Artículos recomendados

Blood pressure is a potent determinant of cardiovascular risk, but the most appropriate targets for blood-pressure lowering have long been debated. Observational studies with a low risk of confounding have shown a linear relationship between blood pressure and cardiovascular risk down to 115/75 mm Hg, but some observational studies with a greater potential for confounding, involving persons at increased risk, have suggested a J-shaped curve — that is, below a given blood pressure, risk would increase. When trials of blood-pressure–lowering drugs have shown benefits in patients without hypertension, these effects have often been ascribed to alternative mechanisms. The widespread uncertainty about blood-pressure targets was increased when the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial showed no significant overall difference in cardiovascular events between patients with type 2 diabetes assigned to a systolic blood-pressure target of less than 120 mm Hg and those assigned to a target of less than 140 mm Hg.

Citado: Perkovic V, Rodgers A. Redefining Blood-Pressure Targets–SPRINT Starts the Marathon. N Engl J Med [Internet]. 2015 [citado 7 Nov 2017];373(22).

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Chronic obstructive pulmonary disease (COPD) is a heterogeneous syndrome defined by the presence of chronic airflow limitation and associated with other clinical and pathological hallmarks, such as chronic bronchitis, emphysema, exacerbations, and comorbidities. COPD is a complex disease, suggesting that both genetic susceptibility and environmental exposures (eg, cigarette smoking and smoke from biomass fuels) contribute to its pathogenesis (figure). In The Lancet Respiratory Medicine, Louise Wain and colleagues report intriguing novel insights into the genetics of smoking behaviour and the airflow obstruction component of COPD.

Citado: Brusselle GG, Bracke KR. Elucidating COPD pathogenesis by large-scale genetic analyses. Lancet Respir Med [Internet]. 2015 [citado 7 Nov 2017];3(10).

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In their review on invasive candidiasis, Kullberg and Arendrup (Oct. 8 issue) raise the question of what is the most appropriate initial antifungal therapy for patients who have previously been exposed to echinocandins for prolonged periods. The authors state that triazoles may be the preferred agent in such cases. Recent epidemiologic data show a shift in the distribution of candida species, with a significant increase in Candida glabrata, a species that is more likely to be resistant to azoles and the most common species resistant to fluconazole. Furthermore, prior exposure to echinocandins has also been shown to promote not only resistance to these agents but also multidrug resistance, defined as candida resistant to fluconazole and one or more echinocandins. Thus, for patients with previous antifungal selection pressure, triazoles may not be the most appropriate first-line treatment. Liposomal amphotericin B, which has a broad spectrum of activity, may be a better choice as an empirical therapy in this clinical setting.

Frederic M. Jacobs, M.D.
Hôpital Antoine-Béclère, Clamart, France

Citado: Kullberg BJ, Arendrup MC. Invasive Candidiasis. N Engl J Med [Internet]. 2016 [citado 7 Nov 2017];374(8).

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Abstract: Several studies point towards alteration in gut microbiota composition and function in coeliac disease, some of which can precede the onset of disease and/or persist when patients are on a gluten-free diet. Evidence also exists that the gut microbiota might promote or reduce coeliac-disease-associated immunopathology. However, additional studies are required in humans and in mice (using gnotobiotic technology) to determine cause-effect relationships and to identify agents for modulating the gut microbiota as a therapeutic or preventative approach for coeliac disease. In this Review, we summarize the current evidence for altered gut microbiota composition in coeliac disease and discuss how the interplay between host genetics, environmental factors and the intestinal microbiota might contribute to its pathogenesis. Moreover, we highlight the importance of utilizing animal models and long-term clinical studies to gain insight into the mechanisms through which host-microbial interactions can influence host responses to gluten.

Citado: Verdu EF, Galipeau HJ, Jabri B. Novel players in coeliac disease pathogenesis: role of the gut microbiota. Nat Rev Gastroenterol Hepatol [Internet]. 2015 [citado 7 Nov 2017];12(9).

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Abstract: Palliative care is the interdisciplinary specialty focused on improving quality of life for persons with serious illness and their families. Over the past decade, the field has undergone substantial growth and change, including an expanded evidence base, new care-delivery models, innovative payment mechanisms, and increasing public and professional awareness.

Citado: Kelley AS, Morrison RS. Palliative Care for the Seriously Ill. N Engl J Med. 2015 Aug 20;373(8).

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The natural history of tuberculosis begins with the inhalation of Mycobacterium tuberculosis organisms; a period of bacterial replication and dissemination ensues, followed by immunologic containment of viable bacilli. The result of this process is asymptomatic latent tuberculosis infection, which is defined as a state of persistent bacterial viability, immune control, and no evidence of clinically manifested active tuberculosis. Currently, it is not possible to directly diagnose M. tuberculosis infection in humans; therefore, latent tuberculosis infection is diagnosed by response to in vivo or in vitro stimulation by M. tuberculosis antigens with the use of the tuberculin skin test or interferon-γ release assays (IGRAs). Studies suggest that active tuberculosis will develop in 5 to 15% of persons with latent infection during their lifetimes (and a higher percentage if the persons are immunocompromised); thus, persons with latent infection serve, according to Osler, as the “seedbeds” of tuberculosis in the community. This article will review the pathogenesis, epidemiology, diagnosis, and treatment of latent tuberculosis infection. It will address critical gaps in the understanding of this complex condition and propose the necessary research agenda.

Citado: Getahun H, Chaisson RE, Raviglione M. Latent Mycobacterium tuberculosis Infection. N Engl J Med. 2015 Sep 17;373(12)

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