Coffee ground emesis and early endoscopy: Is timing actually relevant? / Vómitos en posos de café y valoración endoscópica precoz. ¿Es realmente el tiempo la clave?

OBJECTIVE: Coffee ground vomiting is a classical symptom of upper gastrointestinal bleeding. However, the clinical usefulness is limited, due to the low positive predictive value. Our goal is to determine if whether an urgent endoscopy does modify our therapeutic management with a real impact on survival. PATIENTS AND METHODS: It is a retrospective, observational and descriptive study. We selected all patients that underwent a gastroscopy in our center for coffee ground vomiting over the last 4 years (2017-2021). Two groups were established: urgent endoscopy (first 24h) and scheduled (over 24h). Then we studied differences between both groups regarding survival, ICU admission, hospitalization days and rebleeding. RESULTS: Three hundred and fourteen patients were identified, from which 276 were included, with 176 belonging to the urgency group and 109 to the scheduled group. There were no differences in the ICU admission, hospitalization days, survival or rebleeding after 30 days. There were no differences either in the number of potentially bleeding lesions or the need of endoscopic therapeutic. CONCLUSIONS: Coffee ground vomiting, without any other data supporting upper gastrointestinal bleeding, does not represent a reliable indicator. Performing urgent endoscopy is not beneficial in terms of morbimortality. Therefore, a more conservative strategy would allow to differ endoscopy, decreasing risks and reducing costs, without affecting the prognosis.

Serum phosphate is associated with increased risk of bone fragility fractures in hemodialysis patients.

BACKGROUND: Bone fragility fractures are associated with high morbidity and mortality. This study analysed the association between the current biochemical parameters of CKD-MBD and bone fragility fractures in the COSMOS project. METHODS: COSMOS is a 3-year, multicentre, open cohort, prospective, observational study carried out in 6797 hemodialysis patients (227 centres from 20 European countries). The association of bone fragility fractures (outcome) with serum calcium, phosphate and PTH (exposure), was assessed using Standard Cox proportional hazards regression and Cox proportional hazards regression for recurrent events. Additional analyses were performed considering all-cause mortality as a competitive event for bone fragility fracture occurrence. Multivariable models were used in all strategies, with the fully adjusted model including a total of 24 variables. RESULTS: During a median follow-up of 24 months 252 (4%) patients experienced at least one bone fragility fracture (incident bone fragility fracture rate 28.5 per 1000 patient-years). In the fractured and non-fractured patients, the percentage of men was 43.7% and 61.4%, mean age 68.1 and 63.8 years and a haemodialysis vintage of 55.9 and 38.3 months respectively. Baseline serum phosphate > 6.1 mg/dL (reference value 4.3-6.1 mg/dL) was significantly associated with a higher bone fragility fracture risk in both regression models (HR: 1.53[95%CI: 1.10-2.13] and HR: 1.44[95%CI: 1.02-2.05]. The significant association persisted after competitive risk analysis (subHR: 1.42[95%CI: 1.02-1.98]) but the finding was not confirmed when serum phosphate was considered as a continuous variable. Baseline serum calcium showed no association with bone fragility fracture risk in any regression model. Baseline serum PTH > 800 pg/mL was significantly associated with a higher bone fragility fracture risk in both regression models, but the association disappeared after a competitive risk analysis. CONCLUSIONS: Hyperphosphatemia was independently and consistently associated with an increased bone fracture risk, suggesting serum phosphate could be a novel risk factor for bone fractures in hemodialysis patients.

Irritable bowel syndrome and basal serum tryptase: correlation between subtype, severity, and comorbidities. A pilot study.

INTRODUCTION: the activation of mast cells causes alterations in epithelial and neuromuscular function and is involved in visceral hypersensitivity and dysmotility in gastrointestinal functional disorders. OBJECTIVES: primary: to evaluate differences in basal serum tryptase (BST) between patients with irritable bowel syndrome (IBS) and healthy controls. Secondary: BST depending on IBS subtype (diarrhea: IBS-D; constipation: IBS-C), comorbidities and correlation with IBS severity and quality of life. MATERIAL AND METHODS: a prospective control-case study in IBS patients (Rome IV criteria). BST (ImmunoCAP-Phadia, Sweden®), IBS Severity Score (IBSSS), pain, bloating and flatulence analogue scales, IBS quality of life (IBSQOL), and patient health status (PHQ-9) were determined. BST is the primary variable to achieve the primary endpoint. RESULTS: thirty-two patients were included, 21 (65.6 %) with IBS-D and 11 (34.4 %) with IBS-C; 32 controls were also included. Mean IBSSSS: 326.6 (± 71.4), IBSQOL: 76 (± 20.3), and PHQ9: 10.2 (± 5.9). BST was 4.8 ± 2.6 in IBS and 4.7 ± 2.6 in controls (p = 0.875). There were no differences in BST between IBS subtypes (4.7 ± 2.9 in IBS-D and 5 ± 1.8 in IBS-C; p = 0.315) or IBS severity (p = 0.662). However, BST was higher in patients with IBS and extraintestinal comorbidities compared to other patients and controls (p = 0.029). This subgroup also has more severe bloating (p = 0.021). There was no correlation between BST, quality of life (p = 0.9260), and health status (p = 0.3985). CONCLUSION: BST does not discriminate between IBS patients and controls. However, BST was higher in patients with IBS with extraintestinal comorbidities, which had more severe bloating. This finding is worthy of investigation.

Risk of COVID-19 transmission in esophageal, anorectal manometry and 24-hour impedance-pH monitoring.

BACKGROUND: the impact of the COVID-19 pandemic has led to the interruption of most manometry or impedance-pH monitoring studies. The risk of restarting activities is unknown. OBJECTIVE: assess the risk of SARS-CoV-2 virus infection, both to patients and healthcare workers, in relation to esophageal and anorectal functional tests during the pandemic without protective measures. METHOD: a questionnaire was designed to determine whether patients and healthcare workers had COVID-19, confirmed by either a test or compatible symptoms, after functional studies were performed from January until March 2020. RESULTS: the survey was answered by 263 (92.9 %) patients. Four (1.52 %) patients had confirmed COVID-19 in the two weeks after the functional test (adjusted rate 8.34 cases per 1,000 [95 % CI -0.06-16.74], OR 0.84 [95 % CI: 0.83-0.85], p < 0.001) and no patient after anorectal manometry. Another five had only compatible symptoms, for a total of nine patients (3.42 %) (adjusted rate 27.50 cases/1,000 [95 % CI: 7.27-47.74], OR 2.84 [95 % CI: 2.81-2.87]). In the total study period, 18.25 % had confirmed COVID-19 or compatible symptoms. The average number of days between the procedure and the first day of symptoms was progressively shortened (January: 56 days, February: 33 days, March: 10.5 days). Two of ten healthcare workers (20 %) had confirmed COVID-19. CONCLUSIONS: the risk of COVID-19 infection when performing functional tests is low and more related to the evolution of the pandemic rather than to the procedure itself. The small number of healthcare workers included in the study does not allow a definitive conclusion to be drawn on their risk of infection.

Phenotypic characterization of X-linked hypophosphatemia in pediatric Spanish population.

BACKGROUND: X-linked hypophosphatemia (XLH) is a hereditary rare disease caused by loss-of-function mutations in PHEX gene leading tohypophosphatemia and high renal loss of phosphate. Rickets and growth retardation are the major manifestations of XLH in children, but there is a broad phenotypic variability. Few publications have reported large series of patients. Current data on the clinical spectrum of the disease, the correlation with the underlying gene mutations, and the long-term outcome of patients on conventional treatment are needed, particularly because of the recent availability of new specific medications to treat XLH. RESULTS: The RenalTube database was used to retrospectively analyze 48 Spanish patients (15 men) from 39 different families, ranging from 3 months to 8 years and 2 months of age at the time of diagnosis (median age of 2.0 years), and with XLH confirmed by genetic analysis. Bone deformities, radiological signs of active rickets and growth retardation were the most common findings at diagnosis. Mean (± SEM) height was - 1.89 ± 0.19 SDS and 55% (22/40) of patients had height SDS below-2. All cases had hypophosphatemia, serum phosphate being - 2.81 ± 0.11 SDS. Clinical manifestations and severity of the disease were similar in both genders. No genotype-phenotype correlation was found. Conventional treatment did not attenuate growth retardation after a median follow up of 7.42 years (IQR = 11.26; n = 26 patients) and failed to normalize serum concentrations of phosphate. Eleven patients had mild hyperparathyroidism and 8 patients nephrocalcinosis. CONCLUSIONS: This study shows that growth retardation and rickets were the most prevalent clinical manifestations at diagnosis in a large series of Spanish pediatric patients with XLH confirmed by mutations in the PHEX gene. Traditional treatment with phosphate and vitamin D supplements did not improve height or corrected hypophosphatemia and was associated with a risk of hyperparathyroidism and nephrocalcinosis. The severity of the disease was similar in males and females.

Fulminant gastrointestinal ischemia due to yeyunal volvulus.

Jejunal volvules are a very rare condition, barely reported in the literature, that occur in relation to congenital (eg, intestinal duplication) or acquired disorders (eg, diaphragmatic hernias or tumors). In the event that it becomes complicated with an established intestinal ischemia, its prognosis is further overshadowed by the possible consequences of a complex surgery, given the high risk of short bowel syndrome. Being a PEG probe carrier does not seem to be related to the picture.

Obstructed defecation syndrome: a diagnostic and therapeutic challenge.

Obstructed defecation syndrome produces constipation with anal blockage and a feeling of incomplete evacuation, due to either anatomic and functional causes. This is a complex and multifactorial entity due to diverse etiological factors that may coexist in many patients. Therefore, a diagnostic approach requires structural and functional assessment. The concordance between findings of diagnostic tests is suboptimal, thus an individualized analysis is mandatory in each patient. Therapeutic strategies require the best understanding of anatomic and functional aspects. Consequently, this entity is a diagnostic and therapeutic challenge.

Biodiversity within the city: Effects of land sharing and land sparing urban development on avian diversity.

Urbanization, one of the most extreme human-induced environmental changes, is negatively affecting biodiversity worldwide, strongly suggesting that we should reconcile urban development with conservation. Urbanization can follow two extreme types of development within a continuum: land sharing (buildings mixed with dispersed green space) or land sparing (buildings interspersed with green patches that concentrate biodiversity-supporting vegetation). Recent local-scale studies indicate that biodiversity is typically favored by land sparing. We investigated which of these two types of urbanization is associated with a higher taxonomic (i.e. species richness), functional, and phylogenetic diversity of birds. To do so, we collected information on breeding and wintering bird assemblages in 45 land-sharing and 45 land-sparing areas in nine European cities, which provide the first attempt to explore this question using a large geographical scale and temporal replication. We found that land-sharing urban areas were significantly associated with a higher taxonomic and functional diversity of birds during winter, but not during the breeding season (with only a marginally significant effect for functional diversity). We found no association between the type of urban development and phylogenetic diversity. Our findings indicate that not all components of avian diversity are similarly affected by these two means of urban planning and highlight the importance of integrating the temporal perspective into this kind of studies. Our results also offer useful information to the current debate about the trade-off between biodiversity conservation and human well-being in the context of land sharing and sparing urban practices. In addition, we found that certain small-scale urban landscape characteristics (i.e. few impervious surfaces, high water or tree cover) and human practices (i.e. bird feeders or plants with berries) can help maintaining more diverse urban bird assemblages. We provide specific suggestions for both policymakers and citizens that hopefully will help to create more biodiversity-friendly cities in the future.

Land-sharing vs. land-sparing urban development modulate predator-prey interactions in Europe.

Urban areas are expanding globally as a consequence of human population increases, with overall negative effects on biodiversity. To prevent the further loss of biodiversity, it is urgent to understand the mechanisms behind this loss to develop evidence-based sustainable solutions to preserve biodiversity in urban landscapes. The two extreme urban development types along a continuum, land-sparing (large, continuous green areas and high-density housing) and land-sharing (small, fragmented green areas and low-density housing) have been the recent focus of debates regarding the pattern of urban development. However, in this context, there is no information on the mechanisms behind the observed biodiversity changes. One of the main mechanisms proposed to explain urban biodiversity loss is the alteration of predator-prey interactions. Using ground-nesting birds as a model system and data from nine European cities, we experimentally tested the effects of these two extreme urban development types on artificial ground nest survival and whether nest survival correlates with the local abundance of ground-nesting birds and their nest predators. Nest survival (n = 554) was lower in land-sharing than in land-sparing urban areas. Nest survival decreased with increasing numbers of local predators (cats and corvids) and with nest visibility. Correspondingly, relative abundance of ground-nesting birds was greater in land-sparing than in land-sharing urban areas, though overall bird species richness was unaffected by the pattern of urban development. We provide the first evidence that predator-prey interactions differ between the two extreme urban development types. Changing interactions may explain the higher proportion of ground-nesting birds in land-sparing areas, and suggest a limitation of the land-sharing model. Nest predator control and the provision of more green-covered urban habitats may also improve conservation of sensitive birds in cities. Our findings provide information on how to further expand our cities without severe loss of urban-sensitive species and give support for land-sparing over land-sharing urban development.

Estimation of soil gas permeability for assessing radon risk using Rosetta pedotransfer function based on soil texture and water content.

Radon is a natural source of radioactivity and it can be found in all soils and rocks in the Earth. The presence of radon gas in indoor environments implies a serious risk for human health, already listed as carcinogenic by the World Health Organization. The most relevant methods to infer the risk for radon exposure are based on soil radon concentration and gas permeability that describe the effective radon movement in the soil. However, they neglect crucial soil properties and water content in soil, which can affect greatly soil permeability to gases. Additionally, soil permeability measurement remains expensive, difficult and time-consuming. In this paper we show a new and simple methodology to infer radon risk based on Rosetta3 pedotransfer function as well as soil texture and water content. We also determine the influence of soil texture both on the gas permeability variation in dependence on water content and on the parameter n of the van Genuchten -Mualem model, which establishes the shape of the relative permeability curves. We show that radon risk exposure may change importantly for the same soil with different soil water contents. We finally apply and validate the proposed method using radon permeability data from the Canadian component of the North American Soil Geochemical Landscapes Project (NASGLP). Results highlight that the proposed methodology provides reliable estimations of the gas permeability and reveal that the presence of water content may cross the boundary between two radon risk categories, and consequently, may change the radon risk category to safer situations.

MAPK inhibition and growth hormone: a promising therapy in XLH.

X-linked hypophosphatemia (XLH) leads to growth retardation and bone deformities, which are not fully avoided by conventional treatment with phosphate and vitamin D analogs. Pediatric patients have been treated with growth hormone (GH), and recent findings suggest that blocking fibroblast growth factor 23 actions may be the most effective therapy, but its effects on growth are not known. We here report the effect of MAPK inhibition alone or associated with GH on growth and growth plate and bone structure of young Hyp (the XLH animal model) mice. Untreated Hyp mice were severely growth retarded and had marked alterations in both growth plate structure and dynamics as well as defective bone mineralization. GH accelerated growth and improved mineralization and the cortical bone, but it failed in normalizing growth plate and trabecular bone structures. MAPK inhibition improved growth and rickets and, notably, almost normalized the growth plate organization. The administration of a MAPK pathway inhibitor plus GH was the most beneficial treatment because of the positive synergistic effect on growth plate and bone structures. Thus, the growth-promoting effect of GH is likely linked to increased risk of bone deformities, whereas the association of GH and MAPK inhibition emerges as a promising new therapy for children with XLH.-Fuente, R., Gil-Peña, H., Claramunt-Taberner, D., Hernández-Frías, O., Fernández-Iglesias, Á., Alonso-Durán, L., Rodríguez-Rubio, E., Hermida-Prado, F., Anes-González, G., Rubio-Aliaga, I., Wagner, C., Santos, F. MAPK inhibition and growth hormone: a promising therapy in XLH.

Independent factors associated with the impact of gastroesophageal reflux disease on health-related quality of life.

BACKGROUND: although a number of factors have been associated with a deterioration in quality of life in gastroesophageal reflux disease, it is not known which has an independent influence. OBJECTIVE: to evaluate factors independently associated with the impact of gastroesophageal reflux disease on health-related quality of life. METHODS: a post-hoc analysis of a prospective cohort of patients diagnosed with gastroesophageal reflux disease was performed. The patients completed validated questionnaires to evaluate health-related quality of life (SF 36), gastroesophageal reflux disease (GERQ) and psychological factors (STAI and SCL 90R). RESULTS: the study included 98 patients. The univariate analysis showed that a deterioration in the physical component of the SF36 was significantly associated with female gender, educational level, age, weight loss, severity of typical symptoms, supraesophageal symptoms and monthly income. The mental component was significantly associated with alcohol consumption, epigastric pain and lower scores on the STAI and SCL90 questionnaires. The multivariate analysis showed an independent association between the physical component of the SF36 and educational level (ß = 0.29; p < 0.01), severity of symptoms (ß = -0.38; p < 0.001), body mass index (ß = -0.30; p < 0.005), state anxiety (ß = 0.28; p < 0.01), female gender (ß = -0.23; p < 0.05) and dyspepsia (ß = -0.21; p < 0.05). Associated variables within the mental component included state anxiety (ß = -0.39; p < 0.01) and depression (ß = -0.32; p < 0.05). CONCLUSIONS: the principal factors independently associated with a deterioration in health-related quality of life in patients with gastroesophageal reflux disease included the severity of typical symptoms and the presence of dyspepsia. There is also an additional impact of body mass index and the psychological component.

Metastasis of dermatofibrosarcoma diagnosed by capsule endoscopy.

In the study of obscure gastrointestinal bleeding, which includes iron-deficiency anemia, the capsule endoscopy is a valuable diagnostic tool. In the different series the presence of tumors reaches 16% as the cause of it. We present the case of a rare tumor with metastatic extension in the small intestine in which the capsule endoscopy was key to the diagnosis and survival of the patient.

Distal renal tubular acidosis. Clinical manifestations in patients with different underlying gene mutations.

BACKGROUND: To evaluate whether there are differences in the phenotype of primary distal renal tubular acidosis (dRTA) patients according to the causal defective gene. METHODS: Twenty-seven non-oriental patients with genetically confirmed dRTA were grouped according to the identified underlying mutations in either ATP6V1B1 (n = 10), ATP6V0A4 (n = 12), or SLC4A1 (n = 5) gene. Demographic features, growth impairment, biochemical variables and presence of deafness, nephrocalcinosis, and urolithiasis at diagnosis were compared among the three groups. RESULTS: Patients with SLC4A1 mutations presented later than those with ATP6V1B1 or ATP6V0A4 defects (120 vs. 7 and 3 months, respectively). Hearing loss at diagnosis was present in the majority of patients with ATP6V1B1 mutations, in two patients with ATP6V0A4 mutations, and in none of cases harboring SLC4A1 mutations. Serum potassium concentration (X ± SD) was higher in SLC4A1 group (3.66 ± 0.44 mEq/L) than in ATP6V0A4 group (2.96 ± 0.63 mEq/L) (p = 0.046). There were no differences in the other clinical or biochemical variables analyzed in the three groups. CONCLUSIONS: This study indicates that non-oriental patients with dRTA caused by mutations in the SLC4A1 gene present later and have normokalemia or milder hypokalemia. Hypoacusia at diagnosis is characteristically associated with ATP6V1B1 gene mutations although it may also be present in infants with ATP6V0A4 defects. Other phenotypical manifestations do not allow predicting the involved gene.

Phylogenetic studies in Genabea, Myrmecocystis, and related genera.

A multigene phylogenetic analysis of Genabea, Myrmecocystis, and related genera in Pyronemataceae was conducted to establish genetically supported generic limits. The nuc rDNA 28S gene, translation elongation factor 1-α gene (TEF1), and RNA polymerase II second-largest subunit gene (RPB2) significantly supported the monophyly of several distinct genera of hypogeous Pyronemataceae. The genetic identity of Genabea fragilis is established, and the new species Genabea hyalospora, G. urbana, Myrmecocystis mediterranea, and M. microspora are proposed to accommodate undescribed lineages. Two rare species, M. sphaerospora and M. spinospora, are tentatively identified based on collections that are morphologically similar to the original descriptions. The genus Genea was found to be monophyletic, except for G. cazaresii, which is nested among epigeous species of Humaria. The new combination Humaria cazaresii is proposed to accommodate this species.

Fecal sacs do not increase nest predation in a ground nester.

Most altricial birds remove their nestlings' feces from the nest, but the evolutionary forces driving this behavior are poorly understood. A possible adaptive explanation for this could be that birds avoid the attraction of nest predators to their nests due to the visual or olfactory cues produced by feces (nest predation hypothesis). This hypothesis has received contrasting support indicating that additional experimental studies are needed, particularly with respect to the visual component of fecal sacs. To test this hypothesis, we conducted an experiment manipulating the presence of fecal sacs on inactive Woodlark (Lullula arborea) nests. This ground nester has highly cryptic nests that are mainly depredated by visually oriented nest predators (i.e., corvids) in our study population, making it an excellent system to test for the nest predation hypothesis. Our results showed that the presence of fecal sacs in the nest does not seem to be an important factor explaining nest predation. Interestingly, the effect of nest concealment, the most important factor explaining nest predation in Woodlark nests, depended on whether the nest was depredated the previous year or not, supporting the importance of using different nesting sites between years. Our findings indicate that this important nest sanitation behavior is not likely motivated by nest predation and highlight the need to explore alternative selective pressures in this context.

Chronic diarrhea, weight loss and heart failure. Features of the same disease?

Carcinoid tumors are neoplasm that release hormone-like substances. They can produce liver metastasis and present with symptoms of the carcinoid syndrome. A 78 year old man presented with a history of chronic diarrhea, weight loss and shortness of breath.

Clinical practice guidelines for the management of constipation in adults. Part 2: Diagnosis and treatment. / Guía de práctica clínica sobre el manejo del estreñimiento crónico en el paciente adulto. Parte 2: Diagnóstico y tratamiento.

Constipation is a very common disorder that adversely affects well-being and quality of life. Evidence-based clinical practice guidelines are an essential element for proper patient management and safe, effective treatment. The aim of these guidelines is to provide health care professionals who care for patients with chronic constipation with a tool that allows them to make the best decisions about the prevention, diagnosis and treatment of constipation. The methodology used to draw up these guidelines is described in the Part 1. In this article we will discuss the recommendations for the diagnostic and therapeutic management of constipation.

Clinical practice guidelines for the management of constipation in adults. Part 1: Definition, aetiology and clinical manifestations. / Guía de práctica clínica sobre el manejo del estreñimiento crónico en el paciente adulto. Parte 1: Definición, etiología y manifestaciones clínicas.

Clinical practice guidelines for the management of constipation in adults aim to generate recommendations on the optimal approach to chronic constipation in the primary care and specialized outpatient setting. Their main objective is to provide healthcare professionals who care for patients with chronic constipation with a tool that allows them to make the best decisions about the prevention, diagnosis and treatment of this condition. They are intended for family physicians, primary care and specialist nurses, gastroenterologists and other health professionals involved in the treatment of these patients, as well as patients themselves. The guidelines have been developed in response to the high prevalence of chronic constipation, its impact on patient quality of life and recent advances in pharmacological management. The Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) system has been used to classify the scientific evidence and strengthen the recommendations.