Las guías de práctica clínica de manejo de la dislipemia. Una visión transatlántica.Clinical Practice Guidelines for the Management of Dyslipidemia. Transatlantic Perspectives

Situación de la dislipemia en España. Las guías de práctica clínica (GPC) se han convertido en un instru- mento fundamental en nuestra actividad asistencial. La revisión deta- llada de la evidencia científica disponible permite la elaboración de documentos de recomendaciones diagnósticas y terapéuticas avala- dos por las principales instituciones científicas. A pesar de que habi- tualmente están basadas en los mismos estudios y, por lo tanto, se redactan a partir de los mismos resultados, pueden existir diferentes interpretaciones y distintos enfoques, como ha sucedido reciente- mente en las principales GPC que abordan el manejo de las dislipe- mias. En el año 2011 la Sociedad Europea de Cardiología (ESC) y la European Atherosclerosis Society (EAS) publicaron la Guía ESC/EAS para el manejo de las dislipemias1, con unas recomendaciones que se mantienen vigentes y la mayoría de las sociedades científicas de nuestro entorno respaldan. A finales de 2013, el American College of Cardiology (ACC) y la American Heart Association (AHA) hicieron pública su guía sobre el tratamiento del colesterol sanguíneo para reducir el riesgo cardiovascular aterosclerótico en adultos2. Aunque persiguen la misma finalidad, que es la reducción del riesgo cardio- vascular mediante el tratamiento de la dislipemia, lo hacen con una orientación completamente distinta que ha generado un gran debate en el último año y ha hecho correr ríos de tinta, no solo en la literatura médica, sino también en la prensa generalista. En este número de REVISTA ESPAÑOLA DE CARDIOLOGÍA SUPLEMENTOS se revisarán detalladamente ambas GPC, sus fortalezas y sus debilidades. Como sucede la mayoría de las veces, habrá aspectos positivos en una y otra, y no necesariamente debemos elegir entre las dos, sino que tenemos la oportunidad de conocer la visión de las sociedades impli- cadas y hacer un análisis constructivo de sus recomendaciones. En lo que sí hay un acuerdo total en las GPC del manejo de dislipemia es que el tratamiento debe basarse, además de en medidas de estilo de vida, en la utilización de estatinas como fármacos hipolipemiantes de elección cuando esté indicado, en prevención primaria según el nivel de riesgo y siempre en prevención secundaria, salvo contraindicación. Se ha demostrado rotundamente la eficacia de las estatinas en la disminución del colesterol plasmático, con una reducción proporcional de la morbimortalidad cardiovascular. Las estatinas, por su mecanismo de acción, no solo reducen el colesterol plasmático, sino que también poseen otros efectos extrali- pídicos; estas acciones pleotrópicas se están estudiando en diferentes escenarios, tanto clínicos como experimentales, con la finalidad de establecer posibles beneficios de las estatinas más allá de su capacidad hipolipemiante. Este aspecto, así como la utilización de las estatinas en el síndrome coronario agudo y el manejo de la dislipemia de pacientes con cardiopatía isquémica, diabéticos y otros grupos de riesgo, también se abordará en esta monografía. A lo largo de los seis artículos que la componen, expertos en el manejo de la enfermedad cardiovascular en nuestro país ofrecen una puesta al día sobre el manejo de la dislipemia

Tratamiento fisioterápico de un caso de CDG tipo Ia

El síndrome CDG ó los desordenes congénitos de la glicosilación de las mitocondrias son un grupo de enfermedades metabólicas hereditarias. Esta enfermedad afecta a todas las partes del cuerpo, en especial al sistema nervioso central en grados que varían de unos a otros, pero todos los pacientes tienen afectados el equilibrio y la coordinación. Pueden tener también problemas en el hígado, estrabismo, problemas de coagulación, pericarditis y comúnmente convulsiones. Hay 900 casos en el mundo diagnosticados y en España hay actualmente unos 33 casos. CASO CLÍNICO Niño de 2 años con CDG tipo Ia que acude a nuestro centro remitido por su neuropediatra. A su llegada presenta recorridos articulares pasivos completos tanto en extremidades superiores como inferiores . A nivel de motricidad gruesa presenta control cefálico y comienza a tener control de su tronco en posición sentada. Es capaz de voltear hacia ambos lados de forma autónoma , no es capaz de sentarse solito pero colabora en las tracciones. Se mantiene de pié con ayuda de la fisio. A nivel de motricidad fina es capaz de coger objetos de diferentes pesos y grosores pero no es capaz de darles funcionalidad (no es capaz por ejemplo de sacar aros de un eje , ó de realizar torres de 3 cubos…) Se pautan sesiones de fisioterapia 3 días a la semana donde trabajaremos la motricidad gruesa (trabajando los niveles de evolución motriz y coordinación oculomanual mediante pelotas,aros…), la motricidad fina mediante juegos manipulativos (torres de cubos, aros, encajables etc…) y el mantenimiento y mejora de recorridos articulares y del tono muscular mediante movilizaciones pasivas y activo-asistidas

Two cases of accidental dislocation of the silicone sleeve of an extrusion cannula into the vitreous cavity

Background: fluid-air exchange during vitreoretinal surgery is often used as a tool for subretinal fluid endodrainage. Soft-tipped flexible extrusion cannulas are commonly used to aspirate the posterior subretinal fluid. Methods: this is an observational two-case series describing two patients who underwent 20-G pars plana vitrectomy complicated by the accidental fall of the silicone sleeve of a soft-tipped extrusion cannula into the vitreous cavity. In the first case, the cannula had inadvertently been subjected to sterilization process. Results: while withdrawing the soft-tipped extrusion cannula from the eye, following internal drainage of transvitreal and subretinal fluid, the loose silicone sleeve probably got entangled at the inner lip of the sclerotomy and finally fell on the retinal surface. In both cases, the silicone sleeve was held and removed with an intraocular forceps. Conclusions: this rare complication has been reported in the literature only once previously. Sterilization of disposable subretinal fluid cannulas is not advisable because of the risk of dislocation of the silicone sleeve into the eye. Besides this, it is important to check the integrity of the silicone sleeve before and after surgery

Physical exercise as a multimodal tool for COVID-19: Could it be used as a preventive strategy?

Producción CientíficaThe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or coronavirus disease 2019 (COVID-19) is a novel coronavirus not previously recognized in humans until late 2019. On 31 December 2019, a cluster of cases of pneumonia of unspecified etiology was reported to the World Health Organization in China. The availability of adequate SARS-CoV-2 drugs is also limited, and the efficacy and safety of these drugs for COVID-2019 pneumonia patients need to be assessed by further clinical trials. For these reasons, there is a need for other strategies against COVID-19 that are capable of prevention and treatment. Physical exercise has proven to be an effective therapy for most chronic diseases and microbial infections with preventive/therapeutic benefits, considering that exercise involves primary immunological mediators and/or anti-inflammatory properties. This review aimed to provide an insight into how the implementation of a physical exercise program against COVID-19 may be a useful complementary tool for prevention, which can also enhance recovery, improve quality of life, and provide immune protection against SARS-CoV-2 virus infection in the long term. In summary, physical exercise training exerts immunomodulatory effects, controls the viral gateway, modulates inflammation, stimulates nitric oxide synthesis pathways, and establishes control over oxidative stress

Challenges in Diabetic Macular Edema Management: An Expert Consensus Report

Purpose: This paper aimed to present daily-practice recommendations for the management of diabetic macular edema (DME) patients based on available scientific evidence and the clinical experience of the consensus panel. Methods: A group of Spanish retina experts agreed to discuss different aspects related with the clinical management of DME patients. Results: Panel was mainly focused on therapeutic objectives in DME management; defini-tion terms; and role of biomarkers as prognostic and predictive factors to intravitreal treatment response. The panel recommends to start DME treatment as soon as possible in those eyes with a visual acuity less than 20/25 (always according to the retina unit capacity). Naive patient was defined, in a strict manner, as a patient who, up to that moment, had never received any treatment. A refractory DME patient may be defined as the one who did not achieve a complete resolution of the disease, regardless of the treatment administered. Different optical coherence tomography biomarkers, such as disorganization of the retinal inner layers, hyperreflective dots, and cysts, have been identified as prognostic factors. Conclusion: This document has sought to lay down a set of recommendations and to identify key issues that may be useful for the daily management of DME patients

Descemet’s Membrane Detachment during Phacocanaloplasty: Case Series and In-Depth Literature Review

This article presents three cases of Descemet’s membrane detachment (DMD) occurring during ‘ab externo’ phacocanaloplasty procedures in three patients with uncontrolled primary open-angle glaucoma (OAG) and discusses the management of this condition by reviewing the available literature. Following a successful 360° cannulation of Schlemm’s canal (SC), the microcatheter was withdrawn while an ophthalmic viscosurgical device (OVD) was injected into the canal. During passage through the inferonasal quadrant, a spontaneous separation of the posterior layer of the cornea was observed. Each case was managed differently after diagnosis, with the third case being drained intraoperatively based on experience gained from the previous cases. On the first postoperative day, slit-lamp biomicroscopy (BMC) revealed multiple DMDs in case one and a hyphema in the lower third of a deep anterior chamber. In the other two cases, a single DMD was observed. The second case developed hemorrhagic Descemet membrane detachment (HDMD), while the other two were non-hemorrhagic. In all three cases, anterior segment optical coherence tomography (AS-OCT) revealed the presence of retrocorneal hyperreflective membranes indicative of DMDs. These membranes were located in the periphery of the cornea and did not impact the visual axis. After evaluation, a small incision was made in the inferotemporal DMD of the first case. However, for the two remaining cases, a strategy of watchful waiting was deemed appropriate due to the location and size of the DMDs, as they did not affect the best-corrected visual acuity (BCVA). Over time, the patients demonstrated progressive improvement with a gradual reduction in the size of the DMDs

Type 1 diabetic mellitus patientswith increased atherosclerosisriskdisplay decreased CDKN2A/2B/2BAS gene expression in leukocytes

Background: Type 1 diabetes mellitus (T1DM) patients display increased risk of cardiovascular disease (CVD) and are characterized by a diminished regulatory T (Treg) cell content or function. Previous studies have shown an association between decreased CDKN2A/2B/2BAS gene expression and enhanced CVD. In the present study the potential relationship between CDKN2A/2B/2BAS gene expression, immune cell dysfunction and increased cardiovascular risk in T1DM patients was explored. Methods: A cross-sectional study was performed in 90 subjects divided into controls and T1DM patients. Circulating leukocyte subpopulations analysis by flow cytometry, expression studies on peripheral blood mononuclear cell by qPCR and western blot and correlation studies were performed in both groups of subjects. Results: Analysis indicated that, consistent with the described T cell dysfunction, T1DM subjects showed decreased circulating CD4+CD25+CD127- Treg cells. In addition, T1DM subjects had lower mRNA levels of the transcription factors FOXP3 and RORC and lower levels of IL2 and IL6 which are involved in Treg and Th17 cell differentiation, respectively. T1DM patients also exhibited decreased mRNA levels of CDKN2A (variant 1 p16Ink4a), CDKN2A (p14Arf, variant 4), CDKN2B (p15Ink4b) and CDKN2BAS compared with controls. Notably, T1DM patients had augmented pro-atherogenic CD14++CD16+-monocytes, which predict cardiovascular acute events and enhanced common carotid intima-media thickness (CC-IMT). Conclusions: Decreased expression of CDKN2A/2B/2BAS in leukocytes associates with increased CC-IMT atherosclerosis surrogate marker and proatherogenic CD14++CD16+ monocytes in T1DM patients. These results suggest a potential role of CDKN2A/2B/2BAS genes in CVD risk in T1DM

Novel Immune Features of the Systemic Inflammation Associated with Primary Hypercholesterolemia: Changes in Cytokine/Chemokine Profile, Increased Platelet and Leukocyte Activation

Primary hypercholesterolemia (PH) is associated with a low grade systemic inflammation that is likely the main driver of premature atherosclerosis. Accordingly, we characterized the immune cell behaviour in PH and its potential consequences. Whole blood from 22 PH patients and 21 age-matched controls was analysed by flow cytometry to determine the percentage of leukocyte immunophenotypes, activation, and platelet-leukocyte aggregates. Plasma markers were determined by Enzyme-Linked ImmunoSorbent Assay (ELISA). The adhesion of platelet-leukocyte aggregates to tumor necrosis factor-α (TNFα)-stimulated arterial endothelium was investigated using the dynamic model of the parallel-plate flow chamber. PH patients presented greater percentage of Mon 3 monocytes, Th2 and Th17 lymphocytes, activated platelets, and leukocytes than controls. The higher percentages of circulating platelet-neutrophil, monocyte and lymphocyte aggregates in patients caused increased platelet-leukocyte adhesion to dysfunctional arterial endothelium. Circulating CXCL8, CCL2, CX3CL1, and IL-6 levels positively correlated with key lipid features of PH, whereas negative correlations were found for IL-4 and IL-10. We provide the first evidence that increased platelet and leukocyte activation leads to elevated platelet-leukocyte aggregates in PH and augmented arterial leukocyte adhesiveness, a key event in atherogenesis. Accordingly, modulation of immune system behavior might be a powerful target in the control of further cardiovascular disease in PH

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

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 ± 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

Correlation between clinical parameters characterising peri-implant and periodontal health : a practice-based research in Spain in a series of patients with implants installed 4-5 years ago

Objectives: To explore peri-implant health (and relation with periodontal status) 4-5 years after implant insertion. Study D esign: A practice-based dental research network multicentre study was performed in 11 Spanish centres. The first patient/month with implant insertion in 2004 was considered. Per patient four teeth (one per quadrant) showing the highest bone loss in the 2004 panoramic X-ray were selected for periodontal status assessment. Bone losses in implants were calculated as the differences between 2004 and 2009 bone levels in radiographs. Results: A total of 117 patients were included. Of the 408 teeth considered, 73 (17.9%) were lost in 2009 (losing risk: >50% for bone losses ?7mm). A total of 295 implants were reviewed. Eight of 117 (6.8%) patients had lost implants (13 of 295 implants installed; 4.4%). Implant loss rate (quadrant status) was 1.4% (edentulous), 3.6% (preserved teeth), and 11.1% (lost teeth) (p=0.037). The percentage of implant loss significantly (p<0.001) increased when the medial/distal bone loss was ?3 mm. The highest (p?0.001) pocket depths were found in teeth with ?5mm and implants with ?3mm bone losses, with similar mean values (?4mm), associated with higher rates of plaque index and bleeding by probing. Conclusions: The significant bi-directional relation between plaque and bone loss, and between each of these two parameters/signs and pocket depths or bleeding (both in teeth and implants, and between them) together with the higher percentage of implants lost when the bone loss of the associated teeth was ?3 mm suggest that the patient?s periodontal status is a critical issue in predicting implant health/lesion