Since 1996, the standard of care (SOC) therapy for HIV treatment has consisted of a backbone of two nucleoside analogue reverse transcriptase inhibitors (NRTI) paired with a third agent. Use of ...two-drug combinations (2DC) has been considered for selected patients to avoid toxicities associated with the use of NRTIs. This study aimed to compare the real-world outcomes of integrase strand transfer inhibitor (INSTI)-containing triple therapy (TT) to dolutegravir- (DTG) and/or boosted protease inhibitor (bPI)-based 2DC in a large Spanish cohort of HIV patients.
A retrospective analysis was performed using data from the VACH cohort, a prospective multicentre Spanish cohort of adult HIV patients. All treatment experienced patients initiating a TT of an INSTI combined with two NRTIs or a 2DC-containing DTG and/or a bPI between 01/01/2012 and 01/06/2017 were included. The unit of analysis was patient-regimens. The overall sample analysis was complemented with two sub-analyses. The first sub-analysis focused on patients treated with a backbone plus DTG compared to those treated with DTG+ one other antiretroviral. The second sub-analysis focused on patients with HIV RNA<50 copies/mL at baseline, irrespective of the regimen used. The following endpoints were assessed: time to discontinuation for any reason, time to switch due to virologic failure, and time to switch due to toxicity (reasons for discontinuation according to clinician report in the database). Time-to-event analyses were conducted using Kaplan-Meier survival curves and Cox regression models.
Overall 7,481 patients were included in the analysis, contributing to 9,243 patient-regimens. Patient characteristics at baseline differed among groups, with the 2DC group being significantly older and having a higher proportion of women, a longer time on ART and a higher number of previous virologic failures. Median (95% Confidence Interval C.I.) time to switch was 2.5 years (2.3, 2.7) in 2DC group versus 2.9 years (2.7, 3.0) in TT. Adjusted hazard ratios (95% C.I.) for discontinuation due to any reason, virologic failure and toxicity in the 2DC vs TT group were 1.29 (1.15; 1.44), 2.06 (1.54; 2.77) and 1.18 (0.94; 1.48), respectively. Results were consistent in the two sub-analyses.
In this analysis, time to discontinuation and probability of remaining free of virologic failure were significantly higher in patients on INSTI-based TT compared to DTG- and/or bPI-containing 2DC, with no differences in toxicity.
knowledge of the present features of the HIV epidemic is relevant, especially to develop management programmes directed to poorly controlled patients.
to describe the epidemiological and clinical ...features of HIV infection in a large multicentre cohort.
cross-sectional study.
data of the Spanish VACH Cohort of HIV infected patients.
a total of 53 variables were included. Descriptive statistics were used to report the results. Bivariable statistics were used to assess variation along time on prescribed antiretroviral treatment and on causes of death.
a total of 30,843 patients belonging to most regions of Spain were included: 23,682 (76.78%) were male, mean and standard deviation of age of all patients was 34.03 ± 9.55 years in their first visit and 43.68 ± 10.52 years in their last visit; 12,677 (41.10%) were smokers, 3,521 (11.42%) had diabetes mellitus, 15,351 (49.77%) had acquired HIV via sexual route and 12,714 (41,22%) via parenteral route, 16,057 (52.06%) had positive hepatitis C virus serology. Their median and interquartile range of CD4 lymphocyte count, per cubic millimetre, were: lowest available 198 (79-337) and last available 510 (299-745). Last available HIV viral load was suppressed (<200 RNA copies per mL) in 23,485 (76.14%). Modalities of prescribed antiretroviral treatment varied substantially over time, with integrase inhibitor combinations predominating the last years. Causes of death changed from AIDS defining conditions early in the epidemic to non-AIDS defining conditions more recently.
patients in the Spanish HIV VACH Cohort are predominantly middle-aged men. They acquired HIV via sexual or parenteral routes in similar proportions. Most of them are taking antiretroviral treatment and have their HIV infection properly controlled.
Multi-pathological patients are at high risk of drug interactions and side effects. We aimed to assess the usefulness of 3 online drug interaction checkers.
In a cross-sectional study, carried out in ...the Medicine Department of Hospital General of Castellon, Spain, in February 2020, we assessed drug interaction detection with 3 online electronic checkers, Drugs.com, Lexicomp®, and Medscape, and compared results obtained with the 3 tools. From every hospitalized patient, we obtained the list of drugs he or she had been taking until admission. Bivariable tests were used for analysis. p values <0.05 were considered significant.
We included data from 134 patients; 68 (51%) were male; median (and interquartile range) of their age was 82 (76-88) years. A total of 1,082 substance drugs were entered in the checkers. The number of highest grade interactions found with every program was Drugs.com 85, Lexicomp® 33, and Medscape 67. Positive correlations were found between age and number of drug substances prescribed (p = 0.009) and between number of drug substances prescribed and interactions found with any of the 3 checkers (p < 0.001 in all 3 cases). Regarding highest grade interactions, agreement among all 3 checkers was poor.
The 3 online checkers we assessed found a large number of interactions. The 3 programs gave very discrepant results. Impact on Practice Statements: The analyzed programs, Drugs.com, Lexicomp®, and Medscape Interactions, found a large number of drug interactions in the studied patients. The 3 programs gave very discrepant results among them.
HIV infection is a serious but treatable disease, yet current treatment is limited by development of resistance and high rates of adverse drug reactions. Antiretroviral therapy is especially suitable ...for pharmacogenomic investigation as both drug exposure and treatment response can be reliably measured. Increasing knowledge about genes implicated in pharmacokinetics, mode of action, efficacy, and toxicity of drugs has already provided relevant results for clinical practice, for example: The strong association of the abacavir hypersensitivity reaction with HLA-B*5701 permits testing patients for the allele, and if present avoiding the drug and therefore preventing the reaction. Persons with the allele CYP2B6*6 present higher efavirenz "area under the curve" and have increased risk of neuropsychological toxicity. Additional gene variants are being discovered that influence the action of antiretroviral drugs. And, moreover, it is expected that larger-scale comprehensive genome approaches will profoundly improve the landscape of knowledge of HIV therapy in the future. The present article shows some recent patents related to the treatment of viral infections.
Descemet membrane detachment (DMD) is a complication of a variety of eye procedures that can result in severe visual loss. We report a new case of the condition, in a highly myopic patient that had ...undergone cataract surgery, and presented a macular hemorrhage during the intervention. DMD was successfully treated with a combined technique of intracameral gas injection and transcorneal suturing. Following resolution of this complication, intraocular lens opacification was observed.
Diversas universidades españolas han implantado recientemente programas de docencia de Medicina en inglés, como legua vehicular. Sin embargo existen pocos datos sobre la opinión que sobre dichos ...programas tienen los alumnos que reciben esa modalidad de docencia. Con el presente estudio pretendemos conocer la actitud de dichos alumnos ante ese tipo de enseñanza.
Estudio transversal. Basado en un cuestionario enviado por correo electrónico a los alumnos de tercer curso del Grado de Medicina de la Universitat Jaume I de Castellón, los cuales van a cursar en los meses siguientes la asignatura Enfermedades Infecciosas en inglés como idioma docente.
Se envía el cuestionario a 78 alumnos, de los cuales 49 (63%) son mujeres y 29 (37%) son varones. Lo responden un total de 58 alumnos (74,4%). De los 58 alumnos que lo responden, 41 (70,7%) lo hacen durante las primeras 24 horas en que el cuestionario está disponible. Las respuestas indican que a 33 alumnos (56,9%) les parece bien o muy bien recibir la docencia de la asignatura en inglés; pero a 16 alumnos (27,6%) les parece mal o muy mal recibir ese tipo de docencia. Por otra parte, 39 alumnos (67,2%) consideran que van a tener que dedicar más tiempo del habitual a estudiar la asignatura por el hecho de impartirse en inglés.
La mayoría de los alumnos del estudio consideran positiva la docencia en inglés, si bien una proporción no despreciable de los mismos la consideran negativa.
Several universities in Spain have recently developed educational programs using English as the teaching language. Notwithstanding, there are scant data on the opinion of students about those programs. The aim of this study is to determine the attitude of the students who receive those programs towards that modality of education.
A cross-sectional study was conducted, based on a questionnaire forwarded by e-mail to Third-Year students of the Medical Degree at Jaume I University of Castellon, Spain, as these students are going to study the Infectious Diseases assignment using English as the educational language in the next few months.
The study questionnaire was sent to 78 students, 49 of them (63%) female and 29 (37%) male. The questionnaire was answered by 58 students (74.4%), ofwhich, 41 (70.7%) answered the questionnaire within the first 24hours after being available. The responses show that 33 students (56.9%) are in favour of the teaching program developed in English, with 16 students (27.6%) against that modality of teaching. Moreover, 39 students (67.2%) consider that they will have to spend more time than usual to prepare that subject because it is taught in English.
Most participants in this study consider it positive to receive their medical education in English, but a significant proportion of them consider that modality of teaching as negative.
Aim
To determine if patients with heart failure and preserved ejection fraction (HFpEF) and type 2 diabetes mellitus (T2DM) have a higher comorbidity burden than those without T2DM, if other ...comorbidities are preferentially associated with T2DM and if these conditions confer a worse patient prognosis.
Methods and results
Cohort study based on the RICA Spanish Heart Failure Registry, a multicentre, prospective registry that enrols patients admitted for decompensated HF and follows them for 1 year. We selected only patients with HFpEF, classified as having or not having T2DM and performed an agglomerative hierarchical clustering based on variables such as the presence of arrhythmia, chronic obstructive pulmonary disease, dyslipidemia, liver disease, stroke, dementia, body mass index, haemoglobin levels, estimated glomerular filtration rate and systolic blood pressure. A total of 1934 patients were analysed: 907 had T2DM (mean age 78.4 ± 7.6 years) and 1027 did not (mean age 81.4 ± 7.6 years). The analysis resulted in four clusters in patients with T2DM and three in the reminder. All clusters of patients with T2DM showed higher BMI and more kidney disease and anaemia than those without T2DM. Clusters of patients without T2DM had neither significantly better nor worse outcomes. However, among the T2DM patients, clusters 2, 3 and 4 all had significantly poorer outcomes, the worst being cluster 3 (HR 2.0, 95% CI 1.36‐2.93, P = .001).
Conclusions
Grouping our patients with HFpEF and T2DM into clusters based on comorbidities revealed a greater disease burden and prognostic implications associated with the T2DM phenotype, compared with those without T2DM.
Dabigatran (a direct thrombin inhibitor) and rivaroxaban, apixaban, and edoxaban (direct activated factor X inhibitors) are increasingly being used in clinical practice. Compared with vitamin K ...antagonists, they are more convenient, do not require laboratory monitoring, have limited drug and food interactions, and have fixed dosages suitable for most patients. But the shortcomings of these agents can jeopardize their efficacy and increase the risk of bleeding. Their future role in preventing and treating thromboembolic disease will depend on building clinical experience, but current evidence indicates that they are reasonable alternatives to vitamin K antagonists.
Summary Objective To analyze cases of infective endocarditis in patients who attended the Hospital General de Castellón, Spain, between 1999 and 2004. Methods This was a retrospective study. ...Demographic and clinical characteristics were assessed, variation in presentation over time was analyzed, and factors influencing outcome were determined. Results A total of 54 cases in 48 patients were included; 33 (61%) were in men. The median patient age was 62 years. Infective endocarditis occurred on a native valve in 36 cases (67%), a mechanical prosthetic valve in 12 (22%), and a pacemaker in six (11%). The mitral valve was the most commonly affected site. Transthoracic and/or transesophageal echocardiography showed a vegetation in 45 (83%) cases, moderate or severe valvular regurgitation in 27 (50%), and intracardiac destructive lesions in five (9%). The outcome in 15 (28%) cases was death, and multivariate analysis disclosed significantly increased risk of death associated with older age, lower serum albumin, and higher white blood cell count. Conclusions This study confirmed the protean nature of infective endocarditis, and identified several factors predictive of mortality including advanced age, low serum albumin, and high white blood cell count.
Antiretroviral therapy has greatly improved prognosis of HIV infection, with a dramatic reduction of morbidity and mortality worldwide. Nevertheless, the condition is still a common cause of death in ...many underdeveloped countries, where effective treatment is not always unavailable. More than 20 drugs active against HIV are commercially available, which belong to one of four groups: nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, and fusion/entry inhibitors. In the near future new drugs are expected, including those of a novel group, the integrase inhibitors. To avoid viral resistance, combinations of the drugs must always be used in clinical practice. Adverse reactions are common with antiretrovirals, and they are an important cause of medication non-adherence and suboptimal control of HIV infection. In this article we review the most relevant of those toxicities.
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