Josep Roca

Mortality of HIV-positive and HIV-negative heroin abusers as a function of duration of injecting drug use

Objective: To determine the incidence of mortality of injecting drug users as a function of the duration of injecting drugs and HIV status, and to assess how these effects vary according to age at initiation and calendar period (before and after 1992). Methods and Design: Cohort of 376 intravenous heroin users admitted to detoxification between February 1987 and January 1990. Setting: Patients referred from outpatient clinics of metropolitan Barcelona. Duration and characteristics of drug use were determined by interviews. Blood samples were collected during admission and analyzed for HIV, CD4+ cell count and different biologic parameters. Assessment of vital status and causes of death were obtained by hospital charts, death certificates, and autopsies. Results: The study population consisted of 299 men and 77 women, whose mean age at entry was 26 years, mean duration of injecting drug use before admission 6.1 years; HIV seroprevalence at entry 70.2%. By the end of the follow‐up (median 5.6 years), 21.8% of individuals had died (26.6% in HIV‐positive, and 10.7% in HIV‐negative injecting users). Based on Kaplan‐Meier estimates, 10%, 20%, and 30% of HIV negative patients died by 8.7, 11.3 and 14.3 years, respectively, after initiating injecting drugs. The corresponding survival times for the seropositives were substantially lower: 6.6, 8.5, and 11.6 years, respectively. Overall, the survival time was significantly (p < .05) decreased by 22% in HIV‐positive injecting drug users. Older age at initiation of injecting drug use was significantly (p < .05) associated with mortality in HIV‐positive heroin users but it showed the opposite direction among HIV‐negative people. Death rates in HIV‐positive patients of the same duration of drug use were similar in periods before and after 1992 (relative hazard (RH) = 0.97; 95% confidence interval: 0.58‐1,61). Although not statistically significant, the hazard of death in HIV‐negative injecting drug users was substantially lower after 1992 (RH = 0.59). Conclusions: Before introduction of potent antiretroviral therapies, HIV infection further increased rates of mortality that had already been heightened by injecting drug use. Furthermore, HIV infection modifies the effect of age at initiation and eliminates the seemingly downward trend of mortality in HIV‐negative people.

Syphilis in injecting drug users : clues for high-risk sexual behaviour in female IDUs

The objective was to measure the gender-specific differences for syphilis and for the sexual transmission of human immunodeficiency virus (HIV) in a crosssectional analysis of injecting drug users (IDUs) admitted to detoxification between February 1987 and January 1990. HIV was determined by enzyme-linked immunosorbent assay (ELISA) and confirmed with Western blot. For syphilis reactive samples to a rapid plasma reagent (RPR) were confirmed with treponemal tests (FTA-ABS or MHA-TP). Of the 386 heterosexual IDUs, 68% were HIV-positive and 4.7% had serologic syphilis (RPR and FTA-ABS or MHA-TP positive). Syphilis was higher in women (12%) than in men (3%), and women reported a significantly (P< 0.001) higher number of sex partners. Men had an IDU as a sex partner more often than women did (P=0.001). Serologic syphilis in women was associated with having had more than one sexual partner in the previous year (P=0.028) but this association was not present in men. HIV infection was not associated with syphilis in male IDUs. However, HIV was present in all women with syphilis that reported more than one partner.

Ease of ventilation through the cuffed oropharyngeal airway (COPA), the laryngeal mask airway and the face mask in a cardiopulmonary resuscitation training manikin.

The aim of this study was to compare ease of ventilation of a cardiopulmonary resuscitation manikin using a cuffed oropharyngeal airway (COPA), a laryngeal mask airway (LMA) and a face mask, by two groups of people with different levels of earlier experience in cardiopulmonary resuscitation (CPR). Enrolled were, 108 people identified as experienced (54), or inexperienced (54), in CPR. Training equipment included a manikin, a COPA (n=10), an LMA (n=4), a face mask (n=4) and self-inflating bag-valve device. The same investigator explained the theoretical use and practice of the three techniques with the subjects in groups of three. The variables recorded were the number of attempts needed to achieve correct placement (and a tidal volume of 200 ml, was achieved), the insertion time for the COPA and the LMA, and the average time taken to achieve the first ten correct ventilations. The face mask and LMA required fewer attempts for correct placement than did the COPA. The LMA also took less time to insert than the COPA. The face mask required a significantly shorter total time with all attempts and the mean time of placement and time to achieve ten correct ventilations was shorter than with either the LMA or the COPA (P=0.0001). We conclude that the face mask offers an easier and quicker way to provide ventilation for CPR manikins than does the COPA or the LMA. Earlier experience affects the ease of insertion of the LMA and the total time needed to achieve effective ventilation.

Heart transplant recipient clinical profile improvement following mycophenolate mofetil late incorporation into the treatment schedule

Abstract:  Mycophenolate mofetil (MMF) has a better clinical profile than azathioprine in heart transplantation (HT). Forty‐five recipients (aged 53 ± 9 yr) were retrospectively evaluated (first year of follow‐up) post‐MMF introduction since its advent in 1997 (mean daily dose: 1.97 ± 0.2 g). MMF was used (mean post‐HT time: 40 ± 27 months) for: (i) renal insufficiency attenuation (group 1 = 20); (ii) steroid reduction because of osteoporosis (group 2 = 12); (iii) treatment of persistent cellular rejection (group 3 = 7) and vascular graft disease (VGD) (group 4 = 6). Mean changes (groups 1–2) were: creatinine 172 ± 59, 158 ± 51, 153 ± 57 μmol/L (at baseline, 6 and 12 months, respectively; p < 0.001). Cyclosporine daily dose: 219 ± 37, 166 ± 46, 176 ± 98 mg, respectively (p < 0.001). Cyclosporine blood concentration: 151 ± 40, 103 ± 41, 83 ± 34 ng/mL, respectively (p < 0.004). Prednisone daily dose: 8.3 ± 2, 5.2 ± 1, 4.1 ± 1 mg, respectively (p < 0.001). Cellular rejection (group 3) was successfully treated (86%) but the outcome of VGD did not improve after the switch (group 4). Our limited experience (with caution) confirms the reported benefits of MMF particularly attenuating renal insufficiency.

Valoración de la función esplénica mediante gammagrafía dinámica y estudio de «pits» de la membrana eritrocitaria y de vacuolas submembranarias en los pacientes con traumatismo leve y grave de bazo tratados de forma conservadora o mediante esplenectomía

Fundamento y objetivo Cuantificar la funcion esplenica de los pacientes controlados en el Servicio de Cirugia General y Digestiva del Hospital Universitari Germans Trias i Pujol (HUGTiP) desde 1985 hasta 2003 tras haber sufrido diferentes grados de lesion traumatica del bazo segun la clasificacion de la American Association for the Surgery of Trauma (AAST) del ano 1994 y relacionarla con el tratamiento recibido (no operatorio, esplenectomia total con o sin esplenosis y esplenectomia mas autotrasplante), con la finalidad de detectar disfunciones esplenicas que predispongan al desarrollo de la sepsis tras la esplenectomia. Pacientes y metodo Se ha realizado a 43 pacientes un estudio isotopico con gammagrafia esplenica «dinamica », estudio de «pits» de la membrana eritrocitaria (optica de Nomarsky) y de vacuolas submembranarias (microscopia electronica de transmision). Resultados El grupo de no operados presenta una funcion normal de fagocitosis y filtracion, con una mediana de velocidad de captacion esplenica de 3,46 Kcts/s2 (intervalo, 0,8-6,98). El porcentaje mediano de «pits» de membrana fue del 2% (intervalo, 0-8,8%); el numero de «pits» por hematies, de 0,03 (intervalo, 0-0,12), y el porcentaje de hematies con 1, 2, 3 y 4 «pits», del 1,6, el 0,4, el 0 y el 0%, respectivamente. El porcentaje mediano de hematies con vacuolas submembranarias fue el 2,55% (intervalo, 0-5,6%); el numero de vacuolas por hematie, de 0,03 (intervalo, 0-0,06), y el porcentaje de hematies con 1, 2, 3 y 4 vacuolas, del 2, el 0,2, el 0 y el 0%, respectivamente. En el grupo operado, la velocidad mediana de captacion esplenica fue de 0,08 Kcts/s2 (intervalo, 0-1,75; p Conclusiones La funcion esplenica de los pacientes con antecedentes de traumatismo esplenico tratados de forma conservadora es normal, independientemente del grado de la lesion. Ello refuerza la conveniencia de aplicar de entrada esta actitud a todos los protocolos para intentar evitar la sepsis tras la esplenectomia. En los casos tratados con esplenectomia, con o sin esplenosis, la funcion esplenica esta ausente o muy alterada, mientras que en los casos tratados con esplenectomia y autotrasplante esta parcialmente conservada.

Geographic variation in HIV infection among injecting drug users within Barcelona

In response to a high incidence of AIDS among injecting drug users in Barcelona, Spain, the city established a program in four geographically distinct centers for assistance and surveillance. The centers provided testing, counseling, and monitoring of infectious diseases. In 1991-92, HIV rates were 33% in the northwest center, 39% in the western center, 39% in the east, and 71% in the south. Differences between the rates in the southern center when compared with those in the other centers were very significant (P < or = .001). These data show geographic variation of HIV infection within one city and substantiate the need to provide expanded medical care in the drug misuse treatment setting.

Trasplante cardíaco: nuevos retos para el siglo XXI

Desde el primer trasplante cardiaco (TC) realizado en 1967, este procedimiento quirurgico ha sufrido grandes avatares. A los dificiles inicios que acompanan a cualquier actividad pionera de la medicina, se asociaron unos resultados considerados como inaceptables para muchos cardiologos y cirujanos cardiacos de aquel momento. En los primeros 82 pacientes del grupo de Stanford, la supervivencia era del 48 y del 25% a los 12 y 36 meses, respectivamente1 . La elevada mortalidad por rechazo era la causa de este descredito en todo el mundo, y comentarios como: «el trasplante cardiaco: esa gran especulacion del futuro» eran habituales en los foros medicos. La introduccion de la ciclosporina como tratamiento inmunodepresor en los anos ochenta hizo posible el aumento del numero de trasplantes cardiacos hasta limites impensables en los anos setenta. Por ultimo, la gran especulacion se habia convertido en una realidad que aportaba supervivencias muy superiores a las previas, y actualmente es del 82% al ano y del 68% a los 5 anos2 . El TC era, por tanto, la unica salida para los enfermos con insuficiencia cardiaca (IC) avanzada y en muchos casos resistente a todo tipo de tratamientos, y esta afirmacion no era cuestionada. Por otro lado, los profundos conocimientos de la hiperactividad neurohormonal como base de la fisiopatologia y del pronostico de los pacientes con IC, asi como el papel de la terapia dirigida a controlar y modular esta actividad, han modificado de forma sustancial las expectativas en los pacientes con IC avanzada.

Heart Transplantation: New Challenges for the 21st Century

Since the first heart transplant in 1967, this surgical procedure has seen great vicissitudes. The initial difficulties inherent to any pioneering activity in the field of medicine were complicated by results considered unacceptable by many cardiologists and heart surgeons of the time. The 12- and 36-month survival rates of the first 82 patients of the Stanford group were 48% and 25%, respectively. 1 The high rates of death due to graft rejection were the cause of this worldwide discredit, and comments such as “heart transplantation: that great speculation of the future” were common in medical circles. The

Factores pronósticos tras paro cardiorrespiratorio. Utilidad del vídeo-electroencefalograma precoz

BACKGROUND AND OBJECTIVE Predictors of unfavorable outcome in patients after cardiopulmonary arrest (CPA) are important to make decisions about the limitation of therapeutic efforts. The aim was to analyze the clinical variables in the prognosis of patients recovered after CPA. MATERIAL AND METHOD Retrospective study on comatose patients with recovered CPA. The variables were: age, sex, Glasgow Coma Score (GCS), pupillary light reflex, other variables related to CPA (cause, duration, witnessed or not witnessed), myoclonic status and electroencephalographic (EEG) patterns. RESULTS Fifty patients were studied. The variables associated with mortality were the absence of pupillary light reflex (hazard ratio [HR] 0.277, 95% confidence interval [95% CI] 0.103-0.741, P=.01), a low GCS (HR 0.701, 95% CI 0.542-0.908, P=.007) and myoclonic state (HR 0.38, 95% CI 0.176-0.854, P=.01). We evaluated the EEG patterns in 22 patients. No statistical significance was observed. CONCLUSIONS The absence of pupillary light reflex, a low GCS and myoclonic state are prognostic factors in patients recovered after a CPA. The EEG patterns showed a nonsignificant association with prognosis.