Safety and Efficacy of Dolutegravir Plus Rilpivirine in Treatment-Experienced HIV-Infected Patients: The DORIVIR Study

Objectives:

To analyze the efficacy and safety of dolutegravir/rilpivirine (DTG/RPV) in HIV-infected patients who switched from any other antiretroviral therapy (ART).

Methods:

Open-label, multicenter study including patients who switched to DTG/RPV between February 2015 and February 2016. Efficacy (HIV RNA <50 copies/mL), adverse events, and metabolic changes at 24 weeks were analyzed.

Results:

A total of 104 participants were included, who switched for the following reasons: toxicity/intolerance (42.3%), convenience (27.8%), and drug interactions (17.3%). Prior regimens are protease inhibitor (56.7%), integrase strand transfer inhibitor (26.9%), and non-nucleoside reverse transcriptase inhibitor (16.3%). Efficacy at 24 weeks was 88.4% (intention to treat) and 96.8% (per protocol). Triglyceride levels were reduced, on average, by 12.7% and a mean decrease of 9.0% in the glomerular filtration rate was observed as well (P values of .003 and .002, respectively), whereas total cholesterol, HDL cholesterol, LDL cholesterol, creatinine, and glutamic-pyruvic transaminase remained unchanged. No patient discontinued due to adverse events.

Conclusions:

Dolutegravir/RPV is effective and safe in long-term HIV-infected patients under any prior ART. Toxicity, convenience, and interactions were the main reasons for changing. At 24 weeks, the lipid profile improved with a decrease in triglycerides.

Host availability affects the interaction between pupal parasitoid Coptera haywardi (Hymenoptera: Diiapridae) and larval-pupal parasitoid Diachasmimorpha longicaudata (Hymenoptera: Braconidae)

The use of multiple species in biological control programmes is controversial when interactions among them are not fully understood. We determined the response of the pupal parasitoid Coptera haywardi (Oglobin) to different availability of Anastrepha ludens (Loew) pupae previously parasitized or not by larval-pupal Diachasmimorpha longicaudata (Ashmead). The two types of pupae were exposed at different ages and proportions to different numbers of C. haywardi females for 48 h. The performance of C. haywardi adults emerging from parasitized and unparasitized pupae was measured. Coptera haywardi prefers to attack unparasitized A. ludens pupae rather than pupae parasitized by D. longicaudata. However, when the availability of unparasitized pupae was low or the number of foraging females was high, C. haywardi competed against early immature stages of the D. longicaudata, or hyperparasitized, feeding directly on the advanced-immature developmental stages of the early acting species. Adults of C. haywardi emerging as hyperparasitoids were no different in size, fecundity and longevity from those emerging as primary parasitoids. Our data suggest that simultaneous use of these species in augmentative biological control projects may be feasible but should be carefully planned in order to avoid any detrimental effect of its interaction.

Best Timing to Determine Field Parasitism by Released Diachasmimorpha longicaudata (Hymenoptera: Braconidae) Against Anastrepha (Diptera: Tephritidae) Pest Populations

Our objective was to determine the timing of the highest parasitic activity by released Diachasmimorpha longicaudata (Ashmead) (Hymenoptera: Braconidae) in areas with fruits of sour orange and hog plums infested by Anastrepha ludens (Loew) and Anastrepha obliqua (McQuart) (Diptera: Tephritidae), under shaded and sunny conditions. Percent parasitism along fruit sampling period was related to host availability, which was influenced by the fruit size rather than environmental conditions. The highest parasitism in sour orange was obtained just the first day after release, but in hog plums this was observed during the first 3 days without significant differences between them. The levels of fruit infestation and parasitism were higher in shaded trees in sour orange as in hog plums. The high availability of larvae and the small size of hog plums were decisive for obtaining high levels of parasitism and keeping parasitoids near the release points. By contrast, the size and thick rind of sour orange provided to the larvae a physical refuge that was associated with lower parasitism, causing that parasitoids spread out in search of hosts more accessible. In sour orange, parasitism was exclusively by D. longicaudata, while in hog plums, we additionally found the coexistence of four native parasitoid species. This information suggests that in sour orange, the sampling should be performed 1 day after release, while in hog plums, the samplings can be extended to within the first 3 days. Such sampling can serve to better estimate the effect of D. longicaudata releases against Anastrepha pest populations in different fruit types.

Sequential versus Alternating Regimens in the Treatment of Advanced Breast Cancer

With the object of proving whether seqeuntial or alternate forms of chemotherapy would be advantageous one over the other in treating advanced breast cancer and with the purpose of evaluating two different anthracyclines at equimolecular doses in the above-mentioned alternating regimens, 250 patients who had received no prior chemo- or hormonotherapy were entered in a prospective randomized trial. Group A was administered 4-epiadriamycin and cyclophosphamide for 8 courses, followed by 6 cycles of CMF, and medroxyprogesterone acetate (MPA) from the beginning of therapy until progression. In group B, adriamycin + cyclophosphamide were alternated with CMF every two courses until 14 cycles were completed. Group C received 4'-epiadriamycin + cyclophosphamide alternated with CMF for 14 courses. In groups B and C, MPA was administered as in group A. Two hundred and twenty-four patients were evaluated. CR+PR were observed in 55.8 % of group A, 43.4 % of group B, and 46.4 % of group C. Median duration of responses was 16 months (m) in group A, 13 m in group B and 20 m in group C., and median survival (CR + PR) was 16.5 m in group A, 16 m in group B and 24 m in group C. There were no statsitically significant differences among the three groups in terms of response rate, duration of response and survival; furthermore, toxicity was moderate in all groups. At equimolecular doses there were no differences between adriamycin and epirubicin in the alternating schedules.

Fungitoxic Activity Against Phytopathogenic Fungi and the Chemical Composition of Thymus zygis Essential Oils

The yield, chemical composition, and antifungal properties of essential oils from six populations of Thymus zygis Loefl. ex L. were studied. Phytopathogenic fungi Pythium irregulare, Rhizoctonia solani, Colletotrichum acutatum, Fusarium oxysporum, and Sclerotinia sclerotiorum showed a clear inhibition in the poisoned food test. Inhibition is tested by EC50. This activity indicator ranges from 86 ppm in the most active oils to 577 ppm. Among the identified components of the oils, 3-octanol and α-terpinene had the highest correlation with the antifungal activity. Yield, antifungal activity, and plant morphology, led to the selection of the population T. zygis ssp. gracilis harvested at flowering stage as most suitable for potential agronomical use.

[Single-port video-assisted thoracic surgery in an awake patient]

Video-assisted thoracic surgery is traditionally carried out with general anaesthesia and endotracheal intubation with double lumen tube. However, in the last few years procedures, such as lobectomies, are being performed with loco-regional anaesthesia, with and without sedation, maintaining the patient awake and with spontaneous breathing, in order to avoid the inherent risks of general anaesthesia, double lumen tube intubation and mechanical ventilation. This surgical approach has also shown to be effective in that it allows a good level of analgesia, maintaining a correct oxygenation and providing a better post-operative recovery. Two case reports are presented in which video-assisted thoracic surgery was used, a lung biopsy and a lung resection, both with epidural anaesthesia and maintaining the patient awake and with spontaneous ventilation, as part of a preliminary evaluation of the anaesthetic technique in this type of surgery.

Umbilical cord blood-derived stem cells spontaneously express cardiomyogenic traits

BACKGROUND

Umbilical cord blood (UCB) has been widely used for hematopoietic stem cell transplantation. The UCB-derived stem cells (UCBSCs) have been proposed as an alternative to bone marrow (BM)-derived mesenchymal stem cells (MSCs) for cardiac cell-based therapy. Herein we studied whether UCBSCs spontaneously exhibit cardiac-specific markers in vitro.

METHODS

Human UCBSCs were isolated, expanded, and phenotyped by flow cytometry, quantitative RT-PCR, and immunofluorescence. Cell pluripotency and proliferation were also assessed by adipogenic and osteogenic media and in growth assays.

RESULTS

Among 25 analyzed UCB, 16% of cases afforded primary culture satisfactory generation of UCBSCs. Duplication time (Td) of cultures was 2.16 +/- 0.06 days. The cells were strongly positive for CD105 (18.5 +/- 0.14), CD44 (27 +/- 2.8), CD166 (13 +/- 9), CD29 (59 +/- 9.4), CD90 (60 +/- 11) and consistently negative for CD117 (1.2 +/- 0.1), CD106 (1.1 +/- 0), CD34 (1.2 +/- 0.2), CD14 (1 +/- 0), and CD45 (1 +/- 0), consistent with a mesenchymal lineage. Adipogenesis and osteogenesis of cells resulted in low accumulation of intracellular lipid droplets and high deposition of calcium. The UCBSCs showed gene transcripts for alpha-actinin, connexin (Cx)-43, SERCA-2, and stromal cell-derived factor (SDF)-1alpha. At the protein level, the cells abundantly expressed alpha-actinin, Cx-43, SERCA-2 and SDF-1alpha. In contrast, these cells did not express the cardiac transcription factors GATA-4, Tbx5, and Nkx2.5, nor the sarcomeric proteins beta-myosin heavy chain (beta-MyHC) or cardiac troponin I (cTnI).

CONCLUSIONS

Human UCBSCs may represent an alternative source of stem cells for myocardial-cell replacement. These cells can be highly expanded. They spontaneously express proteins of paramount importance for cardiovascular regeneration, such as Cx-43, SERCA-2, and SDF-1alpha.

Healthcare seeking for constipation: a population-based survey in the Mediterranean area of Spain

BACKGROUND

The use of healthcare resources for the management of constipation is not well-known.

AIM

To analyse healthcare seeking for constipation, defined by three different criteria, and its related factors and to assess the frequency of use of laxatives, suppositories and enemas for the treatment of constipation.

METHODS

A cross-sectional study in the general community. A questionnaire comprising 21-items was developed and delivered by mail to a random sample of 506 subjects aged 18-65 years, and belonging to a Spanish population.

RESULTS

Seeking of health care was high in the sample (16%) and was similar for all definitions of constipation (over 40% of constipated subjects). It was associated with female gender, a higher educational level and two symptoms, such as prolonged defecation and abdominal pain. A 14% of the sample used laxatives, and about a 25% of constipated subjects used laxatives at least once a week. Utilization was more frequent in women, with no differences by age group.

CONCLUSIONS

Chronic constipation is a problem that causes an important consumption of resources in our setting, derived from laxative use and the seeking of medical help to combat the problem. The use of these resources is higher in women.

Multicenter randomized controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding

BACKGROUND/AIMS

The dose of somatostatin used for variceal bleeding (250 microg/h) is lower than that proven to effectively decrease portal pressure and azygos blood flow (500 microg/h). Moreover, i.v. somatostatin boluses have greater effects than continuous infusions. The aim of this study was to investigate whether higher doses of somatostatin and repeated boluses may increase its efficacy in controlling variceal bleeding.

METHODS

A total of 174 patients with acute variceal bleeding were randomized to receive for 48 h: (A) one 250 microg bolus +250 microg/h infusion; (B) three 250 microg boluses +250 microg/h infusion; (C) three 250 microg boluses +500 microg/h infusion.

RESULTS

The three schedules of somatostatin were equally effective in controlling variceal bleeding (73, 75 and 81%, respectively, NS). Multivariate analysis showed active bleeding at endoscopy (n=75) as the only predictor of failure to control bleeding. In these patients, the 500 microg/h infusion dose achieved a higher rate of control of bleeding (82 vs. 60%, P<0.05), less transfusions (3.7 +/- 2.7 vs. 2.5 +/- 2.3 UU, P=0.07) and better survival (93 vs. 70%, P<0.05) than schedules A/B.

CONCLUSIONS

Somatostatin is highly effective in controlling variceal bleeding. Patients with active bleeding at emergency endoscopy may benefit from higher doses of somatostatin infusion.

Influence of post haemodialysis sampling on Kt/V result

The recommended Kt/V is 1.2. Unfortunately there is no written policy for nurses on the procedure for taking blood urea nitrogen samples post haemodialysis. The aim of this study was to establish the Kt/V variability of haemodialysis patients depending on the method of collection of post-haemodialysis blood urea nitrogen. Twenty-two patients were analysed. A Kt/V was performed every 15 days during a period of 2 months. It was taken five times on each patient: 30 minutes before the end of a haemodialysis session (Kt/V30), at the end of haemodialysis (Kt/V1), after slowing flows (50 ml/min) for 2 minutes (Kt/V2) and after the blood circuit had been returned to the patient at 5 and 15 minutes respectively. (Kt/V5, Kt/V15). The Kt/V results were: Kt/V1 1.23 +/- 0.2 Vs Kt/V2 1.14 +/- 0.19 (p < 0.003); Kt/V5- 1.05 +/- 0.19 (p < 0.002 Vs Kt/V2); Kt/V15 1 +/- 0.16 (p < 0.05 Vs Kt/V5); Kt/V30 1.12 +/- 0.21 (pNS Vs Kt/V2). In conclusion, there was a large variability in the Kt/V depending on the method of collection of the blood urea nitrogen sample post-haemodialysis.

[A study of peripheral neural conduction, motor and sensory, in diabetic patients treated with hyperbaric oxygenation]

INTRODUCTION

There are some occlusive disorders in the vasa nervorum and metabolic changes disminishing oxygen liberation by erytrocites at the capillary blood vessels, and these disturbances lead to endoneural microhypoxia. Hyperbaric oxygen reverts hypoxia in the diabetic neuropathy.

OBJECTIVE

We studied motor and sensitive peripheric neuroconduction in nine diabetic patients, with distal symmetrical polyneuropathy, during normoglycemia. Four of them were insulin dependent and five were non insulin dependent.

PATIENTS AND METHODS

The electrophysiological studies were done before treatment with hyperbaric oxygen, in a week, three and six months later. The abnormal electrophysiological parameters detected in diabetics were terminal latencies (enlarged), velocities of conduction (slowed) and distal amplitudes of compound action potentials (reduced).

RESULTS

Neither distal latencies nor distal amplitudes and conduction velocities in peroneal nerve showed significative changes in the statistical analysis. We observed slower conduction velocities in the motor fibers of the median nerve in the examination performed six months after treatment. There was an increase of distal latency and retardation of the velocity of conduction six months later after treatment in the sensitive fibers of median nerve, whereas the amplitudes of sensitive action potentials decreased progressively. These changes suggest large diameter peripheral fibers didn't receive benefit with hyperbaric oxygen treatment.

CONCLUSIONS

In all patients disappeared all symptoms of dysesthesias, paresthesias, distal pains and cramps in the legs and arms, suggesting functional changes in small unmyelinated fibers which we can't test with conventional techniques to prove it.

[Upper gastrointestinal tract hemorrhage: syndromic diagnosis at a hospital emergency unit]

BACKGROUND

To analyze the assistance requirements generated in a hospital emergency unit by the upper gastrointestinal bleeding (UGIB) syndrome, and to assess some strategies intended to improve its syndromic diagnosis prior to admission.

PATIENTS AND METHODS

Prospective study of a cohort including 1,029 consecutive cases assisted because of presumed hematemesis or melenas. At the emergency room UGIB was diagnosed or ruled out according to criteria based on examination of vomits and stools. Those cases not classified were observed before establishing the preadmission diagnosis. Sensitivity (Se), specificity (Sp) and likelihood ratio for a positive or negative test were estimated in each step of the process. The efficacy of the proposed criteria for diagnosis was compared with those accepted by the World Organization of Gastroenterology (WOG). The diagnosis at hospital discharge was used a reference pattern.

RESULTS

A final diagnosis of UGIB was established in 718 cases (59%). The emergency room criteria were applied to 848 out of the 1,029 patients assisted, bleeding being discarded in 216 cases (Se = 0.43; Sp = 0.99) and estimated as present in 632 (Se = 0.79%; Sp = 0.87%). By combining these results with those obtained after observation of the remaining 361 patients, the preadmission diagnosis showed a sensitivity of 0.99% and a specificity of 0.86%. Should the WOG criteria were adopted, the same process was equally sensitive but less specific (Sp = 0.55%).

CONCLUSIONS

In a high proportion of patients assisted in a hospital for a suspected UGIB, this diagnosis is not confirmed. The examination of vomits and stools by nursing or medical staff, followed if needed by an observation period, improves the accuracy of the syndromic diagnosis prior to admission and may avoid an elevated number of unnecessary hospital staying.

Analysis of the predictive value of clinical data in patients with suspected colonic disease

OBJECTIVE

To develop guidelines for predicting colonic disease on the basis of clinical parameters.

EXPERIMENTAL DESIGN

A prospective study of the clinical data prior to colonoscopy. On the basis of the endoscopic findings, the patients were divided into three diagnostic groups: absence of significant disease, significant benign disease and malignant disease. The patient population was divided randomly into two subgroups. The clinical data from one of them was used to build a database which, using Bayes' theorem, was compared with the variables from the other subgroup to predict the diagnosis for each patient.

PATIENTS

A total of 336 patients (170 males and 166 females; mean age: 58 years; range: 15 to 87 years) were evaluated.

RESULTS

When the endoscopic findings were grouped on the basis of their clinical importance, 211 patients (63%) belonged to the group without significant disease, 60 patients (18%) had significant benign disease and 65 (19%) presented a neoplastic disease. Of the 21 variables selected for use in the database, 6 showed statistically significant differences in terms of the absence or presence of malignant disease: age, absence of previous similar episodes, weight loss, rectal bleeding, lack of improvement and the presence of a mass on digital rectal examination. The predictive model differentiated patients with neoplasm from those without malignant disease, but was not capable of identifying differences among the latter. The model was useful for assessing the risk of malignant disease for each patient.

CONCLUSIONS

The predictive model obtained is a useful tool for establishing the diagnosis and the priority in the performance of colonoscopy.

Achalasia-like syndrome as the first manifestation in a patient with CREST syndrome

We report a case of oesophageal disease as the first manifestation in a patient with CREST syndrome. A 46-year-old man with achalasia-like syndrome developed CREST syndrome 4 years later. A pneumatic dilatation of the cardia was performed. After pneumatic dilatation the dysphagia and regurgitation disappeared but the patient developed reflux oesophagitis. Four years after diagnosis of oesophageal disease he presented with a clinical picture of CREST syndrome. An acute ileus and constipation developed later. After receiving medical therapy with omeprazole and cisapride the patient is free of oesophageal symptoms and bowel movements are normal. Oesophageal disease is common in patients with limited and diffuse scleroderma, but to our knowledge achalasia-like syndrome has not been previously described as the first manifestation of the systemic disease.

Prediction of further hemorrhage in bleeding peptic ulcer

OBJECTIVE

To obtain a simple mathematical model able to estimate early the risk of further hemorrhage in bleeding peptic ulcer.

METHODS

A prospective study was conducted on 1567 patients admitted for acutely bleeding peptic ulcer. Ten readily available variables were tested for association with further hemorrhage, and then a logistic regression analysis was carried out.

RESULTS

Further hemorrhage occurred in 312 (20%) patients. The univariate analyses showed age over 65 yr, male sex, alcoholism, associated disease, hematemesis, endoscopic bleeding stigmata and shock, and blood urea over 90 mg/dl at admission to be significantly associated with continuous hemorrhage or rebleeding (p < 0.05 to p < 0.001). When these were assessed in a multivariate logistic regression analysis, the best fitted model (likelihood ratio test = 9.9; p = 0.5) included four independent variables. Bleeding stigmata (p < 0.001; odds ratio = 3.1), shock (p < 0.001, odds ratio = 2.5), hematemesis (p < 0.001; odds ratio = 1.6) and age over 65 (p = 0.04); odds ratio = 1.3) were associated with high risk of further hemorrhage.

CONCLUSIONS

Bleeding stigmata and changes in hemodynamics are confirmed as the most relevant predictors of further hemorrhage. When they are considered with hematemesis and age altogether, other clinical features loss importance for prognosis. By taking advantage of the joint influences of these variables, accuracy of prognosis improves with respect to that obtained when they are considered as individual risk factors.

Efficacy of the heater probe in peptic ulcer with a non-bleeding visible vessel. A controlled, randomised study

A controlled, randomised study was performed to evaluate the efficacy of treatment with heater probe in the prevention of rebleeding from peptic ulcer with a non-bleeding visible vessel. One hundred and one patients were randomised into two groups: patients to be treated by heater probe (n = 51) and controls without active treatment (n = 50). In the heater probe group rebleeding occurred in five patients (10%) v 13 (26%) in the control group (p = 0.03), with a comparative risk of 0.38 in favour of the heater probe group. The difference in proportions of successful treatment for each group was 16.2% in favour of the heater probe (95% CI = 2 to 31%). Haemorrhage directly related to heater probe treatment occurred in four patients. In three of them bleeding was easily controlled by further heater probe pulses. There were no other complications and no death in the heater probe group. One patient in the control group died of pulmonary embolism. No significant differences in the length of stay in hospital, blood transfusions, surgical rates, or death were found; the design of the study, however, precluded an adequate assessment of these variables, because the heater probe was an optional rescue treatment when high surgical risk patients rebled. These results suggest that the heater probe is an effective and safe procedure in the prevention of recurrent haemorrhage in peptic ulcer with a non-bleeding visible vessel.

[The cost effectiveness of hemorrhage units]

Gastrointestinal bleeding units appear as an alternative to intensive care units in the management of patients with gastrointestinal bleeding. Their hospitalization advantages and economic impact, however, are poorly evaluated. A survey was done among 176 Spanish general hospitals over 100 beds. Forty-four percent of the 176 hospitals answering the questionnaire had a protocol for the management of patients with gastrointestinal bleeding. Results from our survey show that gastrointestinal bleeding units are regarded as either useful (53%) or necessary (41%) by most hospitals, and should be equipped to provide intermediate-type care (88%). To the vast majority of hospitals, patient care is paramount to evaluate the yield of gastrointestinal bleeding units; in contrast, cost-efficiency analysis is relevant to only 31%, whereas the combination of cost efficiency and research is relevant to 61% of hospitals. Mean hospital charges for patients in our gastrointestinal bleeding unit, which has an occupancy rate of 95%, are 53% higher than those for regular inpatients, and 64% lower than those for patients in the intensive care unit.

[Digestive hemorrhage units. A national survey]

The results of a national survey carried out on two hundred and five Spanish hospitals, on the treatment of upper gastrointestinal bleeding (UGIB) and special units for gastrointestinal haemorrhages, are reported in this paper. Questionnaires were sent to the chief of every Surgery, Gastroenterology and Internal Medicine Service. We received three hundred and twenty six answered questionnaires from 179 hospitals out of a total number of 582 mailed all over Spain. The Gastroenterology Units manage the UGIB in most hospitals, and in 45% of these, a protocol elaborated by gastroenterologists and surgeons is followed. In general, 94% of answers agree in the convenience or even need of Gastrointestinal Haemorrhage Units. However, when asked about this point in the setting of their own hospital, this figure comes down to 83%. On the other hand, only 46% consider the units to be warranted from the medical care and economical points of view. Most doctors think that to assess the yield of these units, medical care, economical and research criteria should be kept in mind. The general opinion is that should they exist in a given hospital, they should work as intermediate care units (87%), and be dependent of both Gastroenterology and Surgery units (71%). Currently, there are in Spain ten Gastrointestinal Haemorrhage Units, with a mean number of 6 beds, located in large hospitals, most of them run by the Gastroenterology Service. All of them are involved in some research project. In these units, overall mortality rates for UGIB, and mortality rate in bleeding peptic ulcers range close to 7% and 3%, respectively.