Jesús Díez

Estudio multicéntrico sobre prevalencia de las coinfecciones por virus de hepatitis, indicaciÓn de tratamiento de hepatitis crÓnica C y necesidad de trasplante hepático en pacientes infectados por el VIH en España.Estudio GESIDA 29/02-FIPSE 12185/01

Introduccion Los objetivos del estudio son estimar la prevalencia de las coinfecciones por virus de la hepatitis en la poblacion espanola infectada por el VIH y determinar el porcentaje de pacientes candidatos a tratamiento de la hepatitis C cronica (HCC) y a trasplante hepatico dentro de esta poblacion. Metodos Estudio transversal de dos poblaciones de pacientes infectados por el VIH realizado en el ano 2002: 1.260 pacientes de la poblacion de 39 centros de toda la geografia espanola (P1) y 1.560 pacientes de la de tres hospitales de tercer nivel de Madrid (P2). Resultados La prevalencia serica de virus de las hepatitis A (VHA), B (VHB) y HCC encontrada respectivamente en P1 y P2. IgG anti-VHA+: 74% y 78%. HBsAg+: 4,9 y 4,8%. HBsAg−, anti-HBc+, anti-HBs+: 39 y 39%. HBsAg−, anti-HBc+, anti-HBs− : 25 y 31%. HBsAg−, anti-HBc−, anti-HBs+: 7 y 8%. HBsAg−, anti-HBc−, anti-HBs− : 22 y 16%. Anti-VHC+: 61 y 65%. Entre estos 88,8 y 84,6% tenian una PCR VHC+. Coinfeccion multiple por virus de la hepatitis 3,2 y 2,8% y de estos, 70 y 78% con coinfeccion por el VHB, el VHC y el VHD. Cirrosis hepatica el 5,8 y 9,6% de los pacientes coinfectados por el VIH y el VHC, con indicacion de considerar trasplante hepatico aproximadamente en uno de cada seis. El 43 y 37% de los coinfectados por el VHC eran buenos candidatos a tratamiento de HCC, pero solo el 14 y el 15% lo habian iniciado. Conclusiones Un elevado porcentaje de pacientes infectados por el VIH en Espana estan coinfectados por virus de hepatitis, especialmente por el tipo C (VHC). El numero de posibles candidatos a trasplante hepatico es elevado y puede aumentar en los proximos anos. En el futuro sera necesario un mayor esfuerzo de tratamiento en los pacientes coinfectados por el VIH y virus de hepatitis.

Outcomes with respect to disabilities of the upper limb after hand allograft transplantation: a systematic review

The aim of this work is to compare disabilities of the upper limb before and after hand allograft transplantation (HAT), and to describe the side effects of immunosuppressive (IS) agents given to recipients of hand allografts. Clinical cases of HAT published between 1999 and 2011 in English, French, or German were reviewed systematically, with emphasis on comparing disabilities of the arm, shoulder and hand (DASH) scores before and after transplantation. Duration of ischemia, extent of amputation, and time since amputation were evaluated for their effect on intrinsic musculature function. Infectious, metabolic, and oncological complications because of IS therapy were recorded. Twenty‐eight patients were reported in 56 clinical manuscripts. Among these patients, disabilities of the upper limb dropped by a mean of 27.6 (±19.04) points on the DASH score after HAT (Pu2003=u20030.005). Lower DASH scores (Pu2003=u20030.036) were recorded after secondary surgery on hand allografts. The presence of intrinsic muscle function was observed in 57% of the recipients. Duration of ischemia, extent of transplantation, and time since amputation were not associated statistically with the return of intrinsic musculature function. Three grafts were lost to follow‐up because of noncompliance with immunosuppression, rejection, and arterial thrombosis, respectively. Fifty‐two complications caused by IS agents were reported, and they were successfully managed medically or surgically. HAT recipients showed notable functional gains, but most complications resulted from the IS protocols.

HAART is associated with lower hepatic necroinflammatory activity in HIV–hepatitis C virus-coinfected patients with CD4 cell count of more than 350 cells/μl at the time of liver biopsy

Objective:To evaluate the impact of HAART on the liver damage of HIV–hepatitis C virus (HCV)-coinfected patients with relatively preserved immune status. Design:Cross-sectional study of liver biopsies. Methods:HIV–HCV-coinfected patients who underwent liver biopsies and had a CD4 cell count of at least 350 cells/μl at the time of liver biopsy were included. Exclusion criteria included positive hepatitis B surface antigen and prior anti-HCV therapy. Necroinflammatory activity and fibrosis was scored by the Scheuer fibrosis staging system. Steatosis was scored according to the percentage of hepatocytes affected. Logistic regression analysis was used to assess determinants of necroinflammatory activity of at least 3. Results:One hundred and nineteen HIV–HCV coinfected patients were included. In the univariate analysis, alcohol abuse, serum alanine aminotransferase levels, steatosis and a high fibrosis score were significantly associated with higher necroinflammatory activity. In the multivariate analysis, a high level of alanine aminotransferase, advanced fibrosis and absence of HAART were associated with higher necroinflammatory activity. Conclusion:Use of HAART was associated with lower levels of necroinflammatory activity. Necroinflammatory activity was strongly associated with higher fibrosis scores. These results suggest that HAART might decrease hepatitis C activity in HIV–HCV-coinfected patients with CD4 cell count of more than 350 cells/μl.

Factors Influencing Acute Rejection of Human Hand Allografts: A Systematic Review

AbstractAcute rejection (AR) of human hand allografts (HHAs) may carry a risk of graft loss and leads to the need for immunosuppressive treatment. The literature on HHAs was reviewed to determine and evaluate the factors that trigger AR of HHAs. Clinical case reports of hand allograft transplantation published between 1999 and 2011 in English, French, or German were reviewed systematically. The number of AR episodes was the main outcome measure. Sixty-eight episodes of AR were described in 28 recipients. Calcineurin inhibitor-based maintenance regimens were associated with significantly fewer AR episodes than non–calcineurin inhibitor-based regimens (mean 1.9 vs 3.2; P = 0.018). In recipients who experienced cytomegalovirus infection, the mean number of episodes of AR was 4, whereas in those who did not experience cytomegalovirus infection it was 2.25 (P = 0.024). The planning of hand allograft transplantation should take these factors into account to minimize the risk of AR.

Factores asociados con esteatosis hepática en pacientes coinfectados por los virus de la inmunodeficiencia humana y de la hepatitis C

BACKGROUND AND OBJECTIVEnTo determinate the prevalence and factors associated with hepatic steatosis and severity of steatosis in human immunodeficiency virus (HIV) and hepatits C virus (HCV) coinfected patients.nnnPATIENTS AND METHODnLiver histology was assessed in 163 HIV-HCV coinfected patients. Exclusion criteria included positive hepatitis B surface antigen and prior anti-HCV therapy. Steatosis was scored by a single pathologist according to the percentage of affected hepatocytes. Necroinflammatory activity and fibrosis was scored by the Scheuer system. Logistic regression analyses were used to evaluate variables associated with hepatic steatosis.nnnRESULTSnSteatosis was present in 65% of biopsy samples. Moderate-severe steatosis (>30% of hepatocytes) was detected in 17% of patients. 78.5% of patients were under high active antiretroviral therapy at the time of biopsy. In a multivariate analysis, steatosis was associated with body weight, alcohol, advanced fibrosis, stavudine use and non-use of lopinavir/ritonavir. In a multivariate analysis, severity of steatosis (>30% of hepatocytes) was associated with alcohol, HCV genotype 3, HCV load >1,400,000 copies/ml and advanced fibrosis.nnnCONCLUSIONSnThe presence of hepatic steatosis and severity of steatosis were associated with advanced fibrosis in patients coinfected with HIV and HCV. Body weight, consumption of alcohol and antiretroviral therapy (stavudine use and absence of exposure to lopinavir/ritonavir) were modifiable factors associated with the presence of steatosis. Characteristics of HCV infection were associated with the severity of steatosis in this population.

Usefulness of 64-detector computed tomography in the diagnosis and management of patients with congenital heart disease.

INTRODUCTION AND OBJECTIVESnAlthough congenital heart defects are the most common major congenital abnormalities, the associated mortality has been decreasing due to improvements in their diagnosis and treatment. We assessed the usefulness of 64-multidetector computed tomography in the diagnosis and management of these patients.nnnMETHODSnThis 5-year observational, analytical, retrospective, cohort study included a total of 222 tomographic studies of patients with congenital heart disease. Computed tomography scans were read twice and medical records were reviewed. We assessed the complexity of the disease, patient, and radiological technique, and evaluated the contribution of new data in relation to clinical suspicion and diagnostic change. A confidence interval was set at 95% and a P value of<.05 was used as the cutoff for statistical significance.nnnRESULTSnIn 35.1% of patients, the treatment procedure was performed after computed tomography without other tests. Additional diagnostic catheterization was performed in 12.5% of patients. There were new findings in 77% of patients (82.9% with complex disease), which prompted a change in patient management in 35.6%. All unexpected reports described new findings. No significant differences were found by age, sex, study period, urgency of the test order, patient complexity, or difficulty of the technique.nnnCONCLUSIONSnUse of 64-detector computed tomography yields good diagnostic performance in congenital heart disease, prompts changes in management in more than one-third of patients, and reveals new findings in relation to the presumed diagnosis in 77% of patients.

Safety of salvaging impending flap congestion in breast reconstruction by venous supercharging of the cephalic vein.

AbstractAutologous flap breast reconstruction is an established technique that carries a risk of vascular failure. We evaluated the safety of salvaging impending venous congestion by using the cephalic vein for supercharging autologous abdominal flaps. Our main outcome measures were flap survival, triggering or impairing lymphedema as measured by the physician or reported by the patient, and scar severity as measured by the Vancouver scar scale. We were able to save 100% of the flaps, but could not find any statistical association with or without increased lymphedema before and after the procedure. One patient reported that lymphedema worsened. The patients accepted the scars (mean Vancouver scar scale score, 5.7). In sum, using the cephalic vein to improve venous drainage of autologous breast reconstruction was safe and did not trigger or impair lymphedema, but scarring in the upper arm was unavoidable.

VIM-Klebsiella oxytoca outbreak in a Neonatal Intensive Care Unit. This time it wasn't the drain

ObjectivenWe describe an outbreak of VIM-carbapenemase Klebsiella oxytoca (VIM-Kox) in a NICU.nnnMaterials and methodsnProspective Epidemiological Surveillance:Systematically (weekly screening cultures) or on admission, if the patient had a history of previous colonization by VIM-Kox.Clinical cultures, done if infection was suspected.Other possible microorganism sources were investigated: their mothers (rectal microbiota), milk packages and preparation apparata in the lactodietary section, echocardiagram transductors, cribs, the sinks (faucets and drains), washing bowls, etc.Molecular typing was performed using the DiversiLab (bioMérieux) system on all VIM-Kox isolated from environment or patients (one by neonate).nnnResultsnWe identified 20 VIM-Kox cases, the most only presented colonization, but 4 showed infection. Three of the ten sinks (drains) in our NICU, were positive for VIM-Kox. Another four drains harbored P.aeruginosa, S. maltophilia and/or Enterobacter sp. Nevertheless the VIM-Kox bacteria in the sinks (drains) were not the same as those in the patients, who showed three different strains.nnnConclusionsnA VIM-Kox colonization or infection outbreak in a NICU is described. Rather than environment, not even drains, the source of the outbreak was other patients. The outbreak was relatively brief, as a result of the rapidness with which appropriate measures were taken and followed.

Effect of Cold Preservation on Chronic Rejection in a Rat Hindlimb Transplantation Model.

Background: Previous studies on solid organ transplantation have shown that cold ischemia contributes to the development of chronic allograft vasculopathy. The authors evaluated the effect of cold ischemia on the development of chronic rejection in vascularized composite allotransplantation. Methods: Thirty rat hindlimbs were transplanted and divided into two experimental groups: immediate transplantation and transplantation after 7 hours of cold ischemia. The animals received daily low-dose immunosuppression with cyclosporine A for 2 months. Intimal proliferation, arterial permeability rate, leukocyte infiltration, and tissue fibrosis were assessed. The CD3+, CD4+, CD8+, CD20+, and CD68+ cells per microscopic field (200×) were counted, and C4d deposition was investigated. Cytokine RNA analysis was performed to measure tumor necrosis factor-&agr;, interleukin-6, and interleukin-10 levels. Results: Significant differences were found in the intimal proliferation and arterial permeability rate between the two groups (p = 0.004). The arterial permeability rate worsened in the most distal and small vessels (p = 0.047). The numbers of CD3+, CD8+, CD20+, and CD68+ were also statistically higher in the cold ischemia group (p < 0.05, all levels). A trend toward significance was observed with C4d deposition (p = 0.059). No differences were found in the RNA of cytokines. Conclusions: An association between cold ischemia and chronic rejection was observed in experimental vascularized composite allotransplantation. Chronic rejection intensity and distal progression were significantly related with cold ischemia. The leukocyte infiltrates in vascularized composite allotransplantation components were a rejection marker; however, their exact implication in monitoring and their relation with cold ischemia are yet to be clarified.