ABSTRACT
To determine the value of low-risk human papillomavirus (HPV) PCR to screen for "high-grade anal squamous intraepithelial lesion and anal cancer" (HSIL-plus), rate of patients with low-grade anal squamous intraepithelial lesion (LSIL) progressing to HSIL-plus, and progression-related factors. Prospective, longitudinal study of consecutive MSM-LHIV attended between May 2010 and December 2021 and followed for 43 months (IQR: 12-76). HIV-related variables were gathered at baseline, performing anal cytology for HPV detection/genotyping, thin-layer cytological study, and high-resolution anoscopy (HRA). Follow-up was annual when HRA was normal or LSIL, and post-treatment in cases of HSIL-plus, re-evaluating sexual behavior, viral-immunological status, and HPV infection of anal mucosa. The 493 participants had mean age of 36 years: CD4 nadir < 200 cells/uL in 23.1%, virological failure in 4.1%, and tetravalent HPV vaccine > 5 years earlier in 15%. HSIL-plus was ruled out in patients with monoinfection by low-risk HPV genotype and normal cytology (100% sensitivity, 91.9% specificity, PPV 2.9%, and NPV 100%). Progression from LISL to HSIL-plus occurred in 4.27% of patients within 12 months (IQR: 12-12): risk factors were acquisition of high-risk (HR: 4.15; 95% CI: 1.14-15.03) and low-risk (HR: 3.68 95% CI: 1.04-12.94) HPV genotypes, specifically genotype 6 (HR: 4.47, 95% CI: 1.34-14.91), and history of AIDS (HR: 5.81 95% CI: 1.78-18.92). Monoinfection by LR-HPV genotypes in patients with normal cytology is not associated with anal cancer or precursor lesions. Progression from LSIL to HSIL-plus, observed in <5% of patients, was related to acquisition of HR and LR HPV genotypes, especially 6, and a history of AIDS.
Subject(s)
Acquired Immunodeficiency Syndrome , Anus Neoplasms , HIV Infections , Papillomavirus Infections , Sexual and Gender Minorities , Squamous Intraepithelial Lesions , Male , Humans , Adult , Homosexuality, Male , Papillomavirus Infections/complications , Papillomavirus Infections/diagnosis , Prospective Studies , Acquired Immunodeficiency Syndrome/complications , Longitudinal Studies , HIV Infections/complications , Early Detection of Cancer , Sexual Behavior , Anus Neoplasms/diagnosis , Risk Factors , Papillomaviridae/genetics , Squamous Intraepithelial Lesions/complications , Polymerase Chain ReactionABSTRACT
BACKGROUND: The objective of this study in MSM living with HIV was to determine the incidence of HSIL and ASCC, related factors, and the response to treatment. PATIENTS AND METHODS: Data were gathered in 405 consecutive HIV-infected MSM (May 2010-December 2018) at baseline and annually on: sexual behavior, anal cytology, and HPV PCR and/or high-resolution anoscopy results. They could choose mucosectomy with electric scalpel (from May 2010) or self-administration of 5% imiquimod 3 times weekly for 16 weeks (from November 2013). A multivariate logistic regression model was developed for ≥HSIL-related factors using a step-wise approach to select variables, with a significance level of 0.05 for entry and 0.10 for exit, applying the Hosmer-Lemeshow test to assess the goodness of fit. RESULTS: The study included 405 patients with a mean age of 36.2 years; 56.7% had bachelor´s degree, and 52.8% were smokers. They had a mean of 1 (IQR 1-7) sexual partner in the previous 12 months, median time since HIV diagnosis of 2 years, and mean CD4 nadir of 367.9 cells/uL; 86.7% were receiving ART, the mean CD4 level was 689.6 cells/uL, mean CD4/CD8 ratio was 0.77, and 85.9% of patients were undetectable. Incidence rates were 30.86/1,000 patient-years for ≥high squamous intraepithelial lesion (HSIL) and 81.22/100,000 for anal squamous cell carcinoma (ASCC). The ≥HSIL incidence significantly decreased from 42.9% (9/21) in 2010 to 4.1% (10/254) in 2018 (p = 0.034). ≥HSIL risk factors were infection with HPV 11 (OR 3.81; 95%CI 1.76-8.24), HPV 16 (OR 2.69, 95%CI 1.22-5.99), HPV 18 (OR 2.73, 95%CI 1.01-7.36), HPV 53 (OR 2.97, 95%CI 1.002-8.79); HPV 61 (OR 11.88, 95%CI 3.67-38.53); HPV 68 (OR 2.44, CI 95% 1.03-5.8); low CD4 nadir (OR1.002; 95%CI 1-1.004) and history of AIDS (OR 2.373, CI 95% 1.009-5.577). Among HSIL-positive patients, the response rate was higher after imiquimod than after surgical excision (96.7% vs 73.3%, p = 0.009) and there were fewer re-treatments (2.7% vs 23.4%, p = 0.02) and adverse events (2.7% vs 100%, p = 0.046); none developed ASCC. CONCLUSIONS: HSIL screening and treatment programs reduce the incidence of HSIL, which is related to chronic HPV infection and poor immunological status. Self-administration of 5% imiquimod as first-line treatment of HSIL is more effective than surgery in HIV+ MSM.
Subject(s)
Anti-HIV Agents/therapeutic use , HIV Infections/drug therapy , HIV Infections/surgery , Homosexuality, Male/statistics & numerical data , Squamous Intraepithelial Lesions/complications , Squamous Intraepithelial Lesions/pathology , Administration, Topical , Adult , Anti-HIV Agents/administration & dosage , Anus Neoplasms/complications , Anus Neoplasms/pathology , Cohort Studies , Female , HIV Infections/complications , Humans , Male , Middle Aged , Neoplasm Grading , Risk FactorsABSTRACT
No disponible
Subject(s)
Humans , Male , Middle Aged , Necrobiosis Lipoidica/diagnosis , Leg Dermatoses/etiology , Adrenal Cortex Hormones/therapeutic use , Diagnosis, DifferentialSubject(s)
Necrobiosis Lipoidica/diagnosis , Humans , Male , Middle Aged , Necrobiosis Lipoidica/pathologyABSTRACT
Diversos estudios muestran la baja utilización de los diagnósticos de enfermería en el primer nivel de atención sanitaria. Se realizó un estudio cualitativo mediante una técnica de grupo de discusión, cuyo objetivo fue conocer la opinión de las enfermeras del área sanitaria de A Coruña sobre las causas de la baja utilización de los diagnósticos de enfermería (DdE) en atención primaria. Se hicieron 2 grupos, uno formado por ex alumnos de la Escuela Universitaria de Enfermería Juan Canalejo, titulados durante los cursos 1999/2000 y 2000/2001, que habían realizado sus prácticas clínicas en distintos centros de salud, y otro compuesto por enfermeras de atención primaria que desempeñaban su actividad en diferentes centros de salud, con distintas formación pregrado y vinculación laboral. Las opiniones identificadas, mediante análisis de contenido, se clasificaron según las características de los participantes (ex alumnos, profesionales) y según 3 aspectos: utilización de los DdE, factores que influyen en la no utilización y estrategias para su implantación. Resultados. La opinión de ambos grupos fue que los DdE no son de uso habitual. Los ex alumnos pusieron de manifiesto los siguientes factores que influyen en la no utilización: algunos profesionales los consideran innecesarios, complejidad de la estructura y vocabulario, falta de formación, deficiencia de recursos e interés personal del profesional. Los profesionales establecieron los siguientes factores: el modelo médico hegemónico, recursos humanos insuficientes, inmovilismo y falta de motivación, convivencia de distintos modelos de atención, heterogeneidad de los profesionales, incertidumbre en la efectividad de los DdE en la mejora de la salud de la población. Ambos grupos opinaban que la obligación o imposición "con o sin formación" sería la estrategia más adecuada para la implantación de los DdE. Discusión. La falta de conocimientos no aparece como la causa principal de la no utilización de los DdE entre los profesionales, cuando sí lo era en estudios previos. La metodología cualitativa permite identificar los factores relacionados con la no utilización de los DdE, no puestos de manifiesto hasta el momento, así como sugerir las vías para su implantación (AU)
