Prevalence of aphthous stomatitis in patients with inflammatory bowel disease after the treatment with monoclonal antibodies: a systematic review and meta-analysis.

BACKGROUND: Currently, the most frequently employed therapies in the treatment of inflammatory bowel diseases (IBD), i.e., Crohn's Disease (CD), Ulcerative Colitis (UC) or unclassified IBD (IBD-U) are monoclonal anti-TNFs and anti-integrin therapies, such as vedolizumab (VDZ). Forty-seven per cent of these patients present extra-intestinal manifestations, the second most prevalent being aphthous stomatitis (AS). The present study aims to investigate which of the two therapies is associated with a lower prevalence of AS after treatment. MATERIAL AND METHODS: An electronic search of the MEDLINE (via PubMed), Web of Science, SCOPUS, LILACS and OpenGrey databases was carried out. The criteria used were those described by the PRISMA Statement. The search was not temporarily restricted and was updated to January 2022. The quality assessment was analyzed using the JBI Prevalence Critical Appraisal Tool. RESULTS: After searching, 7 studies were included that met the established criteria. Of these, 6 analysed the prevalence of AS in CD patients and 4 in UC. A total of 1,744 patients were analysed (CD=1,477 patients; 84.69%; UC=267; 15.31%). The greatest reduction in AS prevalence was observed after anti-TNF therapy. The effect of these therapies on the prevalence of AS in patients with IBD-U could not be determined. CONCLUSIONS: Both biologic therapies achieve a reduction in the prevalence of AS in IBD patients (CD and UC). However, the best results were obtained in patients treated with anti-TNFs, possibly because VDZ is often used in patients who do not respond adequately to previous treatment with anti-TNFs and because of its intestinal specificity.

Primary resistance to integrase strand transfer inhibitors in Spain using ultrasensitive HIV-1 genotyping.

BACKGROUND: Transmission of resistance mutations to integrase strand transfer inhibitors (INSTIs) in HIV-infected patients may compromise the efficacy of first-line antiretroviral regimens currently recommended worldwide. Continued surveillance of transmitted drug resistance (TDR) is thus warranted. OBJECTIVES: We evaluated the rates and effects on virological outcomes of TDR in a 96 week prospective multicentre cohort study of ART-naive HIV-1-infected subjects initiating INSTI-based ART in Spain between April 2015 and December 2016. METHODS: Pre-ART plasma samples were genotyped for integrase, protease and reverse transcriptase resistance using Sanger population sequencing or MiSeq™ using a ≥ 20% mutant sensitivity cut-off. Those present at 1%-19% of the virus population were considered to be low-frequency variants. RESULTS: From a total of 214 available samples, 173 (80.8%), 210 (98.1%) and 214 (100.0%) were successfully amplified for integrase, reverse transcriptase and protease genes, respectively. Using a Sanger-like cut-off, the overall prevalence of any TDR, INSTI-, NRTI-, NNRTI- and protease inhibitor (PI)-associated mutations was 13.1%, 1.7%, 3.8%, 7.1% and 0.9%, respectively. Only three (1.7%) subjects had INSTI TDR (R263K, E138K and G163R), while minority variants with integrase TDR were detected in 9.6% of subjects. There were no virological failures during 96 weeks of follow-up in subjects harbouring TDR as majority variants. CONCLUSIONS: Transmitted INSTI resistance remains rare in Spain and, to date, is not associated with virological failure to first-line INSTI-based regimens.

Approximate confidence intervals for the likelihood ratios of a binary diagnostic test in the presence of partial disease verification.

The classic parameters used to assess the accuracy of a binary diagnostic test (BDT) are sensitivity and specificity. Other parameters used to describe the performance of a BDT are likelihood ratios (LRs). The LRs depend on the sensitivity and the specificity of the diagnostic test, and they reflect how much greater the probability of a positive or negative diagnostic test result for individuals with the disease than that for the individuals without the disease. In this study, several confidence intervals are studied for the LRs of a BDT in the presence of missing data. Two confidence intervals were studied through the method of maximum likelihood and seven confidence intervals were studied by applying the multiple imputation by chained equations method. A program in R software has been written that allows us to solve the estimation problem posed. The results obtained have been applied to the two real examples.

Reflexiones sobre la actualización PAPPS cardiovascular 2005. Réplica / Reflections on the updating of 2005 cardiovascular PAPPS. Reply

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Actualización en Medicina de Familia. Tratamiento de la hipertensión arterial en los diabéticos: una revisión crítica / Up-date In Family Medicine. Treatment of arterial hypertension in diabetics: a critical review

En este artículo se revisan las evidencias que sustentan las recomendaciones de los consensos con relación al tratamiento de la hipertensión arterial en los diabéticos, en concreto, la diabetes como equivalente de riesgo coronario, los objetivos terapéuticos fijados en 130/80 mmHg y el lugar de las tiazidas, inhibidores de la enzima de conversión de la angiotensina y antagonistas de los receptores de la angiotensina II como fármacos de elección. Hoy parece claro que no todos los diabéticos son iguales. La apresurada consideración de la diabetes como "equivalente de riesgo coronario" por parte de consensos influyentes no se justifica en función del conjunto de las evidencias disponibles. Tampoco las evidencias justifican de modo inequívoco el objetivo de situar la presión arterial (PA) en los diabéticos por debajo de 130/80 mmHg. Más aún, los consensos que defienden esta recomendación la consideran un objetivo flexible y de aplicación individualizada. Respecto al tratamiento de elección de la hipertensión arterial (HTA) en los diabéticos, no existen evidencias que apoyen el uso preferente de inhibidores de la enzima de conversión de la angiotensina (IECA) o de antagonistas de los receptores de la angiotensina II (ARA II). De hecho sólo la American Diabetes Association entre los principales consensos defiende, de modo indirecto, esta actitud. IECA y ARA II no han demostrado una clara superioridad global en la prevención cardiovascular frente a otros antihipertensivos. Tampoco han demostrado cardioprotección específica. Los efectos antiproteinúricos de estos fármacos no justifican por sí mismos su uso preferencial en diabetes al medirse con un conjunto de variables subrogadas sin clara significación clínica. IECA y ARA II sólo han demostrado eficacia en la reducción de complicaciones diabéticas renales duras en pacientes con nefropatía diabética severa (albuminuria superior a 3 g/día) e insuficiencia renal (o al borde). El que la asociación tiazida-IECA sea una opción adecuada para muchos de los pacientes hipertensos y diabéticos no implica que todo diabético deba ser tratado con dos o más fármacos ni que sea preferible utilizar un inhibidor del sistema renina-angiotensina. Tiazidas, como admite y aconseja la Organización Mundial de la Salud y el VII informe del Joint National Commitee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, pueden utilizarse, igual que en la población general, en monoterapia en el tratamiento inicial de los diabéticos

The evidence that supports the consensus recommendations in regards to arterial hypertension treatment in diabetics, specifically, diabetes as equivalent to coronary risk, the therapeutic objectives established at 130/80 mmHg and the place of thiazides, angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists as drugs of choice is reviewed. It presently seems to be clearer that not all diabetics are the same. The hasty consideration of diabetes as "equivalent to coronary risk" by influential consensuses is not justified based on all the evidence available. The evidence also does not unmistakably justify the objective of placing blood pressure in diabetics below 130/80 mmHg. Even more, consensuses that defend this recommendation consider it a flexible objective to be individually applied. Regarding the treatment of choice of HBP in diabetics, there is no evidence that shows the preferential use of ACEI or ARA II. In fact, only ADA among the principal consensuses indirectly defends this attitude. ACEI and ARA II have not shown a clear or global superiority in the cardiovascular prevention versus other antihypertensive agents. It also has not demonstrated specific cardioprotection. The antiproteinuric effects of these drugs do not justify by themselves their preferential use in diabetes when measured with a group of subrogated variables without clear clinical significance. ACEI and ARA II have only demonstrated efficacy in the reduction of strong renal diabetic complications in patients with severe diabetic nephropathy (albuminuria greater than 3 g/day) and renal failure (or close to it). The fact that the thiazide-ACEI association is an adequate option for many hypertensive and diabetic patients does not imply that all diabetics should be treated with 2 or more drugs or that it is preferable to use a renin-angiotensin system inhibitor. Thiazides, as has been admitted and advised by the WHO and JNC VII, can also be used, as in the general population, in single drug therapy in the initial treatment of diabetics

PAPPS cardiovascular 2005: un análisis crítico / Cardiovascular PAPPS 2005: a critical analysis

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Group A streptococcal bacteremia: outcome and prognostic factors / Bacteriemia por estreptococos del grupo A: resultados y factores pronóstico

In the last two decades, an increase in the incidence of invasive group A streptococcus (GAS) infections has been reported. The aim of this study was to determine the clinical and epidemiological characteristics and the natural history of GAS bacteremias at our hospital by performing a retrospective study of all cases of GAS bacteremia diagnosed at our University hospital from 1994 to 2003. We reported 42 cases of GAS bacteremia (27 men, mean age 42.3 ± 31.6 years). None had more than one episode and four cases were nosocomial. The mean annual incidence rate was 1.01 cases per 100,000 population. An increase in the incidence but not in severity of GAS bacteremia was observed in the last 5-year period (p<0.001). The rates were highest in young children and the elderly and those with underlying medical conditions; 73.8% of patients had some underlying chronic illness, and the most relevant conditions included peripheral vascular disease and diabetes mellitus. Mortality was high and the worst outcome corresponded to elderly patients with streptococcal toxic shock syndrome (STSS). Thirty patients (71.4%) had a disruption in the integrity of the skin barrier, 14 (33.3%) were immunocompromised patients and 6 patients (14.3%) were intravenous drug users. A source of the bacteremia was noted in 38 patients (90.5%), with skin and soft tissue infection being the major portals of entry. Twelve patients (28.6%) fulfilled the STSS criteria. All strains were susceptible to penicillin and vancomycin. Resistance to erythromycin was 21.4% and to ciprofloxacin was 17.5%. The global mortality rate was 28.6%. Only STSS was significantly associated with increased mortality in the multivariate analysis

En las dos últimas décadas se ha descrito un aumento de la incidencia de infecciones por estreptococos del grupo A invasivos. El objetivo de este estudio fue determinar las características clínicas y epidemiológicas y la historia natural de las bacteriemias por estreptococos del grupo A en nuestro hospital. Se estudiaron retrospectivamente todos los casos diagnosticados en un solo hospital de nivel terciario entre 1994 y 2003, y describimos 42 (27 varones, edad media 42,3 ± 31,6 años). Ninguno presentó más de un episodio y cuatro fueron infecciones nosocomiales. La tasa media de incidencia anual fue de 1,01 casos por 100.000 habitantes. Se ha observado un aumento en la incidencia de bacteriemia por estreptococos del grupo A, pero no de su gravedad, durante los últimos 5 años (p <0.001). Las tasas de incidencia más altas se observaron en niños y ancianos. El 73,8% de los pacientes afectados presentaron una enfermedad crónica subyacente, siendo las más relevantes la enfermedad vascular periférica y la diabetes mellitus. Treinta pacientes (71,4%) presentaban una herida u otra alteración de la integridad de la barrera cutánea, 14 (33%) estaban inmunodeprimidos y 6 (14,3%) eran drogadictos por vía intravenosa. En 38 casos (90,5%) se registró un foco de entrada de la bacteriemia, siendo los más habituales las infecciones cutáneas y de tejidos blandos. Doce pacientes (28,6%) cumplieron los criterios de síndrome de “shock” tóxico estreptocócico. Todas las cepas fueron sensibles a la penicilina y la vancomicina. La resistencia a la eritromicina fue del 21,4% y al ciprofloxacino del 17,5%. La tasa global de mortalidad fue del 28,6%. En el análisis multivariado, sólo el “shock” tóxico estreptocócico se asoció significativamente a una mayor mortalidad. Durante los últimos cinco años se ha observado un aumento en la incidencia de bacteriemia por estreptococos del grupo A en nuestro hospital. Los niños pequeños, los ancianos y los pacientes con enfermedades subyacentes son más susceptibles a adquirir esta infección. La mortalidad fue alta y los peores resultados se observaron en los pacientes ancianos con síndrome de “shock” tóxico estreptocócico

Cálculo del riesgo cardiovascular y tablas de riesgo en España. Réplica de los autores / Calculation of cardiovascular risk and risk tables in Spain. Reply of the authors

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Group A streptococcal bacteremia: outcome and prognostic factors.

In the last two decades, an increase in the incidence of invasive group A streptococcus (GAS) infections has been reported. The aim of this study was to determine the clinical and epidemiological characteristics and the natural history of GAS bacteremias at our hospital by performing a retrospective study of all cases of GAS bacteremia diagnosed at our University hospital from 1994 to 2003. We reported 42 cases of GAS bacteremia (27 men, mean age 42.3 +/- 31.6 years). None had more than one episode and four cases were nosocomial. The mean annual incidence rate was 1.01 cases per 100,000 population. An increase in the incidence but not in severity of GAS bacteremia was observed in the last 5-year period (p<0.001). The rates were highest in young children and the elderly and those with underlying medical conditions; 73.8% of patients had some underlying chronic illness, and the most relevant conditions included peripheral vascular disease and diabetes mellitus. Mortality was high and the worst outcome corresponded to elderly patients with streptococcal toxic shock syndrome (STSS). Thirty patients (71.4%) had a disruption in the integrity of the skin barrier, 14 (33.3%) were immunocompromised patients and 6 patients (14.3%) were intravenous drug users. A source of the bacteremia was noted in 38 patients (90.5%), with skin and soft tissue infection being the major portals of entry. Twelve patients (28.6%) fulfilled the STSS criteria. All strains were susceptible to penicillin and vancomycin. Resistance to erythromycin was 21.4% and to ciprofloxacin was 17.5%. The global mortality rate was 28.6%. Only STSS was significantly associated with increased mortality in the multivariate analysis.

Prevención primaria con estatinas, consensos y tablas de riesgo / Primary prevention with statins, consensus and risk tables

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[Antiphospholipid syndrome. The use of transesophageal echocardiography]. / Síndrome antifosfolípido. Utilidad de la ecocardiografía transesofágica.

Antiphospholipid syndrome (APS) is defined by the presence of arterial and venous thromboses, recurrent fetal death, cerebrovascular accidents, hemolytic anaemia, thrombocytopenia and various other manifestations in different organs. APS is a clinical entity that can appear commonly alongside systemic lupus erithemathous on it can occur as a primary disease. The syndrome is defined by the presence of antiphospholipid antibodies in serum, a group of immunoglobulins (IgG, IgM, IgA or an mixture of them) that adopt an hexagonal configuration when they are incubated at 37grades C. In APS, it is rather common to find cardiac lesions such as non-verrucous endocarditis, valvular lesions (especially of the mitral valve), microvascular cardiac disease and more risk of thrombosis at this level, myxomas that could be the cause of a systemic inflammation in relation to the production of antiphospholipid antibodies, intracardiac thrombii and congenital heart disease. We present the case of a woman with APS associated with interauricular communication whose initial diagnosis were pulmonary thromboembolism and cerebrovascular stroke. We were able to diagnose the cardiac abnormality by the use of transesophagic echocardiography. We propose the use of this imaging technique for patients with APS even though the transthoracic Doppler echocardiography was found to be normal. In this way we will be able to rule out cardiac lesions which could also be the cause of embolic manifestations.

Síndrome antifosfolípido. Utilidad de la ecocardiografía transesofágica / Antiphospholipid syndrome. The use of transesophagic echocardiography

El síndrome antifosfolípido (SAF) es una alteración inmune que produce trombosis venosas y arteriales, accidente cerebrovascular, aborto recurrente, anemia hemolítica, trombopenia y un sinfín de manifestaciones de órgano. El SAF es una entidad asociada en ocasiones al lupus eritematoso sistémico pudiendo también ser detectado sin enfermedad subyacente de base. El trastorno es debido a la presencia de unas inmunoglobulinas (IgG, IgA, IgM o una combinación de ellas) que adoptan una configuración hexagonal cuando se incuban a 37º. En el SAP es relativamente frecuente encontrar lesiones cardiacas como endocarditis no verrugosa, lesiones valvulares (especialmente de la válvula mitral), enfermedad microvascular cardiaca y mayor riesgo de trombosis a este nivel, mixomas que pueden inducir una inflamación sistémica en relación a la producción de anticuerpos antifosfolípidos , trombos intracardiacos y cardiopatias congénitas. Presentamos el caso de una mujer con SAP asociado a comunicación interauricular que había debutado anteriormente con tromboembolismo pulmonar y accidente cerebrovascular y que pudo ser diagnosticada tras examen con ecografía transesofágica. Proponemos el examen con esta técnica en pacientes con SAP aunque la ecocardiografía con doppler sea normal. Así podremos descartar lesiones cardiacas que puedan además ser causa de fenómenos embolígenos (AU)

Antiphospholipid syndrome (APS) is defined by the presence of arterial and venous thromboses, recurrent fetal death, cerebrovascular accidents, hemolytic anaemia, thrombocytopenia and various other manifestations in different organs. APS is a clinical entity that can appear commonly alongside systemic lupus erithemathous on it can occur as a primary disease. The syndrome is defined by the presence of antiphospholipid antibodies in serum, a group of immunoglobulins (IgG, IgM, IgA or an mixture of them) that adopt an hexagonal configuration when they are incubated at 37 ºC. In APS, it is rather common to find cardiac lesions such as non-verrucous endocarditis, valvular lesions (especially of the mitral valve), microvascular cardiac disease and more risk of thrombosis at this level, myxomas that could be the cause of a systemic inflammation in relation to the production of antiphospholipid antibodies, intracardiac thrombii and congenital heart disease. We present the case of a woman with APS associated with interauricular communication whose initial diagnosis were pulmonary thromboembolism and cerebrovascular stroke. We were able to diagnose the cardiac abnormality by the use of transesophagic echocardiography. We propose the use of this imaging technique for patients with APS even though the transthoracic Doppler echocardiography was found to be normal. In this way we will be able to rule out cardiac lesions which could also be the cause of embolic manifestations (AU)

Acidosis láctica asociada al uso de buformina / Lactic acidosis associated with buformine use

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Bronconeumonía bilateral y mieloma múltiple. Manifestación inicial atípica con nódulos pulmonares y lesiones cutáneas / Bilateral bronchopneumonia and multiple myeloma. Atypical form of presentation with lung nodules and cutaneous lesions

Propósito: Presentamos el caso de un mieloma múltiple de presentación atípica. Caso clínico: Varón de 63 años fumador importante, que debuta con cuadro de dolor torácico osteomuscular y síndrome constitucional. En las exploraciones realizadas se evidenció una condensación en lóbulo superior derecho con múltiples nódulos pulmonares así como imágenes líticas en columna dorsal. Se planteó como diagnóstico inicial la existencia de un carcinoma pulmonar. El estudio anatomopatológico puso de manifiesto que se trataba de un mieloma múltiple que debutó junto a una bronconeumonía bilateral. Discusión: El mieloma múltiple supone una infiltración plasmocitaria de médula ósea. Es frecuente la asociación con procesos infecciosos. La aparición de lesiones cutáneas secundarias a la afectación plasmocitaria y el debut asociado a una bronconeumonía bilateral son dos datos clínicos poco frecuentes. Destacar la necesidad de confirmación anatomopatológica ante cualquier imagen de características tumorales para decidir la actitud terapéutica (AU)

[Adult celiac disease: study of 21 cases and review of the bibliography]. / Enfermedad celíaca del adulto: estudio de 21 casos y revisión de la bibliografía.

Celiac sprue is a chronic disease characterized by a typical lesion in the small intestine and nutrient malabsorption that improves on withdrawal of dietary gluten. Adult celiac disease (or gluten enteropathy) is a common and under-diagnosed disease since presentation varies among a) symptomatic or clinically active forms (including mono- or oligosymptomatic forms), b) asymptomatic, subclinical or silent forms, and c) latent forms. We present a descriptive study of a retrospective series of patients diagnosed with symptomatic or clinically active adult celiac disease who required hospitalization between January 1993 and June 2000. The form of symptomatic expression, biological alterations, investigations that confirm the diagnosis, associated diseases, complications and response to treatment are described.

[Epidemiologic study of an outbreak of echovirus type-9 meningitis]. / Estudio epidemiológico de un brote de meningitis por echovirus tipo-9.

BACKGROUND: Several agents are able to produce lymphocytic meningitis, but sometimes it's not possible their identification. The viruses are the etiological agents more frequently found, especially enteroviruses, mumps virus and herpes simplex virus, with different epidemiological patterns depending on time and geographic location. Most of the infections caused by enteroviruses are asymptomatics. In general the viral meningitis have a good prognostic with an acute benign course and serious signs of neurological affectation are infrequent. From 1991 it has been observed an increase of nonpolio enteroviral meningitis outbreaks in our Country. Echovirus-4 was isolated in most of the outbreaks notified during that year. Echovirus-9 was not isolated in any of them. METHODS: We describe the epidemiological and clinical characteristics of a lymphocytic meningitis outbreak that took place from June to July of 1993 in Burgos. RESULTS: Forty-eight patients, most of them children, were hospitalized with fever, headache, vomits and stiff neck with an increase in the total cell count in cerebospinal fluid (CSF). Echovirus-9 was isolated from fecal samples in eight patients. CONCLUSIONS: The etiology was attributed to Echovirus-9 because of microbiologic and epidemiologic findings. The incubation period can fluctuate between four an five days and fecal-oral transmission is the most probable mechanism.