Francisco Javier Alonso Moreno

Impact of syphilis infection on HIV viral load and CD4 cell counts in HIV-infected patients

Objectives:To assess the effect of early syphilis on HIV viral load (VL) and CD4 cell count in patients with HIV and to analyze factors associated with changes in HIV VL and CD4 cell count. Design:Multicenter study of a series of patients with HIV who were diagnosed with early syphilis infection during 2004 through 2005. Patients who started or changed their highly active antiretroviral therapy (HAART) regimen during the analysis period were excluded. Results:One hundred eighteen patients were analyzed: 95.8% were men, mean patient age was 38.2 years, 83.9% were homosexual men, 50.8% were on antiretroviral therapy at the time syphilis was diagnosed, and HIV and syphilis diagnoses were coincident in 38 (32.2%) cases. CD4 cell counts were lower during syphilis than before (590 vs. 496 cells/μL; P = 0.0001) and after syphilis treatment (509 vs. 597 cells/μL; P = 0.0001). The HIV VL increased in 27.6% of patients during syphilis. The only factor associated with an HIV VL increase was not being on HAART, and the only factor associated with a CD4 count decrease >100 cells/μL during syphilis was the prior CD4 cell count. Conclusions:Syphilis infection was associated with a decrease in the CD4 cell count and an increase in the HIV VL in almost one third of the patients. In this series, more than two thirds of the syphilis cases were diagnosed in patients who were previously known to be infected with HIV.

El rol de Cuidador de personas dependientes y sus repercusiones sobre su Calidad de Vida y su Salud

Resumen es: Objetivo. Conocer la sobrecarga sentida por los cuidadores y las repercusiones que este rol representa sobre su calidad de vida, su salud en las esferas ...

Control de la presión arterial en la población hipertensa española asistida en Atención Primaria. Estudio PRESCAP 2010

BACKGROUND AND OBJECTIVE This study was aimed at determining the degree of blood pressure (BP) control in hypertensive patients attended in primary care (PC) settings. PATIENTS AND METHOD Cross-sectional, multicenter study. Hypertensive patients ≥18 years under antihypertensive treatment attended in Spanish PC settings were included. BP control was regarded as optimum when BP values were <140/90mmHg in general population and <130/80mmHg in patients with diabetes, chronic renal disease or cardiovascular disease. BP control was also calculated for all patients when it was <140/90mmHg. RESULTS A total of 12,961 hypertensive patients (52.0% women) with a mean age of 66.3 (±11.4) years were included. A percentage of 46.3 (95% CI: 45.4-47.1) presented good systolic BP and diastolic BP control; 61.1% (IC 95%: 60.2-61.9) of patients presented good BP control<140/90. A percentage of 63.6% was treated with combination therapy (44.1% with 2 drugs, 19.5% with 3 or more). BP control was significantly higher in evening measurements (50.4%) than in morning measurements (45.1%), and in patients who had taken the treatment before the visit (47.9%) compared with those who had not (30.5%). Factors such as not taking the medication before the visit, heavy alcohol consumption and dyslipemia were the risk factors mostly associated with a poor BP control (P<.001). CONCLUSIONS Five out of 10 hypertensive patients treated in PC settings have an optimal BP control. The degree of control of arterial hypertension has improved with respect to the PRESCAP 2006 study.

Automedida de la presión arterial: estado actual de la cuestión

70 SEMERGEN INTRODUCCIÓN La hipertensión arterial (HTA) es un importante factor de riesgo cardiovascular y un poderoso indicador de riesgo para la supervivencia. En España una de cada tres muertes totales y una de cada dos muertes por enfermedades cardiovasculares están relacionadas con la presión arterial (PA), y la HTA, como entidad propia, lo está con una de cada cuatro muertes totales y una de cada 2,5 muertes cardiovasculares1. La HTA suele requerir para su control el tratamiento crónico con fármacos y su diagnóstico generalmente es efectuado por el médico general/de familia en la consulta de atención primaria (AP), mediante la medición repetida de la PA en condiciones estandarizadas, utilizando el esfigmomanómetro de mercurio y el método auscultatorio de Korotkoff. La gran variabilidad de las cifras de PA en un mismo individuo y sus propias circunstancias hacen que su medida en la consulta del médico pueda no reflejar su valor real en otro ambiente, como el trabajo o el hogar2. Desde hace varias décadas, se ha comprobado que la determinación de la PA aislada en consultorio, aun con el mayor de los cuidados, supera casi siempre a la que se registra en el domicilio del paciente3,4, lo que le confiere al diagnóstico de la HTA por medio de la medición tensional convencional una especificidad del 70-80%, existiendo un 20-30% de hipertensos que realmente son normotensos5. Teniendo en cuenta estas consideraciones, y aun cuando la medida casual de la PA en la consulta ha sido la base para el conocimiento de la HTA y de sus consecuencias como factor de riesgo cardiovascular, así como para establecer el diagnóstico y conocer el grado de control terapéutico6, se han desarrollado nuevos sistemas y han aparecido nuevas técnicas, más precisas, que han permitido seguir profundizando en el conocimiento del comportamiento de la PA y su variabilidad. Esta variabilidad puede dar lugar a un diagnóstico inadecuado o a una clasificación errónea del estado hipertensivo de algunos individuos, así como una estratificación equivocada del riesgo cardiovascular7, precisando, por tanto, de una correcta identificación, que puede realizarse con la automedida de la presión arterial (AMPA) o la monitorización ambulatoria de la presión arterial (MAPA). Esta última técnica tiene como principales inconvenientes su escasa disponibilidad y su elevado coste, estando habitualmente disponible únicamente en el ámbito especializado de la HTA. La AMPA, por el contrario, se puede considerar una técnica diagnóstica sencilla, rápida y de bajo coste, que realizada en unas condiciones determinadas parece segura y fiable8,9, habiendo sido contrastada con la MAPA en países anglosajones10 y en el ámbito de la AP de nuestro país, obteniendo una buena concordancia y fiabilidad (sensibilidad del 84,2% y especificidad del 82,5%)11. Por lo tanto, parece razonable que la AMPA, conocida desde hace años pero todavía con escasa implantación, al amparo de las recomendaciones de los expertos y las sociedades científicas experimente un gran desarrollo y vaya introduciéndose en el diagnóstico, seguimiento y control de HTA en AP12, con el objetivo de identificar mejor a los pacientes hipertensos, mejorar el porcentaje de pacientes con control óptimo de su PA y disminuir de forma concluyente su morbimortalidad. Por otro lado, aunque la AMPA parece un técnica sencilla, no está exenta de complejidades y todavía existen aspectos no totalmente clarificados en la misma que precisan estudios prospectivos que evalúen su utilidad real en condiciones de práctica clínica. Con la intención de recoger toda la evidencia disponible relacionada con la AMPA, un comité de expertos de la Asociación Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEHLELHA), publicó en el año 1998 un informe para proporcionar información a pacientes y personal sanitario13, documento que parecía lógico y necesario dada la incertidumbre en la interpretación y utilización de esta técnica. Desde entonces, han aparecido nuevos datos y recomendaciones al respecto que, conjuntamente con las vigentes, pretende analizar esta revisión. formación continuada

Inercia terapéutica en pacientes hipertensos asistidos en atención primaria en España. Estudio Objetivo Kontrol

OBJECTIVES To determine the level of therapeutic inertia (TI), and the factors associated to the patient, doctor and the health organisation, in hypertensive patients treated in Primary Care (PC). DESIGN Cross-sectional, multicentre study. SETTING A sample of PC Teams from all over Spain. PARTICIPANTS The study was conducted among PC doctors using a questionnaire and clinical records of 4 patients. MAIN MEASUREMENTS The TI was calculated for each patient (TIp) as the proportion of visits in which there was no change in medication when this was indicated. RESULTS A total of 543 PC doctors provided data on 2,032 patients, who fulfilled the indication of a change in requirement. There was TI In 77.8% of cases. The TIp observed was non-existent or low for 17.1% of the patients, intermediate for 42% and high for 40.8%. For the patients, the factors most associated with TIp were, age (P<.001), diabetes (P<.001), stroke (P<.01), obesity (P<.01) and a low education level (P<.001). To be female, be less than 40 years or more than 55 years, to be a family doctor with a training program other than MIR and to work in the public sector increased the probability of TIp (P<.001 for all the assumptions). CONCLUSIONS The results of the study indicate that there is TI in 7 out every 10 visits made by hypertensive patients in Primary care. There are significant differences as regards the clinical characteristics of the patients and of the doctors.

Prevalencia de la enfermedad renal crónica oculta en la población dislipémica asistida en atención primaria. Estudio LIPICAP.

BACKGROUND AND OBJECTIVE: Information about the prevalence of chronic kidney disease (CKD) in population treated in primary care (PC) is scarce. The aim of this study was to determine undetected CKD prevalence in dyslipidemic population measuring creatinine clearance according to the Cockcroft-Gault equation corrected for surface area. PATIENTS AND METHOD: Cross-sectional study including patients with diagnosis of dyslipidemia selected by consecutive sampling in PC. CKD was diagnosed when the glomerular filtration rate (GFR) was < 60 ml/min/1.73 m2. We assessed sociodemographic and clinical data, cardiovascular risk factors, coronary disease risk categories, dyslipidemia characteristics, functional CKD stage, and pharmacological treatments. RESULTS: The sample included 5,990 patients (50.2% women). The mean (standard deviation) age was 60.9 (11.1) years. The main reason for iclusion was hypercholesterolemia (65%), followed by mixed hyperlipidemia (26.4%), low high density lipoproteins (HDL)-cholesterol (4.9%) and hypertrigliceridemia (3.7%). According to the Cockcroft-Gault equation, CKD prevalence was 16.2% (95% confidence interval, 15.3-17.1) and it was significantly higher in women (22.7%) than in men (9.8%) (p < 0.0001). Patients with CKD were older compared with patients with normal GFR, and had higher systolic blood pressure, glucose and HDL-cholesterol (p < 0.001), as well as lower levels of total cholesterol, low density lipoproteins-cholesterol, and triglycerides (p < 0.01). The probability of presenting CKD was related to female gender, age, and lower body mass index. CONCLUSIONS: The LIPICAP study results indicate that almost 20% of PC dyslipidemic patients in Spain present undetected CKD when the GFR is measured according to the Cockcroft-Gault equation corrected for surface area.

Clinical Profile and Blood Pressure Control in Patients Managed in Primary Care in Spain: Are There any Differences Between the Young and the Old?

Although the increase in the worldwide prevalence of hypertension is largely caused by population aging, changes in behavior (sedentary lifestyle, obesity, increased dietary salt intake, etc) have increased the number of individuals who develop hypertension at earlier ages. Thus, specific analysis of the management and degree of blood pressure (BP) control in this collective in Spain would appear to be timely. The PRESCAP 2010 (blood pressure in the Spanish population attending primary care centers) study was designed to determine the degree of BP control in a large hypertensive population managed in the primary care setting and receiving drug therapy. The objective of the study was to analyze the clinical profile and management of hypertensive patients by age group. The PRESCAP 2010 study included 12 961 hypertensive individuals, of which 440 (3.4%) were younger than 45 years; 1672 (12.9%) were aged 45 to 54 years; and 10 849 were older than 54 years. As the patients aged, systolic BP increased, as did the proportion of patients with dyslipidemia, diabetes mellitus, target organ damage, and cardiovascular disease (Table 1). In contrast, patient aging was associated with decreasing diastolic BP and reductions in the proportion of smokers and of patients with a family history of cardiovascular disease. BP control worsened as the patients aged (62.3%, 54.8%, and 44.0%, respectively; P=.0001), despite the more widespread use of combination therapy (43.4%, 49.9%, and 66.4%, respectively; P=.0001) (Table 2). As patient age increased, physicians introduced fewer changes to the hypertensive therapy (36.3%, 35.1%, and 27.5%, respectively; P=.0001). The most common measure in all 3 groups was to associate another medication, followed by increasing the dose and, least frequently, changing the drug therapy, with no significant differences among the age groups (Table 2). In our study, we observed that, as the patients aged, the risk profile deteriorated, with a greater number of risk factors and greater development of target organ damage and associated cardiovascular disease. However, in the youngest patients, although other cardiovascular risk factors were frequently present, clinically evident cardiovascular disease was relatively uncommon. This result is unsurprising since atherosclerotic disease takes years to become apparent. However, because the number of associated risk factors has increased, compared with the situation in earlier decades, the clinical signs of cardiovascular disease appear at increasingly earlier ages. Hypertension has been shown to increase the risk of cardiovascular complications in all age groups, including the youngest. Although adequate BP control has become more widespread in recent years, its prevalence is still far from being acceptable. In our study, patients aged 45 to 54 years had an appreciably higher rate of adequate BP control than those of more advanced age, and BP control was even better among those younger than 45 years. However, 40% to 45% of young hypertensive individuals in Spain do not achieve adequate BP control. Given that only treated hypertensive patients were included in the PRESCAP 2010 study, these rates may be even higher among young hypertensives in the general population. Moreover, there are probably cases of undiagnosed hypertension in this age group since these individuals usually visit their physicians less frequently and more sporadically than older persons. The improvement in BP control observed in recent years has been related in part to the more widespread use of combination therapy. In our study, somewhat less than half of the patients

Primera pauta de tratamiento antirretroviral en pacientes con infección por el virus de la inmunodeficiencia humana. Durabilidad y factores asociados a su modificación

Objetivos Se evaluo la durabilidad de la primera pauta de tratamiento antirretroviral de gran actividad (TARGA) en pacientes sin tratamiento antirretroviral previo infectados por el virus de la inmunodeficiencia humana (VIH) y los factores asociados a su modificacion. Metodos Estudio multicentrico, retrospectivo, de pacientes con infeccion por el VIH que iniciaron su primer TARGA entre 1997 y 2003. La variable principal medida fue la durabilidad de la primera pauta de TARGA hasta su cambio. Se realizo estadistica descriptiva, curvas de Kaplan-Meier para evaluar la durabilidad y se construyo un modelo de regresion multiple de Cox para valorar los factores asociados a la durabilidad. Resultados Iniciaron su primer TARGA 603 pacientes y 130 (21,6%) lo mantuvieron hasta la visita final, con una mediana de duracion de 17,5 meses. Un 36% de los pacientes interrumpio el tratamiento antes del ano. Cuando se excluyeron las causas “no desfavorables” (simplificacion/interrupcion estructurada), la mediana de duracion aumento hasta los 2 anos. La causa principal del cambio fue la toxicidad (25%), seguida de la simplificacion (19%) y el fracaso virologico (15%). Se encontro una mayor durabilidad de las pautas con un inhibidor de la transcriptasa inversa no analogo de nucleosidos (ITINAN) (p Conclusion La mediana de duracion del primer TARGA fue algo menor de 1,5 anos y la causa principal del cambio fue la toxicidad. Se constata una mayor durabilidad de las pautas con ITINAN que, al menos en parte, podria explicarse por su menor numero de comprimidos.

Programa de prevención y control de la tuberculosis en el medio penitenciario

Objetivos Se realizo este estudio en los Centros Penitenciarios de Ocana I y Ocana II para conocer los resultados de la aplicacion y desarrollo del programa de prevencion y control de la tuberculosis (TB). Asi mismo se estudia la relacion entre la TB y variables de riesgo. Sujetos y metodo Se trata de un estudio epidemiologico descriptivo transversal, en el que se incluyeron 559 internos varones, de los 2 centros penitenciarios en el ano 1996. Se analizaron variables sociales, demograficas y factores de riesgo. Resultados El grupo de edad mas destacado fue el comprendido en 20-29 anos (56,7%). Un 49,5% presentaba un primer Mantoux positivo. El principal motivo por lo que no se inicio la quimioprofilaxis (QMP) fue la negativa del propio interno (52,1%). El 42,9% de los casos que inicio la QMP la completaron. El riesgo de presentar TB fue 15,4 veces superior entre los pacientes con anticuerpos frente al virus de la inmunodeficiencia humana (VIH)+ mas que entre los VIH-, con una odds ratio (OR) (IC del 95%) de 15,4 (7,2-33,4). El riesgo de presentar TB fue 8,04 veces superior en los usuarios de drogas por via parenteral (UDVP), que entre los no UDVP, OR (IC del 95%) de 8,04 (3,74-17,7). Conclusiones Se ha encontrado una elevada prevalencia de infeccion tuberculosa, siendo la negativa del propio interno para iniciar la QMP la principal dificultad para desarrollar correctamente el programa. El riesgo de presentar TB es superior en los VIH+ y en los UDVP.

Diferencias de presión arterial entre una toma y la media de 3 tomas medidas automáticamente. Estudio SPRINT

BACKGROUND AND OBJECTIVES There are discrepancies regarding how to measure blood pressure (BP). The goal of this study was to determine the differences between one automatic BP measurement and the mean of 3 automatic BP measurements. PATIENTS AND METHOD Two patient populations were used. A sample population (n=1,337) in which the measurement was performed by a nurse at the health center, and a consecutive series of patients (n=200) who had the measurement performed in front of the doctor in the office. RESULTS The differences found between the first reading and the average of 3 determinations were small in both cases. In the population sample, BP levels ranged from 2.07 to 3.21mmHg, and in patients who had their BP levels measured in the presence of doctor, this value ranged from 2.71±3.82mmHg (systolic pressure), with minimal differences in diastolic BP levels. CONCLUSIONS Little difference was found between the first determination and the average of 3 automatic BP readings.