Compliance with national guidelines for HIV treatment and its association with mortality and treatment outcome: a study in a Spanish cohort.

OBJECTIVES: The aim of the study was to assess the adequacy of initial antiretroviral therapy (ART), in terms of its timing and the choice of regimens, according to the Spanish national treatment guidelines [Spanish AIDS Study Group-National Plan for AIDS (GeSIDA-PNS) Guidelines] for treatment-naïve HIV-infected patients. METHODS: A prospective cohort study of HIV-positive ART-naïve subjects attending 27 centres in Spain from 2004 to 2010 was carried out. Regimens were classified as recommended, alternative or nonrecommended according to the guidelines. Delayed start of treatment was defined as starting treatment later than 12 months after the patient had fulfilled the treatment criteria. Multivariate logistic and Cox regression analyses were performed. RESULTS: A total of 6225 ART-naïve patients were included in the study. Of 4516 patients who started treatment, 91.5% started with a recommended or alternative treatment. The use of a nonrecommended treatment was associated with a CD4 count > 500 cells/µL [odds ratio (OR) 2.03; 95% confidence interval (CI) 1.14-3.59], hepatitis B (OR 2.23; 95% CI 1.50-3.33), treatment in a hospital with < 500 beds, and starting treatment in the years 2004-2006. Fourteen per cent of the patients had a delayed initiation of treatment. Delayed initiation of treatment was more likely in injecting drug users, patients with hepatitis C, patients with higher CD4 counts and during the years 2004-2006, and it was less likely in patients with viral loads > 5 log HIV-1 RNA copies/ml. The use of a nonrecommended regimen was significantly associated with mortality [hazard ratio (HR) 1.61; 95% CI 1.03-2.52; P = 0.035] and lack of virological response. CONCLUSIONS: Compliance with the recommendations of Spanish national guidelines was high with respect to the timing and choice of initial ART. The use of nonrecommended regimens was associated with a lack of virological response and higher mortality.

Dolor abdominal en paciente con infección por VIH / Abdominal painin a HIV-infected patient

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Entrenamiento en habilidades sociales en pacientes con daño cerebral adquirido / Training in social skill in patients with acquired brain damage

Introduction. Brain damaged patients have cognitive deficits, behaviour disorders and personality changes which affect socio-familial behaviour. Frequently, these changes generate considerable disturbance between family members and make it very difficult to return to work. Objective. We describe a pilot study which led to the development and application of a focal rehabilitation programme aimed at retraining this group in social skills. Patients and methods. The programme was intensive (3 months) and included 6 outpatients (5 men and 1 woman) who took part in programmes of neuropsychological rehabilitation after traumatic or vascular cerebral lesions (X= 19.2 months after the lesion occurred). The average age of the patients was 27.2 years and their average IQ 109.2. Individual and group interventions were combined (role-playing, ‘makebelieve’ work, video filming) emphasizing particularly the processes of learning without making mistakes and the extension of achievements to the natural setting (controlled trials). Results and conclusions. We state and describe the relationship between the nature of neuropsychological and psychopathological deficits, and the characteristics of the limitations in social behaviour. The patients showed a significant reduction in the level of anxiety and aggressive behaviour and improvement in consciousness of their defects. Some improvement was seen in expressing opinions and emotions, and in ability to adapt social conduct to different situations (flexible behaviour). Finally we describe the conclusions drawn as to this treatment for future review and improvement of the programme (AU)

Introducción. Los pacientes con daño cerebral presentan déficit cognitivos, conductuales y cambios de personalidad que condicionan su funcionamiento sociofamiliar. Estos cambios generan con frecuencia enorme malestar entre familiares y representan serias dificultades para el restablecimiento de la actividad laboral. Objetivo. Describir una experiencia piloto que supuso el desarrollo y aplicación de un programa de rehabilitación focal dirigido al reentrenamiento de las habilidades sociales de este colectivo. Pacientes y métodos. El programa intensivo (3 meses) contó con seis pacientes ambulatorios (5 varones y 1 mujer), participantes en programas de rehabilitación neuropsicológica tras sufrir lesiones cerebrales de origen traumático o vascular (X= 19,2 meses desde la lesión). La media de edad era de 27,2 años y el CI medio de 109,2. Se combinaron intervención individual y grupal (role-playing, trabajo de supuestos, filmación en vídeo), poniendo especial hincapié en los procesos de aprendizaje sin error y en la generalización de los logros al entorno natural (ensayos controlados). Resultados y conclusiones. Se comprueba y describe la relación existente entre la naturaleza de los déficit neuropsicológicos y psicopatológicos y las características de las limitaciones en el funcionamiento social. Los pacientes mostraron una significativa reducción del nivel de ansiedad y de conductas agresivas y una mejora de la conciencia sobre los déficit. Asimismo, se observó una discreta mejora en la expresión de opiniones y emociones, y en la capacidad de adecuar la conducta social a las diferentes situaciones (flexibilidad conductual). Finalmente, se describen las conclusiones terapéuticas que extrajo el equipo para la futurarevisión y mejora del programa (AU)