Manejo integral de los factores de riesgo en enfermedad arterial periférica. Consenso de expertos / Comprehensive management of risk factors in peripheral vascular disease. Expert consensus

Antecedentes y objetivo: Actualmente existe cierta divergencia entre las principales guías de práctica clínica sobre el manejo de los factores de riesgo de la enfermedad arterial periférica (EAP). El objetivo de este proyecto es conocer el manejo de los factores de riesgo de la EAP en la práctica clínica y alcanzar un consenso multidisciplinar sobre las estrategias que se tienen que seguir para optimizar su identificación, tratamiento y seguimiento. Metodología: Consenso multidisciplinar mediante metodología Delphi. Resultados: En la consulta participaron 130 profesionales con amplia experiencia en EAP. Los resultados sugieren que para optimizar el control de los factores de riesgo, los esfuerzos deben dirigirse a: 1) promover la involucramiento y concienciación de todas las especialidades en la identificación y el cribado de la enfermedad; 2) garantizar la posibilidad de realizar el índice tobillo-brazo (ITB) en todas las especialidades implicadas; 3) fomentar estrategias de deshabituación del tabaquismo mediante el uso de fármacos, programas o derivaciones a unidades especializadas; 4) promover el seguimiento de una alimentación adecuada basada en la dieta mediterránea y la prescripción de ejercicio diario; 5) concienciar sobre la importancia de alcanzar unos valores de colesterol unido a lipoproteínas de baja densidad (cLDL) inferiores a 70 mg/Dl, especialmente en pacientes sintomáticos, pero también en asintomáticos (< 55 mg/dL tras la publicación de la guía de la European Society of Cardiology y la European Atherosclerosis Society [ESC/EAS]); 6) recomendar el uso de antiagregantes plaquetarios en pacientes asintomáticos con diabetes mellitus (DM) y/o ITB patológico; y 7) protocolizar la reevaluación del ITB anualmente en pacientes de alto riesgo. Conclusión: Las 22 estrategias consensuadas en el presente documento pretenden ayudar a los profesionales a optimizar el manejo multidisciplinar de los factores de riesgo de la EAP (AU)

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 (AU)

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.

Presence and significance of intestinal unicellular parasites in a morbidly obese population.

BACKGROUND: Obesity is a chronic disease whose pathogenesis has been related to changes in the intestinal microbiota. Yet, the role of protozoa and other unicellular eukaryotic parasites in this microenvironment is still largely unknown. Their presence within the gut ecosystem in obese subjects warrants further study, as well as their influence on the host metabolism and comorbidities. METHODS: Herein, a single center, cross-sectional study of 104 obese individuals was performed to assess the presence of six intestinal unicellular parasites in stool using a commercially available kit, and to evaluate its relationship with the presence of abdominal symptoms, metabolic comorbidities, variations in body composition and nutritional deficiencies. RESULTS: The overall parasitic colonization rate was 51%, with Blastocystis sp., identified as the most frequent (44.2%), followed by Dientamoeba fragilis (11.5%) and Giardia intestinalis (8.7%), and significantly related to the consumption of ecological fruits and vegetables. Contrary to what previous studies pointed out, colonization with parasites species was significantly associated with fewer abdominal symptoms and depositions per day. The presence of parasites did not correlate with any nutritional deficiencies nor differences in body composition, while it did with significant lower HOMA-IR levels and a lower trend towards metabolic syndrome. CONCLUSION: Obese subjects frequently harbor unicellular enteric parasites, apparently without clinical nor nutritional harm. This evidence suggests that carrying these microorganisms, from an endocrinological perspective, has a beneficial effect, especially on insulin resistance and possibly on the development of related comorbidities.

Resumen ejecutivo: Documento de posicionamiento: evaluación y manejo de la hipoglucemia en el paciente con diabetes mellitus 2020. Grupo de Trabajo de Diabetes Mellitus de la Sociedad Española de Endocrinología y Nutrición / Executive summary: Position document: Evaluation and management of hypoglycemia in the patient with diabetes mellitus 2020. Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition

Proporcionar unas recomendaciones prácticas para la evaluación y el manejo de la hipoglucemia en pacientes con diabetes mellitus. Miembros del Grupo de Trabajo de Diabetes Mellitus de la Sociedad Española de Endocrinología y Nutrición (SEEN). Las recomendaciones se formularon según el sistema Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) para establecer tanto la fuerza de las recomendaciones como el grado de evidencia. Se realizó una búsqueda sistemática en MEDLINE (PubMed) de la evidencia disponible para cada tema, y se revisaron artículos escritos en inglés y castellano con fecha de inclusión hasta el 28 de febrero de 2020. En este resumen ejecutivo incluimos la evidencia reciente incorporada desde 2013. El documento establece unas recomendaciones prácticas basadas en la evidencia acerca de la evaluación y manejo de la hipoglucemia en pacientes con diabetes mellitus.

To provide practical recommendations for the evaluation and management of hypoglycemia in patients with diabetes mellitus. Members of the Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition (SEEN). The recommendations were made based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to establish both the strength of the recommendations and the level of evidence. A systematic search was made in MEDLINE (PubMed) for the available evidence on each subject, and articles written in English and Spanish with an inclusion date up to 28 February 2020 were reviewed. This executive summary takes account of the evidence incorporated since 2013. The document establishes practical evidence-based recommendations regarding the evaluation and management of hypoglycemia in patients with diabetes mellitus.

Hepatic and pancreatic fat as imaging biomarkers of metabolic syndrome. / Valoración de la grasa hepática y pancreática como biomarcadores de imagen en el síndrome metabólico.

OBJECTIVE: To objectively evaluate hepatic and pancreatic involvement in metabolic syndrome through magnetic resonance imaging (MRI) biomarkers. MATERIAL AND METHODS: From an initial retrospective sample of 407 patients diagnosed with metabolic syndrome studied by MRI in a single center during a 2-year period, 154 were excluded because of a lack of clinical and/or laboratory data, pancreatic abnormalities, or inadequate quality of MRI studies. To measure hepatic and pancreatic fat, we used chemical shift imaging (in-phase and out-of-phase), measuring the fat fraction (%) in regions of interest in the pancreas and liver. Associations between the fat fraction and selected clinical and laboratory variables were assessed with beta regression models. RESULTS: In the end, 253 patients were included. The hepatic fat fraction was 4.9% and the pancreatic fat fraction was 7.9%. We found no significant associations between the hepatic fat fraction and any of the clinical or laboratory variables. However, the pancreatic fat fraction was positively associated with age (OR=1.025, p<0.001) and baseline glucose (OR=1.005, p<0.001). Patients with diabetes had higher values of pancreatic fat fraction (OR=2.64, p=0.038). Pancreatic fat fraction and hepatic fat fraction were positively associated (OR=69.44, p<0.001). CONCLUSIONS: Pancreatic steatosis can be considered a marker of metabolic syndrome and diabetes. Quantitative MRI enables the diagnosis and grading of fatty pancreas through simple chemical shift techniques.

Intensified blood glucose treatment in diabetic patients undergoing a liver transplant: impact on graft evolution at 3 months and at 5 years.

PURPOSE: The debate about the impact of intensified hyperglycemia treatment is still ranging. The main objective was to assess whether intensive glycemic control in hospitalized diabetic patients undergoing a liver transplant is associated with a lower rate of graft rejection at 3 months and at 5 years post-transplant. METHODS: Cross-sectional study comparing a cohort of patients undergoing liver transplant in 2010 and 2011, in whom an intensive insulin protocol was applied, with a retrospective group of patients undergoing a liver transplant in 2005 and 2006, in whom a conventional insulin protocol was applied. Both diabetics and non-diabetics were compared. As intensive insulin therapy is applied mainly in diabetic patients, it is expected that, when comparing both periods, the treatment would only benefit those patients. RESULTS: The logistic regression model showed a statistically significant interaction between the treatment group and the presence of diabetes for the rejection rate 3 months and 5 years post-transplant. At both time points, the intensive insulin treatment group had lower rejection rates in the case of diabetic patients, which did not occur in non-diabetic patients. CONCLUSIONS: Our study shows a decrease in the rate of liver graft rejection in diabetic patients undergoing intensive insulin treatment.

Nutritional screening in a case management program for community-living older individuals at high risk of hospital admission.

BACKGROUND: The prevalence of malnutrition in older persons depends on the healthcare setting. In recent years, hospital-based case management programs (CM Programs) targeting individuals in the community with chronic multimorbidity and high use of hospital resources (admissions or emergency visits) have been developed in many countries to reduce the need for complex health care. The objective of this study was to assess the prevalence of risk of malnutrition, using the Short Form of the Mini-Nutritional assessment, of community dwelling patients included in a chronic CM Program. Factors associated with malnutrition risk were also explored. METHODS: Patients included in a hospital-based integrated CM Program for older persons at high risk for hospital readmission after an index admission were studied. MNA-SF was used at program inclusion to assess the risk of malnutrition. An array of factors potentially associated with malnutrition were explored (including feeding route, use of dental prosthesis, dysphagia, consistency of foods, specific therapeutic diets, use of oral nutritional supplements, polypharmacy, falls, and other diseases and geriatric syndromes). RESULTS: 791 participants were included, mean age 79.8 years, 50.1% females. Risk of malnutrition was present in 44.9%. Participants at risk of malnutrition were more frequently female, had a lower BMI, were less likely to be fed orally and used more nutritional supplements. They also had a higher prevalence of dysphagia, needing changes in food consistency or using specific therapeutic diets, and had dementia or cancer more frequently. They also showed a higher need for palliative care. CONCLUSIONS: Risk of malnutrition in patients included in a CM Program is higher than in non-selected community dwelling older individuals. This information may help inform screening policies in similar populations at risk of hospital readmission.

Investigación en sarcopenia: importancia de la metodología. Réplica / Research in sarcopenia: importance of methodology. Reply

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Prevalencia de sarcopenia en una unidad de media y larga estancia / Prevalence of sarcopenia in a media and long stay Unit

Antecedentes. La sarcopenia se caracteriza por la pérdida de masa y fuerza muscular esquelética y representa un factor de riesgo de fragilidad, pérdida de independencia y discapacidad física. Este estudio pretende valorar la prevalencia de sarcopenia en una población de pacientes ingresados en una unidad de media-larga estancia. Pacientes y métodos. Estudio descriptivo, longitudinal y observacional que incluyó a 166 pacientes mayores de 18 años ingresados de forma consecutiva durante un año para tratamiento paliativo, convalecencia o rehabilitación. Se registraron datos administrativos y antropométricos. La detección de sarcopenia se realizó mediante la valoración de la fuerza muscular en cintura escapular y pélvica, fuerza prensil en manos, masa muscular y de la capacidad funcional física. Resultados. La prevalencia global de sarcopenia fue del 77,6%. La mayor parte de los pacientes con sarcopenia presentaban sarcopenia severa (91,2%), con los 3 parámetros valorados disminuidos: fuerza muscular (88,2%), masa muscular (85,5%) y rendimiento físico (94,70%). Conclusiones. La prevalencia de sarcopenia en los pacientes ingresados en nuestra unidad de media-larga estancia es muy elevada, superior a la descrita en población no institucionalizada, y con frecuencia tiene un grado importante de severidad (AU)

Background. Sarcopenia is characterized by the loss of skeletal muscle mass and strength and represents a risk factor for frailty, loss of independence and physical disabilities. This study aimed to assess the prevalence of sarcopenia in a population of patients admitted to a media and long-stay unit. Patients and methods. Descriptive, cross-sectional observational study that included 166 patients over 18 years who were admitted consecutively for a year to palliative care, convalescence or rehabilitation. Administrative and anthropometric data were recorded. Sarcopenia detection was performed by assessing the strength in the scapular and pelvic girdle muscles, grip strength in the hands, muscle mass and physical functional capacity. Results. The overall prevalence of sarcopenia was 77.6%. Most patients had severe sarcopenia (91.2%), with reduced levels of the 3 assessed parameters: muscle strength (88.2%), muscle mass (85.5%) and physical performance (94.70%). Conclusion. The prevalence of sarcopenia in patients admitted to our media and long-stay unit is higher than that reported in noninstitutionalized populations, and often has a significant degree of severity (AU)

Prevalence of sarcopenia in a media and long stay Unit. / Prevalencia de sarcopenia en una unidad de media y larga estancia.

BACKGROUND: Sarcopenia is characterized by the loss of skeletal muscle mass and strength and represents a risk factor for frailty, loss of independence and physical disabilities. This study aimed to assess the prevalence of sarcopenia in a population of patients admitted to a media and long-stay unit. PATIENTS AND METHODS: Descriptive, cross-sectional observational study that included 166 patients over 18 years who were admitted consecutively for a year to palliative care, convalescence or rehabilitation. Administrative and anthropometric data were recorded. Sarcopenia detection was performed by assessing the strength in the scapular and pelvic girdle muscles, grip strength in the hands, muscle mass and physical functional capacity. RESULTS: The overall prevalence of sarcopenia was 77.6%. Most patients had severe sarcopenia (91.2%), with reduced levels of the 3 assessed parameters: muscle strength (88.2%), muscle mass (85.5%) and physical performance (94.70%). CONCLUSION: The prevalence of sarcopenia in patients admitted to our media and long-stay unit is higher than that reported in noninstitutionalized populations, and often has a significant degree of severity.

Detection of glucose abnormalities in patients with acute coronary heart disease: study of reliable tools in clinical practice.

AIM: To investigate the prevalence of glucose abnormalities in patients with acute coronary syndrome and to assess the reliability of certain clinical or analytical variables to predict a pathologic result of oral glucose tolerance test (OGTT) at 3 months from discharge. SUBJECTS AND METHODS: Prospective study of 102 patients admitted to the coronary care units. Patients were classified according to the American Diabetes Association criteria. Three months after discharge, an OGTT was performed to non-diabetic patients. RESULTS: Forty-six (45.1%) patients were identified as diabetic (5 previously undiagnosed) and 56 (54.9%) as non-diabetic. OGTT identified 22% of diabetes, 33% of impaired glucose tolerance, and 45% of normal glucose tolerance. Fasting glucose (r=0.55, p<0.001), glycated hemoglobin (HbA1c) (r=0.46, p<0.001), low HDL cholesterol (HDLc) levels (r=-0.34, p<0.02), waist-hip ratio (r=0.45, p<0.01), high systolic blood pressure (r=0.5, p<0.01), and presence of acute myocardial infarction (r=0.46, p<0.001) at admission resulted significant to predict a pathologic result of OGTT. CONCLUSIONS: Glucose abnormalities are frequent in acute coronary syndrome patients. Certain clinical and analytical markers at admission such as fasting glucose, HbA1c, HDL-c<40 mg/dl, waist-hip ratio, and systolic blood pressure, are useful to recognize patients with a higher predisposition to present a pathologic result in OGTT at 3 months from discharge.

Importance of technical aspects in the beginnings of a pancreas transplantation program.

Pancreas and kidney transplantation is the treatment of choice for patients with type 1 diabetes mellitus and terminal renal insufficiency. Herein we have presented a series of 35 patients transplanted between 2002 and 2009 including periods before and after 2007 divided based on introduction of some technical aspects. In the first phase (learning period) we have noted complications related to pancreatic surgery with a morbidity among 12 of 18 patients (66.6%). In the second period (stabilization period), complications appeared in 6 out of 17 patients (35.2%; P < .028). The reoperation rate was 83.3% in the learning period and 23.5% in the stabilization period (P < .03). Seven transplantectomies were performed in the first period (P < .004). Five patients died, all of them in the learning group (P < .019). Changes in the technical aspects of the procedure were responsible for improved outcomes obtained among pancreas and kidney transplantations.

Diabetes mellitus after kidney transplantation: role of the impaired fasting glucose in the outcome of kidney transplantation.

INTRODUCTION: Most patients suffering from chronic renal insufficiency show impaired carbohydrate metabolism. Our goals were to analyze the accumulated incidence of impaired fasting glucose (IFG) and post-transplant diabetes mellitus (PTDM) after kidney transplantation in our hospital, to assess their impacts on the survival of the graft and of the patient, and to discover the major risk factors for the development of PTDM. MATERIALS AND METHODS: We examined alterations in carbohydrate metabolism in 920 adult patients after they received kidney transplantation. Patients were followed for a minimum period of 5 yr. RESULTS: One year after transplantation, 12.8% of the patients had developed PTDM, and 10.3% showed an IFG level. The IFG had a negative and statistically significant influence on graft and patient survival. Host and donor age, weight, hepatitis C virus infection, and acute rejection were found to be significant risk factors. DISCUSSION: Our study found a high incidence of PTDM, as described in previous studies, but with an emphasis on a greater role played by IFG, not only in its incidence, but also as a prognostic factor for the outcome of graft and patient survival. Identifying patients at risk of developing PTDM is important in offering them early and appropriate treatment.

Determinación ambulatoria de HbA1c / Ambulatory HbA1c determination

La determinación de la HbA1c es el estándar de oro para la valoración del control metabólico en el paciente diabético. Debe ser realizada rutinariamente en todos los pacientes diabéticos para documentar el grado de control glucémico y para valorar la respuesta al tratamiento. La cifra de HbAlc refleja la glucemia media en los 2-4 meses precedentes, siendo el 50% de su valor representativo del mes previo. De entre los diferentes métodos para la determinación de la HbAlc, se deben elegir aquellos que estén estandarizados de acuerdo con el Nacional Glycohemoglobin Standardization Program (NGSP), con un coeficiente de variación (CV) interensayo e intraensayo < 3%, Y un CV interlaboratorio < 5%. La determinación ambulatoria de HbAlc, al utilizar en el caso del DCA 2000 un método de inmunoanálisis, permite la determinación directa de la HbA¡c y tiene una buena correlación con los métodos de laboratorio central (r = 0,92). Además, facilita la tomas de decisiones por su rapidez, y puede suponer un ahorro en costes indirectos al evitar ausencias laborales y visitas a la sala de extracciones

HbA1c testing is the gold standard use to know metabolic control in diabetic patients. HbAlc testing should be performed routinely in all patients with diabetes, first to document the degree of glycemic control and then to evaluate the response to treatment. At least, 50% of the level of HbAlc is determined by the plasma glucose level during the preceding month. Several assays to measure HbAlc are currently available, but there must be chosen those that are standardized in agreement with the Nacional Glycohemoglobin Standardization Program, with a interassay and intraassay CV < 3%, and an interlaboratory CV < 5%. The ambulatory determination of HbA1c with the DCA 2000 using an immunologic method adds the advantages of direct determination of the HbAlc and good correlation with the methods of centrallaboratory (r = 0.92). Furthermore, improves the clinical decision-making process because of it is rapid method and may lead to saving indirect costs due to labour absences and to the time lost during the visits to room extractions

Plasma cell granuloma of the thyroid and Hashimoto thyroiditis.

Plasma cell granuloma of the thyroid is a rare tumor-like lesion formed by a localized proliferation of inflammatory cells, supported by a stroma of fibrous tissue. Few cases have been previously reported in the medical literature. We report a new case of a 41-year-old man presenting a goiter with primary hypothyroidism (thyroid-stimulating hormone, 70 mIU/L; free thyroxine, < 0.01 pmol/L; triiodothyronine, 0.66 nmol/L) and elevation of thyroid antibodies. Several fine-needle aspiration biopsies of the thyroid were fruitless and total thyroidectomy was performed. Histologic and immunohistochemical study demonstrated the polyclonal nature of the cells and yielded a diagnosis of plasma cell granuloma. Histologic findings of Hashimoto thyroiditis were present too.

[Unusual metastasis of differentiated thyroid carcinoma]. / Metástasis poco habituales del carcinoma diferenciado de tiroides.

Distant metastases of differentiated thyroid cancer are usually localised in the lung and bone; less common sites of metastases are the brain, liver, and skin. To find it in other sites it is exceptional. This work shows the clinical, histological and therapeutical characteristic of primary tumour in three cases of non-typical distant metastases of differentiated thyroid cancer. Follicular thyroid carcinoma was displayed in two cases, the first presented one metastases in right adrenal gland and the second in left kidney. Both cases were initially treated only with hemithyroidectomy, without posterior radioiodine. In one case, elevated serum thyroglobulin did not receive radioiodine treatment because Whole-Body Scintigraphy was negative. The thirst case was a papillary thyroid carcinoma treated with total thyroidectomy, ablative radioiodine and suppressor therapy with levothyroxine. However, posterior evolution was unfavourable and tumour presented metastases in common and less common sites like choroid. Histological study showed tall cell variant of papillary thyroid carcinoma. In summary, when the initial treatment of well-differentiated thyroid carcinoma it is inaccurate, it is possible to find common and less common sites metastases. Some variants of papillary thyroid carcinoma, like tall cell, have a worse prognosis and they can present metastases in less common sites.

Consenso sobre diagnóstico y tratamiento de las alteraciones del metabolismo hidrocarbonado en la fibrosis quística / Consensus on the diagnosis and management of cystic fibrosis related diabetes

La alteración del metabolismo hidrocarbonado es una complicación frecuente de la fibrosis quística. La diabetes relacionada con fibrosis quística (DRFQ) se debe a una disminución en la secreción de la insulina secundaria a la insuficiencia pancreática. Los pacientes con fibrosis quística y diabetes presentan mayor morbilidad y mortalidad y el mismo riesgo de las complicaciones crónicas de la diabetes que los pacientes con diabetes tipo 1o 2.El diagnóstico precoz y el tratamiento adecuado de la diabetes de estos pacientes es imprescindible. En mayo de 2000tuvo lugar en Madrid una conferencia de consenso sobre DRFQ para definir las pautas para su diagnóstico y tratamiento (AU)