Efficacy and safety of dolutegravir/rilpivirine in real-world clinical practice. GeSIDA study 1119.

INTRODUCTION: Dolutegravir/rilpivirine (DTG/RPV) is an effective antiretroviral (ART) regimen endorsed by clinical trials as a switch therapy. The aim of our study was to analyse the efficacy and safety of DTG/RPV in real-world clinical practice. METHODS: Observational, multicentre study of patients who started DTG/RPV. Efficacy, adverse events and metabolic changes at 48 weeks were analysed. RESULTS: A total of 348 patients were included; median time of HIV infection was 21.1 years, 33.7% were AIDS cases; median nadir CD4 was 160 cells/µL; 90.5% had received ≥3 lines of ART and 179 (53.8%) had prior virological failure. Convenience (43.5%), toxicity/intolerance (28.4%) and interactions (17.0%) were the main reasons for starting DTG/RPV. Previous regimens were protease inhibitors (PI) (31.6%), non-nucleoside reverse transcriptase inhibitors (NNRTI) (20.4%) and integrase strand transfer inhibitors (INSTI) (14.9%). Efficacy (HIV-RNA <50 copies/mL) at 48 weeks was 89.7% (95% CI 86.1-92.6) by intention-to-treat (ITT) and 94.2% (95% CI 91.3-96.4) by on treatment (OT); 10 patients (3.1%) were not suppressed (3 had abandoned ART). There was a mean decrease in triglycerides, total cholesterol, low-density lipoprotein-cholesterol, glutamic-pyruvic transaminase (GPT), gamma-glutamyl transferase (GGT) and alkaline phosphatase; creatinine increased with a decrease in glomerular filtration rate. CONCLUSIONS: This study confirms the effectiveness, tolerability and safety of DTG/RPV in real-world clinical practice in a different population from clinical trials, with many years of infection, low CD4 nadir, several previous treatment lines, more than half with virological failures, and one-third diagnosed with AIDS. The switch to DTG/RPV was safe with few discontinuations due to adverse effects. Modifications of the lipid and liver profiles were favourable. There were no relevant changes in kidney function.

Outcomes by sex following treatment initiation with darunavir/cobicistat in a large Spanish cohort of the CODAR study (GeSIDA 9316).

BACKGROUND: Few women have been included in darunavir/cobicistat clinical development studies, and hardly any of them were antiretroviral experienced or treated with anything other than triple-based therapies. OBJECTIVES: Our aim was to increase our knowledge about women living with HIV undergoing darunavir/cobicistat-based regimens. METHODS: A multicentre (21 hospitals), retrospective study including a centrally selected random sample of HIV-1 patients starting a darunavir/cobicistat-based regimen from June 2014 to March 2017 was planned. Baseline characteristics, 24 and 48 week viral load response (<50 copies/mL), CD4+ lymphocyte count increase, time to change darunavir/cobicistat and adverse event occurrence were all compared by sex. The study was approved by each of the 21 ethics committees, and patients signed informed consent. RESULTS: Out of 761 participants, 193 were women. Similar characteristics were found for both sexes, except that the women had a longer duration of HIV infection (P = 0.001), and were less frequently pre-treated with darunavir/cobicistat in their previous regimen (P = 0.02). The main reason for using a darunavir/cobicistat-based regimen was simplification, without differences by sex, while monotherapy seems to be more frequently prescribed in women than in men (P = 0.067). The main outcomes, HIV viral load response, CD4+ lymphocyte count increase at 24 or 48 weeks, occurrence of adverse events, main reasons for changing and time to the modify darunavir/cobicistat regimen, did not show differences between the sexes. CONCLUSIONS: No sex disparities were found in the main study outcomes. These results support the use of a darunavir/cobicistat-based regimen in long-term pre-treated women. Clinical Trial.gov No. NCT03042390.

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.

Documento de consenso sobre el manejo de la patología renal en pacientes con infección por VIH / Consensus document on the management of renal disease in HIV-infected patients

OBJETIVO: Actualizar las recomendaciones sobre la evaluación y el manejo de la afectación renal en pacientes con infección por el virus de la inmunodeficiencia humana (VIH). MÉTODOS: Este documento ha sido consensuado por un panel de expertos del Grupo de Estudio de Sida (GESIDA) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), de la Sociedad Española de Nefrología (S.E.N.) y de la Sociedad Española de Química Clínica y Patología Molecular (SEQC). Para la valoración de la calidad de la evidencia y la graduación de las recomendaciones se ha utilizado el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTADOS: La evaluación renal debe incluir la medida de la concentración sérica de creatinina, la estimación del filtrado glomerular (ecuación chronic kidney disease epidemiological collaboration [CKD-EPI]), la medida del cociente proteína/creatinina en orina y un sedimento urinario. El estudio básico de la función tubular ha de incluir la concentración sérica de fosfato y la tira reactiva de orina (glucosuria). En ausencia de alteraciones, el cribado será anual. En pacientes tratados con tenofovir o con factores de riesgo para el desarrollo de enfermedad renal crónica (ERC), se recomienda una evaluación más frecuente. Se debe evitar el uso de antirretrovirales potencialmente nefrotóxicos en pacientes con ERC o factores de riesgo para evitar su progresión. En este documento se revisan las indicaciones de derivación del paciente a Nefrología y las de la biopsia renal, así como las indicaciones y la evaluación y el manejo del paciente en diálisis o del trasplante renal. CONCLUSIONES: La función renal debe monitorizarse en todos los pacientes con infección por el VIH y este documento pretende optimizar la evaluación y el manejo de la afectación renal.(AU)

OBJECTIVE: To update the 2010 recommendations on the evaluation and management of renal disease in HIV-infected patients. METHODS: This document was approved by a panel of experts from the AIDS Working Group (GESIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Nephrology (S.E.N.), and the Spanish Society of Clinical Chemistry and Molecular Pathology (SEQC). The quality of evidence and the level of recommendation were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: The basic renal work-up should include measurements of serum creatinine, estimated glomerular filtration rate by CKD-EPI, Urine protein-to-creatinine ratio, and urinary sediment. Tubular function tests should include determination of serum phosphate levels and urine dipstick for glucosuria. In the absence of abnormal values, renal screening should be performed annually. In patients treated with tenofovir or with risk factors for chronic kidney disease (CKD), more frequent renal screening is recommended. In order to prevent disease progression, potentially nephrotoxic antiretroviral drugs are not recommended in patients with CKD or risk factors for CKD. The document advises on the optimal time for referral of a patient to the nephrologist and provides indications for renal biopsy. The indications for and evaluation and management of dialysis and renal transplantation are also addressed. CONCLUSIONS: Renal function should be monitored in all HIV-infected patients. The information provided in this document should enable clinicians to optimize the evaluation and management of HIV-infected patients with renal disease.(AU)

Latex allergy in primary care providers.

BACKGROUND: Health care workers represent one of the major risk groups for developing latex allergy. Most studies have examined hospital workers. The aims of this study were to analyze the prevalence of latex allergy in primary care providers and to describe the characteristics of health care workers who are allergic to latex. MATERIAL AND METHODS: A self-administered questionnaire on work activity, history of symptoms, and allergic reactions to latex products was completed by a sample of primary care workers. Skin prick tests were performed with a commercial latex extract, and serum specific immunoglobulin (Ig) E to latex and its main allergens was determined. RESULTS: Of the 620 workers contacted, 341 completed the questionnaire and 170 were tested with latex allergens. The prevalence of latex allergy was 5.9% (95% confidence interval 2.4%-9.4%). Most allergic workers with a previous diagnosis of latex allergy showed negative or lowered specific IgE levels and a reduced wheal size to latex in comparison with the previous tests. We found 3 cases with elevated latex-specific IgE due to cross-reactivity with pollen profilin, although the results were not clinically relevant. Allergy to latex was associated with the number of surgical interventions and with allergy to kiwi, banana, chestnuts, and avocado. CONCLUSIONS: The prevalence of latex allergy in this study was 5.9%. The importance of a firm diagnosis at the onset of symptoms should be stressed, since reducing contact with latex can yield negative test results. Assessment of IgE reactivity to the individual latex allergens (component-resolved diagnosis) can detect sensitization to panallergens such as profilin and help to clarify the diagnosis.

[Temporal evolution of renal involvement in a necropsy study of HIV patients from the pre and HAART eras]. / Evolución temporal de la afectación renal en una serie necrópsica de pacientes VIH de las eras pre y TARGA.

BACKGROUND: The aim of the present study is to analyze the impact of high activity antiretroviral therapy (HAART) on renal lesions observed in autopsies of HIV patients. SUBJECTS AND METHODS: Clinical records and renal pathologic samples from 100 HIV patients, who had died between 1984 and 2006, were reviewed, 61 before 1997 (group I) and 39 after. 24 of them had not received HAART (group II) and 15 had (group III). Premortem clinical and analytical data were obtained. Renal samples were stained with hematoxilin-eosin, PAS, Masson trichrome and silver-methenamine. The final pathologic diagnosis was recorded along with the findings at glomerular, tubular and interstitial levels. HIVAN was defined as the presence of focal or segmental glomerulosclerosis with glomerular collapse and microcystic tubulo -interstitial lesions. RESULTS: The main causes of death were infections 68%, tumours 14%, and others 18%, especially liver diseases. Renal failure was present in 42% at the time of death. A predominance of tubular lesions exists in the three study groups, followed by interstitial lesions and glomerular lesions. The main diagnoses were acute tubular necrosis (ATN) and septic nephritis. Four cases of HIVAN were found. When the subjects who received HAART treatment were compared with those who did not, a significantly higher percentage of interstitial lesions in the group with HAART was observed. There were also more cases of acute tubular necrosis but these differences were not statistically significant. CONCLUSIONS: Renal lesions were frequent in HIV patients independent of the presence or absence of HAART.

The relationship between antiretroviral prescription patterns and treatment guidelines in treatment-naïve HIV-1-infected patients.

BACKGROUND: Reports have shown that the publication of practice guidelines does not guarantee their use in clinical practice. The objective of this study was to evaluate the agreement between antiretroviral treatments (ARTs) prescribed in clinical practice and the recommendations in published guidelines. METHODS: A retrospective cohort study was carried out in ART-naïve adults of the Spanish Asociacion Medica Vach de Estudios Multicentricos (VACH) Cohort for the period from 2003 to 2006. RESULTS: A total of 945 patients initiated ART. Of these patients, 12.3% had a CD4 cell count above 350 cells/microL. A 'nonrecommended' antiretroviral regimen was prescribed to 5.3, 5.1 and 7.8% of patients with CD4 counts <200, 200-350 and >350 cells/microL, respectively. Multivariate analyses demonstrated that only a higher viral load was associated with the selection of a combination treatment that was recommended by the guidelines. CONCLUSIONS: Most patients were prescribed initial treatments in agreement with the recommendations. Appropriate routine data collection in databases can be used to evaluate the level of antiretroviral guideline compliance. We propose that routine evaluations of the guidelines must be part of quality assessment to improve medical care.

Targeting only reverse transcriptase with zidovudine/lamivudine/abacavir plus tenofovir in HIV-1-infected patients with multidrug-resistant virus: a multicentre pilot study.

OBJECTIVES: To evaluate the safety, immunological outcome and HIV-1 evolution in the reverse transcriptase (RT) in patients with multidrug resistance receiving zidovudine/lamivudine/abacavir (TZV) plus tenofovir (TDF). METHODS: Pilot analysis of highly experienced patients (n=28), with > or =1 thymidine-associated mutation (TAM) and the M184V mutation. RESULTS: Median of 8.5 treatment regimens, 58% Centers for Disease Control stage C. Baseline (nadir) CD4 count 363 (112) cells/microL. There was a sustained 24-week drop in viral load (VL) of 0.71 HIV-1 RNA copies/mL (P<0.001), with 35.7% (10/28) achieving a VL of <50 copies/mL. The median 24-week decrease in CD4 was -53 cells/microL and only-17 cells/microL when baseline CD4 was <350 cells/microL. There was no evolution in RT mutations, TAMs, accessory mutations or K65R. No clinical progression and one out of 28 suspected abacavir Hypersensitivity Reaction (HSR). Lower probability of achieving VL<400 copies/mL was associated with D67N (P=0.007), D67N/M41L (P=0.01), > or =3 TAMs (P=0.07) and VL>10 000 copies/mL (P=0.01). Mutations conferring zidovudine hypersusceptibility (Y181C, K65R and L74V) did not improve virological or immunological outcomes. Better CD4 outcomes were seen in patients without M41L (P=0.04) or with baseline VL<10,000 copies/mL (P=0.01). CONCLUSIONS: A bridging regimen with TZV+TDF prevents significant immunological decline and may forestall viral evolution in HIV-1 RT despite persistent viral replication.

Recommendations from SPNS/GEAM/SENBA/SENPE/AEDN/SEDCA/GESIDA on nutrition in the HIV-infected patient.

OBJECTIVE: to make recommendations on the approach to nutritional problems (malnutrition, cachexia, micronutrient deficiency, obesity, lipodystrophy) affecting HIV-infected patients. METHODS: these recommendations have been agreed upon by a group of expertes in the nutrition and care of HIV-infected patients, on behalf of the different groups involved in drafting them. Therefore, the latest advances in pathophysiology, epidemiology, and clinical care presented in studies published in medical journals or at scientific meetings were evaluated. RESULTS: there is no single method of evaluating nutrition, and diferent techniques--CT, MRI, and DXA--must be combined. The energy requirements of symptomatic patients increase by 20-30%. There is no evidence to support the increase in protein or fat intake. Micronutrient supplementation in only necessary in special circumstances (vitamin A in children and pregnant woman). Aerobic and resistance excercise is beneficial both for cardiovascular health and for improving lean mass and muscular strength. It is important to follow the rules of food safety at every stage in the chain. Therapeutic intervention in anorexia and cachexia must be tailored, by combining nutritional and pharmacological support (appetite stimulants, anabolic steroids, and, in some cases, testosterone). Artificial nutrition (oral supplementation, enteral or parenteral nutrition) is safe and efficacious, and improves nutritional status and response to therapy. In children, nutritional recommendations must be made early, and are a necessary component of therapy. CONCLUSION: appropriate nutritional evaluation and relevant therapeutic action are an essential part of the care of HIV-infected patients.

Cervical lipomatosis in HIV-infected patients: a case-control study.

OBJECTIVES: The aim of the study was to analyse the prevalence of cervical lipomatosis (CL) in HIV-infected patients on highly active antiretroviral therapy (HAART) and the factors associated with its development. METHODS: This was a multicentre, observational, 1:1 case-control study. HIV-infected patients with CL (cases) and HIV-infected patients from the same cohort, controlled for age (+/-5 years), sex and body mass index (+/-2.5 kg/m(2)) (controls), were included in the study, and a multiple conditional logistic regression was performed to identify factors related to CL. RESULTS: CL was reported in 80 patients (1.8%) from a cohort of 4214 patients on HAART followed up in 10 Spanish hospitals. CL was associated with time of exposure to stavudine [for each 6-month increase, odds ratio (OR) 5.82, 95% confidence interval (CI) 5.70-5.94, P=0.0073] and lipoatrophy (OR 8.04, 95% CI 2.93-22.02, P=0.00001). CONCLUSIONS: Although lipodystrophy is very frequent among HIV-infected patients on HAART, CL is an uncommon type of fat redistribution in this population, and in our cohort it was related to time of exposure to stavudine and lipoatrophy.

Aneurisma micótico de carótida y estenosis carotídea contralateral / Mycotic aneurysm of the carotid artery and contralateral carotid stenosis

Introducción. Los aneurismas micóticos (AM) de la carótida extracraneal son una patología muy infrecuente. Suelen manifestarse como una masa pulsátil cervical, asociada a fenómenos inflamatorios locales y síntomas generales, que requiere un diagnóstico precoz y un tratamiento agresivo. Caso clínico. Mujer de 75 años de edad, con síndrome febril de larga evolución, en cuya exploración física destaca un soplo carotídeo bilateral y una masa pulsátil cervical derecha. El eco-Doppler revela la presencia de un aneurisma de carótida común derecha (CCD) y estenosis grave de carótida interna contralateral. Se confirma el diagnóstico con tomografía computarizada (TC), resonancia magnética (RM), angiografía, escintigrafía y hemocultivos (Salmonella enteritidis). Con la sospecha de AM de carótida, se plantea la intervención en un solo tiempo bajo anestesia regional cervical; se realiza primero una endarterectomía carotídea izquierda y posteriormente ligadura, exclusión y drenaje del AM de la CCD; evoluciona favorablemente y sin complicaciones neurológicas, con un control clínico de cuatro años. Conclusión. El AM de carótida debe tratarse quirúrgicamente. Decidimos la corrección en un tiempo, teniendo en cuenta el riesgo quirúrgico, apoyándonos en la monitorización peroperatoria proporcionada por la anestesia regional cervical con paciente vigil. Las características locales no permitieron la reconstrucción de la continuidad del eje carotídeo derecho

Introduction. Mycotic aneurysms (MA) of the extracranial carotid artery are a very rare pathological condition. They usually appear as a pulsatile mass in the neck, associated with local inflammatory phenomena and general symptoms, which require an early diagnosis and aggressive treatment. Case report. We report the case of a 75-year-oldfemale patient with a long history of a feverish syndrome; the physical exploration revealed a bilateral carotid bruit and a pulsatile mass on the right side of the neck. Doppler ultrasound showed the presence of an aneurysm in the right common carotid artery (RCC) and severe stenosis of the contralateral internal carotid. The diagnosis was confirmed bymeans of computerised tomography (CT), magnetic resonance (MR), angiography, scintigraphy and blood cultures(Salmonella enteritidis). In accordance with the presumptive diagnosis of MA of the carotid artery, a one-time surgical intervention under cervical regional anaesthesia was chosen as treatment. First, a left-side carotid endarterectomy was carried out and this was followed by ligature, exclusion and drainage of the MA of the RCC. The patient progressed favourably with no neurological complications, as seen in a clinical control at four years after the intervention. Conclusions. MA of the carotid artery must be treated surgically. We decided to carry out the correction in a single intervention, bearing in mind the surgical risk, with the support of the peroperative monitoring afforded by the cervical regional anaesthesia with the patient in a waking state. Local features did not allow the reconstruction of the continuation of the right carotid axis. This is the tenth case reported in the literature

Response to liposomal doxorubicin and clinical outcome of HIV-1-infected patients with Kaposi's sarcoma receiving highly active antiretroviral therapy.

PURPOSE: HIV-associated Kaposi's sarcoma (KS) may not resolve despite highly active antiretroviral therapy (HAART). Moreover, the therapeutic goal has shifted from palliative care to long-term durable complete remission. The objective of the study was to assess the impact of liposomal doxorubicin in the treatment of HIV-associated KS in the HAART era. METHOD: In this prospective, noncomparative, multicenter study, patients with more than 10 cutaneous lesions or visceral disease were treated with 20 mg/m(2) of liposomal doxorubicin (Caelyx) every 3 weeks in addition to their antiretroviral therapy. In addition to tumor measurements and laboratory tests, human herpes virus 8 (HHV-8) polymerase chain reaction (PCR) in peripheral blood mononuclear cells (PBMC) was performed. RESULTS: Out of 79 participants enrolled in the study, 47 (59%) had stage T(1), 41 (52%) I(1), and 32 (40%) S(1). Nine individuals were not evaluable for response, 32 (40%) had complete response, 30 (38%) partial response, 5 (6%) stable disease, and 3 (4%) progression. Regression analysis did not find any statistically significant factor predicting response. HHV-8 PCR was positive in 37/53 (70%) patients with available PBMC samples, and HHV-8 viremia cleared in 14/27 (52%) without correlation with clinical response. Eleven (14%) participants experienced a relapse of KS, while at the last update of data, 49 (62%) remained stable. The only risk factor for recurrence identified was the follow-up time (odds ratio [OR] 1.21, 95% CI 1.07-1.36; p =.002). CONCLUSION: The response rate of AIDS-associated KS to liposomal doxorubicin administered with HAART was high, and most often the response was durable. HHV-8 viremia did not correlate well with clinical outcome.

[Effectiveness of preventive activities at 8 years of their introduction in a general medicine practice in a health center]. / Efectividad de las actividades preventivas a los 8 años de su introducción en una consulta de medicina general de un centro de salud.

OBJECTIVES: Main: to assess the change in coronary risk (CR) in adults after 8 years of their involvement in the Programme of Preventive Activities and Health Promotion (PAPPS). Secondary: to determine the level of anti-tetanus vaccination reached and patients' compliance with activities. DESIGN: "Before and after" intervention study without random allocation. SETTING: A general medical clinic at a health centre. PATIENTS: 429 patients (204 men, 225 women) between 30 and 65 monitored for 8 years, recruited by active search for cases at daily consultations. INTERVENTIONS: Blood pressure, cholesterol, weight, tobacco habit, alcohol intake, anti-tetanus vaccination state, CR calculation at 10 years on the Framingham scale, and degree of compliance with activities were all determined at the start, at 4 years and at 8 years. Data was obtained from the clinical notes. RESULTS: Total population: a 0.8 drop in CR (CI difference: 0.4-1.2), equivalent to 8.5% of the initial figure. 64.4% increase in correct anti-tetanus vaccination (CI difference: 59.9-69). Compliance with activities at the start and after eight years: pressure 100%, 71%; tobacco consumption 99.5%, 71%; cholesterol determination 89%, 64%. Initially high CR sub-group: 6.7 drop of CR at 8 years (CI difference: 4.9-8.5), equivalent to 24.8% of the initial figure. CONCLUSIONS: In the total population, the CR drop found was not clinically significant, whereas in the initially high CR sub-group the drop was. There should probably be an active search made for patients with high CR and action taken on them.

Efectividad de las actividades preventivas a los 8 años de su introducción en una consulta de medicina general de un centro de salud / Effectiveness of preventive activities eight years after their introduction at a general medical clinic in a health centre

Objetivo. Principal: valorar la modificación del riesgo coronario (RC) en pacientes adultos tras 8 años de su incorporación al Programa Actividades Preventivas y Promoción Salud (PAPPS).Secundario: determinar nivel de vacunación antitetánica alcanzado y cumplimiento de actividades. Diseño. Estudio de intervención sin asignación aleatoria 'antes-después'. Emplazamiento. Una consulta de medicina general de un centro de salud. Pacientes. Un total de 429 pacientes (204 varones, 225 mujeres) de 30-65 años seguidos durante 8 años, captados por búsqueda activa de casos en la consulta diaria. Intervenciones. Determinación de tensión arterial, colesterol, peso, tabaquismo, ingesta etílica, estado vacunal antitetánico, cálculo del RC a los 10 años según Framinghan y grado de cumplimiento de actividades. Estas variables se determinaron al inicio, a los 4 y a los 8 años. Datos obtenidos de la historia clínica. Resultados. Población total: a los 8 años descenso del RC, 0,8 (IC diferencia, 0,4-1,2), equivalente al 8,5 por ciento del inicial. Incremento obtenido de la vacunación antitetánica correcta del 64,4 por ciento (IC diferencia, 59,9-69 por ciento). Cumplimiento actividades al inicio y al octavo año: tensión, 100 por ciento, 71 por ciento; consumo tabaco, 99,5 por ciento, 71 por ciento; determinación colesterol, 89 por ciento, 64 por ciento. Subgrupo RC inicial alto: a los 8 años descenso del RC, 6,7 (IC diferencia, 4,9-8,5), equivalente al 24,8 por ciento del inicial. Conclusiones. En la población total el descenso del RC obtenido no es clínicamente significativo, mientras que en el subgrupo con RC inicial alto el descenso sí lo ha sido. Probablemente debería hacerse búsqueda activa de los pacientes con RC alto y actuar sobre ellos (AU)

Ambulatory blood pressure during diseases of the kidney.

During the last few years there has been a renewal of interest in blood-pressure-induced kidney damage due to a progressive increase in the incidence and prevalence of hypertension and vascular diseases as a cause of end-stage renal disease (ESRD). The need to prevent ESRD demands a continuation of effort to make the early identification of hypertensives who are at risk possible and to provide them with effective antihypertensive therapy. Since ambulatory blood pressure monitoring has been used successfully to assess blood pressure and identify risk markers for cardiovascular diseases, a logical approach would be to use it also to identify the risk markers for ESRD. Higher than normal percentages of non-dippers have been found among subjects with renal failure, during dialysis (haemofiltration, peritoneal dialysis and continuous ambulatory peritoneal dialysis), among cases of renovascular hypertension or cystic kidney disease and among cases of renal transplantation. Although this non-dipping pattern might be related to the presence of severe hypertension in some patients, such as those who have renovascular hypertension, in other cases the abnormal circadian variability is present with milder forms of hypertension or even in the absence of hypertension. Monitoring ambulatory blood pressure could offer advantages for protection of renal function during antihypertensive treatment of subjects with mild renal insufficiency. Furthermore, ambulatory blood pressure monitoring seems to have been prognostic for the development of proteinuria in a group of refractory hypertensives. Whether higher than normal nocturnal blood pressures and the non-dipping pattern are causes or consequences of renal disease should be addressed in prospective studies. The above notwithstanding, assessment of nocturnal blood pressure seems to be an important aid in the management of patients with hypertension-related renal disease and of patients who are susceptible to developing it.

Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain.

The cases of nine patients with ununited fracture of the posterior process of the talus were reviewed. The most common mechanism of injury was forced plantarflexion. All patients had pain in the posterior ankle region. Common physical findings included tenderness between the lateral malleolus and the Achilles tendon and pain on forced plantarflexion. Of the radiographic imaging modalities used, 99Tc bone scan was found to be the most helpful in diagnosis. All nine patients eventually underwent surgical excision at a mean period of 9.4 months post injury. At average follow-up of 27 months after surgery (range 7-69 months), six of nine patients had good or excellent results with respect to pain relief and return to function. There were two complications of sural neuroma formation, one of which resulted in severe persistent pain after surgery. Based on these findings, we believe the differential diagnosis of chronic posttraumatic ankle pain should include fracture of the posterior process of the talus. Furthermore, excision of an ununited fragment through a lateral approach, taking care to preserve and protect the sural nerve, should lead to the return of painless function in the majority of cases.

Triple arthrodesis in young children: a salvage procedure after failed releases in severely affected feet.

A total of 19 triple arthrodeses were performed in 13 children aged 10 years or less for severe hindfoot deformities after failure of soft tissue releases. This was considered a salvage procedure and an alternative to talectomy. The average age at surgery was 8.4 years and average follow-up was 4 years. There were 68% excellent and good results, 16% fair, and 16% poor results. The nonunion rate was 7% of joints. Average shortening of the foot was 0.81 in but was not significant when compared with a group of clubfoot control patients. Except for one infection, fair and poor results were due to residual rather than recurrent deformity. Triple arthrodesis may be indicated in the young child for residual hindfoot deformity as an alternative to talectomy. The potential problems of increased nonunion, severe compromise of foot length, and recurrence of deformity were not observed in this series.

Atlantal fracture in a child through congenital anterior and posterior arch defects. A case report.

A five-year-old boy sustained a vertical compression injury to the occiput, initial findings were consistent with a cervical spine injury. Evaluation, including plain films, tomograms, and CT scanning, confirmed a C1 fracture through congenital anterior and posterior arch defects. Flexion and extension tomograms showed this rare lesion to be stable, and no surgical intervention was required. Because congenital anomalies of the cervical spine can be confused with traumatic lesions, thorough evaluation is warranted. Treatment should be based on signs of instability, if present.