Artículos recomendados

Abstract: Both genetic and lifestyle factors contribute to individual-level risk of coronary artery disease. The extent to which increased genetic risk can be offset by a healthy lifestyle is unknown. METHODS: Using a polygenic score of DNA sequence polymorphisms, we quantified genetic risk for coronary artery disease in three prospective cohorts – 7814 participants in the Atherosclerosis Risk in Communities (ARIC) study, 21,222 in the Women’s Genome Health Study (WGHS), and 22,389 in the Malmö Diet and Cancer Study (MDCS) – and in 4260 participants in the cross-sectional BioImage Study for whom genotype and covariate data were available. We also determined adherence to a healthy lifestyle among the participants using a scoring system consisting of four factors: no current smoking, no obesity, regular physical activity, and a healthy diet. Leer más…

Resumen: La «presentación de casos» (case-report) ha sido una tradición en medicina clínica de larga data, así como una de las vías más motivantes de compartir experiencias con otros colegas y para transmitir conocimientos y habilidades a los educandos. A ello se unen los beneficios inmediatos que representan para la atención médica con calidad de los enfermos, que contribuyen a mejorar las relaciones humanas y profesionales y despiertan un sentimiento de satisfacción en los que participan, pues se intercambian informaciones, opiniones, experiencias y sugerencias siempre muy gratificantes. Sin embargo, en las últimas décadas, la moda de las actualizaciones, las revisiones sistemáticas, los temas relacionados con la medicina basada en la evidencia, las guías de práctica clínica, los protocolos y los resultados de diversos tipos de investigaciones en el campo de la clínica llevadas a cabo con diseños complejos y la aplicación de métodos estadísticos complicados -todos asuntos de interés y que se deben tener en cuenta-, han venido a ocupar buena parte del espacio que antes se dedicaba a las presentaciones de casos en diversas revistas médicas. Leer más…

A 63-year-old woman presents with a 1-year history of a chronic dry cough, associated with a sensation of “irritation” in the throat. Prolonged bouts of coughing are associated with stress urinary incontinence and occasionally end with retching and vomiting. The cough is triggered by changes in temperature, strong smells (e.g., the smell of cleaning products), laughing, and prolonged talking. She has no notable medical history, reports being otherwise well, and does not smoke. She has been prescribed a bronchodilator and inhaled and nasal glucocorticoids, but has had no benefit from any of these. The results of a physical examination, chest radiography, and spirometry are normal. How would you further evaluate and manage this condition?

Citado: Smith JA, Woodcock A. Chronic Cough. N Engl J Med [Internet]. 2016 [citado 7 Nov 2017];375(16).

The incidence of cholangiocarcinoma in the general population is low; nevertheless, patients with primary sclerosing cholangitis face a lifetime risk of cholangiocarcinoma that is as high as 10%.1 Lazaridis and LaRusso (Sept. 22 issue)2 suggest the use of endoscopic retrograde cholangiopancreatography (ERCP)–guided cytobrushing of the bile duct for cytologic and fluorescence in-situ hybridization (FISH) analysis when strictures in the biliary system predominate, since in these cases the exclusion of cancer is mandatory but can be extremely challenging when noninvasive radiologic imaging is used. Both cytologic analysis and FISH have dismal positive and negative predictive values — 50% and 83%, respectively, for cytologic analysis and 86% and 88% for FISH.3. The use of new endoscopic techniques, such as ERCP-guided single-operator peroral cholangioscopy (SOPC) and probe-based confocal laser endomicroscopy (pCLE), may increase the positive predictive value (to 100% and 82%, respectively) and the negative predictive value (to 95% and 100%) in affected patients with indeterminate dominant strictures. Leer más…

Randomized clinical trials serve as the standard for clinical research and have contributed immensely to advances in patient care. Nevertheless, several shortcomings of randomized clinical trials have been noted, including the need for a large sample size and long study duration, the lack of power to evaluate efficacy overall or in important subgroups, and cost. These and other limitations have been widely acknowledged as limiting medical innovation.1 Adaptive trial design has been proposed as a means to increase the efficiency of randomized clinical trials, potentially benefiting trial participants and future patients while reducing costs and enhancing the likelihood of finding a true benefit, if one exists, of the therapy being studied.

Citado: Bhatt DL, Mehta C. Adaptive Designs for Clinical Trials. N Engl J Med [Internet]. 2016 [citado 7 Nov 2017];375(1).

Over the past 70 years, randomized, controlled trials (RCTs) have reshaped medical knowledge and practice. Popularized by mid-20th-century clinical researchers and statisticians aiming to reduce bias and enhance the accuracy of clinical experimentation, RCTs have often functioned well in that role. Yet the past seven decades also bear witness to many limitations of this new “gold standard.” The scientific and political history of RCTs offers lessons regarding the complexity of medicine and disease and the economic and political forces that shape the production and circulation of medical knowledge.

Citado: Bothwell LE, Greene JA, Podolsky SH, Jones DS. Assessing the Gold Standard– Lessons from the History of RCTs. N Engl J Med [Internet]. 2016 [citado 7 Nov 2017];374(22).

¿Qué es lo que los médicos ofrecen (y ofrecerán en el futuro) que no puede ser brindado por otros profesionales de la salud? Esa interrogante la lanzaba un comentario editorial del British Medical Journal a lo que, también respondía: “Diagnóstico, diagnóstico, diagnóstico”. Un enfermero pudiera trasplantar un corazón un día, un técnico anestesiar a un paciente y un farmacéutico controlar un tratamiento medicamentoso complejo. Pero siempre se necesitarán médicos para que hagan diagnósticos.
Por otra parte, para actividades de gran importancia en nuestro sector, como las de promoción de salud, prevención y rehabilitación, tampoco los médicos siempre tienen el papel protagónico y, en ocasiones, no son imprescindibles. Leer más…

Abstract: Women with gestational diabetes mellitus (GDM) are at risk of developing type 2 diabetes, but individualised risk estimates are unknown. We conducted a meta-analysis to quantify the risk of progression to type 2 diabetes for women with GDM. Methods: We systematically searched the major electronic databases with no language restrictions. Two reviewers independently extracted 2 × 2 tables for dichotomous data and the means plus SEs for continuous data. Risk ratios were calculated and pooled using a random effects model.
Results: There were 39 relevant studies (including 95,750 women) BMI (RR 1.95 [95% CI 1.60, 2.31]), family history of diabetes (RR 1.70 [95% CI 1.47, 1.97]), non-white ethnicity (RR 1.49 [95% CI 1.14, 1.94]) and advanced maternal age (RR 1.20 [95% CI 1.09, 1.34]) were associated with future risk of type 2 diabetes. Leer más…

Resumen: Las descripciones originales de las enfermedades que realizan los médicos, cuyo epónimo usamos a diario, no dejan de ser magníficas observaciones clínicas hechas a través del tiempo por destacadas personalidades incluidas en la historia de la medicina. Se abordan los epónimos médicos en el campo de la Reumatología. En publicaciones de los últimos años, existen contradicciones entre los que están a favor o en contra de los epónimos médicos. Estar al lado de los que pretenden mantenerlos o no invita a reflexiones en el presente artículo. Motivar a la búsqueda de otros cientos, enriquecería el conocimiento, tanto de estudiantes, como de profesionales. Honor a quienes honor merecen.

Citado: Serra Valdés MÁ. Los epónimos médicos y la reumatología. Revista Cubana de Reumatología [Internet]. 2016 [citado 7 Nov 2017];18(1).

Abstract: Objective To assess the effect of antihypertensive treatment on mortality and cardiovascular morbidity in people with diabetes mellitus, at different blood pressure levels. Design Systematic review and meta-analyses of randomised controlled trials. Data sources CENTRAL, Medline, Embase, and BIOSIS were searched using highly sensitive search strategies. When data required according to the protocol were missing but trials were potentially eligible, we contacted researchers, pharmaceutical companies, and authorities.
Eligibility criteria Randomised controlled trials including 100 or more people with diabetes mellitus, treated for 12 months or more, comparing any antihypertensive agent against placebo, two agents against one, or different blood pressure targets. Leer más…

Warkentin (Aug. 13 issue) highlights the misconception that all cases of ischemic limb gangrene are associated with the loss of an arterial pulse and presents the two syndromes associated with disseminated intravascular coagulation in which ischemic limb gangrene can occur with a pulse. However, in so doing, he may have created another misconception — the idea that ischemic limb gangrene with pulses is related to syndromes associated with disseminated intravascular coagulation. It is important to recognize that ischemic limb gangrene with pulses can occur without associated disseminated intravascular coagulation, as it does in calcific uremic arteriolopathy (calciphylaxis) and cholesterol embolization (atheroembolism). Leer más…