El asma no controlada en la atención primaria: implementación y uso práctico de ReferID / Uncontrolled Asthma in Primary Care: Implementation and Practical Use of ReferID

Introducción: la evidencia de vida real muestra deficiencias en alcanzar los objetivos de control del asma, con elevado consumo de agonistas beta-2 de acción corta (SA-BA) y sobreuso de corticoides sistémicos (CS). Métodos: estudio observacional, des-criptivo, aplicando la herramienta ReferID con 4 preguntas para identificar pacientes con asma no controlada y/o en riesgo de crisis severas: en los últimos 12 meses [1] ¿Re-cibió ≥2 ciclos de CS y/o los usó como mantenimiento?; [2] ¿Tuvo ≥2 visitas a emergen-cias por asma?; [3] ¿Estuvo intubado o en Unidad de Cuidados Intensivos (UCI) por as-ma?; [4] ¿Cuántos inhaladores de SABA ha utilizado? Una respuesta afirmativa a las preguntas 1, 2 o 3, o usar ≥3 envases de SABA, sugieren riesgo de ataque grave, nece-sidad de CS y/o riesgo vital. En estos pacientes se recomienda evaluación por especia-listas. Resultados: participaron 441 pacientes de 7 instituciones del Área Metropolita-na de Buenos Aires. Al 60,1% (intervalo de confianza del 95% [IC95]:55,5%-64,7%) se le recomendó evaluación por especialista. El 33,8% (IC95:29,39%-38,21%) recibió ≥2 ciclos de CS y/o los usaba como mantenimiento. El 36,1% (IC95:31,62%-40,58%) asis-tió ≥2 veces a emergencias. El 41,5% (IC95:30,06%-38,94%) usó ≥3 envases de SABA. El 8,8% (IC95:6,16%-11,44%) tenía historia de intubación o UCI. El 37,2% se atendió en instituciones públicas, con indicadores de gravedad significativamente mayores que en las privadas. Conclusiones: ReferID es una herramienta simple que ayuda a identificar a pacientes en riesgo de crisis severa y/o que pudieran tener diagnóstico de asma gra-ve; y que se beneficiarían de una evaluación por un especialista. AU

Introduction: real-life evidence shows deficiencies in achieving asthma control goals, with high use of short-acting beta-2 agonists (SABA) and overuse of systemic cortico-steroids (SC). Methods: observational, descriptive study, applying the ReferID tool with 4 questions to identify patients with uncontrolled asthma and/or at risk of severe crisis: in the last 12 months [1] Have you received ≥2 cycles of CS and/or used them as main-tenance therapy?; [2] Have you had ≥2 emergency visits for asthma?; [3] Have you ever been intubated or admitted to the Intensive Care Unit (ICU) for asthma?; [4] How many SABA inhalers have you used? An affirmative answer to questions 1, 2 or 3, or using ≥3 canisters of SABA, suggests risk of severe attack, need for CS and/or life-threatening risk. In these patients, evaluation by specialists is recommended. Results: 441 patients from 7 institutions in the Metropolitan Area of Buenos Aires were enrolled. An evalu-ation by specialists was recommended for 60.1% (95% confidence interval [95%CI]: 55.5%-64.7%); 33.8% (95%CI:29.39%-38.21%) received ≥2 cycles of CS and/or used them as maintenance; 36.1% (95%CI:31.62%-40.58%) attended ≥2 times to the emer-gency department; 41.5% (95%CI:30.06%-38.94%) used ≥3 containers of SABA; 8.8% (95%CI:6.16%-11.44%) had a history of intubation or ICU admission; 37.2% were as-sisted in public institutions, with significantly higher severity indicators than in private ones. Conclusions: Refer ID is a simple, useful tool to quickly identify asthma patients who are at risk of severe exacerbations and/or may have a diagnosis of severe asthma and would benefit from evaluation by a specialist. AU

A novel, simple, and accurate pulse oximetry indicator for screening adult obstructive sleep apnea.

OBJECTIVE: The objective of the study was to develop a multiparametric oximetry indicator (IMp-SpO2) to diagnose obstructive sleep apnea in adults. MATERIAL AND METHOD: This was an observational, retrospective study of diagnostic accuracy. We included adults who had had a diagnostic polysomnography with few artifacts and a total sleep time of at least 180 min in the sleep laboratory. Obstructive sleep apnea (OSA) was defined as an apnea-hypopnea index (AHI) ≥ 5. The database was randomly divided into an experimental (Exp-G) and validation (Val-G) group. The program calculated several parameters of oxygen saturation variability (Par-VarSpO2): (a) oxygen desaturation index (ODI ≥ 3, 4%) and (b) 90, 95, and 97.5 percentiles of both the number of oxygen desaturations ≥ 3 and 4% (P90-97.5 OD3/4 W5-60) and SpO2 standard deviations in moving windows from 5 to 60 min (P90-P97.5 SDSpO2 W5-10). Area under the ROC curve (AUC-ROC), sensitivity, specificity, positive/negative likelihood ratios, and accuracy were calculated. RESULTS: Of 1141 adults included in the study, experimental (571) and validation group (570) were similar (women 47% vs 45%, BMI 27.5 kg/m2 vs 27.2 kg/m2, and AHI 11.7 vs 12, p NS). The IMp-SpO2 developed in the experimental group consisted of a combination of 10 parameters of oxygen saturation variability. The presence of at least one IMp-SpO2 variable had a high diagnostic performance for OSA (sensitivity/specificity/accuracy: Exp-G: 92.8/94/93.2%; Val-G: 93/95.2/93.7%). The IMp-SpO2 AUC-ROC was higher (Exp-G 0.934, Val-G 0.941) than most of the Par-VarSpO2 (0.898-0.929, p < 0.05). CONCLUSION: The IMp-SpO2 showed a > 90% accuracy for OSA diagnosis in adults.

[Lung cancer diagnosed by transesophageal ecoendoscopy and fine needle aspiration biopsy]. / Cáncer de pulmón diagnosticado mediante ecoendoscopía transesofágica y biopsia por punción con aguja fina.

Lung cancer is one of the leading causes of death worldwide. Pulmonary nodules located in the vicinity of the mediastinum, retrocardiac, near the aorta or pulmonary vessels, and in front of the spine, may be difficult to access through a percutaneous or bronchoscopic approach. Fine needle aspiration/biopsy guided by transesophageal echoendoscopy (EUS-FNA/FNB) is a minimally invasive method with low morbidity that could allow access to lesions in these places. We present the case of a patient with a solitary pulmonary nodule, in which the diagnosis of lung cancer was obtained by EUS-FNA/FNB.

El cáncer de pulmón es la principal causa de muerte por cáncer en todo el mundo. Los nódulos pulmonares ubicados en proximidad al mediastino, retrocardíacos, cercanos a grandes vasos o por delante de la columna vertebral pueden resultar de difícil acceso por vía percutánea o broncoscópica. La punción aspiración/biopsia con aguja fina guiada por ecoendoscopía transesofágica (EUS-FNA/FNB) es un método mini invasivo con baja morbilidad que permitiría acceder a estas localizaciones. Presentamos el caso de un paciente con nódulo pulmonar solitario, en el que se obtuvo el diagnóstico de cáncer de pulmón mediante EUS-FNA/FNB.

Cáncer de pulmón diagnosticado mediante ecoendoscopia transesofágica y biopsia por punción con aguja fina / Lung cancer diagnosed by transesophageal ecoendoscopy and fine needle aspiration biopsy

El cáncer de pulmón es la principal causa de muerte por cáncer en todo el mundo. Los nódulos pulmonares ubicados en proximidad al mediastino, retrocardíacos, cercanos a grandes vasos o por delante de la columna vertebral pueden resultar de difícil acceso por vía percutánea o broncoscópica. La punción aspiración/biopsia con aguja fina guiada por ecoendoscopía transesofágica (EUS-FNA/FNB) es un método mini invasivo con baja morbilidad que permitiría acceder a estas localizaciones. Presentamos el caso de un paciente con nódulo pulmonar solitario, en el que se obtuvo el diagnóstico de cáncer de pulmón mediante EUS-FNA/FNB.

Lung cancer is one of the leading causes of death worldwide. Pulmonary nodules located in the vicinity of the mediastinum, retrocardiac, near the aorta or pulmonary vessels, and in front of the spine, may be difficult to access through a percutaneous or bronchoscopic approach. Fine needle aspiration/biopsy guided by transesophageal echoendoscopy (EUS-FNA/FNB) is a minimally invasive method with low morbidity that could allow access to lesions in these places. We present the case of a patient with a solitary pulmonary nodule, in which the diagnosis of lung cancer was obtained by EUS-FNA/FNB.

El estudio de la epidemiología de la pancreatitis crónica: el gran reto / The study of chronic pancreatitis epidemiology - The big challenge 237-238

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Autoimmune pancreatitis: an underdiagnosed autoimmune disease with clinical, imaging and serological features.

Since Sarles et al. [Sarles H, Sarles JC, Muratore R, Guien C. Chronic inflammatory sclerosis of the pancreas-an autonomous pancreatic disease? Am J Dig Dis 1961; 6: 688-698.] reported a case of pancreatitis associated with hypergammaglobulinemia, many cases have been described, which led to the current concept of "autoimmune pancreatitis (AIP)". Lymphoplasmacytic infiltration and fibrosis on histology together with elevated IgG levels or the presence of autoantibodies on laboratory examinations supported the concept of AIP. In recent years, based on histological and immunohistochemical examination of various organs of patients with AIP, a novel clinicopathological entity, IgG4-related slerosing disease, has been proposed. AIP is a systemic disease that is characterized by dense infiltration of IgG4-positive plasma cells and T lymphocytes in various organs. Clinical manifestations are related with pancreas dysfunction but other organs may be affected such as bile duct, gallbladder, salivary gland, retroperitoneum, kidney, lung and prostate. Increased serum IgG4 levels, the presence of several autoantibodies such as anti-carbonic anhydrase II antibodies (ACA-II), immunostaining IgG4 positive in pancreas tissue and a very good response to steroid therapy are useful for the diagnosis of AIP that can mimic pancreatic cancer.

Hereditary pancreatitis: clinical features and inheritance characteristics of the R122C mutation in the cationic trypsinogen gene (PRSS1) in six Spanish families.

CONTEXT: Hereditary pancreatitis is an autosomal dominant disease which is caused by mutations in the PRSS1 gene. OBJECTIVE: The aim of our study was to describe the penetrance and phenotype-genotype correlations of the c.346C>T (p.R122C) mutation. DESIGN: Case series descriptive study. PATIENTS: Forty-one members of six families from whom DNA samples were analyzed. MAIN OUTCOME MEASURES: In subjects with R122C mutation symptoms, pancreatic calcifications, main pancreatic duct changes, diabetes, steatorrhea, pancreatic cancer and surgery were recorded. RESULTS: The R122C mutation was detected in 22 of the 41 family members studied, and 7 men and 2 women developed pancreatic disease, resulting in a penetrance of 40.9%. One out of the 9 patients was excluded because she died before the mutation was detected. The mean age at symptom onset was 23.5 years (range: 4-51 years). Abdominal pain was present in 6 (75.0%) of the 8 patients with the R122C mutation who developed pancreatic disease. Calcifications had developed in 5 (62.5%) at a mean age of 35.8 years (range: 14-56 years). Five (62.5%) developed changes in the pancreatic ducts at a mean age of 44.2 years (range: 19-65 years). Two patients (25.0%) developed steatorrhea during the follow-up at 26 and 35 years of disease progression. Diabetes developed in five patients (62.5%) at a mean age of 41.4 years old (range: 22-53 years). Three of the patients analyzed (37.5%) developed pancreatic cancer at 59 years of age, 63 years of age and 70 years of age. CONCLUSIONS: Penetrance of the R122C mutation is lower than that described for the R122H and N29I mutations, and there is a tendency toward a predominance of males with the R122C mutation who developed the phenotype of pancreatitis.

Historia del Club Español Biliopancreático (1989–2009) / History of the Spanish Biliopancreatic Club(1989–2009)

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Pancreatic fibrosis in rats and its response to antioxidant treatment.

CONTEXT: Oxidative stress plays a role in the development of pancreatic fibrosis. OBJECTIVES: In the present study, we hypothesized that the administration of an antioxidant complex could ameliorate cerulein and cyclosporin A pancreatic fibrosis, assessed by changes in oxidative stress and a histopathological study in an experimental rat model. ANIMALS: Four groups of ten rats each. In Group A, the rats served as controls and were treated with intraperitoneal saline solution. In Group B, six courses of cerulein pancreatitis were induced at weekly intervals. In Group C, the rats received cyclosporin A the day before and the day on which pancreatitis was induced in Group B. In Group D, the rats were treated as in Group C but also received antioxidants. All rats were sacrificed at the seventh week. MAIN OUTCOME MEASURES: The presence of fibrosis was evaluated according to a scoring system. Glutathione peroxidase was utilized as an indicator of oxidative stress and total antioxidant status as an indicator of total antioxidant tissue capacity. RESULTS: The rats in Groups B and C showed more pancreatic fibrosis than those in Groups A and D (90%, 70%, 0%, and 20%, respectively). The glutathione peroxidase increased in Group B (455+/-196 mU/g protein) and Group C (243+/-206 mU/g protein) with respect to those in Group A (137+/-80 mU/g protein) and Group D (135+/-105 mU/g protein). Total antioxidant status was significantly higher in Groups B (1.41+/-0.96 mmol/g protein) and D (1.28+/-0.09 mmol/g protein) with respect to Groups A (0.10+/-0.06 mmol/g protein) and C (0.15+/-0.09 mmoL/g protein). CONCLUSION: The administration of cerulein and cyclosporin A caused fibrosis, whereas antioxidant administration showed preventive effects regarding cerulein and cyclosporin A-induced pancreatic fibrosis.

[Screening of celiac disease in first-degree relatives]. / Cribado de la enfermedad celíaca en familiares de primer grado.

BACKGROUND AND OBJECTIVE: Our aim was to analyze the prevalence of celiac disease (CD) in first-degree relatives of patients diagnosed with this disorder in Cantabria (Northern Spain). SUBJECTS AND METHOD: A questionnaire was administered and a complete biologic study was performed in 184 relatives. When serum CD-related antibodies were detected, relatives were asked to undergo a jejunal biopsy to confirm the diagnosis. RESULTS: Thirteen relatives had autoantibodies yet only 4 were diagnosed with CD. The biopsy was suggestive of CD in 3 relatives who underwent it. A further relative was diagnosed with CD by the clinical and serological response to a gluten-free diet. CONCLUSIONS: The prevalence found in our study is high enough so that we recommend the screening of autoantibodies, especially anti-gliadin and anti-transglutaminase antibodies, in this risk-population of celiac disease.

Cribado de la enfermedad celíaca en familiares de primer grado / Screening of celiac disease in first-degree relatives

FUNDAMENTO Y OBJETIVO: Dada la elevada prevalencia de la enfermedad celíaca (EC) en familiares de primer grado, nuestro objetivo fue analizar su prevalencia en Cantabria. SUJETOS Y MÉTODO: Se completaron un cuestionario dirigido y un estudio biológico en 184 familiares. En caso de presencia de anticuerpos característicos de EC, se intentó confirmar el diagnóstico mediante biopsia yeyunal. RESULTADOS: Trece familiares tuvieron autoanticuerpos, aunque sólo se diagnosticó EC en 4. La biopsia fue compatible con EC en tres de los 4 que la consintieron. El cuarto diagnóstico de EC se hizo, a pesar de no realizarse la biopsia, dada la respuesta clínica y serológica con la dieta sin gluten. CONCLUSIONES: La prevalencia encontrada recomienda el cribado sistemático en esta población de riesgo mediante la determinación de autoanticuerpos, especialmente antigliadina y antitransglutaminasa (AU)