Análisis de los costes asociados al seguimiento de pacientes con VIH que discontinúan el tratamiento antirretroviral por falta de eficacia o toxicidad inaceptable en España

[Abstract] Objective. To assess the use of resources and the costs associated with following up patients infected with the human immunodeficiency virus after discontinuation of an antiretroviral treatment and initiation of a new one due to a lack of effectiveness or unacceptable toxicity, as compared to the costs involved in the routine follow-up of patients on antiretroviral treatment, from the Spanish National Health System perspective. Method. The use of resources (clinical tests, medical visits, and hospital pharmacy visits) associated with following three profiles of patients infected with the human immunodeficiency virus (stable ones, those discontinuing an existing antiretroviral treatment and being switched to a new one due to a lack of effectiveness, and those discontinuing an existing antiretroviral treatment and being switched to a new one due to unacceptable toxicity) was identified, based on clinical practice guidelines and the findings of a multidisciplinary expert panel (n = 5). The experts agreed on the main adverse events leading to discontinuation, classifying them into gastrointestinal, renal, osseous, musculoskeletal, dermatological, hepatic, lipid profile-related, neuropsychiatric and sexual alterations. Unit costs were identified from official healthcare costs databases. The cost (€, 2020) of following up each patient profile was estimated, excluding the cost of the antiretroviral treatment itself, with a time horizon of two years. Results. The per-patient cost of following up stable patients over two years was estimated at €4,148 (tests: €2,293; visits: €1,855). Patient follow-up after discontinuation of an existing antiretroviral treatment and initiation of a different one due to a lack of effectiveness was estimated at €5,434 (tests: €2,777; visits: €2,657). The cost of follow-up after discontinuation of an existing regimen and initiation of a new one due to unacceptable toxicity varied according to the adverse event prompting the switch, ranging from €4,690 for lipid profile dysregulation, to €5,304, for musculoskeletal alterations. In this patient profile, the cost of tests ranged from €2,403 to €3,017, and that of visits from €2,287 to €2,842. Conclusions. The cost associated with following up of patients infected with the human immunodeficiency virus after discontinuation of an existing antiretroviral regimen and initiation of a new one is higher than that of routine follow-up, without taking the cost of drugs into account. The treatment discontinuation rate is a relevant factor when selecting the most appropriate therapy for each patient.[Resumen] Objetivo. Estimar el uso de recursos y costes asociados al seguimiento de pacientes con infección por el virus de la inmunodeficiencia humana tras discontinuación del tratamiento antirretroviral actual debido a falta de efectividad o toxicidad inaceptable y cambio a un nuevo tratamiento antirretroviral, comparado con el seguimiento habitual de los pacientes con tratamiento antirretroviral, desde la perspectiva del Sistema Nacional de Salud español. Método. Se identificó el uso de recursos (pruebas clínicas, visitas médicas, visitas a la farmacia hospitalaria) asociado al seguimiento de pacientes con infección por el virus de la inmunodeficiencia humana en tres perfiles de pacientes (estable, discontinuación y cambio por falta de efectividad, discontinuación y cambio por toxicidad inaceptable), a partir de las guías de práctica clínica y un panel de expertos multidisciplinar (n = 5). Los expertos consensuaron los principales eventos adversos que conducían a la discontinuación, agrupándolos en: alteraciones gastrointestinales, renales, óseas, musculoesqueléticas, dermatológicas, hepáticas y del perfil lipídico, trastornos neuropsiquiátricos y sexuales. Los costes unitarios se identificaron a partir de bases de datos oficiales de costes sanitarios y de la literatura. Se estimó el coste (€, 2020) del seguimiento en cada perfil de paciente, sin incluir el coste derivado del tratamiento antirretroviral, en un horizonte temporal de dos años. Resultados. El coste por paciente a dos años se estimó en 4.148 € (pruebas: 2.293 €; visitas: 1.855 €) para el seguimiento del paciente estable. El seguimiento del paciente tras discontinuación por falta de efectividad y cambio de tratamiento antirretroviral se estimó en 5.434 € (pruebas: 2.777 €; visitas: 2.657 €). El coste del seguimiento tras la discontinuación por toxicidad inaceptable y cambio de tratamiento antirretroviral varió en función del evento adverso que motivó el cambio, oscilando entre 4.690 € para las alteraciones del perfil lipídico, y 5.304 € para las alteraciones musculoesqueléticas. En este perfil de pacientes, las pruebas variaron entre 2.403 € y 3.017 € y las visitas entre 2.287 € y 2.842 €. Conclusiones. El coste asociado al seguimiento del paciente con infección por el virus de la inmunodeficiencia humana tras discontinuación y cambio a un nuevo tratamiento antirretroviral es mayor comparado con el seguimiento habitual, sin tener en cuenta el coste farmacológico. La tasa de discontinuación del tratamiento antirretroviral es un factor relevante a la hora de seleccionar la terapia más adecuada para cada paciente

Association Among Polyphenol Intake, Uric Acid, and Hyperuricemia: A CrossSectional Analysis in a Population at High Cardiovascular Risk

Dietary polyphenol intake has been associated with a decreased risk of hyperuricemia, but most of this knowledge comes from preclinical studies. The aim of the present study was to assess the association of the intake of different classes of polyphenols with serum uric acid and hyperuricemia. This cross- sectional analysis involved baseline data of 6332 participants. Food polyphenol con- tent was estimated by a validated semiquantitative food frequency questionnaire and from the Phenol-Explorer database. Multivariable-adjusted linear regression models with serum uric acid (milligrams per deciliter) as the outcome and polyphenol intake (quintiles) as the main independent variable were fitted. Cox regression models with constant follow-up time (t=1) were performed to estimate the prevalence ratios (PRs) of hyperuricemia (≥7 mg/dL in men and ≥6 mg/dL in women). An inverse association between the intake of the phenolic acid class (β coefficient, −0.17 mg/dL for quintile 5 versus quintile 1 [95% CI, −0.27 to −0.06]) and hydroxycinnamic acids (β coefficient, −0.19 [95% CI, −0.3 to −0.09]), alkylmethoxyphenols (β coefficient, −0.2 [95% CI, −0.31 to −0.1]), and methoxyphenols (β coefficient, −0.24 [95% CI, −0.34 to −0.13]) subclasses with serum uric acid levels and hyperuricemia (PR, 0.82 [95% CI, 0.71– 0.95]; PR, 0.82 [95% CI, 0.71– 0.95]; PR, 0.80 [95% CI, 0.70– 0.92]; and PR, 0.79 [95% CI, 0.69– 0.91]; respectively) was found. The intake of hydroxybenzoic acids was directly and significantly as- sociated with mean serum uric acid levels (β coefficient, 0.14 for quintile 5 versus quintile 1 [95% CI, 0.02– 0.26]) but not with hyperuricemia

Standardized incidence ratios and risk factors for cancer in patients with systemic sclerosis: Data from the Spanish Scleroderma Registry (RESCLE)

Aim: Patients with systemic sclerosis (SSc) are at increased risk of cancer, a growing cause of non-SSc-related death among these patients. We analyzed the increased cancer risk among Spanish patients with SSc using standardized incidence ratios (SIRs) and identified independent cancer risk factors in this population. Material and methods: Spanish Scleroderma Registry data were analyzed to determine the demographic characteristics of patients with SSc, and logistic regression was used to identify cancer risk factors. SIRs with 95% confidence intervals (CIs) relative to the general Spanish population were calculated. Results: Of 1930 patients with SSc, 206 had cancer, most commonly breast, lung, hematological, and colorectal cancers. Patients with SSc had increased risks of overall cancer (SIR 1.48, 95% CI 1.36-1.60; P < 0.001), and of lung (SIR 2.22, 95% CI 1.77-2.73; P < 0.001), breast (SIR 1.31, 95% CI 1.10-1.54; P = 0.003), and hematological (SIR 2.03, 95% CI 1.52-2.62; P < 0.001) cancers. Cancer was associated with older age at SSc onset (odds ratio [OR] 1.22, 95% CI 1.01-1.03; P < 0.001), the presence of primary biliary cholangitis (OR 2.35, 95% CI 1.18-4.68; P = 0.015) and forced vital capacity <70% (OR 1.8, 95% CI 1.24-2.70; P = 0.002). The presence of anticentromere antibodies lowered the risk of cancer (OR 0.66, 95% CI 0.45-0.97; P = 0.036). Conclusions: Spanish patients with SSc had an increased cancer risk compared with the general population. Some characteristics, including specific autoantibodies, may be related to this increased risk

Ambulatory blood pressure monitoring in heart failure and serum sodium levels.

To determine whether there are differences in blood pressure profile on dynamic assessment by ambulatory blood pressure monitoring (ABPM) according to serum sodium levels in stable heart failure patients. Data were collected from the Spanish National Registry on Ambulatory Blood Pressure Monitoring in Heart Failure (DICUMAP). Patients underwent ABPM by the oscillometric principle using a Spacelabs 90121 monitor. The sample was divided into three groups according to sodium levels and their clinical and laboratory data and echocardiographic findings were analyzed. Robust statistical methods were used to compare the groups in univariate and multivariate models. A total of 175 patients (44.57% male) were analyzed. We found a predominance of anomalous circadian blood pressure profiles in all three groups, with a significantly higher percentage of risers in the lowest serum sodium group (p=0.05). In addition, in this group there were significant differences in mean 24-hour systolic blood pressure (SBP) (24-h SBP, p=0.05) and in mean daytime SBP (dSBP, p=0.008), with significant differences in nocturnal fall in SBP (p=0.05) and in diastolic blood pressure (p=0.005). In multivariate analysis a significant relationship was found between sodium levels and 24-h SBP (OR 0.97, 95% CI 0.95-0.99, p=0.01) and dSBP (OR 0.96, 95% CI 0.94-0.99, p=0.004). A relationship was found between lower sodium levels and lower systolic blood pressure, especially during waking hours, with a lower decline between daytime and night-time blood pressure

Utilidad pronóstica de las cifras ambulatorias de presión arterial en pacientes de edad avanzada con insuficiencia cardíaca. Resultados del estudio DICUMAP = Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study

Introduction: Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. Methods and results: Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p = .024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95%CI 1.70-7.26; p = .001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p = .032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. Conclusion: In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF

The role of carnivores and their relationship to hominin settlements in the TD6-2 level from Gran Dolina (Sierra de Atapuerca, Spain)

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Association Among Polyphenol Intake, Uric Acid, and Hyperuricemia: A Cross‐Sectional Analysis in a Population at High Cardiovascular Risk

Background Dietary polyphenol intake has been associated with a decreased risk of hyperuricemia, but most of this knowledge comes from preclinical studies. The aim of the present study was to assess the association of the intake of different classes of polyphenols with serum uric acid and hyperuricemia. Methods and Results This cross‐sectional analysis involved baseline data of 6332 participants. Food polyphenol content was estimated by a validated semiquantitative food frequency questionnaire and from the Phenol‐Explorer database. Multivariable‐adjusted linear regression models with serum uric acid (milligrams per deciliter) as the outcome and polyphenol intake (quintiles) as the main independent variable were fitted. Cox regression models with constant follow‐up time (t=1) were performed to estimate the prevalence ratios (PRs) of hyperuricemia (≥7 mg/dL in men and ≥6 mg/dL in women). An inverse association between the intake of the phenolic acid class (β coefficient, −0.17 mg/dL for quintile 5 versus quintile 1 [95% CI, −0.27 to −0.06]) and hydroxycinnamic acids (β coefficient, −0.19 [95% CI, −0.3 to −0.09]), alkylmethoxyphenols (β coefficient, −0.2 [95% CI, −0.31 to −0.1]), and methoxyphenols (β coefficient, −0.24 [95% CI, −0.34 to −0.13]) subclasses with serum uric acid levels and hyperuricemia (PR, 0.82 [95% CI, 0.71–0.95]; PR, 0.82 [95% CI, 0.71–0.95]; PR, 0.80 [95% CI, 0.70–0.92]; and PR, 0.79 [95% CI, 0.69–0.91]; respectively) was found. The intake of hydroxybenzoic acids was directly and significantly associated with mean serum uric acid levels (β coefficient, 0.14 for quintile 5 versus quintile 1 [95% CI, 0.02–0.26]) but not with hyperuricemia. Conclusions In individuals with metabolic syndrome, a higher intake of some polyphenol subclasses (hydroxycinnamic acids, alkylmethoxyphenol, and methoxyphenol) was inversely associated with serum uric acid levels and hyperuricemia. Nevertheless, our findings warrant further research

Pneumonia treated in the internal medicine department: Focus on healthcare-associated pneumonia

Patients with pneumonia treated in the internal medicine department (IMD) are often at risk of healthcare-associated pneumonia (HCAP). The importance of HCAP is controversial. We invited physicians from 72 IMDs to report on all patients with pneumonia hospitalized in their department during 2weeks (one each in January and June 2010) to compare HCAP with community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). We analysed 1002 episodes of pneumonia: 58.9% were CAP, 30.6% were HCAP and 10.4% were HAP. A comparison between CAP, HCAP and HAP showed that HCAP patients were older (77, 83 and 80.5years; p<0.001), had poorer functional status (Barthel 100, 30 and 65; p<0.001) and had more risk factors for aspiration pneumonia (18, 50 and 34%; p<0.001). The frequency of testing to establish an aetiological diagnosis was lower among HCAP patients (87, 72 and 79; p<0.001), as was adherence to the therapeutic recommendations of guidelines (70, 23 and 56%; p<0.001). In-hospital mortality increased progressively between CAP, HCAP and HAP (8, 19 and 27%; p<0.001). Streptococcus pneumoniae was the main pathogen in CAP and HCAP. Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) caused 17 and 12.3% of HCAP. In patients with a confirmed aetiological diagnosis, the independent risk factors for pneumonia due do difficult-to-treat microorganisms (Enterobacteriaceae, P. aeruginosa or MRSA) were HCAP, chronic obstructive pulmonary diseases and higher Port Severity Index. Our data confirm the importance of maintaining high awareness of HCAP among patients treated in IMDs, because of the different aetiologies, therapy requirements and prognosis of this population. © 2011 The Authors. Clinical Microbiology and Infection © 2011 European Society of Clinical Microbiology and Infectious Diseases