Consenso Delphi sobre Estrategias Terapéuticas y de Prevención Sanitaria de la hipovitaminosis D / Delphi Consensus on Therapeutic and Preventive Health Strategies for Hypovitaminosis D

Antecedentes: La elevada prevalencia de hipovitaminosis D en España es considerada una verdadera epidemia con importantes implicaciones para la salud por las múltiples funciones que ejerce la vitamina D tanto a nivel esquelético como extraesquelético. Para que las personas con insuficiencia o deficiencia en vitamina D alcancen los niveles séricos más adecuados, deben recibir suplementos de vitamina D. Este estudio se realizó con la finalidad de evaluar si en la práctica clínica habitual, el manejo de la hipovitaminosis D era llevada a cabo según las recomendaciones internacionales establecidas por las sociedades científicas.Métodos: Se realizaron dos rondas de circulación de un cuestionario Delphi entre un panel formado por médicos prescriptores habituales de vitamina D.Resultados: En general, los médicos del panel reconocieron la alta prevalencia de la hipovitaminosis D en España, la necesidad del cribado en los distintos grupos de riesgo y los beneficios de la suplementación en los pacientes con insuficiencia o déficit de vitamina D. Sin embargo, no se alcanzó el consenso en algunas de las aseveraciones relacionadas con los métodos de cuantificación de la vitamina D o con las recomendaciones para el manejo de la hipovitaminosis D.Conclusiones: La ausencia de acuerdo para algunos de los ítems reveló la necesidad de realizar acciones formativas destinadas a proporcionar un conocimiento adecuado y actualizado sobre las evidencias científicas y las recomendaciones para la práctica clínica de la suplementación de vitamina D. (AU)

ScipionTomo: Towards cryo-electron tomography software integration, reproducibility, and validation.

Image processing in cryogenic electron tomography (cryoET) is currently at a similar state as Single Particle Analysis (SPA) in cryogenic electron microscopy (cryoEM) was a few years ago. Its data processing workflows are far from being well defined and the user experience is still not smooth. Moreover, file formats of different software packages and their associated metadata are not standardized, mainly since different packages are developed by different groups, focusing on different steps of the data processing pipeline. The Scipion framework, originally developed for SPA (de la Rosa-Trevín et al., 2016), has a generic python workflow engine that gives it the versatility to be extended to other fields, as demonstrated for model building (Martínez et al., 2020). In this article, we provide an extension of Scipion based on a set of tomography plugins (referred to as ScipionTomo hereafter), with a similar purpose: to allow users to be focused on the data processing and analysis instead of having to deal with multiple software installation issues and the inconvenience of switching from one to another, converting metadata files, managing possible incompatibilities, scripting (writing a simple program in a language that the computer must convert to machine language each time the program is run), etcetera. Additionally, having all the software available in an integrated platform allows comparing the results of different algorithms trying to solve the same problem. In this way, the commonalities and differences between estimated parameters shed light on which results can be more trusted than others. ScipionTomo is developed by a collaborative multidisciplinary team composed of Scipion team engineers, structural biologists, and in some cases, the developers whose software packages have been integrated. It is open to anyone in the field willing to contribute to this project. The result is a framework extension that combines the acquired knowledge of Scipion developers in close collaboration with third-party developers, and the on-demand design of functionalities requested by beta testers applying this solution to actual biological problems.

On bias, variance, overfitting, gold standard and consensus in single-particle analysis by cryo-electron microscopy.

Cryo-electron microscopy (cryoEM) has become a well established technique to elucidate the 3D structures of biological macromolecules. Projection images from thousands of macromolecules that are assumed to be structurally identical are combined into a single 3D map representing the Coulomb potential of the macromolecule under study. This article discusses possible caveats along the image-processing path and how to avoid them to obtain a reliable 3D structure. Some of these problems are very well known in the community. These may be referred to as sample-related (such as specimen denaturation at interfaces or non-uniform projection geometry leading to underrepresented projection directions). The rest are related to the algorithms used. While some have been discussed in depth in the literature, such as the use of an incorrect initial volume, others have received much less attention. However, they are fundamental in any data-analysis approach. Chiefly among them, instabilities in estimating many of the key parameters that are required for a correct 3D reconstruction that occur all along the processing workflow are referred to, which may significantly affect the reliability of the whole process. In the field, the term overfitting has been coined to refer to some particular kinds of artifacts. It is argued that overfitting is a statistical bias in key parameter-estimation steps in the 3D reconstruction process, including intrinsic algorithmic bias. It is also shown that common tools (Fourier shell correlation) and strategies (gold standard) that are normally used to detect or prevent overfitting do not fully protect against it. Alternatively, it is proposed that detecting the bias that leads to overfitting is much easier when addressed at the level of parameter estimation, rather than detecting it once the particle images have been combined into a 3D map. Comparing the results from multiple algorithms (or at least, independent executions of the same algorithm) can detect parameter bias. These multiple executions could then be averaged to give a lower variance estimate of the underlying parameters.

Cryo-EM and Single-Particle Analysis with Scipion.

Cryo-electron microscopy has become one of the most important tools in biological research to reveal the structural information of macromolecules at near-atomic resolution. In single-particle analysis, the vitrified sample is imaged by an electron beam and the detectors at the end of the microscope column produce movies of that sample. These movies contain thousands of images of identical particles in random orientations. The data need to go through an image processing workflow with multiple steps to obtain the final 3D reconstructed volume. The goal of the image processing workflow is to identify the acquisition parameters to be able to reconstruct the specimen under study. Scipion provides all the tools to create this workflow using several image processing packages in an integrative framework, also allowing the traceability of the results. In this article the whole image processing workflow in Scipion is presented and discussed with data coming from a real test case, giving all the details necessary to go from the movies obtained by the microscope to a high resolution final 3D reconstruction. Also, the power of using consensus tools that allow combining methods, and confirming results along every step of the workflow, improving the accuracy of the obtained results, is discussed.

Algorithmic robustness to preferred orientations in single particle analysis by CryoEM.

The presence of preferred orientations in single particle analysis (SPA) by cryo-Electron Microscopy (cryoEM) is currently one of the hurdles preventing many structural analyses from yielding high-resolution structures. Although the existence of preferred orientations is mostly related to the grid preparation, in this technical note, we show that some image processing algorithms used for angular assignment and three-dimensional (3D) reconstruction are more robust than others to these detrimental conditions. We exemplify this argument with three different data sets in which the presence of preferred orientations hindered achieving a 3D reconstruction without artifacts or, even worse, a 3D reconstruction could never be achieved.

Incidence of surgical wound infection in renal surgery. The effect of antibiotic prophylaxis appropriateness. A prospective cohort study. / Incidencia de infección de herida quirúrgica en cirugía renal. Efecto de la adecuación de la profilaxis antibiótica. Estudio de cohortes prospectivo.

OBJECTIVE: To assess compliance with the antibiotic prophylaxis protocol for patients who underwent renal surgery and its effect on the incidence of surgical wound infection. MATERIAL AND METHODS: We performed a prospective cohort study and assessed the overall compliance and each aspect of the antibiotic prophylaxis (start, administration route, antibiotic of choice, duration and dosage) and reported the compliance rates. The qualitative variables were compared with the chi-squared test, and the quantitative variables were compared with Student's t-test. We studied the effect of antibiotic prophylaxis compliance on the incidence of surgical wound infection in renal surgery, with the relative risk. RESULTS: The study included 266 patients, with an overall compliance rate of 90.6%. The major cause of noncompliance (3.8%) was the start of the prophylaxis, and the incidence rate of surgical wound infections was 3.4%. We found no relationship between antibiotic prophylaxis noncompliance and surgical wound infections (RR=0.26; 95%CI: 0.1-1.2; P>.05). Laparoscopic surgery had a lower incidence of surgical wound infections than open surgery (RR=0.10; 95%CI: 0.01-0.79). CONCLUSIONS: The antibiotic prophylaxis compliance was high. The incidence of surgical site infection was low, and there was no relationship between the incidence of surgical site infection and antibiotic prophylaxis compliance. The incidence of infection was lower in laparoscopic surgery.

Influence of the location and number of metastases in the survival of metastatic prostatic cancer patients. / Influencia de la localización y del número de metástasis en la supervivencia de los pacientes con cáncer de próstata metastásico.

INTRODUCTION: The prognosis of patients diagnosed with metastatic prostate cancer seems to be modulated by factors such as the number and site of metastases. Our objective is to evaluate survival outcomes according to the number and site of metastases in our series of metastatic patients over the last 15 years. MATERIALS AND METHODS: A retrospective analysis was performed on patients diagnosed between 1998 and 2014. We analyzed overall survival and progression-free survival, depending on the number and location of metastases on patients with newly diagnosed metastatic prostate cancer. Other potential prognostic factors were also evaluated: age, clinical stage, PSA at diagnosis, Gleason, PSA nadir, time till PSA nadir and first-line or second-line treatment after progression. RESULTS: We analyzed a series of 162 patients. The mean age was 72.7yr (SD: 8.5). The estimated median overall survival was 3.9 yr (95% CI 2.6-5.2). The overall survival in patients with only lymph node metastases was 7 yr (95% CI 4.1-9.7), 3.9 (95%CI 2.3-5.5) in patients with only bone metastases, 2.5 yr (95% CI 2-2.3) in lymph nodes and bone metastases, and 2.2 yr (95% CI 1.4-3) in patients with visceral metastases (P<.001). In multivariate analysis, the location of metastasesis significantly associated with overall survival and progression-free survival. The number of metastases showed no association with survival. CONCLUSIONS: The site of metastases has a clear impact on both overall survival and progression-free survival. Patients with only lymph node involvement had a better prognosis. The number of metastases showed no significant impact on survival in our series.

Diagnostic yield and complications of extended lymphadenectomy versus limited lymphadenectomy combined with radical prostatectomy.

BACKGROUND: Lymphadenectomy for prostate cancer (PC) is the most reliable procedure for detecting lymphatic metastases. The optimal extension of this procedure is still a topic of debate. OBJECTIVE: To analyse the diagnostic performance and complications of extended lymphadenectomy (ELD) and limited lymphadenectomy (LLD) in a series of patients with high-risk PC who underwent radical prostatectomy (RP). MATERIAL AND METHODS: A retrospective study was conducted on patients with high d'Amico risk who underwent RP with lymphadenectomy between 1999 and 2014. A comparative analysis was performed of the diagnostic capacity of lymphatic metastases of ELD and LLD and of postoperative complications at 90 days. RESULTS: Ninety-three patients were analysed, 20 (21.5%) and 73 (78.5%) of whom underwent ELD and LLD, respectively. The mean age of the series was 65.26 years (SD, 5.51). The median follow-up was 1.51 (0.61-2.29) years in the ELD group and 5.94 (3.61-9.10) in the LLD group. The median number of nodes obtained was 13 (9-23) in the ELD group compared with 5 (2-8) in the LLD group (p <.001). The percentages of patients with positive nodes in the ELD and LLD groups were 35% and 5.47%, respectively (p <.001). The overall complication rate at 90 days was 35.5% (33 patients). In the ELD group, 12 patients (60%) had complications, compared with 21 patients (28.8%) in the LLD group (p=.016), with no significant differences in severity according to the Clavien scale (p=.73). CONCLUSIONS: In our series, the detection of metastatic nodes was significantly greater with ELD. ELD increases the number of complications, with no differences compared with LLD in severity according to the modified Clavien scale.

Changes in Gleason score grading on serial follow-up biopsies in prostate cancer patients undergoing active surveillance.

INTRODUCTION: Active surveillance for prostate cancer has grown systematically in the recent years with more robust mid-term outcomes. However, changes in Gleason score during serial biopsies are not detailed in many of these reports. OBJECTIVES: To evaluate changes in Gleason score on follow-up biopsies in low-risk prostate cancer in patients undergoing AS program in our center. MATERIAL AND METHODS: Series of patients diagnosed of prostate cancer between 2004 and 2013 have been analyzed. The inclusion criteria were: PSA ≤ 10 ng/ml + Gleason ≤ 6 + T1c/T2a + ≤ 2 positive cores, and no more than 50% of affected core. The pathology of each of the biopsies was analyzed. RESULTS: We studied a series of 175 patients undergoing AS. Mean follow-up was 3.96 years (SD 2.4). Follow-up biopsies with Gleason scores ≥ 7 were: 5.72% in the first biopsy, 7.39% and 7.41% in subsequent biopsies. By contrast, in 42.03% of cases did not show evident tumor involvement in the first biopsy, 40.74% and 51.85% in the second and third biopsies respectively. Median stay in the AS program was: 90.99 months (95% CI: 53.53-128.46) in patients with first positive biopsy vs. 96.66 months (95% CI: 63.19-130.13) in those without evidence of tumor. CONCLUSIONS: In our series the pathological data of the first 3 biopsies remain stable in terms of the positive biopsy rate, Gleason score, or indication of active treatment proportions. Those patients who do not show evidence of malignancy in the first follow-up biopsy are less likely to need active treatment than the other patients in the series.

Optimization of an early discharge program after laparoscopic radical prostatectomy.

OBJECTIVE: To assess the safety of hospital discharge 24 hours after laparoscopic radical prostatectomy and to identify possible factors associated with longer hospital stays. MATERIAL AND METHODS: Retrospective study of patients diagnosed with localized prostate cancer underwent to laparoscopic radical prostatectomy consecutively between May of 2007 and December of 2010. Those patients who met the following requirements were discharged in less than 24 hours: absence of complications, drainage debit minor than 50 cc, normal oral tolerance, no significant bladder haematuria and good functional recovery. Logistic regression analysis was conducted in order to assess the possible associated variables with longer hospital stays. RESULTS: A total of 266 patients were analysed. The follow-up median was 34 months. Eighty patients (30.1%) were discharged in less than 24 hours. Average stay (SD) of all series was 2.9 days (3.08). Solely HTA, neurovascular bundles sparing and the development of lymphadenectomy were statistically significant between both groups in univariate analysis (discharge<24 hours vs. discharge>24 hours). In multivariate analysis, only HTA (OR=1.98 [CI 95%:1.13-3.47], P=.016) and lymphadenectomy performance (OR=2.56 [CI 95%:1.18-5.56] P=.017) were independent predictive variables of hospital stays longer than 24 hours. CONCLUSIONS: Early hospital discharge of patients underwent to LRP is feasible and safe. In our series, the lymphadenectomy performance and the HTA were associated factors to longer hospital stay.

Oncological outcomes in patients potentially eligible for active surveillance who underwent radical prostatectomy.

OBJECTIVE: To determine whether there are differences in the oncological outcomes after radical prostatectomy (adverse pathology and biochemical recurrence) based on clinical selection criteria used in two active surveillance (AS) protocols. MATERIAL AND METHODS: 442 patients diagnosed with localized prostate cancer (CP) underwent radical prostatectomy at our institution between August 2003 and December 2009. We selected patients with low-risk CP, which could have been included in an AS program. Patients were divided into two groups: group i, those who met the most strict surveillance criteria described by Epstein (PSAD<.15; T1/T2a;<2 positive core, Gleason≤6,<50% involvement of the core) and group ii, those meeting the more open criteria described by Klotz (PSA≤10 or<15 at age 70, Gleason≤6 or<7 [3+4] in over 70 years). We compared both groups to determine differences in pathological stage, positive surgical margins and biochemical recurrence after radical prostatectomy. RESULTS: Of the 442 patients 48% (213 patients) had low-risk PC, and become potential candidates for an AS program. Of the patients operated on 17% (76 patients) met the criteria for AS as of Epstein's and 48% (213 patients) according to Klotz. Comparing patients in both groups there were no statistically significant differences in the presence of pT3 (7.9% vs 10.8%) P=.55, positive margins (22.4% vs. 28.3%) P=.41, nor in biochemical recurrence at 3 years (5.3% vs 5.6%) P=.86. CONCLUSIONS: In our series of patients theoretically candidates for inclusion in a program of active surveillance, we found no differences in the percentage of patients with pathological stage pT3, positive margins and biochemical recurrence according to clinical inclusion criteria currently used.

Safety of active surveillance program for recurrent nonmuscle-invasive bladder carcinoma.

OBJECTIVES: To report our experience with a select group of patients with low-risk tumors included in an observation and monitoring program after the diagnosis of recurrence. METHODS: We performed a prospective cohort study in patients diagnosed with recurrent, nonmuscle-invasive bladder cancer maintained under an active surveillance protocol. The inclusion criteria were papillary tumors with negative cytology findings, previous nonmuscle-invasive tumor (Stage pTa, pT1a), grade 1-2, size <1 cm, and number of tumors <5. No symptomatic patients or those with carcinoma in situ or grade 3 tumors were included. A retrospective analysis of a control group of patients with clinical characteristics similar to those of the patients on active surveillance, but who underwent transurethral resection immediately after the recurrence was diagnosed was also performed. RESULTS: The data from 64 patients (70 observation events) were analyzed. The mean patient age was 66.7 years. The median follow-up was 38.6 months. The median time patients remained in observation was 10.3 months. The tumor histologic features before observation were Stage pTa in 77.1%, Stage pT1a in 22.9%, grade 1 in 67.1%, and grade 2 in 23%. After 10.3 months, 93.5% of the patients had not progressed in stage and 83.8% had not progressed in grade. None of the patients experienced progression to muscle-invasive disease. A comparison between the rates of progression in the study and control groups showed no statistically significant difference. CONCLUSIONS: Patients with recurrent, small (<1 cm), nonmuscle-invasive bladder tumors can be safely offered monitoring under an active surveillance protocol, with a minimal risk of progression in either grade or stage, thus reducing the amount of surgical intervention they might undergo throughout their life.

Aportación del proyecto CARDIORISC al manejo del paciente hipertenso de Atención Primaria en España / Contribution of the CARDIORISC project to the management of hypertensive patients in Primary Health Care in Spain

El proyecto CARDIORISC es una iniciativa de la Sociedad Española de Hipertensión (SEH-LELHA), avalado por la Sociedad Europea de Hipertensión (ESH), iniciado en el año 2004 y que tiene como objetivo general optimizar la asistencia al paciente hipertenso en España. Comprende los registros MAPAPRES que pretende introducir la monitorización ambulatoria de la presión arterial (MAPA) como herramienta rutinaria en la valoración del paciente hipertenso en la práctica clínica en España, el registro AMPAPRES que evaluará el grado de control de la hipertensión arterial (HTA) mediante la automedida de la presión arterial (AMPA) por parte del paciente y el registro piloto FAPRES que evaluará la prevalencia de fibrilación auricular en la población hipertensa en la Comunidad Valenciana. El registro MAPAPRES está generando numerosas evidencias basadas en el análisis de la base de datos de más de 60.000 pacientes, aportadas por más de 1.000 investigadores, que se han incluido hasta la fecha. Se presentan, de manera resumida, en esta publicación algunas de las líneas de investigación más relevantes para la práctica clínica diaria del médico de Atención Primaria

The CARDIORISC project is an initiative of the Spanish Society of Hypertension (SEH-LELHA), endorsed by the European Society of Hypertension (ESH). It was established in the year 2004 and its general purpose is to improve care to the hypertensive patient in Spain. It includes the MAPAPRES registry that aim to introduce ambulatory blood pressure monitoring (ABPM) as a routine tool in the assessment of the hypertensive patient in the clinical practice in Spain, the AMPAPRES registry that will evaluate the control rate of arterial hypertension (AHT) using the self-measurement of blood pressure (SMBP) by the patient and the pilot registry FAPRES that will evaluate the prevalence of atrial fibrillation in the hypertensive population in the Spanish Valencian Community. The MAPAPRES registry is generating a great deal of evidence based on the analysis of the database of more than 60,000 patients provided by more than 1000 investigators. A summary of some of the most relevant lines of research for the daily clinical practice of the Primary Health Care physician are presented in this publication

Importancia de la prevención de la fibrilación auricular en el paciente hipertenso / Importance of the prevention of atrial fibrillation in the hypertensive patient

La hipertensión arterial (HTA) es una patología altamente prevalente, asociándose su presencia a innumerables complicaciones, especialmente cardiovasculares. La fibrilación auricular ocupa un lugar destacado dentro de las manifestaciones de la cardiopatía hipertensiva. La fibrilación auricular es la arritmia cardíaca sostenida más frecuente. Aproximadamente el 70 % de los pacientes afectados se encuentran entre los 65 y 85 años. Los factores de riesgo relacionados con el desarrollo de fibrilación auricular son fundamentalmente la edad, la HTA, la diabetes, la obesidad, la hipertrofia ventricular izquierda y la presencia de enfermedad cardiovascular. La mortalidad en la fibrilación auricular es el doble cuando se la compara con las personas en ritmo sinusal. En la población española el riesgo de ictus aumenta de forma independiente en los pacientes con fibrilación auricular, con cifras de riesgo de 2 a 7 veces más elevadas. En los pacientes con insuficiencia cardíaca congestiva la incidencia de fibrilación auricular va del 15 % al 30 % y conlleva una mayor morbimortalidad y un incremento en el número de hospitalizaciones. El tratamiento agresivo de la HTA, principal factor de riesgo, puede invertir los cambios estructurales en el corazón y retardar o prevenir la ocurrencia de fibrilación auricular. Estudios recientes han demostrado el importante papel clínico de la inhibición del sistema renina-angiotensina-aldosterona en la prevención de la fibrilación auricular

Arterial hypertension is a highly prevalent disease, its presence being associated to numerous complications, especially cardiovascular one. Atrial fibrillation occupies an important place among the manifestations of hypertensive heart disease. Atrial fibrillation is the most frequent sustained cardiac arrhythmia. Approximately 70 % of the affected patients are between 65 and 85 years old. The risk factors related to the development of atrial fibrillation are fundamentally age, arterial hypertension, diabetes, obesity, left ventricular hypertrophy and the presence of cardiovascular disease. Mortality in atrial fibrillation is double when it is compared with those having sinus rhythm. In the Spanish population, the risk of stroke increases independently in patients with atrial fibrillation, the risk values being 2 to 7 times higher. In the patients with congestive heart failure the incidence of atrial fibrillation goes from 15 % to 30 %, and it entails a greater morbidity and mortality and an increase in the number of hospitalizations. Aggressive treatment of the arterial hypertension, the main risk factor, can invert the structural changes in the heart and slow down or prevent the occurrence of atrial fibrillation. Recent studies have demonstrated the important clinical role of inhibiting the renin angiotensin system in the prevention of atrial fibrillation

Influencia de la prediabetes en el pronóstico cardiovascular del paciente hipertenso / Influence of prediabetes in the cardiovascular prognosis of the hypertensive patient

Las diversas características de los pacientes que presentan un riesgo elevado de desarrollar diabetes mellitus han sido descritas de forma reciente, siendo las principales una concentración de glucosa sérica más elevada, índice de masa corporal aumentado, presión arterial sistólica elevada, una cifra de colesterol HDL bajo y la presencia de tratamiento antihipertensivo previo. Sin embargo, se sabe poco respecto al pronóstico a largo plazo de este grupo de pacientes, también denominados «prediabéticos». El estado prediabético ha sido definido por la presencia de intolerancia hidrocarbonada o glucemia anómala en ayunas. Las evidencias acumuladas sugieren que los individuos con hiperglucemia en rango no diabético (prediabéticos) presentan riesgo aumentado de enfermedades cardiovasculares. Esta revisión analiza la necesidad de reconocer de forma precoz a los pacientes hipertensos prediabéticos para desarrollar estrategias de protección cardiovascular y de esta forma disminuir las consecuencias de la precipitación del desarrollo de diabetes y sus efectos deletéreos cardiovasculares y renales

The different characteristics of patients who have an elevated risk of developing diabetes mellitus have recently been described, the main ones being higher serum glucose concentration, increased body mass index, elevated systolic blood pressure, low HDL-cholesterol value and presence of previous antihypertensive treatment. However, little is known about the long term prognosis of this group of patients, also called "prediabetics". The prediabetic state has been defined by the presence of hydrocarbonate intolerance of abnormal fasting glycemia. The accumulated evidence suggests that individuals with hyperglycemia in the non-diabetic range (prediabetics) have increased risk of cardiovascular diseases. This review analyzes the need to recognize prediabetic hypertensive patients early to develop cardiovascular protection strategies and, in this way, to decrease the consequences of the precipitation of the development of diabetes and its cardiovascular and renal harmful effects

Proyecto CRONOPRES: un nuevo enfoque para el control de la hipertensión arterial / CRONOPRES Project: a new approach for the control of arterial hypertension

Introducción. Son muchas las variables biológicas, entre ellas la presión arterial (PA), cuyos valores varían a lo largo del día siguiendo un ritmo circadiano. La incorporación de la monitorización ambulatoria de la presión arterial (MAPA) a la práctica clínica ha permitido conocer los valores de PA que el paciente hipertenso presenta fuera de la consulta del médico, así como describir diferentes patrones circadianos de dicha presión arterial. Tanto estos valores de PA ambulatorios como la ausencia de descenso nocturno de la PA se asocian con una mayor prevalencia de lesión de órganos diana y un riesgo aumentado de complicaciones cardiovasculares. Objetivos. CRONOPRES es un proyecto asistencial, docente e investigador de la Sociedad Española de Hipertensión que pretende facilitar la MAPA a médicos de Atención Primaria y a especialistas en hipertensión para que dispongan de una herramienta útil en el diagnóstico y pronóstico de los pacientes hipertensos y puedan introducir en el esquema terapéutico el concepto de la cronoterapia, esto es, la administración temporalizada de los fármacos antihipertensivos. Métodos. Este proyecto se basa en la puesta en funcionamiento de más de 800 aparatos de MAPA para la práctica clínica habitual de profesionales de Atención Primaria y especialistas de unidades hospitalarias de HTA, con un sistema informático que transmite los datos de las MAPA a un Registro único centralizado. Además se genera un informe personalizado que se envía al médico, se calcula el patrón circadiano y el nivel de riesgo cardiovascular de cada paciente. Resultados. En los últimos 12 meses se han incorporado 767 investigadores al proyecto, y a 1 de junio de 2005 la base de datos del Registro CRONOPRES incluye ya más de 20.000 MAPA. El Proyecto CRONOPRES ha iniciado la primera etapa de su plan de investigación: estudio descriptivo del patrón circadiano en dos subpoblaciones con especial importancia: pacientes hipertensos sin tratamiento farmacológico antihipertensivo y pacientes con hipertensión refractaria. Conclusión. Estos datos y otros que el análisis del Registro irá generando contribuirán a profundizar en el conocimiento de la relación entre la presión arterial ambulatoria y el riesgo cardiovascular en nuestro país, con especial interés en el impacto que las variaciones circadianas de dicha presión arterial ejerzan sobre la morbimortalidad cardiovascular

Introduction. There are many biological variables, among them blood pressure (BP) whose values vary during the day following a circadian rhythm. Incorporation of ambulatory blood pressure monitoring (ABPM) to the clinical practice has made it possible to know the BP values of the hypertensive patient outside of the physician's office and to describe different circadian patterns of this blood pressure. Both these ambulatory BP values and the absence of nighttime decrease of BP are associated with a greater prevalence of target organ lesion and increased risk of cardiovascular complications. Objectives. CRONOPRES is a health care, teaching and investigator project of the Spanish Society of Hypertension, that aims to facilitate ABPM to Primary Care physicians and to specialists in hypertension for them to have a useful tool in the diagnosis and prognosis of hypertensive patients and be able to introduce the concept of chronotherapy into the therapeutic schedule, that is, time-dependent administration of antihypertensive drugs. Methods. This project is based on the implementation of more than 800 apparatus of ABPM for the common clinical practice of Primary Care professionals and specialists of the HBP hospital units, with a computer system that transmits the ABPM data to a single centralized Registry. Furthermore, a personalized report, that is sent to the physician, is generated. The circadian pattern and cardiovascular risk level of each patient is calculated. Results. In the last 12 months, 767 investigators have joined the projects. On June 1, 2005, the data base of the CRONOPRES Registry already included more than 20,000 ABPMs. The CRONOPRES project has initiated the first stage of its research plan: descriptive study of the circadian pattern in two subpopulations with special importance: hypertensive patients without antihypertensive drug treatment and patients with refractory hypertension. Conclusion. These data and others that will be generated by the analysis of the Registry will contribute to go into greater depth into the knowledge of the relationship between ambulatory blood pressure and cardiovascular risk in our country, with special interest in the impact that the circadian variations of this blood pressure exert on cardiovascular morbidity-mortality

Una nueva etapa en la vida de Hipertensión / A new stage in the life of Hipertensión

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Evaluación del riesgo cardiovascular y nuevos factores de riesgo de aterosclerosis / Cardiovascular risk evaluation and new risk factors of atherosclerosis

Las enfermedades cardiovasculares son la principal causa de mortalidad precoz e incapacidad en los países occidentales. En años recientes las sociedades profesionales y las agencias gubernamentales en Europa y Norteamérica han animado a los médicos a que hagan la transición, de enumerar los factores de riesgo a la evaluación cuantitativa del riesgo absoluto de un paciente de sufrir un acontecimiento cardiovascular. Para ello se han desarrollado diferentes modelos para valorar, de forma cuantitativa, el ries-go cardiovascular en los sujetos asintomáticos. Las guías más recientes en Europa recomiendan un nuevo modelo para estimar el riesgo basado en el sistema SCORE (Systematic Coronar y Risk Evaluation). El SCORE permite elaborar tablas de riesgo específicas para cada país cuando se dispone de datos de mortalidad fiables. Estudios epidemiológicos han demostrado que los pacientes con diabetes mellitus e intolerancia a la glucosa tienen un riesgo incrementado para la enfermedad arterial coronaria. Se cree que la presencia del síndrome metabólico puede aumentar el riesgo de un paciente para enfermedad arterial coronaria con cualquier nivel de colesterol ligado a lipoproteínas de baja densidad. La prevención cardiovascular en la práctica clínica habitual requiere de la identificación de los pacientes con riesgo elevado de presentar acontecimientos cardiovasculares en todas las edades. La mejor aproximación para la evaluación del riesgo cardiovascular en los pacientes en España es utilizar las tablas del sistema SCORE sumadas a las pruebas y al juicio clínico en los pacientes con síndrome metabólico y factores de riesgo asociados

Cardiovascular diseases are the main cause of early mortality and incapacity in western countries. In recent years, the professional societies and governmental agencies in Europe and North America have encouraged physicians to make the transition from listing risk factors to quantitative evaluation of absolute risk of a patient to suffer a cardiovascular event. To do so, different methods have been developed to assess quantitatively cardiovascular risk in asymptomatic subjects. The most recent guidelines in Europe recommend a new model to estimate the risk based on the SCORE (Systematic Coronary Risk Evaluation) system. SCORE makes it possible to elaborate specific risk tables for each country when reliable mortality data are available. Epidemiological studies have demonstrated that patients with diabetes mellitus and glucose intolerance have an increased risk for coronary arterial disease. It is believed that the presence of the metabolic syndrome may increase the risk of a patient for coronary arterial disease with any level of low density lipoprotein bond cholesterol. Cardiovascular prevention in the usual clinical practice requires identifying patients with elevated risk of having cardiovascular events at all ages. The best approach for the evaluation of cardiovascular risk in patients in Spain is to use the SCORE system tables added to tests and clinical opinion in patients with metabolic syndrome and associated risk factorsCardiovascular diseases are the main cause of early mortality and incapacity in western countries. In recent years, the professional societies and governmental agencies in Europe and North America have encouraged physicians to make the transition from listing risk factors to quantitative evaluation of absolute risk of a patient to suffer a cardiovascular event. To do so, different methods have been developed to assess quantitatively cardiovascular risk in asymptomatic subjects. The most recent guidelines in Europe recommend a new model to estimate the risk based on the SCORE (Systematic Coronary Risk Evaluation) system. SCORE makes it possible to elaborate specific risk tables for each country when reliable mortality data are available. Epidemiological studies have demonstrated that patients with diabetes mellitus and glucose intolerance have an increased risk for coronary arterial disease. It is believed that the presence of the metabolic syndrome may increase the risk of a patient for coronary arterial disease with any level of low density lipoprotein bond cholesterol. Cardiovascular prevention in the usual clinical practice requires identifying patients with elevated risk of having cardiovascular events at all ages. The best approach for the evaluation of cardiovascular risk in patients in Spain is to use the SCORE system tables added to tests and clinical opinion in patients with metabolic syndrome and associated risk factorsCardiovascular diseases are the main cause of early mortality and incapacity in western countries. In recent years, the professional societies and governmental agencies in Europe and North America have encouraged physicians to make the transition from listing risk factors to quantitative evaluation of absolute risk of a patient to suffer a cardiovascular event. To do so, different methods have been developed to assess quantitatively cardiovascular risk in asymptomatic subjects. The most recent guidelines in Europe recommend a new model to estimate the risk based on the SCORE (Systematic Coronary Risk Evaluation) system. SCORE makes it possible to elaborate specific risk tables for each country when reliable mortality data are available. Epidemiological studies have demonstrated that patients with diabetes mellitus and glucose intolerance have an increased risk for coronary arterial disease. It is believed that the presence of the metabolic syndrome may increase the risk of a patient for coronary arterial disease with any level of low density lipoprotein bond cholesterol. Cardiovascular prevention in the usual clinical practice requires identifying patients with elevated risk of having cardiovascular events at all ages. The best approach for the evaluation of cardiovascular risk in patients in Spain is to use the SCORE system tables added to tests and clinical opinion in patients with metabolic syndrome and associated risk factors

Importancia de la valoración del fondo de ojo en el paciente hipertenso / Importance of fundoscopic examination in hypertensive patients

La hipertensión arterial (HTA) es el principal factor de riesgo para el desarrollo de enfermedades cardiovasculares y también de lesiones vasculares en la retina. Las alteraciones oculares de la HTA incluyen tres manifestaciones distintas e independientes en la retina, nervio óptico y circulación coroidal. El estudio oftalmológico realizado de forma habitual en todo paciente hipertenso ayuda a valorar la gravedad de la hipertensión. Las últimas guías de la European Society of Hypertension-European Society of Cardiology (ESH/ESC) incluyen el examen fundoscópico dentro de los métodos para evaluar la lesión de órgano diana en el paciente hipertenso. La existencia de hemorragias y exudados, signos de hipertensión maligna, obligará a realizar un tratamiento antihipertensivo más agresivo, a la vez que se llevan a cabo exploraciones complementarias. El reciente desarrollo de técnicas de fotografía del fondo de ojo ha permitido una precisa documentación de los signos microvasculares de la retina en la HTA en estudios realizados en población general. En numerosos estudios se ha comunicado la correlación entre las lesiones retinianas microvasculares, las lesiones de órgano diana y el desarrollo de diabetes, además de constituir un predictor independiente de ictus. En esta revisión se presentan las características de las lesiones oculares en la HTA, su clasificación y su correlación con la enfermedad cardiovascular (AU)

Impacto del índice tobillo-brazo sobre la estratificación de riesgo cardiovascular de pacientes hipertensos / Importance of ankle-arm index in cardiovascular risk factor stratification for hypertensive patients

Introducción. El índice de presión arterial tobillo-brazo (ITB) es una prueba diagnóstica eficiente en la detección de vasculopatía periférica y predice la morbimortalidad cardiovascular. El objetivo de este estudio fue evaluar el impacto de la realización de ITB en la estratificación de riesgo de sujetos sin enfermedad cardiovascular (ECV) clínica. Material y métodos. Se incluyeron pacientes con hipertensión arterial esencial, mayores de 65 años, de ambos sexos y al menos con un factor de riesgo cardiovascular. A todos ellos se les calculó los ITB pedios y tibiales de ambos miembros inferiores, determinando la presión arterial sistólica en dichos territorios mediante un detector continuo de pulso por sistema doppler (Vasculascope Model 500, Hayashi Denki Co., Ltd). Se consideró diagnóstico anormal un ITB inferior a 0,9 o superior a 1,3. Se recogieron datos sobre presión arterial, peso, talla, antecedentes personales y familiares, uso de fármacos y hábitos tóxicos. También se tomaron muestras sanguíneas para la valoración del perfil lipídico, bioquímica sanguínea y hemograma. Se incluyeron 130 pacientes hipertensos (62 por ciento varones), con una edad media de 68 ñ 5 años, y un valor de presión arterial sistólica media en brazo dominante de 146 ñ15 mmHg. Resultados. Según la clasificación del riesgo cardiovascular, 59 (45 por ciento) pacientes presentaban un riesgo medio y 71 (55 por ciento) mostraban un riesgo cardiovascular elevado. De los 130 pacientes, 9 (6,9 por ciento; IC 95 por ciento: 2,6 por ciento-11,4 por ciento) presentaron un ITB anormal, dos (3,4 por ciento) en el grupo de riesgo medio y 7 (9,9 por ciento) entre los pacientes de riesgo elevado. Conclusión. La medición del ITB en pacientes hipertensos libres de ECV clínica y diabetes, con riesgo medioalto, no parece ser clínicamente útil debido al escaso número detectado de pacientes con ITB anormal y que podrían obtener beneficios de esta intervención al ser reclasificados como de riesgo muy alto (AU)