Luis González-de Paz

Utilidad de la ecografía portátil en el cribado del aneurisma de aorta abdominal y de la ateromatosis de aorta abdominal

BACKGROUND AND OBJECTIVE To determine the prevalence of abdominal aortic aneurysm (AAA) and abdominal aortic atheromatosis (AA-At) using a hand-held ultrasound by a general practitioner in the public Primary Health Care system. PATIENTS AND METHOD Pilot study that prospectively studied a cohort of men over 50 years with cardiovascular risk factors: active smokers, former smokers, or hypertensive patients, attended in primary health care center. The general practitioner completed an ultrasonography training in an Ultrasound Unit under supervision of experienced radiologists using an standard ultrasound equipment and hand-held ultrasound (VScan(®), General Electric, USA). One hundred and six patients participated in the study and all imaging data recorded were blindly evaluated by a radiologist in order to establish the concordance in the interpretation of images between general practitioner and radiologist. The kappa index was calculated to study the agreement on the presence or absence of AAA and AA-At. RESULTS We observed a prevalence of 5.88% of AAA. Kappa index for concordance in AAA diagnosis was absolute (κ = 1.0), with a sensitivity and specificity of 100%. Otherwise, the general practitioner identified 59 patients (58.4%) with AA-At, while radiologist identified 39 (38.6%) in the image review, with moderate concordance (κ = .435), sensitivity 89.74% and specificity 57.14%. Hypercholesterolemia (odds ratio [OR] 2.61; 95% confidence interval [95% CI] 0.92-7.39) and diabetes mellitus (OR 3.35; 95%CI 0.89-12.55) were independent risk factors for AA-At development in logistic regression. CONCLUSIONS After an adequate training in ultrasonography, hand-held ultrasound is a useful tool for AAA screening in Primary Care. Its simplicity, security, validity, cost-effectiveness and acceptance by the general population, makes it a feasible tool for cardiovascular risk assessment.

Differential Methylation of TCF7L2 Promoter in Peripheral Blood DNA in Newly Diagnosed, Drug-Naïve Patients with Type 2 Diabetes

TCF7L2 is the susceptibility gene for Type 2 diabetes (T2D) with the largest effect on disease risk that has been discovered to date. However, the mechanisms by which TCF7L2 contributes to the disease remain largely elusive. In addition, epigenetic mechanisms, such as changes in DNA methylation patterns, might have a role in the pathophysiology of T2D. This study aimed to investigate the differences in terms of DNA methylation profile of TCF7L2 promoter gene between type 2 diabetic patients and age- and Body Mass Index (BMI)- matched controls. We included 93 type 2 diabetic patients that were recently diagnosed for T2D and exclusively on diet (without any pharmacological treatment). DNA was extracted from whole blood and DNA methylation was assessed using the Sequenom EpiTYPER system. Type 2 diabetic patients were more insulin resistant than their matched controls (mean HOMA IR 2.6 vs 1.8 in controls, P<0.001) and had a poorer beta-cell function (mean HOMA B 75.7 vs. 113.6 in controls, P<0.001). Results showed that 59% of the CpGs analyzed in TCF7L2 promoter had significant differences between type 2 diabetic patients and matched controls. In addition, fasting glucose, HOMA-B, HOMA-IR, total cholesterol and LDL-cholesterol correlated with methylation in specific CpG sites of TCF7L2 promoter. After adjustment by age, BMI, gender, physical inactivity, waist circumference, smoking status and diabetes status uniquely fasting glucose, total cholesterol and LDL-cholesterol remained significant. Taken together, newly diagnosed, drug-naïve type 2 diabetic patients display specific epigenetic changes at the TCF7L2 promoter as compared to age- and BMI-matched controls. Methylation in TCF7L2 promoter is further correlated with fasting glucose in peripheral blood DNA, which sheds new light on the role of epigenetic regulation of TCF7L2 in T2D.

Abdominal aortic aneurysm screening program using hand-held ultrasound in primary healthcare

We determined the feasibility of abdominal aortic aneurysm (AAA) screening program led by family physicians in public primary healthcare setting using hand-held ultrasound device. The potential study population was 11,214 men aged ≥ 60 years attended by three urban, public primary healthcare centers. Participants were recruited by randomly-selected telephone calls. Ultrasound examinations were performed by four trained family physicians with a hand-held ultrasound device (Vscan®). AAA observed were verified by confirmatory imaging using standard ultrasound or computed tomography. Cardiovascular risk factors were determined. The prevalence of AAA was computed as the sum of previously-known aneurysms, aneurysms detected by the screening program and model-based estimated undiagnosed aneurysms. We screened 1,010 men, with mean age of 71.3 (SD 6.9) years; 995 (98.5%) men had normal aortas and 15 (1.5%) had AAA on Vscan®. Eleven out of 14 AAA-cases (78.6%) had AAA on confirmatory imaging (one patient died). The total prevalence of AAA was 2.49% (95%CI 2.20 to 2.78). The median aortic diameter at diagnosis was 3.5 cm in screened patients and 4.7 cm (p<0.001) in patients in whom AAA was diagnosed incidentally. Multivariate logistic regression analysis identified coronary heart disease (OR = 4.6, 95%CI 1.3 to 15.9) as the independent factor with the highest odds ratio. A screening program led by trained family physicians using hand-held ultrasound was a feasible, safe and reliable tool for the early detection of AAA.

Gastric Inhibitory Polypeptide Receptor Methylation in Newly Diagnosed, Drug-Naïve Patients with Type 2 Diabetes: A Case-Control Study

GIP action in type 2 diabetic (T2D) patients is altered. We hypothesized that methylation changes could be present in GIP receptor of T2D patients. This study aimed to assess the differences in DNA methylation profile of GIPR promoter between T2D patients and age- and Body Mass Index (BMI)-matched controls. We included 93 T2D patients (cases) that were uniquely on diet (without any anti-diabetic pharmacological treatment). We matched one control (with oral glucose tolerance test negative, non diabetic), by age and BMI, for every case. Cytokines and hormones were determined by ELISA. DNA was extracted from whole blood and DNA methylation was assessed using the Sequenom EpiTYPER system. Our results showed that T2D patients were more insulin resistant and had a poorer β cell function than their controls. Fasting adiponectin was lower in T2D patients as compared to controls (7.0±3.8 µgr/mL vs. 10.0±4.2 µgr/mL). Levels of IL 12 in serum were almost double in T2D patients (52.8±58.3 pg/mL vs. 29.7±37.4 pg/mL). We found that GIPR promoter was hypomethylated in T2D patients as compared to controls. In addition, HOMA-IR and fasting glucose correlated negatively with mean methylation of GIPR promoter, especially in T2D patients. This case-control study confirms that newly diagnosed, drug-naïve T2D patients are more insulin resistant and have worse β cell function than age- and BMI-matched controls, which is partly related to changes in the insulin-sensitizing metabolites (adiponectin), in the proinflammatory profile (IL12) and we suggest in the methylation pattern of GIPR. Our study provides novel findings on GIPR promoter methylation profile which may improve our ability to understand type 2 diabetes pathogenesis.

Alfabetización en salud en pacientes con insuficiencia cardiaca atendidos en atención primaria

Resumen Objetivos Examinar el nivel de alfabetización en salud y los factores que la condicionan en pacientes con insuficiencia cardiaca visitados en atención primaria. Diseño Estudio transversal multicéntrico. Emplazamiento Diez centros de atención primaria del área metropolitana de Barcelona. Participantes Pacientes con diagnóstico de insuficiencia cardiaca. Criterios de inclusión: visita al centro de salud en el último año, desplazarse al centro de manera autónoma y acceder a participar voluntariamente. Mediciones principales Cuestionarios Health Literacy Survey — European Union (HLS-EU-Q) y versión española de la Escala Europea de Autocuidado en Insuficiencia Cardiaca (EHFScBS). Se analizó la relación entre ambas escalas y variables sociodemográficas y clínicas mediante el test de ANOVA y un modelo de regresión lineal múltiple. Resultados Se incluyeron 318 pacientes (51,2% mujeres), con una media de edad de 77,9 ± 8,7 años. El índice de alfabetización en salud del 79,6% (n = 253) de los participantes fue de competencia insuficiente para comprender la información de salud. Los factores que explicaron la alfabetización en salud fueron el nivel académico (p < 0,001), la clasificación funcional de insuficiencia cardiaca (p = 0,032), los autocuidados y la edad (p < 0,04). El nivel académico explicaba el 61,6% del nivel de alfabetización (IC 95% bootstrap: 44,58%; 46,75%). Conclusiones La alfabetización en salud permite explicar la actitud de los pacientes hacia el régimen terapéutico que requiere la insuficiencia cardiaca. En los pacientes con insuficiencia cardiaca, los médicos y enfermeras de atención primaria han de tener en cuenta los factores que facilitan la comprensión de la información de salud.

Descripción de dos casos de herida, con diferente etiología, tratadas mediante terapia larval desbridante

This paper describes two cases of wounds with different aetiology and dissimilar size which were treated with Larval Debridement Therapy. Two different techniques of Larval Debridement were used for each case: Free Range and BioFoam larvae. Observations and treatment were carried out in a Primary Health Centre in Barcelona, Spain. The application and observations were performed by two nurses with the collaboration of two family physicians. The Larval Therapy efficacy outcome was checked with an Ulcer Reverse Stage Scale (PUSH v2), by taking photographs and a Visual Analogue Pain Scale (VAPS) was completed by both subjects before and after the treatment. It was observed in both cases that the larval therapy caused debridement of all fibrin and collagen tissue, and the slough dropped to a normal level. As a consequence of this change the PUSH scale punctuations were improved. On the negative side, the therapy was associated with an increase in pain. The beneficial effect of applying Larval Therapy enables following a basic wound healing care plan. The larval debridement therapy did not pose any threat for the patients; they could go about their Activities of the Daily Life (ADL) without any change. These wound cases treated with larval debridement therapy are the first ones reported in the Primary Health Care field in Spain.