Delphi-based recommendations for the management of cardiovascular comorbidities in patients with psoriatic arthritis and moderate-to-severe psoriasis.

The aim of this study was to generate practical recommendations to assist rheumatologists and dermatologists in the management of cardiovascular (CV) comorbidities in patients with moderate-to-severe psoriasis (MS-PSO) and psoriatic arthritis (PsA). A two-round Delphi study was conducted. A panel of experts rated their agreement with a set of statements (n = 52) on a nine-point Likert scale (1 = totally disagree; 9 = totally agree). Statements were classified as inappropriate (median 1-3), irrelevant (median 4-6) or appropriate (median 7-9). Consensus was established when at least two-thirds of the panel responded with a score within any one range. A total of 25 experts, 60% rheumatologists and 40% dermatologists, participated in two consultation rounds. There was overall unanimity on the appropriateness of an initial assessment for CV risk factors in all patients with MS-PSO and PsA. Most panelists (88.0%) also supported the evaluation of patients' psychological and physical status. Additionally, most panelists (72.2%) agreed on a novel sequential approach for the management of CV comorbidities. This sequence starts with the assessment of hypertension, diabetes and dyslipidemia along with the identification of depression and anxiety disorders. Once these factors are under control, smoking cessation programs might be initiated. Finally, if patients have not met weight loss goals with lifestyle modifications, they should receive specialized treatment for obesity. This study has drawn up a set of practical recommendations that will facilitate the management of CV comorbidities in patients with MS-PSO and PsA.

Telemedicina, centros penitenciarios y enfermedad por VIH / Telemedicine, prison and illness associated with HIV

OBJETIVOS: Comunicar la actividad de telemedicina, desde su apertura, entre una consulta hospitalaria de enfermedades infecciosas y un centro penitenciario. MATERIAL Y MÉTODOS: Estudio descriptivo de la teleconsulta de enfermedades infecciosas del Hospital Universitario Fundación Alcorcón con el centro penitenciario de Navalcarnero desde 2013 hasta 2017, que se lleva a cabo mediante videoconferencia. Se analizó motivo y número de consultas, diagnóstico de VIH, tratamiento antirretroviral (TAR), situación inmunovirológica, diagnóstico del virus de la hepatitis C (VHC) e intervención realizada por el experto en infecciosas. RESULTADOS: Se valoraron 75 pacientes en un total de 168 consultas (en el primer año 11 consultas y en el quinto 62). El índice de consultas sucesivas/nuevas fue de 1,24 y el 85% de los pacientes requirió menos de 1 año de seguimiento. El 84% de los pacientes no se trasladó al hospital. El 99% de los pacientes aceptó esta modalidad. El 96% era VIH positivo, el 94% de estos tomaba TAR y el 85% tenía carga viral indetectable con 532 CD4/mL de mediana. El 90% tenía serología positiva para VHC. El 72% de las consultas fue para la valoración de tratamiento del VHC, que fue sofosbuvir/ledipasvir en un 63%. Un 40% cambió de TAR (70% para evitar interacciones). CONCLUSIÓN: La mayoría de los pacientes valorados tienen infección por VIH. Esta modalidad de consulta tiene una demanda creciente, es eficiente (evita traslados y es resolutiva) y tiene elevada aceptación. El motivo de consulta más frecuente fue el tratamiento del VHC y más de la tercera parte de los pacientes precisó cambio de TAR

OBJECTIVES: Communicate the activity of telemedicine, from its opening, between a hospital consultation of infectious diseases and a penitentiary center. MATERIAL AND METHODS: Descriptive study of the tele-consultation of infectious diseases of the Alcorcón Foundation University Hospital with the Navalcarnero penitentiary center from 2013 to 2017, which is carried out by videoconference. The reason and number of consultations, diagnosis of HIV, antiretroviral treatment (ART), immunovirological situation, diagnosis of hepatitis C virus (HCV= and intervention performed by the infectious expert were analyzed. RESULTS: A total of 75 patients were evaluated in a total of 168 consultations (in the first year 11 consultations and in the fifth year 62). The index of successive / new consultations was 1.24 and 85% of the patients required less than 1 year of follow-up.84% of patients did not move to the hospital.99% of patients accepted this modality.96% were HIV positive, 94% of them took ART and 85% had undetectable viral load with 532 CD4/mL of medium.90% had positive serology for HCV.72% of the consultations were for the assessment of HCV treatment, which was sofosbuvir/ledipasvir by 63%.40% changed their ART (70% to avoid interactions). CONCLUSION: Most of the evaluated patients have HIV infection. This type of consultation has a growing demand, is efficient (avoids transfers and is decisive) and has high acceptance. The most frequent reason for consultation was the treatment of HCV and more than a third of patients required ART change

¿Puede regresar la arteriosclerosis mediante la disminución extrema del colesterol? Respuestas a partir del estudio GLAGOV / Can arteriosclerosis regress through extreme cholesterol lowering? Answers from the GLAGOV trial

La angiografía convencional ha facilitado la evaluación de la evolución de las estenosis coronarias en las últimas décadas del siglo xx. Con esta técnica se ha demostrado que el tratamiento hipolipemiante con estatinas puede frenar la reducción de la luz vascular coronaria. La incorporación de la ecografía intravascular (IVUS) ha permitido una mejor evaluación de las lesiones aterosclerosas de la pared de las coronarias. Mediante IVUS, se ha demostrado que el tratamiento hipolipemiante intensivo con estatinas es capaz de hacer regresar las lesiones coronarias si se alcanzan valores de colesterol unido a lipoproteínas de baja densidad (cLDL) inferiores a 80 mg/dl. Se han obtenido resultados similares con el uso de ezetimiba. Recientemente se ha evaluado por primera vez el efecto de evolocumab, un anticuerpo humano frente a PCSK9, sobre las lesiones coronarias en el estudio GLAGOV. El evolocumab redujo significativamente, en torno al 60%, los valores de cLDL hasta cifras inferiores a 40 mg/dl en comparación con el placebo y demostró que dicho efecto se asocia a una regresión de las placas coronarias medidas con IVUS, que persiste hasta concentraciones finales de cLDL de 20 mg/dl. Evolocumab ha demostrado estos efectos protectores en ausencia de efectos secundarios significativos. Las implicaciones pronósticas favorables de la regresión de las lesiones aterosclerosas, ya conocidas con las estatinas, han sido recientemente confirmadas para evolocumab en el estudio FOURIER (AU)

Conventional angiography allowed the evaluation of the development of coronary stenosis in the last decades of the twentieth century. This technique has demonstrated that lipid-lowering therapy with statins can halt the shrinking of the coronary lumen. The incorporation of intravascular ultrasound (IVUS) has improved the assessment of atherosclerotic lesions of the coronary artery wall. Through IVUS, it has been demonstrated that lipid-lowering with high-intensity statin therapy is able to induce regression of coronary lesions if low-density lipoprotein cholesterol levels (LDLc) are reduced to below 80 mg/dl. Similar results have been obtained with the use of ezetimibe. Recently, the effect of evolocumab, a human anti-PCSK9 antibody, has been evaluated in the GLAGOV trial. Evolocumab significantly reduced (by around 60%) LDLc levels to levels lower than 40 mg/dl as compared to placebo. This effect was associated with the regression of coronary plaques as demonstrated by IVUS and persisted down to final LDLc levels of 20 mg/dl. The protective effects of evolocumab were obtained in the absence of significant adverse effects. The favourable prognostic implications of the regression of atherosclerotic lesions, already known with statins, have recently been confirmed for evolocumab in the FOURIER trial (AU)

[Monoclonal antibodies against PCSK9: from bench to clinic]. / Anticuerpos monoclonales frente a PCSK9: del desarrollo básico a la clínica.

Antibodies are glycoproteins with high specificity binding to multiple antigens due to the large number of structural conformations of the variable chains. Hybridoma technology (fusion of myeloma cells with immunoglobulin-producing lymphocytes) has allowed the synthesis of large quantities of unique antibodies (monoclonal [mAb]). mAbs were initially murine. Subsequently, chimeric mAbs were developed, followed by humanized mAbs and finally human mAbs. The high selectivity and good tolerance of human mAbs allows their therapeutic administration to block specific exogenous or endogenous molecules. Selective human mAbs to the catalytic domain of PCSK9 have recently been developed. These antibodies block PCSK9, favour low-density lipoprotein receptor recycling and markedly reduce circulating cholesterol. Preliminary studies indicate that lowering cholesterol through anti-PCSK9 antibodies may significantly reduce the cardiovascular complications of arteriosclerosis.

Anticuerpos monoclonales frente a PCSK9: del desarrollo básico a la clínica / Monoclonal antibodies against PCSK9: from bench to clinic

Los anticuerpos son glucoproteínas con alta especificidad de unión a múltiples antígenos gracias al gran número de conformaciones estructurales de sus cadenas variables. La tecnología de los hibridomas (fusión de células de mieloma no secretor con linfocitos productores de inmunoglobulinas) ha permitido la síntesis de grandes cantidades de anticuerpos únicos (monoclonales [mAb]). Los mAb iniciales eran murinos, posteriormente se desarrollaron mAb quiméricos, humanizados y finalmente humanos. La alta selectividad y buena tolerancia de los mAb humanos permite su administración terapéutica para el bloqueo de determinadas moléculas (endógenas o exógenas). Recientemente se han desarrollado mAb humanos selectivos para la zona catalítica de PCSK9 (proproteína convertasa subtilisina/kexina tipo 9). Estos anticuerpos bloquean la PCSK9, favorecen el reciclaje del receptor de lipoproteínas de baja densidad y reducen de modo notable el colesterol circulante. Estudios preliminares indican que la reducción del colesterol mediante anticuerpos anti-PCSK9 puede implicar importantes reducciones en las complicaciones cardiovasculares de la arteriosclerosis

Antibodies are glycoproteins with high specificity binding to multiple antigens due to the large number of structural conformations of the variable chains. Hybridoma technology (fusion of myeloma cells with immunoglobulin-producing lymphocytes) has allowed the synthesis of large quantities of unique antibodies (monoclonal [mAb]). mAbs were initially murine. Subsequently, chimeric mAbs were developed, followed by humanized mAbs and finally human mAbs. The high selectivity and good tolerance of human mAbs allows their therapeutic administration to block specific exogenous or endogenous molecules. Selective human mAbs to the catalytic domain of PCSK9 have recently been developed. These antibodies block PCSK9, favour low-density lipoprotein receptor recycling and markedly reduce circulating cholesterol. Preliminary studies indicate that lowering cholesterol through anti-PCSK9 antibodies may significantly reduce the cardiovascular complications of arteriosclerosis

Consenso sobre los objetivos y pautas de actuación en el control del colesterol ligado a lipoproteínas de baja densidad en pacientes de muy alto riesgo cardiovascular / Consensus on objectives and action guidelines on low density lipoproteins-cholesterol control in very high risk cardiovascular patients

Introducción: La enfermedad cardiovascular es la principal causa de muerte en los países desarrollados. Entre sus factores de riesgo destaca los niveles de colesterol asociado a lipoproteínas de baja densidad (cLDL), pero existe gran controversia sobre la forma de reducirlos. Se obtuvo la opinión de un panel de expertos para clarificar los puntos más relevantes del control de la dislipidemia en pacientes de muy alto riesgo cardiovascular. Material y métodos: Encuesta realizada mediante el método Delphi en 2 rondas a 41 especialistas (cardiología/medicina interna). El cuestionario constaba de 55 ítems, estratificados en 4 bloques: cLDL como diana terapéutica, objetivos de reducción, causas del fracaso en la reducción y recomendaciones para optimizar la consecución de los objetivos terapéuticos. Resultados: Se alcanzó un alto grado de consenso en los ítems consultados en línea con las recomendaciones de las guías europeas. El panel consideró adecuado el objetivo terapéutico de 70 mg/dl de lipoproteínas de baja densidad en pacientes de muy alto riesgo cardiovascular (principalmente enfermedad vascular, diabetes mellitus e insuficiencia renal), empleando si es preciso tratamiento combinado. Sin embargo, la consecución de ese objetivo se vuelve compleja debido a distintos factores, como la falta de adherencia y la inercia. Conclusiones: Los expertos españoles tienen un alto grado de acuerdo con las recomendaciones europeas, ratificando el objetivo de control del cLDL en los pacientes de muy alto riesgo < 70 mg/dl. La simplificación de las guías y el tratamiento combinado pueden favorecer la mejora del control de los objetivos lipídicos

Introduction: Cardiovascular disease is the leading cause of death in developed countries. Among cardiovascular disease risk factors one of the most relevant is low-density lipoprotein-associated cholesterol (LDL-c), but there is controversy about the methods used to control it. The aim was to obtain an expert opinion to clarify the most relevant issues regarding the control of dyslipidemia in very high cardiovascular risk patients. Materials and methods: A survey with 55 items, stratified into 4 blocks: LDL-c as a therapeutic target, therapeutic goals, causes of the failure to achieve LDL-c goals, and recommendations to optimize their achievement, was addressed to 41 specialists (Cardiology and Internal Medicine) using the Delphi method to achieve professional consensus criteria. Results: A high consensus was reached among all items, in line with the European recommendations. The panelists considered that the goal of 70 mg/dl for LDL-c for high cardiovascular disease risk (mainly vascular disease, diabetes mellitus, and renal failure), using combined treatment when necessary. Lack of adherence and therapeutic inertia were considered the main reasons for treatment failure. Conclusion: The Spanish experts show an elevated consensus with the European recommendations, confirming the LDL-c control target of < 70 mg/dl. The simplification of the guidelines and the combined treatment may favor an improvement the achievement of lipid target goals

[Consensus on objectives and action guidelines on low density lipoproteins-cholesterol control in very high risk cardiovascular patients]. / Consenso sobre los objetivos y pautas de actuación en el control del colesterol ligado a lipoproteínas de baja densidad en pacientes de muy alto riesgo cardiovascular.

INTRODUCTION: Cardiovascular disease is the leading cause of death in developed countries. Among cardiovascular disease risk factors one of the most relevant is low-density lipoprotein-associated cholesterol (LDL-c), but there is controversy about the methods used to control it. The aim was to obtain an expert opinion to clarify the most relevant issues regarding the control of dyslipidemia in very high cardiovascular risk patients. MATERIALS AND METHODS: A survey with 55 items, stratified into 4 blocks: LDL-c as a therapeutic target, therapeutic goals, causes of the failure to achieve LDL-c goals, and recommendations to optimize their achievement, was addressed to 41 specialists (Cardiology and Internal Medicine) using the Delphi method to achieve professional consensus criteria. RESULTS: A high consensus was reached among all items, in line with the European recommendations. The panelists considered that the goal of 70mg/dl for LDL-c for high cardiovascular disease risk (mainly vascular disease, diabetes mellitus, and renal failure), using combined treatment when necessary. Lack of adherence and therapeutic inertia were considered the main reasons for treatment failure. CONCLUSION: The Spanish experts show an elevated consensus with the European recommendations, confirming the LDL-c control target of <70mg/dl. The simplification of the guidelines and the combined treatment may favor an improvement the achievement of lipid target goals.

Control del colesterol LDL en pacientes de muy alto riesgo vascular. Algoritmo simplificado para alcanzar objetivos de colesterol LDL «en dos pasos» / LDL cholesterol control in patients with very high cardiovascular risk. A simplified algorithm for achieving LDL cholesterol goals «in two steps»

La reducción de colesterol unido a lipoproteínas de baja densidad (cLDL) es el principal objetivo del tratamiento hipolipemiante del paciente de muy alto riesgo cardiovascular. En estos pacientes el objetivo terapéutico es conseguir un cLDL menor de 70 mg/dl, según las guías de prevención cardiovascular comúnmente utilizadas en España y en Europa. Sin embargo, el grado de consecución de objetivos en este grupo de pacientes es muy bajo. En este artículo se analiza la prevalencia de este problema y las causas que lo motivan. También se dan recomendaciones y herramientas que pueden facilitar el diseño de la estrategia de tratamiento óptima para lograr la consecución de objetivos. Además, se presenta una novedosa herramienta con un sencillo algoritmo que puede permitir el control del paciente de muy alto riesgo cardiovascular «en 2 pasos», es decir, con solo 2 visitas al médico

Reducing low density lipoprotein-cholesterol (LDL-c) is the main lipid goal of treatment for patients with very high cardiovascular risk. In these patients the therapeutic goal is to achieve a LDL-c lower than 70mg/dL, as recommended by the guidelines for cardiovascular prevention commonly used in Spain and Europe. However, the degree of achieving these objectives in this group of patients is very low. This article describes the prevalence of the problem and the causes that motivate it. Recommendations and tools that can facilitate the design of an optimal treatment strategy for achieving the goals are also given. In addition, a new tool with a simple algorithm that can allow these very high risk patients to achieve the goals «in two-steps», i.e., with only two doctor check-ups, is presented

[LDL cholesterol control in patients with very high cardiovascular risk. A simplified algorithm for achieving LDL cholesterol goals "in two steps"]. / Control del colesterol LDL en pacientes de muy alto riesgo vascular. Algoritmo simplificado para alcanzar objetivos de colesterol LDL "en dos pasos".

Reducing low density lipoprotein-cholesterol (LDL-c) is the main lipid goal of treatment for patients with very high cardiovascular risk. In these patients the therapeutic goal is to achieve a LDL-c lower than 70 mg/dL, as recommended by the guidelines for cardiovascular prevention commonly used in Spain and Europe. However, the degree of achieving these objectives in this group of patients is very low. This article describes the prevalence of the problem and the causes that motivate it. Recommendations and tools that can facilitate the design of an optimal treatment strategy for achieving the goals are also given. In addition, a new tool with a simple algorithm that can allow these very high risk patients to achieve the goals "in two-steps", i.e., with only two doctor check-ups, is presented.

Dislipidemias: un reto pendiente en prevención cardiovascular. Documento de consenso CEIPC/SEA / Dyslipidemias: a pending challenge in cardiovascular prevention. Consensus document from CEIPC/SEA Committee

En España, donde la enfermedad cardiovascular (ECV) es la primera causa de muerte, aproximadamente el 20% de los adultos presentan hipercolesterolemia, de los cuales sólo el 12% estarían controlados. El abordaje de las dislipemias debe realizarse en un contexto más amplio, mediante acciones encaminadas a reducir el riesgo cardiovascular (RCV). La medición del RCV facilita la toma de decisiones, pero no puede sustituir al juicio clínico, dadas las limitaciones de los métodos de cálculo disponibles. Este documento, elaborado por el Comité Español Interdisciplinar de Prevención Cardiovascular, a iniciativa de la Sociedad Española de Arteriosclerosis, describe las principales iniciativas en prevención cardiovascular de administraciones sanitarias y sociedades científicas, y el papel que juegan en ellas los profesionales sanitarios. Además de apoyar las iniciativas en marcha, se propone la puesta en marcha de una estrategia nacional de prevención cardiovascular, centrada en la modificación de estilos de vida (prevención del tabaquismo y promoción de la alimentación saludable y la actividad física) mediante acciones en todos los ámbitos. A nivel poblacional, la regulación de la publicidad alimentaria, la eliminación de los ácidos grasos trans y la reducción de azúcares añadidos en la cadena alimentaria constituyen intervenciones viables y coste-efectivas para ayudar a controlar las dislipemias y reducir el RCV. En el ámbito sanitario, se propone reducir las barreras para la aplicación de las guías, mejorar la formación de los profesionales en modificación de estilos de vida e incorporar la valoración del RCV entre los indicadores de calidad de la asistencia. Las sociedades científicas son responsables de colaborar con la administración y contribuir a la generación del conocimiento, su transmisión y su aplicación. Finalmente, está en manos de los profesionales evaluar al paciente dislipémico en el contexto del RCV, promover estilos de vida saludables y hacer un uso eficiente del arsenal terapéutico disponible (AU)

In Spain, where cardiovascular disease (CVD) is the leading cause of death, hypercholesterolemia, one of the most prevalent risk factors in adults, is poorly controlled. Dyslipidemia should not be approached in isolation, but in the context of overall cardiovascular risk (CVR). Measurement of CVR facilitates decision making, but should not be the only tool nor should it take the place of clinical judgment, given the limitations of the available calculation methods. This document, prepared by the Interdisciplinary Spanish Committee on Cardiovascular Prevention, at the proposal of the Spanish Society of Arteriosclerosis, reviews the cardiovascular prevention activities of the regional health authorities, scientific societies and medical professionals. An initiation of a national strategy on cardiovascular prevention is proposed based on lifestyle modification (healthy diet, physical activity and smoking cessation) through actions in different settings. At the population level, regulation of food advertising, elimination of trans fats and reduction of added sugar are feasible and cost-effective interventions to help control dyslipidemias and reduce CVR. In the health setting, it is proposed to facilitate the application of guidelines, improve training for medical professionals, and include CVR assessment among the quality indicators. Scientific societies should collaborate with the health authorities and contribute to the generation and transmission of knowledge. Finally, it is in the hands of professionals to apply the concept of CVR, promote healthy lifestyles, and make efficient use of available pharmacological treatments (AU)

[Dyslipidemias: a pending challenge in cardiovascular prevention. Consensus document from CEIPC/SEA Committee]. / Dislipidemias: un reto pendiente en prevención cardiovascular. Documento de consenso CEIPC/SEA.

In Spain, where cardiovascular disease (CVD) is the leading cause of death, hypercholesterolemia, one of the most prevalent risk factors in adults, is poorly controlled. Dyslipidemia should not be approached in isolation, but in the context of overall cardiovascular risk (CVR). Measurement of CVR facilitates decision making, but should not be the only tool nor should it take the place of clinical judgment, given the limitations of the available calculation methods. This document, prepared by the Interdisciplinary Spanish Committee on Cardiovascular Prevention, at the proposal of the Spanish Society of Arteriosclerosis, reviews the cardiovascular prevention activities of the regional health authorities, scientific societies and medical professionals. An initiation of a national strategy on cardiovascular prevention is proposed based on lifestyle modification (healthy diet, physical activity and smoking cessation) through actions in different settings. At the population level, regulation of food advertising, elimination of trans fats and reduction of added sugar are feasible and cost-effective interventions to help control dyslipidemias and reduce CVR. In the health setting, it is proposed to facilitate the application of guidelines, improve training for medical professionals, and include CVR assessment among the quality indicators. Scientific societies should collaborate with the health authorities and contribute to the generation and transmission of knowledge. Finally, it is in the hands of professionals to apply the concept of CVR, promote healthy lifestyles, and make efficient use of available pharmacological treatments.

Consenso sobre el diagnóstico y tratamiento de la sordera súbita / Consensus on diagnosis and treatment of sudden hearing loss

La sordera súbita idiopática es aquella hipoacusia neurosensorial de inicio súbito, en menos de 72 horas, sin otros antecedentes otológicos previos. Presentamos un consenso sobre el diagnóstico, tratamiento y seguimiento de la sordera súbita, surgido desde la Asociación Madrileña de ORL. Mediante revisión sistemática de la literatura sobre sordera súbita, desde 1966 hasta junio de 2010, sobre los términos MESH “(acute or sudden) hearing loss”, llegando a las siguientes sugerencias: en cuanto al diagnóstico, ante una sospecha clínica de sordera súbita, las pruebas diagnósticas que se consideran necesarias son: otoscopia, acumetría, audiometría tonal, audiometría verbal y timpanograma. Una vez hecho el diagnóstico clínico de sordera súbita, antes de comenzar el tratamiento, se solicitará una batería analítica, debiendo completarse más tarde el estudio con RM de oído interno. Se recomienda que el tratamiento de la sordera súbita esté basado fundamentalmente en los corticoides sistémicos, generalmente por vía oral, apoyados en los corticoides intratimpánicos como rescate. Respecto al seguimiento, se realizará un control a la semana del inicio del mismo, incluyendo audiometría tonal y verbal, y a los 15, 30 y 90 días del diagnóstico, y 12 meses después. Como consenso, el resultado de los tratamientos aplicados debería presentarse, tanto en cuanto a la cantidad de dBs recuperados en el umbral auditivo tonal, como siguiendo la tasa de recuperación en los casos unilaterales, así como con parámetros de audiometría verbal (AU)

Idiopathic sudden sensorineural hearing loss is an unexplained unilateral hearing loss with onset over a period of less than 72hours, without other known otological diseases. We present a consensus on the diagnosis, treatment and follow-up of this disease, designed by AMORL, after a systematic review of the literature from 1966 to June 2010. Diagnosis of sudden sensorineural hearing loss is based on mandatory otoscopy, acoumetry, tonal audiometry, speech audiometry, and tympanometry. After clinical diagnosis is settled, and before treatment is started, a full analysis should be done and an MRI should be requested later. Treatment is based on systemic corticosteroids (orally in most cases), helped by intratympanic doses as rescue after treatment failures. Follow-up should be done at day 7, with tonal and speech audiometries, and regularly at 15, 30, and 90 days after start of therapy, and after 12 months. By consensus, results after treatment should be reported as absolute dBs recovered in pure tonal audiometry, as improvement in the recovery rate in unilateral cases, and as improvement in speech audiometry (AU)

[Consensus on diagnosis and treatment of sudden hearing loss. Asociación Madrileña de ORL]. / Consenso sobre el diagnóstico y tratamiento de la sordera subita.

Idiopathic sudden sensorineural hearing loss is an unexplained unilateral hearing loss with onset over a period of less than 72 hours, without other known otological diseases. We present a consensus on the diagnosis, treatment and follow-up of this disease, designed by AMORL, after a systematic review of the literature from 1966 to June 2010. Diagnosis of sudden sensorineural hearing loss is based on mandatory otoscopy, acoumetry, tonal audiometry, speech audiometry, and tympanometry. After clinical diagnosis is settled, and before treatment is started, a full analysis should be done and an MRI should be requested later. Treatment is based on systemic corticosteroids (orally in most cases), helped by intratympanic doses as rescue after treatment failures. Follow-up should be done at day 7, with tonal and speech audiometries, and regularly at 15, 30, and 90 days after start of therapy, and after 12 months. By consensus, results after treatment should be reported as absolute dBs recovered in pure tonal audiometry, as improvement in the recovery rate in unilateral cases, and as improvement in speech audiometry.

Vía intratimpánica en el tratamiento de patología de oído interno / Intratympanic drug delivery for the treatment of inner ear diseases

Introducción: La vía intratimpánica para el tratamiento de enfermedades laberínticas es un procedimiento poco agresivo y ambulatorio, que maximiza las concentraciones de fármaco en la cóclea y minimiza su difusión sistémica. A través de esta revisión se propone actualizar las técnicas de aplicación y los resultados que ofrecen los diferentes fármacos para las enfermedades cocleovestibulares. Se expone nuevas perspectivas futuras en cuanto al desarrollo de fármacos y de la terapia génica. Material y método: Se analiza la literatura hasta la fecha según las bases médicas MEDLINE y EMBASE. Se ha considerado los artículos relacionados con la técnica de instilación, los resultados en el tratamiento esteroideo y aminoglucósido (gentamicina) y artículos aislados sobre nuevos fármacos o vías de administración. Resultados: La terapia esteroidea ha demostrado su eficacia en los síntomas cocleovestibulares como pauta de rescate tras corticoterapia intravenosa en la sordera súbita y en el control de la enfermedad de Ménière. La administración de gentamicina intratimpánica en pautas a demanda aporta un adecuado control del vértigo en el 80% de los pacientes y un riesgo de hipoacusia del 0–25% en la enfermedad de Ménière. Conclusiones: La vía intratimpánica es un procedimiento eficaz en el control de enfermedades cocleovestibulares, como la sordera súbita y la enfermedad de Méniére. Junto con el tratamiento esteroideo y gentamicina, perspectivas futuras podrían ampliar las indicaciones de su uso y un nuevo arsenal terapéutico farmacológico y génico (AU)

Introduction: Intratympanic drug delivery for labyrinth diseases is a non-aggressive outpatient procedure where drugs reach high concentrations in the cochlea and minimum systemic diffusion. The aim of this review is to update the delivery techniques and report on the results obtained with different substances in cochleovestibular disorders. New perspectives in drug development and gene therapy are discussed. Material and method: We have analyzed the literature published to date using the MEDLINE and EMBASE databases. The categories chosen for the review where the delivery techniques, the results using corticosteroids and aminoglucosides (gentamicin) and isolated papers related with new drugs or pathways to introduce the substance in the inner ear. Results: Intratympanic steroid therapy has been shown to be effective for cochleovestibular symptoms after failure of systemic steroids for sudden deafness and for control of Ménière's disease. Intratympanic gentamicin using a titration method showed vertigo control in 80% of the patients with a 0–25% risk of hearing impairment in Ménière's disease. Conclusions: Intratympanic delivery is an effective procedure for the control of cochleovestibular disorders such as sudden deafness and Ménière's disease. Future perspectives could increase the indications for steroid and gentamicin treatment and open the door to new drugs and gene therapy (AU)

[Intratympanic drug delivery for the treatment of inner ear diseases]. / Vía intratimpánica en el tratamiento de patología de oído interno.

INTRODUCTION: Intratympanic drug delivery for labyrinth diseases is a non-aggressive outpatient procedure where drugs reach high concentrations in the cochlea and minimum systemic diffusion. The aim of this review is to update the delivery techniques and report on the results obtained with different substances in cochleovestibular disorders. New perspectives in drug development and gene therapy are discussed. MATERIAL AND METHOD: We have analyzed the literature published to date using the MEDLINE and EMBASE databases. The categories chosen for the review where the delivery techniques, the results using corticosteroids and aminoglucosides (gentamicin) and isolated papers related with new drugs or pathways to introduce the substance in the inner ear. RESULTS: Intratympanic steroid therapy has been shown to be effective for cochleovestibular symptoms after failure of systemic steroids for sudden deafness and for control of Ménière's disease. Intratympanic gentamicin using a titration method showed vertigo control in 80% of the patients with a 0-25% risk of hearing impairment in Ménière's disease. CONCLUSIONS: Intratympanic delivery is an effective procedure for the control of cochleovestibular disorders such as sudden deafness and Ménière's disease. Future perspectives could increase the indications for steroid and gentamicin treatment and open the door to new drugs and gene therapy.

Auditory discrimination training for tinnitus treatment: the effect of different paradigms.

Acoustic deprivation, i.e. hearing loss, is responsible for a cascade of processes resulting in reorganisation of the cortex. Tinnitus mechanisms are explained by synchronization of the neural spontaneous activity and might be related to cortical re-mapping. Auditory discrimination training (ADT) has demonstrated in both animals and humans to induce tonotopical changes in the auditory pathways through neural plasticity. We hypothesize that ADT could have some effect on tinnitus perception. The objective of this study is to compare the effect on tinnitus following two paradigms of ADT. Only patients from 20 to 60 years of age were recruited. Inclusion criteria were pure tone tinnitus of mild or moderate handicap according to the Tinnitus Handicap Inventory score (<56). ADT patients were randomized in two groups: SAME (ADT in the same frequency of tinnitus pitch, 20 patients) and NONSAME (ADT in the frequency one-octave below tinnitus pitch, 21 patients). Groups of pair of tones (70% standard tones ST, 30% deviant tones ST + 0.1-0.5 kHz) were randomly mixed for 20 min/day during 1 month. Patient had to mark when the two sounds of the pair were similar or different. Control group included 26 patients from the waiting list (WLG). Patients were also divided according to the trained frequency and the deepest hearing-impaired frequency. Outcome parameters were set up according to the answer to the question "is your tinnitus better, same, or worse with the treatment?" (RESP), the tinnitus handicap inventory (THI) and the visual analogue scale from 1 to 10 on tinnitus intensity (VAS). Tinnitus improved in 42.2% of the patients (RESP). VAS and THI scores were reduced but only THI differences were statistically significant (P = 0.003). ADT patients improved significantly compared with WLG in RESP and THI scores (P < 0.01). Training frequencies one-octave below the tinnitus pitch (NONSAME) decreased significantly THI scores compared with patients trained frequencies similar to tinnitus pitch (SAME, P = 0.035). RESP and VAS scores decreased more in NONSAME group though differences were not significant. We did not find any differences when comparing the group training the deepest hearing-impaired frequency and the group who trained other frequencies. Auditory discrimination training significantly improved tinnitus handicap compared to a waiting list group. Those patients who trained frequencies one octave below the tinnitus pitch had better outcome than those who performed the ADT with frequencies similar to the tinnitus pitch (P = 0.035).

Transtympanic steroids for Ménière's disease.

OBJECTIVE: To describe the long-term efficacy of transtympanic steroids (TTS) using methyl-prednisolone in the treatment of Ménière's disease (MD). DESIGN: Descriptive prospective study. MAIN OUTCOME MEASURES: Pure-tone average (PTA) corresponding to the conversational frequencies on the audiogram (0.5, 1, 2, and 3 kHz), visual analog scale on tinnitus annoyance, and number of vertigo spells 24 months after treatment. RESULTS: Thirty-four MD patients referred to a tertiary center were treated with TTS. All patients were diagnosed as probable or definitive MD (following American Academy of Otolaryngology-Head and Neck Surgery 1995 criteria) and treated by TTS (3 consecutive doses). Data from 32 patients were achieved after 12 months. Forty-eight percent of the patients reduced the PTA in 10 or more decibels, average improvement was 8.6 dB compared with initial PTA (p = 0.004). Tinnitus relief was achieved by 81.5% of the patients. Number of vertigo spells was reduced from 4.3 to 0.3 after 12 months (p = 0.002); 81% of the patients were free of vertigo spells, and 92.6% had 1 or less spells of vertigo. Data from 29 patients were achieved after 24 months. A reduction of PTA in 10 or more decibels was shown by the 33.3% of the sample, and PTA improved in 3.3 dB compared with initial PTA (nonsignificant). Tinnitus relief was achieved in 78% of the patients. Number of vertigo spells was reduced from 4.3 to 0.5 (p = 0.033). Seventy-eight percent of the cases were free of vertigo, and 96% had none or 1 spell. Because of an increase in any of the symptoms, 12 patients (35.2%) required retreatment with 1 or 2 series of TTS (1-3 doses) along the 2-year period. Two patients of the sample (6.25%) required transtympanic gentamicin for vertigo control due to lack of benefit with TTS (14 and 18 mo since TTS). CONCLUSION: Transtympanic steroids in this cohort were associated with good preservation of hearing. Tinnitus control is achieved in more than 70% of the patients, and number of vertigo spells can be dramatically reduced in more than 90% of the patients after a 24-month follow-up.

[Diagnostic clues in pulsatile tinnitus (somatosounds)]. / Claves diagnósticas en los somatosonidos o acúfenos pulsátiles.

Pulsatile tinnitus is a sound from within the body, mostly of vascular origin, that stimulates the patient's hearing in the same way as an external sound does, generally at the same pace as the pulse. Although not frequent, the diagnosis of its cause is crucial because of its potential severity in some cases. This article describes some of the diagnostic clues for arterial causes (arteriosclerosis, aberrant carotid artery, arteriovenous fistula or malformations, increased vascularization in Paget's disease) and venous causes (benign intracranial hypertension, high jugular bulb). In some cases we have to rule out other systemic diseases as hypertension, cardiac arrhythmia or hyperthyroidism. A pathological otoscopy result may be secondary to a tympanic glomus. A guided medical history and an algorithm for complementary tests (magnetic resonance or angio-resonance imaging, computerized tomography, blood test, Doppler ultrasonography) may resolve the diagnostic puzzle of pulsatile tinnitus. We present our experience in 80 cases. The most frequent aetiology has been the arteriosclerosis of the carotid artery (17.5 %) and the benign intracranial hypertension syndrome (10 %).

Dolor dorsolumbar y adenopatías supraclaviculares en un varón de 67 años / No disponible

No disponible

Tinnitus retraining therapy: prognosis factors.

INTRODUCTION: Tinnitus retraining therapy (TRT) is, nowadays, one of the most extended treatments for tinnitus control. The goal is the habituation to a nonsignificative signal, that is, tinnitus, first, eliminating its reaction and, second, minimizing its perception. PURPOSE: The objective of this study is to identify the factors that could improve or reduce the efficacy of TRT. MATERIALS AND METHODS: A prospective nonrandomized clinical assay (n = 137) was conducted. Three parameters were considered for tinnitus evaluation at 1-year follow-up: patient self-evaluation, visual analogue scale for intensity, and Tinnitus Handicap Inventory. RESULTS: Tinnitus retraining therapy group improved at 1-year follow-up, considering the 3 parameters. The most important factor of failure to TRT efficacy has been the refuse to instrumentation when it was required, according to TRT recommendations. Tinnitus Handicap Inventory score in this group did not show any improvement (P = .009). Highest scores of tinnitus intensity (visual analogue scale) and handicap (Tinnitus Handicap Inventory) before treatment as well as the most disabled diagnosis (sudden deafness and Meniere's disease) had better response to TRT. Jastreboff's treatment categories, longer presence of tinnitus, existence of hyperacusis or hearing loss, type of prosthesis used, duration of the treatment, and index of assistance to our follow-up program were not related to the effectiveness of TRT. CONCLUSIONS: Tinnitus retraining therapy has demonstrated to be an effective treatment of tinnitus. More severe tinnitus are susceptible to get better response with this approach. Instrumentation, when recommended, is mandatory to obtain a higher relief of this symptom (EMB rating: B-2).