Actualización en Medicina de Familia. Tratamiento de la hipertensión arterial en los diabéticos: una revisión crítica / Up-date In Family Medicine. Treatment of arterial hypertension in diabetics: a critical review

En este artículo se revisan las evidencias que sustentan las recomendaciones de los consensos con relación al tratamiento de la hipertensión arterial en los diabéticos, en concreto, la diabetes como equivalente de riesgo coronario, los objetivos terapéuticos fijados en 130/80 mmHg y el lugar de las tiazidas, inhibidores de la enzima de conversión de la angiotensina y antagonistas de los receptores de la angiotensina II como fármacos de elección. Hoy parece claro que no todos los diabéticos son iguales. La apresurada consideración de la diabetes como "equivalente de riesgo coronario" por parte de consensos influyentes no se justifica en función del conjunto de las evidencias disponibles. Tampoco las evidencias justifican de modo inequívoco el objetivo de situar la presión arterial (PA) en los diabéticos por debajo de 130/80 mmHg. Más aún, los consensos que defienden esta recomendación la consideran un objetivo flexible y de aplicación individualizada. Respecto al tratamiento de elección de la hipertensión arterial (HTA) en los diabéticos, no existen evidencias que apoyen el uso preferente de inhibidores de la enzima de conversión de la angiotensina (IECA) o de antagonistas de los receptores de la angiotensina II (ARA II). De hecho sólo la American Diabetes Association entre los principales consensos defiende, de modo indirecto, esta actitud. IECA y ARA II no han demostrado una clara superioridad global en la prevención cardiovascular frente a otros antihipertensivos. Tampoco han demostrado cardioprotección específica. Los efectos antiproteinúricos de estos fármacos no justifican por sí mismos su uso preferencial en diabetes al medirse con un conjunto de variables subrogadas sin clara significación clínica. IECA y ARA II sólo han demostrado eficacia en la reducción de complicaciones diabéticas renales duras en pacientes con nefropatía diabética severa (albuminuria superior a 3 g/día) e insuficiencia renal (o al borde). El que la asociación tiazida-IECA sea una opción adecuada para muchos de los pacientes hipertensos y diabéticos no implica que todo diabético deba ser tratado con dos o más fármacos ni que sea preferible utilizar un inhibidor del sistema renina-angiotensina. Tiazidas, como admite y aconseja la Organización Mundial de la Salud y el VII informe del Joint National Commitee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, pueden utilizarse, igual que en la población general, en monoterapia en el tratamiento inicial de los diabéticos

The evidence that supports the consensus recommendations in regards to arterial hypertension treatment in diabetics, specifically, diabetes as equivalent to coronary risk, the therapeutic objectives established at 130/80 mmHg and the place of thiazides, angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists as drugs of choice is reviewed. It presently seems to be clearer that not all diabetics are the same. The hasty consideration of diabetes as "equivalent to coronary risk" by influential consensuses is not justified based on all the evidence available. The evidence also does not unmistakably justify the objective of placing blood pressure in diabetics below 130/80 mmHg. Even more, consensuses that defend this recommendation consider it a flexible objective to be individually applied. Regarding the treatment of choice of HBP in diabetics, there is no evidence that shows the preferential use of ACEI or ARA II. In fact, only ADA among the principal consensuses indirectly defends this attitude. ACEI and ARA II have not shown a clear or global superiority in the cardiovascular prevention versus other antihypertensive agents. It also has not demonstrated specific cardioprotection. The antiproteinuric effects of these drugs do not justify by themselves their preferential use in diabetes when measured with a group of subrogated variables without clear clinical significance. ACEI and ARA II have only demonstrated efficacy in the reduction of strong renal diabetic complications in patients with severe diabetic nephropathy (albuminuria greater than 3 g/day) and renal failure (or close to it). The fact that the thiazide-ACEI association is an adequate option for many hypertensive and diabetic patients does not imply that all diabetics should be treated with 2 or more drugs or that it is preferable to use a renin-angiotensin system inhibitor. Thiazides, as has been admitted and advised by the WHO and JNC VII, can also be used, as in the general population, in single drug therapy in the initial treatment of diabetics

Cálculo del riesgo cardiovascular y tablas de riesgo en España. Réplica de los autores / Calculation of cardiovascular risk and risk tables in Spain. Reply of the authors

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Prevención primaria con estatinas, consensos y tablas de riesgo / Primary prevention with statins, consensus and risk tables

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Carcinoma neuroendocrino de fosa nasal ¿una entidad independiente? / Neuroendocrine carcinoma of nasal fossa. An independant entity?

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[The role of video-nystagmography in the diagnosis of acoustic neuroma]. / El papel de la videonistagmografía en el diagnóstico del neurinoma del acústico.

AIM: Schwannoma of the vestibular nerve represents 75% of all expansive processes affecting the pontocerebellosum angle. Hearing loss is the most frequent symptom at diagnosis (86%) with or without tinnitus, in the intracanalicular tumors. Vestibular symptoms are described in 60% of patients. MATERIAL AND METHOD: We study twenty cases of acoustic neuromas diagnosed between years 2000 and 2002 in both Otolaryngology and Neurosurgery Departments in our hospital. Videonystagmography (VNG) was performed in all of them. Videonystagmographic findings were analyzed statistically together with the tumoral size and hypoacusia level. DISCUSSION AND CONCLUSION: According to the medical literature reviewed for this paper, we conclude that caloric tests are the most frequently altered ones (77%), showing vestibular hyporreflexia or arreflexia.

Vértigo posicional paroxístico no benigno / No benign paroxystic positival vertigo

El vértigo posicional es una manifestación clínica frecuente de vértigo de causas muy variadas, siendo el vértigo posicional paroxístico benigno (VPPB) el tipo de vértigo posicional más frecuente, representando incluso la causa más frecuente de vértigo periférico en algunas series. Generalmente de etiología benigna, puede aparecer vértigo posicional en el contexto de entidades de gran gravedad y difícil diagnóstico. En estos casos, la persistencia de los síntomas a pesar de las maniobras de reposicionamiento, la asociación con otra sintomatología otológica o neurológica, así como el nistagmo de características atípicas provocado en la maniobra de Dix-Hallpike, deben hacer sospechar al otorrinolaringólogo de la posible existencia de una patología no benigna. Presentamos un caso de VPP causado por una tumoración intracraneal y revisamos los signos clínicos que nos ayudan a sospechar patologías no benignas que pueden simular un vértigo posicional (AU)

Positional vertigo is a frequent clinical manifestation of vertigo of very different etiologies, being the benign paroxystic positional vertigo (BPPV) the most frequent one of them, representing in some series even the most found etiology of peripheral vertigo. Usually of severe entities, positional vertigo may appear in the context of severe entities and of difficult diagnosis. In these cases, the bearing of the symptoms in spite of the repositioning manoeuvers, the association with otological or neurological symptoms, and the atypical nystagmus evoked by Dix-Hallpike manoeuver, must take the otolaryngologist to suspect of a feasible non benign pathology. We report a case of positional paroxysmal vertigo caused by an intracranial tumour and we review the clinical signs that shoved help us to suspect of non benign pathologies that can mimic a positional vertigo (AU)

Guerra, evidencias, guías y nuestra semFYC / War, evidence and our semFYC

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El papel de la videonistagmografía en el diagnóstico del neurinoma del acústico / The role of videonystagmography in the diagnosis of acoustic neuroma

Objetivo: El Schwannoma del nervio vestibular representa el 75 por ciento de los procesos expansivos del ángulo pontocerebeloso (APC). La hipoacusia con o sin tinnitus es el síntoma debut más frecuente (86 por ciento) en los tumores intrameatales. Los síntomas vestibulares se dan en el 60 por ciento de los pacientes. Material y método: Revisamos 20 casos de neurinomas diagnosticados entre los años 2000 y 2002 en los servicios de Otorrinolaringología y Neurocirugía de nuestro hospital a los que les hemos realizado videonistagmografía (VNG), y analizamos estadísticamente los hallazgos videonistagmográficos en relación con el tamaño tumoral y con el grado de hipoacusia. Discusión y conclusión: Revisamos la literatura médica al respecto y acordamos con ella en que la prueba calórica es la que con más frecuencia se altera (77 por ciento) en forma de hipo o arreflexia vestibular. (AU)

AIM: Schwannoma of the vestibular nerve represents 75% of all expansive processes affecting the pontocerebellosum angle. Hearing loss is the most frequent symptom at diagnosis (86%) with or without tinnitus, in the intracanalicular tumors. Vestibular symptoms are described in 60% of patients. MATERIAL AND METHOD: We study twenty cases of acoustic neuromas diagnosed between years 2000 and 2002 in both Otolaryngology and Neurosurgery Departments in our hospital. Videonystagmography (VNG) was performed in all of them. Videonystagmographic findings were analyzed statistically together with the tumoral size and hypoacusia level. DISCUSSION AND CONCLUSION: According to the medical literature reviewed for this paper, we conclude that caloric tests are the most frequently altered ones (77%), showing vestibular hyporreflexia or arreflexia (AU)

Michel Foucault y el MIR / Michael Foucault and residents

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[Non-benign paroxysmal positional vertigo]. / Vértigo posicional paroxístico no benigno.

Positional vertigo is a frequent clinical manifestation of vertigo of very different etiologies, being the benign paroxystic positional vertigo (BPPV) the most frequent one of them, representing in some series even the most found etiology of peripheral vertigo. Usually of severe entities, positional vertigo may appear in the context of severe entities and of difficult diagnosis. In these cases, the bearing of the symptoms in spite of the repositioning manoeuvers, the association with otological or neurological symptoms, and the atypical nystagmus evoked by Dix-Hallpike manoeuver, must take the otolaryngologist to suspect of a feasible non benign pathology. We report a case of positional paroxysmal vertigo caused by an intracranial tumour and we review the clinical signs that shoved help us to suspect of non benign pathologies that can mimic a positional vertigo.

[Neuroendocrine carcinoma of the nasal fossa. An independent entity?]. / Carcinoma neuroendocrino de fosa nasal. Una entidad independiente?

We present one case of a neuroendocrine carcinoma of nasal fossa and paranasal sinuses, of aggressive behavior, which has been controlled with chemo-radiotherapy after a double postsurgical recurrence. We do a literature revision emphasizing the anatomopathologic differentiation of these tumors with the olfactory neuroblastomas, and the therapeutic controversies in advanced stages.

[Kikuchi-Fujimoto's disease and the association with systemic lupus erythematosus]. / Enfermedad de Kikuchi-Fujimoto y su asociación a lupus eritematoso sistémico.

Kikuchi-Fujimoto's disease (KFD), Histiocytic Necrotizing lymphadenitis, is a rare self-limiting condition characterized by lymphadenopathy, fever and neutropenia. The aetiology of KFD is controversial, and its diagnosis is confirmed histologically. Although KFD has rarely been reported associated to Systemic lupus erythemotosus (SLE) should be ruled out given its different prognosis and management. We present the clinical, histological and evolution the two cases of patients with Kikuchi's disease; one case had evolution classic and the other case were associated with SLE.

Enfermedad de Kikuchi-Fujimoto y su asociación a lupus eritematoso sistémico / Kikuchi-Fujimoto's disease and its association with systemic lupus erytematosus

La enfermedad de Kikuchi-Fujimoto (EKF) o linfadenitis necrotizante histiocítica es una patología autolimitada que se caracteriza por linfadenopatías, fiebre y neutropenia entre otros síntomas. La etiología de la EKF es controvertida y será el estudio histológico el que proporcione el diagnóstico de confirmación. Aunque la EKF no es muy frecuente, se han publicado varios casos en los cuales se asocia a Lupus Eritematoso Sistémico (LES) lo cual se ha de tener presente, puesto que modifica tanto el pronostico como el manejo terapéutico de estos pacientes.Se presentan dos casos de enfermedad de Kikuchi: el primero de los casos presente una evolución clásica de la enfermedad, mientras que el segundo caso asoció un LES (AU)

[Tonsillectomy in adults. Our experience]. / Amigdalectomía en adultos. Nuestra experiencia.

Tosillectomy or palatine tonsils removal was by far as the very middle of the twenty century the commonest surgery in childhood, but owing to the abstinence behavior in past decades this operation has dropped considerabily and in consequence numerous grown up presents frequently tonsillar pathology requiring its removal in middle adult life.

[Cordectomy in the surgical treatment of tumors T1 of the vocal cords. Review of our cases (1974-1990)]. / La cordectomía en el tratamiento quirúrgico de los tumores T1 de cuerda vocal. Revisión de nuestra casuística (1974-1990).

We decided to review the results of cordectomy in our surroundings over the 22 years of existence of our Service. 631 clinic histories of patients undergoing surgery for laryngeal cancer in our Department, between 1974 and 1990, were reexamined, and from those selected 56 pertaining to T1 tumors treated with cordectomy. In this reduced group were studied epidemiology, clinical and pathologic data, complications, survival and death causes as well. The 58 considered were of male sex, middle aged (58-86) excepting 9 patients under 50. Their relation with tobacco eas clear, although less than in our general series (87.93% smokers). Of the 58 patients group 4 of then disappear during the 5 years follow-up term (8.62%). Three died: one from ganglion disease, other from local recurrence and the last one from other condition. In brief, global survival are accounted for 94.34% and the adjusted survival was 96.1%.

[Surgery of cancer of the larynx. Analysis of the results of our cases]. / Cirugía del cáncer de laringe. Análisis de resultados de nuestra casuística.

After 20 years of existence of this Department we decided to carry out a review of the characteristics of our series and also of the results of treatment, according to the protocol elaborated and followed in agreement with the Tumour Committee if the Hospital. 631 medical histories of patients diagnosed and operated for cancer of larynx between 1974 and 1990 were reviewed. 83 of which (13.154%) disappeared during the 5 year follow-up period. Epidemiological, clinical, location, extension and treatment fdata were considered as well as the survival results and a single descriptive statistical analysis performed. The mean age of our study was 59.02 years, showing a clear relation to exposure to tobacco (91.44% were smokers and 63.39% of more than 20 cigarettes per day). The predominant location of the growth was supraglottic (64.05% of cases) followed by glottic in 33.76%. The most frequently used surgical technique was the total laryngectomy and total and extended to either the pharynx or tongue basis in 76.28%, followed by supraglottic laryngectomy in 13m5%. The stages were rather advanced with predominance of stage III /40.60%) and stage IV (21.17%). Global survive rate of our series accounted for 68.61% while the adjusted survival rate was 71.4%.

[Acute epiglottitis in the adult. Retrospective study of 14 cases]. / Epiglotitis aguda del adulto. Análisis retrospectivo de 14 casos.

Acute epiglottitis instead of been a well recognised disease in children, is a rare condition in adult patients. Failure to diagnose epiglottitis early, in adults, undoubtedly contributes to its continuing mortality. We report our experience with acute epiglottitis in grown-up people with a retrospective series of 14 patients seen in our Department from 1993 to 1997. We comment about clinical features and therapeutic management of these patients.