Guidelines for the management of coagulation disorders in patients with cirrhosis.

Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients. These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation.

Detección incidental de niveles de vitamina B12 elevados y su relación con neoplasias / Incidental detection of raised serum levels of vitaminB12 and its association with neoplasms

Antecedentes y objetivo Los niveles elevados de vitaminaB12 se han asociado a enfermedades oncohematológicas. Sin embargo, se desconoce la relevancia de su detección incidental en sujetos sin un diagnóstico previo de cáncer. El objetivo de este estudio es evaluar la relación de la hipercobalaminemia y el diagnóstico de un proceso tumoral y establecer los factores de riesgo. Material y métodos Estudio observacional retrospectivo de una cohorte de pacientes con hipercobalaminemia. Se comparó la incidencia de neoplasias con una cohorte de pacientes con vitaminaB12<1.000pg/ml. Resultados Se seleccionaron 4.800 sujetos con determinaciones de vitaminaB12: 345 (7,1%) presentaban niveles >1.000pg/ml. Se excluyeron 68 (28,4%) por administración exógena, 12 (5%) por datos insuficientes y 15 (3%) por una neoplasia activa, seleccionando 250 pacientes; mediana de seguimiento: 22 (RIQ: 12-39) meses. Se detectó: hepatopatía 59 (23,6%), 44 (18,2%) presentaron cáncer de órgano sólido y 17 (7,1%), hemopatía maligna. El tiempo medio desde la detección de hipercobalaminemia al diagnóstico fue de 10meses. La mediana hasta el diagnóstico fue mayor en el grupo de vitaminaB12 elevada (13 vs 51meses; p<0,001). La hipercobalaminemia (HR_ 11,8; IC95: 2,8-49,6; p=0,001) y el tabaquismo (HR: 4,0; IC95%: 2,15-7,59; p<0,001) resultaron predictores independientes. Conclusiones La detección incidental de niveles séricos de vitaminaB12 >1.000pg/ml es elevada. El diagnóstico de neoplasia órgano sólido y hematológica es frecuente durante el año siguiente de seguimiento, siendo la hipercobalaminemia y el tabaquismo factores predictores de un mayor riesgo de cáncer. (AU)

Background and objective Elevated serum levels of vitaminB12 have been associated with oncohematological diseases. However, the relevance of its incidental detection in subjects without a previous diagnosis of cancer is unknown. The aim of this study was to evaluate the relationship between incidental hypercobalaminemia (vitaminB12 >1000pg/mL) and the diagnosis of a tumor process in patients without a diagnosis and to establish the risk factors. Material and methods Retrospective observational study of a cohort of patients with hypercobalaminemia. The incidence of neoplasms was compared with a cohort of patients with vitaminB12 levels <1000pg/mL. Results Vitamin B12 determinations of 4800 subjects were selected. Of them, 345 (7.1%) had levels >1000pg/ml; 68 (28.4%) were excluded due to exogenous administration, 12 (5%) due to insufficient data, and 15 (3%) due to having an active neoplasia, selecting 250 patients, with a median follow-up of 22 (IQR: 12-39) months. Structural liver disease was detected in 59 (23.6%). 18.2% (44 patients) had solid organ cancer and 17 (7.1%) had malignant hemopathy. The average time from the detection of hypercobalaminemia to the diagnosis of cancer was about 10months. The median until the diagnosis of neoplasia was higher in the high vitaminB12 group (13 vs 51months; P<.001). Hypercobalaminemia (HR: 11.8; 95%CI: 2.8-49.6; P=.001) and smoking (HR: 4.0; 95%CI: 2.15-7.59; P<.001) were independent predictors of neoplasia in the multivariate analysis. Conclusions Incidental detection of serum vitaminB12 levels >1000pg/ml is high in the population. The diagnosis of solid organ and hematological neoplasia is frequent during the following year of follow-up, with hypercobalaminemia and smoking being predictors of a higher risk of cancer. (AU)

Detección incidental de niveles de vitamina B12 elevados y su relación con neoplasias / Incidental detection of raised serum levels of vitaminB12 and its association with neoplasms

Antecedentes y objetivo Los niveles elevados de vitaminaB12 se han asociado a enfermedades oncohematológicas. Sin embargo, se desconoce la relevancia de su detección incidental en sujetos sin un diagnóstico previo de cáncer. El objetivo de este estudio es evaluar la relación de la hipercobalaminemia y el diagnóstico de un proceso tumoral y establecer los factores de riesgo. Material y métodos Estudio observacional retrospectivo de una cohorte de pacientes con hipercobalaminemia. Se comparó la incidencia de neoplasias con una cohorte de pacientes con vitaminaB12<1.000pg/ml. Resultados Se seleccionaron 4.800 sujetos con determinaciones de vitaminaB12: 345 (7,1%) presentaban niveles >1.000pg/ml. Se excluyeron 68 (28,4%) por administración exógena, 12 (5%) por datos insuficientes y 15 (3%) por una neoplasia activa, seleccionando 250 pacientes; mediana de seguimiento: 22 (RIQ: 12-39) meses. Se detectó: hepatopatía 59 (23,6%), 44 (18,2%) presentaron cáncer de órgano sólido y 17 (7,1%), hemopatía maligna. El tiempo medio desde la detección de hipercobalaminemia al diagnóstico fue de 10meses. La mediana hasta el diagnóstico fue mayor en el grupo de vitaminaB12 elevada (13 vs 51meses; p<0,001). La hipercobalaminemia (HR_ 11,8; IC95: 2,8-49,6; p=0,001) y el tabaquismo (HR: 4,0; IC95%: 2,15-7,59; p<0,001) resultaron predictores independientes. Conclusiones La detección incidental de niveles séricos de vitaminaB12 >1.000pg/ml es elevada. El diagnóstico de neoplasia órgano sólido y hematológica es frecuente durante el año siguiente de seguimiento, siendo la hipercobalaminemia y el tabaquismo factores predictores de un mayor riesgo de cáncer. (AU)

Background and objective Elevated serum levels of vitaminB12 have been associated with oncohematological diseases. However, the relevance of its incidental detection in subjects without a previous diagnosis of cancer is unknown. The aim of this study was to evaluate the relationship between incidental hypercobalaminemia (vitaminB12 >1000pg/mL) and the diagnosis of a tumor process in patients without a diagnosis and to establish the risk factors. Material and methods Retrospective observational study of a cohort of patients with hypercobalaminemia. The incidence of neoplasms was compared with a cohort of patients with vitaminB12 levels <1000pg/mL. Results Vitamin B12 determinations of 4800 subjects were selected. Of them, 345 (7.1%) had levels >1000pg/ml; 68 (28.4%) were excluded due to exogenous administration, 12 (5%) due to insufficient data, and 15 (3%) due to having an active neoplasia, selecting 250 patients, with a median follow-up of 22 (IQR: 12-39) months. Structural liver disease was detected in 59 (23.6%). 18.2% (44 patients) had solid organ cancer and 17 (7.1%) had malignant hemopathy. The average time from the detection of hypercobalaminemia to the diagnosis of cancer was about 10months. The median until the diagnosis of neoplasia was higher in the high vitaminB12 group (13 vs 51months; P<.001). Hypercobalaminemia (HR: 11.8; 95%CI: 2.8-49.6; P=.001) and smoking (HR: 4.0; 95%CI: 2.15-7.59; P<.001) were independent predictors of neoplasia in the multivariate analysis. Conclusions Incidental detection of serum vitaminB12 levels >1000pg/ml is high in the population. The diagnosis of solid organ and hematological neoplasia is frequent during the following year of follow-up, with hypercobalaminemia and smoking being predictors of a higher risk of cancer. (AU)

Incidental detection of raised serum levels of vitamin B12 and its association with neoplasms.

BACKGROUND AND OBJECTIVES: Elevated serum levels of vitamin B12 have been associated with oncohematological diseases. However, the relevance of its incidental detection in subjects without a previous diagnosis of cancer is unknown. The aim of this study was to evaluate the relationship between incidental hypercobalaminemia (vitamin B12 > 1000 pg/mL) and the diagnosis of a tumor process in patients without a diagnosis and to establish the risk factors. MATERIAL AND METHODS: Retrospective observational study of a cohort of patients with hypercobalaminemia. The incidence of neoplasms was compared with a cohort of patients with vitamin B12 levels <1000 pg/mL. RESULTS: Vitamin B12 determinations of 4800 subjects were selected. Of them, 345 (7.1%) had levels >1000 pg/mL. 68 (28.4%) were excluded due to exogenous administration, 12 (5%) due to insufficient data and 15 (3%) due to having an active neoplasia, selecting 250 patients, with a median follow-up of 22 (IQR 12-39) months. Structural liver disease was detected in 59 (23.6%). 18.2% (44 patients) had solid organ cancer and 17 (7.1%) had malignant hemopathy. The average time from the detection of hypercobalaminemia to the diagnosis of cancer was about 10 months. The median until the diagnosis of neoplasia was higher in the high vitamin B12 group (13 vs. 51 months p < 0.001). Hypercobalaminemia (HR 11.8; 95% CI 2.8-49.6; p = 0.001) and smoking (HR 4.0; 95% CI, 2.15-7.59; p < 0.001) were independent predictors of neoplasia in the multivariate analysis. CONCLUSIONS: Incidental detection of serum vitamin B12 levels >1000 pg/mL is high in the population. The diagnosis of solid organ and hematological neoplasia is frequent during the following year of follow-up, with hypercobalaminemia and smoking being predictors of a higher risk of cancer.

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.

Grado de consecución de los objetivos lipídicos a largo plazo en una cohorte de pacientes con síndrome coronario agudo en práctica clínica real / Achievement of long-term lipid targets in a cohort of patients with acute coronary syndrome in real-world clinical practice

Introduction and objectives According to the recent European epidemiological studies, the degree of lipid control in patients with very high vascular risk is suboptimal. This study analyzes the epidemiological characteristics, cardiovascular risk factors, lipid profile, recurrence, and degree of achievement of long-term lipid targets, according to the ESC/EAS Guidelines, in a cohort of patients with acute coronary syndrome (ACS) in a real-world clinical practice setting. Methods This work is a retrospective cohort study of patients diagnosed with ACS admitted to the Coronary Unit of a tertiary hospital from January 1, 2012 to December 31, 2015 and followed-up on until March 2022. Results A total of 826 patients were studied. During the follow-up period, greater prescribing of combined lipid-lowering therapy was observed, mainly high- and moderate-intensity statins and ezetimibe. At 24 months after the ACS, 33.6% of living patients had LDL levels <70 mg/dl and 9.3% had LDL levels <55 mg/dl. At the end of the follow-up (101 [88–111] months), the corresponding figures were 54.5% and 21.1%. Some 22.1% of patients had a recurrent coronary event and only 24.6% achieved an LDL level <55 mg/dl. Conclusions Achievement of the LDL targets recommended by the ESC/EAS guidelines is suboptimal in patients with ACS, both at two years and in the long-term (7–10 years), especially in patients with recurrent ACS (AU)

Introducción y objetivos Según los recientes estudios epidemiológicos europeos, el grado de control lipídico de los pacientes de muy alto riesgo vascular es subóptimo. En este estudio se han analizado las características epidemiológicas, los factores de riesgo cardiovascular, el perfil lipídico, la recurrencia y el grado de consecución de los objetivos lipídicos a largo plazo, según las Guías ESC/EAS, en una cohorte de pacientes con síndrome coronario agudo (SCA), en condiciones de práctica clínica real. Métodos Estudio de cohorte retrospectivo de los pacientes con diagnóstico de SCA ingresados en la unidad coronaria de un hospital de tercer nivel, entre el 1 de enero de 2012 y el 31 de diciembre de 2015, y seguidos hasta marzo de 2022. Resultados Se estudiaron 826 pacientes. Durante el periodo de seguimiento se observó una mayor prescripción de terapia hipolipemiante combinada, principalmente estatinas de alta y moderada intensidad y ezetimibe. A los 24 meses del SCA, un 33,6% de los pacientes vivos tenían un LDL < 70 mg/dl y en un 9,3% los niveles eran < 55 mg/dl. Al final del seguimiento (101 [88–111] meses), las correspondientes cifras eran del 54,5 y 21,1%. Un 22,1% de los pacientes presentaron un evento coronario recurrente, y solamente un 24,6% de ellos alcanzaron un nivel de LDL < 55 mg/dl. Conclusiones El cumplimiento de los objetivos recomendados por las Guías ESC/EAS en pacientes con SCA, es subóptimo, tanto a los 2 años como a largo plazo (7-10 años) desde el evento, y en especial en los pacientes con SCA recurrente (AU)

Achievement of long-term lipid targets in a cohort of patients with acute coronary syndrome in real-world clinical practice.

INTRODUCTION AND OBJECTIVES: According to the recent European epidemiological studies, the degree of lipid control in patients with very high vascular risk is suboptimal. This study analyzes the epidemiological characteristics, cardiovascular risk factors, lipid profile, recurrence, and degree of achievement of long-term lipid targets, according to the ESC/EAS Guidelines, in a cohort of patients with acute coronary syndrome (ACS) in a real-world clinical practice setting. METHODS: This work is a retrospective cohort study of patients diagnosed with ACS admitted to the Coronary Unit of a tertiary hospital from January 1, 2012 to December 31, 2015 and followed-up on until March 2022. RESULTS: A total of 826 patients were studied. During the follow-up period, greater prescribing of combined lipid-lowering therapy was observed, mainly high- and moderate-intensity statins and ezetimibe. At 24 months after the ACS, 33.6% of living patients had LDL levels <70 mg/dl and 9.3% had LDL levels <55 mg/dl. At the end of the follow-up (101 [88-111] months), the corresponding figures were 54.5% and 21.1%. Some 22.1% of patients had a recurrent coronary event and only 24.6% achieved an LDL level <55 mg/dl. CONCLUSIONS: Achievement of the LDL targets recommended by the ESC/EAS guidelines is suboptimal in patients with ACS, both at two years and in the long-term (7-10 years), especially in patients with recurrent ACS.

Immune dysregulation and pathophysiology of alcohol consumption and alcoholic liver disease.

Alcoholic liver disease (ALD) is a clinical-pathologic entity caused by the chronic excessive consumption of alcohol. The disease includes a broad spectrum of anomalies at the cellular and tissual level that can cause acute-on-chronic (alcoholic hepatitis) or chronic (fibrosis, cirrhosis, hepatocellular cancer) injury, having a great impact on morbidity and mortality worldwide. Alcohol is metabolized mainly in the liver. During alcohol metabolism, toxic metabolites, such as acetaldehyde and oxygen reactive species, are produced. At the intestinal level, alcohol consumption can cause dysbiosis and alter intestinal permeability, promoting the translocation of bacterial products and causing the production of inflammatory cytokines in the liver, perpetuating local inflammation during the progression of ALD. Different study groups have reported systemic inflammatory response disturbances, but reports containing a compendium of the cytokines and cells involved in the pathophysiology of the disease, from the early stages, are difficult to find. In the present review article, the role of the inflammatory mediators involved in ALD progression are described, from risky patterns of alcohol consumption to advanced stages of the disease, with the aim of understanding the involvement of immune dysregulation in the pathophysiology of ALD.

Fibrilación auricular no valvular y obstrucción venosa retiniana: la Cohorte Valdecilla / Nonvalvular atrial fibrillation and retinal vein occlusion: The Valdecilla Cohort

Introduction and objectives Retinal vein occlusion (RVO) and nonvalvular atrial fibrillation (NVAF) are associated with vascular risk factors (VRF) and aging. The aim of this study is to analyze differences in the prevalence of VRF, vascular events, glaucoma, and anticoagulant treatment in patients with NVAF and RVO compared to a control group of the general population from the same geographic area. Methods This is a prospective, single-center, case-control study. All patients diagnosed with RVO from December 2008 to March 2020 as well as a control group were included. Clinical, laboratory, electrocardiographic, and carotid ultrasound variables were analyzed. Results A total of 386 patients with RVO and 343 controls were studied. Patients with RVO and NVAF were older and more of them had hypertension, a history of vascular events, and carotid atheromatosis than subjects with RVO without NVAF. In patients with NVAF who were on anticoagulants, those who had RVO differed from the controls with NVAF in that they had a higher prevalence of glaucoma (32 vs. 5.3%; p<0.034), with no significant differences regarding age, VRF, vascular events, or type of anticoagulant therapy (acenocumarol or direct-acting oral anticoagulants). Conclusions Patients with RVO and NVAF were older and had a higher prevalence of hypertension and carotid atheromatosis than subjects with RVO without NVAF. Patients with NVAF and RVO had higher prevalence of glaucoma than subjects with NVAF without RVO. In patients with NVAF, it is recommended to optimized VRF treatment and glaucoma control to prevent the development of RVO (AU)

Introducción y objetivos La obstrucción venosa retiniana (OVR) y la fibrilación auricular no valvular (FANV) se relacionan con los factores de riesgo vascular (FRV) y con el envejecimiento. Este trabajo tiene por objetivo analizar las diferencias en la prevalencia de los FRV, de los eventos vasculares, del glaucoma y del tratamiento anticoagulante en los pacientes con FANV y OVR comparada con un grupo control de la población general de la misma área geográfica. Métodos Estudio prospectivo unicéntrico de casos y controles. Se incluyeron todos los pacientes diagnosticados de OVR desde diciembre de 2008 hasta marzo de 2020, y un grupo control. Se analizaron variables clínicas, de laboratorio, electrocardiográficas y de ultrasonidos de carótida. Resultados Se estudiaron 386 pacientes con OVR y 343 controles. Los pacientes con FANV y OVR eran de mayor edad, tenían más hipertensión, antecedente de eventos vasculares y ateromatosis carotídea que los sujetos con OVR sin FANV. En los pacientes con FANV anticoagulados, aquellos que tenían OVR, diferían de los controles con FANV en una mayor prevalencia de glaucoma (32 vs. 5,3%; p<0,034), sin hallarse diferencias significativas respecto a la edad, los FRV, los eventos vasculares o la terapia anticoagulante pautada (acenocumarol o anticoagulantes de acción directa). Conclusiones Los pacientes con OVR y FANV tienen mayor edad y mayor prevalencia de hipertensión arterial, y ateromatosis carotídea que los que no tienen FANV. Aquellos con FANV y OVR difieren de los que no tienen OVR en la mayor incidencia de glaucoma. En los pacientes con FANV sugerimos optimizar el tratamiento de los FRV y el control del glaucoma para prevenir el desarrollo de la OVR (AU)

Relevance of subclinical right ventricular dysfunction measured by feature-tracking cardiac magnetic resonance in non-ischemic dilated cardiomyopathy.

BACKGROUND: Right ventricular (RV) dysfunction in patients with non-ischemic dilated cardiomyopathy (NICM) is associated with cardiovascular events. To analyze the feasibility of assessing RV myocardial deformation by feature tracking (FT)-cardiac magnetic resonance (CMR), and its usefulness as a prognostic marker. METHODS: Retrospective study of NICM patients undergoing CMR. Longitudinal FT-RV free wall (LFT-RVFW) and fractional area change (FAC) were obtained. Correlation with standard RV parameters was studied. An association with combined event (heart failure (HF), ICD implantation or cardiovascular death) was assessed using a logistic regression model. RESULTS: 98 patients (64 ± 13 years) were included. Left ventricular (LV) systolic function (LVEF 29.5 ± 9.6%, 47% with LVEF ≥ 30%) and RV (RVEF 52.2 ± 14.6%, 72% with RVEF ≥ 45%). Follow-up of 38 ± 17 months, 26.5% presented at least one admission for HF. An excellent correlation of LFT-RVFW (r = 0.82) and FAC (r = 0.83) with RVEF was evident. No association of RV-FT parameters with prognosis entire study population was found. However, in patients with LVEF ≥ 30%, admissions for HF were associated with lower LFT-RVFW (-21.6 ± 6.6% vs -31.3 ± 10%; p = 0.006) and FAC (36.6 ± 9.6% vs 50.5 ± 13.4%; p < 0.001) values. Similar differences were observed when only patients with RVEF ≥ 45% were considered. An LFT-RVFW cut-off point of -19.5% and FAC of 36.5% showed good prognostic performance. Decreased LFT-RVFW or FAC represented an independent predictor of combined event in patients with LVEF ≥ 30%. CONCLUSIONS: In NICM patients without severe LV dysfunction, decreased values of LFT-RVFW and/or FAC were associated with HF admissions, independently of RVEF.

Nonvalvular atrial fibrillation and retinal vein occlusion: The Valdecilla Cohort.

INTRODUCTION AND OBJECTIVES: Retinal vein occlusion (RVO) and nonvalvular atrial fibrillation (NVAF) are associated with vascular risk factors (VRF) and aging. The aim of this study is to analyze differences in the prevalence of VRF, vascular events, glaucoma, and anticoagulant treatment in patients with NVAF and RVO compared to a control group of the general population from the same geographic area. METHODS: This is a prospective, single-center, case-control study. All patients diagnosed with RVO from December 2008 to March 2020 as well as a control group were included. Clinical, laboratory, electrocardiographic, and carotid ultrasound variables were analyzed. RESULTS: A total of 386 patients with RVO and 343 controls were studied. Patients with RVO and NVAF were older and more of them had hypertension, a history of vascular events, and carotid atheromatosis than subjects with RVO without NVAF. In patients with NVAF who were on anticoagulants, those who had RVO differed from the controls with NVAF in that they had a higher prevalence of glaucoma (32 vs. 5.3%; p<0.034), with no significant differences regarding age, VRF, vascular events, or type of anticoagulant therapy (acenocumarol or direct-acting oral anticoagulants). CONCLUSIONS: Patients with RVO and NVAF were older and had a higher prevalence of hypertension and carotid atheromatosis than subjects with RVO without NVAF. Patients with NVAF and RVO had higher prevalence of glaucoma than subjects with NVAF without RVO. In patients with NVAF, it is recommended to optimized VRF treatment and glaucoma control to prevent the development of RVO.

Oclusión venosa retiniana en pacientes menores de 50 años. Análisis de factores de riesgo vascular, trombofilia, hallazgos ecográficos carotídeos y etiologías poco frecuentes / Retinal vein occlusion in patients under 50 years. Analysis of vascular risk factors, thrombophilia, carotid ultrasound findings and uncommon aetiologies

Introducción La oclusión venosa retiniana (OVR) se ha relacionado con factores de riesgo vascular y trombofilia. Métodos Se trata de un estudio de cohorte prospectivo de todos los pacientes diagnosticados de OVR y remitidos a una clínica de medicina interna de un hospital universitario terciario durante un período de 10 años. Se analizaron variables clínicas, de laboratorio y ecográficas de troncos supraaórticos y se compararon según la edad. Resultados Se incluyeron unos 309 pacientes diagnosticados de OVR, 25 de ellos menores de 50 años. La prevalencia de hipertensión arterial, dislipidemia, diabetes mellitus, hiperhomocisteinemia y placa carotídea fue significativamente mayor en pacientes > 50 años que en los menores. Sin embargo, la prevalencia de trombofilia hereditaria fue mayor en el grupo más joven (32 vs. 11,4%; p = 0,005). Se observaron enfermedades poco frecuentes relacionadas con la OVR como hepatitis C, talasemia menor, enfermedad de Lyme, vasculitis y perlebitis en pacientes jóvenes sin factores de riesgo vascular. Conclusión Sugerimos realizar un estudio genético de trombofilia en pacientes con OVR menores de 50 años, siendo siempre recomendable un control exhaustivo de los factores de riesgo vascular en todos los pacientes con OVR. Además, sugerimos tener en cuenta las enfermedades poco frecuentes relacionadas con la OVR, especialmente en pacientes jóvenes sin factores de riesgo vascular (AU)

Introduction Retinal vein occlusion (RVO) has been related to vascular risk factors and thrombophilia. Methods This is a prospective cohort study of all patients diagnosed with RVO and referred to an Internal Medicine clinic of a tertiary teaching hospital during a 10-year period. Clinical, laboratory and supra-aortic trunks ultrasound variables were analysed and compared according to age. Results Some 309 patients diagnosed with RVO were included, 25 of them younger than 50 years. The prevalence of high blood pressure, dyslipidaemia, diabetes mellitus, hyperhomocysteinemia, and carotid plaque was significantly higher in patients>50 years than in those below. However, the prevalence of inherited thrombophilia was higher in the younger group (32.0 vs 11.4%; p = 0.005). Uncommon diseases related to RVO such as hepatitis C, thalassemia minor, Lyme disease, vasculitis, and periphlebitis were observed in young patients without vascular risk factors. Conclusion We suggest performing a genetic thrombophilia study in RVO patients younger than 50 years, while an exhaustive control of vascular risk factors is always recommended in all RVO patients. Moreover, we suggest bearing in mind uncommon diseases related to RVO, especially in young patients without vascular risk factors (AU)

Retinal vein occlusion in patients under 50 years. Analysis of vascular risk factors, thrombophilia, carotid ultrasound findings and uncommon aetiologies.

INTRODUTION: Retinal vein occlusion (RVO) has been related to vascular risk factors and thrombophilia. METHODS: This is a prospective cohort study of all patients diagnosed with RVO and referred to an Internal Medicine clinic of a tertiary teaching hospital during a 10-year period. Clinical, laboratory and supra-aortic trunks ultrasound variables were analysed and compared according to age. RESULTS: Some 309 patients diagnosed with RVO were included, 25 of them younger than 50 years. The prevalence of high blood pressure, dyslipidaemia, diabetes mellitus, hyperhomocysteinemia, and carotid plaque was significantly higher in patients >50 years than in those below. However, the prevalence of inherited thrombophilia was higher in the younger group (32.0% vs 11.4%; p = 0.005). Uncommon diseases related to RVO such as hepatitis C, thalassemia minor, Lyme disease, vasculitis, and periphlebitis were observed in young patients without vascular risk factors. CONCLUSION: We suggest performing a genetic thrombophilia study in RVO patients younger than 50 years, while an exhaustive control of vascular risk factors is always recommended in all RVO patients. Moreover, we suggest bearing in mind uncommon diseases related to RVO, especially in young patients without vascular risk factors.

Dataset of physical features from natural water-bodies in a Mediterranean high-mountain context (Sierra Nevada, SE Spain).

This dataset was obtained over repeated field-trips to the Sierra Nevada Massif and contains the physical parameters of its recognised water-bodies. It therefore defines the general cartography of the area, with data on individual features regarding the geographical coordinates (x, y, z), dimensions (length, width, depth), flooded surface area, stored water volume, shoreline length, as well as the area of associated green fringes and the length of their borders. These data were basically obtained using straightforward techniques, such as GPS, tape measurements and photographic interpretation. The data were then previously used to define the role of these water-bodies in the hydrology of the massif: relationships between number of water-bodies and water volumes between 2700 and 3200 m a.s.l. regarding watersheds (Mediterranean, Atlantic and total massif), relationships with green fringes, moment of maximum snowmelt discharge and the estimation of different components of water volumes discharged during the main period of thaw. The formation patterns of each water-body were also identified in their situational context, and the role played by each formation process on the stored water volume: the water-bodies close to the peak line (2918 m mean altitude) are highly dependant on the glacial processes that created the hollows in which they are located. Slope instability created water-bodies mainly located at lower altitudes and are more fragile due intense slope dynamics. In any case, these hydrological data show a paradoxical behaviour because despite its higher xericity, the Mediterranean watershed generally has higher water contents than the Atlantic. The cause of this hydrological imbalance between watersheds seems to be unrelated to the formation processes of the existing water-bodies. Sierra Nevada is considered to be clearly representative of a high mountain Mediterranean environment, where the data collected are a starting point to define the different habitats or for investigation of the hydrological processes of the massif and their evolution. Lack of such data is often a problem that in the present case is solved with this contribution.

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.

Sofosbuvir-velpatasvir in Mexican patients with hepatitis C: A retrospective review.

INTRODUCTION: The sofosbuvir-velpatasvir (SOF/VEL) combination is a direct-acting antiviral therapy that is authorized and available in Mexico, making the performance of a real-world multicenter study that evaluates the sustained virologic response at 12 weeks post-treatment a relevant undertaking. METHODS: A retrospective review of the case records of 241 patients seen at 20 hospitals in Mexico was conducted to assess hepatitis C treatment with the SOF/VEL combination (n = 231) and the sofosbuvir/velpatasvir/ribavirin (SOF/VEL/RBV) combination (n = 10). The primary efficacy endpoint was the percentage of patients that achieved SVR at 12 weeks after the end of treatment. RESULTS: Overall SVR was 98.8% (95% CI 97.35-100%). Only three patients did not achieve SVR, two of whom had cirrhosis and a history of previous treatment with peg-IFN. Of the subgroups analyzed, all the patients with HIV coinfection, three patients with genotype 3, and the patients treated with the SOF/VEL/RBV combination achieved SVR. The subgroups with the lower success rates were patients that were treatment-experienced (96.8%) and patients with F1 fibrosis (95.5%). The most frequent adverse events were fatigue, headache, and insomnia. No serious adverse events were reported. CONCLUSION: Treatments with SOF/VEL and SOF/VEL/RBV were highly safe and effective, results coinciding with those of other international real-world studies.

Efectos de la pandemia por SARS-CoV-2 en una cohorte de pacientes con obstrucción venosa retiniana / Effects of the COVID-19 pandemic on a cohort of patients with vein occlusion

Antecedentes y objetivos En diciembre de 2019 surgió una nueva enfermedad por coronavirus en humanos causada por el virus SARS-CoV-2, la COVID-19, que se ha asociado con fenómenos trombóticos. La obstrucción venosa retiniana (OVR) es principalmente una consecuencia de los factores de riesgo vascular (FRV). El objetivo de este estudio ha sido analizar los casos de infección por SARS-CoV-2 en una cohorte de pacientes con OVR (cohorte Valdecilla). Pacientes y métodos Entre diciembre de 2008 y 2020 hemos atendido 429 pacientes con OVR. Diez han padecido COVID-19, de los que uno no presentaba FRV ni trombofilia. Los otros 9 fueron diagnosticados de OVR antes de la infección: todos tenían FRV; 6 ateromatosis carotídea y 4 presentaban un síndrome antifosfolípido. La infección no causó en ellos fenómenos trombóticos. Conclusiones La OVR es una manifestación infrecuente de la COVID-19. En nuestra cohorte de pacientes con OVR la COVID-19 no indujo eventos trombóticos (AU)

Background and objectives A new coronavirus disease in humans, COVID-19, caused by SARS-CoV-2, emerged in December 2019. It has been associated with the development of thrombotic phenomena. Retinal vein occlusion (RVO) is mainly a consequence of vascular risk factors (VRF). This study aimed to analyze cases of COVID-19 in a cohort of patients with RVO (Valdecilla cohort). Patients and methods Between December 2008 and December 2020, 429 patients with RVO were attended to in our clinic. Ten patients had COVID-19, one of which did not have VRF or thrombophilia. The remaining nine patients had RVO prior to the infection and VRF, six had carotid atherosclerosis, and four had antiphospholipid syndrome. The infection did not cause thrombotic phenomena in any of them. Conclusions RVO is a rare manifestation of COVID-19. In our cohort of patients with RVO, COVID-19 disease did not lead to thrombotic events (AU)

Congenital pulmonary airway malformation (cpam) mimicking an spontaneous pneumothorax in a newborn. / Malformación pulmonar congénita simulando un neumotórax espontáneo en un recién nacido.

INTRODUCTION: Patients with congenital pulmonary airway malformation (CPAM) are usually asymptomatic, but some may present with respiratory distress. We report a rare presentation of a CPAM as an image compatible with persistent and localized spontaneous pneumothorax. CASE REPORT: A 2-month-old male infant without prenatal diagnosis, postnatal distress or barotrauma, was admitted with acute respiratory symptoms and a right tension pneumothorax on chest X-ray. Despite placement of a chest drain, radiological image persisted. CT confirmed the presence of a CPAM. An open surgical approach was decided and a huge bulla depending from the right upper apex lobe was found and resected. Pathological report disclosed type 4 CPAM. DISCUSSION/CONCLUSION: Despite the negative prenatal screening, the diagnosis of CPAM should be considered in a patient with sudden respiratory distress and suspicion of an spontaneous pneumothorax. Type 4 CPAM may appear like unique lung cyst mimicking a spontaneous bullae or a massive pneumothorax.

INTRODUCCION: Los pacientes con malformaciones congénitas pulmonares y de la vía aérea (CPAM en sus siglas inglesas) están habitualmente asintomáticos, aunque algunos pueden presentar dificultad respiratoria. Presentamos un raro caso de CPAM diagnosticado en las pruebas de imagen como un neumotórax aislado y persistente. CASO CLINICO: Varón de dos meses de edad sin diagnóstico prenatal alguno, dificultad respiratoria perinatal o barotrauma, que ingresó con síntomas respiratorios agudos y un neumotórax a tensión derecho visible en la radiografía de tórax que persistió a pesar de la colocación de un drenaje torácico. El TC confirmó la presencia de una CPAM. En la toracotomía practicada se observó, dependiendo del ápex del lóbulo superior derecho, una enorme bulla que fue resecada. El informe anatomopatológico fue de CPAM tipo IV. DISCUSION/CONCLUSION: Aunque no exista diagnóstico prenatal, el diagnóstico de CPAM debe ser considerado en cualquier paciente con dificultad respiratoria aguda y sospecha de neumotórax espontáneo. La CPAM tipo 4 puede aparecer como un quiste único que asemeje a una bulla espontánea o un neumotórax masivo.

Malformación pulmonar congénita simulando un neumotórax espontáneo en un recién nacido / Congenital pulmonary airway malformation (CPAM) mimicking an spontaneous pneumothorax in a newborn

Introducción: Los pacientes con malformaciones congénitas pulmonares y de la vía aérea (CPAM en sus siglas inglesas) están habitualmente asintomáticos, aunque algunos pueden presentar dificultadrespiratoria. Presentamos un raro caso de CPAM diagnosticado en laspruebas de imagen como un neumotórax aislado y persistente. Caso clínico: Varón de dos meses de edad sin diagnóstico prenatal alguno, dificultad respiratoria perinatal o barotrauma, que ingresócon síntomas respiratorios agudos y un neumotórax a tensión derechovisible en la radiografía de tórax que persistió a pesar de la colocaciónde un drenaje torácico. El TC confirmó la presencia de una CPAM. Enla toracotomía practicada se observó, dependiendo del ápex del lóbulosuperior derecho, una enorme bulla que fue resecada. El informe anatomopatológico fue de CPAM tipo IV. Discusión/conclusión: Aunque no exista diagnóstico prenatal, eldiagnóstico de CPAM debe ser considerado en cualquier paciente condificultad respiratoria aguda y sospecha de neumotórax espontáneo. LaCPAM tipo 4 puede aparecer como un quiste único que asemeje a unabulla espontánea o un neumotórax masivo.(AU)

Introduction: Patients with congenital pulmonary airway malformation (CPAM) are usually asymptomatic, but some may present withrespiratory distress. We report a rare presentation of a CPAM as an imagecompatible with persistent and localized spontaneous pneumothorax. Case report: A 2-month-old male infant without prenatal diagnosis,postnatal distress or barotrauma, was admitted with acute respiratorysymptoms and a right tension pneumothorax on chest X-ray. Despiteplacement of a chest drain, radiological image persisted. CT confirmed the presence of a CPAM. An open surgical approach was decided anda huge bulla depending from the right upper apex lobe was found andresected. Pathological report disclosed type 4 CPAM. Discussion/conclusion: Despite the negative prenatal screening,the diagnosis of CPAM should be considered in a patient with suddenrespiratory distress and suspicion of an spontaneous pneumothorax. Type4 CPAM may appear like unique lung cyst mimicking a spontaneousbullae or a massive pneumothorax.(AU)

Asociación Mexicana de Hepatología A.C. Clinical guideline on hepatitis B.

Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.