A novel system for endoscopic closure of iatrogenic colon perforations using the Ovesco® clip and omental patch.

The growing endoscopic activity, both diagnostic and therapeutic, are also globally makes frequent endoscopic complications, perforation being one of the most serious. However, we also have more possibilities for endoscopic resolution of iatrogenic caused. We report the case of a sigmoid perforation during a colonoscopy that was resolved satisfactorily, avoiding surgery, by endoscopic closure with a nitinol clip Ovesco®.

A retrospective study of pediatric endoscopy as performed in an adult endoscopy unit.

Gastrointestinal endoscopy is a safe, efficient technique with minimal complications, and a useful diagnostic tool for the pediatric population. Under ideal conditions endoscopies for children should be performed by experienced pediatric endoscopists. In this study we report our experience with pediatric endoscopy at the general adult endoscopy unit in our hospital. Our goal is to quantify the number of endoscopies performed in children, as well as their indications and findings, the type of sedation or anesthesia used, and the time waiting for the test to occur. Our experience demonstrates that endoscopists in a general adult gastroenterology department, working together with pediatricians, may perform a relevant number of endoscopies in children in a fast, safe, effective manner.

[The adult age in the medical field]. / Mayoría de edad sanitaria.

Two erroneous concepts have been developed over the last two decades In the Spanish medical literature and clinical practice: a) "mature minor," supposed subject whose rights prevail over those of his/her parents and b) "legal age for health care-related decisions" (16 years), really non-existent in our legal regulations. Several thoughts are given concerning the legislations that have been offered with respect to the "legal-age for health care-related decisions".

Validation of the Spanish version of the Phase III ISAAC questionnaire on asthma.

The prevalence of allergic diseases in childhood has increased significantly over the last decades. This increase seems to be closely associated with the way of life of western societies. The high prevalence differences on different regions may be due to linguistic and cultural reasons and not to real variations in prevalence. This is the reason why several authors felt the need to perform an objective validation of their versions. Our working group has published the results of the Phase I validation and now is publishing the Phase III validation in order to guarantee the reliability of this phase results. The study sample is formed by 366 children aged 3 to 17 years. The following steps were followed in this study: I. Assessment of the "Criterion validity" of the Spanish ISAAC-Bronchial Asthma questionnaire, evaluating the sensitivity, specificity, relative value, and positive and negative predictive values. 2. Determine the questionnaire reliability, analysing its "Inner consistency". 3. Statistical comparison between our ISAAC-Bronchial Asthma results and the ones obtained by other groups (external concordance and consistency), in order to prove the previously evaluated reliability. 4. Comparison between the ISAAC-Bronchial asthma questionnaire diagnostic ability and the standard diagnostic criteria universally used in clinical praxis. We could confirm that there is a high and very significant concordance between the questions aimed to detect children with asthma. In this sense, it is especially useful the question about "ever had wheezing" because of its high sensitivity (93.3%) and specificity (89.9%), that make it able to be used as initial screening test in a general population, and that has shown a high concordance percentage with the questions "ever had asthma" (98%), "wheezing with exercise" (75%), and "cough at night"(80%). The questions that give more information about the evolution and control of the asthmatic disease are "wheezing in the last 12 months", "number of attacks in the last 12 months", "wakening at night", "wheezing with exercise" and "dry cough at night in the last 12 months". The questions more related to asthma severity were "number of attacks in the last 12 months", "wakening at night", "stop speaking in order to breath", and "wheezing with exercise". We conclude that ISAAC-Asthma questionnaire Phase III is a useful tool for the assessment of childhood asthma due to its criterion validity, inner consistency and external concordance.

Tonsillectomy and inflammatory bowel disease location.

OBJECTIVE: Epidemiological studies have found an increased frequency of childhood infections and tonsillectomies in patients with inflammatory bowel disease (IBD). The aim of our study was to test whether particular clinical patterns of IBD could be associated with previous tonsillectomy. METHODS: Two hundred and twenty consecutive IBD patients (100 with Crohn's disease (CD) and 120 with ulcerative colitis (UC)) were prospectively assessed and classified into groups according to disease location. In those with a positive history of tonsillectomy, an ear, nose and throat (ENT) examination was carried out to confirm the diagnosis. RESULTS: Eighty-two IBD patients (37%) underwent tonsillectomy in childhood: 47 out of 100 CD patients (47%), and 35 out of 120 UC patients (29%). Disease location in CD patients affected the ileum in 28, and 21 of them were tonsillectomized (tonsillectomy rate of 75%). Thirty-six patients had an ileocolonic location, and 14 of them had had a tonsillectomy (39%). With disease confined to the colon, only 9 out of 29 patients (31%) had undergone previous tonsillectomy. The higher prevalence of tonsillectomy in patients with CD ileitis was statistically significant (P = 0.0034). No significant differences between groups of UC patients according to the extent of the disease were found. CONCLUSION: The ileum is the most prevalent location of disease in CD patients with previous tonsillectomy.

Effect of fiber supplements on internal bleeding hemorrhoids.

BACKGROUND/AIMS: The aim of this study is to assess prospectively the effect of fiber additions on internal bleeding hemorrhoids. MATERIALS AND METHODS: Fifty patients with bleeding internal hemorrhoids are studied and randomized in two groups. Patients in the study group were treated with a commercially available preparation of Plantago Ovata and those in the control group were treated with a placebo. Endoscopy was performed on every patient before and after treatment to establish: a) the degree of hemorrhoidal prolapse, b) the number of congested hemorrhoidal cushions and c) contact bleeding hemorrhoids. RESULTS: During the 15 days of treatment, the average number of bleeding episodes was 4.8 +/- 3.8 for the study group versus 6.4 +/- 3 for the control group (n.s.). During the following 15 days, it decreased to 3.1 +/- 2.7 in the study group versus 5.5 +/- 3.2 (p < 0.05) in the control group and in the last 10 days of treatment a further reduction to 1.1 +/- 1.4 was found in the study group versus 5.5 +/- 2.9 (p < 0.001). The number of congested hemorrhoidal cushions diminished from 2.6 +/- 1 to 1.6 +/- 2.2 after fiber treatment (p < 0.01) and no differences were found in the control group. In the fiber group, hemorrhoids bled on contact in 5 out of 22 patients before treatment and in none after treatment; no differences were found in the control group. No modification of the degree of prolapse was observed after treatment. CONCLUSION: Addition of dietary fiber may improve internal bleeding hemorrhoids although with no immediate effect. Fiber addition should be ensured in patients who refuse invasive treatment, waiting for a more defined form of treatment, or with contraindications.

[Conventional stress test in patients with dilated cardiomyopathy. Variables with prognostic value. Correlations with non-invasive and invasive tests]. / Prueba de esfuerzo convencional en pacientes con cardiomiopatía dilatada. Variables con valor pronóstico. Correlaciones con pruebas no invasivas e invasivas.

The variables of conventional stress testing were studied to determine their prognostic value and their correlations with other tests, in 34 patients with dilated cardiomyopathy divided into a first group of 20 in-patients admitted because of acute pulmonary edema (GI), and a second group of 14 stable out-patients (GII), with a mean follow-up of 3 years. The GI-patients had data of more evolved disease as reflected by a lower fractional shortening (13.5 +/- 4.6 vs 17.8 +/- 3.9%; p < 0.05). The only variables with prognostic capacity were functional aerobic incapacity (FAI), and systolic arterial pressure reached on exercise (SAPE), this being applicable only to GI-patients (FAI: 19.6 +/- 17.34 vs 46 +/- 26.4% in alive vs patients who died respectively; p < 0.05) (SAPE: 155 +/- 23.21 vs 127.14 +/- 24.9 mmHg, respectively; p < 0.05). Also a good correlation between the cardiac rate reached on exercise and the cardiothoracic index on chest X-ray was found (p = 0.0001), again, for GI-patients only. The presence of ventricular arrhythmias (VA) on stress testing had a very good correlation with a Holter VA-score (p < 0.0001), this being applicable for both GI and GII patients. The correlations with haemodynamic variables obtained by, basal or post-dobutamine infusion, right catheterism were not good by and large, except between FAI and systemic resistances. It is conclude that: 1) Conventional stress testing provides variables of prognostic value in dilated cardiomyopathy patients but only in those with more evolved disease. These variables are the FAI and the SAPE. 2) The presence of VA during exercise predicts their presence in daily life, and in this case at an earlier phase of the disease. 3) There are not good correlations between the haemodynamic and stress testing variables except in the case of systemic resistances and FAI.

[Fibrin-fibrinogen degradation products in cerebrospinal fluid of patients with meningococcal infections (author's transl)]. / Productos de degradación de la fibrina-fibrinógeno en el líquido cefalorraquídeo de pacientes con enfermedad meningocócica.

Fibrin degradation products (FDP) D and E, total protein, cell count, and alpha-1-antitrypsin levels have been measured in the cerebrospinal fluid (CSF), and FDP-D and E, and alpha-1-antitrypsin analyzed in serum in 13 cases of meningococcal disease, six with meningococcal septicemia and seven with meningitis. Neisseria meningitidis serotype B was the responsible agent in all cases. The following conclusions are obtained: 1) The presence of FDP in the CSF has no prognostic value, and its detection only in plasma does not exclude a fatal outcome. 2) Statistical analysis of the data suggests that the presence of FDP in the CSF is not the result of passive transfer from plasma but it indicates a meningeal inflammatory reaction. 3) Alpha-1-antitrypsin levels are elevated in meningococcal infections both in plasma and in the CSF, and they significantly correlate with the intensity of the fibrinolytic activity.

[Immunocellular response to fetal antigens in patients with hepatoma (author's transl)]. / Respuesta inmunocelular frente a antígenos fetales en pacientes con hepatoma.

The immunocellular response to fetal antigens was studied in ten patients with hepatocarcinomas. Homogenized extracts of human fetal liver and purified human alpha-fetoprotein were used as antigen substances. The control group included 15 patients with cirrhosis of the liver. The level of circulating T lymphocytes (E-rosettes) was also registered. Patients with hepatocarcinoma showed a definite response to both antigens, determined by the degree of inhibition of leukocyte migration. The migration indices were as follows: x = 0.65 +/- 0.16 for homogenized fetal liver antigen, and x = 0.79 +/- 0.13 for alpha-fetoprotein antigen. These values were 0.93 +/- 0.13 and 0.95 +/- 0.15 respectively in the cirrhotic patients. The differences in the migration indices for the two groups were statistically significant with both antigens (p less than 0.0005 and p less than 0.005). The decrease of the number of T lymphocytes in patients with hepatomas was also significant (p less than 0.005). The determination with homogenized fetal antigen was more sensitive than with alpha-fetoprotein (p less than 0.01). A significant relationship between the severity of the tumor and the immunocellular response could also be seen (r = 0.84; p less than 0.001). Response tended to diminish as the tumor progressed. The disappearance of immunocellular response seemed to depend at least in part on the decreasing number of T lymphocytes, since there was a significant inverse correlation between the two parameters (r = -0.75; p less than 0.01).

[Immunological alterations in a case of desquamative interstitial pneumonia (author's transl)]. / Alteraciones inmunológicas en un caso de neumonía intersticial descamativa.

A 48-years-old patient with a clinical picture of dyspnea, unproductive cough, and nonspecific thoracic pain is reported. The most outstanding finding in the physical examination was the auscultation of fine crepitants after inhalation, located in both pulmonary bases. The chest X-ray desmonstrated the existence of some confluent, bilateral opacities of a net basal predominance, which were suggestive of an interstitial process. The lung biopsy, through a thoracotomy, has allowed for the diagnosis of a desquamative interstitial pneumonia. The alterations found in the humoral immunity, which basically consisted of an important increase of IgG and a less-marked increase of IgA, have shown a regressive tendency, closely correlated to a good response to the steroid therapy. The clinical and roentgenological course of the patient has been similarly favourable.

Estimated incidence of inflammatory bowel disease in Argentina and Panama (1987-1993).

AIM: to estimate the incidence of inflammatory bowel disease (IBD) in two areas from Panama and Argentina. METHOD: during a 7-year period from 1987 to 1993 we surveyed IBD in two well-defined communities from Panama (District of Colón) and Argentina (Partido General Pueyrredón). The mean annual incidence of IBD was estimated from hospital-based registries. Records from the General Records Department and the endoscopy, radiology and pathology services were reviewed at the Hospital MA Guerrero in Colón and at two other hospitals in Partido General Pueyrredón to identify suspected cases of IBD. Cases were confirmed using standard criteria, and disease incidence rates were calculated by dividing the number of cases in which a positive diagnosis could be established by the population served by each hospital. RESULTS: mean annual incidence of ulcerative colitis in Panama was 1.2/100 000 inhabitants/year, and no cases of Crohn's disease (CD) could be diagnosed. Mean annual incidence of IBD in Partido General Pueyrredón was 2.2/100 000 inhabitants/year, with only a single case of CD being identified. We argue that such figures could represent a good estimate of the incidence of IBD in each area, given the wide coverage of the population by the hospitals surveyed in each region. CONCLUSION: according to these results, the incidence rates of IBD seem to be much lower than those published for other "Hispanic" communities outside Latin America. Factors such as population structure, environment or genetic determinants might account for these differences.

Endoscopic anal dilatation for fissure-in-ano: a new outpatient treatment modality.

We describe a new therapeutic procedure for fissure-in-ano, endoscopic anal dilatation. Anal dilatation is performed with a two-valved anoscope under local anesthesia in an ambulatory setting. We report our results using this technique in 62 patients after a mean follow-up of 19 months (range: 12-24 months). Thirty days after the procedure, 55 patients (93%) were symptom-free, whereas 3 of them (4.8%) failed to improve. After nineteen months, one patient out of 47 in follow-up had a recurrence. No bleeding, discharge or defects of continence, either transient or permanent, were noted. The results of endoscopic anal dilatation are comparable with those of lateral sphincterotomy, can be achieved at a lower complication rate, with only minor and temporary complications, and performed by physicians with no specific surgical training.