Javier García-Alegría

Core competencies in Internal Medicine

The working group on Competencies of Internal Medicine from the Spanish Society of Internal Medicine (SEMI) proposes a series of core competencies that we consider should be common to all European internal medicine specialists. The competencies include aspects related to patient care, clinical knowledge, technical skills, communication skills, professionalism, cost-awareness in medical care and academic activities. The proposal could be used as a working document for the Internal Medicine core curriculum in the context of the educational framework of medical specialties in Europe.

Ankle-branch index and HIV: the role of antiretrovirals.

To study the relationship between antiretroviral (ARV) treatment and abnormal ankle–branch index (ABI) and to compare the risk factors for altered ABI.

Ankle-brachial index in HIV infection

Prognosis for patients with the human immunodeficiency virus (HIV) has improved with the introduction of highly active antiretroviral therapy (HAART). Evidence over recent years suggests that the incidence of cardiovascular disease is increasing in HIV patients. The ankle-brachial index (ABI) is a cheap and easy test that has been validated in the general population. Abnormal ABI values are associated with increased cardiovascular mortality. To date, six series of ABI values in persons with HIV have been published, but none was a prospective study. No agreement exists concerning the risk factors for an abnormal ABI, though its prevalence is clearly higher in these patients than in the general population. Whether this higher prevalence of an abnormal ABI is associated with a higher incidence of vascular events remains to be determined.

Pre-hospital antibiotic treatment and mortality caused by invasive meningococcal disease, adjusting for indication bias

BackgroundMortality from invasive meningococcal disease (IMD) has remained stable over the last thirty years and it is unclear whether pre-hospital antibiotherapy actually produces a decrease in this mortality. Our aim was to examine whether pre-hospital oral antibiotherapy reduces mortality from IMD, adjusting for indication bias.MethodsA retrospective analysis was made of clinical reports of all patients (n = 848) diagnosed with IMD from 1995 to 2000 in Andalusia and the Canary Islands, Spain, and of the relationship between the use of pre-hospital oral antibiotherapy and mortality. Indication bias was controlled for by the propensity score technique, and a multivariate analysis was performed to determine the probability of each patient receiving antibiotics, according to the symptoms identified before admission. Data on in-hospital death, use of antibiotics and demographic variables were collected. A logistic regression analysis was then carried out, using death as the dependent variable, and pre-hospital antibiotic use, age, time from onset of symptoms to parenteral antibiotics and the propensity score as independent variables.ResultsData were recorded on 848 patients, 49 (5.72%) of whom died. Of the total number of patients, 226 had received oral antibiotics before admission, mainly betalactams during the previous 48 hours. After adjusting the association between the use of antibiotics and death for age, time between onset of symptoms and in-hospital antibiotic treatment, pre-hospital oral antibiotherapy remained a significant protective factor (Odds Ratio for death 0.37, 95% confidence interval 0.15–0.93).ConclusionPre-hospital oral antibiotherapy appears to reduce IMD mortality.

Disseminated histoplasmosis successfully treated with liposomal amphotericin B following azathioprine therapy in a patient from a nonendemic area

Histoplasma infections in Europe are rare, and acute disseminated histoplasmosis has been observed only in immunocompromised persons. An unusual case of autochthonous disseminated histoplasmosis in a 22-year-old Spanish man who had been treated with azathioprine and prednisone for 4 weeks before admission is reported. The development of an acute form of the disease may represent an endogenous reactivation of a latent infection as a complication of immunosuppression resulting from the use of these drugs. This case illustrates the potential risk of this opportunistic fungal infection in patients receiving azathioprine therapy, an association that has been rarely described before.

Indicadores de calidad relacionados con el reingreso y la muerte precoces tras la hospitalización por insuficiencia cardíaca

BACKGROUND AND OBJECTIVE To determine wether the quality of care criteria applied and the treatment provided to patients hospitalized after congestive heart failure were appropriate to reduce rates of premature readmission and death. PATIENTS AND METHOD We analyzed the epidemiologic, clinical and quality of care data proposed by 3 international organizations: JCAHO, AHA/ACC and ACOVE Project. The dependent variable was defined as readmission or death during the 30 days after discharge. A multivariate analysis was made using multiple binary logistic regression of the parameters of quality of care and treatment appropriateness. RESULTS 225 hospital discharge records were analyzed. There were 21 readmissions and 3 deaths (i.e., 24 cases [10.7%] with a positive dependent variable). 162 records (72%) corresponded to patients aged 65 years and over, who presented a total of 18 (8%) readmissions or premature deaths. A positive association between readmission or premature death was found with regard to 2 variables: appropriate treatment with beta-blockers (odds ratio [OR] = 0.34) and the Charlson index (OR = 3,79 for score of 3 or more vs. score of 2 or less). In the case of patients aged 65 years and over the same 2 variables were positively associated, with OR similar to those cited (OR = 0.31 and 3.21, respectively). No association was found between premature readmission or death and the overall evaluation of the criteria referred to by AHA/ACC, JCAHO or the ACOVE Project. CONCLUSIONS Premature readmission or death of patients with heart failure is more determined by the characteristics of the clinical state of patients (the Charlson comorbidity index) and by the appropriateness of the treatment applied (treatment with beta-blockers) than by the accomplishment of quality of care criteria as proposed by the cited scientific organizations.Fundamento y objetivo: Determinar si los criterios de calidad de cuidados y el tratamiento aplicados a los pacientes hospitalizados por insuficiencia cardiaca congestiva son apropiados para reducir la tasa de reingreso y muerte precoces. Pacientes y metodo: Analizamos los datos epidemiologicos, clinicos y de calidad de cuidados propuestos por 3 organizaciones internacionales: JCAHO, AHA/ACC y Proyecto ACOVE. La variable dependiente se definio como el reingreso o el fallecimiento en los 30 dias siguientes al alta. Se realizo un analisis multivariante mediante regresion logistica con los parametros de calidad de cuidados y lo apropiado del tratamiento. Resultados: Se registraron 225 altas hospitalarias. Se produjeron 21 reingresos y 3 fallecimientos (24 casos de variable dependiente positiva; 10,7%). Un total de 162 altas (72%) correspondian a pacientes mayores de 65 anos, que presentaron 18 (8%) reingresos o muertes precoces. Se hallo una asociacion de la variable dependiente con 2 variables: lo apropiado del tratamiento con bloqueadores beta (odds ratio [OR] = 0,34) y el indice de Charlson (OR = 3,79 para puntuaciones de 3 o superiores frente a 2 o inferiores). En el caso de pacientes mayores de 65 anos, las mismas 2 variables se comportaron como predictores independientes, con OR similares a las anteriores (OR = 0,31 y 3,21, respectivamente). No se hallo relacion con la valoracion global de los criterios indicados por JCAHO, AHA/ACC y el Proyecto ACOVE. Conclusiones: El reingreso y la muerte precoces de los pacientes con insuficiencia cardiaca estan mas determinados por las caracteristicas de la situacion clinica de los pacientes (indice de comorbilidad de Charlson) y lo apropiado del tratamiento aplicado (bloqueadores beta) que por el cumplimiento de los criterios de calidad de cuidados propuestos por diferentes organizaciones cientificas.

Left ventricular hypertrophy detected by echocardiography in HIV-infected patients

BACKGROUND Left ventricular hypertrophy (LVH) is a predictor of overall mortality in the general population. The most sensitive diagnostic method is transthoracic echocardiography (TTE). In this study, we describe the prevalence of LVH, and the factors associated with it, in a group of patients with HIV infection. METHODS TTE was offered to all patients attending the outpatient clinic of the Hospital Costa del Sol (Marbella, Spain) between 1 December 2009 and 28 February 2011. The corresponding demographic and clinical data were obtained. The left ventricular mass (LVM) was calculated and indexed by height(2.7). LVH was defined as LVM >48g/m(2.7) in men or >44g/m(2.7) in women. RESULTS We examined 388 individuals (75.5% male, mean age 45.38years). Of these, 76.1% were receiving HAART; 11.9% had hypertension, 6.2% had diabetes mellitus, 23.2% had dyslipidaemia and 53.6% were tobacco users. The risk of cardiovascular disease at 10years (RV10) was 12.15% (95%CI: 10.99-13.31%). 19.1% of these patients had a high RV10. A total of 69 patients (19.8%) presented high LVM. Age, hypertension, dyslipidaemia, RV10 and the use of nevirapine were associated with a greater presence of LVH in the univariate analysis. In the logistic regression analysis performed, the factors retained in the model were the presence of high RV10 (OR: 2.92, 95%CI: 1.39-6.15) and the use of nevirapine (OR 2.20, 95%CI: 1.18-4.14). CONCLUSIONS In this group of patients, the use of nevirapine and the presence of high RV10 were associated with LVH. The use of nevirapine might be related to its prescription for patients with higher RV10.

Seroprevalence of antibodies to the influenza A (H1N1) virus among healthcare workers prior to the 2009 pandemic peak.

Abstract Objective Our aim was to study the proportion of healthcare workers with a positive serology for Influenza A(H1N1)2009 without having flu, in a Spanish hospital at the beginning of the pandemic. Methods A survey study carried out during August 2009 (before the peak of the pandemic in Spain) in the Hospital Costa del Sol, a second level hospital with almost 300 beds in the South of Spain. The participants were workers in the following hospital units: Emergencies, Medical Area (Internal Medicine, Chest Diseases), Surgical Area (General Surgery and Anaesthesia) of any professional category. A study was made of the proportion of healthcare workers in our hospital with positive serology for the new influenza A (H1N1)2009 virus, as determined by the haemagglutination inhibition technique (≥1/40). The subjects completed a health status questionnaire, and provided a blood sample for serology testing. Results A total of 239 workers participated, of whom 25.1% had positive serology. The hospital area in which most individuals had positive serology was the Emergency Department (36.6%), while the professional category in which most individuals with a positive serology worked was that of the orderlies (41.7%). Conclusion Around 25% of healthcare workers in our hospital had positive serology before the peak of the pandemic, none of them had received vaccine for Influenza A (H1N1) 2009 or had been diagnosed of influenza previously.

Casos autodeclarados de síndrome gripal en trabajadores sanitarios españoles durante la pandemia de gripe A (H1N1) 2009

OBJECTIVES To describe the prevalence of influenza-like syndrome in winter 2009 and the factors associated with its occurrence. METHODS A cross-sectional study was carried out in 18 hospitals in Spain. Volunteers completed a health questionnaire in which they reported the occurrence of influenza-like syndrome and vaccination and demographic status. RESULTS A total of 1,289 healthcare workers participated. Of these, 72 (5.6%) reported influenza in their family, 195 (15.1%) had been vaccinated against the A/California/7/2009/H1N1 virus and 75 (5.8%, 95%CI: 4.5-7.1%) had been diagnosed with influenza like-syndrome. There were differences among regions. In logistic regression analysis, the following factors were associated with a higher prevalence of influenza-like syndrome: working in Madrid (OR=8.31, 95%CI: 1.05-65.39), the occurrence of cases of influenza in the family (OR=2.84, 95%CI: 1.41-5.73) and not having been vaccinated against influenza A (H1N1) (OR=2.68, 95% CI: 1.05-6.82). CONCLUSIONS Differences in the prevalence of influenza-like syndrome were due to the occurrence of familiar cases and region. Vaccination against influenza A (H1N1) was associated with a lower prevalence of the disease.

Raltegravir en pacientes con infección por el virus de la inmunodeficiencia humana y alto riesgo vascular

OBJECTIVES To record the experience with use of raltegravir (RTG) for devising highly active antiretroviral therapy (HAART) regimens based on RTG in high vascular risk patients. METHODS A retrospective study was conducted on high vascular risk patients taking RTG. Case was a patient who, at the time raltegravir was started, had ≥ 20% 10-year risk of cardiovascular disease, estimated by the algorithm of the European AIDS Clinical Society. Patients should have been on stable HAART including RTG for at least six months. A matched control with ≥ 20% risk of cardiovascular disease, was selected for each case. RESULTS Ten controls and ten cases were selected. After six months using RTG, a significant decreased was seen in levels of HDL cholesterol (median -2,5mg/dL in controls versus 2,5mg/dL in cases, p=0.015), triglycerides (10mg/dL versus -101 mg/dL, p=0.009), and TC/HDL-C ratio (0.17 versus -0.73, p=0.002). Ten-year risk of cardiovascular disease was -4.85% in cases versus -0.05% in controls (p=0.07). CONCLUSIONS RTG shows a good profile to be used in people with high vascular risk, with a decrease in TC/HDL-C ratio and vascular risk.