Coração carcinóide – a propósito de um caso clínico

We describe the case of a 76-year-old woman, diagnosed with a neuroendocrine tumor of the cecum in 2004, with liver metastases and carcinoid syndrome since September 2010. The patient had been treated intermittently with chemotherapy cycles, and remained symptomatic, with worsening secondary lesions. In June 2011 she began to present signs and symptoms of right heart failure and was hospitalized in September 2011. Transthoracic two- and three-dimensional echocardiography revealed enlarged right atrium and ventricle and thickened and fixed tricuspid and pulmonary valve leaflets, causing severe tricuspid regurgitation and mild pulmonary regurgitation and stenosis, suggestive of carcinoid heart disease. The authors discuss the clinical importance of transthoracic echocardiography, and the more recent three-dimensional echocardiography, as the diagnostic exam of choice in these cases, as it is especially suitable for assessing the valves and subvalvular apparatus.     

Atención sanitaria e impacto económicoHealthcare and economic impact

This chapter reviews the current model of HIV patient care and its economic impact. There are clinical and geographical differences in the care HIV patients receive and a need to develop new models of comprehen-sive HIV care has been identified.HIV infection in Spain is an important and expensive public health problem. The main costs are due to an-tiretroviral therapy, indirect costs and the cost of admission, consultation and diagnostic testing. A strong correlation between severity and cost has been identified.Patients diagnosed late have a poorer clinical course, increased mortality and require more medical and therapeutic resources.Early detection of the disease significantly improves the clinical outcomes of patients.The increased number of patients receiving treatment and their progressive ageing will increase costs of HIV healthcare in the coming years.     

Osificación heterotópica de las piernas en un varón

Heterotopic ossification is an uncommon disorder that consists of deposition of ectopic bone outside the extraskeletal tissues. In the skin, it can be primary, in association with genetic syndromes, or be secondary to different disorders. The latter include subcutaneous ossification of the legs in chronic venousinsufficiency, an infrequent and unrecognized complication. We report the case of a patient with subcutaneous ossification of both legs secondary to venous insufficiency and review the literature.     

Anticoagulación oral en la enfermedad renal crónica con fibrilación auricular

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomized trials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects.     

Prevención primariaPrimary prevention

HIV infection is still not controlled in Spain. New HIV infection prevention strategies are required, especially in populations of higher incidence, by means of combined interventions.Early diagnosis and treatment of HIV-infected individuals is the most cost-effective strategy to control the epidemic, including interventions designed to motivate behavioural changes.These types of campaigns must not only be directed to the general population through mass channels, but also to key populations through more specific channels and messages.Biomedical interventions like pre-exposure prophylaxis, uses a combination of biomedical tools to reduce the risk of HIV acquisition, and are usually accompanied of behavioural interventions. The influence of structural factors, social justice and defending the rights of people living with HIV have a significant impact on prevention strategies. Structural interventions are designed to influence these factors that make some individuals or populations more vulnerable to HIV infection.     

Impacto pronóstico y factores predictores de la recuperación de la fracción de eyección en pacientes con miocardiopatía dilatada alcohólica

Introduction and objectives

Recovery of left ventricular ejection fraction (LVEF) has been described in alcoholic cardiomyopathy (ACM) after a period of alcohol withdrawal. Nevertheless, the prognostic impact of LVEF recovery in ACM and its determinants have not been studied. We sought to define the role of LVEF improvement in the long-term outcome of ACM and to identify predictors of LVEF recovery in these patients.

Detección tempranaEarly diagnosis

There is broad agreement on the impact that underdiagnosis and late diagnosis of HIV infection have on the health of people with HIV and on the persistence of the epidemic due to an inadvertent increase in transmission. The need to develop strategies that increase the number of diagnoses, and specifically the number of early diagnoses, is therefore urgent. Many such strategies have been launched in other countries and, in Spain, have been recommended by the Ministry of Health, Social Services and Equality (MSSSI). The multidisciplinary group recommends the review and implementation of different measures in both health and community settings.     

Dimensión social del VIH y respuesta estatalSocial dimensión of HIV and state response

HIV infection is strongly conditioned by social factors. Two of the most significant obstacles in the response to HIV is the stigma and the discrimination that is still associated with it. The stigmatization process occurs through individual drivers and structural facilitators that interweave with overlapping stigmas. These stig-mas manifest in several forms and lead to complex consequences that negatively influence prevention, diagnosis, treatment and quality of life. This article reviews these issues and the evidence of stigma in Spain. The response to HIV requires a strong political commitment. However, the economic crisis and the lack of leadership from institutions have slowed down the progress achieved in Spain. HIV must be placed at the forefront of the political agenda in order to achieve international goals.