M. Rodríguez Zapata

Assessing the use of proton pump inhibitors in an internal medicine department

INTRODUCTION proton pump inhibitors (PPIs) block the H+/K+ ATPase enzyme in gastric wall cells, leading to an inhibition of both baseline and stimulated acid secretion. Appropriate indications include: Gastroesophageal reflux, acute upper gastrointestinal bleeding, erosive gastritis or esophagitis, dyspepsia, NSAID-related gastropathy, and stress ulcer prophylaxis in high risk patients. The aims of this study were to review the current indications of PPIs, and to evaluate their use in Guadalajara s University Hospital. MATERIAL AND METHODS a transversal, analytic, randomized study was carried out during 2003 in our internal medicine department. A total of 208 medical records for 832 patients receiving PPIs were reviewed (25%). Mean age was 67 years (range: 16-92), 46.2% were females, and most frequent conditions were HBP, COPD, and DM. RESULTS 34.6% of patients took PPIs before admission, their use being inappropriate in 68.1% of them. Among hospitalized patients 73.03% used PPIs inappropriately, and most of them had no such indication at discharge. CONCLUSIONS results are in accordance with the literature, with a high frequency of incorrect PPI use; a more accurate use of PPIs is to be recommended to avoid side effects and drug interactions, and to provide a more efficient medical care.

A propósito de tres casos de hiperlactacidemia/acidosis láctica tras el tratamiento de la hepatitis C con interferón pegilado y ribavirina en pacientes coinfectados por VIH

La infeccion por virus de la hepatitis C tiene una alta prevalencia entre las personas infectadas por VIH. Por su elevada tasa de evolucion a la cronicidad, pudiendo progresar a cirrosis y carcinoma hepatocelular, y el incremento en la esperanza de vida de estos pacientes es necesario afrontar el tratamiento de esta coinfeccion. La asociacion del TARGA con el interferon y la ribavirina produce interacciones y efectos adversos no bien documentados hasta el momento actual. La hiperlactacidemia/acidosis lactica es uno de los mas potencialmente graves que parece asociado a la combinacion de ribavirina con ddI, d4T o AZT. Se describen tres casos de hiperlactacidemia/acidosis lactica recogidos en el Hospital Universitario de Guadalajara durante el tratamiento de la hepatitis C cronica en pacientes con infeccion por VIH.

Nationwide Study on Peripheral Venous Catheter Associated–Bloodstream Infections in Internal Medicine Departments

BACKGROUND The use of peripheral venous catheters (PVCs) has increased outside intensive care units, as has the rate of PVC-associated-bloodstream infection (PVC-BSI). PVCs are widely used in internal medicine departments (IMDs), but data on the incidence of PVC-BSI and its characteristics in IMDs are scarce. AIM To assess the incidence of PVC-BSI episodes detected in IMDs in Spain. METHODS A one-year multi-centre prospective observational cohort study in 14 Spanish IMDs was undertaken. Adult patients admitted with at least one PVC and bacteraemia were included in the study. Demographic and clinical data were provided by local coordinators. FINDINGS Seventy episodes of PVC-BSI were recorded, representing an overall rate of 1.64 PVC-BSI episodes/1000 IMD admissions. The mean age of patients was 67.44 (standard deviation 16.72) years. It was estimated that 25.7% of PVCs were no longer necessary. Staphylococcus aureus was the most frequently isolated micro-organism (41.7%). Phlebitis was clinically evident in 44 (62.9%) episodes, and proved to be an independent predictor of catheter insertion in emergency departments (odds ratio 5.44). The crude and attributable mortality rates were 12.9% and 5.7%, respectively. CONCLUSIONS PVCs carry a significant risk for bacteraemia in Spanish IMDs. Phlebitis is not always clinically evident in patients with bacteraemia in this population. The study findings support the need for educational and interventional preventive measures in both IMDs and emergency departments to reduce the rate of PVC-BSI and associated comorbidities, and costs.

Ensayo clínico comparativo de eficacia y seguridad de cuatro pautas de tratamiento antirretroviral de alta eficacia (TARGA) en pacientes naive con infección por VIH avanzada

Introduccion Comparacion de la eficacia y seguridad de cuatro pautas de terapia antirretroviral de gran actividad (TARGA) incluyendo dos analogos de nucleosidos (AN) y un inhibidor de proteasa (IP) en pacientes con el virus de la inmunodeficiencia humana (VIH) con infeccion avanzada y naive a antirretrovirales. Pacientes y metodo Ensayo clinico, multicentrico, randomizado y abierto en diez hospitals comunitarios de Castilla-La Mancha y Madrid. La pauta 1 contenia zidovudina (ZDV), lamivudina (3TC) e indinavir (IDV); la pauta 2 incluia ZDV, 3TC y ritonavir (RTV); la pauta 3 era didanosina (DDI), estavudina (D4T) e IDV, y la pauta 4 incluia DDI, D4T y RTV. Se ha valorado como variable principal de respuesta el descenso de la carga viral del VIH (CV), y como variables secundarias: el aumento del numero de linfocitos CD4, el porcentaje de progresion de la enfermedad, las reacciones adversas y la adherencia. Las determinaciones se realizaron en la visita basal y a las 6, 12, 24, 36 y 48 semanas. Resultados Se incluyeron 98 pacientes con una media de CD4 basal de 122 × 106/l (rango de 5-340) y una carga viral basal de 5,1 log copias/ml. A las 48 semanas, en el analisis de los pacientes en tratamiento se observo un incremento medio de los CD4 y una disminucion de la carga viral sin diferencia significativa entre las 4 pautas (103 celulas/2,62 log en la pauta 1, 169 celulas/ 2,86 log en la pauta 2, 171 celulas/2,56 log en la pauta 3 y 141 celulas/1,71 log en la pauta 4). Interrumpieron el tratamiento por reacciones adversas: el 24% en la pauta 1, el 48% en la pauta 2, el 26% en la pauta 3 y el 32% en lapauta 4, sin diferencias significativas. Analizando por grupos de IP el 41% de los pacientes con RTV y el 25% de los pacientes con IDV suspendieron el tratamiento por efectos adversos. Se produjo retirada del tratamiento por progresion de la enfermedad en el 7% de los pacientes con RTV y en el 9% de los pacientes con IDV. Conclusiones En los pacientes VIH positivos con infeccion avanzada la eficacia entre cuatro pautas de TARGA es similar, pero existe una tendencia a precisar mayor retirada por efectos adversos en los grupos de RTV que en los de IDV, los dos usados como IP unico.

Protocolo diagnóstico y terapéutico de las tuberculosis extrapulmonares

El termino de tuberculosis (TB) extrapulmonar o TB no respiratorias define los procesos infecciosos producidos por Mycobacterium tuberculosis que afectan a un organo o sistema diferente al parenquima pulmonar y via aerea, teniendo en cuenta que con frecuencia coexiste la afectacion del pulmon y de otro organo. Representan el 20�25 % de los casos de infeccion tuberculosa. El sexo femenino y la edad joven son factores de riesgo independiente de TB extrapulmonar. Cualquier causa que produce depresion del sistema inmunologico como la infeccion por el virus de inmunodeficiencia humana (VIH), insuficiencia renal cronica, farmacos inmunosupresores como corticoides o anti-TNF predisponen a la diseminacion de la enfermedad tuberculosa. En el presente protocolo nos centraremos en los aspectos del diagnostico y manejo terapeutico de la TB miliar, pleural, linfatica, pericardica, osteoarticular, intestinal, genitourinaria y del sistema nervioso central.

Infecciones por rickettsias y fiebre Q

Rickettsiosis is a disease with considerable worldwide impact due to its high prevalence and morbidity. It is present in our community, where it has been described (as well as the classical diseases) as Mediterranean spotted fever, Q fever and murine typhus. There are other emerging diseases with which general practitioners should be familiar. Rickettsiae are gram-negative, intracellular obligate bacteria, which are transmitted by arthropod vectors such as ticks, fleas and lice. They infect domestic animals such as dogs, cats and rabbits and produce a similar and characteristic initial clinical presentation with fever, headache and arthromylagia. Subsequently, other specific manifestations appear, depending on the type of Rickettsia that caused the disease. Diagnosis is performed by serology during convalescence, which requires a high index of suspicion for typical findings, an appropriate epidemiological setting and the implementation of empiric antibiotic therapy. Doxycycline is the drug of choice.

PARATHYROID HORMONE, BUT NOT 25-HYDROXI VITAMIN D, SERUM LEVELS ASSOCIATE WITH ALDOSTERONE-TO-RENIN RATIO AND NOCTURNAL MEAN BLOOD PRESSURE VARIABILITY

Objective: To assess the association between serum parathyroid hormone (PTH) or vitamin D serum levels with blood pressure, aldosterone-to-renin ratio, and target organ damage in a series of hypertensive patients. Design and method: Observational cross-sectional study of hypertensive patients who undergone 24-hour ambulatory blood pressure monitoring (24-h ABPM), in whom plasma aldosterone, plasma aldosterone-to-renin ratio, PTH and 25-OH D serum levels were available. Blood pressure (BP) was measured by 24-hour ABPM. BP was assessed as average real variability. Renin-angiotensin-aldosterone axis status was assessed through plasma aldosterone levels and aldosterone-to-renin ratio. Electrocardiography, echocardiography and urine albumin-to-creatinine ratio were used to evaluate left ventricular hypertrophy and renal damage, respectively. Patients with primary hyperparathyroidism were excluded. Results: We enrolled 170 consecutive patients (median age [IQR] -year), 52 [42–64]; 48.2%, female). In comparison with patients with normal PTH serum levels (<88 pg/ml), those with high PTH serum levels (>88 pg/ml) showed a significantly increase in plasma aldosterone-to-renin ratio [mean ± SD] (37.8 ± 46.6 vs. 20.7 ± 27.0; p = 0.032), and nocturnal pulse pressure (56.3 ± 17.9 vs. 50.6 ± 13.1 mm Hg; p = 0.029). Furthermore, when compared with patients in the PTH 1st quartile, those in the 4th PTH quartile showed significantly higher nocturnal systolic BP (129.5 ± 25.6 vs. 119.9 ± 14.4 mm Hg; p = 0.038), plasma aldosterone (204.9 ± 128.4 vs. 153.8 ± 88.7 pg/ml; p = 0.037), plasma aldosterone-to-renin ratio (36.4 ± 45.8 vs. 18.9 ± 24.5; p = 0.033), and nocturnal mean BP variability (8.9 ± 4.4 vs. 7.1 ± 1.7 mm Hg; p = 0.016). Differences in aldosterone-to-renin ratio and nocturnal mean BP variability remained significant after adjusting by age, gender, renal function and ACE/ARB therapy in multivariate analysis. No such differences were observed in patients with vitamin D deficiency (25-OH D < 20 ng/ml), when compared with patients with normal vitamin D serum levels. Conclusions: High PTH, but not low 25-OH D serum levels associate with increased aldosterone-to renin ratio and elevated nocturnal mean blood pressure variability. Our results might explain, in part, the lack of consistent clinical benefit of vitamin D supplementation on high blood pressure and cardiovascular risk. We suggest that serum PTH status should be considered in trials searching for cardiovascular benefits from vitamin D supplementation in patients with hypovitaminosis D.

CP-155 Prevalence and effectiveness of antiretroviral treatment combinations used in hiv patients not included in guidelines

Background Most studies in HIV infected patients focus on the effectiveness of antiretroviral therapy (ART) combinations included in clinical guidelines. However, few studies have analysed combinations not listed in these guidelines. Purpose To analyse the prevalence and effectiveness of ART combinations not included in HIV guidelines. Material and methods A retrospective observational study was carried out between January 2014 and December 2015. All patients with ART followed for at least 1 year by the outpatient pharmacy were included. ART were classified in two groups:(1) all combinations listed in the Spanish National AIDS Plan Recommended Guidelines (GESIDA) for initial antiretroviral therapy 2014–2015; and combinations not listed in GESIDA Guidelines. To determine the effectiveness of the treatment, plasma viral load (VL) and CD4+ lymphocytes were reviewed. Two analyses according to different criteria were conducted:(1) criteria reflected in Spanish GESIDA guidelines: VL <50 copies/mL (undetectable) and CD4 repeatedly >300 cells/μL, on at least two consecutive occasions;(2) criteria reflected in the American DHHS guidelines: VL <200 copies/mL (to prevent errors by blip) and CD4 repeatedly >300 cells/μL, on at least two consecutive occasions. Data were analysed with SPSS 20.0 software. Results 245 patients were analysed. 68.6% (168) were men. The median age was 48.5 years (IIC: 43.5 to 53). Patients ART combinations included in guidelines ART combinationsnot included in guidelines Total (n (%)) 224 (91.4) 21 (8.6) VL <50 copies/mL and CD4 >300 cells/μL (n (%)) 110 (49.1) 9 (42.9) OR=1.287 95% CI OR: 0.521–3.174 p=0.584 VL <200 copies/mL and CD4 >300 cells/μL (n (%)) 174 (77.7) 14 (66.7) OR=1.740 95% CI OR: 0.666–4.545 p=0.253 Conclusion This study shows that few patients receive ART combinations not included in clinical practice guidelines. The high power of current ART could explain the similar effectiveness between the listed and non-listed therapies in the guidelines. No conflict of interest

Mujer de 33 años con colitis ulcerosa que presenta fiebre prolongada y hepatoesplenomegalia

espanolMujer de 33 anos de edad, con antecedentes de colitis ulcerosa diagnosticada un ano antes, en tratamiento con azatioprina (100 mg al dia) y 5-amino-salicilico, que acude por presentar, desde hace 10 dias, un cuadro de fiebre diaria de hasta 40 °C, sin claro ritmo circadiano, acompanado de escalofrios, astenia, anorexia, quebrantamiento general y cefalea. No refiere sintomatologia de organo especifica, asi como tampoco cuadro diarreico, dolor abdominal ni emision de sangre por el ano. Entre los antecedentes epidemiologicos resenar, tan solo, que tenia contacto ocasional con un perro. En la exploracion, la enferma tiene aspecto toxico, esta febril, normotensa, con 90 latidos por minuto (lpm), no se palpan adenopatias en ningun territorio; ausencia de signos meningeos, orofaringe normal, auscultacion cardiaca y pulmonar normal, hepatomegalia blanda a 3 cm y esplenomegalia a 4 cm de reborde costal izquierdo en linea medioclavicular. No presentaba lesiones cutaneas, las extremidades eran normales, al igual que la exploracion neurologica. Los estudios de imagen (radiografia de torax y tomografia axial computarizada [TAC] abdominal) no demostraron alteraciones significativas. espanolEn los datos analiticos iniciales destacaban: sistematico de sangre: leucocitos 1.650 (73 N, 19 L, 3M); hemoglobina 9,7 g/l, hematocritos 28,6%; volumen corpuscular medio (VCM) 95; concentracion de hemoglobina corpuscular media (CHCM) 34; plaquetas 157.000. Velocidad de sedimentacion globular (VSG) 47 mm a la primera hora. Frotis: ausencia de hemoparasitos. Linfocitos activados. Coagulacion sin alteraciones, salvo fibrinogeno de 140 mg/dl. Sistematico de orina normal. Bioquimica: ALT 88 UI/l (normal hasta 37), AST 126 UI/l (normal hasta 32), LDH 431 UI/l (normal hasta 190), proteinas 5,4 g/dl, calcio 8,1 mg/dl, albumina 2,7 g/dl.

Infecciones por Salmonella: fiebre tifoidea y salmonelosis no tifoideas

Concepto. La Salmonella es un bacilo gramnegativo movil, que origina en el ser humano una variedad de infecciones como son la fiebre tifoidea, la gastroenteritis, la bacteriemia (primaria o secundaria a enteritis), la infeccion focal no digestiva (osteomielitis, absceso) y el estado de portador cronico asintomatico. Diagnostico de sospecha. Fiebre tifoidea. Se debe pensar en esta enfermedad en cualquier proceso febril, persistente, generalmente sin sintomatologia importante de organo, pero con afectacion del estado general, o cuadro toxico acompanante, sobre todo en aquellos pacientes procedentes de paises en vias de desarrollo o en casos de viajeros. Salmonelosis no tifoideas. El diagnostico de sospecha es clinico ante un cuadro, habitualmente febril, con dolor abdominal, nauseas, vomitos y diarrea de caracteristicas inflamatorias, apareciendo leucocitos polimorfonucleares en el examen en fresco de las heces. Diagnostico diferencial. El diagnostico diferencial de la fiebre tifoidea incluye a un numero importante de entidades, en funcion de la sintomatologia predominante, pudiendo incluir: gripe, neumonia bacteriana, meningoencefalitis, apendicitis, colecistitis, hepatitis virica aguda, enfermedad inflamatoria intestinal, linfoma, brucellosis, rickettsiosis, endocarditis bacteriana, tuberculosis miliar o mononucleosis infecciosa. Tratamiento antibiotico empirico. En el caso de fiebre tifoidea el tratamiento se basa en fluorquinolonas o cefalosporinas de tercera generacion. Por el contrario, en las gastroenteritis por salmonelosis no tifoideas no suelen emplearse los antibioticos salvo en casos de pacientes inmunodeprimidos (neonatos, ancianos, enfermos de sida, leucemia, linfoma, drepanocitosis, presencia de enfermedad cardiovascular, protesis o cuerpos extranos) o en aquellos que presenten enfermedad grave con fiebre alta y gran numero de deposiciones diarreicas. --------------------------------------------------------------------------------