[COPD inhaled therapy narrative review]. / Revisión narrativa de la terapia inhalatoria en la EPOC.

The basis of COPD maintenance treatment is the long-acting bronchodilators and the inhaled corticosteroids. Faced with the recent modifications in the clinical practice guidelines, we have carried out a review of studies that contrast the various therapeutic alternatives and pharmacological agents within each category, with the fundamental purpose of shedding light on which of these options prove to be more effective. Triple therapy stands out as essential in poorly controlled patients or with an eosinophilic phenotype, surpassing dual therapy. However, among the combinations of LAMA/LABA or LAMA/LABA/IC, no drug is observed to be superior in the reviewed evidence. Although triple therapies include corticosteroids, there does not appear to be a significant increase in side effects or pneumonia. Regarding monotherapy with LAMA, no significant differences are seen between the drugs, but in dual therapy with LABA/IC, the budesonide/formoterol combination seems to offer better control than fluticasone/salmeterol.

Revisión narrativa de la terapia inhalatoria en la EPOC / COPD inhaled therapy narrative review

La terapia inhalada con broncodilatadores de acción larga es la base del tratamiento farmacológico de la EPOC. Con el fin conocer los que ofrecen un mejor control, se realizó una búsqueda en Medline (Pubmed). Se analizaron los estudios comparativos de terapia inhaladora en pacientes con EPOC. Tras la comparación entre la combinación fija LABA/LAMA frente LABA/CI en pacientes no exacerbadores, se concluye que hay un mejor control con LABA/LAMA. Dentro de las combinaciones LABA/CI, la combinación budesonida/formoterol ofreció un mejor control. En la terapia LAMA no hay grandes diferencias, pero comparada con LABA ofreció un mayor control. La triple terapia en un único dispositivo se muestra superior a la doble terapia y a la triple terapia en dos dispositivos, no habiendo diferencias relevantes entre las combinaciones disponibles (AU)

Inhaled therapy with long-acting bronchodilators is the base of pharmacological treatment in COPD. In order to find out those that offer better control, a search was carried out in Medline (Pubmed). Comparative studies of inhaler therapy in COPD patients were analyzed. The comparison between the fixed combination LABA/LAMA versus LABA/CI in non-exacerbating patients, revealed a better control with LABA/LAMA. Within the LABA/CI combinations, budesonide/formoterol combination offered better control. LAMA inhalers revealed no great differences, but when compared to LABA, it offered a better control. Regarding triple therapy in a single device, was superior to double therapy and to triple therapy in two devices, with no relevant differences among the available combinations(AU)

[COPD inhaled therapy narrative review]. / Revisión narrativa de la terapia inhalatoria en la EPOC.

Inhaled therapy with long-acting bronchodilators is the base of pharmacological treatment in COPD. In order to find out those that offer better control, a search was carried out in Medline (Pubmed). Comparative studies of inhaler therapy in COPD patients were analyzed. The comparison between the fixed combination LABA/LAMA versus LABA/CI in non-exacerbating patients, revealed a better control with LABA/LAMA. Within the LABA/CI combinations, budesonide/formoterol combination offered better control. LAMA inhalers revealed no great differences, but when compared to LABA, it offered a better control. Regarding triple therapy in a single device, was superior to double therapy and to triple therapy in two devices, with no relevant differences among the available combinations.

[Vitamin D for daily practice]. / Vitamina D para la práctica diaria.

Vitamin D is a fat-soluble vitamin which has the regulation of calcium-phosphorus metabolism in the body as its main function. Vitamin D receptor is present in most of the nucleated cells of the body, and its role in multiple body processes is being discovered. The 3 main sources of vitamin D are ultraviolet sun radiation, diet, and supplementation. The skin, through solar radiation, provides 90% of the bodýs vitamin D needs. In cases of low vitamin D, sun exposure habits and diet must be reviewed, and pharmacological supplementation must be assessed. Measurement in the body is performed by determining 25-hydroxycholecalciferol with values below 20ng/ml being considered insufficient. Universal screening of vitamin D is not currently recommended, only in situations where a deficiency is suspected.

Importancia del déficit selectivo de inmunoglobulina A / Importance of selective immunoglobulin A deficiency

La deficiencia selectiva de inmunoglobulina A (IgA) es la inmunodeficiencia primaria más común. Se conoce muy poco sobre los mecanismos etiopatogénicos que conducen a esta enfermedad. Se estima que la incidencia de la enfermedad en España es de 1:163. Presentamos 3 casos diagnosticados en atención primaria. La mayoría de las personas con déficit selectivo de IgA suelen estar asintomáticas y se diagnostican por casualidad; sin embargo, deberíamos tener presentes a los pacientes con infecciones de vías respiratorias recurrentes, gastrointestinales, alérgicas y enfermedades autoinmunes que pueden estar asociadas a esta afección. A pesar de que no existe tratamiento en el momento actual, su importancia radica en las asociaciones con diferentes enfermedades como la enfermedad celíaca o púrpura trombocitopénica idiopática. Por otra parte, es importante conocer el riesgo de anafilaxia tras realizar transfusiones y su posible progresión a una inmunodeficiencia común variable. Es importante conocer la correcta vacunación en esta enfermedad (AU)

Selective IgA deficiency is the most common primary immunodeficiency. Little is known about the pathogenetic mechanisms leading to this disease. It is estimated that the incidence of this disease in Spain is 1:163. We report 3 cases diagnosed in Primary Care. Most people with selective IgA deficiency are usually asymptomatic and are diagnosed by chance, but patients with recurrent respiratory infections; gastrointestinal, allergic and autoimmune diseases can be associated with this disease. Although there is no treatment at present, its importance lies in the association with different diseases, such as coeliac disease or idiopathic thrombocytopenic purpura. Another important feature is the risk of anaphylaxis after transfusion, and the possible progression to Common Variable Immunodeficiency. It is important to know the vaccines that we can use due to the risk of disease (AU)

[Importance of selective immunoglobulin A deficiency]. / Importancia del déficit selectivo de inmunoglobulina A.

Selective IgA deficiency is the most common primary immunodeficiency. Little is known about the pathogenetic mechanisms leading to this disease. It is estimated that the incidence of this disease in Spain is 1:163. We report 3 cases diagnosed in Primary Care. Most people with selective IgA deficiency are usually asymptomatic and are diagnosed by chance, but patients with recurrent respiratory infections; gastrointestinal, allergic and autoimmune diseases can be associated with this disease. Although there is no treatment at present, its importance lies in the association with different diseases, such as coeliac disease or idiopathic thrombocytopenic purpura. Another important feature is the risk of anaphylaxis after transfusion, and the possible progression to Common Variable Immunodeficiency. It is important to know the vaccines that we can use due to the risk of disease.

[A case of upper extremity deep vein thrombosis]. / Caso de trombosis venosa profunda de miembro superior.

The case is presented of a 41 year-old women with a personal history of smoking and treated with oral contraceptives, who began taking analgesics and muscle relaxants due to a right cervical pain. As her clinical condition did not improve she was seen again. During the physical examination an increase of soft tissue in the right supraclavicular area was observed. The ultrasound revealed thrombosis of the internal jugular, subclavian, brachycephalic, axillar and humeral veins. We believe that upper-extremity deep venous thrombosis is a rare condition that must be considered in patients with oedema of the upper limbs. The key to a prompt diagnosis is to know the risk factors. Ultrasound is the standard approach.

[Colorectal interval cancer and colonoscopy quality criteria: presentation of a case]. / Cáncer colorrectal de intervalo y criterios de calidad de colonoscopia: a propósito de un caso.

We present the case of a 63 year-old woman without any family cancer background, who after having properly followed the cancer screening program for mild risk population, was diagnosed with colorectal cancer (stage IV) 3 years after a clear colonoscopy. This entity is known as interval colorectal cancer (diagnosed between correct screening periods). The colorectal cancer screening strategies and the specialized multidisciplinary units are experiencing important changes. Doctors involved in the screening programs and the follow up of neoplastic lesions (benign and malignant) are increasing. In reference to this case, we must analyze some of the limitations of the colonoscopy in detecting colorectal cancer, and we also review the quality criteria of colonoscopies. These must be remembered in daily practice.

Caso de trombosis venosa profunda de miembro superior / A case of upper extremity deep vein thrombosis

Presentamos el caso de una mujer de 41 años de edad entre cuyos antecedentes relevantes se encuentran ser fumadora y estar en tratamiento con anticonceptivos orales que acude a urgencias por un cuadro de dolor en la región cervical derecha fijo no irradiado pautándose analgésicos y relajantes musculares. Por la persistencia de la sintomatología acudió de nuevo a urgencias, donde se evidenció un aumento de partes blandas de la región laterocervical y supraclavicular derecha que borra el relieve de la clavícula por lo que se solicitó una ecografía de cuello que reveló una trombosis de vena yugular interna, subclavia, tronco braquiocefálico, vena axilar y humeral del lado derecho. Consideramos que la trombosis venosa profunda del miembro superior es una entidad poco frecuente, que se ha considerar en pacientes con edema del miembro superior. Las claves para su diagnóstico precoz pasan por conocer los factores de riesgo. La prueba diagnóstica de elección es la ecografía(AU)

The case is presented of a 41 year-old women with a personal history of smoking and treated with oral contraceptives, who began taking analgesics and muscle relaxants due to a right cervical pain. As her clinical condition did not improve she was seen again. During the physical examination an increase of soft tissue in the right supraclavicular area was observed. The ultrasound revealed thrombosis of the internal jugular, subclavian, brachycephalic, axillar and humeral veins. We believe that upper-extremity deep venous thrombosis is a rare condition that must be considered in patients with oedema of the upper limbs. The key to a prompt diagnosis is to know the risk factors. Ultrasound is the standard approach(AU)

Caso de trombosis venosa profunda de miembro superior / A case of upper extremity deep vein thrombosis

Presentamos el caso de una mujer de 41 años de edad entre cuyos antecedentes relevantes se encuentran ser fumadora y estar en tratamiento con anticonceptivos orales que acude a urgencias por un cuadro de dolor en la región cervical derecha fijo no irradiado pautándose analgésicos y relajantes musculares. Por la persistencia de la sintomatología acudió de nuevo a urgencias, donde se evidenció un aumento de partes blandas de la región laterocervical y supraclavicular derecha que borra el relieve de la clavícula por lo que se solicitó una ecografía de cuello que reveló una trombosis de vena yugular interna, subclavia, tronco braquiocefálico, vena axilar y humeral del lado derecho. Consideramos que la trombosis venosa profunda del miembro superior es una entidad poco frecuente, que se ha considerar en pacientes con edema del miembro superior. Las claves para su diagnóstico precoz pasan por conocer los factores de riesgo. La prueba diagnóstica de elección es la ecografía(AU)

The case is presented of a 41 year-old women with a personal history of smoking and treated with oral contraceptives, who began taking analgesics and muscle relaxants due to a right cervical pain. As her clinical condition did not improve she was seen again. During the physical examination an increase of soft tissue in the right supraclavicular area was observed. The ultrasound revealed thrombosis of the internal jugular, subclavian, brachycephalic, axillar and humeral veins. We believe that upper-extremity deep venous thrombosis is a rare condition that must be considered in patients with oedema of the upper limbs. The key to a prompt diagnosis is to know the risk factors. Ultrasound is the standard approach(AU)

Cáncer colorrectal de intervalo y criterios de calidad de colonoscopia: a propósito de un caso / Colorectal interval cancer and colonoscopyqQuality criteria: presentation of a case

Presentamos el caso de una mujer de 63 años, sin ningún antecedente familiar oncológico, que seguía de forma adecuada las estrategias de cribado de cáncer colorrectal (CCR) para población de riesgo medio. Es diagnosticada de CCR (estadio IV) 3 años después de una colonoscopia sin hallazgos patológicos. Esta entidad es conocida como cáncer colorrectal de intervalo (aquel que es diagnosticado entre períodos de cribado). Las estrategias de cribado de CCR y las unidades multidisciplinarias destinadas a dar un manejo específico en esta enfermedad están experimentando importantes cambios en los últimos años. Los especialistas que toman parte en el cribado poblacional y seguimiento de lesiones neoplásicas (benignas o malignas) van en aumento. A propósito de este caso, analizamos algunas de las limitaciones de la colonoscopia en cuanto a sensibilidad diagnóstica para el cáncer colorrectal, además de recordar los criterios de calidad de la colonoscopia, aquellos que habrá de tener en cuenta el médico peticionario en su práctica clínica diaria (AU)

We present the case of a 63 year-old woman without any family cancer background, who after having properly followed the cancer screening program for mild risk population, was diagnosed with colorectal cancer (stage IV) 3 years after a clear colonoscopy. This entity is known as interval colorectal cancer (diagnosed between correct screening periods). The colorectal cancer screening strategies and the specialized multidisciplinary units are experiencing important changes. Doctors involved in the screening programs and the follow up of neoplastic lesions (benign and malignant) are increasing. In reference to this case, we must analyze some of the limitations of the colonoscopy in detecting colorectal cancer, and we also review the quality criteria of colonoscopies. These must be remembered in daily practice (AU)

Varón de 45 años con tumoración lumbar / A 45 year-old male with lumbar tumours

Hombre de 45 años, con antecedente de infección por virus de la hepatitis B, que consultó por tumoración en la región lumbar desde hace 3 meses. En la exploración se aprecia fuerza muscular disminuida en miembros inferiores, la radiografía de tórax presenta engrosamiento pleural apical bilateral, la prueba de Mantoux fue positiva. La resonancia magnética nuclear lumbar reveló aplastamiento del cuerpo vertebral D4 y absceso de partes blandas a nivel de L1. El estudio microbiológico reveló presencia de Mycobacterium tuberculosis complex. Con el diagnóstico de enfermedad de Pott, se inició tratamiento. Desde la utilización de fármacos antituberculosos la afectación espinal se presenta de forma esporádica pero continúa siendo una enfermedad que provoca morbilidad elevada. El tratamiento de la afectación vertebral se basa en medicamentos antituberculosos y cirugía (AU)

A 45 year old Filipino male, with history of Hepatitis B virus infection, was seen in his primary care clinic with a lumbar mass for the past three months. On physical examination the lower limbs showed decrease strength, chest X-rays showed bilateral thickening of the apical pleura, the Mantoux skin test was positive and a lumbar magnetic resonance imaging study showed a compression fracture of D4 vertebral body and soft-tissue abscess in L1. Microbiological examination was positive for M. tuberculosis complex, and with the diagnosis of Pott's disease, he began treatment. With the advent of anti-tuberculosis drugs, spinal involvement of tuberculosis is rare, but it continues to have a high impact on morbidity. Treatment of vertebral involvement is based on anti-tuberculosis drugs and surgery (AU)

Comunicación intraventicular en un paciente adulto / Ventricular septal defect in an adult patient

Presentamos el caso clínico de un varón asintomático de 46 años en cuya radiografía de tórax se observa un botón aórtico derecho y en la exploración física un soplo sistólico con frémito palpable paraesternal izquierdo. Al realizársele ecocardiografía transesofágica y RMN se encontró una comunicación interventricular (CIV) que únicamente precisa revisiones ecocardiográficas periódicas. La CIV es la cardiopatía congénita más frecuente. Las CIV pueden ser membranosas, de entrada, trabeculadas o infundibulares. La sintomatología puede ser desde anodina únicamente con un soplo pansistólico paraesternal izquierdo en la exploración física, hasta hiperaflujo pulmonar que llegue a causar insuficiencia cardiaca. La radiografía de tórax mostrará cardiomegalia, el electrocardiograma hipertrofia biventricular y la ecocardiografía y la resonancia magnética mostrarán tamaño y número de comunicaciones. El tratamiento es conservador, ya que el 50% se cierran de forma espontánea en los primeros años de vida, reservando la cirugía para los casos sintomáticos y los asintomáticos con cortocircuito significativo (AU)

We report the case of a 46 year old asymptomatic male whose chest X-ray showed a right aortic knob and in the physical examination he had a systolic murmur with a palpable left parasternal heave. On performing the transesophageal echocardiography and MRI a ventricular septal defect (VSD) was observed which only requires periodic echocardiographic reviews. VSD is the most common congenital heart disease. The VSD may be membranous, inlet, trabecular, or infundibular. The clinical signs may range from only anodyne with a left pansystolic parasternal murmur on physical examination, up to lung hyper-flow which may lead to heart failure. The chest X-ray showed cardiomegaly, the electrocardiogram showed biventricular hypertrophy, and the echocardiography and MRI showed the size and number of communications. Treatment is conservative, since 50% close spontaneously in the first years of life, reserving surgery for symptomatic and asymptomatic cases with a significant shunt (AU)