Cribado de adenocarcinoma en el esófago de Barrett: ¿sí o no,cuándo y cómo?

Barrett's esophagus (BE) is the main recognized risk factor for the development of esophageal adenocarcinoma (EAC). The incidence of this cancer and its associated mortality has increased in developed countries during the last few years. Detection of EAC at earlier stages could potentially improve survival dramatically in these patients, which is especially important as mortality from EAC remains high despite the available treatments. Therefore, endoscopic surveillance is an attractive option for patients with Barrett's esophagus. Consequently, periodic endoscopic surveillance is recommended by all the International Gastroenterology Societies in an attempt to detect EAC at an early and potentially curable stage. Currently, the frequency of endoscopic surveillance and its need in Barrett's esophagus with low-grade dysplasia or without dysplasia are under discussion. This review presents the available evidence in order to assist clinicians in the decision-making process.     

Novedades en la epidemiología,la historia natural,el diagnóstico y el tratamiento del síndrome de apneas-hipopneas durante el sue?o

The following review summarises the most important articles published on sleep apnea-hypopnea syndrome (SAHS) during the current year. The analysis of the many factors implicated in the risk of cardiovascular diseases associated with SAHS is currently of great interest to the scientific community. There are many studies on this subject that demonstrate the role of inflammatory and immunological mediators, their relationship with endothelial damage and their influence in the genesis of cardiovascular disease in patients with SAHS. The role of CPAP in preventing this cardiovascular risk has had varied results. Although there is no evidence of benefit or harm in its use in heart failure, in cerebrovascular accidents SAHS has been confirmed as a predisposing factor and the reported increase in mortality would justify the intention to treat SAHS in these patients. Likewise, the reduction in blood pressure found with CPAP treatment could reduce the risk of cardio-cerebrovascular disease. The recent knowledge that there is expression of multiple phenotypes of SAHS gives a glimpse in the future of a disease based on different specific phenotypes, where the traditional symptomatology that defined the syndrome does not limit its treatment. To obtain a reliable and cost-effective diagnostic method that responds to the demands of the public health problem that is SAHS, particularly in sectors of the population that remain under-diagnosed and less well known, such as children, women and the elderly population is another one of the challenges reflected in published studies. In short, the growing knowledge on the biology of SAHS, its cardiovascular implications and its effect on the morbidity and mortality of the population will enable us to understand the true dimension of this disease in the next few years.     

¿Cuál es la utilidad del test de inhibidores de la bomba de protones en el dolor torácico no cardíaco?

Background and aims

Noncardiac chest pain (NCCP) often represents a diagnostic and therapeutic challenge. Given that gastroesophageal reflux disease (GERD) is the most common cause of NCCP, initial treatment with proton-pump inhibitors (PPI) has been proposed for all patients (PPI testing), reserving esophageal function testing solely for non-responders. The aim of the present study was to provide evidence on the clinical utility of PPI testing with high-dose pantoprazole in patients with NCCP.

Patients and methods

We carried out a study of diagnostic performance with a cohort design in patients with NCCP, who had been assessed by the Cardiology Service. All patients underwent upper endoscopy, esophageal manometry, and 24 h esophageal pH monitoring before PPI testing with pantoprazole 40 mg every 12 h for 1 month. Before and after treatment, we assessed the severity (intensity and frequency) of chest pain, quality of life, and anxiety and depression by means of specific questionnaires. The diagnosis of GERD was based on a pathological finding of esophageal pH monitoring. A positive response to PPI testing was defined as an improvement in chest pain > 50% compared with the baseline score after 1 month of PPI therapy.

Results

We included 30 consecutive patients (17 men/13 women) with a mean age of 49 years. Of these 30 patients, 20 with NCCP had GERD (67%, 95% CI: 47%-83%). A positive response to PPI therapy was observed in 13 of the 30 (43%) patients with NCCP: 11 of the 20 (55%) patients in the GERD-positive group and 2 of the 10 (20%) in the GERD-negative group. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PPI testing was 55%, 80%, 85%, 47% and 63%, respectively. A significant reduction in chest pain after pantoprazole therapy (P = .003) and a slight non significant improvement in anxiety and depression was achieved in the GERD-positive group as compared to the GERD-negative group.

Conclusions

In NCCP, PPI testing with pantoprazole has a low sensitivity for the diagnosis of GERD, placing in doubt the strategy of reserving functional study to non-responders to antisecretory therapy. Esophageal function testing and accurate diagnosis would allow appropriate targeted therapy for all patients with NCCP.     

Colonoscopia con insuflación de dióxido de carbono: ¿lujo o necesidad?

Colonoscopy is an essential diagnostic and therapeutic tool for many gastrointestinal diseases and is also a key element in the prevention and early diagnosis of colon cancer. Despite numerous technical advances, colonoscopy continues to be uncomfortable for patients, both during and after the procedure. To a large extent, the discomfort of colonoscopy depends on the need to distend the colon, which usually produces abdominal pain. Although ambient air is usually employed to expand and inflate the colon, in the last few years devices that allow carbon dioxide (CO₂) insufflation in colonoscopy have been developed. This gas is a highly attractive option for pain-free colonoscopy.     

¿Puede ser el tiempo de tránsito de pulso útil para detectar hipertensión arterial en pacientes remitidos a la unidad de sueño?

Introduction

Pulse transit time (PTT) is the time that a pulse wave takes to travel between two different arterial points, and may be useful in estimating blood pressure. This noninvasive technique, which does not add any cost to the procedure, offers the advantage of avoiding ‘arousals’ during sleep measurement as occurs with ambulatory blood pressure monitoring (ABPM). We aim to confirm the usefulness of PTT for the detection of hypertension, and to study the correlation between both measurements.

Methods

Prospective observational study in a multidisciplinary sleep unit. We recruited 30 consecutive patients attending a sleep clinic and ran a baseline polysomnography followed by an ABPM the following day. Average systolic and diastolic blood pressure (SBP, DBP) by PTT were calculated and compared with ABMP results. In accordance with international guidelines, patients with mean nocturnal ABMP ≥ 120/70 mmHg were diagnosed as having arterial hypertension.

Results

Mean age of 60 years; 66% male, 80% suffered from sleep apnoea (OSAS). Taking the ABPM as the reference technique, we found that the diagnostic sensitivity of PTT is 85% with a specificity of 88% in the case of SBP, with a positive predictive value of 85% and negative predictive value of 88%. By studying the relationship between mean SBP measured by ABPM and PTT, we found a linear correlation coefficient (R) of 0.88, showing a distribution of all subjects with a difference of between ± 15 mmHg between tests. There is also a positive correlation between mean DBP measured for the two tests, with a weaker linear correlation.

Conclusions

Pulse transit time shows a strong correlation with blood pressure (measured by ABPM). PTT provides continuous, non-invasive, cuffless blood pressure monitoring free of additional cost and could be an alternative for screening hypertension.     

¿Por qué miramos el asma a través del ojo de la cerradura?

As happens with the rest of pathology, the study of asthma has been traditionally conducted from postulates set by reductionist science. That model still provides answers to theoretical and practical questions that establish diseases, but does not offer us a complete view of their complexity and multidimensionality. To overcome this limitation has emerged medicine directed towards systems based on the application of biological systems concepts and tools. Biological systems is a cross-disciplinary strategy which, from the data generated by the “-omic” sciences, helps to relate the elements of an organism or biological system, to understand the properties arising from the same and to generate mathematical models capable of predicting their dynamic behaviour. The application of biological systems to asthma starts is starting to make ground. The main challenge today is to understand the need to change focus. The starting point is to abandon the idea that asthma is exclusively an airways disease and considering that the whole lung is involved and, even more, the possibility that it is, at least in part, a systemic process. In view of our current limitations, to understand asthma and design personalised treatment strategies for each patient, requires thinking of systems medicine.     

Tratamiento invasivo del síndrome coronario agudo sin elevación del segmento ST: ¿cateterismo cardiaco/revascularización en todos los casos?

Patients admitted to hospital with symptoms and signs of non–ST-segment elevation acute coronary syndromes have different risk profiles and are in need of an individualized approach that takes into consideration not only age and sex but also comorbidities such as diabetes, renal failure, hypertension, heart failure, peripheral artery disease, earlier revascularization, etc. According to evidence-based medicine and as documented in current guidelines, there is currently evidence for early catheterization and, if feasible, revascularization in high-risk patients, especially in men. Nevertheless, because of a lack of definitive evidence, there is uncertainty about treating women in the same way. Because women are usually older and have more comorbidities, they are frailer and revascularization should be indicated with greater caution. There is no evidence that catheterization as such is worse for women than for men; however, for both men and women with low risk, a less invasive approach, such as coronary computed tomography angiography, could be considered as a first diagnostic tool.