Las percepciones de la exclusión social en el medio rural durante la Gran Recesión: una historia de marcos neoliberales, patriarcales e idilio rural

En este artículo se exploran las percepciones de alcaldes rurales sobre los procesos de exclusión social en sus territorios y los marcos ideológicos que las sostienen. La evidencia empírica de nuestro estudio, contextualizado en España durante la crisis de 2008-2014, procede de entrevistas cualitativas en dos proyectos de investigación sobre exclusión social en áreas rurales de Castilla-La Mancha y la Comunidad Valenciana. Nuestro análisis muestra diferencias significativas entre las descripciones objetivas de exclusión social en el medio rural y cómo se perciben. Los alcaldes responsabilizan de esos procesos a la crisis económica y a las decisiones personales, mientras obvian cualquier responsabilidad comunitaria de integración social. Así, identificamos neoliberalismo, patriarcado e idilio rural como los marcos definidores de la percepción de los procesos de exclusión social en el medio rural.This article explores the perceptions that rural mayors have of social exclusion processes in their territories, and the ideological frames that underpin them. The study was conducted in Spain during the 2008-2014 crisis. It draws on evidence from qualitative interviews conducted with rural mayors as part of two research projects on social exclusion in rural areas in the Castilla-La Mancha and Valencian autonomous communities. Our analysis shows significant differences between the objective descriptions of social exclusion in rural areas and how such exclusion was perceived. Mayors held individuals’ responsible for their own exclusion during the economic crisis, which mayors linked to the choices those individuals had made, while ignoring the community’s responsibility for social integration. Based on their accounts, neoliberalism, patriarchy, and rural idyll frames were identified as shaping and defining the perception of social exclusion processes in rural áreas

Impact of heart failure on the clinical profile and outcomes in patients with atrial fibrillation treated with rivaroxaban. Data from the EMIR study

Background: The aim of this study was to analyze the impact of the presence of heart failure (HF) on the clinical profile and outcomes in patients with atrial fibrillation (AF) anticoagulated with rivaroxaban. Methods: Observational and non-interventional study that included AF adults recruited from 79 Spanish centers, anticoagulated with rivaroxaban ≥ 6 months before inclusion. Data were analyzed according to baseline HF status. Results: Out of 1,433 patients, 326 (22.7%) had HF at baseline. Compared to patients without HF, HF patients were older (75.3 ± 9.9 vs. 73.8 ± 9.6 years; p = 0.01), had more diabetes (36.5% vs. 24.3%; p < 0.01), coronary artery disease (28.2% vs. 12.9%; p < 0.01), renal insufficiency (31.7% vs. 22.6%; p = 0.01), higher CHA2DS2-VASc (4.5 ± 1.6 vs. 3.2 ± 1.4; p < 0.01) and HAS-BLED (1.8 ± 1.1 vs. 1.5 ± 1.0; p < 0.01). After a median follow-up of 2.5 years, among HF patients, annual rates of stroke/ /systemic embolism/transient ischemic attack, major adverse cardiovascular events (MACE) (non-fatal myocardial infarction, revascularization and cardiovascular death), cardiovascular death, and major bleeding were 1.2%, 3.0%, 2.0%, and 1.4%, respectively. Compared to those patients without HF, HF patients had greater annual rates of MACE (3.0% vs. 0.5%; p < 0.01) and cardiovascular death (2.0% vs. 0.2%; p < 0.01), without significant differences regarding other outcomes, including thromboembolic or bleeding events. Previous HF was an independent predictor of MACE (odds ratio 3.4; 95% confidence interval 1.6–7.3; p = 0.002) but not for thromboembolic events or major bleeding. Conclusions: Among AF patients anticoagulated with rivaroxaban, HF patients had a worse clinical profile and a higher MACE risk and cardiovascular mortality. HF was independently associated with the development of MACE, but not with thromboembolic events or major bleeding. (Cardiol J 2022; 29, 6: 936–947)

A randomized trial of the discontinuation of primary and secondary prophylaxis against Pneumocystis carinii pneumonia after highly active antiretroviral therapy in patients with HIV infection

Background: Prophylaxis against Pneumocystis carinii pneumonia is indicated in patients with human immunodeficiency virus (HIV) infection who have less than 200 CD4 cells per cubic millimeter and in those with a history of P. carinii pneumonia. However, it is not clear whether prophylaxis can be safely discontinued after CD4 cell counts increase in response to highly active antiretroviral therapy. Methods: We conducted a randomized trial of the discontinuation of primary or secondary prophylaxis against P. carinii pneumonia in HIV-infected patients with a sustained response to antiretroviral therapy, defined by a CD4 cell count of 200 or more per cubic millimeter and a plasma HIV type 1 (HIV-1) RNA level of less than 5000 copies per milliliter for at least three months. Prophylactic treatment was restarted if the CD4 cell count declined to less than 200 per cubic millimeter. Results: The 474 patients receiving primary prophylaxis had a median CD4 cell count at entry of 342 per cubic millimeter, and 38 percent had detectable HIV-1 RNA. After a median follow-up period of 20 months (388 person-years), there had been no episodes of P. carinii pneumonia in the 240 patients who discontinued prophylaxis (95 percent confidence interval, 0 to 0.85 episode per 100 person-years). For the 113 patients receiving secondary prophylaxis, the median CD4 cell count at entry was 355 per cubic millimeter, and 24 percent had detectable HIV-1 RNA. After a median follow-up period of 12 months (65 person-years), there had been no episodes of P. carinii pneumonia in the 60 patients who discontinued prophylaxis (95 percent confidence interval, 0 to 4.57 episodes per 100 person-years). Conclusions: In HIV-infected patients receiving highly active antiretroviral therapy, primary and secondary prophylaxis against P. carinii pneumonia can be safely discontinued after the CD4 cell count has increased to 200 or more per cubic millimeter for more than three months

Dyslipidaemia in HIV-infected women on antiretroviral therapy. Analysis of 922 patients from the Spanish VACH cohort

Background: Information concerning lipid disturbances in HIV-infected women on antiretroviral therapy (ART) is scarce. The objective of the study is to describe the lipid profile in a large cohort of HIV-infected women on contemporary ART and analyse differences between regimes and patient's characteristics. Methods: Observational, multicentre, cross-sectional study from the Spanish VACH Cohort. 922 women on stable ART without lipid-lowering treatment were included. Results: Median age was 42 years, median CD4 lymphocyte count was 544 cells/mm3, and 85.6% presented undetectable HIV-1 viral load. Median total cholesterol (TC) was 189 mg/dL (interquartile range, IQR, 165-221), HDL cholesterol 53 mg/dL (IQR, 44-64), LDL cholesterol 108 mg/dL (IQR, 86-134), and triglycerides 116 mg/dL (IQR, 85-163). Mean accumulated time on ART was 116 months; 47.4% were on NNRTI-based regimes, 44.7% on PI, and 6.7% on only-NRTI therapy. 43.8% were also hepatitis C (HCV) coinfected. Patients on PI treatment presented higher TC/HDL ratio than those on NNRTI (p < 0.001). Significantly higher HDL values were observed in NNRTI-treated patients. HCV-coinfected patients presented lower TC/HDL ratio than the non HCV-coinfected. In multivariate analysis, factors independently associated with TC/HDL ratio were age, triglyceride levels and HCV co-infection. PI treatment presented a non-significant association with higher TC/HDL ratio. Conclusions: In HIV-infected women, the NNRTI-based ART is associated with a better lipid profile than the PI-based. Factors unrelated to ART selection may also exert an independent, significant influence on lipids; in particular, age, and triglyceride levels are associated with an increased TC/HDL ratio while HCV co-infection is associated with a reduced TC/HDL ratio

Impact of heart failure on the clinical profile and outcomes in patients with atrial fibrillation treated with rivaroxaban. Data from the EMIR study

Background: The aim of this study was to analyze the impact of the presence of heart failure (HF) on the clinical profile and outcomes in patients with atrial fibrillation (AF) anticoagulated with rivaroxaban. Methods: Observational and non-interventional study that included AF adults recruited from 79 Spanish centers, anticoagulated with rivaroxaban ≥ 6 months before inclusion. Data were analyzed according to baseline HF status. Results: Out of 1,433 patients, 326 (22.7%) had HF at baseline. Compared to patients without HF, HF patients were older (75.3 ± 9.9 vs. 73.8 ± 9.6 years; p = 0.01), had more diabetes (36.5% vs. 24.3%; p &lt; 0.01), coronary artery disease (28.2% vs. 12.9%; p &lt; 0.01), renal insufficiency (31.7% vs. 22.6%; p = 0.01), higher CHA2DS2-VASc (4.5 ± 1.6 vs. 3.2 ± 1.4; p &lt; 0.01) and HAS-BLED (1.8 ± 1.1 vs. 1.5 ± 1.0; p &lt; 0.01). After a median follow-up of 2.5 years, among HF patients, annual rates of stroke/systemic embolism/transient ischemic attack, MACE-non-fatal myocardial infarction, revascularization and cardiovascular death-, cardiovascular death, and major bleeding were 1.2%, 3.0%, 2.0%, and 1.4%, respectively. Compared to those patients without HF, HF patients had greater annual rates of MACE (3.0% vs. 0.5%; p &lt; 0.01) and cardiovascular death (2.0% vs. 0.2%; p &lt; 0.01), without significant differences regarding other outcomes, including thromboembolic or bleeding events. Previous HF was an independent predictor of MACE (odds ratio 3.4; 95% confidence interval 1.6-7.3; p = 0.002) but not for thromboembolic events or major bleeding. Conclusions: Among AF patients anticoagulated with rivaroxaban, HF patients had a worse clinical profile and a higher MACE risk and cardiovascular mortality. HF was independently associated with the development of MACE, but not with thromboembolic events or major bleeding

European mitochondrial haplogroups are associated with CD4+ T cell recovery in HIV-infected patients on combination antiretroviral therapy.

There is substantial interindividual variability in the rate and extent of CD4+ T cell recovery after starting combination antiretroviral therapy (cART). The aim of our study was to determine whether mitochondrial DNA (mtDNA) haplogroups are associated with recovery of CD4+ in HIV-infected patients on cART. We carried out a retrospective study on 275 cART-naive patients with CD4+ counts <350 cells/mm(3), who were followed-up during at least 24 months after initiating cART. mtDNA genotyping was performed by Sequenom's MassARRAY platform. Patients within cluster JT and haplogroup J had a lower chance of achieving a CD4+ count ≥500 cells/mm(3) than patients within cluster HV and haplogroup H [hazard ratio (HR) = 0.68 (P = 0.058) and HR = 0.48 (P = 0.010), respectively]. The time of follow-up during which the CD4+ count was ≥500 cells/mm(3) was longer in haplogroups HV and H than in haplogroups JT and J [20 months versus 6.2 months (P = 0.029) and 20 months versus 0 months (P = 0.024), respectively]. Additionally, haplogroups HV and H had greater chances of achieving a CD4+ count ≥500 cells/mm(3) during at least 12, 36, 48 and 60 months post-cART initiation compared with patients within haplogroups JT and J. Patients within haplogroup T only had a lesser chance of achieving a CD4+ count ≥500 cells/mm(3) during at least 48 months and 60 months post-cART initiation. European mitochondrial haplogroups might influence CD4+ recovery in HIV-infected patients following initiation with cART. Haplogroups J and T appear to be associated with a worse profile of CD4+ recovery, whereas haplogroup H was associated with a better CD4+ reconstitution.This work has been supported by the Fondo de investigación Sanitaria (FIS) (grant numbers PI08/0738, PI11/00245, PI08/0928 and PI11/01556), Spanish Network for AIDS Research (grant numbers RD12/0017/0024 and RD12/0017/0004) and Fundación para la Investigación y la Prevención del Sida en España (FIPSE) (grant number 361020/10). A. F. R., M. G. F., M. G. A. and M. A. J. S. are supported by the Instituto de Salud Carlos III (grant numbers UIPY-1377/08, CM09/00031, CM08/00101 and CM10/00105, respectively).S

Características diferenciales de la población inmigrante con infección por VIH seguida en la consulta externa de un hospital universitario

Our main objective was to analyze the clinical, epidemiologic and therapeutic differences among HIV immigrant and native patients who are regularly monitored in an outpatient consultation at a University hospital. Methodology: Case-control study including 74 patients under regular monitoring in an outpatient consultation at a University hospital. Results: The origin of the immigrant HIV patients was America (62%), Sub-Saharan Africa (19%), Europe (13,5%) y the Magreb (5,5%). Immigrant patients were significantly younger (33,2 vs 39,1 years old), they showed a higher prevalence of infection acquisition by sexual behaviours (91,8% vs 48,6%) and lower rates of HCV co-infection (11% vs 36,6%). There were not significant differences regarding: sex (35,2% inmigrant females vs 27% native females), C clinical status (29,8% vs 21,6%), CD4 counts at first consultation (289/mm3 vs 356/mm3), viral load at first consultation (48.972 cp/mL vs 29.844 cp/mL), time of follow up (22 months vs 21,8 months), number of examinations during the follow-up (7,73 vs 7,05), needing of antiretroviral therapy (78,4% vs 78,4%), latest CD4 counts (413/mm3 vs 403/mm3) and undetected viral load at the end of the follow-up (64,8% vs 48,6%). Conclusions: Immigrant HIV patients have specific epidemiologic characteristics regarding the ones of the native HIV patients. Nevertheless, once they are integrated in the outpatient monitoring program their disease evolution is similar to the one of the native patients.Resumen: El objetivo principal de esta investigación fue estudiar las diferencias clínicas, epidemiológicas y terapéuticas entre pacientes inmigrantes y aquellos de origen español infectados por VIH que acuden de forma regular a las consultas externas de nuestro Hospital. Material y métodos: Estudio de casos y controles en el que se que incluyó a 74 pacientes en seguimiento habitual en la consulta de enfermedades infecciosas de un hospital universitario. Resultados: El origen de los pacientes inmigrantes fue América (62%), Africa Subsahariana (19%), Europa (13,5%) y el Magreb (5,5%). Los pacientes inmigrantes eran significativamente mas jóvenes (33,2 vs 39,1 años), tenían una mayor prevalencia de adquisición de la infección por vía sexual (91,8% vs 48,6%) y menor proporción de coinfección por el VHC (11% vs 36,6%). No hubo diferencias significativas en cuanto a sexo (35,2% de mujeres inmigrantes vs 27% en el resto de la población), estadio clínico C de infección (29,8% vs 21,6%), CD4 en la primera visita (289/mm3 vs 356/mm3), carga vírica en la primera visita (48.972 cp/mL vs 29.844 cp/mL), tiempo de seguimiento (22 meses vs 21,8 meses), número de visitas durante el seguimiento (7,73 vs 7,05), necesidad de TAR (78,4% vs 78,4%), ni última cifra de CD4 (413/mm3 vs 403/mm3) o carga vírica indetectable al final del seguimiento (64,8% vs 48,6%). Conclusiones: Los pacientes inmigrantes con infección por VIH tienen características epidemiológicas diferenciales respecto a aquellos de origen español. Sin embargo, una vez que llegan al Hospital e inician el seguimiento de su enfermedad su evolución es similar a la resto de los pacientes

Diagnóstico tardío de la infección por el virus de la inmunodeficiencia humana en la Cohorte VACH (1997-2002) Delayed diagnosis of HIV infection in the Spanish VACH cohort (1997-2002)

Objetivo: Estudiar la prevalencia del diagnóstico tardío (DT) de la infección por el virus de la inmunodeficiencia humana (VIH) y sus factores asociados. Métodos: Estudio transversal sobre los pacientes incluidos en la cohorte VACH cuya infección por el VIH hubiese sido diagnosticada entre 1997 y 2002. Consideramos DT los casos diagnosticados de sida concomitantemente o dentro del primer mes desde la primera serología positiva, o con recuento de CD4+ < 200/ml. Comparamos sus características epidemiológicas con las de los demás pacientes. Resultados: De 2.820 nuevos casos de infección por el VIH, 506 (18%) tuvieron DT. Éstos difirieron del resto en su menor edad media, mayor carga viral y en su distribución por sexos (mayor proporción de hombres), situación laboral, antecedentes penitenciarios y grupo de riesgo. La mediana de supervivencia durante el seguimiento fue menor en el grupo de DT. Conclusiones: El DT continúa siendo un problema preocupante por su magnitud y asociación con la mortalidad. Algunas características epidemiológicas proporcionan indicios para orientar futuros programas de información y prevención.<br>Objective: To study the prevalence of delayed diagnosis of HIV infection and associated factors. Methods: A cross sectional study of patients included in the Spanish VACH cohort who had been diagnosed with HIV infection between 1997 and 2002 was performed. Delayed diagnosis was defined as patients diagnosed with HIV infection and AIDS simultaneously or within the first month after the first positive serologic test, or those with a first CD4+ cell count below 200/ml. The epidemiological characteristics of these patients were compared with those of the remaining patients. Results: Of 2,820 new cases of HIV infection, delayed diagnosis was found in 506 (18%). These patients differed from the remaining patients in their lower mean age and higher HIV viral load, as well as in their distribution by sex (higher proportion of males), occupational status, history of incarceration in prison, and HIV-risk transmission group. The median survival during follow-up was significantly lower among AIDS patients with a delayed diagnosis. Conclusions: Delayed diagnosis remains a cause for concern in our environment, due to its magnitude and its association with mortality. Some epidemiological characteristics provide clues to guide future programs directed at increasing information and improving prevention