Delphi-based recommendations for the management of cardiovascular comorbidities in patients with psoriatic arthritis and moderate-to-severe psoriasis.

The aim of this study was to generate practical recommendations to assist rheumatologists and dermatologists in the management of cardiovascular (CV) comorbidities in patients with moderate-to-severe psoriasis (MS-PSO) and psoriatic arthritis (PsA). A two-round Delphi study was conducted. A panel of experts rated their agreement with a set of statements (n = 52) on a nine-point Likert scale (1 = totally disagree; 9 = totally agree). Statements were classified as inappropriate (median 1-3), irrelevant (median 4-6) or appropriate (median 7-9). Consensus was established when at least two-thirds of the panel responded with a score within any one range. A total of 25 experts, 60% rheumatologists and 40% dermatologists, participated in two consultation rounds. There was overall unanimity on the appropriateness of an initial assessment for CV risk factors in all patients with MS-PSO and PsA. Most panelists (88.0%) also supported the evaluation of patients' psychological and physical status. Additionally, most panelists (72.2%) agreed on a novel sequential approach for the management of CV comorbidities. This sequence starts with the assessment of hypertension, diabetes and dyslipidemia along with the identification of depression and anxiety disorders. Once these factors are under control, smoking cessation programs might be initiated. Finally, if patients have not met weight loss goals with lifestyle modifications, they should receive specialized treatment for obesity. This study has drawn up a set of practical recommendations that will facilitate the management of CV comorbidities in patients with MS-PSO and PsA.

Telemedicina, centros penitenciarios y enfermedad por VIH / Telemedicine, prison and illness associated with HIV

OBJETIVOS: Comunicar la actividad de telemedicina, desde su apertura, entre una consulta hospitalaria de enfermedades infecciosas y un centro penitenciario. MATERIAL Y MÉTODOS: Estudio descriptivo de la teleconsulta de enfermedades infecciosas del Hospital Universitario Fundación Alcorcón con el centro penitenciario de Navalcarnero desde 2013 hasta 2017, que se lleva a cabo mediante videoconferencia. Se analizó motivo y número de consultas, diagnóstico de VIH, tratamiento antirretroviral (TAR), situación inmunovirológica, diagnóstico del virus de la hepatitis C (VHC) e intervención realizada por el experto en infecciosas. RESULTADOS: Se valoraron 75 pacientes en un total de 168 consultas (en el primer año 11 consultas y en el quinto 62). El índice de consultas sucesivas/nuevas fue de 1,24 y el 85% de los pacientes requirió menos de 1 año de seguimiento. El 84% de los pacientes no se trasladó al hospital. El 99% de los pacientes aceptó esta modalidad. El 96% era VIH positivo, el 94% de estos tomaba TAR y el 85% tenía carga viral indetectable con 532 CD4/mL de mediana. El 90% tenía serología positiva para VHC. El 72% de las consultas fue para la valoración de tratamiento del VHC, que fue sofosbuvir/ledipasvir en un 63%. Un 40% cambió de TAR (70% para evitar interacciones). CONCLUSIÓN: La mayoría de los pacientes valorados tienen infección por VIH. Esta modalidad de consulta tiene una demanda creciente, es eficiente (evita traslados y es resolutiva) y tiene elevada aceptación. El motivo de consulta más frecuente fue el tratamiento del VHC y más de la tercera parte de los pacientes precisó cambio de TAR

OBJECTIVES: Communicate the activity of telemedicine, from its opening, between a hospital consultation of infectious diseases and a penitentiary center. MATERIAL AND METHODS: Descriptive study of the tele-consultation of infectious diseases of the Alcorcón Foundation University Hospital with the Navalcarnero penitentiary center from 2013 to 2017, which is carried out by videoconference. The reason and number of consultations, diagnosis of HIV, antiretroviral treatment (ART), immunovirological situation, diagnosis of hepatitis C virus (HCV= and intervention performed by the infectious expert were analyzed. RESULTS: A total of 75 patients were evaluated in a total of 168 consultations (in the first year 11 consultations and in the fifth year 62). The index of successive / new consultations was 1.24 and 85% of the patients required less than 1 year of follow-up.84% of patients did not move to the hospital.99% of patients accepted this modality.96% were HIV positive, 94% of them took ART and 85% had undetectable viral load with 532 CD4/mL of medium.90% had positive serology for HCV.72% of the consultations were for the assessment of HCV treatment, which was sofosbuvir/ledipasvir by 63%.40% changed their ART (70% to avoid interactions). CONCLUSION: Most of the evaluated patients have HIV infection. This type of consultation has a growing demand, is efficient (avoids transfers and is decisive) and has high acceptance. The most frequent reason for consultation was the treatment of HCV and more than a third of patients required ART change

¿Puede regresar la arteriosclerosis mediante la disminución extrema del colesterol? Respuestas a partir del estudio GLAGOV / Can arteriosclerosis regress through extreme cholesterol lowering? Answers from the GLAGOV trial

La angiografía convencional ha facilitado la evaluación de la evolución de las estenosis coronarias en las últimas décadas del siglo xx. Con esta técnica se ha demostrado que el tratamiento hipolipemiante con estatinas puede frenar la reducción de la luz vascular coronaria. La incorporación de la ecografía intravascular (IVUS) ha permitido una mejor evaluación de las lesiones aterosclerosas de la pared de las coronarias. Mediante IVUS, se ha demostrado que el tratamiento hipolipemiante intensivo con estatinas es capaz de hacer regresar las lesiones coronarias si se alcanzan valores de colesterol unido a lipoproteínas de baja densidad (cLDL) inferiores a 80 mg/dl. Se han obtenido resultados similares con el uso de ezetimiba. Recientemente se ha evaluado por primera vez el efecto de evolocumab, un anticuerpo humano frente a PCSK9, sobre las lesiones coronarias en el estudio GLAGOV. El evolocumab redujo significativamente, en torno al 60%, los valores de cLDL hasta cifras inferiores a 40 mg/dl en comparación con el placebo y demostró que dicho efecto se asocia a una regresión de las placas coronarias medidas con IVUS, que persiste hasta concentraciones finales de cLDL de 20 mg/dl. Evolocumab ha demostrado estos efectos protectores en ausencia de efectos secundarios significativos. Las implicaciones pronósticas favorables de la regresión de las lesiones aterosclerosas, ya conocidas con las estatinas, han sido recientemente confirmadas para evolocumab en el estudio FOURIER (AU)

Conventional angiography allowed the evaluation of the development of coronary stenosis in the last decades of the twentieth century. This technique has demonstrated that lipid-lowering therapy with statins can halt the shrinking of the coronary lumen. The incorporation of intravascular ultrasound (IVUS) has improved the assessment of atherosclerotic lesions of the coronary artery wall. Through IVUS, it has been demonstrated that lipid-lowering with high-intensity statin therapy is able to induce regression of coronary lesions if low-density lipoprotein cholesterol levels (LDLc) are reduced to below 80 mg/dl. Similar results have been obtained with the use of ezetimibe. Recently, the effect of evolocumab, a human anti-PCSK9 antibody, has been evaluated in the GLAGOV trial. Evolocumab significantly reduced (by around 60%) LDLc levels to levels lower than 40 mg/dl as compared to placebo. This effect was associated with the regression of coronary plaques as demonstrated by IVUS and persisted down to final LDLc levels of 20 mg/dl. The protective effects of evolocumab were obtained in the absence of significant adverse effects. The favourable prognostic implications of the regression of atherosclerotic lesions, already known with statins, have recently been confirmed for evolocumab in the FOURIER trial (AU)

[Monoclonal antibodies against PCSK9: from bench to clinic]. / Anticuerpos monoclonales frente a PCSK9: del desarrollo básico a la clínica.

Antibodies are glycoproteins with high specificity binding to multiple antigens due to the large number of structural conformations of the variable chains. Hybridoma technology (fusion of myeloma cells with immunoglobulin-producing lymphocytes) has allowed the synthesis of large quantities of unique antibodies (monoclonal [mAb]). mAbs were initially murine. Subsequently, chimeric mAbs were developed, followed by humanized mAbs and finally human mAbs. The high selectivity and good tolerance of human mAbs allows their therapeutic administration to block specific exogenous or endogenous molecules. Selective human mAbs to the catalytic domain of PCSK9 have recently been developed. These antibodies block PCSK9, favour low-density lipoprotein receptor recycling and markedly reduce circulating cholesterol. Preliminary studies indicate that lowering cholesterol through anti-PCSK9 antibodies may significantly reduce the cardiovascular complications of arteriosclerosis.

Anticuerpos monoclonales frente a PCSK9: del desarrollo básico a la clínica / Monoclonal antibodies against PCSK9: from bench to clinic

Los anticuerpos son glucoproteínas con alta especificidad de unión a múltiples antígenos gracias al gran número de conformaciones estructurales de sus cadenas variables. La tecnología de los hibridomas (fusión de células de mieloma no secretor con linfocitos productores de inmunoglobulinas) ha permitido la síntesis de grandes cantidades de anticuerpos únicos (monoclonales [mAb]). Los mAb iniciales eran murinos, posteriormente se desarrollaron mAb quiméricos, humanizados y finalmente humanos. La alta selectividad y buena tolerancia de los mAb humanos permite su administración terapéutica para el bloqueo de determinadas moléculas (endógenas o exógenas). Recientemente se han desarrollado mAb humanos selectivos para la zona catalítica de PCSK9 (proproteína convertasa subtilisina/kexina tipo 9). Estos anticuerpos bloquean la PCSK9, favorecen el reciclaje del receptor de lipoproteínas de baja densidad y reducen de modo notable el colesterol circulante. Estudios preliminares indican que la reducción del colesterol mediante anticuerpos anti-PCSK9 puede implicar importantes reducciones en las complicaciones cardiovasculares de la arteriosclerosis

Antibodies are glycoproteins with high specificity binding to multiple antigens due to the large number of structural conformations of the variable chains. Hybridoma technology (fusion of myeloma cells with immunoglobulin-producing lymphocytes) has allowed the synthesis of large quantities of unique antibodies (monoclonal [mAb]). mAbs were initially murine. Subsequently, chimeric mAbs were developed, followed by humanized mAbs and finally human mAbs. The high selectivity and good tolerance of human mAbs allows their therapeutic administration to block specific exogenous or endogenous molecules. Selective human mAbs to the catalytic domain of PCSK9 have recently been developed. These antibodies block PCSK9, favour low-density lipoprotein receptor recycling and markedly reduce circulating cholesterol. Preliminary studies indicate that lowering cholesterol through anti-PCSK9 antibodies may significantly reduce the cardiovascular complications of arteriosclerosis

Consenso sobre los objetivos y pautas de actuación en el control del colesterol ligado a lipoproteínas de baja densidad en pacientes de muy alto riesgo cardiovascular / Consensus on objectives and action guidelines on low density lipoproteins-cholesterol control in very high risk cardiovascular patients

Introducción: La enfermedad cardiovascular es la principal causa de muerte en los países desarrollados. Entre sus factores de riesgo destaca los niveles de colesterol asociado a lipoproteínas de baja densidad (cLDL), pero existe gran controversia sobre la forma de reducirlos. Se obtuvo la opinión de un panel de expertos para clarificar los puntos más relevantes del control de la dislipidemia en pacientes de muy alto riesgo cardiovascular. Material y métodos: Encuesta realizada mediante el método Delphi en 2 rondas a 41 especialistas (cardiología/medicina interna). El cuestionario constaba de 55 ítems, estratificados en 4 bloques: cLDL como diana terapéutica, objetivos de reducción, causas del fracaso en la reducción y recomendaciones para optimizar la consecución de los objetivos terapéuticos. Resultados: Se alcanzó un alto grado de consenso en los ítems consultados en línea con las recomendaciones de las guías europeas. El panel consideró adecuado el objetivo terapéutico de 70 mg/dl de lipoproteínas de baja densidad en pacientes de muy alto riesgo cardiovascular (principalmente enfermedad vascular, diabetes mellitus e insuficiencia renal), empleando si es preciso tratamiento combinado. Sin embargo, la consecución de ese objetivo se vuelve compleja debido a distintos factores, como la falta de adherencia y la inercia. Conclusiones: Los expertos españoles tienen un alto grado de acuerdo con las recomendaciones europeas, ratificando el objetivo de control del cLDL en los pacientes de muy alto riesgo < 70 mg/dl. La simplificación de las guías y el tratamiento combinado pueden favorecer la mejora del control de los objetivos lipídicos

Introduction: Cardiovascular disease is the leading cause of death in developed countries. Among cardiovascular disease risk factors one of the most relevant is low-density lipoprotein-associated cholesterol (LDL-c), but there is controversy about the methods used to control it. The aim was to obtain an expert opinion to clarify the most relevant issues regarding the control of dyslipidemia in very high cardiovascular risk patients. Materials and methods: A survey with 55 items, stratified into 4 blocks: LDL-c as a therapeutic target, therapeutic goals, causes of the failure to achieve LDL-c goals, and recommendations to optimize their achievement, was addressed to 41 specialists (Cardiology and Internal Medicine) using the Delphi method to achieve professional consensus criteria. Results: A high consensus was reached among all items, in line with the European recommendations. The panelists considered that the goal of 70 mg/dl for LDL-c for high cardiovascular disease risk (mainly vascular disease, diabetes mellitus, and renal failure), using combined treatment when necessary. Lack of adherence and therapeutic inertia were considered the main reasons for treatment failure. Conclusion: The Spanish experts show an elevated consensus with the European recommendations, confirming the LDL-c control target of < 70 mg/dl. The simplification of the guidelines and the combined treatment may favor an improvement the achievement of lipid target goals

[Consensus on objectives and action guidelines on low density lipoproteins-cholesterol control in very high risk cardiovascular patients]. / Consenso sobre los objetivos y pautas de actuación en el control del colesterol ligado a lipoproteínas de baja densidad en pacientes de muy alto riesgo cardiovascular.

INTRODUCTION: Cardiovascular disease is the leading cause of death in developed countries. Among cardiovascular disease risk factors one of the most relevant is low-density lipoprotein-associated cholesterol (LDL-c), but there is controversy about the methods used to control it. The aim was to obtain an expert opinion to clarify the most relevant issues regarding the control of dyslipidemia in very high cardiovascular risk patients. MATERIALS AND METHODS: A survey with 55 items, stratified into 4 blocks: LDL-c as a therapeutic target, therapeutic goals, causes of the failure to achieve LDL-c goals, and recommendations to optimize their achievement, was addressed to 41 specialists (Cardiology and Internal Medicine) using the Delphi method to achieve professional consensus criteria. RESULTS: A high consensus was reached among all items, in line with the European recommendations. The panelists considered that the goal of 70mg/dl for LDL-c for high cardiovascular disease risk (mainly vascular disease, diabetes mellitus, and renal failure), using combined treatment when necessary. Lack of adherence and therapeutic inertia were considered the main reasons for treatment failure. CONCLUSION: The Spanish experts show an elevated consensus with the European recommendations, confirming the LDL-c control target of <70mg/dl. The simplification of the guidelines and the combined treatment may favor an improvement the achievement of lipid target goals.

Control del colesterol LDL en pacientes de muy alto riesgo vascular. Algoritmo simplificado para alcanzar objetivos de colesterol LDL «en dos pasos» / LDL cholesterol control in patients with very high cardiovascular risk. A simplified algorithm for achieving LDL cholesterol goals «in two steps»

La reducción de colesterol unido a lipoproteínas de baja densidad (cLDL) es el principal objetivo del tratamiento hipolipemiante del paciente de muy alto riesgo cardiovascular. En estos pacientes el objetivo terapéutico es conseguir un cLDL menor de 70 mg/dl, según las guías de prevención cardiovascular comúnmente utilizadas en España y en Europa. Sin embargo, el grado de consecución de objetivos en este grupo de pacientes es muy bajo. En este artículo se analiza la prevalencia de este problema y las causas que lo motivan. También se dan recomendaciones y herramientas que pueden facilitar el diseño de la estrategia de tratamiento óptima para lograr la consecución de objetivos. Además, se presenta una novedosa herramienta con un sencillo algoritmo que puede permitir el control del paciente de muy alto riesgo cardiovascular «en 2 pasos», es decir, con solo 2 visitas al médico

Reducing low density lipoprotein-cholesterol (LDL-c) is the main lipid goal of treatment for patients with very high cardiovascular risk. In these patients the therapeutic goal is to achieve a LDL-c lower than 70mg/dL, as recommended by the guidelines for cardiovascular prevention commonly used in Spain and Europe. However, the degree of achieving these objectives in this group of patients is very low. This article describes the prevalence of the problem and the causes that motivate it. Recommendations and tools that can facilitate the design of an optimal treatment strategy for achieving the goals are also given. In addition, a new tool with a simple algorithm that can allow these very high risk patients to achieve the goals «in two-steps», i.e., with only two doctor check-ups, is presented

[LDL cholesterol control in patients with very high cardiovascular risk. A simplified algorithm for achieving LDL cholesterol goals "in two steps"]. / Control del colesterol LDL en pacientes de muy alto riesgo vascular. Algoritmo simplificado para alcanzar objetivos de colesterol LDL "en dos pasos".

Reducing low density lipoprotein-cholesterol (LDL-c) is the main lipid goal of treatment for patients with very high cardiovascular risk. In these patients the therapeutic goal is to achieve a LDL-c lower than 70 mg/dL, as recommended by the guidelines for cardiovascular prevention commonly used in Spain and Europe. However, the degree of achieving these objectives in this group of patients is very low. This article describes the prevalence of the problem and the causes that motivate it. Recommendations and tools that can facilitate the design of an optimal treatment strategy for achieving the goals are also given. In addition, a new tool with a simple algorithm that can allow these very high risk patients to achieve the goals "in two-steps", i.e., with only two doctor check-ups, is presented.

Dislipidemias: un reto pendiente en prevención cardiovascular. Documento de consenso CEIPC/SEA / Dyslipidemias: a pending challenge in cardiovascular prevention. Consensus document from CEIPC/SEA Committee

En España, donde la enfermedad cardiovascular (ECV) es la primera causa de muerte, aproximadamente el 20% de los adultos presentan hipercolesterolemia, de los cuales sólo el 12% estarían controlados. El abordaje de las dislipemias debe realizarse en un contexto más amplio, mediante acciones encaminadas a reducir el riesgo cardiovascular (RCV). La medición del RCV facilita la toma de decisiones, pero no puede sustituir al juicio clínico, dadas las limitaciones de los métodos de cálculo disponibles. Este documento, elaborado por el Comité Español Interdisciplinar de Prevención Cardiovascular, a iniciativa de la Sociedad Española de Arteriosclerosis, describe las principales iniciativas en prevención cardiovascular de administraciones sanitarias y sociedades científicas, y el papel que juegan en ellas los profesionales sanitarios. Además de apoyar las iniciativas en marcha, se propone la puesta en marcha de una estrategia nacional de prevención cardiovascular, centrada en la modificación de estilos de vida (prevención del tabaquismo y promoción de la alimentación saludable y la actividad física) mediante acciones en todos los ámbitos. A nivel poblacional, la regulación de la publicidad alimentaria, la eliminación de los ácidos grasos trans y la reducción de azúcares añadidos en la cadena alimentaria constituyen intervenciones viables y coste-efectivas para ayudar a controlar las dislipemias y reducir el RCV. En el ámbito sanitario, se propone reducir las barreras para la aplicación de las guías, mejorar la formación de los profesionales en modificación de estilos de vida e incorporar la valoración del RCV entre los indicadores de calidad de la asistencia. Las sociedades científicas son responsables de colaborar con la administración y contribuir a la generación del conocimiento, su transmisión y su aplicación. Finalmente, está en manos de los profesionales evaluar al paciente dislipémico en el contexto del RCV, promover estilos de vida saludables y hacer un uso eficiente del arsenal terapéutico disponible (AU)

In Spain, where cardiovascular disease (CVD) is the leading cause of death, hypercholesterolemia, one of the most prevalent risk factors in adults, is poorly controlled. Dyslipidemia should not be approached in isolation, but in the context of overall cardiovascular risk (CVR). Measurement of CVR facilitates decision making, but should not be the only tool nor should it take the place of clinical judgment, given the limitations of the available calculation methods. This document, prepared by the Interdisciplinary Spanish Committee on Cardiovascular Prevention, at the proposal of the Spanish Society of Arteriosclerosis, reviews the cardiovascular prevention activities of the regional health authorities, scientific societies and medical professionals. An initiation of a national strategy on cardiovascular prevention is proposed based on lifestyle modification (healthy diet, physical activity and smoking cessation) through actions in different settings. At the population level, regulation of food advertising, elimination of trans fats and reduction of added sugar are feasible and cost-effective interventions to help control dyslipidemias and reduce CVR. In the health setting, it is proposed to facilitate the application of guidelines, improve training for medical professionals, and include CVR assessment among the quality indicators. Scientific societies should collaborate with the health authorities and contribute to the generation and transmission of knowledge. Finally, it is in the hands of professionals to apply the concept of CVR, promote healthy lifestyles, and make efficient use of available pharmacological treatments (AU)

[Dyslipidemias: a pending challenge in cardiovascular prevention. Consensus document from CEIPC/SEA Committee]. / Dislipidemias: un reto pendiente en prevención cardiovascular. Documento de consenso CEIPC/SEA.

In Spain, where cardiovascular disease (CVD) is the leading cause of death, hypercholesterolemia, one of the most prevalent risk factors in adults, is poorly controlled. Dyslipidemia should not be approached in isolation, but in the context of overall cardiovascular risk (CVR). Measurement of CVR facilitates decision making, but should not be the only tool nor should it take the place of clinical judgment, given the limitations of the available calculation methods. This document, prepared by the Interdisciplinary Spanish Committee on Cardiovascular Prevention, at the proposal of the Spanish Society of Arteriosclerosis, reviews the cardiovascular prevention activities of the regional health authorities, scientific societies and medical professionals. An initiation of a national strategy on cardiovascular prevention is proposed based on lifestyle modification (healthy diet, physical activity and smoking cessation) through actions in different settings. At the population level, regulation of food advertising, elimination of trans fats and reduction of added sugar are feasible and cost-effective interventions to help control dyslipidemias and reduce CVR. In the health setting, it is proposed to facilitate the application of guidelines, improve training for medical professionals, and include CVR assessment among the quality indicators. Scientific societies should collaborate with the health authorities and contribute to the generation and transmission of knowledge. Finally, it is in the hands of professionals to apply the concept of CVR, promote healthy lifestyles, and make efficient use of available pharmacological treatments.

Dolor dorsolumbar y adenopatías supraclaviculares en un varón de 67 años / No disponible

No disponible

Futilidad en demencias. Réplica / Futility in dementia. Response

No disponible

Decisiones al final de la vida: suspensión de antibióticos en presencia de infección activa / End-of-life decisions: foregoing antibiotic therapy in patients with an active infection

La limitación de esfuerzos terapéuticos es una medida escasamente evaluada en nuestro medio. Se valoran las características de los pacientes en los que se retiran los antibióticos en presencia de una infección activa. Se recogieron datos de todos los pacientes ancianos ingresados consecutivamente en medicina interna con infección activa a los que se les suspendía el antibiótico. Se compararon las características de los pacientes que fallecieron y de los que no. En el estudio se incluyó a 63 pacientes (8,9% de los ingresos); 84,6 ± 9,1 años. Un 86% tenía demencia, un 73%, incapacidad, y un 30%, neoplasia activa. El motivo de la retirada de los antibióticos fue siempre la percepción de una muerte cercana y/o la falta de respuesta al tratamiento. La mortalidad fue del 89%. Entre los que fallecieron, predominó el sexo femenino (el 95 frente al 76%) y tanto el tiempo sin antibiótico (2,9 frente a 8,5 días) como la estancia media (9,6 frente a 16,0 días) fueron más breves (p < 0,05). La suspensión del antibiótico es una medida no infrecuente en nuestro medio y está concentrada en pacientes con mal pronóstico vital y mala situación previa

Limitation of therapy has been little studied in our environment. Data were gathered on all patients with active infection consecutively admitted to the internal medicine department of our hospital in whom antibiotic therapy was withdrawn or withheld. The characteristics of patients who died and those of patients who survived were compared. A total of 63 patients (8.9% of admissions) were included; the mean age was 84.6 years ± 9.1. Dementia was present in 86%, incapacity in 73% and neoplasms in 30%. In all patients, the reason for withdrawing or withholding antibiotic treatment was the perception of impending death and/or lack of response to active treatment. In all patients, the families were involved in the decision to forego treatment. Mortality was 89%. Female sex was more common (95% versus 76%) and length of stay (9.6 versus 16.0 days) and time without antibiotic treatment (2.9 versus 8.5 days) were shorter in patients who died than in the group who survived. The decision to forego antibiotic treatment is not infrequent in our hospital. Most patients were elderly, had diseases with poor vital prognosis, and showed poor prior health status