castleman’s disease, hyaline-vascular type, who presented with nearly-fatal myocarditis associated with a 2009 pandemic H1N1 influenza virus infection. This is the first case of such an association described in the literature.

Impact of education program on influenza vaccination rates in Spain

OBJECTIVES

To assess the impact of a simple education program on adherence to influenza vaccination.

STUDY DESIGN

Randomized open controlled study.

METHODS

The education program group (EPG) received an education program via surface mail, consisting of information regarding the effectiveness and safety of the influenza vaccine. The no-program group (NPG) received no intervention. All patients in 13 primary care practices in the city of Castellón, Spain, were included if they were 60 years or older on the first day of the 2009 seasonal influenza vaccination campaign.

RESULTS

There were a total of 2402 participants (mean age 70.4 [± 7.1] years); 1338 (55.7%) were women. In 2009, 950 participants (39.5%) received the vaccine, including 900 of the same participants (37.5%) who had received it in 2008 (P = .14). Of those vaccinated in 2009, 501 (52.7%) belonged to the EPG and 449 (47.3%) to the NPG (P = .01). In a logistic regression analysis we found an association between adherence to vaccination in 2009 and both vaccination in the previous year and receiving the educational intervention. Influenza-related morbidity was similar in both groups during the 7 months after vaccination.

CONCLUSIONS

A mailed reminder program was effective to improve influenza vaccination rate, but only to a limited extent. Vaccination the previous year was the main predictor of adherence to vaccination. More programs are needed to improve vaccination rates in the study community.

Interobserver discrepancy in liver fibrosis using transient elastography

Transient elastography is a useful method to assess liver fibrosis, but uncertainties still exist regarding reliability and reproducibility of the technique. We aimed to improve knowledge on interobserver variability with the procedure and tried to find factors associated with such variability. This was a cross-sectional study to compare the results of transient elastography performed by two different operators, one test made just after the other. We assessed both results with correlation tests and with repeated parametric or nonparametric tests, as needed. We also carried out a multivariate analysis to find factors associated with discrepancy in the results obtained by the two operators. We included a total of 333 pairs of transient elastography tests, belonging to 274 different patients. A total of 325 pairs of tests (97.6%) were valid. Results of the first and the second tests were, respectively, median (and interquartile range) of direct measurement 6.2 (4.6-10.6) and 6.0 (4.4-10.1) kPa (P = 0.012), and mean ± standard deviation of log(10) of direct measurement 0.892 ± 0.316 and 0.871 ± 0.324 (P = 0.001). In 87 pairs of tests (26.7%), a discrepancy of at least 2 kPa between both results was found, and in 15 pairs of tests (4.6%), a discrepancy of at least 10 kPa was found. Discordance of at least one stage between both measurements was noted in 74 pairs of tests (22.8%). An association was found between higher stiffness and discrepancy between both operators (P < 0.001). Although transient elastography is a very convenient test to assess liver fibrosis in clinical practice, interobserver discrepancy in results is common and represents a significant problem with the technique. Discrepant results are more common in patients with higher values of stiffness.

Hepatitis C virus co-infection and sexual risk behaviour are associated with a high homocysteine serum level in HIV-infected patients

BACKGROUND AND AIMS

A better understanding of the relationship of homocysteine with cardiovascular risk factors is needed. The objectives of this study were to assess the serum level of homocysteine in HIV-infected patients and to analyse the possible association of increased levels of the amino acid with cardiovascular risk factors, demographic and clinical characteristics of participants.

METHODS

Cross-sectional study carried out as a supplementary task to the usual controls necessary in HIV-infected patients in the outpatient clinic of the Hospital General of Castellon, Spain. For two consecutive visits the demographic, clinical and HIV-related characteristics and blood analyses results were obtained for each participant. Homocysteine serum level was documented and the possible association of the amino acid with all the other study variables was assessed with a multiple linear regression analysis.

RESULTS

A total of 145 patients were included. The mean homocysteine serum level of all participants was 11.9 ± 5.9 µmol/L. A total of 54 patients (37%) presented homocysteine serum levels higher than the upper limit of normal. An association was found between higher homocysteine serum level and the following variables: family history of early coronary disease (P = 0.027), sexual HIV risk behaviour (P = 0.016), hepatitis C virus co-infection (P = 0.002), higher height (P = 0.002), higher diastolic blood pressure (P = 0.049), lower serum level of folic acid (P <0.001), and lower serum level of vitamin B12 (P = <0.001).

CONCLUSION

In the HIV population, increased homocysteine serum level is associated with sexual risk behaviour and hepatitis C virus coinfection.

[Morbidity and costs in complete thyroidectomies. Improvement in Value of the Process by a change in the management]

OBJECTIVES

1) To present the postoperative morbidity of complete thyroidectomies and the results of their clinical management and costs obtained after surgery. 2) To compare the results obtained for the morbidity and costs in the complete thyroidectomy Process, after the management changes introduced by the Endocrine Surgical Unit (ESU). 3) To define whether these changes improve the Value (benefit/cost ratio) of the Process.

MATERIAL AND METHODS

Prospective study of cohorts conducted on 529 complete thyroidectomies performed between 1998 and 2011. We present their clinical-pathological characteristics and we compare the clinical and management results obtained after surgery in 2 time periods: 1998-2006 without ESU (group 1, 205 patients) and 2007-2011 with ESU (group 2, 324 patients). The clinical results and the possible benefits are assessed by studying the morbimortality (recurrent lesions, hypocalcaemia [<8 mg/dl], suffocative haematomas and bleeding), and those of management, for the evaluation of the use of operating room time, the average stay and the total cost of the Process. The statistical comparison study was made using Student t test, for the comparison of means and the Chi(2) to compare percentages, accepting P<.05 as significant.

RESULTS

The global percentage of transient recurrent dysfunctions (TRD) was 6%, and for definitive recurrent paralysis (DRP) it was 1.5%. Hypocalcaemia, at 24 hours was 54.6%, at one month 7%, at six months 6.2% and that of definitive hypoparathyroidism 1.3%. There were 2.8% of suffocative haematomas and 2% adverse effects. The mean surgical time was 98 minutes, and the average stay was 3.66 days. In the comparison of results of the groups, the ESU improved the TRD index by nearly 7 points (10.2 vs. 3.4%, P=.002), that of DRP by 1.5 (2.4 vs. 0.4%; P=.3) until reaching under 1%. The figures on bleeding at 24 hours (53 vs. 44 cc; P=.002) and 48 hours (23 to 17 cc; P<.001), the rate of haematomas by another 6 points (6.3 vs. 0.6%; P<.001), and that of hypocalcaemia at 24 hours (P=.01). The average stay also improved (4.79 vs. 2.94 days; P<.001), the use of operating room time (reduced by 20 minutes/operation; P<.001), the total cost of the Process, decreasing by more than € 2,000/Process (P<.001), and produced a total savings for the hospital in the period of study of € 665,820.

CONCLUSIONS

1) The global results (post-operative morbidity) of our total thyroidectomies are within the quality standards. 2) The surgical specialisation and the changes introduced by the ESU improved the clinical results (greater benefit) and those of management, cutting down the average stay and the operating room usage time and decreasing costs. 3) The change in management increased the Value of the Process.

Nocardiosis complicated with Addison's disease

A 77-year-old woman presented with subacute respiratory symptoms which were demonstrated to be due to nocardiosis. After initial improvement with antimicrobial therapy, new symptoms appeared, consisting of persistent vomits, abdominal pain and hypotension, which led to the diagnosis of Addison's disease.

Factors associated with mortality in patients with exacerbation of chronic obstructive pulmonary disease hospitalized in General Medicine departments

We aim to improve knowledge on risk factors that relate to mortality in subjects with exacerbation of chronic obstructive pulmonary disease (COPD) who are hospitalized in General Medicine departments. In a cross-sectional multicenter study, by means of a logistic regression analysis, we assessed the possible association of death during hospitalization with the following groups of variables of participating patients: sociodemographic features, treatment received prior to admission and during hospitalization, COPD-related clinical features recorded prior to admission, comorbidity diagnosed prior to admission, clinical data recorded during hospitalization, laboratory results recorded during hospitalization, and electrocardiographic findings recorded during hospitalization. A total of 398 patients was included; 353 (88.7%) were male, and the median age of the patients was 75 years. Of these patients, 21 (5.3%) died during hospitalization. Only 270 (67.8%) received inhaled β(2) agonists during hospitalization, while 162 (40.7%) received angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. The median of predicted FEV(1) prior to admission was 42%. A total of 350 patients (87.9%) had been diagnosed with two or more comorbid conditions prior to admission. An association was found between increased risk of death during hospitalization and the previous diagnoses of pneumonia, coronary heart disease, and stroke. In conclusion, comorbidity is an important contributor to mortality among patients hospitalized in General Medicine departments because of COPD exacerbation.

Characteristics and outcome of HIV infection in gypsies in the Spanish VACH Cohort

OBJECTIVE

To study the characteristics of HIV infection in the gypsy (Roma) population in Spain, as compared with those of the Caucasian, non-gypsy majority.

DESIGN

Cross-sectional, historical cohort study from the Spanish VACH Cohort.

METHODS

Patients attending VACH clinics between 1 June 2004 and 30 November 2004 were classified according to their racial and ethnic origin as "gypsies", Caucasian non-gypsy Spanish natives (CNGN), and "other" (the last being excluded from this study). Their sociodemographic and clinico-epidemiological characteristics were compared, as well as the Kaplan-Meier curves of time to AIDS, or death, or disease progression (either of the 2 outcomes).

RESULTS

4819 (48%) of 10,032 cases included in the VACH database were eligible: 210 (4.2%) were gypsies and 4252 (84.8%) were CNGN. Differences were observed in age, household, academic, inmate, marital, and employment history. Injecting drug use had been the most frequent mechanism of transmission in both groups, but to a greater extent among gypsies (72% versus 50%; P<0.000). Sex distribution, CD4 cell counts, and viral loads at the first visit were similar in the 2 groups, as was the percentage of patients with previous AIDS, percentage receiving antiretrovirals, and percentage subsequently starting antiretroviral therapy. Up to 1 April 2005, 416 new AIDS cases and 85 deaths were recorded. The percentage of these outcomes did not differ between groups, but log-rank test showed a shorter time to AIDS and disease progression among gypsies.

CONCLUSIONS

The sociodemographic characteristics of gypsies, the largest minority in the VACH Cohort, show differences relative to those of CNGN. HIV-related outcomes suggest that gypsies have a poorer prognosis.

Castleman's Disease. A Review

Castleman's disease is characterized by a non-clonal lymph node hyperplasia. Pathologically it is classified as hyaline vascular, plasmacytic, or mixed cellularity types, and clinically it may adopt a unicentric (localized) or multicentric presentation. An association of the disease with HIV infection has been found. Many uncertainties remain concerning the etiopathogenesis and the optimal treatment of this rare condition.

Pyomyositis of the iliacus muscle complicated with septic sacroiliitis

We report a rare case of pyomyositis of the iliacus muscle in a 29-year-old woman. After 2 weeks of adequate treatment, secondary septic sacroiliitis occurred, a complication that had not been described previously. Pyomyositis of the iliacus muscle must be considered in the differential diagnosis of acute pain in the hip region.

Pharmacogenomics of antiretrovirals

HIV infection is a serious but treatable disease, yet current treatment is limited by development of resistance and high rates of adverse drug reactions. Antiretroviral therapy is especially suitable for pharmacogenomic investigation as both drug exposure and treatment response can be reliably measured. Increasing knowledge about genes implicated in pharmacokinetics, mode of action, efficacy, and toxicity of drugs has already provided relevant results for clinical practice, for example: The strong association of the abacavir hypersensitivity reaction with HLA-B*5701 permits testing patients for the allele, and if present avoiding the drug and therefore preventing the reaction. Persons with the allele CYP2B6*6 present higher efavirenz "area under the curve" and have increased risk of neuropsychological toxicity. Additional gene variants are being discovered that influence the action of antiretroviral drugs. And, moreover, it is expected that larger-scale comprehensive genome approaches will profoundly improve the landscape of knowledge of HIV therapy in the future. The present article shows some recent patents related to the treatment of viral infections.

[Q fever]

Q fever is a zoonosis caused by Coxiella burnetii. The infection is transmitted to humans mainly through aerosols generated from products of delivery of cows and other animals. Generally the disease presents acutely with fever, pneumonitis and hepatitis. But chronic endocarditis is also a possible occurrence. Diagnosis is usually made by serology. The acute form of the infection responds well to tetracyclines and other antibiotics. But endocarditis is difficult to treat, and its prognosis is grim.