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"textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The studies published by Belloch García<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> and Cornejo Saucedo<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> highlighted 2 aspects of considerable interest to internal medicine professionals. On the one hand, the study is a wake-up call on abdominal aortic aneurysms (AAAs), a process that shares a number of risk factors with arteriosclerosis. On the other, the study highlights the increasing importance of clinical ultrasonography, i.e., point-of-care ultrasonography, performed in this case by internists.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Clinical ultrasonography has become a routine and essential test in numerous specialties beyond radiology, including cardiology, rheumatology, pulmonology, urology and gynecology, not only as a diagnostic tool but also as an assistant in invasive procedures such as thoracentesis, paracentesis and biopsies.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Spanish Society of Internal Medicine created the Clinical Ultrasonography Workgroup in 2011, which since then has organized numerous courses, published manuals, helped increase the widespread use of ultrasonography and even created a website on the subject (<a id="intr0010" class="elsevierStyleInterRef" href="http://www.ecografiaclinica.es/">www.ecografiaclinica.es</a>).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The application of clinical ultrasonography in cardiovascular disease is an example of its use, as can be observed in the studies published in this issue of the journal in which AAA screening is performed on patients hospitalized in internal medicine departments.</p><p id="par0025" class="elsevierStylePara elsevierViewall">AAA (aortic dilation greater than 3<span class="elsevierStyleHsp" style=""></span>cm) is a process with a slow and typically silent progression. The overall mortality rate for spontaneous rupture is very high (80–90%) because, in addition to the mortality rate prior to admission to the emergency department and the lack of surgical indication due to the patient's condition, there is the mortality due to the emergency procedure (50%).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In contrast, elective repair has a very low mortality rate (<5%)<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a>; identifying patients with AAA during the silent period can therefore save numerous lives despite its relatively low prevalence.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The 2014 review by Stather et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> of 35 articles published between 1988 and 2012 found a prevalence of AAA of 2.2%–12.7%. This prevalence depended on sex and age, circumstances that had already been known since 1967 when Fomon et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> published a study on 7642 autopsies performed in Miami between 1935 and 1954, which found 77 AAAs (prevalence rate of 1%). In 1992, Bengtsson et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> conducted a study in Sweden of 45,838 autopsies and found a prevalence of AAA of 4.7% in men and 3% in women, with a maximum rate of 5.9% in 80-year-old men and 4.5% in women older than 90 years. The aging of the population is causing an increase in the prevalence of AAA.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In our setting, a recent study by Bravo-Merino<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> conducted with male primary care patients aged 65–75 years detected a prevalence of 4.6% using ultrasonography, a rate within the 2.6–4.7% range of other studies in the same setting, a finding mentioned by Belloch García.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The novel aspect of the study by Belloch García was the assessment of the prevalence of AAA in a patient group hospitalized in internal medicine departments. The overall prevalence was 2.9%, but since all of the cases (7) occurred in men older than 50 years, the prevalence was 4.6% for men. If almost 75% of the sample is over the age of 65 years, the prevalence in men of this age exceeds 6%, which is higher than the prevalence results in primary care. The study by Cornejo Saucedo<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> found an even higher prevalence (8% in the overall sample and almost 10% in men), given that these were selected patients with high cardiovascular risk.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This higher prevalence in men hospitalized in internal medicine departments than that found in primary care is due to the type of patient admitted to internal medicine departments, where the rates of arterial hypertension, diabetes, dyslipidemia and tobacco use are higher than in the general population. Thus, in the study by Belloch García, arterial hypertension was present in 68.9% of the study patients, diabetes was present in 33.6%, dyslipidemia in 39% and tobacco use in 54.8%. These readings increase for the patients with aneurysms, achieving statistically significant differences in the case of tobacco use. There is agreement in the scientific community that age, the male sex and tobacco use are clear risk factors for developing AAA. In contrast, there are disagreements as to whether other factors such as hypertension, diabetes (as can be seen in the study by Cornejo Saucedo<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a>) and dyslipidemia favorably or unfavorably influence the development of aneurysms and their eventual rupture.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The presence of AAAs is associated with other arteriosclerotic vascular diseases (aneurysms in another part of the aorta or femoral artery, ischemic heart disease, peripheral artery disease, etc.). Hospitalized patients with these antecedents can therefore be candidates for aneurysm screening. In the study by Belloch García, the presence of AAA was associated with an ankle brachial index <0.9. In the study by Cornejo Saucedo,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> peripheral artery disease had an odds ratio of 3.51.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Reduced tobacco use in the general population explains the reduced prevalence recently observed in some communities, which has resulted in a lack of agreement on implementing populational screening due to its lack of cost-effectiveness.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> An alternative could be opportunistic screening, such as that performed in internal medicine hospital wards, where we typically find men older than 65 years with a history of tobacco use, peripheral artery disease or ischemic heart disease.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The main factors that determine an AAA rupture are the size of the aneurysm and its growth rate. The annual rupture rate for AAAs <5<span class="elsevierStyleHsp" style=""></span>cm in diameter is <4%; however, those >5.5<span class="elsevierStyleHsp" style=""></span>cm have a rupture rate of >25%.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> A size >5.5<span class="elsevierStyleHsp" style=""></span>cm and a growth rate >0.5<span class="elsevierStyleHsp" style=""></span>cm in 6 months are indicators of a maximum risk of aneurysm rupture. According to the guidelines of the Spanish Society of Arteriosclerosis and the Spanish Society of Angiology and Vascular Surgery,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> aneurysms ≥50<span class="elsevierStyleHsp" style=""></span>mm in size should be sent for assessment by vascular surgery departments (strong strength of recommendation). Aneurysms ≥80<span class="elsevierStyleHsp" style=""></span>mm in size are of an urgent nature; if they are symptomatic (back or abdominal pain unexplained by other causes) with suspected rupture or evidence of rupture then they are of an emergency nature.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The availability of clinical ultrasonography in the context of internal medicine patients with relatively high likelihood of presenting AAA is an opportunity to save lives, optimize resources and become more efficient.</p></span>"
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