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        "titulo" => "The Epidemiological and Clinical Characteristics of the Epidemic of Syphilis in Barcelona"
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ITS previa y s&#237;filis &#40;porcentajes&#41; y la tendencia lineal del n&#250;mero de parejas sexuales &#40;n&#250;mero mediana por mes&#41; por a&#241;o entre los casos de s&#237;filis temprana en la Unidad de ITS de Vall d&#8217;Hebron-Drassanes&#44; Barcelona&#44; 2003-2013&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Desde el a&#241;o 2000&#44; se ha descrito un aumento progresivo de los casos de s&#237;filis en diferentes ciudades europeas&#44; sobre todo en hombres que tienen sexo con hombres &#40;HSH&#41;&#46; En Europa se han reportado 22&#46;237 casos de s&#237;filis precoz en 2013&#44; con una tasa de 5&#44;5 por 100&#46;000 habitantes&#59; el 62&#37; de los casos fueron notificados por 4 pa&#237;ses&#44; entre los cuales est&#225; Espa&#241;a<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a>&#46; Catalu&#241;a &#40;Espa&#241;a&#41;&#44; con 7 millones de habitantes&#44; report&#243; una tasa de s&#237;filis precoz del 12&#44;4 por 100&#46;000 habitantes en 2014&#44; lo que represent&#243; un incremento del 231&#37; desde el a&#241;o 2005<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a>&#46; La reemergencia de la s&#237;filis en Catalu&#241;a se detect&#243; en Barcelona en el a&#241;o 2002&#44; principalmente en HSH&#44; los cuales presentaban una tasa de coinfecci&#243;n por el VIH del 30&#37;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El objetivo del presente estudio fue describir de manera retrospectiva las caracter&#237;sticas epidemiol&#243;gicas y cl&#237;nicas de los casos de s&#237;filis precoz diagnosticados en la unidad de ITS del Vall d&#8217;Hebron-Drassanes &#40;UITSVD&#41;&#44; en Barcelona&#44; entre los a&#241;os 2003-2013&#44; particularmente en HSH&#46; La atenci&#243;n brindada por la UITSVD durante este tiempo sum&#243; m&#225;s de 25&#46;000 consultas m&#233;dicas por a&#241;o &#40;60&#37; de los cuales fueron HSH&#41; y adem&#225;s report&#243; aproximadamente el 75&#37; de todos los casos de s&#237;filis diagnosticados en Barcelona durante ese periodo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participantes y recolecci&#243;n de datos</span><p id="par0015" class="elsevierStylePara elsevierViewall">Se revisaron todos los casos de s&#237;filis notificados en la UITSVD desde enero del 2003 hasta diciembre del 2013&#46; En total&#44; fueron revisadas 2&#46;209 historias cl&#237;nicas&#44; de las cuales se excluyeron 242&#59; 52 debido a que estaban fuera del periodo del estudio y 190 por ausencia de datos o porque el diagn&#243;stico final de s&#237;filis no estaba claro&#46; En la UITSVD&#44; durante el estudio&#44; se diagnosticaron 2&#46;241 casos &#40;donde un caso se refiere a un episodio&#44; pudiendo el mismo paciente presentar m&#225;s de un episodio&#41;&#44; de los cuales 1&#46;702 se diagnosticaron como s&#237;filis precoz en un total de 1&#46;484 pacientes&#46; Los datos epidemiol&#243;gicos&#44; cl&#237;nicos y microbiol&#243;gicos se recopilaron de forma estandarizada en s&#237;filis primaria&#44; secundaria y latente precoz&#46; Asimismo&#44; se recogieron datos acerca de&#58; tener pareja estable&#47;espor&#225;dica&#44; el n&#250;mero de contactos sexuales y el uso de preservativo durante las relaciones sexuales anales&#46; Las variables que estaban ausentes en m&#225;s del 50&#37; de los casos debido a variaciones en la recolecci&#243;n de datos &#40;p&#46; ej&#46;&#44; el uso de drogas&#41; no fueron analizadas&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedimientos</span><p id="par0020" class="elsevierStylePara elsevierViewall">El diagn&#243;stico de s&#237;filis se realiz&#243; mediante una valoraci&#243;n cl&#237;nica y serol&#243;gica&#44; y con t&#233;cnicas de detecci&#243;n directa si en el examen cl&#237;nico se observaban &#250;lceras&#46; Las pruebas serol&#243;gicas que se usaron fueron el examen de la reagina plasm&#225;tica r&#225;pida &#40;RPR&#41; &#40;Biokit&#174;Izasa&#44; Espa&#241;a&#41;&#44; la prueba de hemaglutinaci&#243;n para el <span class="elsevierStyleItalic">Treponema pallidum &#40;T&#46; pallidum&#41;</span> &#40;TPHA&#41; &#40;Biokit&#174;Izasa&#44; Espa&#241;a&#41; y el inmunoan&#225;lisis enzim&#225;tico trepon&#233;mico &#40;EIA enzygnost syphilis&#44; Siemens Healthcare Diagnostics&#44; Alemania&#41;&#46; El diagn&#243;stico directo se hizo mediante microscopia de campo oscuro o PCR para <span class="elsevierStyleItalic">T&#46; pallidum</span><a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a>&#46; Los casos de s&#237;filis se estadificaron y se clasificaron seg&#250;n las gu&#237;as europeas existentes<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>&#46; La s&#237;filis latente precoz se defini&#243; como la presencia de una prueba serol&#243;gica positiva para s&#237;filis en un paciente con serolog&#237;a negativa en los 12 meses previos&#44; o un incremento de al menos 4 veces &#40;en m&#225;s de 2 diluciones&#41; de los t&#237;tulos de una prueba no trepon&#233;mica dentro de los &#250;ltimos 12 meses&#46; La reinfecci&#243;n se defini&#243; como la presencia de una nueva manifestaci&#243;n cl&#237;nica o el aumento en 2 diluciones de las pruebas no trepon&#233;micas&#46; La curaci&#243;n serol&#243;gica fue definida como la disminuci&#243;n en 4 veces &#40;al menos en 2 diluciones&#41; de la RPR&#46; Las pruebas diagn&#243;sticas utilizadas para la determinaci&#243;n de las infecciones de transmisi&#243;n sexual &#40;ITS&#41; sufrieron algunas modificaciones durante la realizaci&#243;n del estudio&#46; Dentro de estas cabe se&#241;alar la introducci&#243;n de la PCR en tiempo real&#44; realizada desde el 2006 para la detecci&#243;n de la <span class="elsevierStyleItalic">Chlamydia trachomatis</span> &#40;CT&#41;&#44; desde el 2012 para la <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> &#40;NG&#41; y desde el 2013 para el <span class="elsevierStyleItalic">T&#46; pallidum</span>&#46; Una infecci&#243;n concomitante se defini&#243; como el diagn&#243;stico simult&#225;neo de la infecci&#243;n por s&#237;filis con la del VIH&#44; NG o CT &#40;sin tener en cuenta si estas &#250;ltimas se hab&#237;a presentado en una o m&#225;s localizaciones anat&#243;micas&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis estad&#237;stico</span><p id="par0025" class="elsevierStylePara elsevierViewall">Inicialmente&#44; se realiz&#243; un estudio descriptivo de todos los casos y posteriormente se analiz&#243; &#250;nicamente los casos de los HSH &#40;incluyendo a los hombres bisexuales&#41;&#46; Los hallazgos epidemiol&#243;gicos y cl&#237;nicos de estos pacientes fueron comparados seg&#250;n el estatus serol&#243;gico del VIH y el antecedente de s&#237;filis&#44; para lo cual se realiz&#243; un an&#225;lisis de regresi&#243;n log&#237;stica univariado y multivariado&#46; Todos los an&#225;lisis se realizaron en la versi&#243;n R 3&#46;3&#46;1 &#40;The R Foundation for Statistical Computing&#44; Viena&#44; Austria&#41;&#46; Las variables cualitativas se expresaron en porcentajes y las comparaciones se hicieron usando la prueba de la chi al cuadrado o la prueba exacta de Fisher&#44; seg&#250;n fuera lo m&#225;s conveniente&#46; La fuerza de la asociaci&#243;n se midi&#243; utilizando la OR con intervalos de confianza del 95&#37; &#40;IC del 95&#37;&#41;&#46; Las variables cuantitativas se expresaron como medias &#177; desviaci&#243;n est&#225;ndar o medianas y rango intercuart&#237;lico&#46; Los an&#225;lisis comparativos se realizaron mediante el t-test o la prueba U de Mann-Whitney&#44; o ANOVA o la prueba de Kruskal-Wallis con un IC del 95&#37;&#44; si es que se contaba con m&#225;s de 2<span class="elsevierStyleHsp" style=""></span>categor&#237;as&#46; Las variables que resultaron significativas en el an&#225;lisis univariado &#40;p &#60; 0&#44;01&#41; o que se consideraron cl&#237;nicamente relevantes se analizaron mediante un modelo de regresi&#243;n final utilizando los criterios de informaci&#243;n de Akaike&#46; El trabajo recibi&#243; la aprobaci&#243;n del comit&#233; de &#233;tica del Hospital de Vall d&#8217;Hebron&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0030" class="elsevierStylePara elsevierViewall">El n&#250;mero de casos de infecci&#243;n por la s&#237;filis present&#243; un incremento de 68 casos en el 2003 a 277 casos en el 2013&#44; llegando a un total de 1&#46;702 casos durante todo el estudio&#58; el 97&#37; &#40;1&#46;650&#41; de los casos fueron diagnosticados en varones&#44; el 2&#37; &#40;33&#41; en mujeres y el 1&#37; &#40;14&#41; en transexuales&#46; De los 1&#46;702 casos&#44; 1&#46;425 &#40;84&#37;&#41; eran HSH&#44; 155 &#40;9&#37;&#41; eran hombres bisexuales&#44; 112 &#40;6&#44;9&#37;&#41; eran hombres y mujeres heterosexuales&#44; y 10 &#40;0&#44;6&#37;&#41; desconocidos &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La edad promedio fue de 35&#44;3 &#177; 8&#44;9 a&#241;os&#44; sin que se evidenciara un cambio significativo durante el periodo del estudio&#46; En general&#44; el 57&#37; &#40;971&#41; de los casos eran nativos y el 43&#37; &#40;731&#41; extranjeros&#44; observ&#225;ndose un incremento en estos &#250;ltimos&#44; pasando del 32&#37; &#40;22 de 68&#41; en 2003 al 43&#44;5&#37; &#40;120 de 277&#41; en 2013&#59; 1&#46;239 &#40;73&#37;&#41; casos se diagnosticaron por presentar s&#237;ntomas cl&#237;nicos sugestivos de s&#237;filis&#44; 250 &#40;15&#37;&#41; se diagnosticaron incidentalmente a trav&#233;s de pruebas de cribado para ITS&#44; 158 &#40;9&#37;&#41; fueron diagnosticados por estudio de contactos y 54 &#40;3&#37;&#41; gracias a un cribado oportunista en casos sintom&#225;ticos de otras ITS&#46; De todos los casos&#44; 637 &#40;38&#37;&#41; fueron s&#237;filis primarias&#44; 829 &#40;48&#37;&#41; secundarias y 236 &#40;14&#37;&#41; se clasificaron como s&#237;filis latente precoz&#46; Durante los a&#241;os del estudio se evidenciaron cambios en el motivo de consulta&#58; al inicio&#44; la mayor&#237;a de los casos se asociaban a s&#237;ntomas y solo en un 9&#37; &#40;6 de 68&#41; de los casos el diagn&#243;stico se realiz&#243; por cribado&#59; sin embargo&#44; este valor se increment&#243; hasta un 20&#37; &#40;42&#47;215&#41; en 2012&#46; De manera similar&#44; el diagn&#243;stico a trav&#233;s del estudio de contactos sufri&#243; un incremento&#44; pasando del 4&#37; &#40;3&#47;68&#41; en 2003 al 14&#37; &#40;39&#47;277&#41; en 2013&#46; Paralelamente&#44; la proporci&#243;n de pacientes con diagn&#243;stico de s&#237;filis latente precoz tambi&#233;n se increment&#243; desde un 7&#37; &#40;5&#47;68&#41; en 2003 hasta un 19&#37; &#40;53&#47;277&#41; en 2013&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Globalmente&#44; el 30&#37; &#40;n &#61; 517&#41; de los casos eran VIH conocidos en el momento del diagn&#243;stico de la s&#237;filis&#44; sin que hubiese cambios significativos en la prevalencia de la coinfecci&#243;n durante el estudio&#46; En cuanto a los antecedentes de s&#237;filis&#44; el 29&#37; &#40;n &#61; 487&#41; de los casos presentaron al menos un episodio previo de s&#237;filis&#44; evidenci&#225;ndose un incremento progresivo desde el 16&#37; &#40;11&#47;68&#41; en 2003 hasta un 34&#37; &#40;93&#47;277&#41; en 2013&#46; Un incremento similar se evidenci&#243; en otras ITS &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; El 92&#37; de los casos reportaron haber tenido m&#250;ltiples parejas sexuales&#59; presentando una mediana de 1 &#40;0&#44;33-2&#44;00&#41; contacto por mes&#44; observ&#225;ndose un incremento en el n&#250;mero total de parejas durante el periodo de seguimiento del estudio &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; En 615 casos &#40;36&#37;&#41; se contaba con los resultados del cribado de otras ITS&#44; realizado en el momento del diagn&#243;stico de s&#237;filis&#46; De estos casos&#44; 205 &#40;33&#37;&#41; presentaron una infecci&#243;n concomitante&#44; con una prevalencia del 14&#44;5&#37; &#40;89&#47;615&#41;&#44; el 8&#37; &#40;49&#47;615&#41;&#44; el 7&#44;5&#37; &#40;47&#47;615&#41; y el 3&#37; &#40;20&#47;615&#41; para VIH&#44; NG&#44; CT y <span class="elsevierStyleItalic">Lymphogranuloma venereum</span> &#40;LGV&#41;&#44; respectivamente&#46; As&#237; mismo&#44; los cambios en la pr&#225;ctica cl&#237;nica durante el periodo del estudio influyeron de alguna forma sobre estos hallazgos&#44; ya que en el a&#241;o 2003 &#250;nicamente se realizaron pruebas de cribado para otras ITS &#40;exclusivamente para VIH&#41; en el 11&#37; &#40;8&#47;68&#41; de los casos&#44; mientras que en el a&#241;o 2013 el 65&#37; &#40;182&#47;277&#41; de los casos con s&#237;filis fueron cribados para otras ITS&#46; El 20&#37; de los 87 pacientes HSH con diagn&#243;stico concomitante de VIH presentaban el antecedente de s&#237;filis&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A continuaci&#243;n&#44; nos enfocaremos en el an&#225;lisis realizado en los HSH&#44; en donde se incluyeron tambi&#233;n a hombres bisexuales &#40;n &#61; 1&#46;580&#41;&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Comparaci&#243;n entre los pacientes con el virus de la inmunodeficiencia humana positivo y negativo en hombres que tienen sexo con hombres</span><p id="par0045" class="elsevierStylePara elsevierViewall">La informaci&#243;n disponible de los 1&#46;497 casos de s&#237;filis en los HSH permiti&#243; observar que 600 &#40;40&#37;&#41; estaban coinfectados por el VIH&#59; de los cuales&#44; 513 eran VIH positivos conocidos&#44; mientras que 87 fueron diagnosticados juntamente con el diagn&#243;stico de la s&#237;filis&#46; Los datos comparativos entre los pacientes con VIH positivo y con VIH negativo se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; Los casos con VIH positivo ten&#237;an predominantemente mayor edad&#44; en mayor proporci&#243;n eran extranjeros y ten&#237;an antecedentes de ITS y de s&#237;filis&#46; As&#237; mismo&#44; estos pacientes se caracterizaban por presentar un mayor n&#250;mero de contactos sexuales al mes y adem&#225;s ten&#237;an m&#225;s frecuentemente relaciones sexuales anales desprotegidas&#46; En cuanto al estadio de la s&#237;filis&#44; ambos grupos tuvieron con mayor frecuencia una s&#237;filis secundaria&#46; As&#237; mismo&#44; los pacientes con VIH positivo fueron diagnosticados en mayor medida por presentar s&#237;ntomas&#59; sin embargo&#44; no se observaron diferencias respecto a la duraci&#243;n de los mismos &#40;mediana de 8 d&#237;as&#41;&#46; La infecci&#243;n concomitante por CT y LGV fueron m&#225;s frecuentes en los casos con VIH positivo &#40;3 &#91;11&#44;5&#37;&#93; y 14 &#91;4&#37;&#93; de los 199 casos a quienes se les realiz&#243; el cribado&#41;&#44; en comparaci&#243;n con los casos de pacientes con VIH negativo &#40;16 &#91;7&#37;&#93; y 6 &#91;1&#44;5&#37;&#93;&#41; de los 356 casos&#44; respectivamente&#41;&#46; De manera notable&#44; los casos con VIH positivo se asociaron con el antecedente de s&#237;filis &#40;OR ajustada&#44; 5&#44;2 &#91;IC del 95&#37;&#44; 3&#44;32-8&#44;24&#93;&#41; y otras ITS &#40;OR ajustada&#44; 1&#44;62 &#91;IC del 95&#37;&#44; 1&#44;09-2&#44;43&#93;&#41; y con relaciones sexuales anales desprotegidas &#40;OR ajustada&#44; 1&#44;75 &#91;IC del 95&#37;&#44; 1&#44;17-2&#44;63&#93;&#41; en el an&#225;lisis multivariado&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">En el momento del diagn&#243;stico de la s&#237;filis los t&#237;tulos de RPR fueron superiores en los pacientes con VIH positivo&#58; mediana de 1&#47;32 &#40;<span class="elsevierStyleItalic">1&#47;12</span>-1&#47;128&#41; en comparaci&#243;n con la de 1&#47;16 &#40;1&#47;4-1&#47;64&#41; &#40;p &#60; 0&#44;001&#41; en pacientes con VIH negativo&#46; El 40&#37; &#40;612&#47;1497&#41; de todos los casos se perdieron para el seguimiento del control serol&#243;gico sin que se encontraran diferencias significativas seg&#250;n el seroestatus de VIH&#46; La curaci&#243;n serol&#243;gica a los 3 meses se alcanz&#243; antes en los pacientes con VIH negativo&#44; pero fue similar en ambos grupos a los 6 y 12 meses &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Los casos con VIH positivo recibieron con mayor frecuencia las 3 dosis de penicilina benzatina semanal &#40;siguiendo las recomendaciones de expertos publicadas en algunas gu&#237;as cl&#237;nicas anteriores&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Comparaci&#243;n entre los pacientes hombres que tienen sexo con hombres con y sin s&#237;filis previa</span><p id="par0055" class="elsevierStylePara elsevierViewall">La informaci&#243;n acerca de los antecedentes de s&#237;filis previa de los 1&#46;568 casos de HSH demostraron que 475 &#40;30&#37;&#41; de ellos hab&#237;an sufrido por lo menos una vez en su vida un episodio anterior&#46; Algunos de los resultados comparativos entre los casos con y sin antecedentes de s&#237;filis se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; Los pacientes con antecedentes de s&#237;filis ten&#237;an significativamente mayor edad&#44; mayor frecuencia de antecedentes de ITS&#44; estaban en mayor medida coinfectados por VIH y presentaban con menor frecuencia una s&#237;filis primaria &#40;131 &#91;28&#37;&#93; de 475 vs&#46; 435 &#91;40&#37;&#93; de 1&#46;093&#41;&#44; adem&#225;s de presentar una menor duraci&#243;n media de los s&#237;ntomas &#40;mediana 7 vs&#46; 10 d&#237;as&#44; p &#60; 0&#44;001&#41;&#46; En los pacientes con antecedentes de s&#237;filis se objetiv&#243; as&#237; mismo un mayor n&#250;mero de contactos sexuales al mes&#46; La informaci&#243;n disponible de los 582 casos mostr&#243; que el 45&#37; &#40;173&#41; de ellos ten&#237;an una infecci&#243;n concomitante&#44; sin que se pudiera demostrar ninguna diferencia significativa entre ambos grupos &#40;incluyendo el VIH&#41;&#46; De manera remarcable&#44; en el an&#225;lisis multivariado&#44; los casos con antecedentes de s&#237;filis estaban asociados significativamente con la coinfecci&#243;n por el VIH &#40;OR ajustada&#44; 4&#44;43 &#91;IC del 95&#37;&#44; 3&#44;47-5&#44;68&#93;&#41; y con el antecedente de otras ITS &#40;OR ajustada&#44; 1&#44;41 &#91;IC del 95&#37;&#44; 1&#44;1-1&#44;8&#93;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">En el momento del diagn&#243;stico de la s&#237;filis&#44; los t&#237;tulos de RPR fueron superiores en los casos con historia previa de s&#237;filis&#58; mediana de 1&#47;64 &#40;1&#47;16-1&#47;128&#41; en comparaci&#243;n con 1&#47;16 &#40;1&#47;4-1&#47;64&#41; &#40;p &#60; 0&#44;001&#41; de los casos sin historia previa&#46; Una menor proporci&#243;n de los casos con antecedentes de s&#237;filis &#40;163 &#91;34&#37;&#93; de los 475&#41; que en aquellos sin antecedentes &#40;484 &#91;44&#37;&#93; de 1&#46;093&#41; se perdieron para el seguimiento serol&#243;gico &#40;p &#61; 0&#44;002&#41;&#46; Las tasas de curaci&#243;n serol&#243;gica en los primeros 6 meses se alcanzaron antes en los casos sin antecedentes de s&#237;filis&#59; sin embargo&#44; fueron similares en ambos grupos a los 12 meses tras el tratamiento &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0065" class="elsevierStylePara elsevierViewall">En esta unidad de referencia en ITS de Barcelona se document&#243; un incremento sustancial en el n&#250;mero de personas diagnosticadas de s&#237;filis entre los a&#241;os 2003 y 2013&#44; en continuaci&#243;n a la reemergencia observada en el a&#241;o 2002 en Barcelona<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#46; En la curva epid&#233;mica&#44; la fase espec&#237;fica en la que se encontrar&#237;a ser&#237;a el tipo hiperend&#233;mico&#44; lo que significa ausencia de control<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a>&#46; En nuestro medio&#44; el perfil dominante de la epidemia fue el de HSH&#46; De manera global&#44; en pa&#237;ses de rentas altas los HSH representan una carga desproporcionada de las infecciones por s&#237;filis<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>&#46; Diversas pr&#225;cticas de riesgo han sido relacionadas con ello&#44; por ejemplo&#44; un elevado n&#250;mero de contactos sexuales&#44; el uso de drogas durante las relaciones sexuales&#44; las relaciones sexuales anales desprotegidas&#44; el &#171;serosorting&#187;&#44; el sexo an&#243;nimo y el haber contactado con las parejas sexuales utilizando Internet<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9</span></a>&#59; posiblemente relacionado con la introducci&#243;n progresiva del tratamiento antirretroviral para el VIH<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#46; Este incremento de las pr&#225;cticas sexuales de riesgo<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> queda reflejado en el aumento paralelo de m&#250;ltiples ITS descrito en este grupo de poblaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;13</span></a>&#44; hecho que tambi&#233;n se ha observado en nuestro estudio&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Si nos centramos &#250;nicamente en los HSH&#44; los casos de s&#237;filis primaria y secundaria afectaron al 36&#37; &#40;578&#47;1&#46;588&#41; y al 49&#44;5&#37; &#40;787&#47;1&#46;588&#41;&#44; respectivamente&#44; sin que se encontraran diferencias en el an&#225;lisis multivariado en cuanto al estatus serol&#243;gico de la infecci&#243;n por el VIH&#46; A diferencia del nuestro&#44; otros estudios describieron una mayor proporci&#243;n de s&#237;filis latente precoz entre los pacientes con VIH positivo<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&#44; probablemente en relaci&#243;n con la realizaci&#243;n m&#225;s frecuente de pruebas de cribado en este grupo de pacientes&#46; La infecci&#243;n por s&#237;filis y el VIH est&#225;n muy relacionadas&#59; la s&#237;filis podr&#237;a incrementar el riesgo de transmisi&#243;n del VIH por el aumento de descarga viral en las lesiones&#44; as&#237; como su adquisici&#243;n al proveer una puerta de entrada para el virus<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a>&#46; El 34&#37; &#40;513&#47;1497&#41; de los casos de s&#237;filis fueron diagnosticados en pacientes con VIH positivo conocidos&#59; esta proporci&#243;n fue similar a la descrita en otros estudios realizados en Europa y en Norteam&#233;rica<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;16</span></a>&#46; As&#237; mismo&#44; adem&#225;s del diagn&#243;stico de s&#237;filis&#44; en un 9&#37; &#40;87&#47;984&#41; de los HSH se diagnostic&#243; VIH concomitantemente&#44; de los cuales el 20&#37; ten&#237;a adem&#225;s historia previa de s&#237;filis&#46; Esto se&#241;ala que el antecedente de s&#237;filis podr&#237;a predecir una seroconversi&#243;n al VIH&#44; con una incidencia de entre el 5 y el 20&#37;&#44; respectivamente&#44; a los 5 o 10 a&#241;os tras el diagn&#243;stico de la misma<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a>&#46; Por otra parte&#44; aproximadamente la tercera parte de la cohorte hab&#237;a sido diagnosticada previamente de s&#237;filis por lo menos en alguna ocasi&#243;n&#46; Adem&#225;s&#44; los pacientes con VIH positivo presentaban&#44; con una frecuencia 5<span class="elsevierStyleHsp" style=""></span>veces mayor&#44; el antecedente de s&#237;filis en comparaci&#243;n con los pacientes con VIH negativo&#59; datos similares a los publicados en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;18</span></a>&#46; En conjunto&#44; esto indica que la infecci&#243;n por s&#237;filis se transmite en gran medida a trav&#233;s de estrechas redes sexuales y sociales de HSH<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;19</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Los pacientes con VIH positivo presentaron t&#237;tulos superiores de RPR en comparaci&#243;n con los pacientes con VIH negativo&#44; con una disminuci&#243;n de 2 diluciones m&#225;s lenta a los 3 meses&#46; Sin embargo&#44; la respuesta serol&#243;gica tras el tratamiento no mostr&#243; ninguna diferencia entre ambos grupos&#44; tanto a los 6 como a los 12 meses&#46; Estudios anteriores han sugerido la existencia de fracasos terap&#233;uticos con mayor frecuencia entre los pacientes HSH con VIH positivo&#44; probablemente debido a la inmunodeficiencia secundaria al VIH<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a>&#46; Contrariamente&#44; estudios m&#225;s recientes&#44; como el nuestro&#44; demostraron que la respuesta serol&#243;gica depender&#225; principalmente del estadio en la que se encuentra la enfermedad&#44; de los t&#237;tulos de la prueba en el momento del diagn&#243;stico y de la edad del paciente m&#225;s que de la coinfecci&#243;n por VIH&#44; de los antecedentes de s&#237;filis o del tratamiento recibido<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#44;23</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">De manera interesante&#44; nuestro estudio aporta una mayor comprensi&#243;n acerca de las manifestaciones cl&#237;nicas&#44; as&#237; como de la evoluci&#243;n serol&#243;gica de los t&#237;tulos en las pruebas reag&#237;nicas en los pacientes con el antecedente de s&#237;filis&#46; Se observ&#243; que los pacientes con antecedentes de s&#237;filis presentaban significativamente menores tasas de s&#237;filis primaria &#40;28&#37;&#41; en comparaci&#243;n con los pacientes sin antecedentes &#40;40&#37;&#41;&#46; Brewer et al&#46; sugirieron que este hecho se podr&#237;a deber a las diferencias en cuanto a las pr&#225;cticas sexuales&#44; ya que en los pacientes HSH el chancro sifil&#237;tico&#44; por su localizaci&#243;n&#44; en la regi&#243;n anal y oral&#44; podr&#237;a pasar desapercibido<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a>&#46; Este supuesto no explicar&#237;a nuestros resultados&#44; ya que nuestro estudio se realiz&#243; en pacientes HSH&#46; De manera similar&#44; Courjon et al&#46; describieron que&#44; durante la reinfecci&#243;n&#44; las manifestaciones cut&#225;neas sol&#237;an ser m&#225;s tenues<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a>&#46; Esto explicar&#237;a el hecho de que el chancro sifil&#237;tico fuese menos sintom&#225;tico en nuestros pacientes y que pasase desapercibido durante la reinfecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a>&#44; quiz&#225;s debido a factores inmunol&#243;gicos del hu&#233;sped<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a>&#46; Nuestros hallazgos concuerdan con los resultados del estudio experimental realizado por Magnuson et al&#46; en voluntarios<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a>&#44; donde se demostr&#243; que los pacientes tratados previamente por una s&#237;filis desarrollaban con menor frecuencia un chancro sifil&#237;tico cuando se volv&#237;an a inocular con <span class="elsevierStyleItalic">T&#46; pallidum</span>&#46; Por otro lado&#44; se observ&#243; que los pacientes con antecedentes de s&#237;filis presentaban una respuesta serol&#243;gica retardada&#44; datos que se correlacionan con el estudio de Romanowski et al&#46;&#44; que demostr&#243; que los individuos que hab&#237;an tenido una &#250;nica infecci&#243;n presentaban con mayor frecuencia la negativizaci&#243;n del RPR que aquellos con una reinfecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a>&#46; Citando a Magnuson et al&#46;&#58; &#171;Los pacientes que han tenido s&#237;filis en alguna ocasi&#243;n no volver&#237;an a ser inmunol&#243;gicamente iguales&#187;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Nuestro estudio presenta algunas limitaciones&#46; En primer lugar&#44; los resultados fueron obtenidos retrospectivamente a partir de las historias cl&#237;nicas&#44; por lo que algunas variables no se pudieron analizar ya que estaban recogidas de manera imprecisa e incompleta&#46; En segundo lugar&#44; los datos se recolectaron a partir de un &#250;nico centro localizado en Barcelona&#59; sin embargo&#44; el hecho de que durante el estudio no haya habido ning&#250;n cambio en cuanto a la accesibilidad a este centro&#44; as&#237; como que este se mantuviera como centro de referencia de ITS en Barcelona&#44; sugiere que&#44; probablemente&#44; el incremento observado en el n&#250;mero de pacientes diagnosticados de s&#237;filis en este centro sea un reflejo real del aumento en la incidencia de la s&#237;filis en nuestro medio&#46; En tercer lugar&#44; las t&#233;cnicas diagn&#243;sticas&#44; as&#237; como de cribado&#44; sufrieron cambios durante el periodo del estudio&#44; lo que limit&#243; la detecci&#243;n de algunas infecciones concomitantes&#46; Finalmente&#44; los datos del seguimiento posterior al diagn&#243;stico de s&#237;filis se limitaron &#250;nicamente a aquellos pacientes que siguieron las revisiones en nuestro centro&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusiones</span><p id="par0090" class="elsevierStylePara elsevierViewall">Desde el a&#241;o 2003 en Barcelona&#44; y durante m&#225;s de una d&#233;cada&#44; no se ha podido controlar la epidemia de la s&#237;filis&#46; Como en otras partes de Europa occidental y Am&#233;rica del Norte&#44; esta ha afectado de forma desproporcionada a HSH&#59; as&#237; mismo se ha relacionado con la coinfecci&#243;n por el VIH&#46; La s&#237;filis se ha convertido en un problema de salud p&#250;blica importante y complejo&#44; tanto en Barcelona como en otras capitales mundiales&#46; M&#225;s all&#225; de la prevenci&#243;n primaria&#44; debido a un retorno a las pr&#225;cticas sexuales de riesgo&#44; especialmente el sexo anal sin preservativo&#44; los enfoques para el control de la s&#237;filis siguen siendo los propuestos hace casi 100 a&#241;os&#58; cribados generalizados&#44; educaci&#243;n y participaci&#243;n profesional y p&#250;blica&#44; tratamiento precoz e investigaci&#243;n continua para mejorar estos esfuerzos<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a>&#46; Nuestro estudio confirm&#243; que la evoluci&#243;n tanto cl&#237;nica como serol&#243;gica de la s&#237;filis no se ve afectada por la infecci&#243;n del VIH&#46; Por el contrario&#44; la forma de presentaci&#243;n de la s&#237;filis s&#237; se ve influida por la coinfecci&#243;n por el VIH&#44; as&#237; como por el antecedente de s&#237;filis&#46; Sin embargo&#44; no se evidenciaron diferencias en cuanto a la respuesta serol&#243;gica un a&#241;o despu&#233;s de haber recibido el tratamiento&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financiaci&#243;n</span><p id="par0115" class="elsevierStylePara elsevierViewall">Este estudio no ha recibido ninguna beca espec&#237;fica de ninguna agencia de financiaci&#243;n&#44; sector comercial o sin fines de lucro&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicto de intereses</span><p id="par0095" class="elsevierStylePara elsevierViewall">Todos los autores&#58; ning&#250;n conflicto a reportar&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Desde el a&#241;o 2000 se ha descrito un aumento progresivo de los casos de s&#237;filis en diferentes ciudades europeas&#44; sobre todo en hombres que tienen sexo con hombres &#40;HSH&#41;&#46; Las manifestaciones cl&#237;nicas de la s&#237;filis pueden estar influidas por la coinfecci&#243;n del VIH o por el antecedente de s&#237;filis&#46; El objetivo del presente estudio es describir las caracter&#237;sticas epidemiol&#243;gicas y cl&#237;nicas de los casos de s&#237;filis precoz diagnosticados en Barcelona&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de casos de s&#237;filis precoz diagnosticados en Barcelona &#40;2003-2013&#41;&#46; Se revisaron las historias cl&#237;nicas y los datos epidemiol&#243;gicos y cl&#237;nicos fueron recogidos de forma estructurada&#46; Las variables se compararon seg&#250;n el estatus serol&#243;gico del VIH y el antecedente de s&#237;filis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se diagnosticaron 1&#46;702 casos de s&#237;filis precoz &#40;37&#37; primaria&#44; 48&#37; secundaria y 14&#37; latente precoz&#41;&#44; 93&#37; de ellos en HSH&#46; Entre ellos&#44; el 40&#37; presentaba una coinfecci&#243;n por VIH&#46; Los casos de s&#237;filis en pacientes VIH positivos estaban asociados con un episodio previo de s&#237;filis &#40;aOR&#44; 5&#44;2 &#91;IC del 95&#37;&#44; 3&#44;32-8&#44;24&#93;&#41; y con haber tenido sexo anal desprotegido &#40;aOR&#44; 1&#44;75 &#91;IC del 95&#37;&#44; 1&#44;17-2&#44;63&#93;&#41;&#46; Los casos con antecedentes de s&#237;filis se presentaron con menor frecuencia como s&#237;filis primaria &#40;27&#44;5&#37; vs&#46; 40&#37;&#41; &#40;aOR&#44; 0&#44;58 &#91;IC del 95&#37;&#44; 0&#44;44-0&#44;77&#93;&#41;&#46; Un a&#241;o despu&#233;s del tratamiento&#44; la evoluci&#243;n cl&#237;nica y serol&#243;gica fue similar en los pacientes VIH positivo y negativo&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La epidemia de s&#237;filis en Barcelona afecta desproporcionalmente a HSH y est&#225; estrechamente relacionada con el VIH&#46; La forma de presentaci&#243;n de la s&#237;filis est&#225; influida por el antecedente de s&#237;filis y por el VIH&#44; sin diferencias significativas en cuanto a la evoluci&#243;n un a&#241;o despu&#233;s del tratamiento&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Since 2000&#44; substantial increases in syphilis have been reported in metropolitan areas of Western countries&#44; with increases noted among men who have sex with men &#40;MSM&#41;&#46; Clinical manifestations of syphilis might be influenced by concomitant VIH infection and previous episodes of syphilis&#46; The objectives of this study were to describe the epidemiological and clinical characteristics of the cases of syphilis diagnosed in Barcelona&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of cases with early syphilis diagnosed in the referral STI Unit of Barcelona from January 2003 to December 2013&#46; Revision of medical records with structured collection of epidemiological and clinical data&#46; Univariate and multivariate statistical analyses comparing the characteristics of MSM cases with and without VIH infection and with and without previous syphilis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 1702 cases of syphilis &#40;37&#37; primary&#44; 48&#37; secondary and 14&#37; early latent&#41; were diagnosed&#44; 93&#37; of them in MSM&#46; Among MSM 40&#37; were coinfected with VIH&#44; VIH-positive cases were associated with a previous syphilis &#40;aOR&#44; 5&#46;2 &#91;95&#37; CI&#44; 3&#46;32-8&#46;24&#93;&#41; and with unprotected anal intercourse &#40;aOR&#44; 1&#46;75 &#91;95&#37;CI&#44; 1&#46;17-2&#46;63&#93;&#41;&#46; Cases with a history of syphilis presented less often with primary syphilis compared to those without it &#40;27&#46;5&#37; vs&#46; 40&#37;&#41; &#40;aOR&#44; 0&#46;58 &#91;95&#37; CI&#44; 0&#46;44-0&#46;77&#93;&#41;&#46; One year after treatment&#44; the clinical and serological evolution were similar between VIH-positive and VIH-negative cases&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The epidemic of syphilis in Barcelona disproportionately affects MSM and is closelly linked to VIH infection&#46; The presentation of syphilis is influenced by VIH infection and by previous history of syphilis&#44; without significant differences in their evolution after one year of treatment&#46;</p></span>"
        "secciones" => array:4 [
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ITS previa y s&#237;filis &#40;porcentajes&#41; y la tendencia lineal del n&#250;mero de parejas sexuales &#40;n&#250;mero mediana por mes&#41; por a&#241;o entre los casos de s&#237;filis temprana en la Unidad de ITS de Vall d&#8217;Hebron-Drassanes&#44; Barcelona&#44; 2003-2013&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">VIH positivoN &#61; 600 &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ITS previa</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;s&#237;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Parejas sexuales m&#250;ltiples &#40;s&#237;&#41;</span><span class="elsevierStyleItalic">&#40;N &#61; 1&#46;163&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">N&#250;mero de parejas sexuales por mes&#44; mediana &#40;RIQ&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Relaciones sexuales anales desprotegidas &#40;s&#237;&#41;</span><span class="elsevierStyleItalic">&#40;N &#61; 626&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;83 &#40;0&#44;61-1&#44;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Motivo de la consulta</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">451 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">628 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros s&#237;ntomas de ITS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;5&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;1&#44;67-5&#44;87&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cribado de ITS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">n<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Parejas sexuales m&#250;ltiples</span><span class="elsevierStyleItalic">&#40;s&#237;&#41;</span><span class="elsevierStyleItalic">&#40;N &#61; 1&#46;220&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Relaciones sexuales anales desprotegidas</span><span class="elsevierStyleItalic">&#40;N &#61; 660&#41; &#40;s&#237;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Latente precoz&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">2 &#40;1&#44;3-3&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Motivo de consulta</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;992&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;ntomas de s&#237;filis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">790 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros s&#237;ntomas de ITS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;98 &#40;0&#44;51-1&#44;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;38 &#40;0&#44;18-0&#44;76&#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="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cribado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;74 &#40;0&#44;48-1&#44;14&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Estudio de contactos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;94 &#40;0&#44;64-1&#44;37&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;78 &#40;0&#44;48-1&#44;23&#41;&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Hallazgos epidemiol&#243;gicos y cl&#237;nicos entre HSH con s&#237;filis temprana en Barcelona con antecedente de s&#237;filis&#44; 2003-2013</p>"
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              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "European Centre for Disease Prevention and Control&#46; Sexually transmitted infections in Europe 2013&#46; Stockholm&#58; ECDC&#59; 2015 &#91;consultado 27 Feb 2017&#93;&#46; Disponible en&#58; http&#58;&#47;&#47;ecdc&#46;europa&#46;eu&#47;en&#47;publications&#47;Publications&#47;sexual-transmitted-infections-europe-surveillance-report-2013&#46;pdf"
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              "etiqueta" => "2"
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                0 => array:1 [
                  "referenciaCompleta" => "Centre d&#8217;Estudi Epidemiol&#242;gics sobre Infeccions de Transmissi&#243; Sexual i Sida de Catalunya &#40;CEEISCAT&#41;&#46; CEEISCAT Epidemiological Report 2015&#46; Integrated Surveillance System For STI and HIV in Catalonia &#40;SIVES&#41; Technical document N&#46;&#176; 22&#46; Barcelona&#58; CEEISCAT&#59; 2015 consultado 27 Feb 2017&#93;&#46; Disponible en&#58; http&#58;&#47;&#47;www&#46;ceeiscat&#46;cat&#47;documents&#47;sives2015&#95;ENG&#46;pdf"
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              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reemergence of infectious syphilis among homosexual men and HIV coinfection in Barcelona&#44; 2002-2003"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Vall-Mayans"
                            1 => "M&#46; Casals"
                            2 => "A&#46; Vives"
                            3 => "E&#46; Loureiro"
                            4 => "P&#46; Armengol"
                            5 => "B&#46; Sanz"
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                    0 => array:2 [
                      "doi" => "10.1157/13083877"
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                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2006"
                        "volumen" => "126"
                        "paginaInicial" => "94"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Simultaneous PCR detection of Haemophilus ducreyi Treponema pallidum&#44; and herpes simplex virus types 1 and 2 from genital ulcers"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "K&#46;A&#46; Orle"
                            1 => "C&#46;A&#46; Gates"
                            2 => "D&#46;H&#46; Martin"
                            3 => "B&#46;A&#46; Body"
                            4 => "J&#46;B&#46; Weiss"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Microbiol"
                        "fecha" => "1996"
                        "volumen" => "34"
                        "paginaInicial" => "49"
                        "paginaFinal" => "54"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8748271"
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                    0 => array:2 [
                      "doi" => "10.1111/jdv.12734"
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                        "tituloSerie" => "J Eur Acad Dermatology Venereol"
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                0 => array:2 [
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                        "tituloSerie" => "Sex Transm Infect"
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                        "volumen" => "78"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "i14"
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                      "titulo" => "Syphilis trends among men who have sex with men in the United States and Western Europe&#58; A systematic review of trend studies published between 2004 and 2015"
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                          "etal" => false
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                            2 => "R&#46;N&#46; Fanfair"
                            3 => "K&#46;T&#46; Bernstein"
                            4 => "G&#46; Paz-Bailey"
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ORIGINAL
Las características epidemiológicas y clínicas de la epidemia de sífilis en Barcelona
The Epidemiological and Clinical Characteristics of the Epidemic of Syphilis in Barcelona
M. Arandoa,b,
Corresponding author
marando@vhebron.net

Autor para correspondencia.
, E. Caballeroc, A. Currand, P. Armengola, M.J. Barberáa, M. Vall-Mayansa
a Unidad de ITS de Vall d’Hebron-Drassanes, Departamento de Enfermedades Infecciosas, Hospital Vall d’Hebron, Barcelona, España
b Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
c Departamento de Microbiología, Hospital Vall d’Hebron, Barcelona, España
d Departamento de Enfermedades Infecciosas, Hospital Vall d’Hebron, Barcelona, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Desde el a&#241;o 2000&#44; se ha descrito un aumento progresivo de los casos de s&#237;filis en diferentes ciudades europeas&#44; sobre todo en hombres que tienen sexo con hombres &#40;HSH&#41;&#46; En Europa se han reportado 22&#46;237 casos de s&#237;filis precoz en 2013&#44; con una tasa de 5&#44;5 por 100&#46;000 habitantes&#59; el 62&#37; de los casos fueron notificados por 4 pa&#237;ses&#44; entre los cuales est&#225; Espa&#241;a<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a>&#46; Catalu&#241;a &#40;Espa&#241;a&#41;&#44; con 7 millones de habitantes&#44; report&#243; una tasa de s&#237;filis precoz del 12&#44;4 por 100&#46;000 habitantes en 2014&#44; lo que represent&#243; un incremento del 231&#37; desde el a&#241;o 2005<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a>&#46; La reemergencia de la s&#237;filis en Catalu&#241;a se detect&#243; en Barcelona en el a&#241;o 2002&#44; principalmente en HSH&#44; los cuales presentaban una tasa de coinfecci&#243;n por el VIH del 30&#37;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El objetivo del presente estudio fue describir de manera retrospectiva las caracter&#237;sticas epidemiol&#243;gicas y cl&#237;nicas de los casos de s&#237;filis precoz diagnosticados en la unidad de ITS del Vall d&#8217;Hebron-Drassanes &#40;UITSVD&#41;&#44; en Barcelona&#44; entre los a&#241;os 2003-2013&#44; particularmente en HSH&#46; La atenci&#243;n brindada por la UITSVD durante este tiempo sum&#243; m&#225;s de 25&#46;000 consultas m&#233;dicas por a&#241;o &#40;60&#37; de los cuales fueron HSH&#41; y adem&#225;s report&#243; aproximadamente el 75&#37; de todos los casos de s&#237;filis diagnosticados en Barcelona durante ese periodo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participantes y recolecci&#243;n de datos</span><p id="par0015" class="elsevierStylePara elsevierViewall">Se revisaron todos los casos de s&#237;filis notificados en la UITSVD desde enero del 2003 hasta diciembre del 2013&#46; En total&#44; fueron revisadas 2&#46;209 historias cl&#237;nicas&#44; de las cuales se excluyeron 242&#59; 52 debido a que estaban fuera del periodo del estudio y 190 por ausencia de datos o porque el diagn&#243;stico final de s&#237;filis no estaba claro&#46; En la UITSVD&#44; durante el estudio&#44; se diagnosticaron 2&#46;241 casos &#40;donde un caso se refiere a un episodio&#44; pudiendo el mismo paciente presentar m&#225;s de un episodio&#41;&#44; de los cuales 1&#46;702 se diagnosticaron como s&#237;filis precoz en un total de 1&#46;484 pacientes&#46; Los datos epidemiol&#243;gicos&#44; cl&#237;nicos y microbiol&#243;gicos se recopilaron de forma estandarizada en s&#237;filis primaria&#44; secundaria y latente precoz&#46; Asimismo&#44; se recogieron datos acerca de&#58; tener pareja estable&#47;espor&#225;dica&#44; el n&#250;mero de contactos sexuales y el uso de preservativo durante las relaciones sexuales anales&#46; Las variables que estaban ausentes en m&#225;s del 50&#37; de los casos debido a variaciones en la recolecci&#243;n de datos &#40;p&#46; ej&#46;&#44; el uso de drogas&#41; no fueron analizadas&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedimientos</span><p id="par0020" class="elsevierStylePara elsevierViewall">El diagn&#243;stico de s&#237;filis se realiz&#243; mediante una valoraci&#243;n cl&#237;nica y serol&#243;gica&#44; y con t&#233;cnicas de detecci&#243;n directa si en el examen cl&#237;nico se observaban &#250;lceras&#46; Las pruebas serol&#243;gicas que se usaron fueron el examen de la reagina plasm&#225;tica r&#225;pida &#40;RPR&#41; &#40;Biokit&#174;Izasa&#44; Espa&#241;a&#41;&#44; la prueba de hemaglutinaci&#243;n para el <span class="elsevierStyleItalic">Treponema pallidum &#40;T&#46; pallidum&#41;</span> &#40;TPHA&#41; &#40;Biokit&#174;Izasa&#44; Espa&#241;a&#41; y el inmunoan&#225;lisis enzim&#225;tico trepon&#233;mico &#40;EIA enzygnost syphilis&#44; Siemens Healthcare Diagnostics&#44; Alemania&#41;&#46; El diagn&#243;stico directo se hizo mediante microscopia de campo oscuro o PCR para <span class="elsevierStyleItalic">T&#46; pallidum</span><a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a>&#46; Los casos de s&#237;filis se estadificaron y se clasificaron seg&#250;n las gu&#237;as europeas existentes<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>&#46; La s&#237;filis latente precoz se defini&#243; como la presencia de una prueba serol&#243;gica positiva para s&#237;filis en un paciente con serolog&#237;a negativa en los 12 meses previos&#44; o un incremento de al menos 4 veces &#40;en m&#225;s de 2 diluciones&#41; de los t&#237;tulos de una prueba no trepon&#233;mica dentro de los &#250;ltimos 12 meses&#46; La reinfecci&#243;n se defini&#243; como la presencia de una nueva manifestaci&#243;n cl&#237;nica o el aumento en 2 diluciones de las pruebas no trepon&#233;micas&#46; La curaci&#243;n serol&#243;gica fue definida como la disminuci&#243;n en 4 veces &#40;al menos en 2 diluciones&#41; de la RPR&#46; Las pruebas diagn&#243;sticas utilizadas para la determinaci&#243;n de las infecciones de transmisi&#243;n sexual &#40;ITS&#41; sufrieron algunas modificaciones durante la realizaci&#243;n del estudio&#46; Dentro de estas cabe se&#241;alar la introducci&#243;n de la PCR en tiempo real&#44; realizada desde el 2006 para la detecci&#243;n de la <span class="elsevierStyleItalic">Chlamydia trachomatis</span> &#40;CT&#41;&#44; desde el 2012 para la <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> &#40;NG&#41; y desde el 2013 para el <span class="elsevierStyleItalic">T&#46; pallidum</span>&#46; Una infecci&#243;n concomitante se defini&#243; como el diagn&#243;stico simult&#225;neo de la infecci&#243;n por s&#237;filis con la del VIH&#44; NG o CT &#40;sin tener en cuenta si estas &#250;ltimas se hab&#237;a presentado en una o m&#225;s localizaciones anat&#243;micas&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis estad&#237;stico</span><p id="par0025" class="elsevierStylePara elsevierViewall">Inicialmente&#44; se realiz&#243; un estudio descriptivo de todos los casos y posteriormente se analiz&#243; &#250;nicamente los casos de los HSH &#40;incluyendo a los hombres bisexuales&#41;&#46; Los hallazgos epidemiol&#243;gicos y cl&#237;nicos de estos pacientes fueron comparados seg&#250;n el estatus serol&#243;gico del VIH y el antecedente de s&#237;filis&#44; para lo cual se realiz&#243; un an&#225;lisis de regresi&#243;n log&#237;stica univariado y multivariado&#46; Todos los an&#225;lisis se realizaron en la versi&#243;n R 3&#46;3&#46;1 &#40;The R Foundation for Statistical Computing&#44; Viena&#44; Austria&#41;&#46; Las variables cualitativas se expresaron en porcentajes y las comparaciones se hicieron usando la prueba de la chi al cuadrado o la prueba exacta de Fisher&#44; seg&#250;n fuera lo m&#225;s conveniente&#46; La fuerza de la asociaci&#243;n se midi&#243; utilizando la OR con intervalos de confianza del 95&#37; &#40;IC del 95&#37;&#41;&#46; Las variables cuantitativas se expresaron como medias &#177; desviaci&#243;n est&#225;ndar o medianas y rango intercuart&#237;lico&#46; Los an&#225;lisis comparativos se realizaron mediante el t-test o la prueba U de Mann-Whitney&#44; o ANOVA o la prueba de Kruskal-Wallis con un IC del 95&#37;&#44; si es que se contaba con m&#225;s de 2<span class="elsevierStyleHsp" style=""></span>categor&#237;as&#46; Las variables que resultaron significativas en el an&#225;lisis univariado &#40;p &#60; 0&#44;01&#41; o que se consideraron cl&#237;nicamente relevantes se analizaron mediante un modelo de regresi&#243;n final utilizando los criterios de informaci&#243;n de Akaike&#46; El trabajo recibi&#243; la aprobaci&#243;n del comit&#233; de &#233;tica del Hospital de Vall d&#8217;Hebron&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0030" class="elsevierStylePara elsevierViewall">El n&#250;mero de casos de infecci&#243;n por la s&#237;filis present&#243; un incremento de 68 casos en el 2003 a 277 casos en el 2013&#44; llegando a un total de 1&#46;702 casos durante todo el estudio&#58; el 97&#37; &#40;1&#46;650&#41; de los casos fueron diagnosticados en varones&#44; el 2&#37; &#40;33&#41; en mujeres y el 1&#37; &#40;14&#41; en transexuales&#46; De los 1&#46;702 casos&#44; 1&#46;425 &#40;84&#37;&#41; eran HSH&#44; 155 &#40;9&#37;&#41; eran hombres bisexuales&#44; 112 &#40;6&#44;9&#37;&#41; eran hombres y mujeres heterosexuales&#44; y 10 &#40;0&#44;6&#37;&#41; desconocidos &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La edad promedio fue de 35&#44;3 &#177; 8&#44;9 a&#241;os&#44; sin que se evidenciara un cambio significativo durante el periodo del estudio&#46; En general&#44; el 57&#37; &#40;971&#41; de los casos eran nativos y el 43&#37; &#40;731&#41; extranjeros&#44; observ&#225;ndose un incremento en estos &#250;ltimos&#44; pasando del 32&#37; &#40;22 de 68&#41; en 2003 al 43&#44;5&#37; &#40;120 de 277&#41; en 2013&#59; 1&#46;239 &#40;73&#37;&#41; casos se diagnosticaron por presentar s&#237;ntomas cl&#237;nicos sugestivos de s&#237;filis&#44; 250 &#40;15&#37;&#41; se diagnosticaron incidentalmente a trav&#233;s de pruebas de cribado para ITS&#44; 158 &#40;9&#37;&#41; fueron diagnosticados por estudio de contactos y 54 &#40;3&#37;&#41; gracias a un cribado oportunista en casos sintom&#225;ticos de otras ITS&#46; De todos los casos&#44; 637 &#40;38&#37;&#41; fueron s&#237;filis primarias&#44; 829 &#40;48&#37;&#41; secundarias y 236 &#40;14&#37;&#41; se clasificaron como s&#237;filis latente precoz&#46; Durante los a&#241;os del estudio se evidenciaron cambios en el motivo de consulta&#58; al inicio&#44; la mayor&#237;a de los casos se asociaban a s&#237;ntomas y solo en un 9&#37; &#40;6 de 68&#41; de los casos el diagn&#243;stico se realiz&#243; por cribado&#59; sin embargo&#44; este valor se increment&#243; hasta un 20&#37; &#40;42&#47;215&#41; en 2012&#46; De manera similar&#44; el diagn&#243;stico a trav&#233;s del estudio de contactos sufri&#243; un incremento&#44; pasando del 4&#37; &#40;3&#47;68&#41; en 2003 al 14&#37; &#40;39&#47;277&#41; en 2013&#46; Paralelamente&#44; la proporci&#243;n de pacientes con diagn&#243;stico de s&#237;filis latente precoz tambi&#233;n se increment&#243; desde un 7&#37; &#40;5&#47;68&#41; en 2003 hasta un 19&#37; &#40;53&#47;277&#41; en 2013&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Globalmente&#44; el 30&#37; &#40;n &#61; 517&#41; de los casos eran VIH conocidos en el momento del diagn&#243;stico de la s&#237;filis&#44; sin que hubiese cambios significativos en la prevalencia de la coinfecci&#243;n durante el estudio&#46; En cuanto a los antecedentes de s&#237;filis&#44; el 29&#37; &#40;n &#61; 487&#41; de los casos presentaron al menos un episodio previo de s&#237;filis&#44; evidenci&#225;ndose un incremento progresivo desde el 16&#37; &#40;11&#47;68&#41; en 2003 hasta un 34&#37; &#40;93&#47;277&#41; en 2013&#46; Un incremento similar se evidenci&#243; en otras ITS &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; El 92&#37; de los casos reportaron haber tenido m&#250;ltiples parejas sexuales&#59; presentando una mediana de 1 &#40;0&#44;33-2&#44;00&#41; contacto por mes&#44; observ&#225;ndose un incremento en el n&#250;mero total de parejas durante el periodo de seguimiento del estudio &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; En 615 casos &#40;36&#37;&#41; se contaba con los resultados del cribado de otras ITS&#44; realizado en el momento del diagn&#243;stico de s&#237;filis&#46; De estos casos&#44; 205 &#40;33&#37;&#41; presentaron una infecci&#243;n concomitante&#44; con una prevalencia del 14&#44;5&#37; &#40;89&#47;615&#41;&#44; el 8&#37; &#40;49&#47;615&#41;&#44; el 7&#44;5&#37; &#40;47&#47;615&#41; y el 3&#37; &#40;20&#47;615&#41; para VIH&#44; NG&#44; CT y <span class="elsevierStyleItalic">Lymphogranuloma venereum</span> &#40;LGV&#41;&#44; respectivamente&#46; As&#237; mismo&#44; los cambios en la pr&#225;ctica cl&#237;nica durante el periodo del estudio influyeron de alguna forma sobre estos hallazgos&#44; ya que en el a&#241;o 2003 &#250;nicamente se realizaron pruebas de cribado para otras ITS &#40;exclusivamente para VIH&#41; en el 11&#37; &#40;8&#47;68&#41; de los casos&#44; mientras que en el a&#241;o 2013 el 65&#37; &#40;182&#47;277&#41; de los casos con s&#237;filis fueron cribados para otras ITS&#46; El 20&#37; de los 87 pacientes HSH con diagn&#243;stico concomitante de VIH presentaban el antecedente de s&#237;filis&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A continuaci&#243;n&#44; nos enfocaremos en el an&#225;lisis realizado en los HSH&#44; en donde se incluyeron tambi&#233;n a hombres bisexuales &#40;n &#61; 1&#46;580&#41;&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Comparaci&#243;n entre los pacientes con el virus de la inmunodeficiencia humana positivo y negativo en hombres que tienen sexo con hombres</span><p id="par0045" class="elsevierStylePara elsevierViewall">La informaci&#243;n disponible de los 1&#46;497 casos de s&#237;filis en los HSH permiti&#243; observar que 600 &#40;40&#37;&#41; estaban coinfectados por el VIH&#59; de los cuales&#44; 513 eran VIH positivos conocidos&#44; mientras que 87 fueron diagnosticados juntamente con el diagn&#243;stico de la s&#237;filis&#46; Los datos comparativos entre los pacientes con VIH positivo y con VIH negativo se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; Los casos con VIH positivo ten&#237;an predominantemente mayor edad&#44; en mayor proporci&#243;n eran extranjeros y ten&#237;an antecedentes de ITS y de s&#237;filis&#46; As&#237; mismo&#44; estos pacientes se caracterizaban por presentar un mayor n&#250;mero de contactos sexuales al mes y adem&#225;s ten&#237;an m&#225;s frecuentemente relaciones sexuales anales desprotegidas&#46; En cuanto al estadio de la s&#237;filis&#44; ambos grupos tuvieron con mayor frecuencia una s&#237;filis secundaria&#46; As&#237; mismo&#44; los pacientes con VIH positivo fueron diagnosticados en mayor medida por presentar s&#237;ntomas&#59; sin embargo&#44; no se observaron diferencias respecto a la duraci&#243;n de los mismos &#40;mediana de 8 d&#237;as&#41;&#46; La infecci&#243;n concomitante por CT y LGV fueron m&#225;s frecuentes en los casos con VIH positivo &#40;3 &#91;11&#44;5&#37;&#93; y 14 &#91;4&#37;&#93; de los 199 casos a quienes se les realiz&#243; el cribado&#41;&#44; en comparaci&#243;n con los casos de pacientes con VIH negativo &#40;16 &#91;7&#37;&#93; y 6 &#91;1&#44;5&#37;&#93;&#41; de los 356 casos&#44; respectivamente&#41;&#46; De manera notable&#44; los casos con VIH positivo se asociaron con el antecedente de s&#237;filis &#40;OR ajustada&#44; 5&#44;2 &#91;IC del 95&#37;&#44; 3&#44;32-8&#44;24&#93;&#41; y otras ITS &#40;OR ajustada&#44; 1&#44;62 &#91;IC del 95&#37;&#44; 1&#44;09-2&#44;43&#93;&#41; y con relaciones sexuales anales desprotegidas &#40;OR ajustada&#44; 1&#44;75 &#91;IC del 95&#37;&#44; 1&#44;17-2&#44;63&#93;&#41; en el an&#225;lisis multivariado&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">En el momento del diagn&#243;stico de la s&#237;filis los t&#237;tulos de RPR fueron superiores en los pacientes con VIH positivo&#58; mediana de 1&#47;32 &#40;<span class="elsevierStyleItalic">1&#47;12</span>-1&#47;128&#41; en comparaci&#243;n con la de 1&#47;16 &#40;1&#47;4-1&#47;64&#41; &#40;p &#60; 0&#44;001&#41; en pacientes con VIH negativo&#46; El 40&#37; &#40;612&#47;1497&#41; de todos los casos se perdieron para el seguimiento del control serol&#243;gico sin que se encontraran diferencias significativas seg&#250;n el seroestatus de VIH&#46; La curaci&#243;n serol&#243;gica a los 3 meses se alcanz&#243; antes en los pacientes con VIH negativo&#44; pero fue similar en ambos grupos a los 6 y 12 meses &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Los casos con VIH positivo recibieron con mayor frecuencia las 3 dosis de penicilina benzatina semanal &#40;siguiendo las recomendaciones de expertos publicadas en algunas gu&#237;as cl&#237;nicas anteriores&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Comparaci&#243;n entre los pacientes hombres que tienen sexo con hombres con y sin s&#237;filis previa</span><p id="par0055" class="elsevierStylePara elsevierViewall">La informaci&#243;n acerca de los antecedentes de s&#237;filis previa de los 1&#46;568 casos de HSH demostraron que 475 &#40;30&#37;&#41; de ellos hab&#237;an sufrido por lo menos una vez en su vida un episodio anterior&#46; Algunos de los resultados comparativos entre los casos con y sin antecedentes de s&#237;filis se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; Los pacientes con antecedentes de s&#237;filis ten&#237;an significativamente mayor edad&#44; mayor frecuencia de antecedentes de ITS&#44; estaban en mayor medida coinfectados por VIH y presentaban con menor frecuencia una s&#237;filis primaria &#40;131 &#91;28&#37;&#93; de 475 vs&#46; 435 &#91;40&#37;&#93; de 1&#46;093&#41;&#44; adem&#225;s de presentar una menor duraci&#243;n media de los s&#237;ntomas &#40;mediana 7 vs&#46; 10 d&#237;as&#44; p &#60; 0&#44;001&#41;&#46; En los pacientes con antecedentes de s&#237;filis se objetiv&#243; as&#237; mismo un mayor n&#250;mero de contactos sexuales al mes&#46; La informaci&#243;n disponible de los 582 casos mostr&#243; que el 45&#37; &#40;173&#41; de ellos ten&#237;an una infecci&#243;n concomitante&#44; sin que se pudiera demostrar ninguna diferencia significativa entre ambos grupos &#40;incluyendo el VIH&#41;&#46; De manera remarcable&#44; en el an&#225;lisis multivariado&#44; los casos con antecedentes de s&#237;filis estaban asociados significativamente con la coinfecci&#243;n por el VIH &#40;OR ajustada&#44; 4&#44;43 &#91;IC del 95&#37;&#44; 3&#44;47-5&#44;68&#93;&#41; y con el antecedente de otras ITS &#40;OR ajustada&#44; 1&#44;41 &#91;IC del 95&#37;&#44; 1&#44;1-1&#44;8&#93;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">En el momento del diagn&#243;stico de la s&#237;filis&#44; los t&#237;tulos de RPR fueron superiores en los casos con historia previa de s&#237;filis&#58; mediana de 1&#47;64 &#40;1&#47;16-1&#47;128&#41; en comparaci&#243;n con 1&#47;16 &#40;1&#47;4-1&#47;64&#41; &#40;p &#60; 0&#44;001&#41; de los casos sin historia previa&#46; Una menor proporci&#243;n de los casos con antecedentes de s&#237;filis &#40;163 &#91;34&#37;&#93; de los 475&#41; que en aquellos sin antecedentes &#40;484 &#91;44&#37;&#93; de 1&#46;093&#41; se perdieron para el seguimiento serol&#243;gico &#40;p &#61; 0&#44;002&#41;&#46; Las tasas de curaci&#243;n serol&#243;gica en los primeros 6 meses se alcanzaron antes en los casos sin antecedentes de s&#237;filis&#59; sin embargo&#44; fueron similares en ambos grupos a los 12 meses tras el tratamiento &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0065" class="elsevierStylePara elsevierViewall">En esta unidad de referencia en ITS de Barcelona se document&#243; un incremento sustancial en el n&#250;mero de personas diagnosticadas de s&#237;filis entre los a&#241;os 2003 y 2013&#44; en continuaci&#243;n a la reemergencia observada en el a&#241;o 2002 en Barcelona<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#46; En la curva epid&#233;mica&#44; la fase espec&#237;fica en la que se encontrar&#237;a ser&#237;a el tipo hiperend&#233;mico&#44; lo que significa ausencia de control<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a>&#46; En nuestro medio&#44; el perfil dominante de la epidemia fue el de HSH&#46; De manera global&#44; en pa&#237;ses de rentas altas los HSH representan una carga desproporcionada de las infecciones por s&#237;filis<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>&#46; Diversas pr&#225;cticas de riesgo han sido relacionadas con ello&#44; por ejemplo&#44; un elevado n&#250;mero de contactos sexuales&#44; el uso de drogas durante las relaciones sexuales&#44; las relaciones sexuales anales desprotegidas&#44; el &#171;serosorting&#187;&#44; el sexo an&#243;nimo y el haber contactado con las parejas sexuales utilizando Internet<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9</span></a>&#59; posiblemente relacionado con la introducci&#243;n progresiva del tratamiento antirretroviral para el VIH<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#46; Este incremento de las pr&#225;cticas sexuales de riesgo<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> queda reflejado en el aumento paralelo de m&#250;ltiples ITS descrito en este grupo de poblaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;13</span></a>&#44; hecho que tambi&#233;n se ha observado en nuestro estudio&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Si nos centramos &#250;nicamente en los HSH&#44; los casos de s&#237;filis primaria y secundaria afectaron al 36&#37; &#40;578&#47;1&#46;588&#41; y al 49&#44;5&#37; &#40;787&#47;1&#46;588&#41;&#44; respectivamente&#44; sin que se encontraran diferencias en el an&#225;lisis multivariado en cuanto al estatus serol&#243;gico de la infecci&#243;n por el VIH&#46; A diferencia del nuestro&#44; otros estudios describieron una mayor proporci&#243;n de s&#237;filis latente precoz entre los pacientes con VIH positivo<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&#44; probablemente en relaci&#243;n con la realizaci&#243;n m&#225;s frecuente de pruebas de cribado en este grupo de pacientes&#46; La infecci&#243;n por s&#237;filis y el VIH est&#225;n muy relacionadas&#59; la s&#237;filis podr&#237;a incrementar el riesgo de transmisi&#243;n del VIH por el aumento de descarga viral en las lesiones&#44; as&#237; como su adquisici&#243;n al proveer una puerta de entrada para el virus<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a>&#46; El 34&#37; &#40;513&#47;1497&#41; de los casos de s&#237;filis fueron diagnosticados en pacientes con VIH positivo conocidos&#59; esta proporci&#243;n fue similar a la descrita en otros estudios realizados en Europa y en Norteam&#233;rica<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;16</span></a>&#46; As&#237; mismo&#44; adem&#225;s del diagn&#243;stico de s&#237;filis&#44; en un 9&#37; &#40;87&#47;984&#41; de los HSH se diagnostic&#243; VIH concomitantemente&#44; de los cuales el 20&#37; ten&#237;a adem&#225;s historia previa de s&#237;filis&#46; Esto se&#241;ala que el antecedente de s&#237;filis podr&#237;a predecir una seroconversi&#243;n al VIH&#44; con una incidencia de entre el 5 y el 20&#37;&#44; respectivamente&#44; a los 5 o 10 a&#241;os tras el diagn&#243;stico de la misma<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a>&#46; Por otra parte&#44; aproximadamente la tercera parte de la cohorte hab&#237;a sido diagnosticada previamente de s&#237;filis por lo menos en alguna ocasi&#243;n&#46; Adem&#225;s&#44; los pacientes con VIH positivo presentaban&#44; con una frecuencia 5<span class="elsevierStyleHsp" style=""></span>veces mayor&#44; el antecedente de s&#237;filis en comparaci&#243;n con los pacientes con VIH negativo&#59; datos similares a los publicados en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;18</span></a>&#46; En conjunto&#44; esto indica que la infecci&#243;n por s&#237;filis se transmite en gran medida a trav&#233;s de estrechas redes sexuales y sociales de HSH<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;19</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Los pacientes con VIH positivo presentaron t&#237;tulos superiores de RPR en comparaci&#243;n con los pacientes con VIH negativo&#44; con una disminuci&#243;n de 2 diluciones m&#225;s lenta a los 3 meses&#46; Sin embargo&#44; la respuesta serol&#243;gica tras el tratamiento no mostr&#243; ninguna diferencia entre ambos grupos&#44; tanto a los 6 como a los 12 meses&#46; Estudios anteriores han sugerido la existencia de fracasos terap&#233;uticos con mayor frecuencia entre los pacientes HSH con VIH positivo&#44; probablemente debido a la inmunodeficiencia secundaria al VIH<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a>&#46; Contrariamente&#44; estudios m&#225;s recientes&#44; como el nuestro&#44; demostraron que la respuesta serol&#243;gica depender&#225; principalmente del estadio en la que se encuentra la enfermedad&#44; de los t&#237;tulos de la prueba en el momento del diagn&#243;stico y de la edad del paciente m&#225;s que de la coinfecci&#243;n por VIH&#44; de los antecedentes de s&#237;filis o del tratamiento recibido<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#44;23</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">De manera interesante&#44; nuestro estudio aporta una mayor comprensi&#243;n acerca de las manifestaciones cl&#237;nicas&#44; as&#237; como de la evoluci&#243;n serol&#243;gica de los t&#237;tulos en las pruebas reag&#237;nicas en los pacientes con el antecedente de s&#237;filis&#46; Se observ&#243; que los pacientes con antecedentes de s&#237;filis presentaban significativamente menores tasas de s&#237;filis primaria &#40;28&#37;&#41; en comparaci&#243;n con los pacientes sin antecedentes &#40;40&#37;&#41;&#46; Brewer et al&#46; sugirieron que este hecho se podr&#237;a deber a las diferencias en cuanto a las pr&#225;cticas sexuales&#44; ya que en los pacientes HSH el chancro sifil&#237;tico&#44; por su localizaci&#243;n&#44; en la regi&#243;n anal y oral&#44; podr&#237;a pasar desapercibido<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a>&#46; Este supuesto no explicar&#237;a nuestros resultados&#44; ya que nuestro estudio se realiz&#243; en pacientes HSH&#46; De manera similar&#44; Courjon et al&#46; describieron que&#44; durante la reinfecci&#243;n&#44; las manifestaciones cut&#225;neas sol&#237;an ser m&#225;s tenues<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a>&#46; Esto explicar&#237;a el hecho de que el chancro sifil&#237;tico fuese menos sintom&#225;tico en nuestros pacientes y que pasase desapercibido durante la reinfecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a>&#44; quiz&#225;s debido a factores inmunol&#243;gicos del hu&#233;sped<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a>&#46; Nuestros hallazgos concuerdan con los resultados del estudio experimental realizado por Magnuson et al&#46; en voluntarios<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a>&#44; donde se demostr&#243; que los pacientes tratados previamente por una s&#237;filis desarrollaban con menor frecuencia un chancro sifil&#237;tico cuando se volv&#237;an a inocular con <span class="elsevierStyleItalic">T&#46; pallidum</span>&#46; Por otro lado&#44; se observ&#243; que los pacientes con antecedentes de s&#237;filis presentaban una respuesta serol&#243;gica retardada&#44; datos que se correlacionan con el estudio de Romanowski et al&#46;&#44; que demostr&#243; que los individuos que hab&#237;an tenido una &#250;nica infecci&#243;n presentaban con mayor frecuencia la negativizaci&#243;n del RPR que aquellos con una reinfecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a>&#46; Citando a Magnuson et al&#46;&#58; &#171;Los pacientes que han tenido s&#237;filis en alguna ocasi&#243;n no volver&#237;an a ser inmunol&#243;gicamente iguales&#187;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Nuestro estudio presenta algunas limitaciones&#46; En primer lugar&#44; los resultados fueron obtenidos retrospectivamente a partir de las historias cl&#237;nicas&#44; por lo que algunas variables no se pudieron analizar ya que estaban recogidas de manera imprecisa e incompleta&#46; En segundo lugar&#44; los datos se recolectaron a partir de un &#250;nico centro localizado en Barcelona&#59; sin embargo&#44; el hecho de que durante el estudio no haya habido ning&#250;n cambio en cuanto a la accesibilidad a este centro&#44; as&#237; como que este se mantuviera como centro de referencia de ITS en Barcelona&#44; sugiere que&#44; probablemente&#44; el incremento observado en el n&#250;mero de pacientes diagnosticados de s&#237;filis en este centro sea un reflejo real del aumento en la incidencia de la s&#237;filis en nuestro medio&#46; En tercer lugar&#44; las t&#233;cnicas diagn&#243;sticas&#44; as&#237; como de cribado&#44; sufrieron cambios durante el periodo del estudio&#44; lo que limit&#243; la detecci&#243;n de algunas infecciones concomitantes&#46; Finalmente&#44; los datos del seguimiento posterior al diagn&#243;stico de s&#237;filis se limitaron &#250;nicamente a aquellos pacientes que siguieron las revisiones en nuestro centro&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusiones</span><p id="par0090" class="elsevierStylePara elsevierViewall">Desde el a&#241;o 2003 en Barcelona&#44; y durante m&#225;s de una d&#233;cada&#44; no se ha podido controlar la epidemia de la s&#237;filis&#46; Como en otras partes de Europa occidental y Am&#233;rica del Norte&#44; esta ha afectado de forma desproporcionada a HSH&#59; as&#237; mismo se ha relacionado con la coinfecci&#243;n por el VIH&#46; La s&#237;filis se ha convertido en un problema de salud p&#250;blica importante y complejo&#44; tanto en Barcelona como en otras capitales mundiales&#46; M&#225;s all&#225; de la prevenci&#243;n primaria&#44; debido a un retorno a las pr&#225;cticas sexuales de riesgo&#44; especialmente el sexo anal sin preservativo&#44; los enfoques para el control de la s&#237;filis siguen siendo los propuestos hace casi 100 a&#241;os&#58; cribados generalizados&#44; educaci&#243;n y participaci&#243;n profesional y p&#250;blica&#44; tratamiento precoz e investigaci&#243;n continua para mejorar estos esfuerzos<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a>&#46; Nuestro estudio confirm&#243; que la evoluci&#243;n tanto cl&#237;nica como serol&#243;gica de la s&#237;filis no se ve afectada por la infecci&#243;n del VIH&#46; Por el contrario&#44; la forma de presentaci&#243;n de la s&#237;filis s&#237; se ve influida por la coinfecci&#243;n por el VIH&#44; as&#237; como por el antecedente de s&#237;filis&#46; Sin embargo&#44; no se evidenciaron diferencias en cuanto a la respuesta serol&#243;gica un a&#241;o despu&#233;s de haber recibido el tratamiento&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financiaci&#243;n</span><p id="par0115" class="elsevierStylePara elsevierViewall">Este estudio no ha recibido ninguna beca espec&#237;fica de ninguna agencia de financiaci&#243;n&#44; sector comercial o sin fines de lucro&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicto de intereses</span><p id="par0095" class="elsevierStylePara elsevierViewall">Todos los autores&#58; ning&#250;n conflicto a reportar&#46;</p></span></span>"
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              "titulo" => "An&#225;lisis estad&#237;stico"
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          "titulo" => "Resultados"
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            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Comparaci&#243;n entre los pacientes con el virus de la inmunodeficiencia humana positivo y negativo en hombres que tienen sexo con hombres"
            ]
            1 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Comparaci&#243;n entre los pacientes hombres que tienen sexo con hombres con y sin s&#237;filis previa"
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          "identificador" => "sec0045"
          "titulo" => "Discusi&#243;n"
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          "titulo" => "Conclusiones"
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          "titulo" => "Financiaci&#243;n"
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          "identificador" => "sec0055"
          "titulo" => "Conflicto de intereses"
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          "identificador" => "xack436715"
          "titulo" => "Agradecimientos"
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          "titulo" => "Bibliograf&#237;a"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-10-16"
    "fechaAceptado" => "2019-03-13"
    "PalabrasClave" => array:2 [
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1176980"
          "palabras" => array:5 [
            0 => "S&#237;filis precoz"
            1 => "Hombres que tienen sexo con hombres"
            2 => "Virus de la inmunodeficiencia humana"
            3 => "Antecedente de s&#237;filis"
            4 => "Respuesta serol&#243;gica"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1176979"
          "palabras" => array:5 [
            0 => "Early syphilis"
            1 => "Men who have sex with men"
            2 => "Human immunodeficiency virus"
            3 => "Previous syphilis"
            4 => "Serological response"
          ]
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Desde el a&#241;o 2000 se ha descrito un aumento progresivo de los casos de s&#237;filis en diferentes ciudades europeas&#44; sobre todo en hombres que tienen sexo con hombres &#40;HSH&#41;&#46; Las manifestaciones cl&#237;nicas de la s&#237;filis pueden estar influidas por la coinfecci&#243;n del VIH o por el antecedente de s&#237;filis&#46; El objetivo del presente estudio es describir las caracter&#237;sticas epidemiol&#243;gicas y cl&#237;nicas de los casos de s&#237;filis precoz diagnosticados en Barcelona&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de casos de s&#237;filis precoz diagnosticados en Barcelona &#40;2003-2013&#41;&#46; Se revisaron las historias cl&#237;nicas y los datos epidemiol&#243;gicos y cl&#237;nicos fueron recogidos de forma estructurada&#46; Las variables se compararon seg&#250;n el estatus serol&#243;gico del VIH y el antecedente de s&#237;filis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se diagnosticaron 1&#46;702 casos de s&#237;filis precoz &#40;37&#37; primaria&#44; 48&#37; secundaria y 14&#37; latente precoz&#41;&#44; 93&#37; de ellos en HSH&#46; Entre ellos&#44; el 40&#37; presentaba una coinfecci&#243;n por VIH&#46; Los casos de s&#237;filis en pacientes VIH positivos estaban asociados con un episodio previo de s&#237;filis &#40;aOR&#44; 5&#44;2 &#91;IC del 95&#37;&#44; 3&#44;32-8&#44;24&#93;&#41; y con haber tenido sexo anal desprotegido &#40;aOR&#44; 1&#44;75 &#91;IC del 95&#37;&#44; 1&#44;17-2&#44;63&#93;&#41;&#46; Los casos con antecedentes de s&#237;filis se presentaron con menor frecuencia como s&#237;filis primaria &#40;27&#44;5&#37; vs&#46; 40&#37;&#41; &#40;aOR&#44; 0&#44;58 &#91;IC del 95&#37;&#44; 0&#44;44-0&#44;77&#93;&#41;&#46; Un a&#241;o despu&#233;s del tratamiento&#44; la evoluci&#243;n cl&#237;nica y serol&#243;gica fue similar en los pacientes VIH positivo y negativo&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La epidemia de s&#237;filis en Barcelona afecta desproporcionalmente a HSH y est&#225; estrechamente relacionada con el VIH&#46; La forma de presentaci&#243;n de la s&#237;filis est&#225; influida por el antecedente de s&#237;filis y por el VIH&#44; sin diferencias significativas en cuanto a la evoluci&#243;n un a&#241;o despu&#233;s del tratamiento&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Since 2000&#44; substantial increases in syphilis have been reported in metropolitan areas of Western countries&#44; with increases noted among men who have sex with men &#40;MSM&#41;&#46; Clinical manifestations of syphilis might be influenced by concomitant VIH infection and previous episodes of syphilis&#46; The objectives of this study were to describe the epidemiological and clinical characteristics of the cases of syphilis diagnosed in Barcelona&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of cases with early syphilis diagnosed in the referral STI Unit of Barcelona from January 2003 to December 2013&#46; Revision of medical records with structured collection of epidemiological and clinical data&#46; Univariate and multivariate statistical analyses comparing the characteristics of MSM cases with and without VIH infection and with and without previous syphilis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 1702 cases of syphilis &#40;37&#37; primary&#44; 48&#37; secondary and 14&#37; early latent&#41; were diagnosed&#44; 93&#37; of them in MSM&#46; Among MSM 40&#37; were coinfected with VIH&#44; VIH-positive cases were associated with a previous syphilis &#40;aOR&#44; 5&#46;2 &#91;95&#37; CI&#44; 3&#46;32-8&#46;24&#93;&#41; and with unprotected anal intercourse &#40;aOR&#44; 1&#46;75 &#91;95&#37;CI&#44; 1&#46;17-2&#46;63&#93;&#41;&#46; Cases with a history of syphilis presented less often with primary syphilis compared to those without it &#40;27&#46;5&#37; vs&#46; 40&#37;&#41; &#40;aOR&#44; 0&#46;58 &#91;95&#37; CI&#44; 0&#46;44-0&#46;77&#93;&#41;&#46; One year after treatment&#44; the clinical and serological evolution were similar between VIH-positive and VIH-negative cases&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The epidemic of syphilis in Barcelona disproportionately affects MSM and is closelly linked to VIH infection&#46; The presentation of syphilis is influenced by VIH infection and by previous history of syphilis&#44; without significant differences in their evolution after one year of treatment&#46;</p></span>"
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            "titulo" => "Background"
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            "identificador" => "abst0030"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
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            "identificador" => "abst0040"
            "titulo" => "Conclusion"
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        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
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            "imagen" => "gr1.jpeg"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Casos de s&#237;filis precoz&#44; total y entre HSH &#40;incluyendo hombres bisexuales&#41;&#44; por a&#241;o en la Unidad de ITS de Vall d&#8217;Hebron-Drassanes&#44; Barcelona&#44; 2003-2013 &#40;N &#61; 1&#46;702&#41;&#46;</p>"
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        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ITS previa y s&#237;filis &#40;porcentajes&#41; y la tendencia lineal del n&#250;mero de parejas sexuales &#40;n&#250;mero mediana por mes&#41; por a&#241;o entre los casos de s&#237;filis temprana en la Unidad de ITS de Vall d&#8217;Hebron-Drassanes&#44; Barcelona&#44; 2003-2013&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Los datos representan el n&#250;mero &#40;&#37;&#41; salvo se indique lo contrario&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR &#40;IC del 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR ajustada &#40;IC del 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ITS previa</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;s&#237;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Parejas sexuales m&#250;ltiples &#40;s&#237;&#41;</span><span class="elsevierStyleItalic">&#40;N &#61; 1&#46;163&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">N&#250;mero de parejas sexuales por mes&#44; mediana &#40;RIQ&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Relaciones sexuales anales desprotegidas &#40;s&#237;&#41;</span><span class="elsevierStyleItalic">&#40;N &#61; 626&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Fase de la s&#237;filis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">324 &#40;54&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">337 &#40;37&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cribado de ITS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#40;A&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">VIH positivo&#40;N &#61; 600&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">VIH negativo&#40;N &#61; 897&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#40;B&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Infecci&#243;n previa por s&#237;filis&#40;N &#61; 475&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No infecci&#243;n de s&#237;filis previa &#40;N &#61; 1&#46;093&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Parejas sexuales m&#250;ltiples</span><span class="elsevierStyleItalic">&#40;s&#237;&#41;</span><span class="elsevierStyleItalic">&#40;N &#61; 1&#46;220&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">N&#250;mero de parejas sexuales por mes&#44; mediana &#40;RIQ&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cribado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">73 &#40;15&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Estudio de contactos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">102 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;94 &#40;0&#44;64-1&#44;37&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;78 &#40;0&#44;48-1&#44;23&#41;&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 00017310
Original language: Spanish
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