Optimizing blood pressure control through telemedicine in Primary Care in Spain (Iniciativa Óptima): Results from a Delphi study

Atención primaria; Hipertensión; TelemedicinaAtenció primària; Hipertensió; TelemedicinaPrimary care; Hypertension; TelemedicineAim: Members of the working groups on hypertension or cardiovascular disease of the Spanish Societies of Primary Care Physicians (PCPs) [SEMERGEN], Family and Community Medicine [semFYC] and General and Family Physicians [SEMG], conducted a Delphi study to validate with a panel of PCPs with expertise in hypertension several recommendations to optimize teleconsultation in hypertensive patients. Materials and methods: Delphi study based on an online questionnaire with 59 recommendations based on the available evidence and the clinical experience of the authors. Results: 118 PCPs participated in two rounds of the questionnaire (98.3% of the invited physicians), reaching consensus in 53/62 statements (85%). The Primary Care team must proactively select the hypertensive patients suitable for telematic consultation and contact them to set up an appointment. Telematic consultation must begin explaining the reason and aims pursued, continuing with anamnesis, which must explore signs and symptoms of disease worsening, current treatments and level of adherence. In patients with a home blood pressure measurement (HBPM) ≤135/85mmHg, it is recommended to schedule a new telematic appointment in 3-6months. On the contrary, asymptomatic patients with a HBPM ≥135/85mmHg should undergo ambulatory blood pressure monitoring, treatment modification or, in case of warning signs or symptoms, referral to a face-to-face visit or to emergency department. Conclusions: Teleconsultation can complement face-to-face consultation, constituting an additional tool for the appropriate follow-up of hypertensive patients.Objetivo Representantes de los grupos de trabajo de hipertensión o enfermedad cardiovascular de las Sociedades Españolas de Médicos de Atención Primaria (MAP) [SEMERGEN], de Medicina Familiar y Comunitaria [semFYC] y de Médicos Generales y de Familia [SEMG] realizaron un estudio Delphi para validar con un panel de MAP expertos en hipertensión una propuesta de recomendaciones para optimizar la teleconsulta en pacientes hipertensos. Materiales y métodos Estudio Delphi basado en un cuestionario online con 59 recomendaciones, elaborado en base a la bibliografía relacionada disponible y a la experiencia clínica aportada por los autores. Resultados Un total de 118 MAP participaron en dos rondas del cuestionario (98,3% de los invitados), alcanzándose el consenso en 53/62 sentencias (85%). El equipo de Atención Primaria debe seleccionar a los pacientes hipertensos candidatos a realizar la consulta telemática proactivamente, informando de la cita con antelación. Al iniciar la consulta telemática, se recomienda explicar el motivo y los objetivos de la misma, y realizar la anamnesis preguntando por signos y síntomas de empeoramiento de la enfermedad, tratamientos actuales y adherencia a los mismos. En pacientes con una automedida de la presión arterial (AMPA) ≤ 135/85 mmHg se recomienda pautar una nueva cita telemática en 3-6 meses. Por el contrario, en pacientes asintomáticos que reporten una AMPA ≥ 135/85 mmHg se recomienda la monitorización ambulatoria de la presión arterial, modificar el tratamiento, o derivar al paciente a visita presencial o al hospital en caso de signos o síntomas de alarma. Conclusiones La teleconsulta puede complementar la consulta presencial, constituyendo un elemento más a tener en cuenta para el adecuado control de los pacientes hipertensos

Standardized incidence ratios and risk factors for cancer in patients with systemic sclerosis: Data from the Spanish Scleroderma Registry (RESCLE)

Aim: Patients with systemic sclerosis (SSc) are at increased risk of cancer, a growing cause of non-SSc-related death among these patients. We analyzed the increased cancer risk among Spanish patients with SSc using standardized incidence ratios (SIRs) and identified independent cancer risk factors in this population. Material and methods: Spanish Scleroderma Registry data were analyzed to determine the demographic characteristics of patients with SSc, and logistic regression was used to identify cancer risk factors. SIRs with 95% confidence intervals (CIs) relative to the general Spanish population were calculated. Results: Of 1930 patients with SSc, 206 had cancer, most commonly breast, lung, hematological, and colorectal cancers. Patients with SSc had increased risks of overall cancer (SIR 1.48, 95% CI 1.36-1.60; P < 0.001), and of lung (SIR 2.22, 95% CI 1.77-2.73; P < 0.001), breast (SIR 1.31, 95% CI 1.10-1.54; P = 0.003), and hematological (SIR 2.03, 95% CI 1.52-2.62; P < 0.001) cancers. Cancer was associated with older age at SSc onset (odds ratio [OR] 1.22, 95% CI 1.01-1.03; P < 0.001), the presence of primary biliary cholangitis (OR 2.35, 95% CI 1.18-4.68; P = 0.015) and forced vital capacity <70% (OR 1.8, 95% CI 1.24-2.70; P = 0.002). The presence of anticentromere antibodies lowered the risk of cancer (OR 0.66, 95% CI 0.45-0.97; P = 0.036). Conclusions: Spanish patients with SSc had an increased cancer risk compared with the general population. Some characteristics, including specific autoantibodies, may be related to this increased risk

Impact of interstitial lung disease on the survival of systemic sclerosis with pulmonary arterial hypertension

To assess severity markers and outcomes of patients with systemic sclerosis (SSc) with or without pulmonary arterial hypertension (PAH-SSc/non-PAH-SSc), and the impact of interstitial lung disease (ILD) on PAH-SSc. Non-PAH-SSc patients from the Spanish SSc registry and PAH-SSc patients from the Spanish PAH registry were included. A total of 364 PAH-SSc and 1589 non-PAH-SSc patients were included. PAH-SSc patients had worse NYHA-functional class (NYHA-FC), worse forced vital capacity (FVC) (81.2 +/- 20.6% vs 93.6 +/- 20.6%, P < 0.001), worse tricuspid annular plane systolic excursion (TAPSE) (17.4 +/- 5.2 mm vs 19.9 +/- 6.7 mm, P < 0.001), higher incidence of pericardial effusion (30% vs 5.2%, P < 0.001) and similar prevalence of ILD (41.8% vs. 44.9%). In individuals with PAH-SSc, ILD was associated with worse hemodynamics and pulmonary function tests (PFT). Up-front combination therapy was used in 59.8% and 61.7% of patients with and without ILD, respectively. Five-year transplant-free survival rate was 41.1% in PAH-SSc patients and 93.9% in non-PAH-SSc patients (P < 0.001). Global survival of PAH-SSc patients was not affected by ILD regardless its severity. The multivariate survival analysis in PAH-SSc patients confirmed age at diagnosis, worse NYHA-FC, increased PVR, reduced DLCO, and lower management with up-front combination therapy as major risk factors. In conclusion, in PAH-SSc cohort risk of death was greatly increased by clinical, PFT, and hemodynamic factors, whereas it was decreased by up-front combination therapy. Concomitant ILD worsened hemodynamics and PFT in PAH-SSc but not survival regardless of FVC impairment

Impact of interstitial lung disease on the survival of systemic sclerosis with pulmonary arterial hypertension

To assess severity markers and outcomes of patients with systemic sclerosis (SSc) with or without pulmonary arterial hypertension (PAH-SSc/non-PAH-SSc), and the impact of interstitial lung disease (ILD) on PAH-SSc. Non-PAH-SSc patients from the Spanish SSc registry and PAH-SSc patients from the Spanish PAH registry were included. A total of 364 PAH-SSc and 1589 non-PAH-SSc patients were included. PAH-SSc patients had worse NYHA-functional class (NYHA-FC), worse forced vital capacity (FVC) (81.2 ± 20.6% vs 93.6 ± 20.6%, P &lt; 0.001), worse tricuspid annular plane systolic excursion (TAPSE) (17.4 ± 5.2 mm vs 19.9 ± 6.7 mm, P &lt; 0.001), higher incidence of pericardial effusion (30% vs 5.2%, P &lt; 0.001) and similar prevalence of ILD (41.8% vs. 44.9%). In individuals with PAH-SSc, ILD was associated with worse hemodynamics and pulmonary function tests (PFT). Up-front combination therapy was used in 59.8% and 61.7% of patients with and without ILD, respectively. Five-year transplant-free survival rate was 41.1% in PAH-SSc patients and 93.9% in non-PAH-SSc patients (P &lt; 0.001). Global survival of PAH-SSc patients was not affected by ILD regardless its severity. The multivariate survival analysis in PAH-SSc patients confirmed age at diagnosis, worse NYHA-FC, increased PVR, reduced DLCO, and lower management with up-front combination therapy as major risk factors. In conclusion, in PAH-SSc cohort risk of death was greatly increased by clinical, PFT, and hemodynamic factors, whereas it was decreased by up-front combination therapy. Concomitant ILD worsened hemodynamics and PFT in PAH-SSc but not survival regardless of FVC impairment

Erratum: Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

Interpretation: By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning

Clinical and practical management of sodium-glucose cotransporter type 2 inhibitors in patients with chronic kidney disease

El descubrimiento del papel nefroprotector de los fármacos inhibidores del cotransportador sodio-glucosa tipo 2 (ISGLT2) en las personas con diabetes mellitus tipo 2 (DM 2) tras los resultados obtenidos en los respectivos ensayos de seguridad cardiovascular, supuso un cambio en el abordaje de la enfermedad renal diabética en los últimos años, posicionando a este grupo en el primer escalón de tratamiento de dicha comorbilidad. La publicación de los resultados del estudio DAPA-CKD con dapagliflozina, en los que se demuestra su beneficio frenando la progresión de la Enfermedad Renal Crónica (ERC) en pacientes con y sin DM ha abierto una nueva era en el manejo de esta patología. Se trata además de fármacos seguros y de fácil manejo para el clínico. En este artículo se revisa el manejo de los ISGLT2 en pacientes con ERC diabética y no diabética.The discovery of the nephroprotective role of sodium-glucose cotransporter type 2 (ISGLT2) inhibitor drugs in people with type 2 diabetes mellitus (DM 2) following the results obtained in the respective cardiovascular safety trials led to a change in the approach to diabetic kidney disease in recent years, positioning this group in the first step in the treatment of this comorbidity. The publication of the results of the DAPA-CKD study with dapagliflozin, demonstrating its benefit in slowing the progression of Chronic Kidney Disease (CKD) in patients with and without DM, has opened a new age in the management of this pathology. These drugs are also safe and easy to use for the clinician. This article reviews the management of ISGLT2 in patients with diabetic and non-diabetic CKD

Effect of vehicle driver age on frequency doubling perimetry.

OBJETIVO: Determinar la influencia de la edad de los conductores de vehículos en la sensibilidad al contraste medida mediante perimetría de duplicación de frecuencia. MÉTODO: Las medidas de sensibilidad al contraste se obtuvieron para estímulos de frecuencia duplicada (0.25 c/g a 25 Hz) en 17 posiciones (4 por cuadrante cada uno de 10º de diámetro y uno central de 5º) usando el perímetro FDT (Humphrey Instruments, California, EE.UU). Se examinaron los ojos derechos de 219 sujetos que acudieron a un centro de reconocimiento de conductores. Se estratificaron por edad en 5 grupos (21-30, 31-40, 41-50, 51-60, 61-70 años). Todos los conductores cumplían los requisitos visuales exigidos para conducir vehículos. RESULTADOS: La media de sensibilidad al contraste (dB) de todo el campo visual (20º) por grupo de edad fue: 31.5, 30.8, 30.2, 21.1, 28.5. Siendo la reducción media por década de 0.75 dB (p> 0.01). Los valores medios para el estímulo central de mácula fueron; 32.1,32,31.1,30.4,30.3 y para el resto de estímulos: 31.5,30.8,30.1,29,28.4. Para ambos casos la edad influyó significativamente. Asimismo, la media de sensibilidad al contraste obtenida en cada una de las 17 localizaciones del estímulo disminuyó significativamente (p<0.01) con la edad. CONCLUSIONES: Con el aumento de la edad la sensibilidad al contraste disminuyó significativamente para la detección de estímulos con duplicación de frecuencia.Depto. de Optometría y VisiónFac. de Óptica y OptometríaTRUEpu

New instrument to measure contrast sensitivity without and with glare

OBJETIVO/MÉTODO: valorar la sensibilidad al contraste fotópica, sin y con deslumbramiento con un nuevo instrumento. Se estudiaron 78 ojos derechos de 49 adultos jóvenes y de 29 adultos entre 35 y 55 años. La sensibilidad al contraste se midió con el Contrast Glarester CGT-1000 mediante una estrategia automatizada de reconocimiento para seis frecuencias espaciales. RESULTADOS/CONCLUSIONES: Los valores de sensibilidad al contraste fueron semejantes a los obtenidos con otros test clínicos. El aumento de la edad disminuyó significativamente la sensibilidad al contraste sin y con deslumbramiento. Sin embargo, el deslumbramiento no modificó la sensibilidad al contraste fotópica.Depto. de Optometría y VisiónFac. de Óptica y OptometríaTRUEpubPagado por el auto

Sensibilidad mesópica al contraste y discapacidad por deslumbramiento en conductores.

Visual Acuity is a poor predictor of driving ability and it is likely to be a poor predictor of many aspects of real-world vision, because the real world is not composed purely of fine objects with sharp edges at high contrast. Although not all objects are at contrst treshold either, it has been shown that a loss of contrast sensitivity (CS) is roughly equivalent to a loss of image contrast in the normal eye (OWSLEY, 1994). The extent of contrast loss required before real-world performance is reduced depends on the real-world task being performed. Somo tasks, such as optimal speed reading and mobility orientation in a well-llit room, tolerate large reductions in contrast (Elliot, 1996; Leffe, 1993; Pelli, 1986). These tasks would probably only be affected in patients with a severe loss of contrast sensitivity. However, other tasks such as speed reading newspaper-size print and face recognition are moderately affected by contrast reduction (Elliot, 1996). Further, mobility orientation under dim illumination has been shown to be seriously affected by reduced contrast. Thus, under low-iluminance conditions and when a subject is working near his or her acuity limit, tolerance to contrast loss is reduced (Legge, 1993)Depto. de Optometría y VisiónFac. de Óptica y OptometríaTRUEpu