Trends in hospital admissions, re-admissions, and in-hospital mortality among HIV-infected patients between 1993 and 2013: Impact of hepatitis C co-infection | Enfermedades Infecciosas y Microbiología Clínica

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Joinpoint regression analysis: trends in hospitalizations in HIV/HCV coinfected and HIV monoinfected patients. Estimated Annual percent change (bold if statistically significant, P<.001 in all cases). 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"referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "José" "apellidos" => "Pedreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Eva" "apellidos" => "Poveda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Quiron, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Epidemiología Clínica y Bioestadística, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Admisión y Documentación Clínica, Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, A Coruña, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tendencia de las hospitalizaciones, reingresos y mortalidad intrahospitalaria en los pacientes infectados por VIH entre 1993-2013: impacto de la coinfección por el virus de la hepatitis C" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1385 "Ancho" => 2491 "Tamanyo" => 226571 ] ] "descripcion" => array:1 [ "en" => "Hospitalization in PLWH between 1993 and 2013; black area indicates mortality (%). Patients on follow-up each year." ] ] ] "textoCompleto" => "BackgroundSince the introduction of Highly Active Antiretroviral Therapy (HAART) in 1996, the profile of people living with HIV infection (PLWH) has changed significantly; with an appreciable decline of mortality related to AIDS-defining diseases and an improvement in life expectancy. However, the incidence of other comorbidities, mainly cardiovascular diseases and non-AIDS tumors has increased, due to the longer life expectancy, aging and persistent inflammation related to the HIV-infection, even in a context of long-term suppression of viremia.<a class="elsevierStyleCrossRefs" href="#bib0145">1–5</a>From a public health perspective, it is important to understand trends and characteristics of hospitalizations, re-admissions and mortality rates among PLWH. However, there are few available data among too heterogeneous study populations in different socioeconomic contexts and Health Care systems. In the general population, 30-days readmission rates are increasingly becoming a benchmark for hospital quality of care and costs, also for PLWH.<a class="elsevierStyleCrossRef" href="#bib0170">6</a>The causes of hospitalizations have been changing in the HAART era. AIDS defining illnesses are less represented nowadays, but patients are older with more comorbidities. Therefore, the reasons for hospitalizations incidence, mortality and readmission rates might be changing.<a class="elsevierStyleCrossRefs" href="#bib0170">6–10</a>Chronic hepatitis C virus (HCV) coinfection is common in PLWH (30–50% according to different series).<a class="elsevierStyleCrossRef" href="#bib0195">11</a> It is estimated that at least 30% of patients with HCV develop cirrhosis and around 1–4% of these will develop hepatocellular carcinoma. The risk of progression of liver disease is 2–6 times higher in HIV/HCV coinfected than in HCV mono-infected patients, which involves a high-related morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0200">12–16</a> However, the risk of hepatic decompensation and progression of liver fibrosis is drastically reduced with treatment and cure of HCV infection.<a class="elsevierStyleCrossRefs" href="#bib0225">17,18</a>In this context, the aim of this study was to analyze trends in hospitalization, re-admission and mortality rates in PLWH followed in a reference hospital in Northwest Spain in the last 20 years. Moreover, the impact of HCV coinfection in the dynamic of all these parameters was also evaluated.MethodsThe Complexo Hospitalario Universitario de A Coruña (CHUAC) is a 1422-bed, full service, 24h ICU availability, tertiary acute university care hospital, serving in the Northwest of Spain. The influence population in 2013 was 547,776 citizens, and that year reported 40,869 admissions (21% scheduled). The HIV and Hepatitis Viral Unit offers outpatient and inpatient medical care to all PLWH in this reference area, attending more than 1400 PLWH by HIV-trained doctors. PLWH are not attended in other hospitals in this area.Data collectionAll hospital admissions of HIV-infected patients at CHUAC between 1993 and 2013 were obtained through the Hospital-coding Department. Hospitalization reasons were collected following the International Classification of Diseases, Ninth Revision (ICD-9). Several steps were taken in assigning each hospitalization to a single diagnostic category. To determine the reliably ICD-9 code the first listed referring to neither HIV (042, V08, 795.71, V01.79) nor chronic hepatitis C (070.44, 070.54, 070.70, 070.71) nor oral candidiasis (120.0) was defined as the primary code for hospitalization. These codes represent comorbidities that are not, by themselves, sufficient to justify hospitalization. Recurrent bacterial pneumonia was defined as a bacterial pneumonia admission occurring within >30 but <365 days of a previous such admission. Hospitalizations whose first ICD-9 code was chemotherapeutic treatment were assigned to the first code based on the type of cancer. Clinical Classification Software (CCS), developed by the Agency for Healthcare Research and Quality<a class="elsevierStyleCrossRef" href="#bib0235">19</a> was used to assign primary ICD-9 code into one of 18 first-level categories. Finally, using a method similar to one it has previously employed,<a class="elsevierStyleCrossRef" href="#bib0175">7</a> CCS classification was modified and categories were pooled together at major syndromes for further analysis.Epidemiological and clinical data related to hospitalizations and mortality were recorded. HIV/HCV coinfection was considered if RNA-HCV viral load was detectable. Mean length of hospital stay was evaluated by subtracting the date of discharge – the date of admission and adding 1. For patients that were discharged the day of admission, it was considered 1. Re-admission was defined as hospitalization occurred before 30 days after discharge. Years of active outpatient care were defined by having at least one HIV clinician visit and one measured CD4 cell count. Scheduled admissions were considered if the patient were not in the Emergency Department prior to hospitalization. Death due to an AIDS-defining illness was defined as death attributable to one of the Centers for Disease Control Prevention (CDC) category C diseases. Death due to non AIDS-defining illness was classified according to CoDe protocol (“Coding of Death in HIV”, in <a id="intr0005" class="elsevierStyleInterRef" href="http://www.cphiv.dk/CoDe">www.cphiv.dk/CoDe</a>).The study is in accordance with the community standards and approved by the ethics committee. The study's protocol was reviewed and approved by the Medical Ethics Committee of the University Hospital of Galicia. All clinical data were anonymous and de-identified prior to analyze, the identification numbers of the patients were recorded blindly.Statistical analysesHospitalization rate was evaluated as number of hospitalizations per 100 patients. For the denominator, the number of patients in care each year in the HIV clinic, was used; it was collected from medical records and electronic database of patients in follow up. The study was divided in two periods of time (1993–2002 and 2003–2013) to be compared with a comparative cross-sectional analysis.Quantitative data were reported using means±standard deviations (SD) or median (range), as indicated. For qualitative variables, absolute numbers and percentages were computed. The comparison of quantitative parameters was carried out using Student's t test. The association of qualitative variables was carried out using Chi-squared statistic; the relative risk (RR) was calculated. A two-sided type I error of 5% was considered statistically significant.A time-trend joinpoint regression analysis was performed. This technique provides the estimated annual percent change (APC) and allows detecting points in time at which significant changes in the trends occur. For each APC estimate, 95% confidence interval was also calculated. Statistical analysis was performed using SPSS for Windows (version 19.0, SPSS Inc., Chicago, IL).ResultsDemographic characteristics and hospitalization parametersA total of 2498 PLWH were followed during the period study, contributing to 22,901 patient-years (PY). In the study period 6917 hospital admissions were recorded, corresponding to 1937 subjects. Of them, 75.0% were male, mean age (at first hospitalization) was 36.4±10.6 years, and 37.2% were HIV/HCV coinfected. Among those PLWH hospitalized, 789 (40.7%) have one admission; the median number of admission was 2 (IQR: 1–4). The hospitalization rate showed a reduction from 30.7/100 patients (CI95%: 27.7–33.8) in 1993 to 19.9/100 patients (17.7–22.2) in 2013 (P<.001); <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the hospitalization and mortality each year and the number of patients on follow-up.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In the comparative analysis between both periods (1993–2002 vs. 2003–2013), differences in hospitalization reasons were recognized among periods (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The main 5 reasons for hospitalization were: pneumonia (10.5%), chronic pulmonary disease/respiratory failure (8.3%), tuberculosis (7.4%), hepatic decompensation (6.3%) and psychiatric disorder/drug-abuse (5.3%). Overall, 23.1% of the total of 6917 hospitalizations was AIDS-defining illnesses, with differences between first (28.0%) and second period (16.2%), P<.001.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Re-admissions and mortality rates by clinical unitsOverall, 5759 (83.3%) were considered primary hospitalizations, 998 (14.4%) were first re-admissions and 160 (2.3%) were subsequent re-admissions in a chain. The median length of hospital stay was 8.0 days (5.0–16.0).The re-admission rate was 20.1% (CI95%: 19.1–21.2) without differences by gender (20.3% in men vs. 19.7% in women, P=.21). Mean age of patients in hospitalizations without a re-admission (37.4±10.4) was similar than those re-admitted (37.9±10.9 years). A higher rate of re-admissions was observed for some services such as Onco-Hematology (68.5%), Gynecology–Obstetrics (24.2%), Internal Medicine-Infectious Diseases (20.0%) or Pediatric Unit (16.3%). Those with lower rate were: surgery units (13.2%) or Psychiatry Unit (8.2%). Main reasons for hospital admission have different re-admission rates: tumoral diseases 33.8%, hepatic decompensations 23.5%, chronic pulmonary diseases 20.8%, infectious diseases 18.9%, cardiovascular diseases 14.9%, and psychiatric disorders 12.8%.Between 1993–2013, 453 in-hospital deaths were identified, with an overall inpatient mortality rate of 6.5% (CI95%: 6.0–7.1). Globally, the mortality of hospitalizations for males was higher than for women (7.4% vs. 4.4%, RR: 1.7 [1.3–2.1], P<.001). Mean age of patients who died during the hospitalizations was 40.1±11.3 years, significantly higher (P<.001) than that of those who did not die (37.3±10.4 years). Mortality of primary hospitalizations was 5.7% vs. 11.0% among re-admissions (RR 1.93 [1.59–2.35], P<.001). AIDS-defining illnesses hospitalizations presented a mortality of 13.4%, while in non AIDS-defining diseases was 4.5% (RR: 3.0 [2.5–3.6], P<.001).There were differences in mortality rate by Units (P=.005): Onco-Hematology (12.4%), Internal Medicine-Infectious Diseases (6.7%), Surgery (3.6%) and Pediatric (3.5%). No patient's death in Gynecology–Obstetrics or Psychiatry Unit. There were 24 hospitalizations admitted in ICU directly from the Emergency Department, 21 of them (87.5%), died during the ICU stay. Hospitalizations that were admitted in ICU (whenever during the hospitalization) had higher mortality rate (35.5%) than those without ICU care (5.3%) (RR 6.6 [5.5–8.0], P<.001). The main causes of in-patient death and the change between both periods are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.HIV/HCV coinfectionA total of 716 HIV/HCV coinfected patients were hospitalized at least once during the study period, giving a total of 3525 hospitalizations (1408 between 1993–2002 and 2117 between 2003–2013). <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> depicts the changes in incidence during the follow up. In the joinpoint regression analysis, two different trends were observed. Hospitalizations rate increased between 1993 and 1996 in all cohort (APC=11.8%). Between 1997 and 2013, hospitalizations rate decreased much more in HIV mono-infected (APC=−4.9%) than in HIV/HCV coinfected (APC=−1.7%), P<.001.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Overall, the mean length of stay in HCV coinfected patients was similar than in mono-infected (median: 10.1 days [6.3–15.9] vs. 11.0 [6.0–19.5], P=.24); but coinfected had more hospitalizations per patient (median: 3.0 [1.0–6.0] vs. 2.0 [1.0–3.0], P<.001) and higher readmission rates (21.5% vs. 19.1%, RR: 1.1 [1.0–1.2], P<.001). The sum of total days of hospitalization per patient during the follow-up was higher among HIV/HCV coinfected than in HIV mono-infected (median: 36.0 days [14.0–77.5] vs. 23.0 days [9.0–51.0], respectively; P<.001).The main causes of hospitalization in coinfected patients, comparatively with HIV-monoinfected, are illustrated in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>. A decrease of infectious diseases and psychiatric disorders was evidenced. On the other hand, an important increase in hospitalizations due to hepatic decompensations was found (from 5.8% to 11.5%, RR: 2.0 [CI95%: 1.5–2.6], P<.001).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Mortality rate of hospitalizations in HIV/HCV coinfected increases from 4.0% (1993–2002) to 6.2% (2003–2013), RR=1.5 (1.1–2.1, P<.001). There were also differences in mortality reasons: infectious diseases mortality decreased significantly (RR=.6 [.4–.9], P<.001), tumors increased (RR=2.1 [.5–8.8], P=.01) and hepatic decompensations also increased from 15.6% to 21.2% (RR: 1.4 [.6–3.3], P=.005) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).DiscussionThis study evaluates trends in hospitalizations among PLWH in a medical reference area of Northwest Spain. Overall, the hospitalizations rate showed a decline from 31/100 patients in 1993 to 20/100 patients in 2013, but remains higher than in the general population. These results are concordant with other previously published in different countries and different Health Care Systems.<a class="elsevierStyleCrossRefs" href="#bib0170">6,21</a> The joinpoint analysis established a point of change in 1996. This behavior is related with the introduction of HAART and its rapid impact in AIDS-defining illnesses. In this year, the trend of hospitalization incidence changed from a yearly growing of 11.8% toward a yearly decreasing of 3.4%.Changes in the reasons of hospital admission were also observed between the two periods evaluated. Thus, a significant decrease in hospitalizations due to infectious (mainly AIDS-defining diseases) and psychiatric disease or drugs abuse was recognized in contrast to a progressive increase of malignancies specially those non AIDS-defining, chronic respiratory, cardiovascular and liver related diseases. Overall, hospitalizations due to AIDS-defining diseases dropped (from 28.0% to 16.2%) in our cohort, but their mortality did not change significantly (15.0% in 1993–2003 and 12.3% in 2004–2013). AIDS-defining diseases and their high mortality remain a current problem worldwide; this problem must be addressed from the universalization of HAART and improving the diagnostic strategies.<a class="elsevierStyleCrossRef" href="#bib0175">7</a>Accordingly, changes in hospitalization units were also observed. Thus, in the second period there was an increase in hospitalizations in surgical areas and onco-haematologic units, likely due to an increase in the life expectancy among HIV-infected patients in the second period because the access to specific treatments as for the general population. The rates of ICU admissions increased up to 3-times, probably caused by the same reasons.However, the average length of stay and re-admission rates remain high, similar to those reflected in other studies,<a class="elsevierStyleCrossRefs" href="#bib0190">10,20</a> probably due to an increase in the comorbidities associated with HIV infection, that involve greater complexity of clinical management in this group of patients.Despite the improvement in the care of PLWH, the in-hospital mortality remains high; in this cohort the mortality in men is 1.7 times higher than in women, according to data published previously.<a class="elsevierStyleCrossRefs" href="#bib0245">21,22</a> Non-AIDS deaths increased significantly during the ART era and nowadays are the main cause of in-hospital mortality in PLWH. Non-AIDS infections, cirrhosis and its complications, and malignancies were major contributors to mortality. Non-AIDS mortality increased by 80.5% between first and second period; consequently, AIDS mortality decreased by 49.0%. Cowell et al., reported similar trends recently, in a huge American cohort.<a class="elsevierStyleCrossRef" href="#bib0255">23</a>The 30 days re-admission rate in our cohort was 20.1%, similar to data recently reported by Berry et al. (19.3%).<a class="elsevierStyleCrossRef" href="#bib0170">6</a> The re-admission rate has an important impact on long-term health and mortality rate of PLWH. Indeed, some mathematical models are developed to predict re-admission, but they need to be validated in other populations.<a class="elsevierStyleCrossRef" href="#bib0260">24</a>Within this cohort, nearly 40% were HIV/HCV coinfected patients. They had more hospitalizations, re-admissions and the sum of the total stays were significantly greater than for HIV mono-infected, similarly to that previously published.<a class="elsevierStyleCrossRef" href="#bib0220">16</a> Interestingly, the incidence of hospitalizations in 2013 was double in coinfected compared to HIV mono-infected. Indeed, although the hospitalization rate decreases since 1996, the APC is near to three times higher in mono-infected than in coinfected. Therefore, in terms of hospitalizations and in-hospital mortality, HCV coinfection seems to mask the beneficial effect of HAART and improvements in HIV care, although other factors such IDU or alcohol could also play a significant role. Hospitalizations due to hepatic decompensation are double in the last ten years (2003–2013) compared with the first period (1993–2002). Moreover, Meyers et al. described recently that HCV mortality appears to be relatively stable while total HIV/AIDS deaths are on a decline across the state of Massachusetts in a trend analysis of HIV and HCV using multiple cause of death.<a class="elsevierStyleCrossRef" href="#bib0265">25</a> All these data suggest that hospitalizations, decompensations and mortality will increase in the next years if HCV infection is not eradicated. The impact of a wide access to new anti-HCV therapies in HIV-infected patients must be evaluated in the near future.<a class="elsevierStyleCrossRefs" href="#bib0270">26-28</a>There are some limitations in our study that merit discussion. This is a retrospective observational study, using data recorded from a single hospital that it could affect the generalizability of our finding. However, this is a reference hospital with more than 1000-beds and a large cohort of HIV- and HCV-infected patients in follow-up in this institution since the beginning of both epidemics. Although there are not other HIV outpatient clinics in our area, some patients had an admission without any follow up in our clinic; it could overestimate hospitalization rates. Moreover, there are some variables that might be also associated with mortality that were not collected (i.e. smoking, or years under HAART exposure) and therefore its specific impact in hospitalizations and rates of mortality could not be analyzed. Data of CD4 count, HAART and viral suppression were not available, the effect of this important factors in PLWH was not analyzed. Patients admitted in Onco-Hematology Units to receive scheduled chemotherapy (12%) could overestimate the hospitalization rate in these Units and underestimate the in-hospital mortality in them. The study did not include HCV-infected patients treated with new DAAs based therapies, neither a control group of hospitalized HIV-negative patients. Finally, it is possible that the use of the ICD-9 coding system might introduce coding errors, although minority.In summary, in this large cohort of PLWH, followed during 20 years, a decrease in the hospitalizations rate and a progressive decline of AIDS defining illnesses have been recognized. Consequently, chronic comorbidities and malignancies have been increasing within the last ten years. However, the length of stay, re-admission and the mortality rate remains high. HCV coinfection has a negative impact in these parameters and is associated with increases in the morbidity and mortality and therefore in the resource consumption among PLWH. These findings are essential to improve and optimize the clinical management of PLWH and to pay special attention in those comorbidities that favor the hospitalization and mortality rates nowadays.Conflicts of interestAll authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres796936" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec795125" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres796937" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec795124" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Data collection" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical analyses" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Demographic characteristics and hospitalization parameters" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Re-admissions and mortality rates by clinical units" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "HIV/HCV coinfection" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack266918" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-05-10" "fechaAceptado" => "2016-07-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec795125" "palabras" => array:4 [ 0 => "HIV/AIDS" 1 => "HCV co-infection" 2 => "Hospital admission" 3 => "Re-admission" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec795124" "palabras" => array:4 [ 0 => "VIH/sida" 1 => "Coinfección VIH/VHC" 2 => "Hospitalización" 3 => "Reingreso" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundNew patterns in epidemiological characteristics of people living with HIV infection (PLWH) and the introduction of Highly Active Antiretroviral Therapy (HAART) have changed the profile of hospital admissions in this population. The aim of this study was to evaluate trends in hospital admissions, re-admissions, and mortality rates in HIV patients and to analyze the role of HCV co-infection. MethodsA retrospective cohort study conducted on all hospital admissions of HIV patients between 1993 and 2013. The study time was divided in two periods (1993–2002 and 2003–2013) to be compared by conducting a comparative cross-sectional analysis. ResultsA total of 22,901 patient-years were included in the analysis, with 6917 hospital admissions, corresponding to 1937 subjects (75% male, mean age 36±11 years, 37% HIV/HCV co-infected patients). The median length of hospital stay was 8 days (5–16), and the 30-day hospital re-admission rate was 20.1%. A significant decrease in hospital admissions related with infectious and psychiatric diseases was observed in the last period (2003–2013), but there was an increase in those related with malignancies, cardiovascular, gastrointestinal, and chronic respiratory diseases. In-hospital mortality remained high (6.8% in the first period vs. 6.3% in the second one), with a progressive increase of non-AIDS-defining illness deaths (37.9% vs. 68.3%, P<.001). The admission rate significantly dropped after 1996 (4.9% yearly), but it was less pronounced in HCV co-infected patients (1.7% yearly). ConclusionsHospital admissions due to infectious and psychiatric disorders have decreased, with a significant increase in non-AIDS-defining malignancies, cardiovascular, and chronic respiratory diseases. In-hospital mortality is currently still high, but mainly because of non-AIDS-defining illnesses. HCV co-infection increased the hospital stay and re-admissions during the study period." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLos cambios en las características epidemiológicas de los pacientes con infección por el VIH, y la introducción del tratamiento antirretroviral de alta eficacia, han modificado el perfil de las hospitalizaciones en esta población. El objetivo del estudio fue evaluar las tendencias en hospitalización, reingreso y mortalidad en pacientes VIH, y analizar el papel de la coinfección por el VHC. MétodosEstudio de cohortes retrospectivo, que incluyó todas las hospitalizaciones de pacientes VIH entre 1993-2013. El estudio fue dividido en 2 periodos (1993-2002 y 2003-2013) para ser comparados mediante un análisis transversal. ResultadosSe analizaron 22.901 pacientes/años, que presentaron 6.917 hospitalizaciones que correspondieron a 1.937 pacientes (75% varones, edad media 36±11 años, 37% coinfectados VIH/VHC). La mediana de estancia hospitalaria fue de 8 días (5-16), y la tasa de reingreso a los 30 días del 20,1%. Se observó un descenso significativo en el segundo periodo (2003-2013) de las hospitalizaciones motivadas por enfermedades infecciosas y trastornos psiquiátricos, y un incremento de aquellas relacionadas con neoplasias, enfermedad cardiovascular, gastrointestinal y enfermedades respiratorias crónicas. La mortalidad intrahospitalaria permanece elevada (6,8% en el primer periodo vs. 6,3% en el segundo), con un aumento progresivo de las muertes por enfermedades no definitorias de sida (37,9 vs. 68,3%; p<0,001). La tasa de hospitalización disminuyó de manera significativa después de 1996 (4,9% anual), pero este descenso fue menos acusado en los pacientes coinfectados VIH/VHC (1,7% anual). ConclusionesLas hospitalizaciones motivadas por enfermedades infecciosas y trastornos psiquiátricos han descendido; por el contrario, se observó un aumento significativo de aquellas relacionadas con neoplasias no definitorias de sida, enfermedad cardiovascular y enfermedades respiratorias crónicas. La mortalidad intrahospitalaria permanece a día de hoy elevada, pero a expensas fundamentalmente de enfermedades no definitorias de sida. La coinfección VIH/VHC incrementó los días de hospitalización y los reingresos durante el periodo de estudio." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "These authors contributed equally in this work." "identificador" => "fn0005" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1385 "Ancho" => 2491 "Tamanyo" => 226571 ] ] "descripcion" => array:1 [ "en" => "Hospitalization in PLWH between 1993 and 2013; black area indicates mortality (%). Patients on follow-up each year." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1662 "Ancho" => 2335 "Tamanyo" => 238267 ] ] "descripcion" => array:1 [ "en" => "Hospitalization rate in HIV/HCV coinfected and HIV monoinfected patients. Joinpoint regression analysis: trends in hospitalizations in HIV/HCV coinfected and HIV monoinfected patients. Estimated Annual percent change (bold if statistically significant, P<.001 in all cases). In comparison between HIV/HCV coinfected and HIV monoinfected patients, P=.65 in the first period (1993–1996) and P<.001 in the second (1996–2013)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2117 "Ancho" => 2239 "Tamanyo" => 234586 ] ] "descripcion" => array:1 [ "en" => "Main reasons of hospital admission (a) and in-hospital mortality (b) in HIV-mono and HIV/HCV-coinfected patients during 1993–2002 and 2003–2013." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Main causes of in-hospital mortality.Statistically significant results (P<.05) are shown in bold." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1993–2002 (N=3463) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2003–2013 (N=3454) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Relative change (%) (CI 95%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scheduled admissions (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−36.3 (−40.5; −31.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Length of stay (median, IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.0 (5.0–16.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.0 (4.0–15.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−9.9 (−18.7; 2.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Re-admission (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.0 (−9.2; 13.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mortality (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7.0 (−22.1; 18.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Hospitalization reasons (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infectious diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−28.1 (−32.0; −23.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aids-defining infections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−30.2 (−36.0; −23.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psyquiatric illness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−42.7 (−52.0; −31.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Malignancies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115.8 (75.4; 165.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aids-defining tumors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−34.8 (−46.0; −21.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiac diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">205.6 (116.3; 331.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Digestive system diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.8 (53.6; 98.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatic decompensations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103.3 (67.6; 146.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic respiratory diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.4 (66.3; 131.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Hospitalization units (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internal medicine/infectious diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−16.7 (−18.9; −14.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical units \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">108.0 (74.6; 147.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Onco-hematology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">116.5 (63.4; 186.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gynecology/obstetrics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.9 (23.3; 104.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pediatrics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−80.7 (−90.2; −62.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intensive care unit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">200.8 (130.0; 293.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cause of in-hospital death (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">235/453 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">218/453 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AIDS related illness: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−49.0 (−59.1; −36.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aids related encephalopaty<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−70.4 (−84.4; −43.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MAI-MTB infection<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−61.1 (−78.8; −28.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pneumocistis jirovecci pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−48.1 (−72.5; −2.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aids related malignancy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.4 (−26.4; 127.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disseminated candidiasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−88.0 (−98.5; −6.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recurrent bacterial pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−46.1 (−83.5; 76.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wasting syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.1 (−86.3; 112.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Non-AIDS related illness: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80.5 (49.7; 117.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(02.1) Bacterial infection<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.2 (2.9; 168.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(02.1.1) Bacterial infection with sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.6 (5.0; 238.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(03.1.1) HCV with cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115.6 (10.5; 320.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(04) Malignancy<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">277.3 (55.2; 817.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(16)Violent death/(19)substance abuse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−59.6 (−89.1; 50.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(9) Stroke and (23) other CNS disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.7 (−32.6; 288.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(13) Chronic obstructive lung disease<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">205.4 (22.7; 660.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(08) MI and other heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">223.4 (−66.1; 2985.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(90) Other causes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−46.1 (−83.5; 76.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1336610.png" ] ] ] "notaPie" => array:5 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Including progressive multifocal leukoencephalopathy, cryptococcal meningitis and cerebral toxoplasmosis." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Micobacterium Avium Intracellulare and Micobacterium Tuberculosis." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Only due to pneumonia." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "Including hepatocarcinoma." ] 4 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "e" "nota" => "Including other chronic respiratory diseases." ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of 6917 hospital admissions between periods (1993–2002 and 2003–2013)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0145" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Decline in the AIDS and death rates in the EuroSIDA study: an observational study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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Original article

Trends in hospital admissions, re-admissions, and in-hospital mortality among HIV-infected patients between 1993 and 2013: Impact of hepatitis C co-infection

Tendencia de las hospitalizaciones, reingresos y mortalidad intrahospitalaria en los pacientes infectados por VIH entre 1993-2013: impacto de la coinfección por el virus de la hepatitis C

Héctor Meijidea,b,◊, Álvaro Menaa,◊,

Corresponding author

alvaro.mena.de.cea@sergas.es

Corresponding author.

, Iria Rodríguez-Osorioa, Sonia Pértegac, Ángeles Castro-Iglesiasa, Guillermo Rodríguez-Martínezd, José Pedreiraa, Eva Povedaa

a Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain

b Servicio de Medicina Interna, Hospital Quiron, A Coruña, Spain

c Unidad de Epidemiología Clínica y Bioestadística, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain

d Unidad de Admisión y Documentación Clínica, Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, A Coruña, Spain

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it is important to understand trends and characteristics of hospitalizations&#44; re-admissions and mortality rates among PLWH&#46; However&#44; there are few available data among too heterogeneous study populations in different socioeconomic contexts and Health Care systems&#46; In the general population&#44; 30-days readmission rates are increasingly becoming a benchmark for hospital quality of care and costs&#44; also for PLWH&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The causes of hospitalizations have been changing in the HAART era&#46; AIDS defining illnesses are less represented nowadays&#44; but patients are older with more comorbidities&#46; Therefore&#44; the reasons for hospitalizations incidence&#44; mortality and readmission rates might be changing&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Chronic hepatitis C virus &#40;HCV&#41; coinfection is common in PLWH &#40;30&#8211;50&#37; according to different series&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> It is estimated that at least 30&#37; of patients with HCV develop cirrhosis and around 1&#8211;4&#37; of these will develop hepatocellular carcinoma&#46; The risk of progression of liver disease is 2&#8211;6 times higher in HIV&#47;HCV coinfected than in HCV mono-infected patients&#44; which involves a high-related morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">12&#8211;16</span></a> However&#44; the risk of hepatic decompensation and progression of liver fibrosis is drastically reduced with treatment and cure of HCV infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this context&#44; the aim of this study was to analyze trends in hospitalization&#44; re-admission and mortality rates in PLWH followed in a reference hospital in Northwest Spain in the last 20 years&#46; Moreover&#44; the impact of HCV coinfection in the dynamic of all these parameters was also evaluated&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">The Complexo Hospitalario Universitario de A Coru&#241;a &#40;CHUAC&#41; is a 1422-bed&#44; full service&#44; 24<span class="elsevierStyleHsp" style=""></span>h ICU availability&#44; tertiary acute university care hospital&#44; serving in the Northwest of Spain&#46; The influence population in 2013 was 547&#44;776 citizens&#44; and that year reported 40&#44;869 admissions &#40;21&#37; scheduled&#41;&#46; The HIV and Hepatitis Viral Unit offers outpatient and inpatient medical care to all PLWH in this reference area&#44; attending more than 1400 PLWH by HIV-trained doctors&#46; PLWH are not attended in other hospitals in this area&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Data collection</span><p id="par0035" class="elsevierStylePara elsevierViewall">All hospital admissions of HIV-infected patients at CHUAC between 1993 and 2013 were obtained through the Hospital-coding Department&#46; Hospitalization reasons were collected following the International Classification of Diseases&#44; Ninth Revision &#40;ICD-9&#41;&#46; Several steps were taken in assigning each hospitalization to a single diagnostic category&#46; To determine the reliably ICD-9 code the first listed referring to neither HIV &#40;042&#44; V08&#44; 795&#46;71&#44; V01&#46;79&#41; nor chronic hepatitis C &#40;070&#46;44&#44; 070&#46;54&#44; 070&#46;70&#44; 070&#46;71&#41; nor oral candidiasis &#40;120&#46;0&#41; was defined as the primary code for hospitalization&#46; These codes represent comorbidities that are not&#44; 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HIV&#47;HCV coinfection was considered if RNA-HCV viral load was detectable&#46; Mean length of hospital stay was evaluated by subtracting the date of discharge &#8211; the date of admission and adding 1&#46; For patients that were discharged the day of admission&#44; it was considered 1&#46; Re-admission was defined as hospitalization occurred before 30 days after discharge&#46; Years of active outpatient care were defined by having at least one HIV clinician visit and one measured CD4 cell count&#46; Scheduled admissions were considered if the patient were not in the Emergency Department prior to hospitalization&#46; Death due to an AIDS-defining illness was defined as death attributable to one of the Centers for Disease Control Prevention &#40;CDC&#41; category C diseases&#46; Death due to non AIDS-defining illness was classified according to CoDe protocol &#40;&#8220;Coding of Death in HIV&#8221;&#44; in <a id="intr0005" class="elsevierStyleInterRef" href="http://www.cphiv.dk/CoDe">www&#46;cphiv&#46;dk&#47;CoDe</a>&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study is in accordance with the community standards and approved by the ethics committee&#46; 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or median &#40;range&#41;&#44; as indicated&#46; For qualitative variables&#44; absolute numbers and percentages were computed&#46; The comparison of quantitative parameters was carried out using Student&#39;s <span class="elsevierStyleItalic">t</span> test&#46; The association of qualitative variables was carried out using Chi-squared statistic&#59; the relative risk &#40;RR&#41; was calculated&#46; A two-sided type I error of 5&#37; was considered statistically significant&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A time-trend joinpoint regression analysis was performed&#46; This technique provides the estimated annual percent change &#40;APC&#41; and allows detecting points in time at which significant changes in the trends occur&#46; For each APC estimate&#44; 95&#37; confidence interval was also calculated&#46; Statistical analysis was performed using SPSS for Windows &#40;version 19&#46;0&#44; SPSS Inc&#46;&#44; Chicago&#44; IL&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Demographic characteristics and hospitalization parameters</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 2498 PLWH were followed during the period study&#44; contributing to 22&#44;901 patient-years &#40;PY&#41;&#46; In the study period 6917 hospital admissions were recorded&#44; corresponding to 1937 subjects&#46; Of them&#44; 75&#46;0&#37; were male&#44; mean age &#40;at first hospitalization&#41; was 36&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;6 years&#44; and 37&#46;2&#37; were HIV&#47;HCV coinfected&#46; Among those PLWH hospitalized&#44; 789 &#40;40&#46;7&#37;&#41; have one admission&#59; the median number of admission was 2 &#40;IQR&#58; 1&#8211;4&#41;&#46; The hospitalization rate showed a reduction from 30&#46;7&#47;100 patients &#40;CI95&#37;&#58; 27&#46;7&#8211;33&#46;8&#41; in 1993 to 19&#46;9&#47;100 patients &#40;17&#46;7&#8211;22&#46;2&#41; in 2013 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#59; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the hospitalization and mortality each year and the number of patients on follow-up&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In the comparative analysis between both periods &#40;1993&#8211;2002 vs&#46; 2003&#8211;2013&#41;&#44; differences in hospitalization reasons were recognized among periods &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The main 5 reasons for hospitalization were&#58; pneumonia &#40;10&#46;5&#37;&#41;&#44; chronic pulmonary disease&#47;respiratory failure &#40;8&#46;3&#37;&#41;&#44; tuberculosis &#40;7&#46;4&#37;&#41;&#44; hepatic decompensation &#40;6&#46;3&#37;&#41; and psychiatric disorder&#47;drug-abuse &#40;5&#46;3&#37;&#41;&#46; Overall&#44; 23&#46;1&#37; of the total of 6917 hospitalizations was AIDS-defining illnesses&#44; with differences between first &#40;28&#46;0&#37;&#41; and second period &#40;16&#46;2&#37;&#41;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Re-admissions and mortality rates by clinical units</span><p id="par0075" class="elsevierStylePara elsevierViewall">Overall&#44; 5759 &#40;83&#46;3&#37;&#41; were considered primary hospitalizations&#44; 998 &#40;14&#46;4&#37;&#41; were first re-admissions and 160 &#40;2&#46;3&#37;&#41; were subsequent re-admissions in a chain&#46; The median length of hospital stay was 8&#46;0 days &#40;5&#46;0&#8211;16&#46;0&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The re-admission rate was 20&#46;1&#37; &#40;CI95&#37;&#58; 19&#46;1&#8211;21&#46;2&#41; without differences by gender &#40;20&#46;3&#37; in men vs&#46; 19&#46;7&#37; in women&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;21&#41;&#46; Mean age of patients in hospitalizations without a re-admission &#40;37&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;4&#41; was similar than those re-admitted &#40;37&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;9 years&#41;&#46; A higher rate of re-admissions was observed for some services such as Onco-Hematology &#40;68&#46;5&#37;&#41;&#44; Gynecology&#8211;Obstetrics &#40;24&#46;2&#37;&#41;&#44; Internal Medicine-Infectious Diseases &#40;20&#46;0&#37;&#41; or Pediatric Unit &#40;16&#46;3&#37;&#41;&#46; Those with lower rate were&#58; surgery units &#40;13&#46;2&#37;&#41; or Psychiatry Unit &#40;8&#46;2&#37;&#41;&#46; Main reasons for hospital admission have different re-admission rates&#58; tumoral diseases 33&#46;8&#37;&#44; hepatic decompensations 23&#46;5&#37;&#44; chronic pulmonary diseases 20&#46;8&#37;&#44; infectious diseases 18&#46;9&#37;&#44; cardiovascular diseases 14&#46;9&#37;&#44; and psychiatric disorders 12&#46;8&#37;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Between 1993&#8211;2013&#44; 453 in-hospital deaths were identified&#44; with an overall inpatient mortality rate of 6&#46;5&#37; &#40;CI95&#37;&#58; 6&#46;0&#8211;7&#46;1&#41;&#46; Globally&#44; the mortality of hospitalizations for males was higher than for women &#40;7&#46;4&#37; vs&#46; 4&#46;4&#37;&#44; RR&#58; 1&#46;7 &#91;1&#46;3&#8211;2&#46;1&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Mean age of patients who died during the hospitalizations was 40&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;3 years&#44; significantly higher &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; than that of those who did not die &#40;37&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;4 years&#41;&#46; Mortality of primary hospitalizations was 5&#46;7&#37; vs&#46; 11&#46;0&#37; among re-admissions &#40;RR 1&#46;93 &#91;1&#46;59&#8211;2&#46;35&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; AIDS-defining illnesses hospitalizations presented a mortality of 13&#46;4&#37;&#44; while in non AIDS-defining diseases was 4&#46;5&#37; &#40;RR&#58; 3&#46;0 &#91;2&#46;5&#8211;3&#46;6&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">There were differences in mortality rate by Units &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41;&#58; Onco-Hematology &#40;12&#46;4&#37;&#41;&#44; Internal Medicine-Infectious Diseases &#40;6&#46;7&#37;&#41;&#44; Surgery &#40;3&#46;6&#37;&#41; and Pediatric &#40;3&#46;5&#37;&#41;&#46; No patient&#39;s death in Gynecology&#8211;Obstetrics or Psychiatry Unit&#46; There were 24 hospitalizations admitted in ICU directly from the Emergency Department&#44; 21 of them &#40;87&#46;5&#37;&#41;&#44; died during the ICU stay&#46; Hospitalizations that were admitted in ICU &#40;whenever during the hospitalization&#41; had higher mortality rate &#40;35&#46;5&#37;&#41; than those without ICU care &#40;5&#46;3&#37;&#41; &#40;RR 6&#46;6 &#91;5&#46;5&#8211;8&#46;0&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The main causes of in-patient death and the change between both periods are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">HIV&#47;HCV coinfection</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 716 HIV&#47;HCV coinfected patients were hospitalized at least once during the study period&#44; giving a total of 3525 hospitalizations &#40;1408 between 1993&#8211;2002 and 2117 between 2003&#8211;2013&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> depicts the changes in incidence during the follow up&#46; In the joinpoint regression analysis&#44; two different trends were observed&#46; Hospitalizations rate increased between 1993 and 1996 in all cohort &#40;APC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#46;8&#37;&#41;&#46; Between 1997 and 2013&#44; hospitalizations rate decreased much more in HIV mono-infected &#40;APC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;4&#46;9&#37;&#41; than in HIV&#47;HCV coinfected &#40;APC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;1&#46;7&#37;&#41;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Overall&#44; the mean length of stay in HCV coinfected patients was similar than in mono-infected &#40;median&#58; 10&#46;1 days &#91;6&#46;3&#8211;15&#46;9&#93; vs&#46; 11&#46;0 &#91;6&#46;0&#8211;19&#46;5&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;24&#41;&#59; but coinfected had more hospitalizations per patient &#40;median&#58; 3&#46;0 &#91;1&#46;0&#8211;6&#46;0&#93; vs&#46; 2&#46;0 &#91;1&#46;0&#8211;3&#46;0&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and higher readmission rates &#40;21&#46;5&#37; vs&#46; 19&#46;1&#37;&#44; RR&#58; 1&#46;1 &#91;1&#46;0&#8211;1&#46;2&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The sum of total days of hospitalization per patient during the follow-up was higher among HIV&#47;HCV coinfected than in HIV mono-infected &#40;median&#58; 36&#46;0 days &#91;14&#46;0&#8211;77&#46;5&#93; vs&#46; 23&#46;0 days &#91;9&#46;0&#8211;51&#46;0&#93;&#44; respectively&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The main causes of hospitalization in coinfected patients&#44; comparatively with HIV-monoinfected&#44; are illustrated in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; A decrease of infectious diseases and psychiatric disorders was evidenced&#46; On the other hand&#44; an important increase in hospitalizations due to hepatic decompensations was found &#40;from 5&#46;8&#37; to 11&#46;5&#37;&#44; RR&#58; 2&#46;0 &#91;CI95&#37;&#58; 1&#46;5&#8211;2&#46;6&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Mortality rate of hospitalizations in HIV&#47;HCV coinfected increases from 4&#46;0&#37; &#40;1993&#8211;2002&#41; to 6&#46;2&#37; &#40;2003&#8211;2013&#41;&#44; RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;5 &#40;1&#46;1&#8211;2&#46;1&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; There were also differences in mortality reasons&#58; infectious diseases mortality decreased significantly &#40;RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;6 &#91;&#46;4&#8211;&#46;9&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; tumors increased &#40;RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;1 &#91;&#46;5&#8211;8&#46;8&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; and hepatic decompensations also increased from 15&#46;6&#37; to 21&#46;2&#37; &#40;RR&#58; 1&#46;4 &#91;&#46;6&#8211;3&#46;3&#93;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">This study evaluates trends in hospitalizations among PLWH in a medical reference area of Northwest Spain&#46; Overall&#44; the hospitalizations rate showed a decline from 31&#47;100 patients in 1993 to 20&#47;100 patients in 2013&#44; but remains higher than in the general population&#46; These results are concordant with other previously published in different countries and different Health Care Systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;21</span></a> The joinpoint analysis established a point of change in 1996&#46; This behavior is related with the introduction of HAART and its rapid impact in AIDS-defining illnesses&#46; In this year&#44; the trend of hospitalization incidence changed from a yearly growing of 11&#46;8&#37; toward a yearly decreasing of 3&#46;4&#37;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Changes in the reasons of hospital admission were also observed between the two periods evaluated&#46; Thus&#44; a significant decrease in hospitalizations due to infectious &#40;mainly AIDS-defining diseases&#41; and psychiatric disease or drugs abuse was recognized in contrast to a progressive increase of malignancies specially those non AIDS-defining&#44; chronic respiratory&#44; cardiovascular and liver related diseases&#46; Overall&#44; hospitalizations due to AIDS-defining diseases dropped &#40;from 28&#46;0&#37; to 16&#46;2&#37;&#41; in our cohort&#44; but their mortality did not change significantly &#40;15&#46;0&#37; in 1993&#8211;2003 and 12&#46;3&#37; in 2004&#8211;2013&#41;&#46; AIDS-defining diseases and their high mortality remain a current problem worldwide&#59; this problem must be addressed from the universalization of HAART and improving the diagnostic strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Accordingly&#44; changes in hospitalization units were also observed&#46; Thus&#44; in the second period there was an increase in hospitalizations in surgical areas and onco-haematologic units&#44; likely due to an increase in the life expectancy among HIV-infected patients in the second period because the access to specific treatments as for the general population&#46; The rates of ICU admissions increased up to 3-times&#44; probably caused by the same reasons&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">However&#44; the average length of stay and re-admission rates remain high&#44; similar to those reflected in other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">10&#44;20</span></a> probably due to an increase in the comorbidities associated with HIV infection&#44; that involve greater complexity of clinical management in this group of patients&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Despite the improvement in the care of PLWH&#44; the in-hospital mortality remains high&#59; in this cohort the mortality in men is 1&#46;7 times higher than in women&#44; according to data published previously&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">21&#44;22</span></a> Non-AIDS deaths increased significantly during the ART era and nowadays are the main cause of in-hospital mortality in PLWH&#46; Non-AIDS infections&#44; cirrhosis and its complications&#44; and malignancies were major contributors to mortality&#46; Non-AIDS mortality increased by 80&#46;5&#37; between first and second period&#59; consequently&#44; AIDS mortality decreased by 49&#46;0&#37;&#46; Cowell et al&#46;&#44; reported similar trends recently&#44; in a huge American cohort&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The 30 days re-admission rate in our cohort was 20&#46;1&#37;&#44; similar to data recently reported by Berry et al&#46; &#40;19&#46;3&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a> The re-admission rate has an important impact on long-term health and mortality rate of PLWH&#46; Indeed&#44; some mathematical models are developed to predict re-admission&#44; but they need to be validated in other populations&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Within this cohort&#44; nearly 40&#37; were HIV&#47;HCV coinfected patients&#46; They had more hospitalizations&#44; re-admissions and the sum of the total stays were significantly greater than for HIV mono-infected&#44; similarly to that previously published&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> Interestingly&#44; the incidence of hospitalizations in 2013 was double in coinfected compared to HIV mono-infected&#46; Indeed&#44; although the hospitalization rate decreases since 1996&#44; the APC is near to three times higher in mono-infected than in coinfected&#46; Therefore&#44; in terms of hospitalizations and in-hospital mortality&#44; HCV coinfection seems to mask the beneficial effect of HAART and improvements in HIV care&#44; although other factors such IDU or alcohol could also play a significant role&#46; Hospitalizations due to hepatic decompensation are double in the last ten years &#40;2003&#8211;2013&#41; compared with the first period &#40;1993&#8211;2002&#41;&#46; Moreover&#44; Meyers et al&#46; described recently that HCV mortality appears to be relatively stable while total HIV&#47;AIDS deaths are on a decline across the state of Massachusetts in a trend analysis of HIV and HCV using multiple cause of death&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a> All these data suggest that hospitalizations&#44; decompensations and mortality will increase in the next years if HCV infection is not eradicated&#46; The impact of a wide access to new anti-HCV therapies in HIV-infected patients must be evaluated in the near future&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">26-28</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">There are some limitations in our study that merit discussion&#46; This is a retrospective observational study&#44; using data recorded from a single hospital that it could affect the generalizability of our finding&#46; However&#44; this is a reference hospital with more than 1000-beds and a large cohort of HIV- and HCV-infected patients in follow-up in this institution since the beginning of both epidemics&#46; Although there are not other HIV outpatient clinics in our area&#44; some patients had an admission without any follow up in our clinic&#59; it could overestimate hospitalization rates&#46; Moreover&#44; there are some variables that might be also associated with mortality that were not collected &#40;i&#46;e&#46; smoking&#44; or years under HAART exposure&#41; and therefore its specific impact in hospitalizations and rates of mortality could not be analyzed&#46; Data of CD4 count&#44; HAART and viral suppression were not available&#44; the effect of this important factors in PLWH was not analyzed&#46; Patients admitted in Onco-Hematology Units to receive scheduled chemotherapy &#40;12&#37;&#41; could overestimate the hospitalization rate in these Units and underestimate the in-hospital mortality in them&#46; The study did not include HCV-infected patients treated with new DAAs based therapies&#44; neither a control group of hospitalized HIV-negative patients&#46; Finally&#44; it is possible that the use of the ICD-9 coding system might introduce coding errors&#44; although minority&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In summary&#44; in this large cohort of PLWH&#44; followed during 20 years&#44; a decrease in the hospitalizations rate and a progressive decline of AIDS defining illnesses have been recognized&#46; Consequently&#44; chronic comorbidities and malignancies have been increasing within the last ten years&#46; However&#44; the length of stay&#44; re-admission and the mortality rate remains high&#46; HCV coinfection has a negative impact in these parameters and is associated with increases in the morbidity and mortality and therefore in the resource consumption among PLWH&#46; These findings are essential to improve and optimize the clinical management of PLWH and to pay special attention in those comorbidities that favor the hospitalization and mortality rates nowadays&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">All authors declare no conflicts of interest&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">New patterns in epidemiological characteristics of people living with HIV infection &#40;PLWH&#41; and the introduction of Highly Active Antiretroviral Therapy &#40;HAART&#41; have changed the profile of hospital admissions in this population&#46; The aim of this study was to evaluate trends in hospital admissions&#44; re-admissions&#44; and mortality rates in HIV patients and to analyze the role of HCV co-infection&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective cohort study conducted on all hospital admissions of HIV patients between 1993 and 2013&#46; The study time was divided in two periods &#40;1993&#8211;2002 and 2003&#8211;2013&#41; to be compared by conducting a comparative cross-sectional analysis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 22&#44;901 patient-years were included in the analysis&#44; with 6917 hospital admissions&#44; corresponding to 1937 subjects &#40;75&#37; male&#44; mean age 36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 years&#44; 37&#37; HIV&#47;HCV co-infected patients&#41;&#46; The median length of hospital stay was 8 days &#40;5&#8211;16&#41;&#44; and the 30-day hospital re-admission rate was 20&#46;1&#37;&#46; A significant decrease in hospital admissions related with infectious and psychiatric diseases was observed in the last period &#40;2003&#8211;2013&#41;&#44; but there was an increase in those related with malignancies&#44; cardiovascular&#44; gastrointestinal&#44; and chronic respiratory diseases&#46; In-hospital mortality remained high &#40;6&#46;8&#37; in the first period vs&#46; 6&#46;3&#37; in the second one&#41;&#44; with a progressive increase of non-AIDS-defining illness deaths &#40;37&#46;9&#37; vs&#46; 68&#46;3&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The admission rate significantly dropped after 1996 &#40;4&#46;9&#37; yearly&#41;&#44; but it was less pronounced in HCV co-infected patients &#40;1&#46;7&#37; yearly&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hospital admissions due to infectious and psychiatric disorders have decreased&#44; with a significant increase in non-AIDS-defining malignancies&#44; cardiovascular&#44; and chronic respiratory diseases&#46; In-hospital mortality is currently still high&#44; but mainly because of non-AIDS-defining illnesses&#46; HCV co-infection increased the hospital stay and re-admissions during the study period&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los cambios en las caracter&#237;sticas epidemiol&#243;gicas de los pacientes con infecci&#243;n por el VIH&#44; y la introducci&#243;n del tratamiento antirretroviral de alta eficacia&#44; han modificado el perfil de las hospitalizaciones en esta poblaci&#243;n&#46; El objetivo del estudio fue evaluar las tendencias en hospitalizaci&#243;n&#44; reingreso y mortalidad en pacientes VIH&#44; y analizar el papel de la coinfecci&#243;n por el VHC&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes retrospectivo&#44; que incluy&#243; todas las hospitalizaciones de pacientes VIH entre 1993-2013&#46; El estudio fue dividido en 2 periodos &#40;1993-2002 y 2003-2013&#41; para ser comparados mediante un an&#225;lisis transversal&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 22&#46;901 pacientes&#47;a&#241;os&#44; que presentaron 6&#46;917 hospitalizaciones que correspondieron a 1&#46;937 pacientes &#40;75&#37; varones&#44; edad media 36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 a&#241;os&#44; 37&#37; coinfectados VIH&#47;VHC&#41;&#46; La mediana de estancia hospitalaria fue de 8 d&#237;as &#40;5-16&#41;&#44; y la tasa de reingreso a los 30 d&#237;as del 20&#44;1&#37;&#46; Se observ&#243; un descenso significativo en el segundo periodo &#40;2003-2013&#41; de las hospitalizaciones motivadas por enfermedades infecciosas y trastornos psiqui&#225;tricos&#44; y un incremento de aquellas relacionadas con neoplasias&#44; enfermedad cardiovascular&#44; gastrointestinal y enfermedades respiratorias cr&#243;nicas&#46; La mortalidad intrahospitalaria permanece elevada &#40;6&#44;8&#37; en el primer periodo vs&#46; 6&#44;3&#37; en el segundo&#41;&#44; con un aumento progresivo de las muertes por enfermedades no definitorias de sida &#40;37&#44;9 vs&#46; 68&#44;3&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La tasa de hospitalizaci&#243;n disminuy&#243; de manera significativa despu&#233;s de 1996 &#40;4&#44;9&#37; anual&#41;&#44; pero este descenso fue menos acusado en los pacientes coinfectados VIH&#47;VHC &#40;1&#44;7&#37; anual&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las hospitalizaciones motivadas por enfermedades infecciosas y trastornos psiqui&#225;tricos han descendido&#59; por el contrario&#44; se observ&#243; un aumento significativo de aquellas relacionadas con neoplasias no definitorias de sida&#44; enfermedad cardiovascular y enfermedades respiratorias cr&#243;nicas&#46; La mortalidad intrahospitalaria permanece a d&#237;a de hoy elevada&#44; pero a expensas fundamentalmente de enfermedades no definitorias de sida&#46; La coinfecci&#243;n VIH&#47;VHC increment&#243; los d&#237;as de hospitalizaci&#243;n y los reingresos durante el periodo de estudio&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">These authors contributed equally in this work&#46;</p>"
        "identificador" => "fn0005"
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        "etiqueta" => "Fig&#46; 1"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Hospitalization in PLWH between 1993 and 2013&#59; black area indicates mortality &#40;&#37;&#41;&#46; Patients on follow-up each year&#46;</p>"
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        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Hospitalization rate in HIV&#47;HCV coinfected and HIV monoinfected patients&#46; Joinpoint regression analysis&#58; trends in hospitalizations in HIV&#47;HCV coinfected and HIV monoinfected patients&#46; Estimated Annual percent change &#40;bold if statistically significant&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 in all cases&#41;&#46; In comparison between HIV&#47;HCV coinfected and HIV monoinfected patients&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;65 in the first period &#40;1993&#8211;1996&#41; and <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 in the second &#40;1996&#8211;2013&#41;&#46;</p>"
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        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Main reasons of hospital admission &#40;a&#41; and in-hospital mortality &#40;b&#41; in HIV-mono and HIV&#47;HCV-coinfected patients during 1993&#8211;2002 and 2003&#8211;2013&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Main causes of in-hospital mortality&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Statistically significant results &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; are shown in bold&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1993&#8211;2002 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3463&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2003&#8211;2013 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3454&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Relative change &#40;&#37;&#41; &#40;CI 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Scheduled admissions &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;36&#46;3 &#40;&#8722;40&#46;5&#59; &#8722;31&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Length of stay &#40;median&#44; IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;0 &#40;5&#46;0&#8211;16&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;0 &#40;4&#46;0&#8211;15&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;9&#46;9 &#40;&#8722;18&#46;7&#59; 2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Re-admission &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;0 &#40;&#8722;9&#46;2&#59; 13&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Mortality &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;7&#46;0 &#40;&#8722;22&#46;1&#59; 18&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleBold">Hospitalization reasons &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Infectious diseases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;28&#46;1 &#40;&#8722;32&#46;0&#59; &#8722;23&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Aids-defining infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;30&#46;2 &#40;&#8722;36&#46;0&#59; &#8722;23&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Psyquiatric illness</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;42&#46;7 &#40;&#8722;52&#46;0&#59; &#8722;31&#46;6&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Malignancies</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">115&#46;8 &#40;75&#46;4&#59; 165&#46;3&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Aids-defining tumors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;34&#46;8 &#40;&#8722;46&#46;0&#59; &#8722;21&#46;2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cardiac diseases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">205&#46;6 &#40;116&#46;3&#59; 331&#46;6&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Digestive system diseases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">74&#46;8 &#40;53&#46;6&#59; 98&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hepatic decompensations</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">103&#46;3 &#40;67&#46;6&#59; 146&#46;6&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chronic respiratory diseases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">96&#46;4 &#40;66&#46;3&#59; 131&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleBold">Hospitalization units &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Internal medicine&#47;infectious diseases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;16&#46;7 &#40;&#8722;18&#46;9&#59; &#8722;14&#46;5&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Surgical units</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">108&#46;0 &#40;74&#46;6&#59; 147&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Onco-hematology</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">116&#46;5 &#40;63&#46;4&#59; 186&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Gynecology&#47;obstetrics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">58&#46;9 &#40;23&#46;3&#59; 104&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pediatrics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;80&#46;7 &#40;&#8722;90&#46;2&#59; &#8722;62&#46;1&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Intensive care unit</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">200&#46;8 &#40;130&#46;0&#59; 293&#46;4&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Cause of in-hospital death &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">235&#47;453</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">218&#47;453</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">AIDS related illness&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">62&#46;1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">31&#46;7</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;49&#46;0 &#40;&#8722;59&#46;1&#59; &#8722;36&#46;6&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Aids related encephalopaty<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;70&#46;4 &#40;&#8722;84&#46;4&#59; &#8722;43&#46;7&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>MAI-MTB infection<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;61&#46;1 &#40;&#8722;78&#46;8&#59; &#8722;28&#46;6&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pneumocistis jirovecci pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;48&#46;1 &#40;&#8722;72&#46;5&#59; &#8722;2&#46;0&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Aids related malignancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;4 &#40;&#8722;26&#46;4&#59; 127&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Disseminated candidiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8722;88&#46;0 &#40;&#8722;98&#46;5&#59; &#8722;6&#46;2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Recurrent bacterial pneumoniae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;46&#46;1 &#40;&#8722;83&#46;5&#59; 76&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Wasting syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;1 &#40;&#8722;86&#46;3&#59; 112&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Non-AIDS related illness&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">37&#46;9</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">68&#46;3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">80&#46;5 &#40;49&#46;7&#59; 117&#46;6&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;02&#46;1&#41; Bacterial infection<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">66&#46;2 &#40;2&#46;9&#59; 168&#46;4&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;02&#46;1&#46;1&#41; Bacterial infection with sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">88&#46;6 &#40;5&#46;0&#59; 238&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;03&#46;1&#46;1&#41; HCV with cirrhosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">115&#46;6 &#40;10&#46;5&#59; 320&#46;5&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;04&#41; Malignancy<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">277&#46;3 &#40;55&#46;2&#59; 817&#46;3&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;16&#41;Violent death&#47;&#40;19&#41;substance abuse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;59&#46;6 &#40;&#8722;89&#46;1&#59; 50&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;9&#41; Stroke and &#40;23&#41; other CNS disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&#46;7 &#40;&#8722;32&#46;6&#59; 288&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;13&#41; Chronic obstructive lung disease<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">205&#46;4 &#40;22&#46;7&#59; 660&#46;5&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;08&#41; MI and other heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">223&#46;4 &#40;&#8722;66&#46;1&#59; 2985&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#40;90&#41; Other causes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;8&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 0213005X
Original language: English

DOI:10.1016/j.eimc.2016.07.012

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Year/Month	Html	Pdf	Total

2024 November	2	0	2
2024 October	18	5	23
2024 September	27	4	31
2024 August	14	2	16
2024 July	13	4	17
2024 June	7	5	12
2024 May	12	1	13
2024 April	14	11	25
2024 March	44	6	50
2024 February	29	7	36
2024 January	17	0	17
2023 December	13	4	17
2023 November	32	3	35
2023 October	30	6	36
2023 September	21	0	21
2023 August	6	0	6
2023 July	15	3	18
2023 June	13	1	14
2023 May	13	1	14
2023 April	18	1	19
2023 March	15	4	19
2023 February	22	11	33
2023 January	25	13	38
2022 December	22	7	29
2022 November	32	15	47
2022 October	25	15	40
2022 September	24	18	42
2022 August	21	7	28
2022 July	22	8	30
2022 June	15	6	21
2022 May	20	11	31
2022 April	16	21	37
2022 March	27	18	45
2022 February	27	5	32
2022 January	41	7	48
2021 December	31	11	42
2021 November	41	9	50
2021 October	26	10	36
2021 September	21	9	30
2021 August	24	12	36
2021 July	64	11	75
2021 June	27	6	33
2021 May	33	11	44
2021 April	49	15	64
2021 March	30	7	37
2021 February	39	27	66
2021 January	34	12	46
2020 December	25	8	33
2020 November	11	12	23
2020 October	16	9	25
2020 September	33	14	47
2020 August	19	10	29
2020 July	27	11	38
2020 June	20	10	30
2020 May	28	10	38
2020 April	16	12	28
2020 March	16	9	25
2020 February	34	6	40
2020 January	31	29	60
2019 December	33	6	39
2019 November	6	6	12
2019 October	11	15	26
2019 September	12	3	15
2019 August	19	6	25
2019 July	25	17	42
2019 June	53	23	76
2019 May	142	31	173
2019 April	48	9	57
2019 March	12	2	14
2019 February	21	2	23
2019 January	12	2	14
2018 December	13	2	15
2018 November	30	3	33
2018 October	20	2	22
2018 September	24	6	30
2018 August	7	7	14
2018 July	8	4	12
2018 June	8	7	15
2018 May	13	7	20
2018 April	20	4	24
2018 March	11	1	12
2018 February	10	2	12
2018 January	4	3	7
2017 December	15	0	15
2017 November	10	6	16
2017 October	13	10	23
2017 September	28	12	40
2017 August	30	6	36
2017 July	9	6	15
2017 June	1	0	1
2017 April	1	0	1
2017 March	9	1	10
2017 February	90	13	103
2017 January	5	1	6
2016 December	7	9	16
2016 November	3	12	15
2016 October	13	17	30
2016 September	11	31	42

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