[Experience of a single-centre in the preparation of choosing wisely lists in Internal Medicine]. / Experiencia de un centro único en la preparación de listas choosing wisely en Medicina Interna.

OBJECTIVES: To identify areas for improvement, using a local list of interventions with low diagnostic and therapeutic usefulness for the 5 Related Diagnostic Groups, as well as the 5 main diagnoses most frequently seen in the hospital outpatient clinic. METHOD: A literature review method was used, supplemented with a Delphi process with 2 rounds. In the first round, participants in the selection process identified low-value interventions in relation to the most frequently observed diagnoses. In the second round, those interventions with lower usefulness were selected based on their frequency, cost, and risk to the patient. RESULTS: Out of a total of 100 recommendations made by 19 scientific societies, 23 received the highest number of votes in the first round. In the second round, 5 recommendations were selected for inpatients and 5 recommendations for outpatients. CONCLUSIONS: A simple method is described for developing a local guide to reduce the use of unnecessary medical interventions.

Intestinal spirochetosis as a cause of chronic diarrhoea in patients with HIV infection: case report and review of the literature.

We describe a 77-year-old patient with HIV infection suffering from chronic diarrhoea whose colonoscopy findings showed normal appearance mucosa and tissue samples revealed the presence of a dense layer of spirochetes attached to the apical cell membrane. A literature search from 1996 to April 2009 identified 19 additional cases of intestinal spirochetosis in patients with HIV infection. Analysis of cases showed that intestinal spirochetosis causes chronic diarrhoea in men who have sex with men (92% of patients with reported HIV infection risk factors) who are not severely immunosuppressed (70% with CD4 lymphocyte cells >200/microL). Colonoscopy examination often revealed normal appearance mucosa. Haematoxylin and eosin stain of biopsy samples showed the presence of spirochetes, but Warthin-Starry silver staining makes organisms easier to detect. Patients promptly responded to metronidazole or penicillin therapy. In summary, invasive intestinal spirochetosis should be considered in the differential diagnosis of patients with HIV infection and chronic diarrhoea.

Leishmaniasis as an opportunistic infection in HIV-infected patients: determinants of relapse and mortality in a collaborative study of 228 episodes in a Mediterreanean region.

The clinical presentation of visceral leishmaniasis shares similarities with other geographically specific infectious diseases associated with AIDS in terms of relapsing course and atypical presentation. However, visceral leishmaniasis has not, until now, been included in the AIDS case definition. The aim of this study was to describe the clinical features and determinants for relapse and case-fatality of visceral leishmaniasis in HIV-infected patients from a Spanish Mediterranean area. A chart review was conducted in 16 hospitals in the autonomous communities of Valencia and Murcia (Spain). From 1988 to 2001, a total of 228 episodes of visceral leishmaniasis were diagnosed in 155 HIV-infected patients by the detection of amastigotes in bone marrow aspirates or in other tissue samples. Most patients had advanced HIV disease, with a median CD4(+) lymphocyte cell count of 55 cells x 10(9) l, and 56% of them had a previous AIDS-indicator disease. The median duration of follow-up was 8.4 months. HIV-infected patients with visceral leishmaniasis presented with fever (76%), hepatomegaly (77%), splenomegaly (78%), and varying degrees of cytopenias. Leishmania was detected in atypical sites in 22 (14%) patients. A total of 37 (24%) patients had a relapse of visceral leishmaniasis. Female gender was a risk factor for relapse, whereas administration of secondary prophylaxis for visceral leishmaniasis and a completed therapy for visceral leishmaniasis were protective factors against relapse. A total of 86 (54%) patients died. Independent determinants for survival were CD4(+) lymphocyte cell count, completed therapy for leishmania, and secondary prophylaxis for visceral leishmaniasis. The findings show that, in HIV-infected patients, visceral leishmaniasis occurs in late stages of HIV disease and often has a relapsing course. Secondary prophylaxis reduces the risk of relapse. Visceral leishmaniasis in the HIV-infected population should be included in the CDC clinical category C for the definition of AIDS in the same way that other geographically specific opportunistic infections are included.

[Risk factors related to infections during the first year of highly active antiretroviral therapy]. / Factores de riesgo asociados a la aparición de infecciones durante el primer año de tratamiento antirretroviral de alta eficacia.

BACKGROUND: To evaluate the immunological, virological and clinical response of HIV-infected patients who start combined therapy with protease inhibitors (PI) in a community hospital. To identify risk factors related with infections. PATIENTS AND METHOD: Clinical review of patients with combined therapy, assessing CD4+ cell counts, viral load (Amplicor) and development of infections during the first year on PI (group A) and comparative study with the same patients during the previous year with PI (group B). RESULTS: 134 patients were included in group A and 84 in Group B. Nadir of CD4+ was 169 X 10(6)/l. After 6 months of PI therapy, the mean CD4 increased from 217 to 355 X 10(6)/l and the median viral load decreased from 88,000 copies/ml (14,000-485,000) to less than 400 copies /ml (< 400-9,000), 60% of patients had less than 400 copies/ml. The incidence of non-opportunistic infections was similar in both groups (36 vs 43%; p = NS). However, the rate of opportunistic infections decreased from 30 to 15% (RR: 0.41 [CI 0.21-0.81]; p = 0.007) in the group with PI, particularly Pneumocystis carinii pneumonia and toxoplasmosis. Multivariated analysis including CD4+ cell count, nadir of CD4+, viral load and risk behavior only nadir of CD4 < 100 X 10(6)/l was associated with a lower risk of developing opportunistic infections (RR: 0.2 [CI: 0.1-0.7]; p = 0.001). CONCLUSIONS: Combined therapy with PI improved immunological and virological markers and decreased the rate of opportunistic infections. A CD4+ cell count nadir higher than 100 X 10(6)/l was a marker of good prognosis during the first year with PI irrespective of response to therapy.

[Genotypic resistance to antiretroviral drugs in patients with therapeutic failure to highly active antiretroviral therapy]. / Resistencias genotípicas a los fármacos antirretrovirales en fracasos terapéuticos con pautas de alta eficacia.

BACKGROUND: To assess genotypic resistance mutations in patients with virological failure with highly active antiretroviral therapy (HAART) METHODS: Genotyping of reverse transcriptase (RT) and protease (PRO) HIV-1 genes were carried out in 33 adherent patients failing on HAART. RESULTS: Resistance mutations were found in 32 of the 33; 27 of them (81.8%) being primary mutations: 26 (78.8%) in the RT gene and 60 (60.6%) in the PRO gene. Overall, 66.6% had genotypic resistance to two drugs and 60.6% showed resistance to drugs belonging to the two main classes of antiretroviral drugs. At the time of treatment failure, 72.7% had on their therapeutic regimen one antiretroviral drug to which they had resistance mutations, 48.5% had genotypic resistance to two drugs of the therapeutic regimen and 21.2% to three drugs. CONCLUSIONS: Most adherent patients failing on HAART carry drug resistant genotypes. These patients may constitute a reservoir of multidrug resistant HIV that may limit treatment options in the future.

Once-a-month administration of intravenous pentamidine to patients infected with human immunodeficiency virus as prophylaxis for Pneumocystis carinii pneumonia.

We reviewed the charts of 52 patients infected with human immunodeficiency virus (HIV) who received at least three consecutive doses of intravenous pentamidine as prophylaxis for Pneumocystis carinii infections. Pentamidine isethionate was administered intravenously over 60-90 minutes once a month, at a dosage of 4 mg/kg, in 250 mL of 5% dextrose in water. During 387 months of administration of primary prophylaxis to 37 patients, no cases of P. carinii pneumonia were observed. During 200 months of administration of secondary prophylaxis to 15 patients, only one case of P. carinii pneumonia was diagnosed (6.0 cases per 100 patient-years). Side effects associated with the intravenous pentamidine were mild and did not necessitate withdrawal of the drug. Once-a-month administration of intravenous pentamidine is a valid alternative as prophylaxis for P. carinii pneumonia for patients who are intolerant of sulfonamides.

[Pneumatocele as a form of presentation of Pneumocystis carinii pneumonia]. / Neumatoceles como forma de presentación de neumonía por Pneumocystis carinii.

Pulmonary infection by Pneumocystis carinii in patients with acquired immunodeficiency syndrome (AIDS) can result in different radiological patterns with an ever expanding spectrum. A 40-year-old male, infected with the human immunodeficiency virus (HIV), presented with toxic symptoms and multiple pulmonary cystic lesions in the context of a Pneumocystis carinii pneumonia. The rarity of this radiological presentation is discussed and literature is reviewed. In addition, the possible pathogenetic mechanisms are discussed, and emphasis is made on the need for higher suspicion index in similar presentations in patients at risk of HIV infection.

Fragmentation haemolysis in patients with severe diabetic angiopathy.

Haemolytic anaemia associated with prominent red cell fragmentation is described in seven patients with long-standing diabetes mellitus. A common freature in the patients was severe microangiopathy as detected by retinal examination and microscopic examination of the kidneys. Renal or pancreatic islet malfunction per se is not involved in the haemolytic syndrome, since red cell abnormalities persisted in one patient for over a year following successful renal and pancreatic transplantation--this, despite the maintenance of normal renal and carbohydrate homeostasis. The kinetics of fragmentation was sutdied by tranfusing snormal type O cells into this type A patient. With reisolation of these cells by the Ashby-technique, rapid and porgressive red cell fragmentation was demonstrated by: (a) membrane lipid loss; (b) osmotic fragility increase; and (c) increase in mean cell haemoblobin concentration. This studies indicate that a red-cell-fragmentation haemolytic anaemia may occur in long-standing diabetes mellitus, related to the angiopathy of this disease and not to insulin deficiency or renal malfunction.