Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient.

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

Cyclosporine in the treatment of severe attack of ulcerative colitis: a systematic review.

INTRODUCTION: Intravenous steroid therapy is the standard treatment in severe attacks of ulcerative colitis (UC), but 20% to 60% of patients fail to respond and require colectomy. Cyclosporine (CyA) has shown efficacy in steroid failures and could avoid surgery, but controversy remains. AIM: The objective of this study was to conduct a systematic review to evaluate the effectiveness and safety of CyA in inducing remission in patients with a severe attack of UC. METHODS: We did a systematic review using Cochrane methodology, including data from published (in English, French, Spanish or German) clinical trials done in adults using intravenous or oral CyA in UC. Data on efficacy are obtained from controlled and observational clinical trials, and for safety issues case reports are also considered. RESULTS: 31 studies were identified which met the inclusion criteria, 22 (18 uncontrolled, 4 controlled) with intravenous CyA, and 9 (all uncontrolled) using oral CyA. Only 4 controlled trials (one in abstract form) are available, and only one compares CyA to placebo. However, efficacy results are very consistent in these 4 trials, and very similar to those in observational studies. CyA achieves remission in 91,4% and 71.4% of patients in controlled and uncontrolled studies using intravenous route, and in 71,2% using oral route. Two mg/kg/day seems so efficacious and safer as previous standard 4 mg/kg/day dose. Minor side effects are rather common but do not seriously limit therapy. Severe side effects, specially infections, are uncommon but clinically relevant with several deaths reported. CONCLUSION: CyA (intravenous, 2 mg/kg/day) constitutes an efficacious and relatively safe alternative in the treatment of severe, steroid-refractory, attack of UC. To optimize treatment, the correct selection of patients, a standardized protocol and clinical surveillance are recommended.

[Duodenal Crohn's disease: diagnostic and therapeutic complexity]. / Enfermedad de Crohn duodenal. Complejidad diagnóstica y terapéutica.

Crohn's disease may involve any area of the digestive tract, but its localization in the duodenum is rare. The clinical, radiological or endoscopic findings may simulate those of peptic ulcer and histologic examination is not diagnostic. In contrast with Crohn's disease of any other localization, the formation of fistulas is exceptional. The authors present one case of duodenal Crohn's disease the unspecific symptomatology of which deviated the original orientation towards the more common diseases. Steroid treatment was not sufficient to control the disease which led to complications with the formation of an enterocutaneous fistula. The association of azathioprine was very effective not only in achieving remission of the process, but also in resolving the complications.

[Hypothyroidism as a complication of the treatment of hepatitis C with interferon]. / Hipotiroidismo como complicación del tratamiento con interferón de la hepatitis C.

Interferon is becoming the most important therapy for chronic hepatitis due to hepatitis C virus. Secondary effects are frequent and sometimes so important to stop the therapy. Autoimmune disorders, specially autoimmune thyroid diseases may occur. We report two out of 69 chronic hepatitis C patients treated with interferon who developed hypothyroidism, that required definitive substitutive therapy.

[Hepatitis C following administration of intravenous immunoglobulins]. / Hepatitis C tras administración de inmunoglobulinas intravenosas.

Five patients with hepatitis C virus infection of different severity and evolution following the administration of intravenous (i.v.) immunoglobulins (Igs) are presented. The important morbidity of hepatitis C virus infection and the need for adequate donor screening are discussed, as is accurate indication of these drugs in the management of patients with immunosuppression and other diseases.

[Hemorrhagic diathesis as initial clinical manifestation of celiac disease]. / Diátesis hemorrágica como manifestación clínica inicial de la enfermedad celíaca.

Coeliac disease is the most frequent malabsortive syndrome in daily practice. However, its true prevalence is not exactly known. The symptoms vary from patient to patient, ranging from the classic presentation with diarrhea, weight loss and fatigue to oligosymptomatic forms, being the latter more common in adults. We report two patients in which urinary and skin spontaneous hemorrhage were the only symptoms, and led to the diagnosis. We insist on the importance of considering the diagnosis of coeliac disease in patients with this kind of clinical manifestations. The early diagnosis will allow us to reduce both the morbidity and mortality in coeliac patients.

[Inflammatoru bowel disease in Aragón: a more and more frequent diagnosis]. / Enfermedad inflamatoria intestinal en Aragón: un diagnóstico cada vez más frecuente.

OBJECT: To study the frequency of inflammatory bowel disease in our area. MATERIAL AND METHODS: A retrospective, hospital-based analysis identifying potential cases, with a posterior study of case records following a predefined protocol, according to international standards in diagnosis. PATIENTS: All patients with a confirmed diagnosis of Crohn's disease, ulcerative colitis, or indeterminate colitis established between 1975 and 1992 at our Hospital. RESULTS: 222 cases (ulcerative colitis: 109; Crohn's disease 93; indeterminate colitis 20) were identified and a clear trend for an increased incidence was found for the three diagnoses; with annual incidence below 1 for them all in the 1975-1977 period versus 3.66; 3.33; and 1 respectively in the 1990-1992 period. This trend was evident both for ulcerative colitis and Crohn's disease. CONCLUSIONS: The global frequency of inflammatory bowel disease has increased in the last years in Zaragoza (Spain), and its incidence in now very similar to that reported in northern European countries. Possible factors associated with this phenomenon should be pursued in future studies.

Acid inhibition and long-term treatment of peptic ulcer disease.

Acid is an influencing factor in most peptic diseases, including peptic ulcers. Acid inhibition, whatever the means used to obtain it, is followed by healing of most peptic ulcers. If acid inhibition is maintained recurrences are prevented (or diminished). A quantitative correlation between the degree of acid inhibition obtained and the effectiveness of treatment has been suggested in different studies. However, it is not possible to predict in the individual subject which rate of acid inhibition is needed for healing, and which rate is needed for avoiding relapse. Acid inhibition, apart from intrinsic toxicity of the drugs used to obtain it, is not without theoretical risks, particularly bacterial overgrowth and gastric carcinogenesis. To date, these effects lack practical importance at least with the doses and durations of treatments reported. Empirical data on acid inhibition and treatment of peptic ulcers, especially duodenal ulcers, are abundant. However, pathophysiological studies are scarce. Pathophysiological data should be studied in the future in groups of patients in order to design new strategies of treatment, particularly individual treatments. Acid inhibition by drugs or surgery remains the most important treatment of peptic ulcer disease. Long-term acid inhibition by drugs is safe and effective.