Clindamycin but not Intravenous Immunoglobulins reduces mortality in a retrospective cohort of critically ill patients with bacteremic Group A Streptococcal infections.

OBJECTIVE: Mortality of patients requiring Intensive Care Unit (ICU) admission for an invasive group A streptococcal (GAS) infection continues being high. In critically ill patients with bacteremic GAS infection we aimed at determining risk factors for mortality. METHODS: Retrospective multicentre study carried out in nine ICU in Southern Spain. All adult patients admitted to the participant ICUs from January 2014 to June 2019 with one positive blood culture for S. pyogenes were included in this study. Patient characteristics, infection-related variables, therapeutic interventions, failure of organs, and outcomes were registered. Risk factors independently associated with ICU and in-hospital mortalities were determined by multivariate regression analyses. RESULTS: Fifty-seven patients were included: median age was 63 (45-73) years, median SOFA score at admission was 11 (7-13). The most frequent source was skin and soft tissue infection (n=32) followed by unknown origin of bacteremia (n=12). In the multivariate analysis, age (OR 1.079; 95% CI 1.016-1.145), SOFA score (OR 2.129; 95% CI 1.339-3.383) were the risk factors for ICU mortality and the use of clindamycin was identified as a protective factor (OR 0.049; 95% CI 0.003-0.737). Age and SOFA were the independent factors associated with hospital mortality however the use of clindamycin showed a strong trend but without reaching statistical significance (OR 0.085; 95% CI 0.007-1.095). CONCLUSIONS: In this cohort of critically ill patients the use of intravenous immunoglobulin was not identified as a protective factor for ICU or hospital mortality treatment with clindamycin significantly reduced mortality after controlling for confounders.

The keys to successful TIPS in patients with portal vein thrombosis and cavernous transformation. / Trombosis y cavernomatosis portal: las claves para el éxito de un TIPS.

Portal vein thrombosis is a common complication in patients with cirrhosis. Anticoagulation involves a high risk of bleeding secondary to portal hypertension, so placing transjugular intrahepatic portosystemic shunts (TIPS) has become an alternative treatment for portal vein thrombosis. Three strategies for TIPS placement have been reported: 1) portal recanalization and conventional implantation of the TIPS through the jugular vein; 2) portal recanalization through percutaneous transhepatic/transsplenic) access; and (3) insertion of the TIPS between the suprahepatic vein and a periportal collateral vessel without portal recanalization. We describe different materials that can be used as fluoroscopic targets for the TIPS needle and for portal recanalization. This article aims to show the success of TIPS implantation using different combinations of the techniques listed above, which is a good treatment alternative in these patients whose clinical condition makes them difficult to manage, and to show that portal vein thrombosis/cavernous transformation should not be considered a contraindication for TIPS.

[Neuromyelitis optica spectrum disorders: profile of a cohort according to the 2015 diagnostic criteria]. / Espectro de neuromielitis optica: descripcion de una cohorte segun los criterios diagnosticos de 2015.

INTRODUCTION: The new 2015 criteria for neuromyelitis optica spectrum disorders (NMOSD) have been recently incorporated in the study of different international cohorts. AIM: To describe clinical-radiological characteristics and prognostic factors in patients with NMOSD according to the 2015 criteria. PATIENTS AND METHODS: Retrospective analysis of 36 patients diagnosed with NMOSD according to serologic AQP4 status (positive, negative, unknown and negative + unknown). Clinical and radiological characteristics were compared and possible disability prognostic factors were evaluated. RESULTS: AQP4 were positive in 7 patients, negative in 12 and unknown in 17. Age of presentation was 36.6 ± 16 years, with higher female proportion (4:1). Mean disease duration was 7.4 ± 7.6 years. Most frequent presenting symptoms were acute myelitis (61%), optic neuritis (33%) and area postrema syndrome (11%). Most frequent MRI lesion was longitudinally extensive transverse myelitis (75%). All patients received acute treatment during attacks, and preventive treatment was used in 81% (azathioprine and rituximab mostly prescribed). Median EDSS was 2.0 at the end of follow-up. No differences were observed in any of the variables comparing serologic status. Age of first attack was prognostic, with direct correlation with EDSS. First attack in < 30 years was protective, meanwhile > 50 years old patients had increased risk of disability. CONCLUSIONS: The 2015 criteria allow the description and classification of NMOSD patients within different cohorts. Age of first attack seems to be a prognostic factor for developing disability.

TITLE: Espectro de neuromielitis optica: descripcion de una cohorte segun los criterios diagnosticos de 2015.Introduccion. Los nuevos criterios diagnosticos de 2015 del espectro de neuromielitis optica (NMO) estan comenzando a utilizarse en diferentes poblaciones en el mundo. Objetivo. Describir las caracteristicas clinicorradiologicas y pronosticas de pacientes diagnosticados de NMO con los criterios de 2015. Pacientes y metodos. Analizamos retrospectivamente 36 pacientes diagnosticados de NMO con los actuales criterios. Se generaron cuatro grupos segun la serologia de antiacuaporina 4 (positivos, negativos, desconocidos y negativos mas desconocidos agrupados). Se compararon sus caracteristicas clinicorradiologicas y se evaluaron posibles variables pronosticas de discapacidad. Resultados. Encontramos siete pacientes seropositivos, 12 negativos y 17 desconocidos. La edad de inicio fue de 36 ± 16 años, con mayor proporcion de mujeres (4 a 1). La duracion de la enfermedad fue de 7,4 ± 7,6 años. Los sintomas iniciales mas frecuentes fueron mielitis (61%), neuritis optica (33%) y sindrome del area postrema (11%). La lesion mas frecuente en la resonancia magnetica fue la mielitis longitudinalmente extensa (75%). Todos los pacientes recibieron tratamiento agudo, y el preventivo se utilizo en el 81%; la azatioprina y el rituximab fueron los que mas se usaron. La mediana de la Expanded Disability Status Scale (EDSS) fue de 2 al final del seguimiento. No hubo diferencias significativas en las variables clinicorradiologicas entre los distintos grupos de pacientes. La edad de inicio fue pronostica y presenta correlacion directa con la EDSS. El inicio antes de los 30 años fue protector y, despues de los 50 años, un factor de riesgo para mayor discapacidad. Conclusiones. Los actuales criterios permiten describir diferentes cohortes. La edad de inicio parece ser un factor pronostico para desarrollar discapacidad.

Haemobilia due to iatrogenic portobiliary fistula after cholecystectomy.

Haemobilia, defined as bleeding into the biliary tree is a rare condition. We describe a case report of a patient who presented it as a complication of iatrogenic portobiliary fistula, followed after an open cholecystectomy. The patient presented to the emergency department with late onset symptoms of haematemesis and melena a month after surgery. Findings were confirmed by Doppler ultrasound that showed the appearance of intragallbladder mass with high echogenicity representing a blood clot. Also, next to the portal vein and the biliary duct a lesion with mixed blood flow was detected confirming a portobiliary fistula. This case was successfully managed by angiography and selective embolisation.

[Musculoskeletal hydatidosis: an unusual location]. / Hidatidosis musculoesquelética: una localización atípica.

Hydatidosis is a zoonosis with a continuing high prevalence in our environment. The most commonly affected organs are the lungs and the liver, with the musculoskeletal location being considered an unusual one. We comment the case of a patient who presented a series of lesions in his left iliac crest and middle left buttock with spontaneous fistulization to the skin surface. In this case a combined treatment was given; prior to the surgical operation we administered a cycle of albendazol. Following removal of the lesion, the patient was given two further cycles of albendazol in order to minimize the risk of a recurrence of the illness. This patient is currently free of any symptoms relating to this illness.

[Spontaneous intramural dissection of the esophagus]. / Perforación intramural espontánea del esófago.

Spontaneous intramural dissection of the esophagus (SIDE) is an unusual clinical entity. It is a benign disease that, despite its alarming endoscopic appearance, usually responds well to conservative management and has an excellent prognosis. Nevertheless, some situations require emergency surgical treatment. These situations include esophageal perforation with mediastinitis, massive bleeding, and abscess, among others. Upper gastrointestinal endoscopy is a useful diagnostic test when radiological examinations (hydrosoluble contrast esophagogram, computed tomography, or magnetic resonance imaging) have excluded perforation. We present the case of a 42-year-old woman who was admitted to our hospital complaining of acute chest pain, dysphagia, and odynophagia. Because of the persistence of symptoms and diagnostic uncertainty (SIDE versus complicated esophageal duplication cyst) surgery was performed. The definitive diagnosis was SIDE.

Biliopancreatic tumors: patient survival and quality of life after palliative treatment.

OBJECTIVES: to analyse survival and quality of life of patients with malignant obstructive jaundice after palliative treatment, comparing endoscopic stent insertion and palliative surgical (palliative resection and bypass surgical). PATIENTS AND METHOD: eighty and seven patients were included in a trial. They were distributed to endoscopic stent (50) and palliative surgical (37). It analysed survival, quality of life and comfort index of jaundiced patients. The good quality of life was defined by absence of jaundice, pruritus and cholangitis after the initial treatment. RESULTS: the median survival of the patients treated to endoscopic stent was 9,6 months whereas the patients to surgical treatment survived a median of 17 months. The time free of disease was 4 months in stented patients and 10,5 months in surgical patients. There was no significant difference in comfort index between the two groups (stented 34%, surgical 42,5%) Neither was there significant difference in survival and quality of life between palliative resection and bypass surgery. CONCLUSIONS: despite the survival and time free of disease being better in surgical patients, there was no significant difference in overall quality of life between the two groups. The survival and quality of life are the same after palliative resection as after bypass surgery, for this should not be performed routinely or to justify resection as a debulking procedure.

Failure of endoscopic therapy in upper gastrointestinal hemorrhage due to duodenal ulcers.

OBJECTIVES: to evaluate the efficacy of endoscopic treatment in patients with upper gastrointestinal (UGIH) due to duodenal ulcer with high risk of persistent or recurrent bleeding and to determine the associated failure factors of this procedure. PATIENTS AND METHOD: three hundred and thirty-six patients with UGIH due to duodenal ulcer requiring endoscopic treatment were analyzed between January 1992 and December 2001. The patients were classified according to the endoscopic findings: a) patients with limited bleeding; and b) patients with persistent and/or recurrent bleeding due to therapeutic failure. The clinical guidelines followed in patients with endoscopic treatment failure were previously established in the internal protocol. The variables that obtained statistical significance in the univariate analysis were included in the logistic regression model to identify those with an independent predictive value for failure of the endoscopic treatment. RESULTS: mean age of the patients was 60 +/- 17 years, 271 (81%) were male. Bleeding with severe hemodynamic affectation was detected in 82 patients (24%). The most common location of the duodenal ulcer was on the anterosuperior part of the duodenal bulb (227 patients, 68%). In 43 patients (13%) the ulcer was larger than 2 cm. The bleeding stigmata were classified as: Forrest I in 125 (38%) and Forrest II in 211 (62%). It was initially reached in 297 patients (88%). Twenty-two patients required emergency surgery (6,5%) and the global mortality rate was 3%. Severe hemodynamic affectation at admission (OR 11.8, p>0.001), ulcers exceeding 2 cm (OR 6.95, p = 0.019) and the presence of active bleeding during endoscopy (Forrest I) (OR 3.55, p = 0.08) were the variables included in the multivariate analysis independently associated to endoscopic therapy failure. CONCLUSION: endoscopic therapy is an efficient treatment of upper gastrointestinal bleeding due to duodenal ulcer. By means of a clinical variable, the hemodynamic status and two endoscopies, bleeding stigmata and the size of the ulcer, a group of patients with high risk of endoscopic treatment failure can be selected.

[Factors associated with failure of endoscopic therapy in gastric ulcer bleeding]. / Factores asociados al fracaso de la terapéutica endoscópica en la hemorragia digestiva por úlcera gástrica.

INTRODUCTION: Endoscopic therapy is an effective technique in the control of bleeding due to peptic ulcer. However, bleeding persists or recurs in as many as 10-30% of patients. Gastric and duodenal ulcers present different clinical and endoscopic features and consequently the efficacy of endoscopic therapy and the factors associated with its failure should be studied separately. OBJECTIVES: To analyze the efficacy of endoscopic therapy in patients at high risk of persistent or recurrent bleeding due to gastric ulcer and to identify the factors associated with the failure of this technique. PATIENTS AND METHODS: We performed a retrospective study based on a clinical intervention protocol. Two hundred eight patients admitted for bleeding secondary to gastric ulcer with active bleeding or stigmas of recent bleeding who received endoscopic therapy between January 1992 and December 2001 were analyzed. Clinical, laboratory and endoscopic variables on admission, as well as the medical treatment and endoscopic procedure applied, were registered. Endoscopy was performed within 12 hours of admission. Patients were classified according to their response to endoscopic therapy: a) patients with limited bleeding, and b) patients with persistent or recurrent bleeding due to therapeutic failure. Intervention in patients with therapeutic failure was performed according to a previously established protocol. Variables that were statistically significant in the univariate analysis were included in a logistic regression model to identify those with an independent predictive value for failure of endoscopic therapy. RESULTS: Definitive hemostasis was achieved after initial therapy in 181 patients (87%). The efficacy of a second procedure increased the percentage of hemostasis to 91% of the patients. In the logistic regression model, the only variables that were independently associated with initial therapeutic failure were: hemodynamic status on admission (p = 0.016; OR = 3.99), the need for transfusion of blood products prior to endoscopy (p = 0.025; OR = 3.48), upper localization of the gastric ulcer (p = 0.050; OR = 3.08) and unsatisfactory endoscopic therapy (p = 0.009; OR = 17.39). CONCLUSION: These variables could contribute to the early identification of a subgroup of patients, which would enable us to increase medical-surgical surveillance and offer them other therapeutic alternatives.

[Early-onset acute toxic hepatitis induced by intravenous amiodarone administration]. / Hepatitis tóxica aguda de instauración precoz por amiodarona intravenosa.

Amiodarone is a widely used and effective long-term antiarrhythmic drug but with known adverse effects. Prolonged oral administration of this drug has been implicated in numerous hepatic lesions, ranging from isolated, asymptomatic transaminase elevation to fulminant, fatal liver failure. Few cases of acute hepatotoxicity due to intravenous administration have been reported. We present a 69-year-old woman with atrial fibrillation who developed acute hepatitis within 24 hours of amiodarone infusion at the recommended dosage. The drug was withdrawn and laboratory findings progressively returned to normal over the following days. We analyze a possible mechanism of action for hepatotoxicity and highlight the importance of monitoring liver function in patients receiving this drug.

[Role of early colonoscopy in severe acute lower gastrointestinal bleeding]. / Rendimiento de la colonoscopia precoz en la hemorragia digestiva baja aguda grave.

BACKGROUND: Severe acute lower gastrointestinal bleeding (SALGIB) accounts for 15% of cases of acute lower gastrointestinal bleeding (ALGIB). The incidence increases with age and comorbidity. Identification of the origin of bleeding may be difficult. Colonoscopy has been proposed as the primary investigative tool. AIM: To assess the role of early colonoscopy as the primary method of evaluation in patients with SALGIB. PATIENTS AND METHOD: Retrospective study based on a guideline for clinical practice approved in our institution. The study included 50 patients with SALGIB admitted to our gastrointestinal bleeding unit between January 1998 and April 2000. SALGIB was suspected when patients fulfilled two or more of the following criteria: 1) significant hemodynamic compromise, 2) decrease in hemoglobin 2 g/dl, and 3) transfusion requirement >= 2 blood units. Early colonoscopy was performed within 24 hours of onset of bleeding. An accurate endoscopic diagnosis was established if a lesion with active bleeding, visible non-hemorrhagic vessel or adherent red clot was identified. A presumptive diagnosis was made when hematochezia or fresh blood localized in a colonic segment, associated with a single, potentially hemorrhagic lesion, was observed and when the results of esophagogastroduodenoscopy were negative. Colonoscopy, esophagogastroduodenoscopy, barium studies, nuclear scan and angiography were performed. RESULTS: Two hundred twenty-two patients were admitted for ALGIB. Fifty patients(22%) fulfilled the SALGIB criteria. The male/female ratio was 1:1. Definitive diagnosis was accurate in 20 patients. The most frequent cause was angiodysplasia (6 patients) and rectal ulcer (6 patients). Eighteen patients had a presumptive diagnosis; of these 14 had diverticulosis. In 12 patients, no cause was identified. Colonoscopy was performed in 45 patients, of which 32 were performed early and 13 electively. Accurate endoscopic diagnosis was more frequently established with early colonoscopy than with elective colonoscopy (15 [47%] vs 2 [15%], p < 0.05). The results of urgent nuclear scans contributed to accurate diagnosis in 5 out of the 10 patients in whom this technique was performed. Angiography was performed in 2 patients. Endoscopic therapy was attempted in 4 patients, all during early colonoscopy. Ten patients (20%) underwent surgery and 3 patients (6%) died. CONCLUSIONS: In 22% of patients with ALGIB admitted to our hospital bleeding was severe. Colonoscopy is the diagnostic tool of choice. When performed within 24 hours of hospital admission, this technique provides more accurate diagnosis than when performed electively.

[Clinical approach to portal hypertension]. / Aspectos clínicos del síndrome de hipertensión portal.

Portal Hypertension is one of the most common and severe complication arising from hepatic cirrhosis natural history. Its development conditions the patient prognosis, and its diagnosis and correct evaluation contribute to the correct management of the patient. New techniques for the measurement of portal pressure gradient allow the study and follow-up of patients with esophageal and gastric varices and with risk of hemorrhage, analyzing the efficacy of the treatment applied in a reliable and secure way. It has been probed its utility in the study of the patient with hepatocellular carcinoma, complications after liver transplantation, portal hypertension with no hepatopathy, etc. This review analyzes, from a clinical point of view, the repercussion of the development of portal hypertension in the patient with hepatic cirrhosis, its diagnosis and interpretation, and the importance that its adequate valuation has for the clinical practice.

[Endoscopic drainage with polyethylene endoprosthesis of malignant obstructive jaundice]. / Drenaje endoscópico mediante prótesis de polietileno de la ictericia obstructiva maligna.

AIM: To evaluate the efficacy and complications of endoscopic drainage of malignant obstructive jaundice with plastic endoprosthesis as well as to identify possible factors related with occlusion. PATIENTS AND METHODS: One-hundred and forty patients with malignant obstructive jaundice were retrospectively evaluated. The site of obstruction was proximal in 35 patients (25.0%), distal in 64 (45.7) and ampullary in 41 (29.3). Amsterdam or pigtail polyethylene prostheses of variable caliber and length were used. Drainage was preoperative in 41 patients and palliative in 99. Seventy-seven patients who underwent with palliative drainage were followed up long-term. RESULTS: Drainage was satisfactory in 132 patients (94.2%). Early morbidity was 10.7% (14/140) and early mortality related with the technique was 5% (7/140). Time free of obstruction was 4.6 +/- 1.0 months and in 47/77 (60%) the prostheses were still working at the end of follow-up. The actuarial rate of obstruction at 6 months was 42%, the majority (61%) occurring in the first 3 months. The median survival was 5.9 +/- 1.3 months. Of all the factors analyzed, greater permeability was found only in the ampullary tumors (p < 0.01) and in prostheses of caliber equal or superior to 10 French (p < 0.01). CONCLUSIONS: Endoscopic biliary drainage using plastic prostheses is satisfactory in the majority of patients with malignant jaundice. It has a low complication rate and provides acceptable palliation: the majority of patients do not require prostheses to be replaced and, when they becomes clogged, substitution usually solves the problem. Ampullary tumors and prostheses of higher caliber (> or = 10F) have been associated with greater permeability.

[The predictive factors of a good response to the transfusion of erythrocyte concentrates in patients with controlled digestive hemorrhage]. / Factores predictivos de buena respuesta a la transfusión de concentrados de hematíes en pacientes con hemorragia digestiva controlada.

INTRODUCTION: Not all patients respond the same to the transfusion of erythrocyte concentrates (EC) after achieving the control of gastrointestinal bleeding. AIM: The aim of the present study was to analyze the predictive factors of good response to EC transfusion in patients with controlled gastrointestinal hemorrhage and determine the stability of transfusion performance. PATIENTS AND METHODS: A prospective study was carried out in 61 patients with controlled gastrointestinal bleeding. The epidemiologic data were compared and prior to transfusion different analytical and hemodynamic variables were compared basally. On completion of the transfusion analytical controls were performed at 4 and 24 hours. The response was considered as optimum when pretransfusional basal hemoglobin (Hb) increased at least 1 g and the hematocrit (HCT) rose 3 points for each EC administered. RESULTS: The response to transfusion was optimum in 29 patients and bad in 32. The women responded significantly better than the men (p < 0.05), as did patients with lower weight (p < 0.05) and body surface (p < 0.05). The mean age of the responding patients was greater (p = 0.06) and the height, to the contrary, lower (p = 0.09). No significant differences were observed in the presence or not of associated disease, type of lesion causing the hemorrhage, or number of EC transfused. Likewise, no differences were found with regard to the pretransfusional values of TAM, TAS, FC, PVC, Hb, HCT, VCM, HCM, urea and creatinine. The only variables with independent predictive value of good response were female sex and low body surface. The difference between the Hb and HCT values at 4 and 24 h after transfusion did not achieve statistical significance. CONCLUSIONS: 1. The hemodynamic state and the degree of basal anemia do not condition response to EC transfusion in controlled gastrointestinal bleeding. 2. The response to the administration of EC is better in women and subjects of lower body surface. 3. Postransfusional analytical control at 4 hours allows early evaluation of the effects of the transfusion in patients at risk of recurrent hemorrhage.