Outcomes of leadless pacemaker implantation in patients with mechanical heart valves.

INTRODUCTION: Device infections constitute a major complication of transvenous pacemakers. Mechanical heart valves (MHV) increase the risk of infective endocarditis (IE) and pacemaker infection, requiring lifelong vitamin K-antagonists (VKA), which may affect patient management. Leadless pacemakers (LP) are associated with low infection rates, posing an attractive option in MHV patients requiring permanent pacing. This study describes outcomes following LP implantation in patients with MHV. METHODS: This is a multicenter, observational, retrospective study including consecutive patients implanted with an LP at 5 centers between June 2015 and January 2020. Procedural outcomes, antithrombotic management, complications, performance during follow-up and episodes of bacteremia and IE were compared between patients with and without an MHV (MHV and non-MHV groups). RESULTS: Four hundred fifty-nine patients were included (74 in the MHV group, 16.1%, and 385 in the non-MHV group, 83.9%). Procedural outcomes and acute electrical performance were comparable between groups. Vascular complications and cardiac perforation occurred in 2.7 versus 2.3% (p = 1) and 0% versus 0.8% (p = 1) in the MHV group and non-MHV group. One case of IE occurred in the MHV group and 2 in the non-MHV group. In MHV patients, uninterrupted VKA was used in 83.8%, whereas 16.2% were heparin-bridged. Vascular complication or tamponade occurred in 1 (8.3%) MHV heparin-bridged patient versus 1 (1.6%) MHV uninterrupted VKA patient (p = .3). CONCLUSION: LP implantation outcomes in MHV patients are comparable to the general LP population. Device-related infections are rare following LP implantation, including in patients with MHV. In the MHV group, periprocedural anticoagulation management was not associated with significantly different rates of tamponade or vascular complication.

Trastornos del sueño en emergencias y desastres / Sleep disorders in emergencies and disasters

Los trastornos del sueño son frecuentes en la población y una causa importante de morbilidad. El objetivo de esta revisión es evaluar las alteraciones del sueño en periodos de emergencia y desastres. A lo largo de la historia, la esfera biopsicosocial y el sueño de las personas ha sido abrumada por múltiples eventos a gran escala, tales como desastres naturales, tragedias provocadas por el hombre, conflictos bélicos, crisis sociales y pandemias, cuya experiencia puede derivar en problemas de salud a corto, mediano y/o largo plazo. En los estudios analizados, se ha observado el impacto negativo de las emergencias y desastres en el sueño, por lo que ha cobrado gran relevancia la difusión y promoción de medidas que incentiven el buen dormir. Debido a la llegada del COVID-19 y a la situación de confinamiento por periodos prolongados en el hogar para prevenir su propagación, han surgido importantes consecuencias a nivel social. Ciertos factores ocupacionales y características de los desastres se asocian a mayor comorbilidad, un alto riesgo de experimentar agotamiento físico, trastornos psicológicos e insomnio en grupos altamente vulnerables, como lo son los profesionales de la salud, rescatistas y socorristas. El insomnio es el trastorno de sueño más frecuente en la población general y su empeoramiento en el contexto de pandemia por COVID-19 representa un nuevo problema en salud pública. Es por ello, que es indispensable promover campañas de prevención de salud física y mental orientados a la pesquisa precoz y manejo de patologías de la esfera psicosocial, dentro de las posibilidades socioeconómicas.

Sleep disorders are common in the population and are major cause of morbidity. The objective of this review is to assess sleep disturbances in times of emergency and disasters. Throughout history, the biopsychosocial field and sleep have been affected by multiple large-scale events, such as natural disasters, man-caused tragedies, armed conflicts, social crises and pandemics, the experience of which can lead to short, medium and/or long term health problems. In several studies, the negative impact of emergencies and disasters on sleep have been analyzed, emphasizing the importance of the diffusion and promotion of measures that encourage good sleep. The arrival of COVID-19 and consequent home confinement for prolonged periods caused important social consequences. Certain occupational factors and characteristics of disasters are associated with greater comorbidity: a high risk of experiencing physical exhaustion, psychological disorders and insomnia, especially in highly vulnerable groups, such as health professionals, rescuers and first aids-responders. Insomnia is the most frequent sleep disorder in the general population and its worsening in the context of the COVID-19 pandemic, represents a new public health problem. It is essential to promote physical and mental health prevention campaigns, aimed at early screening and management of pathologies in the psychosocial sphere, within socioeconomic possibilities.

Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery: An Open-label, Nonrandomized, Crossover, Clinical Trial.

BACKGROUND: Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. METHODS: Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above intraabdominal pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. RESULTS: Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. CONCLUSIONS: Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.

Outcomes after Split Abdominal Wall Muscle Flap Repair for Large Congenital Diaphragmatic Hernias.

INTRODUCTION: Repair of large congenital diaphragmatic hernias (CDHs) is challenging. As primary repair is not always feasible, patches are commonly used. An alternative treatment is split abdominal wall muscle flap repair, which uses vascularized autologous tissue. The aim of this study was to analyze the long-term outcome of large CDH defects undergoing split abdominal wall muscle repair. MATERIALS AND METHODS: This is a retrospective review (2003-2016) of large CDH treated by split abdominal wall muscle flap repair. RESULTS: In a total of 107 CDH patients, the abdominal muscle flap technique was used in 10 (9.3%); 7 had been prenatally treated with tracheal occlusion. Two patients experienced recurrence at 2 months and 6 years, respectively. Only one patient required abdominoplasty due to abdominal wall muscle weakness. Two patients developed progressive scoliosis; one of them required orthopaedic treatment. Minor chest wall deformities were detected in seven, but only one required orthopaedic treatment. The lung-to-head ratio was 0.79 in patients developing musculoskeletal deformities, and 1.5 in those without this complication (p < 0.05). Median follow-up was 11.2 years (3.5-14.2), and all patients were alive at the time of writing this article. CONCLUSION: The split abdominal wall muscle flap technique is a valid option for repair of large CDH. Associated musculoskeletal deformities seem to be influenced not only by the repair technique used but also by the degree of pulmonary hypoplasia and inherent pathophysiological changes.

Lessons learned in attempting catheter-based interatrial electrical disconnection for nonpharmacologic rate control of atrial fibrillation or flutter.

PURPOSE: Ablation of atrioventricular (AV) conduction and pacemaker implantation is the therapy of last resort for symptomatic atrial tachyarrythmias when rhythm and rate control fail, but is far from ideal. To evaluate whether interatrial electrical disconnection as a result of catheter ablation is feasible and of potential clinical utility as a means of non-pharmacological heart rate control. METHODS: Eleven patients with medically refractory atrial fibrillation or left atrial flutter and symptomatic rapid ventricular response were included. The ablation strategy consisted primarily of right atrial ablation of the interatrial electrical connections, which were located by electroanatomical activation maps performed during coronary sinus stimulation. Successive activation maps were performed as each connection was blocked. If the procedure was considered unsuccessful AV nodal ablation was performed. RESULTS: The coronary sinus ostium was earliest in 10/11 and could be ablated in 5/10 patients. Interatrial conduction block was only achieved in one patient (9.1%). An unexpected AV nodal modulation with an increase in the Wenckebach cycle length (> 50 ms) occurred in 8/11 patients. These patients remained without pacemaker implantation and only 1/8 required AV nodal ablation during the 1-year follow-up. Quality of life questionnaires indicated significant improvement in patients with AV nodal modulation. CONCLUSION: Interatrial electrical disconnection by right atrial catheter ablation is a not feasible with present day technology. The extensive right atrial septal ablation performed resulted in significant AV nodal modulation in most patients, which persisted and resulted in improvement in quality of life.

Resultados en España de la encuesta de la Sociedad Europea de Cardiología sobre terapia de resincronización cardiaca (CRT-Survey II) / Spanish results of the Second European Cardiac resynchronization therapy survey (CRT-Survey II)

Introducción y objetivos: Se describen los resultados en España de la segunda encuesta de la Sociedad Europea de Cardiología sobre terapia de resincronización cardiaca (CRT-Survey II) y se comparan con los de los demás países participantes. Métodos: Pacientes a los que se implantó un dispositivo de terapia de resincronización cardiaca entre octubre de 2015 y diciembre de 2016 en 36 centros participantes. Se recogieron datos sobre las características basales de los pacientes y del implante, y un seguimiento a corto plazo hasta el alta hospitalaria. Resultados: La tasa de éxito del implante fue del 95,9%. La mediana [intervalo intercuartílico] de implantes anuales/centro en España fue significativamente menor que en los demás países participantes: 30 [21-50] frente a 55 [33-100] implantes/año (p=0,00003). En los centros españoles hubo una menor proporción de pacientes de edad ≥ 75 años (el 27,9 frente al 32,4%; p=0,0071), una mayor proporción de pacientes en clase funcional II de la New York Heart Association (el 46,9 frente al 36,9%; p <0,00001) y un mayor porcentaje de pacientes con criterios electrocardiográficos de bloqueo de rama izquierda (el 82,9 frente al 74,6%; p <0,00001). La media de la estancia hospitalaria fue menor en los centros españoles (5,8+/-8,5 frente a 6,4+/-11,6; p <0,00001) y una mayor proporción de pacientes recibieron un cable de ventrículo izquierdo cuadripolar (el 74 frente al 56%; p <0,00001) y fueron seguidos a distancia (el 55,8 frente al 27,7%; p <0,00001). Conclusiones: La encuesta CRT-Survey II muestra que en España hay una menor proporción de pacientes de 75 o más años que reciben un dispositivo de terapia de resincronización cardiaca, una mayor proporción de pacientes en clase funcional II de la New York Heart Association, con bloqueo completo de la rama izquierda del haz de His y con seguimiento a distancia, con estancias hospitalarias significativamente menores

Introduction and objectives: We describe the results for Spain of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II) and compare them with those of the other participating countries. Methods: We included patients undergoing CRT device implantation between October 2015 and December 2016 in 36 participating Spanish centers. We registered the patients' baseline characteristics, implant procedure data, and short-term follow-up information until hospital discharge. Results: Implant success was achieved in 95.9%. The median [interquartile range] annual implantation rate by center was significantly lower in Spain than in the other participating countries: 30 implants/y [21-50] vs 55 implants/y [33-100]; P=.00003. In Spanish centers, there was a lower proportion of patients ≥ 75 years (27.9% vs 32.4%; P=.0071), a higher proportion in NYHA class II (46.9% vs 36.9%, P <.00001), and a higher percentage with electrocardiographic criteria of left bundle branch block (82.9% vs 74.6%; P <.00001). The mean length of hospital stay was significantly lower in Spanish centers (5.8+/-8.5 days vs 6.4+/-11.6; P <.00001). Spanish patients were more likely to receive a quadripolar LV lead (74% vs 56%, P <.00001) and to be followed up by remote monitoring (55.8% vs 27.7%; P <.00001). Conclusions: The CRT-Survey II shows that, compared with other participating countries, fewer patients in Spain aged ≥ 75 years received a CRT device, while more patients were in New York Heart Association functional class II and had left bundle branch block. In addition, the length of hospital stay was shorter, and there was greater use of quadripolar LV leads and remote CRT monitoring

Spanish Results of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II).

INTRODUCTION AND OBJECTIVES: We describe the results for Spain of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II) and compare them with those of the other participating countries. METHODS: We included patients undergoing CRT device implantation between October 2015 and December 2016 in 36 participating Spanish centers. We registered the patients' baseline characteristics, implant procedure data, and short-term follow-up information until hospital discharge. RESULTS: Implant success was achieved in 95.9%. The median [interquartile range] annual implantation rate by center was significantly lower in Spain than in the other participating countries: 30 implants/y [21-50] vs 55 implants/y [33-100]; P=.00003. In Spanish centers, there was a lower proportion of patients ≥ 75 years (27.9% vs 32.4%; P=.0071), a higher proportion in New York Heart Association functional class II (46.9% vs 36.9%; P <.00001), and a higher percentage with electrocardiographic criteria of left bundle branch block (82.9% vs 74.6%; P <.00001). The mean length of hospital stay was significantly lower in Spanish centers (5.8±8.5 days vs 6.4±11.6; P <.00001). Spanish patients were more likely to receive a quadripolar LV lead (74% vs 56%; P <.00001) and to be followed up by remote monitoring (55.8% vs 27.7%; P <.00001). CONCLUSIONS: The CRT-Survey II shows that, compared with other participating countries, fewer patients in Spain aged ≥ 75 years received a CRT device, while more patients were in New York Heart Association functional class II and had left bundle branch block. In addition, the length of hospital stay was shorter, and there was greater use of quadripolar LV leads and remote CRT monitoring.

Registro español de ablación con catéter. XVI informe oficial de la sección de electrofisiología y arritmias de la Sociedad Española de Cardiología (2016) / Spanish catheter ablation registry. 16th official report of the spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2016)

Introducción y objetivos: Se describen los resultados del Registro Español de Ablación con Catéter correspondientes al año 2016. Métodos: La recogida de datos se llevó a cabo retrospectivamente mediante un formulario de recogida de datos que cada uno de los centros participantes cumplimentó. Resultados: Se analizaron datos de 83 centros. El número total de procedimientos de ablación fue de 13.482 (el más alto comunicado en la historia de este registro) con una media de 162,4 ± 116 y una mediana de 136 procedimientos. El sustrato abordado con más frecuencia fue la ablación de taquicardia intranodular (n = 3.058 [22,7%]), seguida de la fibrilación auricular (n = 2.953 [21,9%]) y el istmo cavotricuspídeo (n = 2.892 [21,4%]). Se observa un pico en el número de ablaciones de fibrilación auricular, que es por primera vez el segundo sustrato más tratado. La tasa total de éxito, excluidas la fibrilación auricular y las taquicardias ventriculares con cardiopatía, fue del 86%; la de complicaciones mayores, del 2,3% y la mortalidad, del 0,05%. El 2,7% de las ablaciones se realizaron en pacientes pediátricos. Conclusiones: El Registro Español de Ablación con Catéter recoge sistemática e ininterrumpidamente los procedimientos de ablación realizados en España, lo que permite observar con el paso de los años un aumento progresivo del número de ablaciones manteniendo una alta tasa de éxito y bajos porcentajes de complicaciones (AU)

Introduction and objectives: This report describes the findings of the 2016 Spanish Catheter Ablation Registry. Methods: Data were retrospectively collected by means of a standardized questionnaire completed by each of the participating centers. Results: Data were collected from 83 centers. A total of 13 482 ablation procedures were performed (the highest historically reported in this registry), with a mean of 162.4 ± 116 and a median of 136 procedures per center. The most frequently treated ablation targets were atrioventricular nodal re-entrant tachycardia (n = 3058; 22.7%), atrial fibrillation (n = 2953; 21.9%), and cavotricuspid isthmus (n = 2892; 21.4%). There was a peak in ablation procedures for atrial fibrillation, which, for the first time in this registry, became the second most treated substrate. After exclusion of atrial fibrillation and ventricular tachycardia with underlying heart disease, the overall success rate was 86%. The rate of major complications was 2.3%, and the mortality rate was 0.05%. In all, 2.7% of the ablations were performed in pediatric patients. Conclusions: The Spanish Catheter Ablation Registry systematically and uninterruptedly records the ablation procedures performed in Spain, showing a progressive rise in the number of ablations performed, with a high success rate and a low percentage of complications (AU)

Spanish Catheter Ablation Registry. 16th Official Report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2016).

INTRODUCTION AND OBJECTIVES: This report describes the findings of the 2016 Spanish Catheter Ablation Registry. METHODS: Data were retrospectively collected by means of a standardized questionnaire completed by each of the participating centers. RESULTS: Data were collected from 83 centers. A total of 13 482 ablation procedures were performed (the highest historically reported in this registry), with a mean of 162.4 ± 116 and a median of 136 procedures per center. The most frequently treated ablation targets were atrioventricular nodal re-entrant tachycardia (n = 3058; 22.7%), atrial fibrillation (n = 2953; 21.9%), and cavotricuspid isthmus (n = 2892; 21.4%). There was a peak in ablation procedures for atrial fibrillation, which, for the first time in this registry, became the second most treated substrate. After exclusion of atrial fibrillation and ventricular tachycardia with underlying heart disease, the overall success rate was 86%. The rate of major complications was 2.3%, and the mortality rate was 0.05%. In all, 2.7% of the ablations were performed in pediatric patients. CONCLUSIONS: The Spanish Catheter Ablation Registry systematically and uninterruptedly records the ablation procedures performed in Spain, showing a progressive rise in the number of ablations performed, with a high success rate and a low percentage of complications.

[The reform of Spanish abortion law]. / La reforma de la legislación del aborto en España.

The article focuses on the different factors and circumstances that have led to the reform of Spanish Abortion Law (1985). Judicial investigations of several abortion clinics have demonstrated that up until today there has been a widespread tendency of the clinics to practice beyond the limits established by the law. Nonetheless, the reaction of the government has not been to protect the life of the unborn. Its reaction has been, however, to cover the irregularities committed by the abortionists through the legalization of their abusive practices. Besides, the reform of the law has been inspired by elements of radical feminism. The author points out the major reasons that make this reform unconstitutional and offers alternative solutions for the protection of the mother and the unborn child.

Tècnica mínimament invasiva per a la correcció del Pectus excavatum. Una realitat a Catalunya / Nueva técnica en la corrección del pectus excavatum. Una realidad en Catalunya / A new minimally invasive technique for the correction of pectus excavatum. A fact in Catalonia

Introducció. El Pectus excavatum (PE) és una malformació freqüent de la paret toràcica anterior. Pot cursar de forma asimptomàtica o presentar compromís de la funció cardiopulmonar per compressió. A la majoria dels casos es presenten problemes psicològics pel defecte estètic que comporta. Per a la seva correcció, s’han utilitzat diverses tècniques agressives basades en osteotomies i reseccions costals. Actualment s’ha descrit una nova tècnica mínimament invasiva que hem començat a utilitzar en el nostre àmbit. Cas clínic. Pacient baró de 14 anys que presenta un PE sever que cursa asimptomàtic, però amb una afectació psicològica important. Després d’una avaluació preoperatò- ria amb radiologia i TAC toràcic, es practica la correcció quirúrgica del PE amb la tècnica de Nuss. A través de dues petites incisions laterals i sota control toracoscòpic, es fa passar una barra metàl•lica còncava preformada entre el pericardi i l’estèrnum. Una vegada girada i fixada als seus extrems, la barra manté elevat l’estèrnum, desapareixent el PE. Es va administrar analgèsia per un catèter epidural durant el primers dies postoperatoris, i es va donar d’alta hospitalària després de 6 dies. No s’han presentat complicacions i el resultat estètic és excel•lent després d’un any de seguiment. Comentaris. Després de 50 anys utilitzant la tècnica de Ravitch, amb osteotomia de l’estèrnum i reseccions dels cartílags costals, per a la correcció del PE, ha aparegut una tècnica mínimament invasiva, descrita per Donald Nuss, que mostra bons resultats amb menor agressivitat sobre el pacient. Donat que la paret toràcica té una gran elasticitat durant l’edat pediàtrica i és potencialment mal•leable, es deixa durant 2 anys una barra metàl•lica convexa que manté l’estèrnum aixecat. Aquesta nova tècnica suposa una alternativa per a la correcció del PE, per no condemnar aquests pacients a ocultar el seu defecte. Actualment ens podem beneficiar d’ella al nostre entorn (AU)

Introducción. El Pectus excavatum (PE) es una malformación frecuente de la pared torácica anterior. Puede cursar de forma asintomática o presentar compromiso de la función cardiopulmonar por compresión. En la mayoria de los casos se presentan problemas psicológicos por el defecto estético que comporta. Para su corrección, se han utilizado diversas técnicas agresivas basadas en osteotomías y resecciones costales. Actualmente se ha descrito una nueva técnica mínimamente invasiva que hemos empezado a utilizar en nuestro ámbito. Caso clínico. Paciente varón de 14 años que presenta un PE severo que cursa asintomático, pero con una afectación psicológica importante. Después de una evaluación preoperatoria con radiología y TAC torácico, se practica la corrección quirúrgica del PE mediante la técnica de Nuss. A través de dos pequeñas incisiones laterales y bajo control toracoscópico, se pasa una barra metálica cóncava preformada entre el pericardio y el esternón. Una vez girada y fijada en sus extremos, la barra mantiene elevado el esternón, desapareciendo el PE. Se administró analgesia por un catéter epidural durante los primeros días postoperatorios, y se dió de alta hospitalaria después de 6 dies. No se han presentado complicaciones y el resultado estético es excelente después de un año de seguimiento. Comentaris. Después de 50 años utilizando la técnica de Ravitch, con osteotomía del esternón y resecciones de los cartílagos costales, para la corrección del PE, ha aparecido una técnica mínimamente invasiva, descrita per Donald Nuss, que muestra buenos resultados con menor agresividad sobre el paciente. Dado que la pared torácica tiene una gran elasticidad durante la edad pediátrica y es potencialmente maleable, se deja una barra metálica convexa durante 2 años, que mantiene el esternón elevado. Esta nueva técnica supone una alternativa en la correcció del PE, para no condenar a estos pacientes a ocultar su defecto. Actualmente nos podemos beneficiar de ella en nuestro entorno (AU)

Introduction. Pectus excavatum (PE) is a frequent malformation of the anterior thoracic wall. It can be completely asymptomatic or it can impact severely the cardiopulmonary function by compression. In the majority of the patients, the deformity results in significant psychological disturbances. Most corrective procedures involve aggressive techniques based on osteotomies and rib resections. In recent years, a new minimally invasive technique has been reported. Case report. A 14 year-old boy presented with severe asymptomatic PE deformity causing major psychological disturbance. Correction of the deformity was performed using the Nuss technique. By means of two small lateral incisions, and under thoracoscopic control, a preformed concave steel bar was inserted between the pericardium and the sternum. The pectus bar was then flipped over and both ends were fixed, thus supporting the sternum up. Epidural analgesia was used during the first postoperative days. The patient was discharged after 6 days. No complications developed, and the patient has had an excellent aesthetic outcome at 1-year follow-up. Comments. The Ravitch technique for the correction of PE has been extensively used over the past 50 years. This technique involves sternal osteotomies and costal cartilage resections. This new minimally invasive technique, designed by Donald Nuss, results in excellent outcome. Because of the thoracic wall elasticity in the pediatric age, PE can be corrected by inserting a convex steel bar that will remain for 2 years and which will revert the sternal depression. This new technique represents an alternative option in the treatment of PE, and is now available in our community (AU)

Angiogénesis y estatinas, ¿a mayor dosis, mayor beneficio? / Angiogenesis and statins, the highest the dose the best?

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