Immune-mediated hepatitis: Basic concepts and treatment.

Immunotherapy with immune checkpoint inhibitors (ICIs) has revolutionized advanced cancer management. Nevertheless, the generalized use of these medications has led to an increase in the incidence of adverse immune-mediated events and the liver is one of the most frequently affected organs. Liver involvement associated with the administration of immunotherapy is known as immune-mediated hepatitis (IMH), whose incidence and clinical characteristics have been described by different authors. It often presents as mild elevations of amino transferase levels, seen in routine blood tests, that spontaneously return to normal, but it can also manifest as severe transaminitis, possibly leading to the permanent discontinuation of treatment. The aim of the following review was to describe the most up-to-date concepts regarding the epidemiology, diagnosis, risk factors, and progression of IMH, as well as its incidence in different types of common cancers, including hepatocellular carcinoma. Treatment recommendations according to the most current guidelines are also provided.

Beyond conventional physical examination in hepatology: POCUS.

Point-of-care ultrasound (POCUS) refers to the use of ultrasound imaging through pocket-sized sonographic devices at the patient's bedside, to make a diagnosis or direct a procedure and immediately answer a clinical question. Its goal is to broaden the physical examination, not to replace conventional ultrasound studies. POCUS has evolved as a complement to physical examination and has been adopted by different medical specialties, including hepatology. A narrative synthesis of the evidence on the applications of POCUS in hepatology was carried out, describing its usefulness in the diagnosis of cirrhosis of the liver, metabolic dysfunction-associated steatotic liver disease (MASLD), decompensated cirrhosis, and portal hypertension. The review also encompasses more recent applications in the hemodynamic evaluation of the critically ill patient with cirrhosis of the liver, patients with other liver diseases, as well as in the ultrasound guidance of procedures. POCUS could make up part of the daily clinical practice of gastroenterologists and hepatologists, simplifying the initial evaluation of patients and optimizing clinical management. Its accessibility, ease of use, and low adverse event profile make POCUS a useful tool for the properly trained physician in the adequate clinical setting. The aim of this review was to describe the available evidence on the usefulness of POCUS in the daily clinical practice of gastroenterologists and hepatologists.

Current vision on diagnosis and comprehensive care in hepatic encephalopathy.

The first clinical guidelines on hepatic encephalopathy were published in 2009. Almost 14 years since that first publication, numerous advances in the field of diagnosis, treatment, and special condition care have been made. Therefore, as an initiative of the Asociación Mexicana de Gastroenterología A.C., we present a current view of those aspects. The manuscript described herein was formulated by 24 experts that participated in six working groups, analyzing, discussing, and summarizing the following topics: Definition of hepatic encephalopathy; recommended classifications; epidemiologic panorama, worldwide and in Mexico; diagnostic tools; conditions that merit a differential diagnosis; treatment; and primary and secondary prophylaxis. Likewise, these guidelines emphasize the management of certain special conditions, such as hepatic encephalopathy in acute liver failure and acute-on-chronic liver failure, as well as specific care in patients with hepatic encephalopathy, such as the use of medications and types of sedation, describing those that are permitted or recommended, and those that are not.

Evaluation and management of emergencies in the patient with cirrhosis.

The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.

Approach to the patient with cholestasis and jaundice syndrome. Joint AMH, AMG, and AMEG scientific position statement.

The term cholestasis refers to bile acid retention, whether within the hepatocyte or in the bile ducts of any caliber. Biochemically, it is defined by a level of alkaline phosphatase that is 1.67-times higher than the upper limit of normal. Cholestatic diseases can be associated with an inflammatory process of the liver that destroys hepatocytes (hepatitis), withjaundice (yellowing of the skin and mucus membranes, associated with elevated serum bilirubin levels), or with both, albeit the three concepts should not be considered synonymous. Cholestatic diseases can be classified as intrahepatic or extrahepatic, depending on their etiology. Knowing the cause of the condition is important for choosing the adequate diagnostic studies and appropriate treatment in each case. A complete medical history, together with a thorough physical examination and basic initial studies, such as liver ultrasound and liver function tests, aid the clinician in deciding which path to follow, when managing the patient with cholestasis. In a joint effort, the Asociación Mexicana de Hepatología (AMH), the Asociación Mexicana de Gastroenterología (AMG) and the Asociación Mexicana de Endoscopia Gastrointestinal (AMEG) developed the first Mexican scientific position statement on said theme.

The Mexican consensus on alcoholic hepatitis. / Consenso Mexicano de hepatitis alcohólica.

Alcoholic hepatitis is a frequent condition in the Mexican population. It is characterized by acute-on-chronic liver failure, important systemic inflammatory response, and multiple organ failure. The severe variant of the disease implies elevated mortality. Therefore, the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología brought together a multidisciplinary team of health professionals to formulate the first Mexican consensus on alcoholic hepatitis, carried out utilizing the Delphi method and resulting in 37 recommendations. Alcohol-related liver disease covers a broad spectrum of pathologies that includes steatosis, steatohepatitis, different grades of fibrosis, and cirrhosis and its complications. Severe alcoholic hepatitis is defined by a modified Maddrey's discriminant function score ≥ 32 or by a Model for End-Stage Liver Disease (MELD) score equal to or above 21. There is currently no specific biomarker for its diagnosis. Leukocytosis with neutrophilia, hyperbilirubinemia (> 3 mg/dL), AST > 50 U/l (< 400 U/l), and an AST/ALT ratio > 1.5-2 can guide the diagnosis. Abstinence from alcohol, together with nutritional support, is the cornerstone of treatment. Steroids are indicated for severe disease and have been effective in reducing the 28-day mortality rate. At present, liver transplantation is the only life-saving option for patients that are nonresponders to steroids. Certain drugs, such as N-acetylcysteine, granulocyte-colony stimulating factor, and metadoxine, can be adjuvant therapies with a positive impact on patient survival.

Hepatic manifestations and impact of COVID-19 on the cirrhotic patient. / Manifestaciones hepáticas y repercusión en el paciente cirrótico de COVID-19.

The novel SARS-CoV-2 coronavirus is responsible for the infectious disease caused by coronavirus 19 (COVID-19). The current pandemic is growing worldwide and could affect 50-60% of the world population in the months to come. The most severe disease manifestations are atypical pneumonia and sepsis, but the gastrointestinal tract, particularly the liver, has recently been reported to be affected by SARS-CoV-2. Therefore, the aim of the present work was to review the literature available on the topic and provide information about COVID-19, in both healthy and diseased livers, and issue recommendations. The incidence of liver injury specifically associated with COVID-19 varies from 14.8-53%. The majority of case series have reported altered ALT and AST, elevated total bilirubin, and low serum albumin and liver compromise has been associated with the most severe cases of COVID-19. Cirrhosis of the liver has a recognized immune dysfunction status that includes immunodeficiency and systemic inflammation, making it reasonable for those patients to be more susceptible to SARS-CoV-2 infection. The recommendations for those patients, in addition to the general measures of physical distancing and handwashing for all persons, include social, medical, and psychologic support during the period of home quarantine to prevent lapses in treatment. Patients should be made aware that they need to keep abreast of changes in recommendations and social policies.

Extrahepatic complications of non-alcoholic fatty liver disease: Its impact beyond the liver. / Complicaciones extrahepáticas de la enfermedad por hígado graso no alcohólico: impacto más allá del hígado.

Non-alcoholic fatty liver disease (NAFLD) is currently one of the main causes of chronic liver disease in Western countries, with a 25% prevalence reported in the general population worldwide. Visceral adiposity and liver fat promote a state of systemic inflammation, predisposing individuals with NAFLD to the extrahepatic pathologies of cardiovascular disease (the most common cause of death in patients with NAFLD), diabetes mellitus, chronic kidney disease, hypothyroidism, polycystic ovary syndrome, obstructive sleep apnea, and an increased risk for presenting with gastrointestinal and extraintestinal neoplasias. Different mechanisms between NAFLD and its association with extrahepatic diseases have been reported, and lipotoxicity is the main cause of inflammatory pathway activation that results in extrahepatic tissue damage.

Validez de la medida aislada de la presión arterial en farmacia comunitaria. Puntos de corte óptimos / Diagnostic validity of the isolated measurement of blood pressure in the community pharmacy. Optimum cut-off points

Introducción y objetivos: El objetivo es cuantificar la validez diagnóstica de la medida de la presión arterial en farmacia comunitaria (PAFC) y establecer los puntos de corte de la presión arterial sistólica (PAS) y de la presión arterial diastólica (PAD) que maximicen la citada validez, usando como patrón de oro la monitorización ambulatoria de la presión arterial (MAPA) de 24 h. Material y métodos: Estudio transversal, con selección consecutiva de pacientes usuarios de la farmacia comunitaria andaluza. Se midió la PAFC y, a continuación, una MAPA de 24 h, con lo que se evaluó la validez diagnóstica de PAFC. También se calculó el área bajo la curva ROC para PAS y PAD, los valores predictivos positivos y negativos para diferentes prevalencias, así como la variación de la sensibilidad y de la especificidad para los distintos puntos de corte de PAS/PAD, lo que sirvió para el cálculo de los puntos de corte óptimos. Resultados: Colaboraron 167 farmacias comunitarias, con 1.170 pacientes, de los que 1.110 aportaron datos válidos. La PAFC presenta una sensibilidad del 60,41% (IC 95%: 56,40-64,29), una especificidad del 79,77% (IC 95%: 76,12-82,99), un valor predictivo positivo de 76,96% (IC 95%: 72,89-80,57) y un valor predictivo negativo de 64,31% (IC 95%: 60,55%-67,90%). Por el método de curva ROC, los puntos de corte óptimos para la PAS y para la PAD son, respectivamente, 134/81mm Hg, puntos donde la sensibilidad y la especificidad se equilibran y se maximiza el índice de Youden. Conclusiones: La sensibilidad es relativamente baja. Para mejorarla se propone bajar el punto de corte de PAS y PAD. El óptimo calculado es 134/81mm Hg. Viene ello a aportar datos sobre la conveniencia de revisar a la baja el actual punto de corte (140/90), como propone la guía de 2017 de ACC/AHA

Introduction and objectives: The aim of this study is to determine the diagnostic validity of blood pressure measurement in the community pharmacy (CPBP), and to set the cut-off points in systolic blood pressure (SBP) and diastolic blood pressure (DBP) in order to maximise the aforementioned validity, using 24 hour ambulatory blood pressure monitoring (ABPM) as the reference method. Material and methods: A cross-sectional study with consecutive selection of patient users of the community pharmacy in Andalusia. The CPBP was measured, followed by 24-hour ABPM, which assessed the diagnostic validity of the CPBP. The AUC of the ROC curve was also calculated for SBP and DBP, along with the positive and negative predictive values, for different prevalences and the variation of sensitivity and specificity for the different cut-off points for SBP/DBP. Results: A total of 167 community pharmacy participated with 1,170 patients, of which 1,110 were valid. The CPBP showed a sensitivity of 60.41% (95% CI: 56.40-64.29), and a specificity of the 79.77% (95% CI: 76.12-82.99), a positive predictive values of 76.96% (95% CI: 72.89-80.57), and a negative predictive values of 64.31% (95% CI: 60.55%-67.90%). By using the ROC curve method, the optimal cut-off points are 134/81mm Hg, the point where the sensitivity and specificity and are balanced and the Youden index is maximised. Conclusions: The sensitivity is relatively low. To improve it tends to lower the cut-off points of SBP and DBP. The calculated optimum is 134/81mm Hg. This provides data on the desirability to review the current cut-off points (140/90), as proposed by the ACC/AHA 2017

[Diagnostic validity of the isolated measurement of blood pressure in the community pharmacy. Optimum cut-off points]. / Validez de la medida aislada de la presión arterial en farmacia comunitaria. Puntos de corte óptimos.

INTRODUCTION AND OBJECTIVES: The aim of this study is to determine the diagnostic validity of blood pressure measurement in the community pharmacy (CPBP), and to set the cut-off points in systolic blood pressure (SBP) and diastolic blood pressure (DBP) in order to maximise the aforementioned validity, using 24 hour ambulatory blood pressure monitoring (ABPM) as the reference method. MATERIAL AND METHODS: A cross-sectional study with consecutive selection of patient users of the community pharmacy in Andalusia. The CPBP was measured, followed by 24-hour ABPM, which assessed the diagnostic validity of the CPBP. The AUC of the ROC curve was also calculated for SBP and DBP, along with the positive and negative predictive values, for different prevalences and the variation of sensitivity and specificity for the different cut-off points for SBP/DBP. RESULTS: A total of 167 community pharmacy participated with 1,170 patients, of which 1,110 were valid. The CPBP showed a sensitivity of 60.41% (95% CI: 56.40-64.29), and a specificity of the 79.77% (95% CI: 76.12-82.99), a positive predictive values of 76.96% (95% CI: 72.89-80.57), and a negative predictive values of 64.31% (95% CI: 60.55%-67.90%). By using the ROC curve method, the optimal cut-off points are 134/81mm Hg, the point where the sensitivity and specificity and are balanced and the Youden index is maximised. CONCLUSIONS: The sensitivity is relatively low. To improve it tends to lower the cut-off points of SBP and DBP. The calculated optimum is 134/81mm Hg. This provides data on the desirability to review the current cut-off points (140/90), as proposed by the ACC/AHA 2017.

Análisis del consumo simultáneo de medicamentos y plantas medicinales en población española mayor de 65 años / Appropriate or inappropriate use of simultaneous consumption of drugs and preparations of medicinal plants that makes the 65-year-old population in Spain

Objetivos: Analizar el uso apropiado o inapropiado de la utilización conjunta de medicamentos y preparados de plantas medicinales que realiza la población mayor de 65 años en la provincia de Guadalajara (España). Materiales y métodos: Estudio observacional, descriptivo, de corte transversal, realizado en Guadalajara (España) capital y provincia. La recogida de datos de los pacientes se efectuó durante los años 2012 y 2013. Siendo, por tanto, las variables dependientes usadas el porcentaje de consumo de Preparados de plantas medicinales y el porcentaje de consumo de medicamentos. La población diana fueron pacientes polimedicados mayores de 65 años, varones o mujeres, que residieran en sus casas o en Residencias de Ancianos y que voluntariamente decidieron participar en este trabajo. Resultados: Se incluyeron 384 pacientes, 129 fueron varones (33,60%). Consumieron plantas medicinales el 88,30%. Consumieron PCPM 183 (47,6%) y PIPM 339 que representó el 88,3%. Con consumo total de 852 infusiones al día, un promedio de 2,21 infusiones diarias. Se encontraron 22 asociaciones potencialmente peligrosas y 10 potencialmente beneficiosas. Conclusiones: Se ha puesto de manifiesto que ciertas asociaciones de planta-medicamento, pueden contribuir a mejorar la situación del paciente, pero también ha evidenciado la necesidad de una atención farmacéutica en el consumo de preparados de plantas medicinales en relación con la farmacoterapia que tiene prescrita, a fin de evitar combinaciones que pudieran reducir la eficacia de los tratamientos o incrementar el riesgo de otras alteraciones

Objective: To analyze the appropriate or inappropriate simultaneous use of drugs and preparations of medicinal plants that makes the population over 65 years old in the province of Guadalajara (Spain). Methodology: It was done an observational, descriptive, cross-sectional study, held in Guadalajara (Spain) both, capital and province. Patients’ data collection was carried out during the years 2012 and 2013. The dependent variables used were the percentage of medicinal plants preparations consumed and the percentage of medicines’ consumption. The target population was poly-medicated patients over 65 years old, men or women, that lived in their own homes or in residences for the elderly and decided to participate in this work voluntarily. Results: 384 patients were included, 129 were males (33.60%). 88.30% of them consumed medicinal plants. 183 consumed PCPM (47.6%) and 339, PIPM that represented 88.3%. There was a total consumption of 852 infusions per day, an average of 2.21 daily infusions. There were found 22 potentially dangerous associations and 10 potentially beneficial. Conclusions: There were identified potentially harmful associations and other beneficial drug-medicinal plant associations. It was concluded that pharmaceutical care is necessary for patients that take medicines and medicinal plants simultaneously in order to avoid combinations that could reduce treatments effectiveness or increase the risk of having other alterations

Revisión de estrategias utilizadas para la mejora de la adherencia al tratamiento farmacológico / Review of strategies used to Improve drug adherence

La falta de adherencia al tratamiento farmacológico es un problema relacionado con el proceso de uso de los medicamentos que puede dar lugar si no se soluciona a resultados negativos asociados a la medicación. Es necesaria la aplicación de medidas y estrategias que permitan corregir esta situación. El objetivo del estudio es identificar las estrategias de ayuda al cumplimiento del tratamiento armacológico que sean aplicables en la práctica clínica por los profesionales de la salud para ayudar a los pacientes a conseguir los resultados en salud que se esperan de los medicamentos. Tras esta revisión, se han encontrado siete tipos de estrategias para abordar y mejorar la adherencia al tratamiento y que presentan posibilidades para su aplicación en la práctica clínica son: Estrategias técnicas, educativas, conductuales, tratamiento de observación directa, técnicas de apoyo social, técnicas dirigidas a profesionales y recuerdo de las estrategias

Non-adherence to drug treatment is a problem related to the process of using medicines. If this problem is not solved, it can give room for negative results associated with medication. It is necessary to apply some measures and strategies to correct this fact. The aim of this study is to identify the aid strategies to treatment compliance. These strategies have to be applied by health prof essionals in clinical practice so as to help patients to achieve the health outcomes that are expected from medicines. After this revision, we have found seven types of strategies, which offer possibilities to be applied in clinical practice, to address and improve adherence to treatment. These strategies are: Technical Strategies, educational, behavioral, directly observed treatment, social support techniques, techniques for professionals and remembrance of the strategies

Evaluación del nivel de calidad del proceso de dispensación durante los años de certificación según la norma UNE-EN-ISO 9001 de las farmacias del proyecto CALIFARMA. Dispensación / Assessment of the quality of the dispensing process during years certified according to the UNE-EN-ISO 9001 quality standard by pharmacies in the CALIFARMA project. Dispensing

El proceso de dispensación es el servicio profesional del farmacéutico encaminado a garantizar, tras una evaluación individual, que los pacientes reciban y utilicen los medicamentos de forma adecuada a sus necesidades clínicas, en las dosis precisas según sus requerimientos individuales, durante el periodo adecuado, con la información para su correcto uso y de acuerdo con la normativa vigente. Objetivos: El primer objetivo del estudio fue evaluar y consensuar, con expertos en calidad, los puntos críticos detectados durante el proceso de dispensación: comunicación con el paciente, selección del medicamento prescrito o publicitario y/o el producto sanitario, venta, información al paciente y facturación. El segundo objetivo fue medir la evolución del grado de implantación del proceso de dispensación según los requisitos establecidos en la norma UNE-EN-ISO 90011 en las farmacias comunitarias del proyecto CALIFARMA, en Murcia, en los años de certificación comprendidos entre 2008 y 2010. Material y métodos: Se realizaron dos metodologías. En un primer estudio, de investigación cualitativa mediante metodología Delphi2, se consensuó con un grupo de expertos el sistema para medir los puntos críticos de los procesos de la farmacia (identificados en un estudio anterior3) utilizando como fuente de información un grupo de personas con un conocimiento elevado en materia de calidad y/o farmacia comunitaria. En una segunda fase se realizó un estudio cuasi-experimental antes-después. Los datos introducidos por cada farmacia del proyecto CALIFARMA en el programa de gestión documental del sistema de calidad, instalado en la plataforma Lotus Notes v.6.5, fueron revisados y analizados por el Departamento de Calidad del Colegio Oficial de Farmacéuticos de la Región de Murcia, de acuerdo con la clasificación y ponderación obtenida como resultado del Delphi. El análisis estadístico empleado fue un descriptivo univariante que mostró la frecuencia de aparición de las distintas variables en la población de estudio, así como de las pérdidas producidas durante el trabajo de campo. Para las variables cualitativas se obtuvieron tablas de frecuencias, y para las cuantitativas, medidas de tendencia central (media) y medidas de dispersión (desviación estándar). Se utilizó el test de la ji al cuadrado (X2) para la comparación de variables categóricas, la t de Student para las variables cuantitativas y también el test de ANOVA. Se trabajó con el SPSS v.17.0, y se alcanzó significación estadística con p <0,05. Se aplicó también la prueba de Kruskal-Wallis y Bonferroni para comparar las poblaciones en caso de que la distribución no fuese normal. Resultados: Las incidencias en el proceso de dispensación de la farmacia comunitaria se categorizaron de acuerdo con las decisiones del panel de expertos tras el Delphi. Las farmacias del proyecto CALIFARMA recogieron dichas incidencias clasificadas en 12 indicadores relativos a forma farmacéutica, cantidad, dosis, presentación, nomenclatura, duración del tratamiento, posología, incidencias en la sustitución de un medicamento o producto sanitario por otro, incidencias en vacunas, incidencias en la facturación, incumplimiento de los plazos de dispensación legalmente establecidos e información aportada al paciente. Una vez establecidas las categorías, se comprobó que durante los 3 años de la implantación del sistema de calidad el proceso de dispensación fue mejorando de forma progresiva con la disminución del número de incidencias producidas. Durante el primer año de certificación, el 68% de las farmacias se encontraban englobadas en el nivel avanzado de certificación, en el tercer año de certificación este número ascendió al 92% de las farmacias del proyecto y el 8% se encontraban en un nivel de calidad óptimo. La detección de las incidencias previo al proceso de dispensación y la comunicación con el médico de dichas incidencias hicieron posible la disminución de las diferencias entre la prescripción y la dispensación de medicamentos y/o productos sanitarios en las oficinas de farmacia del proyecto. Conclusiones: El consenso del grupo de expertos en calidad y farmacia comunitaria permitió establecer un sistema para medir el grado de implantación del proceso de dispensación en tres categorías -avanzado, óptimo y normal- a través de 12 indicadores. Tras la aplicación del proyecto CALIFARMA, 9 de cada 10 farmacias se encontraban en el nivel avanzado, lo que supuso un incremento del 24% respecto al primer año. Las incidencias más registradas en la dispensación fueron las atribuibles a diferencias en la forma farmacéutica, dosis, nomenclatura y vacunas (AU)

The dispensing process is the professional service provided by the pharmacist aimed at ensuring, following an individual assessment, that patients receive and use their medication in a way appropriate to their clinical needs, in the exact doses according to their individual requirements, for the right period of time, with information on their correct use and in accordance with current regulations. Aims: The first aim of the study was to assess and agree, together with quality experts, the critical points identified in the dispensing process: communication with the patient, selection of the medication prescribed or advertised and/or the healthcare product, sale, information to the patient and charging. The second aim was to measure the evolution of the degree of implementation of the dispensing process according to the requirements laid down in the UNE-EN-ISO 9001 standard1 in the community pharmacies in the CALIFARMA project, in Murcia, in the years certified between 2008 and 2010. Materials and methods: Two methodologies were constructed. In a first study, qualitative research using Delphi2 methodology, a system was agreed upon with experts to measure the critical points in pharmacy processes (as identified in a previous study3), using a group of people with considerable knowledge in the area of quality and/or community pharmacy as a source of information. In a second phase a quasi-experimental before and after study was conducted. The data entered by each pharmacy in the CALIFARMA project in the quality system document management program, using the Lotus Notes v.6.5 platform, were reviewed and assessed by the quality Department of the Official College of Pharmacists of the Murcia Region, according to the classification and weighting obtained through the Delphi method. The statistical analysis used was a descriptive univariant system which showed how often the different variables appeared in the sample population, as well as the losses which occurred during the fieldwork. For the qualitative variables frequency tables were obtained and for the quantitative ones measures of central tendency (mean) and measures of dispersion (standard deviation). The Chi squared (X2) test was used to compare categorical variables, the Student t for quantitative variables and also the ANOVA test. SPSS v.17.0 was used and a statistical significance of p <0.05 was achieved. The Kruskal-Wallis & Bonferroni test was also used to compare populations where the distribution was not normal. Results: Incidents with the community pharmacy dispensing process were categorised according to the decisions of the panel of experts after Delphi. The pharmacies in the CALIFARMA project compiled incidents in this process classified into 12 indicators relating to pharmaceutical form, quantity, dose, format, name, duration of treatment, posology, incidents in replacing a drug or healthcare product with another, incidents with vaccines, billing incidents, failure to meet legally stipulated dispensing times and information given to the patient. After establishing the categories, it was found that during the three years the system had been implemented the dispensing process had improved steadily with a decrease in the number of incidents that occurred. During the first year of implementation, 68% of the pharmacies were included in the advanced level of certification and in the third year of certification this percentage reached 92% of the pharmacies in the project with 8% reaching an optimum quality level. Detecting incidents before the dispensing process and notifying the doctor of such incidents made it possible to decrease the difference between the prescriptions and the dispensing of medicines and/or healthcare products in the pharmacies involved in the project. Conclusions: The consensus of the group of experts in quality and community pharmacy made it possible to establish a system to measure the degree of implementation of the dispensing process in 3 categories -advanced, optimum and ordinary- through 12 indicators. After rolling out the CALIFARMA project, 9 out of 10 pharmacies were at the advanced level, representing an increase of 24% on the first year. The most commonly recorded incidents in dispensing were those attributable to the pharmaceutical form, dose, name and vaccines (AU)

Influencia de las características sociodemográficas y clínicas en la adherencia al tratamiento farmacológico de pacientes con riesgo cardiovascular / Influence of sociodemographics and clinical characteristics in the adherence of pharmacological treatment of patients with cardiovascular risk

Introducción: Algunos autores han señalado más de 200 factores y variables relacionados con el incumplimiento, que se deben tener en cuenta si se pretende modificarlo. Objetivo: Identificar las características sociodemográficas y clínicas asociadas a la adherencia al tratamiento farmacológico en pacientes ambulatorios con riesgo cardiovascular (RCV). Metodología: A los pacientes que cumplieron los criterios de inclusión se les hizo una entrevista inicial, que incluyó la recogida de las características sociodemográficas y clínicas y el test de adherencia. Se tomaron y registraron los valores de colesterol total y presión arterial, y se determinó el RCV del paciente. Si el RCV era moderado o alto, el paciente se incluía en el estudio. Resultados: La adherencia está favorecida por la percepción por parte del paciente del estado de salud como regular, malo o muy malo, por el sexo femenino y por la presencia de algún factor de RCV, como la dislipemia. Conclusiones: Es necesario considerar las diferentes variables que pueden influir en la adherencia y establecer estrategias individualizadas para luchar contra el incumplimiento del tratamiento farmacológico (AU)

Introduction: Some authors have pointed out more than 200 factors and variables related to the breach, to be taken into account if it is to change it. Objective: To identify sociodemographic and clinical characteristics associated with pharmacological treatment adherence in outpatients with cardiovascular risk. Methodology: Patients who met the inclusion criteria were asked an initial interview, which included collection of demographic and clinical characteristics and the adherence test. Were collected and recorded the values of total cholesterol and blood pressure, and determined the patient’s cardiovascular risk. If the cardiovascular risk was moderate or high, the patient was included in the study. Results: Adherence is favored by the patient’s perception of health status as fair, poor or very poor, for the female gender and the presence of any cardiovascular risk factor such as dyslipidemia. Conclusioins: It is therefore necessary to consider the different variables that may infl uence adherence and set individualized strategies for combating non-compliance with pharmacological treatment (AU)

Impacto de la intervención farmacéutica en la adherencia al tratamiento antirretroviral en pacientes de un hospital de Lima (Perú) / Pharmacist intervention in the improvement of adherence in HIV/AIDS patients with antiretroviral treatment in Lima (Peru)

Introducción: La atención farmacéutica mejora la adherencia del paciente al tratamiento, por lo que es necesario que el farmacéutico cuente con instrumentos para evaluarla y mejorarla mediante su intervención en el seguimiento farmacoterapéutico (SFT). Objetivos: Evaluar el impacto de la intervención farmacéutica en la mejora de la adherencia de los pacientes con virus de la inmunodeficiencia humana (VIH) y sida, e identificar los factores que influyen en ella y que pueden ser modificados por la intervención farmacéutica en el SFT. Métodos: Se realizó SFT durante 23 meses a 52 pacientes mayores de 18 años de edad, con tratamiento antirretroviral durante más de 3 meses, que dieron su consentimiento informado. La adherencia se evaluó con el CEAT-VIH (cuestionario para evaluar la adhesión al tratamiento antirretroviral) al inicio y al final de 6 meses de SFT. Resultados: La puntuación total del CEAT-VIH (p <0,05; intervalo de confianza del 95%), el cumplimiento del tratamiento (p <0,001) y la percepción del paciente respecto a su enfermedad y tratamiento antirretroviral (p <0,001) incrementaron significativamente su valor. La educación al paciente para incrementar la adherencia al tratamiento (46%) fue la intervención farmacéutica más frecuente. Conclusiones: Se demuestra que la intervención del farmacéutico, mediante el SFT, mejora la adherencia al tratamiento antirretroviral. El farmacéutico mejoró los aspectos de cumplimiento y percepción del paciente sobre su tratamiento y enfermedad. Los farmacéuticos pueden utilizar el CEAT-VIH como instrumento para evaluar la adherencia en la práctica del SFT (AU)

Introduction: Pharmaceutical care improves medication adherence that is why is important that the pharmacist uses instruments to evaluate and improves it through pharmaceutical intervention at pharmaceutical care. Objective: To evaluate the impact of the pharmaceutical intervention in the improvement of the medication adherence of the patients with HIV and AIDS, and to identify the factors that influence on medication adherence and which one could be modified by the pharmaceutical intervention during pharmaceutical care. Methods: Pharmacotherapeutic follow-up was realized for 23 months to 52 patients, older than 18 years, with antiretroviral treatment for up to three months, consent informed was obtained from patients. Medication adherence was evaluated with CEAT-HIV (questionnaire to evaluate the adhesion to the antiretroviral treatment) at the beginning and at the end of the study (6 months). Results: The final score from CEAT-HIV (p <0.05; 95% IC), treatment compliance (p <0.001) and patient’s beliefs to the disease and antiretroviral treatment (p <0.001) improved significantly with the pharmaceutical intervention. The more frequent pharmaceutical intervention was education to the patient to increment the adherence to the treatment (46%). Conclusion: These results demonstrate that the pharmacists’ intervention through pharmacotherapeutic follow-up improves the adherence to the antiretroviral treatment. The pharmacist was able to improve aspects of compliance and patient’s beliefs about the treatment and disease. The pharmacist could utilize CEAT-VIH as an instrument to evaluate the adherence in HIV/AIDS patients (AU)

Sífilis y embarazo / Syphilis and pregnancy

El número de casos de sífilis diagnosticados durante la gestación y, en consecuencia, de sífilis congénita ha disminuido de manera importante en los países desarrollados. Sin embargo no ocurre lo mismo en países en vías de desarrollo y especialmente en aquellos en los que existe una elevada tasa de VIH.Presentamos un caso clínico de sífilis secundaria en una paciente embarazada de 18 semanas cuya gestación no había sido controlada hasta el momento del diagnóstico.Dada la elevada probabilidad de que aumente el número de casos como éste, en países desarrollados, debido al fenómeno migratorio que acontece en la actualidad se realiza una revisión de la epidemiología, la clínica, el diagnóstico y el tratamiento de esta entidad durante la gestación (AU)

Cases of syphilis during pregnancy and congenital syphilis have markedly decreased in developed countries. However, the same is not true of developing countries, especially in those with high HIV rates.We present a case of secondary syphilis in a woman with an 18-week pregnancy without prenatal care until diagnosis. Due to current migratory phenomena, cases such as this will probably increase in developed countries. We provide a review of the epidemiology, clinical features, diagnosis and treatment of syphilis during pregnancy (AU)

Papel del citocromo P450 en la farmacocinética y en la farmacogenética de los fármacos antihipertensivos / Role of CYP450 in pharmacokinetics and pharmacogenetics of antihypertensive drugs

Introducción Los fármacos antihipertensivos son metabolizados principalmente por enzimas de la familia del citocromo P450 (CYP450). La respuesta al tratamiento antihipertensivo cuya base genética está empezando a conocerse está sujeta a diferencias interindividuales en los pacientes. Objetivo El objetivo de esta revisión es documentar la metabolización de los fármacos antihipertensivos por enzimas del citocromo P450 e identificar cuáles pueden ser los polimorfismos más relevantes en los genes que codifican para estas enzimas con el fin de facilitar futuros estudios sobre la farmacogenética de la hipertensión. Métodos Se realizó una búsqueda por palabras clave en las bases de datos bibliográficas Pubmed, Rxlist y Medscape. Así mismo se consultaron las bases públicas de polimorfismos genéticos PharmGKB, NCBI y la página del comité para la nomenclatura de alelos del CYP450.ResultadosLas enzimas CYP2D6, CYP2C9, CYP2D19 y CYP3A4 participan en el metabolismo de la mayoría de los fármacos antihipertensivos. Teniendo en cuenta la frecuencia alélica en la población y la variabilidad en la respuesta clínica asociada sería interesante el estudio de los siguientes alelos: CYP2D6 *2, *4, deleción y duplicación; CYP2C9*2 y *3, CYP2C19 *2 y CYP3A4*1B.ConclusionesEl estudio de polimorfismos en los genes del citocromo P450 puede contribuir a una terapia individualizada en el tratamiento antihipertensivo (AU)

Introduction Antihypertensive drugs are principally metabolised by enzymes of the P450 (CYP450) cytochrome family. Response to hypertensive treatment whose genetic basis is beginning to be known presents inter-individual differences among patients. Objective The aim of this review is to document the role of cytochrome enzymes P450 in the metabolising process of antihypertensive drugs, and to identify the most relevant polymorphisms in genes that code for these enzymes in order to facilitate future studies in hypertension pharmacogenetics. Methods: A keyword search was performed in the following literature databases: Pubmed, Rxlist and Medscape. Genetic polymorphism public databases were also consulted (PharmGKB, NCBI and the CYP450 allele nomenclature committee web page. Results Enzymes CYP2D6, CYP2C9, CYP2D19 and CYP3A4 participate in the metabolising process of most antihypertensive drugs. Considering the allelic frequency in the population and the variability in the clinical response associated with genetic polymorphism, we find the study of the following alleles CYP2D6 *2, *4, deletion and duplication; CYP2C9*2 and *3, CYP2C19 *2 and CYP3A4*1B to be of crucial importance. Conclusions The study of polymorphisms in P450 cytochrome genes may contribute to an individualised therapy in the treatment against hypertension (AU)

Evaluación de la influencia del uso de antiagregantes plaquetarios orales en el valor de la razón normalizada internacional (INR) / Evaluation of the influence of the use of oral antiplatelet therapies on the value of the INR

Introducción: La razón normalizada internacional (INR) expresa el resultado de la determinación del tiempo de protrombina. Por tanto, ofrece el resultado del control de la anticoagulación que se debe practicar a todos los pacientes anticoagulados. Objetivo: El objetivo del trabajo es evaluar la influencia del uso de antiagregantes plaquetarios orales en el valor de la INR en los pacientes con algún factor de riesgo cardiovascular (FRCV). Métodos: Estudio observacional, descriptivo y transversal. El estudio se realizó durante el mes de febrero de 2009. Se identificaron dos grupos de pacientes: los que tomaban antiagregantes y los que no. La determinación de la INR se realizó mediante coagulómetro Coagucheck(R) XS. Resultados: Se incluyeron 41 pacientes, de los que 18 utilizaban antiagregantes orales (un 44,44% eran mujeres), con una media de edad de 75,33 años. Los antiagregantes utilizados fueron: ácido acetilsalicílico (77,77%), clopidogrel (16,66%) y triflusal (5,55%). El valor medio ± desviación estándar de la INR fue de 1,067 ± 0,076. Se identificó a 23 pacientes que no tomaban antiagregantes, con una media de edad de 67,08 años (un 65,21% eran mujeres). El valor medio de la INR fue de 1,009 ± 0,120. Discusión: El valor de la INR no presentó diferencias significativas entre grupos (p= 0,083). Por tanto, el uso de antiagregantes orales en los pacientes con algún FRCV, que fueron objeto de este estudio, no influyó en el valor de la INR del paciente con respecto a los pacientes del mismo grupo de población que no utilizaban antiagregantes orales (AU)

Introduction: The INR expresses the result of the determination of prothrombin time. Therefore, it offers the result of the anticoagulation control that all anticoagulated patients should undergo. Objective: The objective of this study is to evaluate the influence of the use of oral antiplatelet therapies on the value of the INR in patients with a cardiovascular risk factor. Method: An observational, cross-sectional descriptive study. The study period was in February 2009. Two groups of patients were identified: those who were taking antiplatelet therapies and those who were not. The INR was determined using the coagulometer Coagucheck(R) XS. Results: 41 patients were included, 18 of which were using oral antiplatelet therapies, 44.44% women. Mean age: 75.33 years. The antiplatelet therapies used were: ASA, 77.77%; clopidogrel, 16.66%; and triflusal, 5.55%. The mean INR value was 1.067 (SD±0.076). Twenty-three patients not taking antiplatelet therapies were identified. Mean age: 67.08 years, 65.21% women. The mean INR value was 1.009 (SD±0.120). Conclusion: no significant differences were found in INR values between the groups (p= 0.083). Therefore, the use of oral antiplatelet therapies by patients with a cardiovascular risk factor, who were the subject of this study, did not have an influence on the INR value of the patient with regard to patients of the same population group who were not using oral antiplatelet therapies (AU)

Role of CYP450 in pharmacokinetics and pharmacogenetics of antihypertensive drugs.

INTRODUCTION: Antihypertensive drugs are principally metabolised by enzymes of the P450 (CYP450) cytochrome family. Response to hypertensive treatment whose genetic basis is beginning to be known presents inter-individual differences among patients. OBJECTIVE: The aim of this review is to document the role of cytochrome enzymes P450 in the metabolising process of antihypertensive drugs, and to identify the most relevant polymorphisms in genes that code for these enzymes in order to facilitate future studies in hypertension pharmacogenetics. METHODS: A keyword search was performed in the following literature databases: Pubmed, Rxlist and Medscape. Genetic polymorphism public databases were also consulted (PharmGKB, NCBI and the CYP450 allele nomenclature committee web page. RESULTS: Enzymes CYP2D6, CYP2C9, CYP2D19 and CYP3A4 participate in the metabolising process of most antihypertensive drugs. Considering the allelic frequency in the population and the variability in the clinical response associated with genetic polymorphism, we find the study of the following alleles CYP2D6 *2, *4, deletion and duplication; CYP2C9*2 and *3, CYP2C19 *2 and CYP3A4*1B to be of crucial importance. CONCLUSIONS: The study of polymorphisms in P450 cytochrome genes may contribute to an individualised therapy in the treatment against hypertension.

Cumplimiento farmacoterapéutico de antiagregantes orales en pacientes que acuden a farmacias rurales de Girona y Almería / Pharmacotherapy compliance of oral antiplatelets in patients who go to the rural drugstores in Girona and Almeria

La falta de cumplimiento terapéutico puede producir un fracaso del tratamiento. En el caso de los antiagregantes, podría aumentar el riesgo de episodios cerebrovasculares y cardiovasculares, por lo que sería importante cuantificar y mejorar su cumplimiento. Objetivos: Comprobar el grado de cumplimiento farmacoterapéutico de los antiagregantes en los pacientes que acuden a farmacias rurales de Girona y Almería. Método: Estudio observacional, descriptivo y transversal, realizado entre febrero y marzo de 2008. Los datos se procesaron con el programa SPSS en su versión 15.0, con un intervalo de confi anza del 95%, y se utilizaron las pruebas de la t de Student y de la chi cuadrado. Resultados: La población incluida fue de 121 pacientes. Viven más personas solas en Girona, la población tiene una edad más avanzada y el nivel cultural es inferior. En Girona existen unos hábitos más saludables, y el 63% de la población realiza prevención primaria, mientras que en Almería el 87% hace prevención secundaria. El test de Morisky indica que en ambas poblaciones se incumple el tratamiento en un 43% de los casos. Cumplen más los pacientes a quienes les recogen la medicación, los que tienen estudios universitarios y los que están en prevención primaria. Incumplen más los varones y los pacientes que viven solos. Conclusión: Los pacientes que utilizan antiagregantes incumplen en un 43%, independientemente de las diferencias de perfil, y la principal causa es el olvido de la toma. Durante el primer año de tratamiento sólo incumple una cuarta parte de ellos, y aumenta hasta el 50% a partir del segundo año. En este estudio comprobamos que el test de Batalla identifica mejor el conocimiento y el test de Morisky el incumplimiento, por lo que es importante elegir el método que mejor se adapte a la población estudiada(AU)

Non-adherence to the drug therapy may cause therapeutic failure. In patients treated with antiplatelet drugs, non-adherence increases the risk of cardiovascular diseases. It would be important to quantify and to improve their compliance. Objectives: Check the pharmacotherapy compliance of the antiplatelet therapy of patients that go to rural drugstores in Girona and Almeria. Method: Observational cross-sectional descriptive study, from February to March 2008. The data were processed with SPSS V.15 CI: 95%, using the t-Student and Chi-square. Results: 121 patients were included in the study. There are more patients living alone in Girona, they are older and their cultural level is lower. In Girona there are some healthier habits, and 63% of the population is in primary prevention while in Almeria 87% of patients are in secondary prevention. The Morisky test in both populations indicates that there is non-adherence to the treatment in a 43%. The patients who comply the most are those whose medicine is picked up for them, who has studies in the university and who is in primary prevention. Men and patients living alone present a lower compliance. Conclusion: Patients using antiplatelet agents are non-compliant in 43%, with no relation to the profi le of the population, being the main reason for not taking the medication to forget to take it. During the fi rst year of treatment there is one quarter of non-compliant patients, increasing to 50% from the second year. In this study we found that the Batalla test is better for identifying the knowledge and the Morisky test for the compliance, so it is important when choosing the method to consider the population studied(AU)