Sobre la dificultad diagnóstica de las ausencias en el adulto

Sr. Editor: El relato de las características de una crisis convulsiva por parte de testigos es la base para el diagnóstico, la clasificación y el tratamiento de los síndromes epilépticos, pero es un elemento que en muchas ocasiones no puede estar presente. En la práctica clínica, un tercio de las convulsiones focales con alteraciones cognitivas no son controladas con la medicación antiepiléptica, siendo aún común el error diagnóstico, motivo por el cual la monitorización con vídeo- electroencefalograma (EEG) provee una ayuda inestimable en el momento del diagnóstico, la clasificación y el tratamiento. A continuación, presentamos un caso que expone la dificultad que puede suponer la evaluación de un paciente adulto con «crisis de ausencias» en el cual el tratamiento y un «reset» en la historia clínica puede llevar al diagnóstico correcto y por ende un buen tratamiento. Se trata de un paciente de 45 años de edad referido de otro centro hospitalario, sin antecedentes familiares de relevancia, que desarrolla 15 años antes un cuadro de recurrente «desconexión» del medio con ocasionales automatismos orales de aproximadamente 5 s de duración en los cuales se mantenía la postura..

Síndrome de parkinsonismo-hiperpirexia

El síndrome parkinsonismo-hiperpirexia (SPH), también conocido como síndrome neuroléptico maligno-like, crisis acinética o síndrome dopaminérgico maligno, es una rara y potencialmente letal complicación de la enfermedad de Parkinson. Clínicamente se caracteriza por hipertermia, disfunción autonómica, alteración del nivel de la conciencia, rigidez muscular y elevación de los niveles séricos de CPK. En la mayoría de los casos este síndrome es desencadenado por cambios en la medicación antiparkinsoniana, sea su retirada o reducción de dosis de forma más o menos brusca. Reconocerlo a tiempo y tratarlo adecuadamente (levodopa y agonistas dopaminérgicos) son elementos cruciales para una resolución favorable del cuadro clínico..

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide versus dolutegravir /abacavir/lamivudine in antiretroviral-naïve adults (SYMTRI): a multicenter randomized open-label study (PReEC/RIS-57)

D/C/F/TAF is the reference for combination therapy based on protease inhibitors but has not been compared with regimens containing integrase inhibitors as initial ART. We could not demonstrate D/C/F/TAF noninferiority relative to DTG/ABC/3TC, although both regimens were similarly well tolerated. Background Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) is the reference for combination therapy based on protease inhibitors due to its efficacy, tolerability, and convenience. Head-to-head randomized comparisons between D/C/F/TAF and combination therapy based on integrase inhibitors in antiretroviral-naive patients are lacking. Methods Adult (>18 years old) human immunodeficiency virus-infected antiretroviral-naive patients (HLA-B*5701 negative and hepatitis B virus negative), with viral load (VL) >= 500 c/mL, were centrally randomized to initiate D/C/F/TAF or dolutegravir/abacavir/lamivudine (DTG/3TC/ABC) after stratifying by VL and CD4 count. Clinical and analytical assessments were performed at weeks 0, 4, 12, 24, and 48. The primary endpoint was VL 100 000 copies/mL, and 13% had <200 CD4 cells/mu L. Median weight was 73 kg and median body mass index was 24 kg/m(2). At 48 weeks, 79% (D/C/F/TAF) versus 82% (DTG/3TC/ABC) had VL <50 c/mL (difference, -2.4%; 95% confidence interval [CI], -11.3 to 6.6). Eight percent versus four percent experienced virologic failure but no resistance-associated mutations emerged. Four percent versus six percent had drug discontinuation due to adverse events. In the per-protocol analysis, 94% versus 96% of patients had VL <50 c/mL (difference, -2%; 95% CI, -8.1 to 3.5). There were no differences in CD4 cell count or weight changes. Conclusions We could not demonstrate the noninferiority of D/C/F/TAF relative to DTG/ABC/3TC as initial antiretroviral therapy, although both regimens were similarly well tolerated

4kscore test, prostate cancer prevention trial-risk calculator y european research screening prostate-risk calculator en la predicción del cáncer de próstata de alto grado; estudio preliminar

Introducción: Frente al sobrediagnóstico y al sobretratamiento en cáncer de próstata (CaP) se establecen estrategias terapéuticas como la vigilancia activa o la terapia focal, o métodos para precisar el diagnóstico del CaP de alto grado (CaP-AG), Gleason = 7, como la resonancia magnética multiparamétrica o nuevos marcadores como el 4Kscore Test (4KsT).: Es nuestro propósito testar mediante un estudio piloto la capacidad del 4KsT como identificador de CaP-AG (suma de Gleason = 7) en biopsia de próstata (Bx) y compararlo con otros modelos pronósticos multivariantes disponibles, como el Prostate Cancer Prevention Trial-Risk Calculator 2.0 (PCPTRC 2.0) y el European Research Screening Prostate Cancer-Risk Calculator 4 (ERSPC-RC 4). Material y métodos: Cincuenta y un pacientes sometidos a BxP según práctica clínica habitual, con un mínimo de 10 cilindros. Diagnóstico de CaP-AG consensuado por 4 uropatólogos. Comparación de las predicciones ofrecidas por los diferentes modelos mediante prueba U Mann-Whitney, áreas bajo la curva ROC (AUC) (test de DeLong), funciones de densidad de probabilidad, diagramas de caja y curvas de utilidad clínica (CUC). Resultados: Un 43% presentaron CaP y un 23,5% CaP-AG. Las medianas de probabilidad de 4KsT, PCPTRC 2.0 y ERSPC-RC 4 fueron significativamente diferentes entre los pacientes con CaP-AG y no CaP-AG (p = 0,022), siendo más diferenciadas en el caso de 4KsT (mediana en CaP-AG: 51,5% [percentil 25-75: 25-80,5%], frente a 16% [P 25-75: 8-26,5%] en no CaP-AG [p = 0,002]). Todos los modelos mostraron AUC por encima de 0,7 sin diferencias significativas entre ninguno de ellos y 4KsT (p = 0,20). Las funciones de densidad de probabilidad y diagramas de caja muestran una buena capacidad discriminativa, especialmente en los modelos de ERSPC-RC 4 y 4KsT. Las CUC muestran como un punto de corte del 9% de 4KsT identifica a todos los CaP-AG y permite un ahorro del 22% de biopsias, similar a lo que ocurre con los modelos de ERSPC-RC 4 y un punto de corte del 3%. Conclusiones: Los modelos predictivos evaluados ofrecen una buena capacidad de discriminación del CaP-AG en Bx. 4KsT es un buen modelo clasificatorio en su conjunto, seguido de ERSPC-RC 4 y PCPTRC 2.0. Las CUC permiten sugerir puntos de corte de decisión clínica: 9% para 4KsT y 3% en ERSPC-RC 4. Este estudio preliminar debe ser interpretado con cautela por su limitado tamaño muestral. Introduction: To prevent the overdiagnosis and overtreatment of prostate cancer (PC), therapeutic strategies have been established such as active surveillance and focal therapy, as well as methods for clarifying the diagnosis of high-grade prostate cancer (HGPC) (defined as a Gleason score =7), such as multiparametric magnetic resonance imaging and new markers such as the 4Kscore test (4. KsT).By means of a pilot study, we aim to test the ability of the 4. KsT to identify HGPC in prostate biopsies (Bx) and compare the test with other multivariate prognostic models such as the Prostate Cancer Prevention Trial Risk Calculator 2.0 (PCPTRC 2.0) and the European Research Screening Prostate Cancer Risk Calculator 4 (ERSPC-RC 4). Material and methods: Fifty-one patients underwent a prostate Bx according to standard clinical practice, with a minimum of 10 cores. The diagnosis of HGPC was agreed upon by 4 uropathologists. We compared the predictions from the various models by using the Mann-Whitney U test, area under the ROC curve (AUC) (DeLong test), probability density function (PDF), box plots and clinical utility curves. Results: Forty-three percent of the patients had PC, and 23.5% had HGPC. The medians of probability for the 4. KsT, PCPTRC 2.0 and ERSPC-RC 4 were significantly different between the patients with HGPC and those without HGPC (p=.022) and were more differentiated in the case of 4. KsT (51.5% for HGPC 25-75 percentile: 25-80.5%] vs. 16% P 25-75: 8-26.5%] for non-HGPC; p = 002). All models presented AUCs above 0.7, with no significant differences between any of them and 4. KsT (p=.20). The PDF and box plots showed good discriminative ability, especially in the ERSPC-RC 4 and 4. KsT models. The utility curves showed how a cutoff of 9% for 4. KsT identified all cases of HGPC and provided a 22% savings in biopsies, which is similar to what occurs with the ERSPC-RC 4 models and a cutoff of 3%. Conclusions: The assessed predictive models offer good discriminative ability for HGPCs in Bx. The 4. KsT is a good classification model as a whole, followed by ERSPC-RC 4 and PCPTRC 2.0. The clinical utility curves help suggest cutoff points for clinical decisions: 9% for 4. KsT and 3% for ERSPC-RC 4. This preliminary study should be interpreted with caution due to its limited sample size

Epidemiological trends of HIV/HCV coinfection in Spain, 2015-2019

Objectives: We assessed the prevalence of anti-hepatitis C virus (HCV) antibodies and active HCV infection (HCV-RNA-positive) in people living with HIV (PLWH) in Spain in 2019 and compared the results with those of four similar studies performed during 2015-2018. Methods: The study was performed in 41 centres. Sample size was estimated for an accuracy of 1%. Patients were selected by random sampling with proportional allocation. Results: The reference population comprised 41 973 PLWH, and the sample size was 1325. HCV serostatus was known in 1316 PLWH (99.3%), of whom 376 (28.6%) were HCV antibody (Ab)-positive (78.7% were prior injection drug users); 29 were HCV-RNA-positive (2.2%). Of the 29 HCV-RNA-positive PLWH, infection was chronic in 24, it was acute/recent in one, and it was of unknown duration in four. Cirrhosis was present in 71 (5.4%) PLWH overall, three (10.3%) HCV-RNA-positive patients and 68 (23.4%) of those who cleared HCV after anti-HCV therapy (p = 0.04). The prevalence of anti-HCV antibodies decreased steadily from 37.7% in 2015 to 28.6% in 2019 (p < 0.001); the prevalence of active HCV infection decreased from 22.1% in 2015 to 2.2% in 2019 (p < 0.001). Uptake of anti-HCV treatment increased from 53.9% in 2015 to 95.0% in 2019 (p < 0.001). Conclusions: In Spain, the prevalence of active HCV infection among PLWH at the end of 2019 was 2.2%, i.e. 90.0% lower than in 2015. Increased exposure to DAAs was probably the main reason for this sharp reduction. Despite the high coverage of treatment with direct-acting antiviral agents, HCV-related cirrhosis remains significant in this population.This work was supported in part by the Spanish AIDS Research Network (RD16/0025/0017, RD16/0025/0018), which is included in the Spanish I+D+I Plan and is co-funded by the ISCIII-Subdirección General de Evaluación and European Funding for Regional Development (FEDER). The sponsors had no role in the study design, the collection, analysis and interpretation of data, the writing of the report, or the decision to submit the article for publication.S

Constraints on the χ_(c1) versus χ_(c2) polarizations in proton-proton collisions at √s = 8 TeV

The polarizations of promptly produced χ_(c1) and χ_(c2) mesons are studied using data collected by the CMS experiment at the LHC, in proton-proton collisions at √s=8  TeV. The χ_c states are reconstructed via their radiative decays χ_c → J/ψγ, with the photons being measured through conversions to e⁺e⁻, which allows the two states to be well resolved. The polarizations are measured in the helicity frame, through the analysis of the χ_(c2) to χ_(c1) yield ratio as a function of the polar or azimuthal angle of the positive muon emitted in the J/ψ → μ⁺μ⁻ decay, in three bins of J/ψ transverse momentum. While no differences are seen between the two states in terms of azimuthal decay angle distributions, they are observed to have significantly different polar anisotropies. The measurement favors a scenario where at least one of the two states is strongly polarized along the helicity quantization axis, in agreement with nonrelativistic quantum chromodynamics predictions. This is the first measurement of significantly polarized quarkonia produced at high transverse momentum