Consensus document for the training of residents in cardiovascular risk. / Documento de consenso para la formación de residentes en riesgo vascular.

Vascular disease is currently a major health problem, not only for its high prevalence but also for the considerable morbidity, mortality and disability that it entails. Medical internists play a central role in diagnosing and treating vascular disease and controlling the cardiovascular risk factors (CRFs) that cause it. In fact, the clinical care of patients in cardiovascular risk units is a specific characteristic of an internist's field of action. This article contains the consensus document for the training of residents in CRFs. This proposal by the Cardiovascular Risk Workgroup of the Spanish Society of Internal Medicine emerged as a response by our Society to the specific need for training in CRFs. Implementing this proposal would provide an important benefit, not only for medical internists in training but also for society as a whole.

Results of the screening program for Fabry disease in patients with cornea verticillata at the University Hospital of Navarre.

INTRODUCTION: Cornea verticillata (CV) or vortex keratopathy is characterized by the presence of spiral-shaped deposits in the corneal epithelium. The most frequent causes are antimalarial drugs and amiodarone and, among systemic causes, Fabry disease (FD). MATERIAL AND METHODS: A multidisciplinary, prospective, descriptive study was conducted in a tertiary reference center in Spain's Autonomous Community of Navarre after the implementation of a FD screening program for patients attended to in the Ophthalmology Department. The study analyzed those diagnosed with CV, who were subsequently referred to the rare disease clinic of the University Hospital of Navarre's Internal Medicine Department for an FD study. RESULTS: Two women and four men with a mean age of 76.8 years were diagnosed with CV out of a total of 17,280 patients evaluated in outpatient consultations by three ophthalmology specialists during the period from April 2018 to April 2020. One patient died before performing the screening study and no patients were diagnosed with FD. CONCLUSIONS: Despite the fact that the University Hospital of Navarre's FD screening program for patients with CV did not confirm any cases of FD, ophthalmology specialists should consider the possible diagnosis of FD in patients with CV in their routine consultations.

Statin-associated muscle symptoms: Myth or reality?

Statin-associated muscle symptoms is an entity that encompasses a constellation of various clinical manifestations of variyng severity. Since the introduction of the first statins, numerous studies have been published regarding its incidence, pathophysiology, diagnosis and treatment; however, to this day these aspects are still controversial. With the progressive increase in the use of statins in the general population, notifications of adverse reactions related to its use have multiplied, particularly those related to muscular toxicity. Nevertheless, the differences between the published studies, both in methodology and in the results obtained, make this relationship a complex issue of great interest for clinicians and patients. The integration of the evidence that we currently have can help us understand better this entity and facilitate its management in clinical practice.

[Q fever: 54 new cases from a tertiary hospital in Madrid]. / Fiebre Q: 54 nuevos casos de un hospital terciario de Madrid.

OBJECTIVES: To describe the epidemiological and clinical characteristics of Q fever in an urban zone of the Community of Madrid (Spain). MATERIAL AND METHODS: An observational, retrospective study was performed of a cohort of cases diagnosed of Q fever within a single center in Madrid from January 2001 to December 2008. The diagnosis of acute Q fever was made by detection of antibodies against phase II antigen by Enzyme-Linked Immunosorbent Assay (ELISA) and indirect immunofluorescence (IFA), based on isolated titer ≥ 1/80 or when they showed seroconversion or seroreinforcement. Chronic Q fever was diagnosed using antibodies against phase I with a positive value if IgG ≥ 1/800. RESULTS: A total of 54 cases of Q fever in adults were diagnosed; 51 patients had acute Q fever and only 3 chronic. There was a predominance of men over > 50 years and from urban areas. The most frequent manifestation was pneumonia (54%), followed by renal failure (33%), hepatitis and fever without focality (25% in both), with concomitant infection in 37% of the cases. The clinical and serological monitoring in most of the patients were inadequate. The best response to treatment was with doxycycline in acute illness, although duration was inadequate in 10%.

Utility of Doppler ultrasound for the study of ocular vascular disease.

Ocular vascular problems represent an emerging pathology within the activity of the internist. Ocular ultrasound is a widely used technique to evaluate a variety of eye conditions. Specifically, Doppler ultrasound of the ophthalmic vessels has become a very useful tool in diagnosing various eye diseases. Doppler ultrasound allows for examining blood flow in the eye even in the presence of eye opacities that impede viewing the posterior segment of the eye. In this review, we describe the principles and techniques of an ocular vascular Doppler ultrasound examination in clinical practice and provide a general approach to the ultrasound characteristics of the most important vascular eye disorders for internists. These include central retinal artery and vein occlusions, chronic retinal ischemic syndrome, anterior optic ischemic neuropathy, and diabetic retinopathy.

Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. / Atención al ictus agudo durante la pandemia por COVID-19. Recomendaciones Plan Ictus Madrid.

INTRODUCTION: The COVID-19 pandemic has resulted in complete saturation of healthcare capacities, making it necessary to reorganise healthcare systems. In this context, we must guarantee the provision of acute stroke care and optimise code stroke protocols to reduce the risk of SARS-CoV-2 infection and rationalise the use of hospital resources. The Madrid Stroke multidisciplinary group presents a series of recommendations to achieve these goals. METHODS: We conducted a non-systematic literature search using the keywords "stroke" and "COVID-19" or "coronavirus" or "SARS-CoV-2." Our literature review also included other relevant studies known to the authors. Based on this literature review, a series of consensus recommendations were established by the Madrid Stroke multidisciplinary group and its neurology committee. RESULTS: These recommendations address 5 main objectives: 1) coordination of action protocols to ensure access to hospital care for stroke patients; 2) recognition of potentially COVID-19-positive stroke patients; 3) organisation of patient management to prevent SARS-CoV-2 infection among healthcare professionals; 4) avoidance of unnecessary neuroimaging studies and other procedures that may increase the risk of infection; and 5) safe, early discharge and follow-up to ensure bed availability. This management protocol has been called CORONA (Coordinate, Recognise, Organise, Neuroimaging, At home). CONCLUSIONS: The recommendations presented here may assist in the organisation of acute stroke care and the optimisation of healthcare resources, while ensuring the safety of healthcare professionals.

[Periodic familial fever]. / Fiebre periódica hereditaria.

The familial periodic fevers are Known as autoinflammatory syndromes. It is important in clinical practice to recognize these uncommon illnesses characterized by recurrent bouts of unspecific systemic symptoms associated to elevation of acute phase reactants without autoantibodies or underlying infection. The clinical suspicion supported on the molecular diagnosis represents a new perspective in relation to treatment and prognosis of these patients.

[Crohn s disease: is still the reason of fever of unknown origin?]. / Enfermedad de Crohn: ¿todavía hoy causa de fiebre de origen desconocido clásica?

We present two patients with Crohn's disease who presented with fever unknown origin, and mild intestinal symptoms. In case 1, the debut was with intermittent fever and symmetrical polyarthritis of the wrists, elbows, ankles and knees; in the case 2, prolonged fever associated to unspecific colicky abdominal pain. The initial approach was fever unknown origin yielded no etiology in both of them. The barium studies of the intestinal tract of paramount importance to reach a positive diagnosis in both cases. We strongly recommend the use of barium studies as a first line diagnostic tool in the approach of fever unknown origin.

Budesonide combined with ursodeoxycholic acid in primary biliary cirrhosis with advanced liver damage.

We describe two patients with primary biliary cirrhosis who rapidly suffered progressive liver failure and developed jaundice, despite having undergone correct therapy using ursodeoxycholic acid. Both cases showed an extraordinary clinical and biochemical response 2 months after budesonide was added to standard therapy, leading to recovery of normal liver function.

Alterations in plasma and cerebrospinal fluid levels of neuropeptides in idiopathic senile anorexia.

Plasma and cerebrospinal fluid (CSF) concentrations of three well-known satiety neuropeptides, cholecystokinin (CCK), somatostatin and calcitonin gene-related peptide (CGRP), along with two powerful orexigenic neuropeptides, neuropeptide Y (NPY) and beta-endorphin have been measured in elderly persons with idiopathic anorexia and normal weight healthy subjects in a similar age range. Plasma and CSF immunoreactivity levels of the two main fractions of CCK (CCK8s and CCK33) after being separated by HPLC were measured by a radioimmunoassay (RIA) developed in our laboratory, whereas the other neuropeptides were assayed by commercially available RIA kits. Elderly underweight anorectic patients had significantly lower levels of beta-endorphin but increased concentrations of NPY in both plasma and CSF when compared to controls. In addition to significantly higher levels of CCK8s but not CCK33 in plasma, we found a trend to higher CSF concentrations of CCK8s and a positive correlation between the body mass index and either beta-endorphin (r = 0.58, P < 0.05) or CCK8s (r = 0.69, P < 0.01) concentrations in CSF in the anorectic group. CSF somatostatin concentrations were decreased significantly, but plasma somatostatin levels and plasma and CSF concentrations of CGRP were similar in senile anorectics and controls. Treatment of five anorectic patients with megestrol acetate, 480 mg daily for 6 months, reversed only the decrease in CSF beta-endorphin levels but did not normalize the body weight or the fat body mass. On the basis of our findings, we hypothesize that a decrease in CSF beta-endorphin concentration along with a rise in plasma levels of CCK8s might be accounted for the primary anorexia of aging.

Postprandial glucose-dependent insulinotropic polypeptide and insulin responses in patients with chronic pancreatitis with and without secondary diabetes.

OBJECTIVE: To study GIP and insulin release after a test meal in patients with chronic pancreatitis with and without secondary diabetes mellitus. METHODS: 28 patients with chronic pancreatitis were classified in groups I and II according to the presence or absence of secondary diabetes mellitus. Twelve healthy subjects were included as controls. After a test meal plasma GIP levels and serum insulin levels were determined at 0, 30, 60, 120 and 180 min. RESULTS: A significant diminished GIP response was found in the groups of patients with respect to the control group. No association could be detected with severity of pancreatic insufficiency. Higher values of GIP were demonstrated at 60 and 120 min in patients without diabetes than in patients with it. CONCLUSIONS: An abnormal GIP response is present in cases of chronic pancreatitis irrespective of the presence or severity of pancreatic insufficiency. This response is further affected if secondary diabetes mellitus is present.

Relationship of basal and postprandial intraduodenal bile acid concentrations and plasma cholecystokinin levels with abdominal pain in patients with chronic pancreatitis.

Abdominal pain in patients with chronic pancreatitis has been related to an increase in plasma cholecystokinin (CCK) levels. The aim of the study was to disclose the relation of the altered response with the low intraduodenal bile acids levels found in these patients. Twenty patients with chronic pancreatitis were classified into groups I (n = 11) and II (n = 9) according to the presence or absence of pain. Intraduodenal trypsin and bile acids concentrations and plasma CCK levels were measured before and 30, 60, and 90 min after a test meal. Comparisons between values in both groups were carried out. Correlation of intraduodenal trypsin and bile acids with plasma CCK was analyzed. Patients with pain exhibited significantly lower intraduodenal trypsin levels at 30 and 90 min and lower basal and postprandial intraduodenal bile acids levels than patients without pain. In patients with pain, basal and postprandial plasma CCK levels were significantly higher than in patients without pain. A negative correlation was demonstrated between intraduodenal bile acids and plasma CCK. In patients with chronic pancreatitis and pain, a reduction in intraduodenal postprandial trypsin and basal and postprandial bile acids concentrations, as well as an increase in basal and postprandial plasma CCK levels, was encountered. A negative correlation between intraduodenal bile acids and plasma CCK concentrations was detected that may be implicated in the pathogenesis of pain.

Protein-losing enteropathy is associated with peritoneal functional abnormalities in peritoneal dialysis patients.

OBJECTIVE: To evaluate the relationship between acquired peritoneal transport disorders and the presence of protein-losing enteropathy (PLE), and their contribution to the protein malnutrition in peritoneal dialysis (PD) patients. PATIENTS AND METHODS: We studied 31 clinically stable PD patients that received a fat overload diet for 3 days. We measured intestinal absorption of fecal fat (normal < 6 g/24-hour stool) and nitrogen (normal < 2 g/24-hr stool), intestinal protein permeability [fecal clearance of alpha1-antitrypsin (Calpha1AT) (normal < 12 mL/24-hr stool)], and nutritional markers [normalized protein nitrogen appearance (nPNA), half-life medium-term proteins, and body mass index]. Peritoneal solute transport was measured by mass transfer coefficient (MTC), and water transport by peritoneal ultrafiltration (UF) capacity. To define protein maldigestion it was necessary to find high fecal nitrogen values with normal Calpha1AT; PLE was defined when both values were elevated. RESULTS: High fecal nitrogen (mean 2.1+/-1 g/24-hr stool) and fat (mean 5.8+/-3.6 g/24-hr stool) were found in 15 patients; 6 patients had high Calpha1AT levels (PLE). These 6 patients showed a worse nutritional status: lower albumin (3.57+/-0.57 g/dL vs 3.98+/-0.38 g/dL, p < 0.05) and transferrin (243+/-70 mg/dL vs 272+/-44.3 mg/dL, p < 0.05), as well as lower triglycerides (131.3+/-31.7 mg/dL vs 187+/-116 mg/dL, p< 0.05). Higher urea MTCs were found in 10 patients, normal in 7, and lower in 14. Higher creatinine MTCs were found in 8 patients, normal in 15, and lower in 8. Normal peritoneal UF capacity was found in 25 and lower in 6 patients. These 6 patients showed higher urea and creatinine MTCs and Calpha1AT. A positive linear correlation between Calpha1AT, urea MTC (r = 0.56, p < 0.01), and creatinine MTC (r = 0.46, p < 0.01) was found. A similar situation occurred between Calpha1AT, fecal fat (r = 0.45, p < 0.05), and fecal nitrogen (r = 0.43, p < 0.05). Thirteen patients with previous history of peritonitis showed higher Calpha1AT than those without peritonitis (10.2+/-8 mL/24-hr stool vs 5.2+/-4.4 mL/24-hr stool, p < 0.05). CONCLUSIONS: We confirm that protein and fat malabsorption, maldigestion, and PLE are present in some PD patients. Higher fecal Calpha1AT is associated with malnutrition and poorer showings of the viability markers of peritoneal membrane function.

Computed tomography findings of peritoneal tuberculosis: systematic review of seven patients diagnosed in 6 years (1996-2001).

OBJECTIVE: The aim of this study was to describe the computed tomography (CT) findings in patients with demonstrated peritoneal tuberculosis (TB) and their concordance with the three types from the traditional classification (wet, fibrotic, and dry plastic). METHODS: We reviewed the CT images of all patients with microbiologically proven peritoneal tuberculosis over a 6-year period (1996-2001). RESULTS: Seven patients were included. Ascites was present in 5 patients (free ascites in 3 patients and loculated in 2). Involvement of the mesentery was found in 5 patients, the omentum in 4, and the parietal peritoneum in 3. Tuberculous lymphadenitis was the most common associated finding (6 patients). Two patients had hepatic lesions. The fibrotic type was found in all the patients, and 5 patients had an association of the fibrotic and wet types. None of the patients had lesions consistent with the dry plastic type. CONCLUSION: Peritoneal tuberculosis is best described as a combination of ascites, peritoneal lesions, and lymphadenopathy, rather than the three types from the traditional classification.

[Invasive pulmonary aspergillosis associated with influenza virus]. / Aspergilosis pulmonar invasiva asociada a virus de la influenza.

Invasive pulmonary aspergillosis can occur after viral influenza infection. It is described a previously healthy 58-year-old man with influenza virus infection who later suffered pulmonary aspergillosis. His response to amphotericin B was successful. The seven similar cases reported in the literature are revised and some common features established. Early antifungal therapy should be administered to any patient with previous flu illness presenting bilateral pulmonary infiltrates without response to antibiotics, if Aspergillus is isolated from the respiratory secretions.

[Diagnosis with helical CT and echocardiography of patients with suspected chronic thromboembolic pulmonary hypertension]. / Diagnóstico con TAC helicoidal y ecocardiografía de la hipertensión pulmonar por tromboembolismo pulmonar crónico.

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a serious disease with a very high mortality after variable periods of time. Early diagnosis of CTEPH is critical because thromboendarterectomy can improve survival, hemodimamics and functional capacity. Based on our experience we have performed a review of diagnostic techniques. Echocardiography, pulmonary angiography, fiberoptic angioscopy, helical CT an MRI. For each diagnostic procedure we have analysed its accuracy, invasiveness and easiness of use. We conclude that currently the most useful techniques are echocardiography (to asses pulmonary hypertension), and helical CT which is a good alternative to pulmonary angiography and can detect very specific findings such as dilatation of central pulmonary arteries, eccentric localized thrombi and mosaic attenuation of the pulmonary parenchyma. Even more accurate findings can be expected by the use of multislice CT, which could allow to asses the degree of narrowing of the pulmonary vessels and bronchial circulation.

[Homocysteine. The cardiovascular risk factor of the next millennium?]. / La homocisteína. El factor de riesgo cardiovascular del próximo milenio?

Several epidemiologic studies have demonstrated that hyperhomocysteinemia is a risk factor for arteriosclerosis in coronary, cerebral, peripheral and aortic arteries. This risk is independent of other cardiovascular risk factors, and it is dose related. However, prospective studies show contradictory findings. Hyperhomocysteinemia is also associated with a higher risk of venous thrombosis to which other coagulation disorders, such as factor V Leiden, could contribute. Hyperhomocysteinemia can be due to genetic defects in the enzymes that control homocysteine metabolism, and also to other factors, mainly nutritional (deficiencies in vitamin B6, vitamin B12, or folic acid). Dietary supplements of these vitamins reduce plasma homocysteine levels. Randomized clinical trials are still needed to demonstrate that reducing plasma homocysteine levels will reduce the risk for cardiovascular disease.

[Trichinosis. A study of a large outbreak on the Iberian peninsula]. / Triquinosis. Estudio de un amplio brote en la Península Ibérica.

An epidemic outbreak of trichinosis after wild boar meat ingestion was analysed. The most frequent clinical manifestations were: muscular pain, fever, periorbitary edema and conjunctivitis. Laboratory tests showed eosinophilia and increased muscular enzymes. There was no mortality. 10 patients had electromyograms, which all showed an inflammatory myopathy pattern. The one fiber study showed similar signs as those found in cases of polymyositis. There was a significant statistical relationship between intensity and duration of symptoms in the intestinal phase and eosinophils levels in peripheral blood. There was also a statistically significant relationship between CPK levels and decrease of mean duration of motor unit potential. Treatment with thiabendazole and steroids was useful. The indirect immunofluorescence test (IIT) proved an excellent method for diagnosing trichinosis.