Risk factors associated with retinal vein occlusion.

AIMS: Retinal vein occlusion (RVO) is the most frequent retinal vascular disease after diabetic retinopathy in which arterial risk factors are much more relevant than venous factors. The objective was to evaluate the role of risk factors in the development of the first episode of RVO. SUBJECTS AND METHODS: One hundred patients with RVO [mean age 56 years, 42% females and mean body mass index (BMI) 27.5 kg/m(2)] were recruited consecutively from the outpatient clinic of a tertiary hospital in Valencia (Spain). All subjects underwent clinical assessment including anthropometric and blood pressure measurements and laboratory test including homocysteine, antiphospholipid antibodies (aPLAs) and thrombophilia studies. In half of the subjects, a carotid ultrasonography was performed. Three control populations matched by age, sex and BMI from different population-based studies were used to compare the levels and prevalence of arterial risk factors. One cohort of young patients with venous thromboembolic disease was used to compare the venous risk factors. RESULTS: Blood pressure levels and the prevalence of hypertension were significantly higher in the RVO population when compared with those for the general populations. There was also a large proportion of undiagnosed hypertension within the RVO group. Moreover, carotid evaluation revealed that a large proportion of patients with RVO had evidence of subclinical organ damage. In addition, homocysteine levels and prevalence of aPLAs were similar to the results obtained in our cohort of venous thromboembolic disease. CONCLUSIONS: The results indicate that hypertension is the key factor in the development of RVO, and that RVO can be the first manifestation of an undiagnosed hypertension. Furthermore, the majority of these patients had evidence of atherosclerotic disease. Among the venous factors, a thrombophilia study does not seem to be useful and only the prevalence of hyperhomocysteinaemia and aPLAs is higher than in the general population.

Effectiveness of Twitter Threads to Improve Medical Student Electrocardiogram (ECG) Reading-Skills. The TwittUVa-ECG Non-Randomized Pre-Post Study.

Introduction: social media is increasingly used in medical education, but its real educational effectiveness is unclear. In this study we assess the effectiveness of Twitter threads (TTS) in improving electrocardiogram (ECG) basic reading skills (ECGBRS). Materials and Methods: Seven TTS describing ECGBRS were published from October 28, 2021, to November 24, 2021. Tests were used to assess medical students ECGBRS pre and post intervention. All third and sixth-year medical students were invited to participate. Sixty-three students were enrolled (33 third year and 30 sixth year). Nine (14.3%) participants dropped out. Results: Sixth year medical students had higher ECGBRS at baseline. The number of correct items increased after the Twitter intervention; median correct pre-test items were 20 out of 56, (interquartile range (IQR) 14-23), and median post-test were 29 out of 56, (IQR 21-36) (p < 0.001). The improvement in sixth year students was greater than for third year students; 10 more correct items (IQR 4-14) vs. 7 (IQR 1-14) items (p = 0.045). The more TTS followed, the greater the improvement in ECGBRS (p = 0.004). The QRS axis calculation was the ECG reading skill with the lowest scores. Most medical students were definitely (35%) or very probably (46%) interested in repeating another on-line learning experience and found the TTS extremely (39%) or very (46%) interesting. Conclusions: The use of specifically designed TTS was associated with improvement in medical students' interpretation of ECGs. The effectiveness of the threads was higher in the final years of medical school when basic skills had already been acquired. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01885-x.

[Complexity in chronic obstructive pulmonary disease. Individualized treatment, new approaches, phenotypes and comorbidities]. / Complejidad de la EPOC. Tratamiento individualizado, nuevas aproximaciones, fenotipos, comorbilidades.

The current definition and severity stages of chronic obstructive pulmonary disease (COPD) focus excessively on spirometric criteria alone. Measurement of chronic airflow obstruction and its degree of reversibility is complex. The etiology of this disease cannot be fully explained in relation to smoking and the heterogeneity of this systemic disease that affects mainly the lung cannot be expressed through forced expiratory volume in 1 second (FEV(1)) alone. This simplification was useful for a period but the loss of clinical subtlety in large studies hampers interpretation of their results and their conclusions lose external validity. Accepting the complexity of COPD requires substituting the analytic focus centered on FEV(1) for a multifaceted approach that integrates other aspects in the analysis of real COPD patients. Identifying and classifying clinically significant subgroups or "COPD phenotypes" may help to guide treatment more efficiently. In patients with COPD, mortality due to cardiovascular diseases or malignancies occurs earlier than that due to respiratory causes; that is, deaths from COPD occur in patients not succumbing to cardiovascular diseases or cancer. To prolong survival in these patients, comorbidity should be evaluated and treated. COPD treatment based on severity measured by lung function can no longer be recommended. The various therapeutic options should be individualized according to the patient's other characteristics.

[Approach to COPD management in Internal Medicine]. / Conducta a seguir ante la EPOC desde Medicina Interna.

A 60-year old male patient with obesity and type 2 diabetes mellitus consulted due to high blood pressure, fearful of suffering ischemic heart disease. He also had a background of smoking 20 cigarettes/day for the last 30 years, but this did not concern him. In the questioning, he reported, although he did not consider it important, that he had cough and dyspnea on moderate exertions for some years. It is very unlikely that any internal medicine physician would doubt about whether to evaluate and treat his type 2 diabetes mellitus or high blood pressure, calculate his cardiovascular risk or if he has a metabolic syndrome, attempt to reduce his obesity and to make him stop smoking. However, should we label him as having chronic bronchitis or COPD? Should we perform a spirometry and bronchodilator test, treat his probable COPD? All his current symptoms are probably only due to COPD.

LDL particle size and composition and incident cardiovascular disease in a South-European population: The Hortega-Liposcale Follow-up Study.

BACKGROUND: The association of low-density lipoprotein (LDL) particle composition with cardiovascular risk has not been explored before. The aim was to evaluate the relationship between baseline LDL particle size and composition (proportions of large, medium and small LDL particles over their sum expressed as small-LDL %, medium-LDL % and large-LDL %) and incident cardiovascular disease in a population-based study. METHODS: Direct measurement of LDL particles was performed using a two-dimensional NMR-technique (Liposcale®). LDL cholesterol was assessed using both standard photometrical methods and the Liposcale® technique in a representative sample of 1162 adult men and women from Spain. RESULTS: The geometric mean of total LDL particle concentration in the study sample was 827.2 mg/dL (95% CI 814.7, 839.8). During a mean follow-up of 12.4 ±â€¯3.3 years, a total of 159 events occurred. Medium LDL particles were positively associated with all cardiovascular disease, coronary heart disease (CHD) and stroke after adjustment for traditional risk factors and treatment. Regarding LDL particle composition, the multivariable adjusted hazard ratios for CHD for a 5% increase in medium and small LDL % by a corresponding decrease of large LDL % were 1.93 (1.55, 2.39) and 1.41 (1.14, 1.74), respectively. CONCLUSIONS: Medium LDL particles were associated with incident cardiovascular disease. LDL particles showed the strongest association with cardiovascular events when the particle composition, rather than the total concentration, was investigated. A change in baseline composition of LDL particles from large to medium and small LDL particles was associated with an increased cardiovascular risk, especially for CHD.

[Type 2 diabetes mellitus and health-related quality of life: results from the Hortega Study]. / Diabetes mellitus tipo 2 y calidad de vida relacionada con la salud: resultados del Estudio Hortega.

OBJECTIVE: To evaluate which health-related quality of life (HRQOL) aspects are affected by type 2 diabetes mellitus (DM) and influence of glycemic control and associated cardiovascular risk factors (CVRF). METHOD: A descriptive cross-sectional study was carried out in the health coverage area of our hospital. Following a multiphase sampling a final sample of 495 people, representative of the general population, was analyzed. HRQOL was evaluated with the Short-Form 36 (SF-36). RESULTS: After adjustment for sociodemographic variables (age, sex, education level, marital status, number of persons residing together, labor situation, social class and rural or urban ambience), comorbidity and CVRF (smoking, systolic blood pressure, LDL-cholesterol level and body mass index), the patients with DM presented lower scores on four SF-36 scales: physical function, bodily pain, general health and vitality. Among people with diabetes systolic blood pressure, body mass index and glycosylated hemoglobin, but not lipid levels, were negatively correlated to some SF-36 scores. CONCLUSIONS: In our population patients with DM present a poorer HRQOL, specifically in the physical dimensions, but neither their social function nor their mental health was affected. Hypertension, obesity and poor glycemic control are associated with worst subjective state of health.

[Mitral insufficiency simulating aortic stenosis]. / Insuficiencia mitral que simula una estenosis aórtica.

We report a patient with a mitral insufficiency due to myxomatous valve change, with a regurgitation murmur heard principally at aortic area and radiating to the neck base. Even though the topography of the murmur seemed to suggest aortic stenosis, the other auscultation findings and the initial clinical tests clearly supported its source in a mitral insufficiency. The echocardiography allowed us not only to confirm our suspicion, but also to explain this auscultation finding mechanism, to show a severe mitral insufficiency with a anterior and medial jet, which struck the aorta and atrial septum. The surgery found a clear aortic vibration, which disappeared after implanting the mitral protheses. Our case illustrates the value of new diagnostic image techniques to complement the semiologic findings.

[Smoking in the general population: a description of prevalence, degree of consolidation and phase of cessation]. / Hábito tabáquico en una población general: descripción de la prevalencia, grado de consolidación y fase de abandono.

Smoking is a risk factor associated with high and preventable mortality and morbidity. An understanding of smoking consolidation and the desire to quit in specific subgroups of the general population will facilitate appropriate planning of health care resource utilization. We performed a multistage, random, stratified cross-sectional study in the general population of Valladolid (Spain) during 1998 and 1999 as part of a cardiovascular disease risk survey. Data collected by questionnaire and interview included number of cigarettes smoked per day, nicotine dependence and stage in the process of smoking cessation. Venous carboxyhemoglobin was also measured. The percentage of reported smokers in the general population was 29.3% (95% CI: 25.7-32.9%). Prevalence was 41.8% (95% CI: 39.2-44.5%) in the 26-to-45-year-old age group and fell to 6% (95% CI: 5.6-6.5%) among subjects over 66 years of age. Analysis by sex, 31.2% (95% CI: 26.1-36.4%) of men and 27.4% (95% CI: 24.1-30.7%) of women were smokers. In rural areas the percentage of smokers was 26.9% (95% CI: 20.2-33.5%) whereas the percentage in urban areas was 31.2% (95% CI: 26.1-36.4%). The number of cigarettes/day, venous carboxyhemoglobin and nicotine dependence differed by age range, sex and place of residence and helped to describe the degree of consolidation of smoking by strata. Phases of cessation were distributed similarly by age range but not by sex. The prevalence of smoking is still high, particularly among young people and women, although it is tending to decrease. Smoking is better established in the 26-45 year-old age range, among men, among those living in rural areas and among older smokers who, probably, can not quit smoking alone.

[Prevalence of mild to moderate chronic kidney disease in the general population of Spain. Hortega study]. / Prevalencia de la enfermedad renal crónica leve y moderada en población general. Estudio Hortega.

BACKGROUND: Although the epidemiology of subjects with end-stage renal disease is well-known in Spain, the prevalence of mild to moderate chronic kidney disease (CKD) in the general population is unknown. In order to measure this, it is necessary to carry out studies in the general population including those who are not health service patients. During epidemiology studies, the method of measuring glomerular filtration rate can change significantly the measurements of the prevalence of mild to moderate CKD. METHODS: Between 1997 and 2000, we performed a multi-phase descriptive polistratified epidemiological transversal study. The section of public chosen was between the ages of 15 and 85 living in the health area of western Valladolid (Spain). We calculated creatinine clearance using four methods: serum creatinine concentration, creatinine clearance using 24-hour urine samples adjusting the volume to the expected creatinuria with the Walser formulas, using the Cockcroft-Gault (CG) equation and applying the Modification of Diet in Renal Disease (MDRD) study abbreviated formula. We classified the level of kidney function, according to the National Kidney Foundation-Dialysis Outcomes Initiative (NFK-DOQI) guidelines. RESULTS: The instances of stages 2 and 3 CKD rise with age and are more common in women than men. This tendency is apparent in middle age and persons of 65 and above. Using the CG method, almost half the old women had a stage 3 CKD as opposed to a third of the men. If the measurement is performed using the abbreviated MDRD study, there are very few differences between the sexes. The prevalence of stage 3 CKD is similar (around 8%) but the prevalence of stage 2 CKD rises to 60% as opposed to 36% calculated using the CG equation. After comparing the results obtained with those of the third National Health and Nutrition Examination Survey Study (see table VII), the measurements of stage 3 CKD using the CG formula or by means of expected creatininuria coincide relatively, although the prevalence of stage 2 CKD is higher in persons of 65 and over. If we use the abreviated MDRD study, the prevalences increase by more than 20%. CONCLUSIONS: The prevalence of stages 2 and 3 CKD is clearly influenced by the method of calculation used. The prevalence of stage 2 CKD affects at least a third of the general population while those affected by stage 3 CKD are between 3.3% and 8.5%.

[Intracranial hypertension and subarachnoid hemorrhage: the forms of presentation of neurobrucellosis]. / Hipertensión intracraneal y hemorragia subaracnoidea, formas de presentación de la neurobrucelosis.

2 exceptional cases of neurobrucellosis, which manifested as intracranial hypertension and subdural hemorrhage, are presented. A revision of the subject was carried out. We consider that the association of two antibiotics (rifampin, doxycycline or trimethoprim/sulfamethoxazole) are valid and should be administered until the symptoms disappear and the CSF becomes normal. We suggest that all nervous system symptoms in our area, which are not clear, should be studied for brucella because sometimes these are the only features of neurobrucellosis.

[Necrotizing myelopathy associated with neoplasia. A clinico-pathological study of 2 cases and a review of the literature]. / Mielopatía necrosante asociada a neoplasia. Estudio clínico-patológico de dos casos y revisión de la literatura.

Two cases of necrotic myelopathy are presented. This is a very rare paraneoplasic syndrome. One patient had clear cell renal carcinoma and other had lymphatic metastasis of malignant melanoma without filiation of the primary tumor. The complete spinal study (MNR, CT, myelography) proved normal. Diagnosis is possible when all other causes of spinal disease have been discarded. Nowadays, it is possible to diagnose this disease premortem. The international literature reviewed showed 31 cases published since 1903, associated mainly to malignant diseases such as lymphomas, lung cancer, renal carcinoma, breast cancer, leukemias, etc. The differential diagnosis appears in the comments, as well as the presentation and evolution of the cases described up until now.

[Adverse reactions to antihypertensive drugs]. / Reacciones adversas a fármacos antihipertensivos.

OBJECTIVE: In chronic therapies, the less number of adverse effects (AE) to drugs is decisive to improve the rate of performance and reach the protective objective. We can make comparisons in the rate of tolerance of antihypertensive drugs (AD) if we study all of them with the same method in patients with real hypertension. METHODS: Analyzed 922 hospitalized hypertensive patients looking for adverse effects (AE) reported systematically and spontaneously form, the causality must to excel in two algorithms the uncertain grade. RESULTS: 13.47% of antihypertensive drugs presented an AE, beta-blockers presented more AE than diuretics and angiotensin-converting enzyme (ACE) inhibitors. CONCLUSIONS: The AD haven't the same AE neither feature nor frequency. If to dependent on a poor fulfillment, we lose the protective effectiveness, the application independently of the economic cost isn't right.

[Cardiovascular risk factors in diabetic patients. Cross-sectional study in general population: Hortega study]. / Factores de riesgo cardiovascular en pacientes diabéticos. Estudio epidemiológico transversal en población general: estudio Hortega.

OBJECTIVE: To find in our population with diabetes mellitus (DM) the prevalence of other cardiovascular risk factors, as well as their degree of control. METHOD: A cross-sectional study was carried out in 15-82 years population of our health coverage area, by means of a mailed survey sent to a simple random sample composed of 33,022 individuals, and a interview with collection of exploration and analitic data to a 495 people sub-sample. RESULTS: Among patients with DM 47/ have history of hypertension, and 58/ blood pressure =140/90 mmHg. Only 33/ have values <130/85 mmHg, and the percentage of patients with controlled blood pressure is significantly inferior between the women. There is history of hipercholesterolaemia in 45 210 / of diabetic patients versus 19/ of non-diabetic population; in the former group the total and LDL cholesterol levels are significantly lower. Smoking affects equally to both groups, while obesity and central obesity are more frequent between diabetic patients, although only in the case of women. CONCLUSIONS: In our diabetic population blood pressure control is limited: two third parts of the patients show values above recommended. This fact forms a contrast with a high degree of dyslipidemia control. We should pay a greater attention to hypertension treatment in patients with diabetes, mainly in women, and promote smoking cessation interventions essentially in males.

[Mortality in an internal medicine department within a third-level hospital; twenty years experience]. / Mortalidad en un servicio de medicina interna de un hospital de tercer nivel; 20 años de experiencia.

OBJECTIVES: To know and to analyze the main causes of death in an Internal Medicine Department (IM) and the mortality rate in such a Department. MATERIALS AND METHODS: From 1977 to 1996, a total of 77,310 patients were attended in the service under analysis. There were a total of 4,720 deaths. Clinical and epidemiological variables were analyzed so do management parameters related to inpatient deaths. RESULTS: Global mortality rate was 6.1%; the number of admissions increased along the study, whereas mortality rate tended to decrease. Median age was 72.8 years in death patients, and this age tended to increase during the period of study. Women's age was greater than men's one. The causes of the demise were cardiovascular (stroke and cardiopathy), neoplasm and respiratory disease, in that order. Neoplastic diseases were the leading death cause in men as they were in patients younger than 65 years-old, and AIDS was the main reason of death in patients younger than 35 years. Finally, 28.7% who died had been inpatients for no more than 48 hours. CONCLUSIONS: We can conclude that deaths in our IM department affect, as a rule, elderly patients with cardiovascular or neoplastic disease. Moreover, AIDS has experienced an increasing frequency, so it had became the first cause of death in patients under the age of 35. The old age of patients who die in our service, the great percentage of early deaths and the fact that the motive was, in the majority of the patients, a terminal disease, support the idea that new social customs tend to remove illness and death from family home, approving demise as a hospital event.

[Acute bilateral ophthalmoplegia and nasopharyngeal neoplasms]. / Oftalmoplejía bilateral aguda y neoplasias nasofaríngeas.

The cranial nerves, due to its location, are not infrequently involved in the nasopharyngeal neoplasm evolutionary course. In this paper we describe two cases in which the neoplastic infiltration in both cavernous sinuses brought the appearance of an acute bilateral ophthalmolegia on. This symptomatology meant, in the first case, the onset of disease. In the second one, it was the reason of consultation. Later we discuss the topographic location of the damages in both cavernous sinuses considering the observed neurological shortcomings. Finally we approach a short revision of the causes of bilateral ophthalmoplegia found in literature, as well as an evaluation of different radiological diagnosis methods for this kind of damages.

Chronic obstructive pulmonary disease. Are the times changing?

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent diseases and a major cause of morbidity and mortality in Spain. Currently, COPD is considered a treatable disease with an inflammatory origin that is frequently associated with other diseases. The prevalence of comorbidity is clearly increased in patients with COPD, irrespective of other confounding variables such as smoking. Current treatments have been proven to slow the loss of lung function, decrease the number of exacerbations and improve health-related quality of life and survival. New advances regarding the classics and more recent phenotypes such as patients with frequent exacerbations or COPD with associated comorbidity should allow for more individualized treatment while advances in genetic research and inflammatory mechanisms of the disease will help us to increase our knowledge of the disease and the development of new treatments.