Multisectoral approach to address Female Genital Mutilation: a case study from Portugal

Issue

Female genital mutilation (FGM) comprises all procedures that injury female genital organs for non-medical reasons, with several health impacts. Due to global migration, FGM has been increasingly recognised as a healthcare issue in Europe, affecting nearly 1 million women. In Portugal it is estimated that 5483 migrant women have undergone FGM in the Lisbon region. Intervention is required to tackle this issue.

Description

Portugal launched the “Healthy Practices: End of FGM”, a multiagency project targeting Lisbon and Tagus Valley region. Project implementation started in Nov 2018 at 5 local public health units (PHU) and was scaled-up to 5 more in Feb 2020. Project comprises 3 main axes: 1) inclusion in public policy instruments; 2) professionals’ education and awareness; and 3) community intervention. We describe inclusion of FGM in public policy, professionals training and changes in FGM recording before and after intervention.

Results

Between 2018-2022, inclusion of FGM in municipalities’ migration policies doubled. Between 2019-2021, 110 training sessions (n = 1722 professionals) were promoted. During pandemic years, only 344 (2020) and 202 (2021) were trained. Raising awareness and empowerment to risk communities happened mainly through local/online open sessions, workshops, flyer distribution, video projections. These occurred in all 10 PHU, mostly through partnerships with Non-Governmental Organizations and municipalities. According to the Portuguese Health Records, until 2018 there were only 300 women registered with FGM. Between 2019-2021, 363 more were added.

Lessons

The multisectoral approach allowed PHU professionals to collaborate directly with external organizations from different society sectors. COVID-19 pandemic posed a challenge to implementation, especially in the community intervention axis. Notification numbers increased after interventions, though causality could not be established and impact evaluation is yet to be performed.

Key messages

• Multisectoral projects for FGM intervention have specific implementation challenges, including how to justify and evaluate them, that must be considered in each setting.

• Training health professionals might increase identification and notification of FGM, but the impact in preventing FGM in the Portuguese reality is still largely unknown.

Transient endothelial injury and release of lupus anticoagulant in COVID-19

Introduction

Purpose

Methods

Results

Conclusions

Pregnancy outcomes after ultrasound-guided high-intensity focused ultrasound (USgHIFU) for conservative treatment of uterine fibroids: experience of a single institution

OBJECTIVE

To assess the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation for uterine fibroids on fertility.

MATERIAL AND METHODS

A retrospective observational study was conducted of 560 reproductive-age women with symptomatic uterine fibroids who underwent USgHIFU therapy at Mútua Terrassa University Hospital, Spain, between February 2008 and February 2018. We analyzed pregnancy outcomes including time to conception, pregnancy approach, gestational age, delivery mode, neonatal outcomes and complications during pregnancy and delivery.

RESULTS

After USgHIFU treatment, 71 pregnancies were obtained in 55 patients. Of these, 58 (82%) cases were natural pregnancies and 13 (18%) were in vitro fertilization (IVF) pregnancies. The median time to conception was 12 (range 1-72) months. There were 43 (61%) successful deliveries, including a twin gestation, 22 (31%) spontaneous abortions and 6 (8%) therapeutic abortions. The rate of full-term deliveries was 91% (39/43) and the remaining 9% (4/43) were preterm deliveries. Of the 44 live births, 25 (57%) were born vaginally and 19 (43%) by cesarean section. The complications reported included 3 women with retained placenta (7%), 2 with placenta previa (5%) and 1 with severe preeclampsia (2%). The mean birth weight was 3.1 (range: 1.4-4.3) kg, and except for a baby born with a tetralogy of Fallot, all newborns developed well without complications during postpartum and breastfeeding.

CONCLUSION

Patients undergoing USgHIFU treatment of uterine fibroids can achieve full-term pregnancies with few intrapartum or postpartum complications. More studies are required to compare fertility and perinatal outcomes between patients who underwent or not USgHIFU.

Efficacy and Safety of Pembrolizumab Plus Docetaxel vs Docetaxel Alone in Patients With Previously Treated Advanced Non-Small Cell Lung Cancer: The PROLUNG Phase 2 Randomized Clinical Trial

Importance

Because of socioeconomic factors, many patients with advanced non-small cell lung cancer (NSCLC) do not receive immunotherapy in the first-line setting. It is unknown if the combination of immunotherapy with chemotherapy can provide clinical benefits in immunotherapy-naive patients with disease progression after treatment with platinum-based chemotherapy.

Objective

To evaluate the safety and efficacy of the combination of pembrolizumab plus docetaxel in patients with previously treated advanced NSCLC following platinum-based chemotherapy regardless of EGFR variants or programmed cell death ligand 1 status.

Design, Setting, and Participants

The Pembrolizumab Plus Docetaxel for Advanced Non-Small Cell Lung Cancer (PROLUNG) trial randomized 78 patients with histologically confirmed advanced NSCLC in a 1:1 ratio to receive either pembrolizumab plus docetaxel or docetaxel alone from December 2016 through May 2019.

Interventions

The experimental arm received docetaxel on day 1 (75 mg/m2) plus pembrolizumab on day 8 (200 mg) every 3 weeks for up to 6 cycles followed by pembrolizumab maintenance until progression or unacceptable toxic effects. The control arm received docetaxel monotherapy.

Main Outcomes and Measures

The primary end point was overall response rate (ORR). Secondary end points included progression-free survival (PFS), overall survival, and safety.

Results

Among 78 recruited patients, 32 (41%) were men, 34 (44%) were never smokers, and 25 (32%) had an EGFR/ALK alteration. Forty patients were allocated to receive pembrolizumab plus docetaxel, and 38 were allocated to receive docetaxel. A statistically significant difference in ORR, assessed by an independent reviewer, was found in patients receiving pembrolizumab plus docetaxel vs patients receiving docetaxel (42.5% vs 15.8%; odds ratio, 3.94; 95% CI, 1.34-11.54; P = .01). Patients without EGFR variations had a considerable difference in ORR of 35.7% vs 12.0% (P = .06), whereas patients with EGFR variations had an ORR of 58.3% vs 23.1% (P = .14). Overall, PFS was longer in patients who received pembrolizumab plus docetaxel (9.5 months; 95% CI, 4.2-not reached) than in patients who received docetaxel (3.9 months; 95% CI, 3.2-5.7) (hazard ratio, 0.24; 95% CI, 0.13-0.46; P < .001). For patients without variations, PFS was 9.5 months (95% CI, 3.9-not reached) vs 4.1 months (95% CI, 3.5-5.3) (P < .001), whereas in patients with EGFR variations, PFS was 6.8 months (95% CI, 6.2-not reached) vs 3.5 months (95% CI, 2.3-6.2) (P = .04). In terms of safety, 23% (9 of 40) vs 5% (2 of 38) of patients experienced grade 1 to 2 pneumonitis in the pembrolizumab plus docetaxel and docetaxel arms, respectively (P = .03), while 28% (11 of 40) vs 3% (1 of 38) experienced any-grade hypothyroidism (P = .002). No new safety signals were identified.

Conclusions and Relevance

In this phase 2 study, the combination of pembrolizumab plus docetaxel was well tolerated and substantially improved ORR and PFS in patients with advanced NSCLC who had previous progression after platinum-based chemotherapy, including NSCLC with EGFR variations.

Trial Registration

ClinicalTrials.gov Identifier: NCT02574598.

Impact of Covid-19 infection in high-risk coronary patients

Background

Methods

Results

Conclusions

Residual inflammation is a major determinant of myocardial recovery and cardiovascular outcome in takotsubo patients

Background

Recent insights have emphasized the importance of myocardial and systemic inflammation in Takotsubo Syndrome (TTS).

Objective

In a large registry of unselected patients, we sought to evaluate whether residual high inflammatory response (RHIR) could impact cardiovascular outcome after TTS.

Methods

Patients with TTS were retrospectively included between 2008 and 2018 in three general hospitals. 385 patients with TTS were split into three subgroups, according to tertiles of C-reactive protein (CRP) levels at discharge (CRP&lt;5.2 mg/l, CRP range 5.2 to 19 mg/l, and CRP&gt;19 mg/L). The primary endpoint was the impact of RHIR, defined as CRP&gt;19 mg/L at discharge, on cardiac death or hospitalization for heart failure.

Results

Follow-up was obtained in 382 patients (99%) after a median of 747 days. RHIR patients were more likely to have a history of cancer or a physical trigger. Left ventricular ejection fraction (LVEF) at admission and at discharge were comparable between groups. By contrast, RHIR was associated with lower LVEF at follow-up (61.7 vs. 60.7 vs. 57.9%; p=0.004) and increased cardiac late mortality (0% vs. 0% vs. 10%; p=0.001). By multivariate Cox regression analysis, RHIR was an independent predictor of cardiac death or hospitalization for heart failure (hazard ratio: 1.97; 95% confidence interval: 1.11 to 3.49; p=0.02).

Conclusions

RHIR was associated with impaired LVEF recovery and was evidenced as an independent factor of cardiovascular events. All together these findings underline RHIR patients as a high-risk subgroup, to target in future clinical trials with specific therapies to attenuate RHIR.

Main results

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): GERCA (Groupe pour l'Enseignement, la prévention et la Recherche Cardiovasculaire en Alsace)

Ending female genital mutilation – a city’s coordinated effort

Female genital mutilation (FGM) has short and long-term impacts on the health of girls/women. In Portugal, an estimated 5246 women were subjected to it, with 568 of them residing in the city of Amadora, in the metropolitan area of the capital Lisbon. As such, Amadora was considered a priority area for developing strategies to prevent female genital mutilation, under the coordination of the local public health unit.

Our aim was to capacitate professionals to recognise and act on risk/danger and on minimising potential health impacts of FGM on the local institutions these girls/women might come into contact with.

We created a task force that held meetings with different local actors: hospital, teams at the primary healthcare facility, city hall of Amadora, child protection services, a school, social inclusion projects, representatives of the justice system and a non-governmental organisation. We designed different scenarios for the different needs and entry points of these girls/women in the system and created appropriate procedures for all these actors. Within the primary healthcare facility, we created guidelines specifying criteria for referral to other specialties. This led to the development of a county protocol targeting FGM during the summer of 2019.

We trained 160 healthcare professionals. In addition, we created a booklet for schools and held sessions in school groups targeting teachers, psychologists and operational assistants with a focus on risk and danger indicators and on how to proceed. Overall, 360 school professionals received training. During these sessions, we also presented resources on how to integrate FGM in discussions with students regarding gender violence and human rights.

This intervention will be evaluated after one year (summer of 2020) through mixed-methods to understand the impact on the practice of the professionals in Amadora. We will conduct interviews and apply questionnaires to capture the implementation of this city-wide protocol.

Key messages

Given the complexity of FGM a wide societal and multidisciplinary approach should be used with a public health team coordinating the intervention. In Portugal there is a need for an organised and systematic response by professionals regarding FGM; our county-specific protocol aimed to create that response.

Planned teenage pregnancy: a sociocultural health problem that lead to a local intervention

According to data from the National Statistics Institute (2018), Portugal was the country with the second highest birth rate in the European Union in mothers between 15 and 19 years old. This number of births may be influenced by ethnic-cultural issues, such as acceptance and encouragement of marriage and early motherhood, especially in some African ethnic-cultural groups. Our public health unit is located in Amadora, a suburban area of the Portuguese capital with a high percentage of migrants, a high rate of teenage pregnancies and economically deprived areas.

The aim of our research was to understand beliefs and values in both native and migrant girls regarding motherhood in order to better tailor interventions aiming to prevent teenage pregnancy.

We interviewed fifteen participants, seven migrants and eight natives, who were or had been teenage mothers. The participants were selected through non-probabilistic snowball sampling. Afterwards, we performed a qualitative content analysis.

Overall, we found no difference between the 2 groups of participants with most, 12, having wished for their pregnancies. The social and religious framing of fertility as a gift was often stated. The housing context was also mentioned given several participants lived in overcrowded houses with poor conditions and believed pregnancy could have provided a way out of their living situation. Low education and poor job prospects were also mentioned as pregnancy was framed as a “life project” in the absence of a career prospect.

We found evidence of a “social and cultural pregnancy” not related to certain migrant cultures but associated with a “neighbourhood” culture associated with economic deprivation. As such, we are now implementing a pilot study within the community, by creating regular group sessions to discuss the meaning and impact of motherhood to try to capacitate girls to find a different life project other than choosing pregnancy during teenage years.

Key messages

Teenage pregnancy can be planned who use it to try to find a life project, be accepted within their community and escape their daily conditions. Public health interventions aiming to prevent teenage pregnancies should acknowledge social and cultural factors that encourage these pregnancies.

A partnership between a local public health unit and schools to end female genital mutilation

Key messages

There is potential for a closer collaboration with schools to try to end female genital mutilation and to address other health topics. Local public health units should establish and mobilise local networks of institutions and community partners to tackle complex public health problems.

Acute Cardiac Failure Due to Takotsubo Cardiomyopathy Secondary to a Phone Call for Lung Transplantation: A Case Report

Lung transplantation is a therapeutic option for certain end-stage lung diseases. The phone call for lung transplantation is a major event in the life of these patients; as a result, it can generate significant stress. We herein present the case of a 58-year-old female patient with end-stage chronic obstructive pulmonary disease (COPD) who, while on the lung transplantation waiting list, received such a call. Complete transplant work-up, including cardiac tests undertaken shortly before, had revealed no contraindication to lung transplantation. She was admitted with severe acute respiratory failure, and her extensive work-up was compatible with pulmonary edema due to takotsubo cardiomyopathy. The lung transplantation was thus cancelled, owing to the patient's health condition and the poor quality of the graft as well. The patient stayed in the intensive care unit for several days, requiring noninvasive ventilation. The left ventricular function recovered completely within 10 days postdiagnosis, and the patient was discharged 13 days after her admission. The patient was transplanted 1 month thereafter, without any particular problems; she is currently, 8 months post-transplantation, in good condition. In the given case, the call for lung transplantation could have generated emotional stress severe enough to lead to takotsubo cardiomyopathy.

P6485Incremental prognostic value of electrocardiographic strain after transcatheter aortic valve replacement for aortic stenosis

Background

Electrocardiographic (ECG) strain pattern has recently been associated with increased adverse outcome in aortic stenosis (AS) and after surgical aortic valve replacement (AVR). However, the relation linking ECG strain and cardiovascular MACE in patients with transcatheter aortic valve replacement (TAVR) has not been yet described.

Objectives

The aim of our study was to determine the impact and incremental value of ECG Strain pattern in predicting adverse outcome after TAVR.

Methods

585 patients with severe AS (mean age: 83±7 male 39.8%) were enrolled from November 2012 to May 2018. ECG strain pattern was defined as ≥1 mm concave down-sloping ST-segment depression and asymmetrical T-wave inversion in the lateral leads. Patients with baseline left bundle branch block (LBBB), right bundle branch block (RBBB) or ventricular paced rhythm were excluded. All patients underwent transthoracic echocardiography (TTE) before TAVR and at 30 days follow up. The primary endpoints of the study were the overall all-cause mortality after TAVR, rehospitalization for Hearth failure (HF), myocardial infarction and stroke.

Results

178 (30.4%) patients were excluded from analyses owing to the presence of either LBBB (n=103) or RBBB (n=75). Among the 407 remaining patients, 106 had ECG strain pattern (26.04%). Patients with ECG strain were significantly younger (81.6±8 years vs 83.5±6.8 years; p=0.022), had lower BMI (23±4.5 kg.m2 vs 27.9±6.8 kg.m2; p=0.02) more severe AS (mean gradient 52.3±15.2 mmHg vs 47.9±11.8 mmHg; p=0.003), significant lower LVEF (51.8±15% vs 58.4±10.7%; p<0.001). Left ventricular hypertrophy (LVH) was more frequent in patients with ECG Strain (indexed left ventricular mass (135.9±33.4 g.m2 vs 123.6±31.9 g.m2; p=0.002)). Death from any cause (22 (20.8%) vs 61 (20.3%); p=0.508) did not differ significantly between groups. Major adverse cardiovascular events (MACE) including death, stroke and heart failure at 1 month showed similar incidence (7 (6.6%) vs 17 (5.6%), p=0.439). Rehospitalization for hearth failure (HF) was significantly higher (33 (31.1%) vs 33 (11%); p<0.001) in patients with ECG strain pattern. In univariate model, ECG Strain was a strong predictor of rehospitalization for HF (HR 2.621 95% CI (1.607–4.277), p=0.001), independently of LVH assessed either by ECG criteria (HR 1.181 95% CI (0.698–1.997; p=0.536) or TTE (HR 1.557 95% (CI 0.701–3.458; p=0.277). ECG Strain remained associated with a higher risk of rehospitalization for hearth failure in multivariate analyses (HR 2.747 95% (CI 1.614- 4.674); p<0.001)

Conclusion

In patients with AS eligible for TAVR, ECG Strain Pattern is frequent and associated with an increased risk of post interventional heart failure regardless of preoperative LVH. ECG Strain pattern represents an easy, objective, reliable and low-cost tool to identify patients who may benefit from an extend and intensified post-interventional follow-up.

Consensus guidelines for diagnosis, treatment and follow-up of patients with pancreatic cancer in Spain

The management of patients with pancreatic cancer has advanced over the last few years. We convey a multidisciplinary group of experts in an attempt to stablish practical guidelines for the diagnoses, staging and management of these patients. This paper summarizes the main conclusions of the working group. Patients with suspected pancreatic ductal adenocarcinoma should be rapidly evaluated and referred to high-volume centers. Multidisciplinary supervision is critical for proper diagnoses, staging and to frame a treatment plan. Surgical resection together with chemotherapy offers the highest chance for cure in early stage disease. Patients with advanced disease should be classified in treatment groups to guide systemic treatment. New chemotherapeutic regimens have resulted in improved survival. Symptomatic management is critical in this disease. Enrollment in a clinical trial is, in general, recommended.

Ramucirumab in the treatment of non-small cell lung cancer

INTRODUCTION

Therapeutic options for treating Non-Small Cell Lung Cancer (NSCLC) have recently increased. Ramucirumab (Cyramza), an anti-angionenic agent was approved in 2014 for treatment of several malignancies, including second-line treatment of patients with NSCLC with disease progression on or after platinum-based chemotherapy. Areas covered: We performed a comprehensive search of the literature focused on clinical trials with use of ramucirumab, targeting its evolution in the treatment of NSCLC. This review summarizes the results regarding its safety and efficacy. Expert opinion: Angiogenesis has been widely recognized as a quintessential feature in cancer, intrinsically mediating tumor survival and progression. Ramucirumab, an anti-VEGFR2 agent, combined with docetaxel, was FDA-approved for NSCLC patients. Results from a phase III trial have demonstrated the usefulness of this combination, with benefits in progression free survival and overall survival for NSCLC patients. A greater magnitude of benefit is seen in patients with aggressive tumor behavior. Treatment with ramucirumab is generally tolerable, however, there is potential for severe toxicity. Adverse events reported with this combination include neutropenia, febrile neutropenia and hypertension. Also, there is the intrinsic risk of bleeding resulting from the mechanism of action. As such, adverse events should be identified timely, so drug-related complications can be prevented.

Immunogenicity and safety of AS03-adjuvanted H1N1 pandemic vaccines in children and adolescents

Vaccines with acceptable efficacy profile against the H1N1 A/California/7/2009 virus are needed for use in children. The two studies presented here evaluated the immunogenicity and the reactogenicity/safety of A/H1N1/2009 vaccines containing either 3.75 μg haemagglutinin antigen (HA) and AS03(A)-adjuvant (3.75 μg HA/AS03(A) study) (N=210 [53, 57 and 100 in the 3-5, 6-9 and 10-17 years age strata, respectively]) or 1.9 μg HA and AS03(B)-adjuvant (1.9 μg HA/AS03(B) study) (N=244 [61, 65 and 118 in the 3-5, 6-9 and 10-17 years age strata, respectively]), given as two-dose series. Although the haemagglutination inhibition antibody titres were higher in the 3.75 μg HA/AS03(A) study, both vaccine dosages were highly immunogenic and exceeded regulatory acceptance criteria after the first and the second doses. Seroprotection rates reached 100% and seroconversion rates ranged from 98.2% to 99.1% after each dose of both vaccine dosages. Geometric mean titres increased from 456.5 to 1538.5 and from 297.9 to 1106.7 between the first and the second doses in the 3.75 μg HA/AS03(A) study and the 1.9 μg HA/AS03(B) study, respectively. Despite an observed slight increase of the reactogenicity following the second dose in the 3.75 μg HA/AS03(A) study, the vaccines safety profiles were considered clinically acceptable. In conclusion, both dosages of the AS03-adjuvanted A/H1N1/2009 pandemic influenza vaccines were highly immunogenic and well-tolerated in children and adolescents.

Impact of different patterns of nonadherence on the outcome of highly active antiretroviral therapy in patients with long-term follow-up

OBJECTIVES

The aim of the study was to evaluate the impact of different patterns of nonadherence on treatment outcomes in patients with long-term follow-up.

METHODS

This cohort study included patients who began highly active antiretroviral therapy during 1996-1999, with the last follow-up in 2007. Adherence was evaluated every 2 months by monitoring of pharmacy refills and by using self-reports. Patients were considered nonadherent at a specific visit when less than 90% of the prescribed drugs had been taken. Adherence was categorized as follows. (A) Continuous adherence: a patient had to be adherent in all of the evaluations throughout the period of follow-up. (B) Treatment interruption: drugs were not taken for more than 3 days, for any reason. Treatment failure was defined as viral load >500 HIV-1 RNA copies/mL or death. Cox proportional risk models were used to calculate adjusted relative hazards (ARHs) of treatment failure.

RESULTS

A total of 540 patients were included in the study, with a median follow-up of 8.3 years. Only 32.78% of patients achieved and maintained continuous adherence, and 42.78% of patients had treatment interruptions. Noncontinuous adherence [ARH 1.48; 95% confidence interval (CI) 1.02-2.14] and treatment interruptions (ARH 1.39; 95% CI 1.04-1.85) were associated with treatment failure for the overall cohort; however, for patients with more than 3 years of follow-up, only treatment interruptions were independently associated with treatment failure.

CONCLUSIONS

Only one-third of patients managed to achieve continuous adherence, and almost half of the patients had treatment interruptions, which have a particularly marked effect on treatment outcomes over the long term.

Quantitative micro-analysis of metal ions in subcellular compartments of cultured dopaminergic cells by combination of three ion beam techniques

Quantification of the trace element content of subcellular compartments is a challenging task because of the lack of analytical quantitative techniques with adequate spatial resolution and sensitivity. Ion beam micro-analysis, using MeV protons or alpha particles, offers a unique combination of analytical methods that can be used with micrometric resolution for the determination of chemical element distributions. This work illustrates how the association of three ion beam analytical methods, PIXE (particle induced X-ray emission), BS (backscattering spectrometry), and STIM (scanning transmission ion spectrometry), allows quantitative determination of the trace element content of single cells. PIXE is used for trace element detection while BS enables beam-current normalization, and STIM local mass determination. These methods were applied to freeze-dried cells, following a specific cryogenic protocol for sample preparation which preserves biological structures and chemical distributions in the cells. We investigated how iron accumulates into dopaminergic cells cultured in vitro. We found that the iron content increases in dopaminergic cells exposed to an excess iron, with marked accumulation within distal ends, suggesting interaction between iron and dopamine within neurotransmitter vesicles. Increased iron content of dopaminergic neurons is suspected to promote neurodegeneration in Parkinson's disease.

Enfuvirtida: primer fármaco de una nueva familia de antirretrovirales

Enfuvirtide or T-20 is the first drug approved by the FDA and the EMEA within the group of fusion inhibitors. Its mechanism of action is based on the blockade of the entry of the HIV to the body cells. Enfuvirtide is recommended in combination with other antiretroviral drugs for the treatment of patients infected by HIV that have developed resistance or intolerance to other prior antiretroviral therapies. Clinical trials have shown the effectiveness and safety of the treatment with this drug. Side effects most commonly reported are local reactions in the injection site. Enfuvirtide contributes to increase the therapeutic arsenal available for the management of the HIV infection, providing rescue therapy for patients in which prior treatments have failed.

[Evaluation of a pharmaceutical care program to improve adherence to antiretroviral therapy]

OBJECTIVE

To establish the impact of a pharmaceutical care program on the improvement of adherence to antiretroviral therapy, and on patient immunologic and virologic outcome.

MATERIALS AND METHODS

A multicenter, observational, prospective study in a HIV-infected patient cohort under treatment with antiretrovirals selected by random sampling in 19 Spanish hospitals. The study lasted 12 months, in which the program was applied through a baseline preprocedural visit and 4 quarterly visits. Adherence estimation was based on pill counting. An adherence > or = 90, or > or = 95% was considered adequate (in two time points).

RESULTS

541 patients were included, most of them were males (68.8%) between 20 and 78 years of age. Major risk groups included injecting drug users (43.4%) and heterosexuals (29.4%). Sixty percent had already received treatment for more than 3 years. Mean baseline viral load and CD4 count values were 32,866 copies/ml and 485 cells/mm3, respectively. Throughout the study a slight increase in the percentage of adherent patients was seen; however, statistical significance was not reached (64.3 and 79.2% of patients showed an adherence > 95 and > 90%, respectively, during the fourth quarter, versus 59.8 and 75.5% at baseline). A statistically significant decrease in viral load and increase in CD4 cells was seen following program application. The percentage of patients with a viral load < 200 copies/ml was 72.2, 76.7, and 75.0% at the 2nd, 3rd, and 4th quarters, respectively, versus 64.2% at baseline. CD4 cell counts increased by 50 cells/mm3 on average from the start to the end of follow-up.

CONCLUSIONS

Patients included in the program had a good immunologic and virologic outcome, and a trend towards an increased percentage of patients with good adherence was also seen. These results confirm the need to implement follow-up programs for patients receiving antiretrovirals in order to ensure maximum therapeutic benefits.

Virologic outcome and predictors of virologic failure of highly active antiretroviral therapy containing protease inhibitors

In this observational single-center cohort study outside the clinical trial setting, outcome and predictors of virologic failure of highly active antiretroviral therapy (HAART) containing a protease inhibitor were evaluated in human immunodeficiency (HIV)-infected persons. The study population consisted of 807 protease inhibitor-naive HIV-seropositive patients who initiated antiretroviral therapy with reverse transcriptase inhibitors and protease inhibitors (indinavir, nelfinavir, ritonavir) between January 1997 and January 1999. Demographic variable, plasma HIV-1 RNA levels, CD4+ T-cell count, adverse drug reactions, and adherence to HAART were assessed. Virologic treatment response was defined as a decrease in plasma HIV-1 RNA load from baseline to below 500 copies per milliliter after 12 months of therapy. Levels of HIV-1 RNA were undetectable in 43% of patients at 12 months. Factors associated with failure to suppress viral load included age 40 years or younger, baseline CD4+ T cell count less than 200 x 10(6) per liter baseline viral load greater than 4.3 log(10) per milliliter, and non-adherence to HAART. After adjustment by logistic regression, non-adherence was the only statistically significant variable associated with virologic failure (odds ratio 0.38, 95% confidence interval 0.21 to 0.67). Unselected patients in whom protease inhibitor is started in a usual clinical setting achieve viral suppression less frequently than do patients in controlled clinical trials. Failure to adherence to HAART was the strongest predictor of virologic failure.

[Drugs, inhibitors and other stories. From cancer chemotherapy to nutritional toxicology]

The designation as speaker of the XVIII Annual Conference "Karl Gaede", sponsored by the Asociación Venezolana de Bioquímica y Biología Molecular, provided me with the opportunity to revisit the path constructed in twenty five years of biochemical research. This path stretches from cancer chemotherapy to nutritional toxicology, following the elusive thread that interconnects the metabolic network buried in the ground of any biological process. This work summarizes experiences derived from the use of drugs, inhibitors and stimulators that act on specific enzymatic steps. As a metabolic artisan, I have used these tools to unveil the peculiarities and the inherent character that give continuity to the conductive thread across the whole biological universe.

Anatomical variations in the human paranasal sinus region studied by CT

A precise knowledge of the anatomy of the paranasal sinuses is essential for the clinician. Conventional radiology does not permit a detailed study of the nasal cavity and paranasal sinuses, and has now largely been replaced by computerised tomographic (CT) imaging. This gives an applied anatomical view of the region and the anatomical variants that are very often found. The detection of these variants to prevent potential hazards is essential for the use of current of endoscopic surgery on the sinuses. In the present work, we have studied the anatomical variants observed in the nasal fossae and paranasal sinuses in 110 Spanish subjects, using CT in the coronal plane, complemented by horizontal views. We have concentrated on the variants of the nasal septum, middle nasal concha, ethmoid unciform process and ethmoid bulla, together with others of lesser frequency. The population studied showed great anatomical variability, and a high percentage (67%) presented one or more anatomical variants. Discounting agger nasi air cells and asymmetry of both cavities of the sphenoidal sinus, which were present in all our cases, the variations most often observed were, in order, deviation of the nasal septum, the presence of a concha bullosa, bony spurs of the nasal septum and Onodi air cells.