Statement of the Spanish Interdisciplinary Cardiovascular Prevention Committee (CEIPC for its Spanish acronym) on the 2012 European Cardiovascular Prevention Guidelines.

Based on the two main frameworks for evaluating scientific evidence (SEC and GRADE) European cardiovascular prevention guidelines recommend interventions across all life stages using a combination of population-based and high-risk strategies with diet as the cornerstone of prevention. The evaluation of cardiovascular risk (CVR) incorporates HDL levels and psychosocial factors, a very high risk category, and the concept of age-risk. They also recommend cognitive-behavioural methods (e.g., motivational interviewing, psychological interventions) led by health professionals and with the participation of the patient's family, to counterbalance psychosocial stress and reduce CVR through the institution of positive habits such as a healthy diet, physical activity, smoking cessation, and adherence to treatment. Additionally, public health interventions - such as smoking ban in public areas or the elimination of trans fatty acids from the food chain - are also essential. Other innovations include abandoning antiplatelet therapy in primary prevention and the recommendation of maintaining blood pressure within the 130-139/80-85 mmHg range in diabetic patients and individuals with high CVR. Finally, due to the significant impact on patient progress and medical costs, special emphasis is given to the low therapeutic adherence levels observed. In sum, improving cardiovascular prevention requires a true partnership among the political class, public administrations, scientific and professional associations, health foundations, consumer associations, patients and their families. Such partnership would promote population-based and individual strategies by taking advantage of the broad spectrum of scientific evidence available, from clinical trials to observational studies and mathematical models to evaluate population-based interventions, including cost-effectiveness analyses.

Disseminated fusariosis in immunocompromised children: a case series and review of literature.

In the era of antifungal prophylaxis for cancer patients, Fusarium genus has become the second leading cause of invasive fungal infections and mortality in this group of patients. The intrinsic resistance to antifungal agents and the patient's risk factors are the most important variables for prognosis and survival. Currently, the use of monotherapy in comparison to combined antifungal treatment information is scarce. In this report, we present a series of three cases of children with acute lymphoblastic leukemia and disseminated fusariosis categorized according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG). Furthermore, we present a current literature review focused on treatment using monotherapy or combined antifungal treatment.

A narrow and highly significant linkage signal for severe bipolar disorder in the chromosome 5q33 region in Latin American pedigrees.

We previously reported linkage of bipolar disorder to 5q33-q34 in families from two closely related population isolates, the Central Valley of Costa Rica (CVCR) and Antioquia, Colombia (CO). Here we present follow up results from fine-scale mapping in large CVCR and CO families segregating severe bipolar disorder, BP-I, and in 343 population trios/duos from CVCR and CO. Employing densely spaced SNPs to fine map the prior linkage peak region increases linkage evidence and clarifies the position of the putative BP-I locus. We performed two-point linkage analysis with 1134 SNPs in an approximately 9 Mb region between markers D5S410 and D5S422. Combining pedigrees from CVCR and CO yields a LOD score of 4.9 at SNP rs10035961. Two other SNPs (rs7721142 and rs1422795) within the same 94 kb region also displayed LOD scores greater than 4. This linkage peak coincides with our prior microsatellite results and suggests a narrowed BP-I susceptibility regions in these families. To investigate if the locus implicated in the familial form of BP-I also contributes to disease risk in the population, we followed up the family results with association analysis in duo and trio samples, obtaining signals within 2 Mb of the peak linkage signal in the pedigrees; rs12523547 and rs267015 (P = 0.00004 and 0.00016, respectively) in the CO sample and rs244960 in the CVCR sample and the combined sample, with P = 0.00032 and 0.00016, respectively. It remains unclear whether these association results reflect the same locus contributing to BP susceptibility within the extended pedigrees.

[Control of anticoagulation in patients with non-valvular atrial fibrillation in a primary care clinical practice setting in the different autonomous communities. PAULA study]. / Control de la anticoagulación en pacientes con fibrilación auricular no valvular en práctica clínica de atención primaria en las diferentes comunidades autónomas. Estudio PAULA.

AIMS: To determine the differences between regions in the level of control of patients with non-valvular atrial fibrillation treated with vitamin K antagonists, included in the PAULA study. METHODS: Observational, and coss-sectional/retrospective study, including 139 Primary Care physicians from 99 Health Care centres in all autonomous communities (except La Rioja). Anticoagulation control was defined as the time in therapeutic range assessed by either the direct method (poor control <60%), or the Rosendaal method (poor control <65%). RESULTS: A total of 1,524 patients were included. Small differences in baseline characteristics of the patients were observed. Differences in the percentage of time in therapeutic range were observed, according to the Rosendaal method (mean 69.0±17.7%), from 78.1%±16.6 (Basque Country) to 61.5±14% (Balearic Islands), by the direct method (mean 63.2±17.9%) from 73.6%±16.6 (Basque Country) to 57.5±15.7% (Extremadura). When comparing regions, in those where the Primary Care physicians assumed full control without restrictions on prescription, the percentage of time in therapeutic range by the direct method was 63.89 vs. 60.95% in those with restrictions (p=.006), by Rosendaal method, 69.39% compared with 67.68% (p=.1036). CONCLUSIONS: There are significant differences in the level of control between some regions are still inadequate. Regions in which the Primary Care physicians assumed the management of anticoagulation and without restrictions, time in therapeutic range was somewhat higher, and showed a favourable trend for better control. These findings may have clinical implications, and deserve consideration and specific analysis.

Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice. / Adaptación española de las guías europeas de 2016 sobre prevención de la enfermedad cardiovascular en la práctica clínica.

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]. / Adaptación española de las guías europeas de 2016 sobre prevención de la enfermedad cardiovascular en la práctica clínica.

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

[Coordination between primary and cardiological care: the opinion of the family doctor]. / La coordinación entre asistencia primaria y cardiología. La opinión del médico de familia.

OBJECTIVE: To analyse the relationship between Primary and Cardiological Care from the perspective of family physicians. METHODS: A descriptive-crossover study was carried out by a questionnaire sent by mail to a sample of 384 doctors systematically selected from the database of the College of Physicians of Madrid. RESULTS: One hundred forty-eight physicians (38.5%) answered the questionnaire, 75% of whom saw more than 30 patients/week with cardiovascular risk factors and more than 10 patients/week with cardiac syndromes, in the following order: ischaemic heart disease, heart failure, arrhythmias, valvular disease, cor pulmonale and others. Ninety percent of the physicians refer less than 10 patients/month to cardiologists, with a time delay of greater than a month in 50% of the cases. The document used for referral is the consultation form (98%) that is always or frequently answered. The quality of the cardiologist's report is either good or excellent in 50% of the cases. Accessibility to electrocardiograms and thorax x-rays by family doctors is of 99.3%. Family physicians have a very positive opinion regarding the need for hospital collaboration in their continuous training and coordination with cardiologists.

[Vitreous hemorrhage after vitrectomy in diabetic retinopathy and tissue plasminogen activator]. / Hemorragia vítrea postvitrectomía en retinopatía diabética y activador tisular del plasminógeno.

PURPOSE: To determine if intraocular recombinant tissue plasminogen activator (r-TPA) can be used to treat fibrin blood clots (hyphemas/vitreous) after vitrectomy surgery for diabetic retinopathy. MATERIAL AND METHOD: After a retrospective review of medical records, we found 52 patients who underwent vitrectomy for diabetic retinopathy and non-resolving vitreous hemorrhage and/or hyphema during the early postoperative (6 weeks). They were administered r-TPA in dose of 25 microgr/0.1 ml. Hyphemas and vitreous hemorrhages were classified in four grades. RESULTS: Tissue Plasminogen Activator was used after vitrectomy surgery in 52 fibrin clotted eyes (52 patients), within the first 3 days post surgery. Vitreous hemorrhages were categorized as grade 2 (21%), grade 3 (67.3%) and grade 4 (11.5%). Hyphemas observed in 18 eyes presented grade 3 (38.9%) and grade 4 (61%). We saw no evidence of intraocular reactions against the r-TPA solution at the dose used in this study. CONCLUSIONS: Fibrin blood clots can successfully and effectively be treated with intraocular r-TPA in doses of 25 microgr/0.1 ml (Arch Soc Esp Oftalmol 2002; 77: 7-12).

[Suprachoroidal haemorrhage and acute glaucoma associated with systemic fibrinolysis]. / Hemorragia supracoroidea y glaucoma agudo asociado a fibrinolisis sistémica.

PURPOSE/METHOD: To describe the clinical case of a patient with acute myocardial infarction and an ocular haemorrhage as a complication of the use of systemic thrombolytic agents. RESULTS/CONCLUSIONS: A patient who received therapy with tissue plasminogen activator for an acute myocardial infarction developed three hours later a massive suprachoroidal haemorrhage with secondary acute angle closure. In patients who have undergone systemic thrombolytic agents, the presence of loss of vision and pain must alert to the possibility of secondary ocular haemorrhage. These patients may benefit from continuous control (Arch Soc Esp Oftalmol 2002; 77: 459-462).

In-stent restenosis. Acute and long-term outcomes after excimer laser coronary angioplasty.

OBJECTIVE: With the increased use of intracoronary stents, in-stent restenosis has become a clinically significant drawback in invasive cardiology. We retrospectively assessed the short- and long-term outcomes after excimer laser coronary angioplasty of in-stent restenosis. METHODS: Twenty-five patients with 33 incidents of in-stent restenosis treated with excimer laser coronary angioplasty (ELCA) were analyzed. Sixty-six percent were males, mean age of 73 +/- 11 years, and 83% were functional class III-IV (NYHA). ELCA was performed using 23 concentric and 10 eccentric catheters with a diameter of 1.6-2.2 mm, followed by balloon angioplasty (PTCA) and ultrasound monitoring. The procedure was performed in the following vessels: left anterior descending artery, 10; left circumflex artery, 8; right coronary artery, 6; left main coronary artery, 2; and venous bypass graft, 7. RESULTS: The ELCA was successful in 71% of the cases, and PTCA was 100% successful. The diameter of the treated vessels was 3.44 +/- 0.5 mm; the minimal luminal diameter (MLD) increased from 0.30 mm pre-ECLA to 1.97 mm post-ELCA, and to 2.94 mm post-PTCA (p < 0.001). The percent stenosis was reduced from 91.4 +/- 9.5% before ECLA to 42.3 +/- 14.9% after ELCA and to 14.6 +/- 9.3% after PTCA (p < 0.001). Seventeen (68%) patients were asymptomatic at 6 months and 15 (60%) at 1 year. New restenosis rates were 8/33 (24.2%) at 6 months and 9/33 (27.3%) at 12 months. CONCLUSION: ELCA is safe and effective for the treatment of in-stent restenosis. In the present sample, a slight increase in new restenotic lesions between 6 and 12 months was found.

[Acute liver failure as presentation form of small cell carcinoma of the lung]. / Insuficiencia hepática aguda como forma de presentación de un carcinoma microcítico de pulmón.

Metastatic infiltration of the liver is an uncommon cause of acute hepatic failure. We describe the case of a 55-yr-old man who presented with signs and symptoms of liver disease. Diagnostic testing revealed a small cell carcinoma of the lung with massive hepatic metastases.

[Spanish version of the CAM-ICU (Confusion Assessment Method for the Intensive Care Unit). Pilot study of validation]. / Versión en español del método para la evaluación de la confusión en cuidados intensivos, estudio piloto de validación.

OBJECTIVE: To validate the Spanish version of the CAM-ICU. DESIGN: Validation study. The inter-rater reliability and validity were evaluated using a blind comparison with the DSM-IVTR criteria (reference standard) in a group of patients hospitalized in an Intensive Care Unit (ICU). SETTING: Medical-surgical ICU. PATIENTS: 129 adults with RASS >-4 score, within the 24-48 h of ICU admission. Independent application of the CAM-ICU by two intensive care specialists and evaluation by a psychiatrist using the DSM-IVTR criteria for delirium. RESULTS: Prevalence of delirium in the sample was 26.4%, this being and 48.3% in the 29 patients who received mechanical ventilation. Inter-rater reliability in the whole sample according to the Kappa index was 0.792 (95% CI 0.662-0.922, p<0.001) and in those who received mechanical ventilation was 0.726 (95% CI 0.487-0.965, p<0.001). The sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were 79.4% (95% CI 63.2-89.7%); 97.9% (95% CI 92.6-99.4%); 93.1% (95% CI 78.0-98.1%); 93.0% (95% CI 86.3-96.6%); 37.72 (95% CI 9.47-150.20) and 0.21(95% CI 0.11-0.41), respectively, in the whole sample. In mechanically-ventilated patients, sensitivity, specificity, PPV, NPV, +LR and -LR were 92.9% (95% CI 68.5-98.7%); 86.7% (95% CI 62.1-96.3%); 86.7% (95% CI 62.1-96.3%); 92.9% (95% CI 68.5-98.7%); 6.96(95% CI 1.90-25.51) and 0.08 (95% CI 0.01-0.55), respectively. CONCLUSION: The Spanish version of the CAM-ICU is reliable. Its sensitivity, specificity and predictive values should be considered good.

[Non-invasive evaluation of pulmonary artery occlusion pressure in critically ill patients with mechanical ventilation]. / Evaluación no invasiva de la presión de oclusión de la arteria pulmonar en el paciente crítico mecánicamente ventilado.

OBJECTIVE: To compare the measurements of pulmonary artery occlusion pressure (PAOP) by means of the use a pulmonary artery catheter and those obtained through a formula that relates the systolic artery pressure before and after a Valsalva maneuver. DESIGN: Prospective observational study. SCOPE: Medical-surgical intensive care unit. PATIENTS: A total of 120 patients mechanically ventilated and with deep sedation who had pulmonary artery catheter and arterial line. INTERVENTIONS: Provocation of a Valsalva maneuver by maintaining airway pressure at 30 mmHg for 10 seconds that was subsequently released. MAIN VARIABLES OF INTEREST: PAOP measured at the end of expiration by means of the use of a pulmonary artery catheter, PAOP was calculated by means of the use of a formula that relates the systolic artery pressure before and after a Valsalva maneuver. RESULTS: There was a limited correlation between the measured PAOP and that calculated by means of the Valsalva maneuver in the total population (r=0.44, CI 95%: 0.28 to 0.57, p=0.0001). There was a better correlation in the post-surgical subgroup (r=0.518, CI 95%: 0.1055 to 0.7738, p=0.016) and in the sub-group of "Others diagnosis" (r=0.62, CI: 95%: 0.30 to 0.81, p=0.001). CONCLUSIONS: The prediction of the PAOP by means of the Valsalva maneuver showed a limited correlation with that obtained by means of the pulmonary artery catheter.

[Brain natriuretic peptide in primary care: diagnostic value in heart failure]. / Péptido cerebral natriurético en atención primaria: valor diagnóstico en la insuficiencia cardíaca.

OBJECTIVE: To determine the validity and usefulness of brain natriuretic peptide (BNP) for diagnosing left ventricular dysfunction (LVD). DESIGN: Prospective, descriptive, multi-centred study to validate the diagnostic test. SETTING: Primary care centres in the Community of Madrid, Spain. PARTICIPANTS: Consecutive sample of patients at high risk of presenting with LVD. INTERVENTIONS: Data will be gathered from anamnesis, physical examination, ECG, and chest x-ray to find the risk factor(s) for LVD and the presence or absence of symptoms of congestive heart failure according to the Framingham scale. BNP will be determined at PC clinics in all patients who meet the inclusion criteria, using the "triage BNP test." All patients included in the study will be referred to an echocardiography service for an echocardiogram, which will be the gold standard test. Two independent cardiologists will evaluate the echocardiograph without knowing the BNP values. MAIN MEASUREMENTS: BNP concentrations will be compared against the kind and degree of LVD. ROC curves analysis will test the capacity of BNP to diagnose LVD. Optimal sensitivity and specificity value will be calculated by means of the position on the curve resulting from the minimum distance at the cut-off point for best sensitivity and specificity. Then, sensitivity, specificity, and positive and negative predictive values will be calculated. DISCUSSION: BNP can complement the information provided by other diagnostic tests. It should be included as an important factor in the taking of clinical-therapeutic decisions.