[Oral Findings in Patients With COVID-19]. / Hallazgos bucales en pacientes COVID-19.

The aim of this study was to describe oral lesions in a group of patients with COVID-19. We recruited 55 patients, 25 women (45.5%) and 30 men (54.5%), aged between 1 and 89 years with confirmed COVID-19 at different stages of severity. After obtaining informed consent, we examined their mouths and recorded clinical findings. Forty percent of the patients had at least 1 oral lesion. The most common lesions were candidiasis and ulcers (7 patients each); 2 patients had enanthems. Geographic tongue and caviar tongue were also observed. Altered taste, dry mouth, and painful/burning mouth were noted in 60%, 27.3%, and 36.4% of patients, respectively. Oral mucosal alterations and lesions were prevalent in this series of COVID-19 patients. Altered taste and a painful/burning mouth were common symptoms.

[Telemedicine, ethics, and law in times of COVID-19. A look towards the future]. / Telemedicina, ética y derecho en tiempos de COVID-19. Una mirada hacia el futuro.

The health emergency in Spain caused by COVID-19 was of such a magnitude that on March 14, 2020, a state of alarm was declared that lasted for more than three months. This ongoing pandemic has affected a vast number of people. Among the measures taken to reduce the risk of contagion, visits to health centers have been reduced and virtual consultations have increased. Once the pandemic ends, it will be necessary to consider whether telemedicine should be limited to periods of health crises or whether it could become a new way of practicing medicine. Telemedicine lacks specific regulations and has loopholes that leave physicians with a considerable degree of insecurity. This article analyzes the limits, precautions, and legal standards of the use of telemedicine.

Oral Findings in Patients With COVID-19.

The aim of this study was to describe oral lesions in a group of patients with COVID-19. We recruited 55 patients, 25 women (45.5%) and 30 men (54.5%), aged between 1 and 89 years with confirmed COVID-19 at different stages of severity. After obtaining informed consent, we examined their mouths and recorded clinical findings. Forty percent of the patients had at least 1 oral lesion. The most common lesions were candidiasis and ulcers (7 patients each); 2 patients had enanthems. Geographic tongue and caviar tongue were also observed. Altered taste, dry mouth, and painful/burning mouth were noted in 60%, 27.3%, and 36.4% of patients, respectively. Oral mucosal alterations and lesions were prevalent in this series of COVID-19 patients. Altered taste and a painful/burning mouth were common symptoms.

El propósito de este trabajo fue caracterizar las alteraciones orales en un grupo de pacientes COVID-19. Para ello se evaluaron 55 pacientes hospitalizados, confirmados COVID-19 en distintos estadios de severidad. Previo consentimiento informado, se examinó la cavidad oral y se registraron los hallazgos clínicos. El grupo de estudio estuvo conformado por 25 mujeres (45,5%) y 30 hombres (54,5%), con edades comprendidas entre 1 y 89 años. Un 40% de los pacientes mostraron alguna lesión bucal. Las lesiones más comunes fueron candidiasis y ulceraciones (7 pacientes cada uno) y en dos pacientes se observó enantema. También se encontraron alteraciones de la normalidad como glositis migratoria y varicosidades linguales. Asimismo, se registraron alteraciones del gusto, xerostomía y dolor/ardor bucal en el 60%, 27,3% y 36,4% respectivamente. En los pacientes COVID-19 se observaron con frecuencia alteraciones y lesiones en la mucosa bucal. Finalmente, la disgeusia y el dolor y/o el ardor oral fueron síntomas comunes en estos pacientes.

Metabolomics allows the discrimination of the pathophysiological relevance of hyperinsulinism in obese prepubertal children.

BACKGROUND/OBJECTIVES: Insulin resistance (IR) is the cornerstone of the obesity-associated metabolic derangements observed in obese children. Targeted metabolomics was employed to explore the pathophysiological relevance of hyperinsulinemia in childhood obesity in order to identify biomarkers of IR with potential clinical application. SUBJECTS/METHODS: One hundred prepubertal obese children (50 girls/50 boys, 50% IR and 50% non-IR in each group), underwent an oral glucose tolerance test for usual carbohydrate and lipid metabolism determinations. Fasting serum leptin, total and high molecular weight-adiponectin and high-sensitivity C-reactive protein (CRP) levels were measured and the metabolites showing significant differences between IR and non-IR groups in a previous metabolomics study were quantified. Enrichment of metabolic pathways (quantitative enrichment analysis) and the correlations between lipid and carbohydrate metabolism parameters, adipokines and serum metabolites were investigated, with their discriminatory capacity being evaluated by receiver operating characteristic (ROC) analysis. RESULTS: Twenty-three metabolite sets were enriched in the serum metabolome of IR obese children (P<0.05, false discovery rate (FDR)<5%). The urea cycle, alanine metabolism and glucose-alanine cycle were the most significantly enriched pathways (PFDR<0.00005). The high correlation between metabolites related to fatty acid oxidation and amino acids (mainly branched chain and aromatic amino acids) pointed to the possible contribution of mitochondrial dysfunction in IR. The degree of body mass index-standard deviation score (BMI-SDS) excess did not correlate with any of the metabolomic components studied. In the ROC analysis, the combination of leptin and alanine showed a high IR discrimination value in the whole cohort (area under curve, AUCALL=0.87), as well as in boys (AUCM=0.84) and girls (AUCF=0.91) when considered separately. However, the specific metabolite/adipokine combinations with highest sensitivity were different between the sexes. CONCLUSIONS: Combined sets of metabolic, adipokine and metabolomic parameters can identify pathophysiological relevant IR in a single fasting sample, suggesting a potential application of metabolomic analysis in clinical practice to better identify children at risk without using invasive protocols.

Insulin resistance in prepubertal obese children correlates with sex-dependent early onset metabolomic alterations.

BACKGROUND: Insulin resistance (IR) is usually the first metabolic alteration diagnosed in obese children and the key risk factor for development of comorbidities. The factors determining whether or not IR develops as a result of excess body mass index (BMI) are still not completely understood. OBJECTIVES: This study aimed to elucidate the mechanisms underpinning the predisposition toward hyperinsulinemia-related complications in obese children by using a metabolomic strategy that allows a profound interpretation of metabolic profiles potentially affected by IR. METHODS: Serum from 60 prepubertal obese children (30 girls/30 boys, 50% IR and 50% non-IR in each group, but with similar BMIs) were analyzed by using liquid chromatography-mass spectrometry, gas chromatography-mass spectrometry and capillary electrophoresis-mass spectrometry following an untargeted metabolomics approach. Validation was then performed on a group of 100 additional children with the same characteristics. RESULTS: When obese children with and without IR were compared, 47 metabolites out of 818 compounds (P<0.05) obtained after data pre-processing were found to be significantly different. Bile acids exhibit the greatest changes (that is, approximately a 90% increase in IR). The majority of metabolites differing between groups were lysophospholipids (15) and amino acids (17), indicating inflammation and central carbon metabolism as the most altered processes in impaired insulin signaling. Multivariate analysis (OPLS-DA models) showed subtle differences between groups that were magnified when females were analyzed alone. CONCLUSIONS: Inflammation and central carbon metabolism, together with the contribution of the gut microbiota, are the most altered processes in obese children with impaired insulin signaling in a sex-specific fashion despite their prepubertal status.

Peritumoral adipose tissue as a source of inflammatory and angiogenic factors in colorectal cancer.

PURPOSE: Obesity is a risk factor for the development of human colorectal cancer (CC). The aim of this work is to report the inflammatory and angiogenic scenario in lean (BMI < 25 kg/m2) and obese (BMI > 30 kg/m2) patients with and without CC and to assess the role of peritumoral adipose tissue in CC-induced inflammation. MATERIAL AND METHODS: Patients were divided in four experimental groups: obese patients with CC (OB-CC), lean patients with CC (LEAN-CC), obese patients without CC (OB), and lean patients without CC (LEAN). RESULTS: Plasma levels of pro-inflammatory cytokines (interleukin (IL)-6, IL-4, IL-8) and granulocyte-macrophage colony-stimulating factor (GM-CSF) were increased in OB-CC patients. Peritumoral adipose tissue (TF) explants and cultured mature adipocytes secreted higher amounts of nitrites and nitrates than did control and non-tumoral (NTF) adipose tissue both alone and in response to lipopolysaccharide (LPS). Nitrite and nitrate secretion was also increased in TF explants from OB-CC patients compared with that from LEAN-CC patients. Gene expression of adiponectin, tumor necrosis factor alpha (TNF-α), insulin-like growth factor type I (IGF-I), cyclooxygenase-2 (COX-2), and peroxisome proliferator-activated receptor γ (PPAR-γ) was increased in TF explants from CC patients. LPS increased the gene expression of IL-6, IL-10, TNF-α, vascular endothelial growth factor (VEGF), and COX-2 in OB and in TF explants from OB-CC patients. COX-2 and PPAR-γ inhibition further increased LPS-induced release of nitrites and nitrates in TF explants and adipocytes from OB-CC patients. CONCLUSIONS: In conclusion, OB-CC patients have increased plasma levels of pro-inflammatory and angiogenic factors. TF from OB-CC patients shows an increased secretion of inflammatory markers compared with both TF from LEAN-CC and non-tumoral adipose tissue (AT) through a COX-2- and PPAR-γ-independent mechanism.

Cost-effectiveness of the CNIC-Polypill versus separate monocomponents in cardiovascular secondary prevention in Spain.

INTRODUCTION AND OBJECTIVES: Despite advances in treatment, cardiovascular disease is the second leading cause of death in Spain. The objective of this study was to determine the cost-effectiveness of the CNIC-Polypill strategy (acetylsalicylic acid 100 mg, atorvastatin 20/40 mg, ramipril 2.5/5/10 mg) compared with the same separate monocomponents for the secondary prevention of recurrent cardiovascular events in adults in Spain. MATERIALS AND METHODS: A Markov cost-utility model was adapted considering 4 health states (stable, subsequent major adverse cardiovascular event, subsequent ischemic stroke and death) and the SMART risk equation over a lifetime horizon from the perspective of the Spanish National Healthcare System. The CNIC-Polypill strategy was compared with monocomponents in a hypothetical cohort of 1000 secondary prevention patients. Effectiveness, epidemiological, cost and utilities data were obtained from the NEPTUNO study, official databases and literature. Outcomes were costs (in 2021 euros) per life-year (LY) and quality-adjusted LY (QALY) gained. A 3% discount rate was applied. Deterministic one-way and probabilistic sensitivity analyses evaluated the robustness of the model. RESULTS: The CNIC-Polypill strategy in secondary prevention results in more LY (13.22) and QALY (11.64) gains at a lower cost than monocomponents. The CNIC-Polypill is dominant and saves є280.68 per patient compared with monocomponents. The probabilistic sensitivity analysis shows that 82.4% of the simulations are below the threshold of є25,000 per QALY gained. CONCLUSIONS: The CNIC-Polypill strategy in secondary cardiovascular prevention is cost-effective compared with the same separate monocomponents, resulting in a cost-saving strategy to the Spanish National Healthcare System.

[The natriuretic peptides in the diagnosis of heart failure in primary care setting]. / Los péptidos natriuréticos en el diagnóstico de la insuficiencia cardíaca en atención primaria.

Heart failure (HF) is a clinical syndrome characterized by symptoms and signs caused by structural and/or functional abnormalities of the heart that cause reduced cardiac output and/or elevated intracardiac pressures at rest or during exercise. Its prevalence and incidence are increasing and it is the leading cause of hospitalization in people over 65years of age. The new American and European guidelines for the management of HF emphasize that the measurement of natriuretic peptide (NP) concentrations constitutes a cornerstone of the diagnostic management of HF, and that the history, physical examination, electrocardiogram, and chest X-ray, complete the beginning of the HF diagnostic process. All these actions and diagnostic tests can be performed and requested from the primary care office. The authors of this document, on behalf of the SEMERGEN Hypertension and Cardiovascular Disease Working Group, have reviewed the most recent scientific evidence related to the preventive diagnostic management of NP in patients with HF in primary care setting.

Comprehensive management of risk factors in peripheral vascular disease. Expert consensus.

INTRODUCTION: There is currently a degree of divergence among the main clinical practice guidelines on the management of risk factors for peripheral arterial disease (PAD). This project aims to gain understanding of the management of PAD risk factors in clinical practice and to reach a multidisciplinary consensus on the strategies to be followed in order to optimize its identification, treatment, and follow-up. METHODOLOGY: A multidisciplinary consensus following the Delphi methodology. RESULTS: Professionals (n = 130) with extensive experience in PAD participated in this consultation. The results suggest that in order to optimize the control of risk factors, efforts should be aimed at: (1) promoting the involvement and awareness of all specialists in the identification of and screening for the disease; (2) guaranteeing the possibility of evaluating the ankle-brachial index (ABI) in all the medical specialties involved; (3) promoting strategies for patients to quit smoking through the use of drugs, programs, or referrals to specialized units; (4) promoting an appropriate Mediterranean-based diet and the prescription of daily exercise; (5) raising awareness of the importance of ensuring LDL cholesterol values below 70 mg/dL, especially in symptomatic but also in asymptomatic patients (<55 mg/dL following the publication of the ESC/EAS guide); (6) recommending the use of antiplatelet therapy in asymptomatic patients with diabetes mellitus (DM) and/or a pathological ABI; and (7) protocolizing the annual evaluation of ABI in high-risk patients. CONCLUSION: This document presents the 22 agreed-upon strategies which are intended to help professionals optimize multidisciplinary management of PAD risk factors.

[SEMERGEN positioning on approaching chronic heart failure in primary care]. / Posicionamiento SEMERGEN en el abordaje de la insuficiencia cardíaca crónica en atención primaria.

Heart failure (HF) is a public health problem that generates a large healthcare burden both in hospitals and in Primary Care (PC). The publication of numerous studies about HF in recent years has led to a paradigm shift in the approach to this syndrome, in which the work of PC teams is gaining greater prominence. The recent guidelines published by the European Society of Cardiology have fundamentally introduced changes in the management of patients with HF. The new proposed strategy, with drugs that reduce hospitalizations and slow the progression of the disease, should now be a priority for all professionals involved. This position document analyzes a proposal for an approach based on multidisciplinary teams with the leadership of family doctors, key to providing quality care throughout the entire process of the disease, from its prevention to the end of the life.

Evaluation of prophylaxis in primary prevention with acetylsalicylic acid in people with diabetes: A scoping review.

BACKGROUND: The efficacy and safety of acetylsalicylic acid (ASA) prophylaxis for the primary prevention of atherosclerotic cardiovascular disease (ACVD) remain controversial in people with diabetes (DM) without ACVD, because the possible increased risk of major bleeding could outweigh the potential reduction in the risk of mortality and of major adverse cardiovascular events (MACE) considered individually or together. OBJECTIVE: To evaluate the overall risk-benefit of ASA prophylaxis in primary prevention in people with DM and to compare the recommendations of the guidelines with the results of the meta-analyses (MA) and systematic reviews (SR). MATERIAL AND METHODS: We searched Medline, Google Scholar, Embase, and the Cochrane Library for SR and MA published from 2009 to 2020 which compared the effects of ASA prophylaxis versus placebo or control followed up for at least one year in people with DM without ACVD. Heterogeneity among the randomized clinical trials (RCT) included in the SR and MA was assessed. Cardiovascular outcomes of efficacy (all-cause mortality [ACM], cardiovascular mortality [CVM], myocardial infarction [MI], stroke and MACE) and of safety (major bleeding events [MBE], major gastrointestinal bleeding events [MGIBE], and intracranial and extracranial bleeding) were shown. RESULTS: The recommendations of 12 guidelines were evaluated. The results of 25 SR and MA that included a total of 20 RCT were assessed. None of the MA or SR showed that ASA prophylaxis decreased the risk of ACM, CVM or MI. Only two of the 19 SR and MA that evaluated ischemic stroke showed a decrease in the stroke risk (mean 20.0% [SD±5.7]), bordering on statistical significance. Almost half of the MA and SR showed, bordering on statistical significance, a risk reduction for the MACE composite endpoint (mean 10.5% [SD±3.3]). The significant increases in MGIBE risk ranged from 35% to 55%. The significant increases in the risk of MBE and extracraneal bleeding were 33.4% (SD±14.9) and 54.5% (SD±0.7) respectively. CONCLUSION: The overall risk-benefit assessment of ASA prophylaxis in primary prevention suggests that it should not be applied in people with DM.

Serum visfatin and vaspin levels in prepubertal children: effect of obesity and weight loss after behavior modifications on their secretion and relationship with glucose metabolism.

OBJECTIVE: To investigate the impact of obesity, weight loss and oral glucose ingestion on serum visfatin and vaspin levels in prepubertal children. SUBJECTS AND METHODS: A total of 100 prepubertal obese Caucasian children (OB) and 42 controls (C) were studied. The OB group was studied at baseline and after moderate (n=46) and extensive (n=14) body mass index (BMI) reduction by conservative treatment, undergoing body composition studies (dual-energy X-ray absorptiometry) and oral glucose tolerance tests (OGTTs). Serum visfatin and vaspin levels were studied throughout the OGTT, as were their relationships with insulin, leptin, leptin soluble receptor (sOB-R), adiponectin (total and high molecular weight), resistin, interleukin-6 (IL-6) and tumor necrosis factor-α levels at every time point. RESULTS: OB had higher visfatin (P<0.001), but similar vaspin than C. BMI reduction decreased visfatin levels (P<0.001), with BMI, waist circumference and the surrogate markers of body fat (leptin and sOB-R) showing significant correlations (P<0.05) with this peptide, but not with vaspin. Visfatin and vaspin decreased during the OGTT (P<0.001). Weight reduction did not alter visfatin dynamics in the OGTT, but decreased the area under the curve (AUC) for vaspin (P<0.001), with a correlation between the AUCs for vaspin and insulin after weight loss (P<0.05). Visfatin levels were positively correlated with resistin and IL-6, after controlling for BMI and HOMA (homeostatic model assessment) index at every time point in the study. CONCLUSION: Serum visfatin, but not vaspin, levels are influenced by body fat content in obese children, whereas both adipokines are modulated by glucose intake in a BMI-dependent manner.

Acylated ghrelin levels in pre-pubertal obese children at diagnosis and after weight reduction: effect of oral glucose ingestion.

BACKGROUND: Ghrelin isoforms are involved in energy homeostasis and carbohydrate metabolism. AIM: To determine the influence of oral glucose ingestion and weight reduction on acylated ghrelin (AG) serum levels and on the AG to total ghrelin (TG) ratio (AG/TGr) in obese pre-pubertal children. SUBJECTS AND METHODS: Seventy obese children were studied at diagnosis (D) and after reduction of their body mass index (BMI) of over 1 (-1; no.=51) and 2 SD score (-2; no.=21). Body composition was analyzed and serum levels of glucose, insulin, TG and AG, and the AG/TGr were determined at every time-point in an oral glucose tolerance test (OGTT) at D and at -2. The control group consisted of 32 lean children. RESULTS: At D AG and TG levels were lower in obese children and negatively correlated with BMI. TG levels were negatively correlated with the homeostasis model assessment (HOMA) index in the whole cohort, as with the body fat content (BFC) in the obese patients. Weight loss exclusively reduced BFC and improved HOMA, increasing AG transiently and TG sustainedly, with AG/TGr exclusively decreasing at -2. Glucose ingestion caused a sustained increase in AG and decrease in TG, thus increasing the AG/TGr throughout the entire OGTT; this remained unaltered after weight reduction. CONCLUSIONS: TG and AG levels are influenced by BMI, showing an impairment in childhood obesity that can be improved through weight loss. The different fractions of ghrelin appear to play different roles in carbohydrate metabolism and the calculation of AG/TGr could be useful in the follow up of childhood obesity.

Effect of recombinant growth hormone on leptin, adiponectin, resistin, interleukin-6, tumor necrosis factor-α and ghrelin levels in growth hormone-deficient children.

BACKGROUND: Treatment with GH promotes linear growth and decreases body fat in patients with isolated GH deficiency (GHD). However, few studies have analyzed how GH replacement modifies ghrelin levels and the adipokine profile and the relationship of these modifications with the metabolic changes. AIMS: To analyze the eventual differences between serum levels of leptin, leptin soluble receptor (sOBR), resistin, adiponectin, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), total (TG) and acylated ghrelin (AG) and lipid and glycemic profiles in children with GHD, as well as to determine the effect of GH replacement on these parameters during the first year of therapy. SUBJECTS AND METHODS: Thirty pre-pubertal (Tanner stage I) GHD children and 30 matched controls were enrolled. Children with GHD were studied before and after 6 and 12 months of GH treatment. Weight, height, BMI, fasting glucose, insulin, lipid profile and serum levels of adipokines and ghrelin were studied at every visit. Adi - pokines, insulin and ghrelin levels were determined by using commercial radio- and enzymoimmunoassays. RESULTS: At baseline children with GHD had significantly higher sOBR (p<0.01) and adiponectin (p<0.01) levels than controls. Treatment with GH resulted in a decline in leptin (p<0.05) and TG (p<0.001) levels, an increase of homeostasis model assessment index and restored IGF-I levels (p<0.001). CONCLUSIONS: These data indicate that GH replacement has a negative effect on leptin levels and may also produce a slight unfavorable effect on carbohydrate metabolism. In addition, the changes observed in the adipokine profile appear to be independent of body mass index.

[Computerized interpretation of the electrocardiogram in the diagnosis of left ventricular hypertrophy. The ELECTROPRES project]. / Interpretación computarizada del electrocardiograma para el diagnóstico de hipertrofia del ventrículo izquierdo. Proyecto ELECTROPRES.

INTRODUCTION: Despite its low sensitivity, the electrocardiogram (ECG) is the tool used the most in the daily practice for detection of left ventricular hypertrophy (LVH). This study has aimed to assess the impact of the computerized interpretation of the ECG on the diagnosis of LVH in the practical clinical setting. METHODS: ELECTROPRES is a project based on a free access computer platform that permits an online interpretation of the electrocardiogram. It includes 19 different left LVH criteria previously validated by echocardiography in a substudy. We analyzed the data from the first 669 patients with essential arterial hypertension (ATH) included in the ELECTROPRES platform from 21 primary care centers in 9 of the 17 Spanish autonomous communities. RESULTS: Up to April 2010, a cohort of 669 hypertensive patients (51.7% women), with a mean age of 66.3±11.89 years, was analyzed. The mean evolution of the disease was 8 years, and the patients had been receiving an average of 2.4 antihypertensive agents. Systolic blood pressure was 139±17 mmHg and diastolic blood pressure 76±11. The ECG-known frequency of LVH was 3%. The prevalence of LVH increased up to 33.3% (P<0.001) with the ELECTROPRES platform. When all the criteria were independently examined, the Lewis index (R-I+S-III) and the Cornell product [(R-aVL+S-V3 (+6 for women)] were those in which the most cases of left ventricular hypertrophy were detected (24.8% and 13.3%, respectively). The Lewis index and the Cornell product were the criteria that detected more cases of left ventricular hypertrophy, regardless of the AHT stage and of the presence of cardiovascular complications. CONCLUSIONS: The ECG computerized reading (ELECTROPRES platform) significantly increases detection of left ventricular hypertrophy in a population of essential hypertense subjects compared to conventional detection with the ECG by the physician in the usual clinical practice setting.

Telemedicine, ethics, and law in times of COVID-19. A look towards the future.

The health emergency in Spain caused by COVID-19 was of such a magnitude that on March 14, 2020, a state of alarm was declared that lasted for more than three months. This ongoing pandemic has affected a vast number of people. Among the measures taken to reduce the risk of contagion, visits to health centers have been reduced and virtual consultations have increased. Once the pandemic ends, it will be necessary to consider whether telemedicine should be limited to periods of health crises or whether it could become a new way of practicing medicine. Telemedicine lacks specific regulations and has loopholes that leave physicians with a considerable degree of insecurity. This article analyzes the limits, precautions, and legal standards of the use of telemedicine.

[Should we modify our therapeutic behavior as a consequence of the 2009 revision of the ESH/ESC guidelines for the management of arterial hypertension]. / ¿Debemos modificar nuestra conducta terapéutica como consecuencia de la revisión de 2009 de la guía para el manejo de la hipertensión arterial de la ESH/ESC?

The recent publication in November 2009 of the revision of the European guidelines on hypertension management by the European Society of hypertension has aroused great interest. It has included the results of new important studies on hypertension, reinforcing the evidence on which the recommendations of the 2007 ESH/ESC guidelines were based. However, some of the recommendations that were firmly established until now are reconsidered. This dual aspect can generate some relevant doubts in clinical practice, even more so if we consider that some recommendations are opposite to other recently published guidelines. The presentation of a frequently appearing clinical case, as a hypertensive and diabetic female patient >65 years old, provides us the opportunity to analyze and interpret new recommendations, in comparison to the previous ones and to establish the best clinical action approach in the daily practice. In addition to the changes in the management of diabetic patients, some especially relevant aspects of the revised guide are updated, for example, subclinical injury of the target organ and its affect on cardiovascular risk stratification, how to manage those patients with high normal blood pressure values and other cardiovascular risk factors, the "new" blood pressure goals, as well as the objectives and the treatments under specific conditions such as the elderly population and the associated cardiovascular disease.

Management of patients with heart failure treated in cardiology consultations: IC-BERG Study. / Manejo de los pacientes con insuficiencia cardiaca atendidos en la consulta de cardiología: Estudio IC-BERG.

OBJECTIVE: To determine the perception and management of heart failure with reduced ejection fraction (HFrEF) by clinical cardiologists and to establish a consensus with recommendations. METHODS: We employed the modified Delphi method among a panel of 150 experts who answered a questionnaire that included three blocks: definition and perception of patients with «stable¼ HFrEF (15 statements), management of patients with «stable¼ HFrEF (51 statements) and recommendations for optimising the management and follow-up (9 statements). The level of agreement was assessed with a Likert 9-point scale. RESULTS: A consensus of agreement was reached on 49 statements, a consensus of disagreement was reached on 16, and 10 statements remained undetermined. There was consensus regarding the definition of «stable¼ HF (82%), that HFrEF had a silent nature that could increase the mortality risk for mildly symptomatic patients (96%) and that the drug treatment should be optimised, regardless of whether a patient with HFrEF remains stable in the same functional class (98.7%). In contrast, there was a consensus of disagreement regarding the notion that treatment with an angiotensin receptor-neprilysin inhibitor is justified only when the functional class worsens (90.7%). CONCLUSIONS: Our current understanding of «stable¼ HF is insufficient, and the treatment needs to be optimised, even for apparently stable patients, to decrease the risk of disease progression.

Diabetes and hypertension. What is new?

Diabetes mellitus and hypertension are interrelated diseases that strongly predispose to atherosclerotic cardiovascular disease. If blood pressure control is critical to improve cardiovascular prognosis in the hypertensive population, this is even more important in high risk patients, such as those with diabetes. Despite that, most of them do not achieve blood pressure targets. The inhibition of the renin angiotensin system is the first logical therapy in the management of hypertensive patients with diabetes. However, since most of them will need at least two antihypertensive agents to attain blood pressure goals, the current question to be answered is which drugs are the best to associate. According to available evidence, two are the main options: a diuretic or a calcium channel blocker. Many beneficial effects have been described with the use of both. The recent results of ACCOMPLISH trial started to clarify this issue. However, there are still many questions to be resolved before a categorical recommendation may be given about this matter. In the present manuscript, the current data about the treatment of patients with hypertension and diabetes are reviewed.

[Failure Mode and Effects Analysis (FMEA) method applied to anticoagulation of patients with non-valvular atrial fibrillation]. / El método AMFE (Análisis Modal de Fallos y Efectos) aplicado a la anticoagulación de pacientes con fibrilación auricular no valvular.

OBJECTIVES: To contribute to the improvement of the process of anticoagulation in patients with nonvalvular atrial fibrillation (NVAF) through awareness and training activities for Primary Care Physicians. MATERIALS AND METHODS: A total of 38 focus groups, sequenced according to an adaptation of the Failure Mode and Effects Analysis (FMEA) method. Each meeting was driven by «brainstorming¼ methodology. The geographical representation was homogeneous, with a total of 482 national. physicians (444 Primary Care Physicians, and 38 cardiologists). The meetings were held between March 28 and June 20, 2017. RESULTS: The main unsafe actions that can lead to a haemorrhagic or thrombotic event are incorrect anticoagulation or lack of patient follow-up. These events are mainly caused by training deficiencies in the management of NVAF, or by not taking into account possible interactions with vitamin K antagonist drugs. The main recommendations to alleviate these failures were focused on a good follow-up of patients with NVAF, on creating or updating the protocols or clinical practice guidelines, and on promoting the continuous training of physicians who usually manage patients with non-valvular AF treated with oral anticoagulants. CONCLUSIONS: A significant percentage of patients with NVAF are not correctly anticoagulated. Specific actions are required to alleviate this problem. Among them, the importance of a general anticoagulation training was emphasised, and particularly, the use of direct oral anticoagulants.