Effects of a long-term lifestyle intervention program with Mediterranean diet and exercise for the management of patients with metabolic syndrome in a primary care setting.

BACKGROUND: The impact of a lifestyle intervention (LSI) program for the long-term management of subjects with metabolic syndrome in a primary care setting is not known. METHODS: This 3-year prospective controlled trial randomized adult subjects with metabolic syndrome to receive intensive LSI or to usual care in a community health centre in Malaga, Spain. LSI subjects received instruction on Mediterranean diet and a regular aerobic exercise program by their primary care professionals. Primary outcome included changes from baseline on different components of metabolic syndrome (abdominal circumference, blood pressure, HDL-cholesterol, fasting plasma glucose and triglycerides). RESULTS: Among the 2,492 subjects screened, 601 subjects with metabolic syndrome (24.1%) were randomized to LSI (n = 298) or to usual care (n = 303); of them, a 77% and a 58%, respectively, completed the study. At the end of the study period, LSI resulted in significant differences vs. usual care in abdominal circumference (-0.4 ± 6 cm vs. + 2.1 ± 6.7 cm, p < 0.001), systolic blood pressure (-5.5 ± 15 mmHg vs. -0.6 ± 19 mmHg, p = 0.004), diastolic blood pressure (-4.6 ± 10 mmHg vs. -0.2 ± 13 mmHg, p < 0.001) and HDL-cholesterol (+4 ± 12 mg/dL vs. + 2 ± 12 mg/dL, p = 0.05); however, there were no differences in fasting plasma glucose and triglyceride concentration (-4 ± 35 mg/dl vs. -1 ± 32 mg/dl, p = 0.43 and -0.4 ± 83 mg/dl vs. +6 ± 113 mg/dl, p = 0.28). CONCLUSION: Intensive LSI counseling provided by primary care professionals resulted in significant improvements in abdominal circumference, blood pressure and HDL-cholesterol but had limited effects on glucose and triglyceride levels in patients with metabolic syndrome.

Assessment of an educational intervention in the management of non-critical inpatient glycemic control.

In hospitalized diabetic patients, the recommended insulin therapy is basal bolus plus correction-dose regimen instead of sliding-scale insulin. The purpose of this study was to evaluate the effect of the implementation of a new protocol based on basal bolus therapy on managing diabetes in a university hospital setting. We performed a cross-sectional study before and 12 months after a 4-month intervention period to implement a basal bolus regimen in hospitalized patients. Non-critical patients admitted into the hospital for at least 72 h were included. Changes in prescribing habits, glucose control and incidence of hypoglycemia were evaluated. An increase in the use of the new protocol and a decrease in sliding scale were observed after the intervention. In the pre-intervention group, a total of 59.2% glucose readings were between 70 and 180 mg/dL versus 57.1% after the intervention, without observing statistical differences. Significant reductions in hypoglycemia between pre- and post-intervention (13.04 vs. 4.08%, p = 0.0215) were observed. The percentage of hospitalized diabetic patients who had HbA1c was 10.43 and 4.08% in pre- and post-intervention phases, respectively. The protocol showed beneficial outcomes in terms of fewer hypoglycemia episodes and reflected a change in prescription habits, but it did not improve glycemic control. Furthermore, the percentage of patients who had an HbA1c test during their hospitalization remained very low after the intervention. This fact may seriously limit the correct management of hyperglycemia after the hospital discharge.

Compliance with cardiovascular drug prevention measures in a general population: the Multidisciplinary Intervention in Primary Care (IMAP) study.

AIMS: To evaluate adherence to guideline-recommended drug therapies for primary and secondary cardiovascular prevention in a general Mediterranean population. SUBJECTS AND METHODS: A cross-sectional study was conducted in a random sample of 2270 individuals (18-80 years) assigned to a health centre in Malaga (Spain). The appropriate use was analysed of statins, antithrombotics, beta-blockers, and angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II type 1 receptor blockers (ARB), based on the criteria of the European Guidelines on Cardiovascular Prevention and the European Society of Hypertension-European Society of Cardiology. RESULTS: The prescription rate of statins, antithrombotics, beta-blockers, and ACEI/ARB was 7.8%, 5.1%, 3.3%, and 11%, respectively. The prescription of these drugs was inappropriate in 36.2%, 22.4%, 64.5%, and 0%, respectively. Overtreatment was more frequent in subjects with greater comorbidity or ≥ 2 vascular risk factors (p < 0.001). The percentage of individuals with prescription criteria but who did not receive the treatment was 19.5%, 4.7%, 2%, and 9.3%, respectively, increasing significantly with age, Charlson index, and the presence of ≥ 2 risk factors (p < 0.001). Only 11% of patients in secondary prevention received combination therapy with statins, antithrombotics, and ACEI/ARB. Patients with ischaemic heart disease, as compared to non-coronary vascular patients, more frequently received statins (56.1% vs. 25.6%; p = 0.0001) and antithrombotic drugs (66.7% vs. 56.4%; p = 0.02). CONCLUSIONS: We detected a low adherence to existing pharmacological guidelines for the prevention of cardiovascular disease. A priority is to establish appropriate training and dissemination of cardiovascular prevention guidelines in the field of primary care.

HbA(1c) in adults without known diabetes from southern Europe. Impact of the new diagnostic criteria in clinical practice.

AIMS: To analyse the differences in the prevalence of diabetes and dysglycaemia using fasting plasma glucose and HbA(1c) criteria. METHODS: Analytical cross-sectional study undertaken in a random sample of 2144 individuals (age 18-80 years) without known diabetes from the primary care setting in Malaga (Spain). Dysglycaemia was defined as fasting plasma glucose 5.6-6.9 mmol/l or HbA(1c) 39-46 mmol/mol (5.7-6.4%) and diabetes as fasting plasma glucose ≥ 7.0 mmol/l or HbA(1c)≥ 48 mmol/mol (≥ 6.5%). RESULTS: The proportion of subjects who were normoglycaemic was significantly higher using fasting plasma glucose than HbA(1c) (83.5 vs. 65%) (P < 0.0001). Compared with fasting plasma glucose, HbA(1c) detects more cases of dysglycaemia (32 vs. 14.8%) (P < 0.0001) and diabetes (3 vs. 1.7%) (P < 0.0001). CONCLUSIONS: In our environment, using HbA(1c) for the diagnosis of pre-diabetes and diabetes could increase the target population for preventive and therapeutic measures. Further cost-effectiveness studies are needed before the widespread diagnostic use of HbA(1c) can be recommended.

Prevalence of cardiovascular risk factors in an urban adult population from southern Spain. IMAP Study.

AIMS: To study the prevalence of cardiovascular risk factors in an urban population of Malaga, Spain and its relationship with educational level. METHODS: A cross-sectional study was performed with a random representative sample of 2270 individuals from the adult population (18­80 years) from a specific Health-Care Centre in Malaga City. All participants underwent a clinical interview, including social-demographical information and a physical examination. A blood sample was also drawn. RESULTS: The mean age of the participants was 43.6 ± 15.6 years and 57.6% had a low educational level. The prevalence of cardiovascular risk factors was: smoking 27.7%, hypertension 33.1%, diabetes 7.1% and dyslipidaemia 65.4%. Over 60% were either overweight or obese, and 76.7% had a sedentary lifestyle. Except for smoking and a low-HDL cholesterol, the prevalence of the other cardiovascular risk factors increased with age. A low educational level was associated with a high prevalence of cardiovascular risk factors, and this association was significant with regard to smoking, obesity, abdominal obesity and hypertriglyceridaemia. CONCLUSIONS: The population studied presents a high prevalence of cardiovascular risk factors, especially dyslipidaemia and obesity. The low academic level was associated with an increased prevalence of smoking, obesity and dyslipidaemia. People with a low socio-cultural level are a priority target for introducing policies to prevent and control cardiovascular disease.

[Transient ischemic attack due to Lambl's excrescence. Report of a case and review of the literature]. / Accidente isquémico transitorio secundario a excrecencia de Lambl. Descripción de un caso y revisión de la literatura.

We describe a 42-year-old man presenting in the emergency department with transient ischemic attack without cardiovascular risk factors. Systemic disease and hypercoagulability substract was discarded. Only transesophageal echocardiography could confirm the presence of a Lambl's excrescence in the aortic valve (valvular strand). We review clinical management and new therapeutic options in stroke prevention used in this unusual source of cardiac embolism.

Accidente isquémico transitorio secundario a excrecencia de Lambl. Descripción de un caso y revisión de la literatura / Transient ischemic attack due to Lambl s excrecence. Report of a case and review of the literature

Describimos el caso de un varón de 42 años, sin factores de riesgo cardiovasculares conocidos que presentó un accidente isquémico transitorio. Se descartó enfermedad sistémica y sustrato de hipercoagulabilidad como causa del mismo. Sólo mediante un estudio ecocardiográfico transesofágico se pudo confirmar una excrecencia de Lambl localizada en la válvula aórtica (strand valvular). Se realiza una revisión acerca del manejo clínico y las nuevas opciones terapéuticas en la prevención del ictus de esta inusual fuente cardioembólica

We describe a 42-year-old man presenting in the emergengy departament with transient ischemic attack without cardiovascular risk factors. Systemic disease and hypercoagulability substract was discarded. Only transesophageal echocardiography could confirm the presence of a Lambl’s excrescence in the aortic valve (valvular strand). We review clinical management and new therapeutic options in stroke prevention used in this unusual source of cardiac embolism

Sindrome de Zieve / Zieve's syndrome

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Leiomioma duodenal gigante: a propósito de un caso / Giant duodenal leiomioma, case report

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[Fever of unknown origin as initial manifestation of Castleman's disease: apropos of 2 cases]. / Fiebre de origen desconocido como primera manifestación de enfermedad de Castleman: a propósito de dos casos.

Castleman's disease is a rare lymphoproliferative disorder with a great range of clinical presentation and localization. It usually appears in young people and its etiology is unknown. Clinical features are not specific: fever, asthenia, hypochromic anemia and hypergammaglobulinemia. We report here two cases of Castleman's disease whose peculiarity lies in the fact that the first sign was fever of unknown origin. In both cases the use of a CT scan was very important for the diagnosis.

[Effect of cyclosporine on plasma levels of uric acid in patients treated with bone marrow transplantation]. / Efecto de la ciclosporina sobre los niveles plasmáticos de ácido úrico en pacientes trasplantados de médula ósea.

In patients treated with cyclosporine, an increase in the incidence of goiter has been demonstrated. This agent produces changes in the lipidic metabolisms, among which the increase in VLDL stands put. Given that the hyperlipemia more frequently associated to hyperuricemia is the increase of such lipoprotein, we decided to study the behaviour of plasmatic uric acid in patients receiving treatment with cyclosporine. The study was conducted in patients with bone marrow transplant undergoing immunosuppressive therapy, considering the effect of cyclosporine as the only drug or following a scheme of mixed immunosuppression associated to prednisone. We observed a reversible increase in the plasmatic levels of uric acid in patients treated with cyclosporine, which was positively correlated to an increase in VLDL triglycerides. Hence, the cyclosporine produced an increase of uric acid which was neither observed when associated to prednisone nor in the group of self-transplanted patients.