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Vascular disease is currently a major health problem, not only for its high prevalence but also for the considerable morbidity, mortality and disability that it entails. Medical internists play a central role in diagnosing and treating vascular disease and controlling the cardiovascular risk factors (CRFs) that cause it. In fact, the clinical care of patients in cardiovascular risk units is a specific characteristic of an internist’s field of action. This article contains the consensus document for the training of residents in CRFs. This proposal by the Cardiovascular Risk Workgroup of the Spanish Society of Internal Medicine emerged as a response by our society to the specific need for training in CRFs. Implementing this proposal would provide an important benefit, not only for medical internists in training but also for society as a whole.

Grupo de Trabajo de Riesgo Vascular de la SEMI., [ES ]En la actualidad la enfermedad vascular constituye un problema de salud de primer orden, no solo por su elevada prevalencia, sino también por la gran morbimortalidad y discapacidad que conlleva. El médico internista juega un papel central en el diagnóstico y tratamiento de la enfermedad vascular, así como en el control de los factores de riesgo vascular (RV) que la causan. De hecho, dentro del campo de acción del internista figura específicamente la atención clínica a enfermos en unidades de RV. En este artículo se recoge el documento de consenso para la formación de residentes en RV. Esta propuesta del Grupo de Trabajo de Riesgo Vascular de la Sociedad Española de Medicina Interna surge como respuesta de nuestra Sociedad a una necesidad específica formativa en RV. Pensamos que su implantación supondrá un beneficio importante, no solo para el médico internista en formación, sino también para la sociedad en su conjunto., [EN] Vascular disease is currently a major health problem, not only for its high prevalence but also for the considerable morbidity, mortality and disability that it entails. Medical internists play a central role in diagnosing and treating vascular disease and controlling the cardiovascular risk factors (CRFs) that cause it. In fact, the clinical care of patients in cardiovascular risk units is a specific characteristic of an internist's field of action. This article contains the consensus document for the training of residents in CRFs. This proposal by the Cardiovascular Risk Workgroup of the Spanish Society of Internal Medicine emerged as a response by our Society to the specific need for training in CRFs. Implementing this proposal would provide an important benefit, not only for medical internists in training but also for society as a whole.

Summary Background Elevated proinflammatory cytokines are associated with greater COVID-19 severity. We aimed to assess safety and efficacy of sarilumab, an interleukin-6 receptor inhibitor, in patients with severe (requiring supplemental oxygen by nasal cannula or face mask) or critical (requiring greater supplemental oxygen, mechanical ventilation, or extracorporeal support) COVID-19. Methods We did a 60-day, randomised, double-blind, placebo-controlled, multinational phase 3 trial at 45 hospitals in Argentina, Brazil, Canada, Chile, France, Germany, Israel, Italy, Japan, Russia, and Spain. We included adults (≥18 years) admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and pneumonia, who required oxygen supplementation or intensive care. Patients were randomly assigned (2:2:1 with permuted blocks of five) to receive intravenous sarilumab 400 mg, sarilumab 200 mg, or placebo. Patients, care providers, outcome assessors, and investigators remained masked to assigned intervention throughout the course of the study. The primary endpoint was time to clinical improvement of two or more points (seven point scale ranging from 1 [death] to 7 [discharged from hospital]) in the modified intention-to-treat population. The key secondary endpoint was proportion of patients alive at day 29. Safety outcomes included adverse events and laboratory assessments. This study is registered with ClinicalTrials.gov, NCT04327388; EudraCT, 2020-001162-12; and WHO, U1111-1249-6021. Findings Between March 28 and July 3, 2020, of 431 patients who were screened, 420 patients were randomly assigned and 416 received placebo (n=84 [20%]), sarilumab 200 mg (n=159 [38%]), or sarilumab 400 mg (n=173 [42%]). At day 29, no significant differences were seen in median time to an improvement of two or more points between placebo (12·0 days [95% CI 9·0 to 15·0]) and sarilumab 200 mg (10·0 days [9·0 to 12·0]; hazard ratio [HR] 1·03 [95% CI 0·75 to 1·40]; log-rank p=0·96) or sarilumab 400 mg (10·0 days [9·0 to 13·0]; HR 1·14 [95% CI 0·84 to 1·54]; log-rank p=0·34), or in proportions of patients alive (77 [92%] of 84 patients in the placebo group; 143 [90%] of 159 patients in the sarilumab 200 mg group; difference −1·7 [−9·3 to 5·8]; p=0·63 vs placebo; and 159 [92%] of 173 patients in the sarilumab 400 mg group; difference 0·2 [−6·9 to 7·4]; p=0·85 vs placebo). At day 29, there were numerical, non-significant survival differences between sarilumab 400 mg (88%) and placebo (79%; difference +8·9% [95% CI −7·7 to 25·5]; p=0·25) for patients who had critical disease. No unexpected safety signals were seen. The rates of treatment-emergent adverse events were 65% (55 of 84) in the placebo group, 65% (103 of 159) in the sarilumab 200 mg group, and 70% (121 of 173) in the sarilumab 400 mg group, and of those leading to death 11% (nine of 84) were in the placebo group, 11% (17 of 159) were in the sarilumab 200 mg group, and 10% (18 of 173) were in the sarilumab 400 mg group. Interpretation This trial did not show efficacy of sarilumab in patients admitted to hospital with COVID-19 and receiving supplemental oxygen. Adequately powered trials of targeted immunomodulatory therapies assessing survival as a primary endpoint are suggested in patients with critical COVID-19. Funding Sanofi and Regeneron Pharmaceuticals.

Patients with subaneurysmal aortic dilation (SAD, 25&ndash, 29 mm diameter) are likely to progress to true abdominal aortic aneurysm (AAA). Despite these patients having a higher risk of all-cause mortality than subjects with aortic size &lt, 24 mm, early diagnostic biomarkers are lacking. MicroRNAs (miRs) are well-recognized potential biomarkers due to their differential expression in different tissues and their stability in blood. We have investigated whether a plasma miRs profile could identify the presence of SAD in high cardiovascular risk patients. Using qRT-PCR arrays in plasma samples, we determined miRs differentially expressed between SAD patients and patients with normal aortic diameter. We then selected 12 miRs to be investigated as biomarkers by construction of ROC curves. A total of 82 significantly differentially expressed miRs were found by qPCR array, and 12 were validated by qRT-PCR. ROC curve analyses showed that seven selected miRs (miR-28-3p, miR-29a-3p, miR-93-3p, miR-150-5p, miR-338-3p, miR-339-3p, and miR-378a-3p) could be valuable biomarkers for distinguishing SAD patients. MiR-339-3p showed the best sensitivity and specificity, even after combination with other miRs. Decreased miR-339-3p expression was associated with increased aortic abdominal diameter. MiR-339-3p, alone or in combination with other miRs, could be used for SAD screening in high cardiovascular risk patients, helping to the early diagnosis of asymptomatic AAA.

Inhibitors of the protein PCSK9, available since 2015, are capable of reducing the concentration of low density lipoprotein cholesterol by 40 to 70%, thus reducing the cardiovascular risk. The present case reports an adverse cardiovascular event that appeared when spacing out the administration of lipid-lowering treatment. A discussion will be presented on the importance of maintaining low cholesterol levels in order to achieve a greater benefit, according to the latest published clinical studies.

Inhibitors of the protein PCSK9, available since 2015, are capable of reducing the concentration of low density lipoprotein cholesterol by 40–70%, thus reducing the cardiovascular risk. The present case reports an adverse cardiovascular event that appeared when spacing out the administration of lipid-lowering treatment. A discussion will be presented on the importance of maintaining low cholesterol levels in order to achieve a greater benefit, according to the latest published clinical studies.

Background To determine the prevalence of abdominal aortic aneurysm (AAA) (arterial diameter ≥30 mm), in patients with high or very high cardiovascular risk (CVR) and to evaluate their clinical features. Patients and methods Observational, cross-sectional and multicentric study conducted in Spanish Internal Medicine Services. We enrolled men with age >55 years and women >65 years who had a high or very high CVR. Results The study included 659 patients. The prevalence of AAA was 8% (53 patients). 76.9% were male with a mean age of 71 ± 8.7 years. The multivariate analysis showed an association between AAA and age (OR: 1.06; 95% CI: 1.02–1.1; P Conclusions The prevalence of AAA in patients with high CVR is high. Ultrasound screening can be performed by general practitioners. Men >65 years with elevated CVR could benefit, particularly in the presence of active smoking or peripheral arterial disease.

Resumen Objetivo Determinar la prevalencia de aneurisma de aorta abdominal (AAA), definido por un diametro arterial ≥ 30 mm, en pacientes con alto o muy alto riesgo cardiovascular (RCV) y evaluar sus caracteristicas clinicas. Pacientes y metodos Estudio observacional, transversal y multicentrico realizado en servicios de Medicina Interna del pais a varones con edad > 55 anos y mujeres > 65 anos que tenian un RCV alto o muy alto reclutados durante 24 meses. Resultados Se incluyeron 659 pacientes. La prevalencia de AAA fue del 8% (53 pacientes). El 76,9% fueron varones, con edad media de 71 ± 8,7 anos. El analisis multivariante demostro asociacion entre AAA y la edad (OR: 1,06; IC 95%: 1,02-1,1; p Conclusiones La prevalencia de AAA en pacientes de alto RCV es elevada. El cribado ecografico puede ser realizado por medicos generalistas. Pueden beneficiarse de un cribado oportunista los varones de mas de 65 anos, con RCV elevado, especialmente si presentan tabaquismo activo o arteriopatia periferica.

Many patients with familial hypercholesterolaemia (FH) or in secondary prevention situations and with statin intolerance do not achieve LDL-C targets, and require treatment with PCSK9 inhibitors (iPCSK9) and ezetimibe. The case is presented on a patient with FH and total intolerance to statins. Treatment with iPCSK9 and ezetimibe failed to achieve her LDL-C target. A compound with red yeast rice derivatives containing 3 mg of monacolin K was added, with good therapeutic compliance, and a very good control of LDL-C. The addition of red yeast rice derivatives containing low doses of monacolin K, together with IPCSK9 in patients with total intolerance to statins, may open a new path to obtain LDL-C targets in patients with high/very high cardiovascular risk.

Metabolic syndrome (MS) is an association of cardiovascular risk factors that increases the risk of coronary disease or type 2 diabetes mellitus (DM2), and has also been associated with the presence of liver steatosis (LS). In this study the relation of MS and LS with cholesterol control was analyzed in very high cardiovascular risk patients (coronary patients and/or DM2).A cross-sectional epidemiological study including 6988 patients, from whom information was obtained on their characteristics, lipid profile and treatments.4455 patients (65%) of the total study population had MS. Of MS criteria, high BP was the criterion most represented in the total population, while high TGs was the least. Within the total population, coronary patients showed a greater proportion of high BP, high TG and low HDL-c than those without coronary disease. Although no influence of MS was seen on the achievement of LDL-c targets (70 mg/dL), the presence of high BP, high blood glucose and low HDL-c was related to poorer control of LDL-c. Finally, patients with MS showed a greater proportion of liver steatosis and this was associated in turn with poorer control of LDL-c.The criteria for MS are closely related to cholesterol control. LS is more prevalent in patients with MS, and it is associated with poorer control of LDL-c. We should focus on the presence of MS in high and very high CV risk patients in order to improve their lipid control.

Objective:To describe the clinical presentation and evolution of a severe and rare adverse reaction to hydroclorothiazide.Design and method:We present the case of a 74-year-old woman with a personal history of permanent atrial fibrillation under treatment with acenocumarol, pacemaker carrier, rheuma

As the name suggests, the budget for the construction of a ship, in this case a Suezmax, means to specifically pre-suppose in economic terms, the activities and movements to carry out during the construction of said ship. The importance of this essential phase of the construction process lie one hand in budgeting a competitive price in the market, but without causing economic losses for the shipyard, in order to make a profit for the company. This study proposes the use of the Monte Carlo method to obtain a greater reliability in the valuation of the Suezmax vessel; in this case, the triangular method will be used, which starting point is based on results obtained from previous research and from which the most likely, most pessimistic and most optimistic ship budget is obtained in order to later perform a simulation. For the realization of said simulation the ship is divided into different items, that will be assigned an optimistic and pessimist percentage based on a likely budget, according to the degree of trust of the shipyard in said concept.The final scope will be the calculation of the management reserve used to rectify any unforeseen item(s) in the construction of the ship.

This study reviews recent developments concerning the effects of alcohol on plasma triglycerides. The focus will be on population, intervention and metabolic studies with respect to alcohol and plasma triglycerides.Alcohol consumption and fat ingestion are closely associated and stimulated by each other via hypothalamic signals and by an elevated cephalic response. A J-shaped relationship between alcohol intake and plasma triglycerides has been described. A normal body weight, polyphenols in red wine and specific polymorphisms of the apolipoprotein A-V and apolipoprotein C-III genes may protect against alcohol-associated hypertriglyceridemia. In contrast, obesity exaggerates alcohol-associated hypertriglyceridemia and therefore the risk of pancreatitis.High alcohol intake remains harmful since it is associated with elevated plasma triglycerides, but also with cardiovascular disease, alcoholic fatty liver disease and the development of pancreatitis. Alcohol-induced hypertriglyceridemia is due to increased very-low-density lipoprotein secretion, impaired lipolysis and increased free fatty acid fluxes from adipose tissue to the liver. However, light to moderate alcohol consumption may be associated with decreased plasma triglycerides, probably determined by the type of alcoholic beverage consumed, genetic polymorphisms and lifestyle factors. Nevertheless, patients should be advised to reduce or stop alcohol consumption in case of hypertriglyceridemia.

Resumen Antecedentes y objetivo Las guias de practica clinica aconsejan conseguir concentraciones de colesterol LDL (cLDL) menor de 100 mg/dl (y en ciertos casos menor de 70 mg/dl) en pacientes con enfermedad coronaria y/o diabetes mellitus tipo 2 (DM2). Hemos examinado el cumplimiento de estos objetivos en enfermos atendidos en Espana con estas afecciones. Metodos Estudio epidemiologico transversal. Los datos se obtuvieron en la visita del estudio o, en su defecto, a partir de datos que constaban en la historia clinica. Participaron 874 medicos de 17 comunidades autonomas de Espana. Se recogieron datos demograficos, factores de riesgo cardiovascular y tratamientos prescritos. Resultados En el analisis final se incluyeron 6.988 pacientes (varones, 62,7%) de los cuales 2.586 (37%) tenian enfermedad coronaria, 2.654 (38%) DM2 y 1.748 (25%) ambas afecciones. El 65% tenian sindrome metabolico y la mediana de factores de riesgo vascular fue de 4. Un 57 y un 86% mostraron una concentracion de cLDL > 100 y > 70 mg/dl, respectivamente. La proporcion de pacientes con cLDL > 100 mg/dl fue un 4% superior en el grupo DM2 (62,4%) que entre los enfermos coronarios (57,1%; p 150 mg/dl fue superior entre los enfermos con DM2 (50,5%), que entre los enfermos coronarios (43,5%; p 70 mg/dl fue similar en el grupo coronario y en el grupo DM2 (88,4 y 87,0%, respectivamente). Algo mas de la mitad de los enfermos con afeccion coronaria (57,5%) o DM2 (55,7%) mostraron unos niveles de HDL inadecuados (varones, Conclusiones Mas de la mitad de los pacientes con diabetes mellitus y/o arteriopatia coronaria incluidos en el estudio CODIMET no alcanzan el objetivo de colesterol LDL recomendado para pacientes de alto riesgo cardiovascular.

Fasting and postprandial triglyceride concentrations largely depend on dietary and lifestyle factors. Alcohol intake is associated with triglycerides, but the effect of alcohol on diurnal triglyceridemia in a free living situation is unknown. During three days, 139 men (range: 18–80 years) measured their own capillary triglyceride (cTG) concentrations daily on six fixed time-points before and after meals, and the total daily alcohol intake was recorded. The impact of daily alcohol intake (none, low, &lt, 10 g/day, moderate, 10–30 g/day, high, &gt, 30 g/day) on diurnal triglyceridemia was analyzed by the incremental area under the cTG curve (∆cTG-AUC) reflecting the mean of the six different time-points. Fasting cTG were similar between the alcohol groups, but a trend of increased cTG was observed in men with moderate and high alcohol intake after dinner and at bedtime (p for trend &lt, 0.001) which persisted after adjustment for age, smoking and body mass index. The ∆cTG-AUC was significantly lower in males with low alcohol intake (3.0 ± 1.9 mmol·h/L) (n = 27) compared to males with no (7.0 ± 1.8 mmol·h/L) (n = 34), moderate (6.5 ± 1.8 mmol·h/L) (n = 54) or high alcohol intake (7.2 ± 2.2 mmol·h/L) (n = 24), when adjusted for age, smoking and body mass index (adjusted p value &lt, 0.05). In males, low alcohol intake was associated with decreased diurnal triglyceridemia, whereas moderate and high alcohol intake was associated with increased triglycerides after dinner and at bed time.