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The objective of the systematic review is to analyze the efficacy of direct-acting oral anticoagulants (DOAC) in the prophylaxis of thrombosis in antiphospholipid syndrome (APS). We searched for clinical trials, cohort studies and meta-analyses published from January 1, 2012 to September 30, 2022. Articles that analyzed the efficacy of DOAC in the prevention of thrombosis recurrence, with or without comparison with antivitamin K (VKA) drugs, were selected. DOACs, specifically rivaroxaban and apixaban, were significantly less effective than VKAs in preventing recurrence of thrombosis in patients with APS and prior arterial thrombosis or the concomitant presence of two or three different antiphospholipid antibodies. The proportion of patients with severe bleeding as side effect are similar in those treated with DOAC and with VKA. The results argue against the use of DOAC in the treatment of patients with thrombotic APS., (Copyright © 2023 Elsevier España, S.L.U. All rights reserved.)

In the elderly, pneumonia often has a less florid clinical presentation and is frequently complicated by decompensation of concomitant diseases. Elderly patients have special characteristics in terms of the pathogens involved in pneumonia; they are at greater risk of multiresistant bacterial infections because of their frequent contact with the health services. Lung infections in immunosuppressed individuals have different causes depending on the immune deficiency in question. Admission to hospital or ambulatory treatment will be decided after stratifying the risk; this treatment will be determined by the characteristics at the time of onset of the pneumonia, the local epidemiological situation in terms of the percentage of antibiotic resistance in the area, and the clinical particularities., (.)

Objectives: Assess clinical and serological data as parameters indicative of a possible evolution to endocarditis after an episode of acute Q fever., Patients and Methods: Retrospective cohort study of evolution to endocarditis after an acute Q fever episode, analyzing the clinical and serological evolution and the antibiotic treatment administered., Results: Eighty patients were recruited, 20% of whom had phase i IgG antibody levels ≥ 1:1024 in the first 3 months. Only 44% of the patients underwent antibiotherapy in the acute phase; only 2 patients underwent extended antibiotherapy. Fifteen percent of the patients underwent an echocardiogram. None of the patients had symptoms suggestive of chronic infection or progressed to endocarditis after a median follow-up of 100 months, regardless of the early increase in phase i IgG antibodies., Conclusions: The early increase in phase i IgG antibodies in asymptomatic patients is not associated with progression to endocarditis despite not undergoing prolonged antibiotic treatment., (Copyright © 2015 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Objective: The objective of this study was the analysis of the prevalence and type of primary resistance to antiretroviral drugs in patients diagnosed with HIV infection, and to determine the most appropriate empirical treatment to obtain a virological and immunological response., Patients and Methods: An observational analysis of patients with a de novo diagnosis of HIV infection during the period 2008-2010. Clinical, immunological and virological characteristics, including genotype analysis of resistance to antiretrovirals, were considered as independent variables. The dependent variable was an undetectable HIV viral load after six months of treatment. Data are provided as median (interquartile range) and absolute number (percentage)., Results: Seventy-three patients with a de novo diagnosis of HIV infection were included [53 males (73%); 36 (30-46) years-old; prior use of intravenous drugs: 5 patients (7%); hepatitis C virus co-infection: 13 individuals (18%)]. Ten patients (14%) showed symptoms attributable to acute HIV infection. A CD4+ T cell count lower than 350 mm(3) was detected in a 37% (n=27) of all patients. The initiation of antiretroviral therapy followed the GESIDA recommendations (no therapy: 20 patients; tenofovir+emtricitabine+efavirenz: 28 patients; abacavir+lamivudine+efavirenz: 1 patient; tenofovir+emtricitabine+protease inhibitors: 5 patients; abacavir+lamivudine+protease inhibitors: 1 patient; 18 patients were lost in the follow-up). After starting antiretroviral therapy, the resistance analyses detected the existence of primary resistance to antiretrovirals in 12.7% (confidence interval 95%: 3-22) of the patients, distributed as follows: isolated resistance to, nucleosides was detected in 2% (M184V), to nevirapine/efavirenz in 9% (K103N), and combined resistance to nucleosides and non-nucleosides in 2%; there were no cases of resistance to protease inhibitors. Consequently, antiretroviral therapy was changed in 5 (14%) out of 35 patients, attaining an undetectable HIV viral load at 6 months in all of them. The primary resistance to antiretrovirals was not related with epidemiological, virological (including infection by non B subtype) or immunological variables., Conclusions: In the present study, a change in the epidemiological pattern of de novo diagnosis of HIV infection in our area has been observed. The existence of resistance mutations in more than 5% of the new cases is noteworthy. This finding must be considered in order to establish the rules of empirical treatment in our area., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Objective: The aim of this study was to assess whether measurement of hepatitis C virus RNA (HCV-RNA) at 12 weeks post-treatment could predict sustained virological response (SVR) to antiviral therapy for chronic hepatitis C (pegylated interferon alfa-2a and ribavirin) in HIV-co-infected patients., Patients and Methods: HIV-HCV co-infected patients were included if they completed a full course of anti-HCV therapy, achieved an end-of-treatment response and complied with the week +12 and +24 post-treatment follow-up schedule for serum HCV-RNA determination (Real-time HCV (Abbott, Wiesbaden, Germany) (lower limit of detection, 12 IU/ml)., Results: Forty out of 66 patients (61%) showed an end-of-treatment response. They were assessed in a follow-up visit at +12 and at +24 weeks post-treatment. Serum HCV-RNA was undetectable in 28 of them at +12 weeks, and 100% of these remained undetectable at 24 weeks post-treatment (the gold standard of (SVR). The positive predictive value was 100% (95% confidence interval, 98.21-100%)., Conclusion: Post-treatment follow-up to identify virological relapse could be shortened to 12 weeks, providing a new definition of sustained virological response., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Objective: To analyze differences in neuropsychological test results of former intravenous drug abusers, who were divided into 2 groups based on the presence or absence of HIV-1 infection., Methods: Higher-level cognitive functions were assessed with neuropsychological tests in 40 former drug abusers (20 with and 20 without HIV-1 infection)., Results: As compared to individuals without infection, patients with HIV-1 infection showed significantly poorer performance in areas related to attention, learning, working memory, verbal fluency, information processing, problem solving, and flexibility., Conclusion: Independently of the effect of drug addiction, HIV infection was associated with cognitive alterations in all the areas examined., ((c) 2008 Elsevier España, S.L. All rights reserved.)

Introduction: Progressive multifocal leukoencephalopathy (PML), which is caused by the reactivation of an infection due to the JC human polyoma virus, affects immunocompromised patients and more especially those infected by the human immunodeficiency virus. It produces a multifocal neurological clinical picture due to the destruction of oligodendrocytes and the subsequent demyelination., Aims: To analyse the epidemiological, semiological and radiological characteristics of a sample of patients diagnosed with PML in the province of Cadiz, and to study their rates of survival., Patients and Methods: Our sample consisted of 23 patients with PML who presented an unfavourable immunological situation and deficient therapeutic compliance. Factors studied included time to progression of the symptoms, clinical features, neuroimaging and survival., Results: The mean time elapsed between the appearance of symptoms and diagnosis was 30 days. There was a wide range of manifestations: motor symptoms were the most prevalent and cognitive compromise was far less common. All the patients submitted to magnetic resonance imaging of the head and only eight of those who underwent computerised axial tomography displayed multiple insults. The mean survival time was 60 days in the case of the seven deaths and over two years in those who survived., Conclusions: The symptoms of the patients were similar to those reported in the literature, except for the absence of dementia. Magnetic resonance imaging was better than tomography at detecting multiple, dispersed insults and is more cost-effective for diagnosing PML. The survival time of most of the patients was higher than that reported in previous studies.

Background: The main cause of death in patients undergoing hemodialysis are cardiovascular events. We have analyzed the association between intradialysis fractional clearance of urea or Kt/V index in patients with chronic renal failure in hemodialysis as an indicator of adequate dialysis and the classical factors of cardiovascular risk., Patients and Methods: A total of 47 patients with chronic renal failure on hemodialysis were included. Diabetes mellitus was considered an exclusion criteria. Optimization of dialysis was analyzed by Kt/v index in accordance with the Daugirdas formula. The cardiovascular risk factors evaluated were: insulin resistance, calculated according to the HOMA method, total cholesterol, LDL-cholesterol, triglycerides, arterial hypertension, obesity and metabolic syndrome. The relationship between cardiovascular risk factors and Kt/V index was analyzed with the variant and multivariant analysis., Results: The HOMA median (interquartile range) of the patients was 1.16 (0.53-5.77). HOMA was correlated with triglycerides and HDL-cholesterol levels. HOMA was significantly greater in those who had less adapted dialysis (Kt/V < 1.4) (1.9 +/- 1.3 vs 1.0 +/- 0.3, p = 0.02). Furthermore, a negative correlation was found between HOMA and Kt/V. The multivariant analysis of the factors associated to HOMA demonstrated that the only associated parameters were Kt/V greater than 1.4, body mass index and age., Conclusions: In patients with chronic renal failure, adapted dialysis, determined by the Kt/V index, correlated negatively with insulin resistance. Based on these data, we suggest the need for longitudinal studies that consider this index as a predictive variable of cardiovascular events in this type of patients.

Respiratory tract infections are frequent and they are one of the commonest causes of antibiotic prescription. However, there are few clinical guidelines that consider this group of infections. This document has been written by the Andalusian Infectious Diseases Society and the Andalusian Family and Community Medicine Society. The primary objective has been to define the recommendations for the diagnosis and antibiotic treatment of respiratory tract infections apart from pneumonia. The clinical syndromes evaluated have been: a) pharyngitis; b) sinusitis; c) acute otitis media and otitis externa; d) acute bronchitis, laryngitis, epiglottitis; e) acute exacerbation of chronic bronchitis; and f) respiratory infectious in patients with bronchiectasis. This document has focused on immunocompetent patients.

Respiratory tract infections are frequent and they are one of the commonest causes of antibiotic prescription. However, there are few clinical guidelines that consider this group of infections. This document has been written by the Andalusian Infectious Diseases Society and the Andalusian Family and Community Medicine Society. The primary objective has been to define the recommendations for the diagnosis and antibiotic treatment of respiratory tract infections apart from pneumonia. The clinical syndromes evaluated have been: a) pharyngitis; b) sinusitis; c) acute otitis media and otitis externa; d) acute bronchitis, laryngitis, epiglottitis; e) acute exacerbation of chronic bronchitis; and f) respiratory infectious in patients with bronchiectasis. This document has focused on immunocompetent patients.

Objective: The objective of our study was to determinate the health resource utilization and economic cost associated to diabetes in a patient group with type 1 diabetes., Patients and Methods: We designed a cross-sectional study that involved 71 type 1 diabetes patients (59.4% women) with 29.2 +/- 12.2 years old mean age and 10.5 +/- 7.9 years of diabetes evolution attended in Endocrinology Service of Puerta del Mar Hospital in Cádiz. Direct and indirect cost associated to diabetes during a year period were determinated by information obtained from patient medical history and hospital, emergency, primary care and medical inspection of social insurance databases., Results: Type 1 diabetes patients presented a total cost associated to diabetes of 3.311 euros/patient/year (95% IC: 2.202-4.420 euros/patient/year). Direct cost (2.104 euros/patient/year; 95% IC: 1.825-2.383 euros/patient/year) was higher than indirect cost (1.250 euros/patient/year; 95% IC: 291-2.225 euros/patient/year). Multiple regression analysis showed an independent association between total cost associated to diabetes (dependent variable) and variables number of hospitalizations related to diabetes (p = 0.006), pensioner situation (p = 0.02) and micro and macrovascular complications (p = 0.001)., Conclusions: We conclude that economic cost associated to type 1 diabetes is important and presents a notable and independent increase with hospitalizations related to diabetes, pensioner situation and micro and macrovascular complications.

Objective: To analyze the impact of highly active anti-retroviral therapy (HAART) on the admissions and mortality of patients with human immunodeficiency virus (HIV) infection and of all patients cared in an Internal Medicine Department., Methods: A retrospective study with analysis of admissions and deaths in the Internal Medicine Department of a third-level care hospital between January 1996 and December 2000. HAART was introduced starting in 1997. Age, gender, main diagnosis at discharge, diagnosis related group (DRG) weight, death cause, and hospital stay were assessed globally and annually., Results: During the study period 7,580 admissions took place, of which 939 were secondary to HIV infection related diseases. The incidence of HIV-related admissions declined in 32.9% and the case-fatality rate in 67.8% between 1996 and 2000, with increase at the same time of the number of patients with noninfectious respiratory pathology and of overall number of patients with infections. Average hospital stay of patients cared in the Internal Medicine Department remained stable, with reduction of 31.5% of that of the group with HIV infection starting in 1997. DRG complexity in this group decreased 0.56 points., Conclusions: The introduction of HAART has been associated to a reduction in the incidence of admissions, in the complexity of the diagnoses, and in the mortality in the group of patients with HIV infection. At the same time there was an increased in the number of patients with respiratory and infectious pathology different from that related to HIV.

The polymicrobial nature of the odontogenic infections as well as the variety of associated conditions are a consequence of the diversity of the buccal microbiota and the anatomical and functional complexity of the oral cavity. In addition to this, all these processes can give way to multiple complications which range from the local to the systemic level. The appropriate choice of antibiotic and posology is crucial in the successful management of these infections. Pharmacodynamics provides those parameters that make it possible to assess how antibiotics activity varies in time. As a general rule, the first step in the initial management of orofacial infections in adults, included odontogenic infections, will be the administration of 875 mg of amoxicillin and 125 mg of clavulanic every 8 hours. Therapeutic compliance is paramount to avoid resistance, therefore patient acceptance must be sought. In this sense, it has been proved that Augmentine Plus (2000/125) every twelve hours both as profylaxis and as treatment significantly decreases the rate of infective complications associated to extraction of the third molar.

Arcanobacterium haemolyticum is a grampositive rod wich belonged, until a short time ago, to Corynebacterium genus, and recently classified in a new genus, with only one specie. Human is the main reservoir. It has been isolated from the skin and pharinx of healthy individuals, but also it is cause of infection, specially pharingitis, in children, and chronic cutaneous ulcus, in diabetic patients. Less frequently, it is cause of osteomyelitis, meningitis, pneumonia, abscess, endocarditis and sepsis. Diagnosis is difficult because its double quality: comensal and pathogen. There are not established guidelines for the treatment of these infections, although most of isolated strains are susceptibles to penicillin, erythromicin, clindamycin and tetracycline. High doses of penicillin, with or without gentamicin, it is recommended for the treatment of deep infections.

In order to analyze the nutritional status of HIV infected patients and the involvement of the tumour necrosis factor-alpha (TNF-alpha) and its soluble receptors (sTNFRI and sTNFRII) in such an status, forty HIV infected patients, with no associated systemic opportunist infections, were prospectively followed for eight months. From each patient the following were obtained: clinical history, dietetic survey, anthropometric measurements, CD4+ T lymphocyte/mm3 count, HIV load, and serum concentration of TNF and sTNFRI and sTNFRII. Patients showed a nutritional disorder which involved mainly the fat compartment (mean tricipital skin fold 9.8 +/- 4.2 mm, that is, 65.7 +/- 27.4% of the ideal fold), associated with a hypocaloric intake (mean daily intake 1,659.5 +/- 543.0 kcal), with normal proportions of the different organic principles. Serum concentrations of TNF (87.9 +/- 79.2 vs 8.7 +/- 6.1 pg/ml, p = 0.048) and its receptors, sTNFRI (6.1 +/- 2.6 vs 1.0 +/- 0.8 pg/ml, p < 0.001) and sTNFRII (41.9 +/- 18.6 vs 6.3 +/- 3.6 pg/ml, p < 0.001) were significantly higher than those detected in a sample of ten healthy controls. No correlation was found between nutritional alterations and concentrations of TNF or its receptors, viral load, and counts of CD4+ T lymphocytes/mm3. Seventeen patients completed the follow-up period. During this period, no significant modifications in the analyzed parameters were observed: tricipital skin fold, arm circumference, serum concentrations of albumin or transferrin, concentrations of tumoral necrosis factor or its receptor and caloric intake. The conclusion is that, despite the detected nutritional alterations in the nutritional status and those in the TNF/receptor system, our data no support and interrelationship between them.

Objective: One-year prospective observational study of meningitis diagnosed at a third level hospital., Patients and Methods: All patients with a cerebrospinal fluid (CSF) specimen with cyto-biochemical characteristics and clinical picture consistent with meningitis were included in the study. They were followed from admission to hospital up to discharge or exitus. The epidemiologic characteristics of patients, etiology, related risk factors and predisposing situations, CSF characteristics, clinical manifestations, clinical course, and antibiotic susceptibility of the causative agents were analyzed., Results: Ninety-five cases were included. Seventy-six (69.4%) were community acquired and 29 (30.5%) nosocomially acquired meningitis. Among community acquired meningitis, 31 (46.9%) were of bacterial origin (8 N. meningitidis, 3 H. influenzae, 2 S. pneumoniae, 1 Streptococcus group B, 1 Listeria monocytogenes, 1 Staphylococcus aureus, and 1 Brucella spp.); CSF culture was negative in 14 cases (41.2%). In most cases neither risk factor nor predisposing situations were detected. Patients with purulent meningitis and negative CSF culture had a significantly lower number of complications than patients with positive CSF culture. Among patients previously treated with beta-lactam antibiotics (8 cases) the probability of a negative CSF culture was greater than among not treated patients (OR 16.00, 95% CI 1.45-764.68; p = 0.011). The remaining cyto-biochemical characteristics were similar in both groups. Thirty-five cases (53.03%) of community acquisition were lymphocytic meningitis (31 viral, 3 tuberculous, and 1 luetic meningitis). Among nosocomial cases (29 cases, 30.5%), most were caused by gram-negative bacilli and microorganisms of the Staphylococcus genus. Fourteen cases (48.2%) were related to some type of neurosurgical procedure. Overall, only two exitus cases were recorded., Conclusions: The etiologic agents of community acquired meningitis are mainly N. meningitidis, S. pneumoniae and Haemophilus influenzae. The previous antibiotic therapy did not influence thy cyto-biochemical characteristics of CSF but it did influence the yielding of culture. Meningitis with negative CSF culture has a significantly lower number of complications. The availability of a Neurosurgery Department at a hospital confers a change in the epidemiologic spectrum of diagnosed meningitis, with a higher incidence of nosocomial meningitis. In our environment, a substantial proportion of cases due to Staphylococcus microorganisms was observed.

The Graves's Disease is the most frequent cause of hyperthyroidism. Currently, there is a lack of consensus with respect to the therapeutical role played by synthetic antithyroids, radioactive iodine and surgery. In order to study in depth this issue, we have analyzed the results of the therapy administered to 217 patients with Graves's Disease: 96 were treated with synthetical anti-thyroids, 46 with surgery and 75 with radioactive iodine. After twelve months of therapy with synthetic antithyroids, remission of the disease was observed in 64 patients (67%); the only factor predicting such remission was the absence of ophthalmopathy (p < 0.05); all 64 patients were followed-up during 12 months, detecting the recurrence of hyperthyroidism in 33 of them. Such recurrence is predicted by the serum levels of thyroid hormones before the administration of the therapy (p < 0.001). On the contrary, in patients treated with surgery or radioactive iodine, hyperthyroidism was controlled in 91% and 100% of them, respectively. Given the evolution of patients with Graves's Disease treated with synthetic antithyroids, we suggest the use of a more aggressive approach for the management of these patients.