Lactulose enemas in the treatment of hepatic encephalopathy. Do we help or harm?

The administration of lactulose enemas instead of or in combination with oral lactulose is common practice in patients with hepatic encephalopathy. Lactulose is a non-absorbable disaccharide that is catabolized by the bacterial flora to short chain fatty acids (e.g., lactic acid and acetic acid) which lower the colonic pH. This pH favors the formation of non-absorbable NH4+ from NH3, trapping NH4+ in the colon and thus reducing plasma ammonia concentrations. Lactulose therapy is considered as a first-line treatment and can be administered both orally and rectally.

Practical aspects of high resolution esophageal manometry.

High resolution esophageal manometry (HRM) is currently under development as can be seen in the various Chicago classifications. In order to standardize criteria in certain practical aspects with limited scientific evidence, the First National Meeting for Consensus in High Resolution Manometry of the Spanish Digestive Motility Group took place, bringing together a wide group of experts. The proposals were based on a prior survey composed of 47 questions, an exhaustive review of the available literature and the experience of the participants. Methodological aspects relating to the poorly defined analysis criteria of certain new high resolution parameters were discussed, as well as other issues previously overlooked such as spontaneous activity or secondary waves. Final conclusions were drawn with practical applications.

Weight Gain and Somatization are Associated With the Onset of Gastroesophageal Reflux Diseases: Results of Two 5-year Follow-up Studies.

BACKGROUND: Although 2% to 4% of the population develop gastroesophageal reflux disease (GERD) annually, factors associated with the onset of GERD are scarcely known. OBJECTIVE: To assess whether such factors include weight gain and psychological distress. METHODS: Two cohorts (first: N=222; second N=754) drawn from 2 case-control studies were followed up for around 5 years. In 2004, all participants were directly interviewed using a validated questionnaire to collect data on body weight, height, GERD symptoms, and psychological distress. In 2009 to 2010, these same participants were again interviewed using the same methodology. RESULTS: The response rate was 83.3% in cohort 1 and 39.1% in cohort 2, after a follow-up of 4.3±0.7 and 5.6±0.3 years, respectively. The multivariate analysis showed only weight gain and psychological distress as being independently associated with the onset of GERD in both cohorts. Weight gain per kilogram showed an adjusted odds ratio (OR) of 1.21 (1.01-1.44) in the first cohort, and a gain of 5 kg or more showed an adjusted OR of 4.65 (1.72-12.53) in the second. Somatization scores showed an adjusted OR of 1.09 (1.04-1.15) in the first cohort (measured as Minnesota Multiphasic Personality Inventory 2 hypochondriasis score) and 2.88 (1.04-8.02) in the second (measured as psychosomatic symptoms score). Body mass index on attaining overweight or obese status was associated with the onset of GERD in the unadjusted but not in the adjusted analysis. CONCLUSIONS: Weight gain and somatization are the main factors associated with the onset of GERD. The association between GERD and obesity is just the ultimate consequence of gaining weight.

Medication list assessment in Spanish hospital emergency departments.

BACKGROUND: Medication errors lead to morbidity and mortality among emergency department (ED) patients. An inaccurate medication history is one of the underlying causes of these errors. OBJECTIVES: This study was performed to determine the prevalence of patients with discrepancies between the medical list information contained in the clinical history compiled on admission to the ED and the list of medications patients are actually taking, to characterize the discrepancies found, and to analyze whether certain factors are associated with the risk of discrepancies. METHODS: We conducted a cross-sectional, descriptive, observational, multicenter study with an analytic component in the EDs of 11 hospitals in Spain. We compared pharmacist-obtained medication lists (PML) with ED-obtained medication lists (EDML). Discrepancy was defined as one or more differences (in drug or dosage or route of administration) between the EDML and PML. The endpoints were the proportion of patients with discrepancies in their home medical lists, and the prevalence of certain factors among patients with discrepancies and those without. RESULTS: We detected 1476 discrepancies in 387 patients; no discrepancies were found in 20.7%. The most frequent discrepancies involved incomplete information (44.2%) and omission (41.8%). In the bivariate analysis, age, number of medications, and Charlson comorbidity score were significantly associated with discrepancy. In the multivariate analysis, number of medications and hospital were the variables associated with discrepancy. CONCLUSIONS: The EDML differed from the list of medications patients were actually taking in 79.3% of cases. Incomplete information and omission were the most frequent discrepancies. Age, number of medications, and comorbidities were related to the risk of discrepancies.

Translation, cultural adaptation and validation of a Spanish version of the Irritable Bowel Syndrome Severity Score.

BACKGROUND: the Irritable Bowel Syndrome Severity Score (IBSSS) is a questionnaire only available in English that classifies IBS patients according to the severity of their symptoms and can be used to guide and monitor the treatment. AIMS: to adapt and validate into Spanish the English version of the IBSSS questionnaire. METHODS: the Spanish version of the questionnaire was obtained through a process of translation-evaluation of the comprehensibility and back translation. In a later phase we evaluated the applicability(n = 15), reproducibility (n = 31) and sensitivity to change (n = 40) of the Spanish version of the questionnaire. Finally we evaluated an alternative version of the ISBSS using a numerical scoring system instead of the original analog visual scale (n = 40). RESULTS: the Spanish version of the IBSSS showed an excellent reproducibility (r = 0.81 for global score) and an adequate sensitivity to change: a decrease of 45 points or more identified worsening of IBS with a 70.6% sensitivity and 87.5% specificity; an increase of 45 points or more identified improvement of IBS with a 85.7% sensitivity and 87.5% specificity. The severity score was practically the same regardless of the scoring system used (r = 0.96). CONCLUSIONS: the Spanish version of the IBSSS is a reproducible tool that is able to identify relevant changes over the course of the disease. The use of a numerical scoring system is a valid alternative to the visual scale that improves the applicability of the questionnaire to situations when the written communication is limited or not possible.

Promoting clinical pharmacy services through advanced medication review in the emergency department.

Objectives: To determine if an advanced medication review carried out in the emergency department (ED) increases the number of pharmacotherapy recommendations (PR) and the severity of the detected prescribing errors. Methods: We designed an analytic observational prospective cohort study with preintervention assessment (PRE) and postintervention assessment (POST). In PRE, prescription review was done by pharmacists located in the pharmacy department; they took into account only the information provided by the computerised physician order entry system. In POST, pharmacists were physically present in the ED and performed an advanced medication review. The main variables were number of PR and the severity of detected prescribing errors according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) severity index. Clinical variables were number of calls to physicians on duty during the first 48 hours of admission, readmissions at 30 days, visits to the ED at 30 days, inhospital mortality and length of stay. Results: The study population comprised 102 patients (51 in PRE and 51 in POST). In PRE, the number of PR per patient was 1.1; in POST, this value increased by 53% (1.7 PR per patient; P=0.014), especially in the case of PR related to home medications. The severity of prescribing errors was higher in POST (P=0.004). There was a trend towards better results for all clinical outcomes in POST although statistical significance was not reached. Conclusions: An advanced medication review in the ED increases the number of PR and the severity of the detected prescribing errors.

Drug safety surveillance within a strategy for the management of non-chemotherapy drug-induced neutropenia.

Background Severe non-chemotherapy drug-induced neutropenia is a rare idiosyncratic drug reaction that is considered potentially fatal. Objective To report, in terms of drug safety surveillance, the results of an institutional strategy for NCDIN. Method An observational and prospective study including all adult patients who received filgrastim for the treatment of NCDIN from June 2015 to December 2017 was carried out by hematologists and clinical pharmacists. Results 13 patients with severe NCDIN were included in the study. The median age was 51 (range 24-80) years old and 46.2% were male. Seven patients had one or more negative prognostic factors (age > 65 years, renal impairment, autoimmune diseases and/or a neutrophil count at diagnosis < 0.1 × 109 cells/L). A single drug was identified as causative in 3 patients, while in 10 cases, 2-3 drugs were considered as potentially causative. The most frequent drugs were metamizole, piperacillin/tazobactam, dexketoprofen and linezolid, among others. Seven patients developed NCDIN during their hospital stay while 6 were admitted to the emergency department. Patients were using a median of 11 drugs (IQR 8-15) at the time of diagnosis. No deaths were recorded. Conclusion Metamizole and piperacillin/tazobactam are the most common drugs linked to non-chemotherapy drug-induced neutropenia in our cohort.

Level of concordance between two risk-assessment models for predicting venous thromboembolism in medical patients at admission.

OBJECTIVES: To evaluate the level of concordance between the 2007 PRETEMED guidelines and the 2012 American College of Chest Physicians (ACCP) guidelines in medical patients at admission. METHODS: A cross-sectional, observational and descriptive study was designed and included all adult medical patients admitted from an emergency department. Firstly, patients classified as low-moderate risk and high risk according to PRETEMED were compared to those classified by ACCP as low and high risk. Secondly, the same analysis was performed but this time low and moderate-high risk patients according to PRETEMED were compared to ACCP low and high risk patients. The level of concordance was calculated using the kappa concordance index. The study was approved by the Ethics Committee for Clinical Research of the hospital. RESULTS: The analysis was performed with 207 patients; 53.1% were male and the median age was 75.3 years (minimum 18, maximum 100 years old). The most common diagnosis at admission was related to a respiratory disease (37.2%). The level of concordance was 0.59 (95% CI 0.48 to 0.70) when moderate risk patients were grouped with low-risk patients and 0.53 (95% CI 0.42 to 0.65) when moderate risk patients were grouped with high-risk patients. CONCLUSIONS: The level of concordance between both guides is moderate. It would be helpful to confirm whether the level of agreement improves when the patient's condition stabilises after several days of hospitalisation.

[Causes of the emergency department visits in cancer patients: postchemotherapy toxicity]. / Análisis descriptivo de los motivos que originan visitas a urgencias en pacientes oncológicos: toxicidad postquimioterapia.

PURPOSE: to assess the causes of the Emergency Department visits in cancer patients treated with antineoplastics. The secondary objective is to analyse the use of growth stimulating factors in febrile neutropenia. METHODS: a retrospective observational study was conducted during six months of 2012. The adult patients diagnosed with solid tumour that visited the Emergency Department and whose physician was an oncologist, were included. RESULTS: a total of 83 patients fulfilled the inclusion criteria. The causes of visits were: 63% due to the tumour, 31% due to the chemotherapy toxicity and 6% due to other causes. In patients with chemotherapy toxicity, 65% had fever or infection, 50% pain and 42% febrile neutropenia. The treatment and prophylaxis with filgrastim followed the recommendations. CONCLUSIONS: in cancer patients, most of emergencies are due to the tumour. The management of the pain, the fever and the neutropenia is important.

Objetivo: cuantificar y analizar las causas por las que los pacientes oncológicos acuden al Servicio de Urgencias y analizar el uso de factores estimulantes de colonias para la profilaxis o el tratamiento de la neutropenia febril. Método: estudio retrospectivo de seis meses del año 2012. Se incluyeron pacientes adultos con tumor sólido y tratamiento activo atendidos por oncólogos en el Servicio de Urgencias. Resultados: se incluyeron 83 pacientes. Respecto al motivo de consulta: en el 63% es causa tumoral, 31% toxicidad postquimioterapia y 6% otras causas. En los que acuden por toxicidad, el 65% presentaron fiebre o síntomas de infección, el 50% dolor y el 42% neutropenia febril. La profilaxis y el tratamiento de la neutropenia febril con filgrastim siguieron las recomendaciones. Conclusiones: la mayor parte de los episodios oncológicos en Urgencias son debidos al propio proceso tumoral. Algunos problemas importantes son el manejo del dolor, la fiebre y la neutropenia.

Multi-element including rare earth content of lichens, bark, soils, and waste following industrial closure.

The fate of rare earth and other rare elements entering the environment is largely unknown. The lichen Hypogymnia physodes was transplanted over a 40 km long transect centered on a major metallurgical waste dump close to the Zlatna town center two weeks after smelter closure. Lichens, bark, soil, and waste dump materials were analyzed for 56 elements (including REE). Lichen and bark multi-element compositions were alike, reflecting fixation of elements of environmental concern and the ability for tree canopies to concentrate substances leading to enhanced deposition to both lichens and bark. Higher REE enrichment in lichens than in soil confirm efficient fixation in lichens. The negative europium anomaly in lichens and soil, similar to that in upper crust, confirm a strong crustal influence on lichen signatures across the transect area. Multi-element analysis supports the view that epiphytic lichens, unlike trees, are not influenced by lower groundwater, and they are excellent indicators for REE and other rare elements entering the surface environment, difficult to detect by conventional means.