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Malheiro DT, Bernardez-Pereira S, Parreira KCJ, Pagliuso JGD, de Paula Gomes E, de Mesquita Escobosa D, de Araújo CI, Pimenta BS, Lin V, de Almeida SM, Tuma P, Laselva CR, Neto MC, Klajner S, Teich VD, Kobayashi T, Edmond MB, Marra AR. Prevalence, predictors, and patient-reported outcomes of long COVID in hospitalized and non-hospitalized patients from the city of São Paulo, Brazil. Front Public Health 2024; 11:1302669. [PMID: 38317683 PMCID: PMC10839020 DOI: 10.3389/fpubh.2023.1302669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/20/2023] [Indexed: 02/07/2024] Open
Abstract
Background Robust data comparing long COVID in hospitalized and non-hospitalized patients in middle-income countries are limited. Methods A retrospective cohort study was conducted in Brazil, including hospitalized and non-hospitalized patients. Long COVID was diagnosed at 90-day follow-up using WHO criteria. Demographic and clinical information, including the depression screening scale (PHQ-2) at day 30, was compared between the groups. If the PHQ-2 score is 3 or greater, major depressive disorder is likely. Logistic regression analysis identified predictors and protective factors for long COVID. Results A total of 291 hospitalized and 1,118 non-hospitalized patients with COVID-19 were included. The prevalence of long COVID was 47.1% and 49.5%, respectively. Multivariable logistic regression showed female sex (odds ratio [OR] = 4.50, 95% confidence interval (CI) 2.51-8.37), hypertension (OR = 2.90, 95% CI 1.52-5.69), PHQ-2 > 3 (OR = 6.50, 95% CI 1.68-33.4) and corticosteroid use during hospital stay (OR = 2.43, 95% CI 1.20-5.04) as predictors of long COVID in hospitalized patients, while female sex (OR = 2.52, 95% CI 1.95-3.27) and PHQ-2 > 3 (OR = 3.88, 95% CI 2.52-6.16) were predictors in non-hospitalized patients. Conclusion Long COVID was prevalent in both groups. Positive depression screening at day 30 post-infection can predict long COVID. Early screening of depression helps health staff to identify patients at a higher risk of long COVID, allowing an early diagnosis of the condition.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vivian Lin
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Paula Tuma
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | | - Takaaki Kobayashi
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Michael B. Edmond
- West Virginia University School of Medicine, Morgantown, WV, United States
| | - Alexandre R. Marra
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States
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Oliveira RMC, de Sousa AHF, de Salvo MA, Petenate AJ, Gushken AKF, Ribas E, Torelly EMS, Silva KCCD, Bass LM, Tuma P, Borem P, Ue LY, de Barros CG, Vernal S. Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units. J Hosp Infect 2024; 143:8-17. [PMID: 37806451 DOI: 10.1016/j.jhin.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/14/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate. AIM To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach. METHODS A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative. RESULTS The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%. CONCLUSION Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.
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Affiliation(s)
| | | | - M A de Salvo
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - A J Petenate
- Institute for Healthcare Improvement, Cambridge, MA, USA
| | | | - E Ribas
- Hospital Moinhos de Vento, Porto Alegre, Brazil
| | | | | | - L M Bass
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - P Tuma
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Institute for Healthcare Improvement, Cambridge, MA, USA
| | - P Borem
- Institute for Healthcare Improvement, Cambridge, MA, USA
| | - L Y Ue
- Ministério da Saúde, Brasilia, Brazil
| | - C G de Barros
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - S Vernal
- Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil; Hcor, Sao Paulo, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Hospital Moinhos de Vento, Porto Alegre, Brazil; Hospital Sírio-Libanês, Sao Paulo, Brazil.
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Tuma P, Vieira Júnior JM, Ribas E, Silva KCCD, Gushken AKF, Torelly EMS, de Moura RM, Tavares BM, Prandini CM, Borem P, Delgado P, Ue LY, de Barros CG, Vernal S. The impact of the coronavirus disease 2019 (COVID-19) pandemic on a national project preventing healthcare-associated infections in intensive care units - ERRATUM. Infect Control Hosp Epidemiol 2023; 44:2018. [PMID: 37609861 DOI: 10.1017/ice.2023.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
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4
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Tuma P, Vieira Júnior JM, Ribas E, Silva KCCD, Gushken AKF, Torelly EMS, de Moura RM, Tavares BM, Prandini CM, Borem P, Delgado P, Ue LY, de Barros CG, Vernal S. The impact of the coronavirus disease 2019 (COVID-19) pandemic on a national project preventing healthcare-associated infections in intensive care units. Infect Control Hosp Epidemiol 2023; 44:2071-2073. [PMID: 37462100 DOI: 10.1017/ice.2023.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Beginning in 2018, a quality improvement collaborative initiative in Brazil successfully reduced the baseline incidence density of healthcare-associated infections in intensive care settings after 2 years. We describe the adaptations of the quality improvement interventions as the COVID-19 pandemic emerged and how the pandemic affected the project outcomes.
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Affiliation(s)
- Paula Tuma
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- Institute for Healthcare Improvement, Cambridge, Massachusetts, United States
| | | | - Elenara Ribas
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | | | | | | | | | - Paulo Borem
- Institute for Healthcare Improvement, Cambridge, Massachusetts, United States
| | - Pedro Delgado
- Institute for Healthcare Improvement, Cambridge, Massachusetts, United States
| | - Luciana Y Ue
- Ministério da Saúde, Brasília, Distrito Federal, Brazil
| | | | - Sebastian Vernal
- Hospital Alemão Oswaldo Cruz, São Paulo, São Paulo, Brazil
- Hcor - Hospital do Coracao, São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
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5
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Pedroso AC, Fernandes FP, Tuma P, Vernal S, Pellizzari M, Seisdedos MG, Prieto C, Wilckens BO, Villamizar OJS, Olaya LAC, Delgado P, Cendoroglo Neto M. Patient safety culture in South America: a cross-sectional study. BMJ Open Qual 2023; 12:e002362. [PMID: 37802541 PMCID: PMC10565275 DOI: 10.1136/bmjoq-2023-002362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Every year, millions of patients suffer injuries or die due to unsafe and poor-quality healthcare. A culture of safety care is crucial to prevent risks, errors and harm that may result from medical assistance. Measurement of patient safety culture (PSC) identifies strengths and weaknesses, serving as a guide to improvement interventions; nevertheless, there is a lack of studies related to PSC in Latin America. AIM To assess the PSC in South American hospitals. METHODS A multicentre international cross-sectional study was performed between July and September 2021 by the Latin American Alliance of Health Institutions, composed of four hospitals from Argentina, Brazil, Chile and Colombia. The Hospital Survey on Patient Safety Culture (HSOPSC V.1.0) was used. Participation was voluntary. Subgroup analyses were performed to assess the difference between leadership positions and professional categories. RESULTS A total of 5695 records were analysed: a 30.1% response rate (range 25%-55%). The highest percentage of positive responses was observed in items related to patient safety as the top priority (89.2%). Contrarily, the lowest percentage was observed in items regarding their mistakes/failures being recorded (23.8%). The strongest dimensions (average score ≥75%) were organisational learning, teamwork within units and management support for patient safety (82%, 79% and 78%, respectively). The dimensions 'requiring improvement' (average score <50%) were staffing and non-punitive responses to error (41% and 37%, respectively). All mean scores were higher in health workers with a leadership position except for the hospital handoff/transitions item. Significant differences were found by professional categories, mainly between physicians, nurses, and other professionals. CONCLUSION Our findings lead to a better overview of PSC in Latin America, serving as a baseline and benchmarking to facilitate the recognition of weaknesses and to guide quality improvement strategies regionally and globally. Despite South American PSC not being well-exploited, local institutions revealed a strengthened culture of safety care.
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Affiliation(s)
- Aline Cristina Pedroso
- Qualidade e Segurança do Paciente, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Paula Tuma
- Qualidade e Segurança do Paciente, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Sebastian Vernal
- Escritório de Excelência, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Constanza Prieto
- Clinica Alemana de Santiago SA, Vitacura, Metropolitan Region, Chile
| | | | | | | | - Pedro Delgado
- Latin America and Europe Regions, Institute for Healthcare Improvement, Belfast, UK
| | - Miguel Cendoroglo Neto
- Qualidade e Segurança do Paciente, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Tuma P, Junior JMV, Ribas E, Silva KCCD, Gushken AKF, Torelly EMS, de Moura RM, Tavares BM, Prandini CM, Borem P, Delgado P, Ue LY, de Barros CG, Vernal S. A national implementation project to prevent healthcare-associated infections in intensive care units: a collaborative initiative using the Breakthrough Series model. Open Forum Infect Dis 2023; 10:ofad129. [PMID: 37077504 PMCID: PMC10109530 DOI: 10.1093/ofid/ofad129] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/08/2023] [Indexed: 03/19/2023] Open
Abstract
Abstract
Background
Although there are simple and low-cost measures to prevent healthcare-associated infections (HAI), they remain a major public health problem. Quality issues and a lack of knowledge about HAI control among healthcare professionals may contribute to this scenario.
Aim
To present the implementation of a project to prevent HAI in intensive care units (ICU) using the quality improvement (QI) collaborative model Breakthrough Series (BTS).
Methods
A QI report was conducted to assess the results of a national project in Brazil between January/2018 and February/2020. A one-year pre-intervention analysis was conducted to determine the incidence density baseline of the three main HAI: central line-associated bloodstream infections (CLABSI), ventilation-associated pneumonia (VAP), and catheter-associated urinary tract infections (CA-UTI). The BTS methodology was applied during the intervention period to coach and empower healthcare professionals providing evidence-based, structured, systematic, and auditable methodologies and QI tools to improve patients’ care outcomes.
Results
A total of 116 ICUs were included in this study. The three HAI showed a significant decrease of 43.5%, 52.1%, and 65.8% for CLABSI, VAP, and CA-UTI, respectively. A total of 5,140 infections were prevented. Adherence to bundles inversely correlated with the HAI incidence densities: CLABSI insertion and maintenance bundle (R = -0.50, P-value = 0.010 and R = -0.85, P-value <0.001, respectively), VAP prevention bundle (R = -0.69, P-value <0.001), and CA-UTI insertion and maintenance bundle (R = -0.82, P-value <0.001 and R = -0.54, P-value = 0.004, respectively).
Conclusion
Descriptive data from the evaluation of this project show that the BTS methodology is a feasible and promising approach to preventing HAI in critical care settings.
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Affiliation(s)
- Paula Tuma
- Hospital Israelita Albert Einstein , São Paulo , Brazil
- Institute for Healthcare Improvement , Cambridge, MA , USA
| | | | | | | | | | | | | | | | | | - Paulo Borem
- Institute for Healthcare Improvement , Cambridge, MA , USA
| | - Pedro Delgado
- Institute for Healthcare Improvement , Cambridge, MA , USA
| | | | | | - Sebastian Vernal
- Hospital Alemão Oswaldo Cruz , São Paulo , Brazil
- Hospital do Coração , São Paulo , Brazil
- Hospital Israelita Albert Einstein , São Paulo , Brazil
- Hospital Moinhos de Vento , Porto Alegre , Brazil
- Hospital Sírio-Libanês , São Paulo , Brazil
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Abstract
Making rapid change during covid-19 has lessons for how to improve healthcare, argue Amar Shah and colleagues
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Affiliation(s)
- Amar Shah
- East London NHS Foundation Trust, London, UK
- University of Leicester, Leicester, UK
| | | | - Paula Tuma
- Hospital Israelita Albert Einstein, Brazil
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8
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Silva LLE, Ferreira DB, Goto JM, Silva DFMD, Jr OMB, Tuma P, Medeiros ES. A ADESÃO AO PACOTE DE 3 HORAS DO TRATAMENTO DA SEPSE EM PACIENTES COM DOENÇA ONCO‐HEMATOLÓGICA TEM RELAÇÃO COM A LETALIDADE? Braz J Infect Dis 2018. [DOI: 10.1016/j.bjid.2018.10.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Machado FR, Ferreira EM, Schippers P, de Paula IC, Saes LSV, de Oliveira FI, Tuma P, Nogueira Filho W, Piza F, Guare S, Mangini C, Guth GZ, Azevedo LCP, Freitas FGR, do Amaral JLG, Mansur NS, Salomão R. Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results. Crit Care 2017; 21:268. [PMID: 29089025 PMCID: PMC5664817 DOI: 10.1186/s13054-017-1858-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 10/05/2017] [Indexed: 01/21/2023]
Abstract
Background Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality. Methods We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance. Results We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle. Conclusions Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1858-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Flavia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil. .,Latin American Sepsis Institute, São Paulo, SP, Brazil. .,Latin American Sepsis Institute, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715 - 6° andar, Vila Clementino, 04024-002, São Paulo, SP, Brazil.
| | | | | | | | | | | | - Paula Tuma
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | - Felipe Piza
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | - Sandra Guare
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | - Cláudia Mangini
- Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | | | - Flavio Geraldo Resende Freitas
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil.,Latin American Sepsis Institute, São Paulo, SP, Brazil
| | - Jose Luiz Gomes do Amaral
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil.,Latin American Sepsis Institute, São Paulo, SP, Brazil.,Sociedade Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, SP, Brazil
| | | | - Reinaldo Salomão
- Latin American Sepsis Institute, São Paulo, SP, Brazil.,Infectious Disease Department, Federal University of São Paulo, São Paulo, SP, Brazil
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Gojda J, Strakova R, Rossmeislova L, Tumova J, Elkalaf M, Jacek M, Tuma P, Potockova J, Trnka J, Stich V, Andel M. OR013: Chronic Dietary Exposure to Branched Chain AMINO ACIDS Causes Impaired Glucose Disposal and Higher Adipose Tissue Lipogenesis. Clin Nutr 2015. [DOI: 10.1016/s0261-5614(15)30110-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tuma P, Pineda JA, Labarga P, Vidal F, Rodriguez C, Poveda E, Santos J, Gonzalez-García J, Sobrino P, Tural C, Soriano V. HBV primary drug resistance in newly diagnosed HIV-HBV-coinfected individuals in Spain. Antivir Ther 2011; 16:585-9. [PMID: 21685546 DOI: 10.3851/imp1778] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The wide use of lamivudine (3TC) as oral therapy for chronic HBV infection has favoured the selection and circulation of 3TC-resistant HBV strains worldwide. Although transmission of 3TC-resistant HBV variants has been reported only sporadically, few studies have been conducted in the HIV population where exposure to 3TC has been greater forming part of antiretroviral therapy (ART) regimens. METHODS All individuals positive for serum hepatitis B surface antigen (HBsAg), newly diagnosed with HIV-1 infection, naive to ART and enrolled in the Spanish HIV cohort (CoRIS) since 2004 were identified. The HBV polymerase gene was sequenced and drug resistance mutations were characterized retrospectively in stored frozen plasma specimens. RESULTS From 4,419 ART-naive HIV-1-infected individuals, 223 (5.1%) were positive for serum HBsAg. Baseline stored sera were available for 84 patients, of whom 73 could be characterized virologically. This population was mainly represented by men who had sex with men (52.1%), native Spaniards (65.7%) and Latin Americans (16.4%). The mean age was 36 years, mean CD4(+) T-cell count 375 cells/mm(3) and mean plasma HIV RNA 4.5 log(10) copies/ml. The HBV genotype distribution was 64% A, 20% F, 12% D and 4% others. Drug-resistant mutations in the HBV polymerase were found in four (5.5%) patients: two harboured rtL180M, one rtL80V and one rtV173L. CONCLUSIONS The rate of primary drug resistance in HBV among newly diagnosed HIV-HBV-coinfected patients in Spain is currently low (5.5%) and restricted to 3TC. Thus, HBV drug resistance testing before prescription of oral antiviral therapy is not warranted, although periodic surveillance might be recommended.
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Affiliation(s)
- Paula Tuma
- Department of Infectious Diseases, Hospital Carlos III, Madrid, Spain
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12
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Martín-Carbonero L, Tuma P, Vispo E, Medrano J, Labarga P, González-Lahoz J, Barreiro P, Soriano V. Treatment of chronic hepatitis C in HIV-infected patients with compensated liver cirrhosis. J Viral Hepat 2011; 18:542-8. [PMID: 20819149 DOI: 10.1111/j.1365-2893.2010.01334.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The greatest benefit of hepatitis C virus (HCV) therapy is seen in cirrhotics attaining sustained virological response (SVR). However, concerns about toxicity and poorer responses often discourage treatment of cirrhotics. This may be particularly relevant in HIV-HCV-coinfected patients, in whom progression of liver fibrosis is faster and treatment responses lower. This is a retrospective analysis of HIV-HCV-coinfected patients who had received peginterferon-ribavirin therapy at our institution. Individuals naïve for interferon in whom liver fibrosis had been assessed using elastometry within the year before being treated were chosen. Response rates and toxicities were compared in cirrhotics (>14.5 KPa) and noncirrhotics. Patients with previous liver decompensation were excluded. Overall, 41 cirrhotics and 190 noncirrhotics entered the study. Groups were similar in age, gender, HCV genotypes and baseline serum HCV-RNA. SVR occurred at similar rates in cirrhotic and noncirrhotics, either considered by intention-to-treat (39%vs 45%; P = 0.4) or as treated (50%vs 52%, P = 0.8). In multivariate analysis (odds ratio, 95% CI, P), SVR was associated with HCV genotypes 2-3 (5, 2.9-11, <0.01) and lower serum HCV-RNA (2, 1.4-3.03 for every log decrease, <0.01) but not with cirrhosis (1.2, 0.4-3.6, 0.6). Treatment discontinuations because of adverse events tended to be more common in cirrhotics than in noncirrhotics (17%vs 12%; P = 0.2), but only severe thrombocytopenia was more frequent in cirrhotics than in non-cirrhotics (20%vs 3% at week 24; P < 0.01). Response to peginterferon-ribavirin therapy is similar in HIV-HCV coinfected patients with and without liver cirrhosis. Therefore, treatment must be encouraged in all compensated cirrhotic patients, although closer monitoring and management of side effects, mainly thrombocytopenia, may be warranted.
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13
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Medrano J, Resino S, Vispo E, Madejón A, Labarga P, Tuma P, Martín-Carbonero L, Barreiro P, Rodriguez-Novoa S, Jiménez-Nacher I, Soriano V. Hepatitis C virus (HCV) treatment uptake and changes in the prevalence of HCV genotypes in HIV/HCV-coinfected patients. J Viral Hepat 2011; 18:325-30. [PMID: 20456635 DOI: 10.1111/j.1365-2893.2010.01309.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The efficacy of current hepatitis C therapy in HIV/HCV-coinfected patients is largely dependent on HCV genotype. The annual prevalence of HCV genotypes/subtypes and their influence on HCV clearance with antiviral treatment were examined in a dynamic cohort of HIV/HCV-coinfected patients followed up in Madrid since 2000. Patients entered the cohort at first visit and left the cohort when HCV clearance was achieved with HCV therapy or when follow-up was interrupted for any reason, including death. A total of 672 HIV/HCV-coinfected patients constituted the cohort. The mean follow-up time was 5.5 years, corresponding to 4108 patient-years. Mean age at entry was 37 years, and 73% were men and 86% were intravenous drug users. Overall distribution of HCV genotypes was as follows: 57.1% HCV-1 (1a: 29.2%, 1b: 20.4%, unknown: 7.6%), 1.3% HCV-2, 25.4% HCV-3 and 15.9% HCV-4. A total of 274 (40.8%) patients were treated with peginterferon-ribavirin, of whom 116 (42.3%) achieved HCV clearance following 1-3 courses of therapy. The proportion of HCV-1/4 rose from 71.7% in 2000 to 76.8% in 2008, whereas the proportion of HCV-2/3 fell from 28.1% in 2000 to 23.2% in 2008. The yearly prevalence increased for HCV-1 (R(2) : 0.92, b: 0.59, P < 0.001) and HCV-4 (R(2) : 0.77, b: 0.33, P < 0.005) and conversely diminished for HCV-3 (R(2) : 0.94, b: -0.82, P < 0.001). In summary, the prevalence of HCV-1 and HCV-4 has increased over the last decade in HIV/HCV-coinfected patients, whereas conversely it has declined for HCV-3, in association with the wider use of HCV therapy (41%) in this population.
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Affiliation(s)
- J Medrano
- Department of Infectious Diseases & CIBERehd, Hospital Carlos III, Madrid, Spain
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Blanco F, Barreiro P, Ryan P, Vispo E, Martín-Carbonero L, Tuma P, Labarga P, Medrano J, González-Lahoz J, Soriano V. Risk factors for advanced liver fibrosis in HIV-infected individuals: role of antiretroviral drugs and insulin resistance. J Viral Hepat 2011; 18:11-6. [PMID: 20088890 DOI: 10.1111/j.1365-2893.2009.01261.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver damage may result from multiple factors in HIV-infected patients. The availability of reliable noninvasive tools to measure liver fibrosis has permitted the screening of large patient populations. Cross-sectional study of all consecutive HIV outpatients who underwent examination by transient elastometry (FibroScan) at one HIV reference clinic during 2007. Advanced liver fibrosis (ALF) was defined as hepatic stiffness >9.5 kilopascals, which corresponds to Metavir stages F3-F4 in the liver biopsy. A total of 681 consecutive HIV-infected patients (64% injecting drug users; mean age 43; 78% male; 98% on antiretroviral therapy) had at least one valid FibroScan evaluation. ALF was diagnosed in 215 (32%) of them. In the univariate analysis, ALF was significantly associated with older age, low CD4 counts, chronic hepatitis C, past alcohol abuse, elevated ALT, high triglycerides, low cholesterol, high homeostasis model assessment (HOMA) index and exposure to didanosine and/or stavudine. In a multivariate model (OR, 95% CI), chronic hepatitis C (2.83, 1.57-5.08), past alcohol abuse (2.26, 1.37-3.74), exposure to didanosine and/or stavudine (1.85, 1.14-3.01), high HOMA index (1.25, 1.04-1.51), older age (1.09, 1.05-1.14) and elevated ALT (1.04, 1.03-1.06) remained as independently associated with ALF. Therefore, in addition to chronic hepatitis C and alcohol abuse, insulin resistance and/or exposure to dideoxy-nucleosides may contribute to ALF in HIV-infected patients.
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Affiliation(s)
- F Blanco
- Department of Infectious Diseases, Hospital Carlos III, Madrid, Spain
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Tuma P, Medrano J, Resino S, Vispo E, Madejón A, Sánchez-Piedra C, Rivas P, Labarga P, Martín-Carbonero L, Barreiro P, Soriano V. Incidence of liver cirrhosis in HIV-infected patients with chronic hepatitis B or C in the era of highly active antiretroviral therapy. Antivir Ther 2010; 15:881-6. [PMID: 20834100 DOI: 10.3851/imp1630] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Longitudinal assessment of liver fibrosis with transient elastometry (TE) in patients with chronic viral hepatitis is becoming routine clinical practice in many clinics, as this procedure is non-invasive, easy to perform and relatively inexpensive, allowing early detection of cirrhosis. Herein, we examine the incidence of cirrhosis, using TE assessment, in HIV-infected individuals with chronic hepatitis B or C receiving highly active antiretroviral therapy (HAART). METHODS A longitudinal study was performed on a cohort of HIV-infected patients with chronic hepatitis B or C who were followed since 2004 at Hospital Carlos III (Madrid, Spain) with periodic TE assessments. The primary outcome was the development of cirrhosis, defined as liver stiffness >12.5 KPa. RESULTS A total of 508 HIV-infected patients were examined, of whom 54 developed liver cirrhosis during a mean ±(SD) follow-up of 2.6 ±1.0 years (overall incidence was 41.13 cases per 1,000 person-years). The risk of developing cirrhosis was significantly higher in 297 HCV-RNA-positive patients (either untreated or non-responders to hepatitis C therapy) compared with 55 patients who had cleared HCV with therapy (odds ratio 3.73, 95% confidence interval 1.06-13.17; P=0.04). By contrast, the risk of developing cirrhosis was low and similar in 24 HIV-HBV-coinfected patients under long-term suppressive HBV therapy (mainly tenofovir disoproxil fumarate), 132 HIV-infected patients without chronic liver disease and those who had cleared HCV with therapy. CONCLUSIONS Development of liver cirrhosis in HIV-infected individuals in the HAART era is mainly associated with active HCV coinfection. The risk of developing cirrhosis is negligible in patients who cleared HCV with therapy, as well as in HIV-HBV-coinfected patients on long-term suppressive tenofovir disoproxil fumarate therapy.
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Affiliation(s)
- Paula Tuma
- Department of Infectious Diseases, Hospital Carlos III, Madrid, Spain
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16
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Labarga P, Vispo E, Barreiro P, Rodríguez-Novoa S, Pinilla J, Morello J, Martín-Carbonero L, Tuma P, Medrano J, Soriano V. Rate and predictors of success in the retreatment of chronic hepatitis C virus in HIV/hepatitis C Virus coinfected patients with prior nonresponse or relapse. J Acquir Immune Defic Syndr 2010; 53:364-8. [PMID: 20101191 DOI: 10.1097/qai.0b013e3181bd5ce1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND In hepatitis C virus (HCV)/HIV-coinfected patients who failed a course of suboptimal hepatitis C therapy, retreatment with adequate doses and duration of pegylated interferon (pegIFN) plus ribavirin (RBV) is advisable in the presence of compensated advanced liver fibrosis. METHODS The efficacy and safety of pegIFN-alpha2a (180 microg/wk) plus RBV (<75 kg: 1000 mg/d; > or = 75 kg: 1200 mg/d) given for 12 months was prospectively assessed in HIV/HCV patients with nonresponse or relapse to a prior course of suboptimal hepatitis C therapy. The main endpoint was the achievement of sustained virological response (SVR). RESULTS A total of 52 patients were enrolled in the study (78% HCV genotypes 1 or 4; 56% with advanced liver fibrosis). Prior suboptimal regimens were IFN monotherapy (20%), IFN plus RBV (29%), and pegIFN plus RBV 800 mg/d (51%). Overall, 61% were nonresponders and 39% relapsers. Retreatment provided SVR in 30.8% of patients (19.5% for genotypes 1/4 vs. 72.7% for genotypes 2/3; P = 0.002). In multivariate analysis, HCV genotypes 2/3 [OR 22.2, 95% confidence interval (CI), 2.9-166.7, P = 0.003] and RBV plasma trough concentrations at week 4 [OR 3.9 (95% CI, 1.3-11.8), P = 0.01] were the only independent predictors of SVR. CONCLUSIONS Retreatment with pegIFN-alpha2a plus weight-based RBV for 12 months permits to achieve HCV clearance in nearly onethird of HIV/HCV-coinfected patients who failed a prior suboptimal course of hepatitis C therapy. Patients with HCV genotypes 2/3 and those with RBV plasma trough levels above 2.07 microg/mL show the highest chances of SVR.
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Affiliation(s)
- Pablo Labarga
- Department of Infectious Diseases, Hospital Carlos III, Calle Sinesio Delgado 10, Madrid 28029, Spain
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17
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Medrano J, Barreiro P, Resino S, Tuma P, Rodríguez V, Vispo E, Labarga P, Madejón A, García-Samaniego J, Jiménez-Nácher I, Martín-Carbonero L, Soriano V. Rate and timing of hepatitis C virus relapse after a successful course of pegylated interferon plus ribavirin in HIV-infected and HIV-uninfected patients. Clin Infect Dis 2009; 49:1397-401. [PMID: 19814621 DOI: 10.1086/630205] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Information on the rate and timing of hepatitis C virus (HCV) relapse after treatment with pegylated interferon plus ribavirin is scarce. Among 604 patients treated for chronic hepatitis C, the 386 who were human immunodeficiency virus (HIV) positive attained an end-of-treatment response less frequently and experienced relapse more often than did the 218 who were HIV negative. However, episodes of HCV relapse occurred before week 12 in most cases, regardless of HIV status.
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Affiliation(s)
- José Medrano
- Department of Infectious Diseases, Hospital Carlos III, Madrid, Spain
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18
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Treviño A, Soriano V, Madejon A, Rodriguez C, Barros C, Botecchia M, Tuma P, Del Romero J, de Mendoza C. Short communication: transmission of hepatitis B viruses with lamivudine resistance mutations in newly diagnosed HIV individuals. AIDS Res Hum Retroviruses 2009; 25:1273-6. [PMID: 20001517 DOI: 10.1089/aid.2009.0119] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
From 1519 newly diagnosed HIV individuals seen in Madrid between the years 2000 and 2008, 65 (4.3%) were HBsAg(+). Two HIV/HBV-coinfected patients showed the lamivudine resistance mutation M204V in HBV while no drug resistance mutations were recognized in HIV. None of them admitted prior exposure to antiretroviral drugs. Thus, HIV/HBV-coinfected patients might benefit from baseline drug resistance testing for both HIV and HBV to optimize the selection of anti-HBV active antiviral therapy.
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Affiliation(s)
- Ana Treviño
- Service of Infectious Diseases, Hospital Carlos III, Hospital de Mostoles, Madrid, Spain
| | - Vincent Soriano
- Service of Infectious Diseases, Hospital Carlos III, Hospital de Mostoles, Madrid, Spain
| | - Antonio Madejon
- Service of Infectious Diseases, Hospital Carlos III, Hospital de Mostoles, Madrid, Spain
| | | | - Carlos Barros
- Service of Internal Medicine, Hospital de Mostoles, Madrid, Spain
| | - Marcelle Botecchia
- Service of Infectious Diseases, Hospital Carlos III, Hospital de Mostoles, Madrid, Spain
| | - Paula Tuma
- Service of Infectious Diseases, Hospital Carlos III, Hospital de Mostoles, Madrid, Spain
| | | | - Carmen de Mendoza
- Service of Infectious Diseases, Hospital Carlos III, Hospital de Mostoles, Madrid, Spain
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Soukupova M, Dolezal T, Prochazkova M, Janovsky M, Tuma P, Kubicek V, Krsiak M. 267 THE EFFECT OF PARACETAMOL ON PERIAQUEDUCTAL GRAY RELEASE OF GLYCINE IN THE INFLAMMATORY PAIN. Eur J Pain 2009. [DOI: 10.1016/s1090-3801(09)60270-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- M. Soukupova
- Department of Pharmacology 3rd Faculty of Medicine, Charles University, Prague 10, Czech Republic
| | - T. Dolezal
- Department of Pharmacology 3rd Faculty of Medicine, Charles University, Prague 10, Czech Republic
| | - M. Prochazkova
- Department of Pharmacology 3rd Faculty of Medicine, Charles University, Prague 10, Czech Republic
| | - M. Janovsky
- Department of Pharmacology 3rd Faculty of Medicine, Charles University, Prague 10, Czech Republic
| | - P. Tuma
- Institute of Biochemistry, Cell and Molecular Biology, 3rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - V. Kubicek
- Department of Biophysics and Physical Chemistry, Faculty of Pharmacy, Charles University Prague, Hradec kralove, Czech Republic
| | - M. Krsiak
- Department of Pharmacology 3rd Faculty of Medicine, Charles University, Prague 10, Czech Republic
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20
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Bagni R, Barsov E, Ortiz-Conde B, Dittmer D, Kewalramani V, Ott D, Sadowski C, Tuma P, Ruscetti F, Whitby D. Dendritic cell-mediated infection of primary B cells with KSHV. Infect Agent Cancer 2009. [PMCID: PMC4261850 DOI: 10.1186/1750-9378-4-s2-p9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
Chronic hepatitis C virus (HCV) infection is common in HIV-infected individuals, especially if the route of infection is intravenous (e.g. intravenous drug use or blood transfusion). Prognosis is poorer in patients with HCV and HIV coinfection than in those with HCV monoinfection, mainly due to the immunodepression caused by HIV infection and probably also to a direct effect of HIV on the liver. Moreover, although antiretroviral therapy can cause liver damage, there is little doubt about the net benefits obtained with triple therapy in coinfected individuals, since suppression of HIV replication and immune recovery help to halt liver damage. However, not all antiretroviral agents are equal and those with the lowest hepatotoxicity and best metabolic profile should be used in coinfected patients, since hepatic steatosis accelerates progression of hepatic fibrosis and insulin resistance hampers the success of treatment with interferon and ribavirin. Tenofovir is currently one of the safest nucleos(t)ide analogues, due to its low hepatotoxicity and its lack of negative interference on treatment of HCV infection.
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Affiliation(s)
- Paula Tuma
- Servicio de Enfermedades Infecciosas, Hospital Carlos III, Madrid, España
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22
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Soriano V, Tuma P, Vispo E, Labarga P, Fernández JV, Medrano J, Barreiro P. Hepatitis B in HIV patients: what is the current treatment and what are the challenges? J HIV Ther 2009; 14:13-18. [PMID: 19731560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Chronic hepatitis B affects 5-10% of HIV patients in Western countries. Lamivudine should no longer be used as a single anti-HBV agent in HIV-HBV co-infected patients, given its limited antiviral potency and high risk of selection of resistance, which further results in wide cross-resistance to all other nucleoside analogues. Recent reports of transmission of lamivudine-resistant HBV in HIV patients are of especial concern, and large surveillance studies suggest that it may occur in up to 10% of new HBV infections in Western countries. Another worrisome aspect of the selection of lamivudine-resistant HBV is the potential for selection of vaccine escape mutants. Currently, tenofovir must be viewed as the drug of choice in HIV-HBV co-infected patients in whom antiretroviral therapy is advised. Its co-formulation with emtricitabine (Truvada) is particularly convenient for treating both HIV and HBV in co-infected individuals. While pegIFN-alpha monotherapy for 1 year may be considered for HIV-HBV coinfected individuals with good spontaneous HIV control (elevated CD4 cell count, low plasma HIV-RNA), and certain HBV features (genotype A, HBeAg+, low serum HBV-DNA and elevated ALT), it is clear that very few coinfected patients fulfill these criteria. In HBeAg-negative HIV patients, adefovir may be an option but the relatively low antiviral potency of this drug discourages its wide use. Given its potential anti-HIV activity, both entecavir and telbivudine must only be prescribed with antiretroviral agents. Lack of information about potential pharmacodynamic interactions between entecavir and abacavir (both are guanosine analogues) or between telbivudine and zidovudine or stavudine (all are thymidine analogues) further discourages their concomitant use. At this time, most experts agree that early introduction of anti-HBV active HAART is the best strategy for the treatment of chronic hepatitis B in HIV patients, and Truvada must be part of the triple regimen.
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Affiliation(s)
- Vincent Soriano
- Department of Infectious Diseases, Hospital Carlos III, Madrid, Spain.
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23
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Soriano V, Madejon A, Vispo E, Labarga P, Garcia-Samaniego J, Martin-Carbonero L, Sheldon J, Bottecchia M, Tuma P, Barreiro P. Emerging drugs for hepatitis C. Expert Opin Emerg Drugs 2008; 13:1-19. [PMID: 18321145 DOI: 10.1517/14728214.13.1.1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic hepatitis C virus (HCV) infection remains a global health threat with approximately 200 million carriers worldwide. Current treatment consists of the use of peginterferon (pegIFN)/ribavirin (RBV) for 24 or 48 weeks depending on HCV genotype. Serious side effects and the fact that less than half of patients infected with HCV genotypes 1 and 4 (which are the most common) accomplish sustained virological response with this medication warrant the need for novel anti-HCV therapies. OBJECTIVE Description of specifically targeted antiviral therapies for hepatitis C (STAT-C) designed to inhibit the serine protease and the RNA-dependent HCV-RNA polymerase. METHODS Review of available data reported in peer-reviewed journals and medical conferences. RESULTS/CONCLUSIONS Early preclinical studies using these compounds produced encouraging results, but the initial enthusiasm has been hampered by toxicity issues and rapid selection of resistance. Therefore, combination therapy with a backbone of pegIFN/RBV, or perhaps in the future using several of these small molecules, preferably having distinct modes of action and resistance profiles, will be required.
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Affiliation(s)
- Vincent Soriano
- Hospital Carlos III, Department of Infectious Diseases, Calle Sinesio Delgado 10, Madrid 28029, Spain.
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24
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Medrano J, Barreiro P, Tuma P, Vispo E, Labarga P, Blanco F, Soriano V. Risk for immune-mediated liver reactions by nevirapine revisited. AIDS Rev 2008; 10:110-115. [PMID: 18615121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Implementation of combination antiretroviral therapies has transformed the prognosis of HIV infection during the past decade. Because of its low-pill burden, convenient administration once or twice daily without food restrictions and, in the case of nevirapine, favorable metabolic profile and proven safety in pregnant women and newborns, nonnucleoside reverse transcriptase inhibitors have been shown to be often superior to protease inhibitors as third agents in combination with a backbone of two nucleoside reverse transcriptase inhibitors. Therefore, two nucleoside reverse transcriptase inhibitors plus one nonnucleoside reverse transcriptase inhibitor are currently the most popular used first-line therapies. Hepatotoxicity during the first weeks of therapy with nevirapine, particularly when initiated in women with CD4 counts > 250 cells/mm3, has prompted changes in guidelines and led to a modification in the product label. Recent data, however, suggest that virologically suppressed patients under any other antiretroviral drug combination may safely switch to nevirapine as a part of a simplification strategy, regardless of their current CD4 count. This subset of patients does not show an increased risk of hepatotoxicity or rash with elevated CD4 counts, as has been reported in drug-naive HIV persons. This information is important and may expand the number of candidates who could benefit from nevirapine use, since a substantial proportion of HIV patients show metabolic abnormalities (dyslipidemia, insulin resistance, liver steatosis) and are at increased cardiovascular risk. Fortunately, many of these conditions may ameliorate or improve using nevirapine.
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Affiliation(s)
- José Medrano
- Infectious Diseases Department, Hospital Carlos III, Madrid, Spain.
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25
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Blanco F, Barreiro P, Ryan P, Vispo E, Martin-Carbonero L, Tuma P, Labarga P, González-Lahoz J, Soriano V. Risk factors for advanced liver fibrosis in HIV-infected individuals: role of the metabolic syndrome. J Int AIDS Soc 2008. [DOI: 10.1186/1758-2652-11-s1-p137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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26
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Tuma P, Vispo E, Medrano J, Barreiro P, Martin-Carbonero L, Labarga P, Soriano V. A 4-year follow-up of a cohort of HIV-positive cirrhotic patients. J Int AIDS Soc 2008. [DOI: 10.1186/1758-2652-11-s1-p265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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27
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Medrano J, Resino S, Vispo E, Tuma P, García-Samaniego J, Martin-Carbonero L, Labarga P, Jimenez I, Romero M, Barreiro P, Soriano V. HCV relapse after peg-interferon (IFN) plus ribavirin (RBV) therapy: is 12-week follow-up enough to determine sustained HCV clearance? J Int AIDS Soc 2008. [DOI: 10.1186/1758-2652-11-s1-p268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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28
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Figueira EJG, Cazzo E, Tuma P, Silva Filho CRD, Conterno LDO. Apreensão de tópicos em ética médica no ensino-aprendizagem de pequenos grupos: comparando a aprendizagem baseada em problemas com o modelo tradicional. Rev Assoc Med Bras (1992) 2004; 50:133-41. [PMID: 15286859 DOI: 10.1590/s0104-42302004000200027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Aiming to evaluate the acquisition of skills on Medical Ethics among medical students from Marilia Medical School, some of them from the small group learning-teaching method, others from traditional teaching method. METHODS A prospective analytical study was done based on the application of questionnaires about general themes on Ethics, at two different times. RESULTS There weren't significant differences on the skills' acquisition between the two methods. Students from late graduation years showed a significantly better performance than those from early years. The themes that presented worse results were medical secret, legal responsible consent, patient autonomy, medical prescription, medical handbook and corporative feeling in the presence of medical mistake. CONCLUSION The most important difference between the groups was not the pedagogical pattern but the exposition time to the theme. PBL gives the chance to distribute the theme in different situations accelerating the acquisition of knowledge in Medical Ethics. It was realized that a revitalization on Medical Ethics teaching is necessary at our institution, aiming a better integration with the socio-economical situation in our country.
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Abrahamova J, Wagnerova M, Kubala E, Malec V, Simova E, Sirakova I, Pavlikova E, Machova D, Kocak I, Pavlikova I, Tuma P, Prausova J, Kroslakova D, Van Praagh I. Vinorelbine, epirubicin, and methotrexate (VEM) as primary treatment in locally advanced breast cancer. Oncologist 2001; 6:347-52. [PMID: 11524553 DOI: 10.1634/theoncologist.6-4-347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE This phase II trial of VEM (vinorelbine + epirubicine + methotrexate) in the treatment of locally advanced breast cancer was conducted to obtain downstaging to allow surgery and breast conservation. PATIENTS AND METHODS This multicenter study recruited 58 patients with locally advanced breast cancer (two patients ineligible); 56 were evaluable for response and tolerance. RESULTS Downstaging was obtained in 77% of the patients with a pathological complete response (pCR) rate of 9%. At 33 months of follow-up, median survival has not been reached. Neutropenia grade 3-4 was reported in 31% of cycles with 3% of cycles with infection grade 3. Alopecia grade 3 was noticed for 71% of patients. CONCLUSION VEM represents an effective regimen for patients with locally advanced breast cancer, allowing an important pCR. Moreover, this regimen appears to be particularly well tolerated.
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Affiliation(s)
- J Abrahamova
- Thomayer Memorial Teaching Hospital, Praha, Czech Republic.
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30
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Tuma P, Arrunategui G, Wada A, Friedhofer H, Ferreira MC. Rectangular flaps technique for treatment of congenital hand syndactyly. Rev Hosp Clin Fac Med Sao Paulo 1999; 54:107-10. [PMID: 10779816 DOI: 10.1590/s0041-87811999000400001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The authors analysed a series of 22 patients undergoing surgical correction of congenital hand syndactyly by the rectangular flap technique. Using our evaluation method, we found that good functional and aesthetic results were obtained in 77.3% of the patients, with a complication rate of 13.6%. We concluded that the rectangular flap technique has a simple design, is easily reproducible by in-training staff, has good results, and can be applied on the majority of the syndactyly cases.
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Affiliation(s)
- P Tuma
- Division of Plastic Surgery - Hospital das Clinicas, School of Medicine, University of Sao Paulo, São Paulo, SP, Brazil
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31
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Silverman HJ, Tuma P, Schaeffer MH, Singh B. Implementation of the patient self-determination act in a hospital setting. An initial evaluation. Arch Intern Med 1995; 155:502-510. [PMID: 7864706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND The Patient Self-Determination Act aims to enhance patient awareness of advance directives by requiring health-care institutions to ask patients whether they have advance directives and to inform patients of their rights to prepare these documents. We investigated the following: (1) compliance of the hospital staff with implementing this act, (2) the effects of this act on the extent to which patients discuss and prepare advance directives, and (3) variables that might influence patient discussions on advance planning and preparation of advance directives. METHODS We surveyed 219 patients from a university hospital that implemented a nurse-dependent advance directive program. We also conducted a telephone interview with 57% of these patients at least 6 months after hospital discharge. RESULTS Nurses asked 70% of the patients about the existence of an advance directive and of these patients, only 57% remembered the inquiry. Only 57% of the patients received the brochure on advance directives and of these patients, only 55% read the brochure. Only 2% of the patients requested to receive additional information on advance directives. Less than one quarter of the patients had discussions on advance planning while in the hospital and of those patients who were contacted within 6 months after hospital discharge, 39% had discussions on advance planning and 15% prepared an advance directive. Race was an independent predictor for hospital discussions, and educational level was an independent predictor for discussions and preparation of advance directives after hospital discharge. CONCLUSIONS To enhance the effectiveness of a nurse-dependent advance directive program, hospitals may need (1) to strengthen the quality of the patient-nurse encounter in which the issue of advance directives is raised to more effectively promote patient interest, discussions, and preparation of advance directives and (2) to account for the social diversity of their patient population.
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Affiliation(s)
- H J Silverman
- Department of Medicine, University of Maryland School of Medicine, Baltimore
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Abstract
We wanted to determine the efficacy of dobutamine infusions and Prbc transfusions on splanchnic tissue oxygen utilization by measuring gastric pHi. Physiologic parameters and pHi measurements via the use of a gastric tonometer were obtained in 21 septic patients before and after the administration of a dobutamine infusion (5 micrograms/kg/min) or the transfusion of two units of Prbc. Subsets of measurements with normal (greater than 7.32) and with low (less than 7.32) pHi were separately analyzed for each intervention. In the dobutamine low pHi group, pHi increased significantly from 7.16 +/- 0.03 to 7.24 +/- 0.03 (n = 9, p less than 0.05). In contrast, pHi failed to increase in the Prbc low pHi subgroup (7.16 +/- 0.05 to 7.17 +/- 0.04 [n = 10, p greater than 0.80]). We conclude that dobutamine rather than Prbc transfusions should be administered to reverse gastric intramucosal acidosis.
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Affiliation(s)
- H J Silverman
- Department of Medicine, University of Maryland School of Medicine, Baltimore
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Abstract
One hundred three patients underwent abdominoplasty combined with other intraabdominal procedures including 67 tubal ligations, 34 total abdominal hysterectomies and 2 cholecystectomies, from January 1983 to July 1991. The patients were divided into two groups, those undergoing the standard or total abdominoplasty and those undergoing limited abdominoplasty with or without liposuction in delimited areas. In this series of 103 patients, we found only two minor complications and only three patients were transfused with autologous units of blood. When performed by well-schooled surgical teams, abdominoplasty may be combined with intraabdominal procedures with gratifying results.
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Affiliation(s)
- R Gemperli
- Division of Plastic and Reconstructive Surgery, University of São Paulo School of Medicine, Brazil
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Tuma P. Anatomy of the marginal and cervical branches of the facial nerve. Plast Reconstr Surg 1991. [DOI: 10.1097/00006534-199105000-00064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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