Hipertensión nocturna aislada en individuos con el virus de la inmunodeficiencia humana / Isolated nocturnal hypertension in individuals with human immunodeficiency virus

Introducción: La hipertensión nocturna aislada se asocia a mayor cantidad de eventos cardiovasculares y daño de órgano blanco por hipertensión arterial. La prevalencia en poblaciones especiales no se encuentra del todo descrita. El objetivo del siguiente estudio es describir la prevalencia de hipertensión nocturna aislada en población conviviendo con el virus de la inmunodeficiencia humana, y observar su relación con las categorías de presión arterial en el consultorio y los fenotipos de la medición ambulatoria de presión arterial de 24h. Metodología: Se realizó una cohorte retrospectiva en una población con el virus de la inmunodeficiencia humana en un hospital público de España, se registraron características clínico epidemiológicas, mediciones de presión arterial en consultorio y medición ambulatoria de presión arterial de 24h (MAPA). Se realizó un análisis en función de los diferentes fenotipos de presión arterial por MAPA, así como también en función de las diferentes categorías de presión arterial de consultorio se calcularon los riesgos para la hipertensión nocturna aislada. Resultados: Se incluyeron en el análisis 116 individuos, sin medicación antihipertensiva ni antecedentes de enfermedad cardiovascular establecida. Se describió una prevalencia de hipertensión nocturna del 23,3%. No se pudo demostrar diferencias significativas entre fenotipos por MAPA de ninguna variable propia del VIH. No hubo diferencias de riesgo ajustadas entre las diferentes categorías de normotensos en consultorio. Conclusiones: La hipertensión nocturna aislada es más frecuente en pacientes con VIH, y los valores de presión arterial de consultorio en normotensos no son suficientes para predecir HTA nocturna aislada. (AU)

Introduction: Isolated nocturnal hypertension is associated with a greater number of cardiovascular events and target organ damage due to arterial hypertension. It has been observed that patients in the general population with this entity do not have high blood pressure figures in the office; and it is necessary to perform an outpatient measurement to unmask it. The prevalence in special populations is not fully described. The objective of the following study is to describe the prevalence of isolated nocturnal hypertension in a population living with the human immunodeficiency virus and to observe its relationship with the categories of office blood pressure and the phenotypes of the 24-hour ambulatory blood pressure measurement. Methodology: A retrospective cohort was carried out in a population with human immunodeficiency virus in a public hospital in Spain, clinical epidemiological characteristics, office blood pressure measurements and 24-hour ambulatory blood pressure measurement (ABPM) were recorded. An analysis was performed based on the different ABPM blood pressure phenotypes, as well as based on the different office blood pressure categories, the risks for isolated nocturnal hypertension were calculated. Results: One hundred and sixteen individuals, without antihypertensive medication or history of established cardiovascular disease, were included in the analysis. A prevalence of nocturnal hypertension of 23.3% was described. It was not possible to demonstrate significant differences between phenotypes by ABPM of any variable specific to HIV. There were no adjusted risk differences between the different categories of office normotensives. Conclusions: Isolated nocturnal hypertension is more frequent in patients with HIV and office blood pressure values in normotensive patients are not sufficient to predict isolated nocturnal hypertension. (AU)

[Isolated nocturnal hypertension in individuals with human immunodeficiency virus]. / Hipertensión nocturna aislada en individuos con el virus de la inmunodeficiencia humana.

INTRODUCTION: Isolated nocturnal hypertension is associated with a greater number of cardiovascular events and target organ damage due to arterial hypertension. It has been observed that patients in the general population with this entity do not have high blood pressure figures in the office; and it is necessary to perform an outpatient measurement to unmask it. The prevalence in special populations is not fully described. The objective of the following study is to describe the prevalence of isolated nocturnal hypertension in a population living with the human immunodeficiency virus and to observe its relationship with the categories of office blood pressure and the phenotypes of the 24-hour ambulatory blood pressure measurement. METHODOLOGY: A retrospective cohort was carried out in a population with human immunodeficiency virus in a public hospital in Spain, clinical epidemiological characteristics, office blood pressure measurements and 24-hour ambulatory blood pressure measurement (ABPM) were recorded. An analysis was performed based on the different ABPM blood pressure phenotypes, as well as based on the different office blood pressure categories, the risks for isolated nocturnal hypertension were calculated. RESULTS: One hundred and sixteen individuals, without antihypertensive medication or history of established cardiovascular disease, were included in the analysis. A prevalence of nocturnal hypertension of 23.3% was described. It was not possible to demonstrate significant differences between phenotypes by ABPM of any variable specific to HIV. There were no adjusted risk differences between the different categories of office normotensives. CONCLUSIONS: Isolated nocturnal hypertension is more frequent in patients with HIV and office blood pressure values in normotensive patients are not sufficient to predict isolated nocturnal hypertension.

Impact of the implementation of a Sepsis Code Program in medical patient management: a cohort study in an Internal Medicine ward.

OBJECTIVE: Sepsis is the main cause of death in hospitals and the implementation of diagnosis and treatment bundles has shown to improve its evolution. However, there is a lack of evidence about patients attended in conventional units. METHODS: A 3-year retrospective cohort study was conducted. Patients hospitalized in Internal Medicine units with sepsis were included and assigned to two cohorts according to Sepsis Code (SC) activation (group A) or not (B). Baseline and evolution variables were collected. RESULTS: A total of 653 patients were included. In 296 cases SC was activated. Mean age was 81.43 years, median Charlson comorbidity index (CCI) was 2 and 63.25% showed some functional disability. More bundles were completed in group A: blood cultures 95.2% vs 72.5% (p <0.001), extended spectrum antibiotics 59.1% vs 41.4% (p < 0.001), fluid resuscitation 96.62% vs 80.95% (p < 0.001). Infection control at 72 hours was quite higher in group A (81.42% vs 55.18%, odds ratio 3.55 [2.48-5.09]). Antibiotic was optimized more frequently in group A (60.77% vs 47.03%, p 0.008). Mean in-hospital stay was 10.63 days (11.44 vs 8.53 days, p < 0.001). Complications during hospitalization appeared in 51.76% of patients, especially in group B (45.95% vs 56.58%, odds ratio 1.53 [1.12-2.09]). Hospital readmissions were higher in group A (40% vs 24.76%, p < 0.001). 28-day mortality was significantly lower in group A (20.95% vs 42.86%, odds ratio 0.33 [0.23-0.47]). CONCLUSIONS: Implementation of SC seems to be effective in improving short-term outcomes in IM patients, although therapy should be tailored in an individual basis.

Farmacocinética, perfil de seguridad e interacciones de los regímenes basados en Sofosbuvir / Pharmacokinetic, safety profile and DDI interactions of Sofosbuvir based regimens

Sofosbuvir (SOF) es un profármaco nucleotídico que se metaboliza ampliamente. El metabolito activo se forma en los hepatocitos y no se encuentra en el plasma. El principal metabolito (>90 %), GS-331007, es inactivo. SOF se elimina principalmente a través de los riñones (la mayoría, 80%, como GS-331007). SOF y GS-331007 no son sustratos ni inhibidores de UGT1A1 ni de las enzimas CYP3A4, CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19 y CYP2D6. Los ensayos clínicos fase III y diferentes cohortes de vida real publicadas hasta la fecha sugieren que los regímenes de tratamiento basados en SOF para los pacientes infectados por el VHC con o sin cirrosis son efectivos y seguros. La tasa de abandono a la terapia por efectos adversos es ínfima (<1%). Los efectos secundarios más frecuentemente recogidos en los ensayos clínicos son la fatiga, la cefalea y las náuseas. SOF es substrato del transportador de fármacos glicoproteína P (P-gp) y de la proteína de resistencia al cáncer de mama (BCRP), aunque GS-331007 no lo es. La administración conjunta de SOF con fármacos que sean potentes inductores de la P-gp está contraindicada debido al potencial descenso de las concentraciones plasmáticas de SOF por disminución de la absorción intestinal. No se recomienda la administración conjunta de SOF con fármacos inductores moderados de la P-gp. Debido a las vías metabólicas comentadas, las interacciones farmacológicas de SOF son escasas, y son pocos los fármacos que están contraindicados conjuntamente

Sofosbuvir (SOF) is a nucleotide prodrug that is extensively metabolized. The active metabolite is produced in hepatocytes and is not found in plasma. The main metabolite (> 90%), GS-331007, is inactive. SOF is eliminated primarily through the kidneys (most, 80%, such as GS-331007). SOF and GS-331007 are neither substrates nor inhibitors of UGT1A1 nor of the enzymes CYP3A4, CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19 and CYP2D6. Phase III clinical trials and different real-life cohorts published to date suggest that SOF-based treatment regimens are effective and safe in HCV-infected patients with or without cirrhosis. The rate of withdrawal of therapy due to adverse effects is negligible (<1%). The most frequently reported side effects in clinical trials are fatigue, headache and nausea. SOF is a substrate of the drug transporter P glycoprotein (P-gp) and of the breast cancer resistance protein (BCRP), although GS-331007 is not. Co-administration of SOF with drugs that are potent inducers of P-gp is contraindicated due to the potential decrease in SOF plasma concentrations due to decreased intestinal absorption. Co-administration of SOF with moderate inducers of P-gp is also not recommended. Due to the metabolic pathways discussed, the pharmacological interactions of SOF are very scarce, and few concomitant drugs are contraindicated

Efficacy of and risk of bleeding during pegylated interferon plus ribavirin treatment in HIV/HCV-coinfected patients with pretreatment thrombocytopenia.

The aim of this study was to assess the efficacy of and the risk of major bleeding during pegylated interferon (peg-IFN)/ribavirin (RBV) treatment among human immunodeficiency virus (HIV)/hepatitis C virus (HCV)-coinfected patients according to the pretreatment platelet count. Two hundred and seventy-four HCV/HIV-coinfected, previously naïve individuals with compensated cirrhosis enrolled in one Spanish prospective cohort who received peg-IFN/RBV were included in this study. The frequency of severe bleeding and sustained virological response (SVR) rate were compared between patients with a pretreatment platelet count ≤70,000/mm(3) and >70,000/mm(3), respectively. Sixty-one (22 %) patients had a baseline platelet count ≤70,000/mm(3). The median (Q1-Q3) pretreatment platelet count was 58,000 (49,000-65,000) cells/mm(3) in the platelet ≤70,000 group and 129,000 (102,500-166,000) cells/mm(3) in the platelet >70,000 group (p < 0.0001). Seventeen (28 %) subjects of the platelet ≤70,000 group and 71 (33 %) patients of the platelet >70,000 group achieved SVR (p = 0.4). Only 2 (3.2 %) patients in the platelet ≤70,000 group developed a severe hemorrhagic event, specifically esophageal variceal bleeding. The efficacy of therapy with peg-IFN/RBV in HIV/HCV-coinfected patients with low pretreatment platelet counts is comparable to that found in the overall subset of subjects with compensated cirrhosis. The frequency of severe hemorrhagic events related with this therapy is low in this population.

Insulin resistance is associated with liver stiffness in HIV/HCV co-infected patients.

BACKGROUND: The factors that influence liver fibrosis progression in patients co-infected with human immunodeficiency virus/hepatitis C virus (HIV/HCV) are not completely understood. It is not known if insulin resistance (IR), a condition that promotes liver fibrosis in HCV mono-infected individuals, is one of these factors. OBJECTIVE: To evaluate the association between IR and liver stiffness (LS). DESIGN: Multicentre cross-sectional study. PATIENTS: 330 patients co-infected with HIV/HCV. METHODS: LS was assessed by transient elastography, which has shown a high accuracy to predict significant fibrosis in patients co-infected with HIV/HCV. The outcome variable of the study was LS. Patients with LS> or =9 kPa were considered as having significant fibrosis. IR was calculated using the HOMA method. RESULTS: LS was > or =9 kPa in 150 (45%) patients. HOMA correlated with LS (Spearman's rho correlation coefficient, 0.37; p<0.0001). The median (Q1-Q3) HOMA in patients with LS> or =9 kPa was 3.30 (2.17-5.16) while it was 2.09 (1.37-3.22) in patients with LS <9 kPa (p<0.0001). Ninety-six (39%) individuals with a HOMA <4 and 54 (63%) with a HOMA > or =4 showed LS> or =9 kPa (p<0.0001). Analyses after excluding patients with cirrhosis yielded similar results. After multivariate analyses, age > or =40 years (adjusted odds ratio (AOR), 1.85; 95% confidence interval (CI), 1.03 to 3.29; p = 0.03), CD4 cell count <200 cells/ml (AOR, 3.45; 95% CI, 1.67 to 7.11; p = 0.001), hepatitis B virus co-infection (AOR, 9.25; 95% CI, 2.42 to 35.31; p = 0.001), and HOMA > or =4 (AOR, 5.33; 95% CI, 2.70 to 10.49; p<0.0001) were the independent predictors of LS> or =9 kPa. CONCLUSION: IR is associated with LS in patients co-infected with HIV/HCV.

[Prevalence of hepatitis C virus among HIV-infected patients in Area 2 of Madrid]. / Prevalencia de hepatitis C en población infectada por el VIH en el Area 2 de Madrid.

INTRODUCTION: The evolution of HIV infection, a rapid and fatal illness not long time ago, has become a chronic disease due to the implementation of new antiretroviral treatment. Therefore it is essential to focus on the management of concurrent illnesses such as chronic hepatitis C infection, specially as they share common routes of transmission. METHODS: A cross sectional survey was done to determine the prevalence of HIV and HCV coinfection, measuring different HIV and HCV variables among 651 HIV infected patients of a health area in Madrid. RESULTS: 500 patients (76.8%) were male and 151 female (23%). HCV serology was performed in all the patients and resulted positive in 45.7% (298) most of them drug users (84.8%). The CD4 cell count was lower in patients HIV-HCV coinfected compared to those HCV negative (p < 0.001). CONCLUSION: This study shows a high prevalence of HIV-HCV coinfection, mainly due to parenteral transmission. We emphasize the low percentage of coinfected patients treated with interferon and ribavirine which probably will increase in the future.

Prevalencia de hepatitis C en población infectada por el VIH en el Área 2 de Madrid / Prevalence of hepatitis C virus among HIV-infected patients in Madrid

Introducción: La evolución de la infección por VIH, antes inexorablemente fatal, se ha visto alterada por la introducción de nuevos fármacos antirretrovirales hasta convertirse en un proceso crónico. Por ello en el manejo del paciente VIH+ cobra especial importancia la presencia de otros procesos que a largo plazo puedan influir en la evolución de la enfermedad como es el caso de la infección por VHC, más aún compartiendo ambos virus similares vías de transmisión. Métodos: Para determinar la prevalencia de la coinfección por VIH-VHC realizamos un estudio transversal analizando diversos parámetros referentes al VIH y al VHC en 651 pacientes VIH+ en el Área 2 de Madrid. Resultados: El número de pacientes varones fue de 500 (76,8%) y el de mujeres 151 (23,2%). Se realizó serología para VHC en el 100% de los pacientes y se obtuvo resultado positivo en el 45,7% (298 pacientes), con un marcado predominio de ADVP dentro de este subgrupo (84,8%). El número de CD4 era significativamente menor en pacientes coinfectados comparados con pacientes no infectados por VHC (p < 0,001). Conclusión: Nuestro estudio muestra un alto índice de coinfección por VHC, referido fundamentalmente a la vía de transmisión parenteral y es de destacar el escaso porcentaje de pacientes tratados con interferón y ribavirina, que con seguridad va a aumentar en los próximos años

Introduction: The evolution of HIV infection, a rapid and fatal illness not long time ago, has become a chronic disease due to the implementation of new antiretroviral treatment. Therefore it is essential to focus on the management of concurrent illnesses such as chronic hepatitis C infection, specially as they share common routes of transmission. Methods: A cross sectional survey was done to determine the prevalence of HIV and HCV coinfection, measuring different HIV and HCV variables among 651 HIV infected patients of a health area in Madrid. Results: 500 patients (76,8%) were male and 151 female (23%). HCV serology was performed in all the patients and resulted positive in 45.7% (298) most of them drug users (84.8%). The CD4 cell count was lower in patients HIV-HCV coinfected compared to those HCV negative (p < 0.001). Conclusion: This study shows a high prevalence of HIV-HCV coinfection, mainly due to parenteral transmission. We emphasize the low percentage of coinfected patients treated with interferon and ribavirine which probably will increase in the future

[Treatment with interferon and ribavirin of chronic hepatitis C in HIV-infected patients]. / Tratamiento con interferón y ribavirina de la hepatitis crónica por virus C en pacientes con infección por VIH.

BACKGROUND: The rapid progression of chronic hepatitis C (CHC) in HIV-infected patients is now the most important cause of morbidity, mortality and hospital admissions. In order to avoid this evolution, the treatment of CHC is a major challenge in these patients. PATIENTS AND METHOD: The aim of this study is to evaluate the safety and efficacy of treatment of CHC in HIV-infected patients with subcutaneous IFN (3 MU 3 times a week) plus Ribavirin (RBV) administered per 200 mg dosage depending on their body weight, for 24 weeks for genotype 2 or 3 and 48 weeks for genotype 1 or 4. All the patients have a CD4 count over 150 cells/microl and HIV viral load < 50,000 copies/ml, with or without antiretroviral treatment. We defined sustained response as RNA-VHC below level of detection 24 weeks after the end of treatment. RESULTS: We included 28 patients in the study, with median age of 36.6 y.o. 82% of the patients were on antiretroviral treatment, with AZT in 60% of them. Genotype distribution was HCV-1 in 50%, HCV-3 in 35.7%, HCV-4 in 10.7% and HCV-2 in 3%. Liver biopsy was performed in all the patients. Adverse events leading to treatment discontinuation occurred in 5 patients (17.8%). The overall sustained response rate in the intent-to-treat analysis was 25.8% (50% for genotype 3 and 14% for genotype 1). CONCLUSION: This therapy provides cure in a rate significantly lower than that seen in HCV-monoinfected individuals, with a similar safety. The modern formulations of IFN (pegylated) will provide new expectatives in this group of patients.

Tratamiento con interferón y ribavirina de la hepatitis crónica por virus C en pacientes con infección por VIH / Treatment whith interferon and ribavirin of chronic hepatits C in HIV-infected patients

Introducción: Actualmente, las complicaciones de la hepatitis crónica por virus C en pacientes infectados por el VIH son la causa más importante de morbilidad, mortalidad e ingreso hospitalario en estos pacientes. Estos hechos han conducido a que cada vez sea más prioritario el tratamiento de la hepatitis crónica en este tipo de pacientes. Pacientes y método: Hemos evaluado la eficacia y seguridad del tratamiento de la hepatitis crónica por VHC en pacientes infectados por VIH, con interferón (IFN) 3 MU 3 veces por semana por vía subcutánea y ribavirina (RBV) en comprimidos de 200 mg en dosis dependiente del peso, durante 24 semanas para genotipo 2 ó 3 y 48 semanas para genotipo 1 ó 4. Todos los pacientes tenían más de 150 CD4/µl y carga viral de VIH <50.000 copias/ml, con o sin tratamiento antirretroviral. Se consideró respuesta sostenida si el ARN-VHC era indetectable 24 semanas después de finalizar el tratamiento. Resultados: Hemos incluido 28 pacientes infectados por ambos virus, con edad media de 36,6 años. El 82 por ciento estaban con tratamiento antirretroviral que incluía AZT en el 60 por ciento. La distribución por genotipos fue: 1 en 14 (50 por ciento), 3 en 10 (35,7 por ciento), 4 en 3 (10,7 por ciento) y 2 en 1 (3 por ciento). Todos los pacientes tenían realizada biopsia hepática. Hubo 5 abandonos de tratamiento (17,8 por ciento) debido a efectos adversos. Se observó respuesta sostenida "por intención de tratamiento" en el 25,8 por ciento de los pacientes (50 por ciento para genotipo 3 y 14 por ciento para genotipo 1). Discusión: La eficacia del tratamiento combinado con IFN y RBV en la hepatitis crónica de los pacientes coinfectados por VHC y VIH es menor que la descrita para pacientes VIH negativos, aunque la tolerancia y seguridad son similares. Las nuevas formas de IFN (pegilado) abren una nueva posibilidad para optimizar el tratamiento de estos pacientes (AU)

[Tuberculous peripheral multifocal choroiditis]. / Coroiditis multifocal periférica tuberculosa.

CASE REPORT: A healthy 57 year-old woman with past untreated pulmonary tuberculosis, disclosed a bilateral uveitic syndrome characte rized by iritis, vitreitis, multiple peripheral retinal punched-out lesions, and cystoid macular edema. Systemic evaluation was unremarkable except for a 30 mm tuberculin skin test. Relapses occurred after oral and periocular corticosteroids were interrupted, but the inflammation completely disappeared after a 6 month course of isoniazid, rifampicin and pyrazinamide. DISCUSSION: Intraocular tuberculosis should be considered as a treatable cause of peripheral multifocal choroiditis, after ruling out other etiologies.

Coroiditis multifocal periférica tuberculosa / Tuberculous peripheral multifocal choroiditis

Caso clínico: Mujer sana de 57 años, con antecedentes de tuberculosis pulmonar Mantoux de 30 mm, y clínica inflamatoria ocular bilateral caracterizada por : iridociclitis sinequiante, vitritis, lesiones retinianas redondeades blanquecinas periféricas adyacentes a cicatrices pigmentadas en sacabocados y edema macular quístico. Ante la escasa respuesta al tratamiento corticoideo local y sistémico, con recidivas tras su interrumpción, se instauró tratamiento durente 6 meses con isoniacida, rifampicina y pirimetamida, desapariciendo completamente el cuadro inflamatorio. Discusión: Una vez descartadas otras etiologías, la tuberculosis debe ser considerada como una causa tratable de coroiditis multifocal periférica (AU)

Linfocitopenia T CD4+ idiopática asociada a criptococosis diseminada / Idiopathic CD4+ T-cell lymphocytopenia associated with disseminated cryptococcosis

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Neumonía cavitada por neumococo en la infección por el virus de la inmunodeficiencia humana

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Biopsia prostática y espondilodiscitis / Prostatic biopsy and spondylodiscitis

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