Changing trends in polypoid colorectal cancer diagnosed by colonoscopy.

AIM: This study analysed trends in polypoid colorectal cancer (PCRC) diagnosed by colonoscopy during the period 1995-2008 and compared the patterns observed in the years 2005-2008 with 1995-1998. METHOD: In the period 1995-2008, 24,245 colonoscopies were performed and 1041 patients with PCRC were diagnosed: pediculated (n = 220) or sessile (n = 821). RESULTS: The mean age at diagnosis was 68.3 ± 11.6 years. Males were more likely to have PCRC (males 62.6%vs females 37.4%; P < 0.0001). Significantly more pediculated PCRCs were located in the distal colon (P < 0.001). In the 2005-2008 period the prevalence of PCRC among patients undergoing colonoscopy decreased, the number of polypectomies increased significantly (P < 0.0001) and the pediculated PCRC location changed, with a significant increase in right-sided lesions. CONCLUSION: The prevalence of PCRC in patients undergoing colonoscopy decreased, with a significant increase in the number of polypectomies in the last decade. Pediculated PCRCs were more often located in the left colon and sessile PCRCs in the right colon. From the period 1995-1998 to 2005-2008 the location of pediculated PCRCs changed, with an increase in right-sided lesions.

Endoscopist experience as a risk factor for colonoscopic complications.

AIM: We aimed to determine the incidence of colonic perforation (CP) following colonoscopy and postpolypectomy bleeding (PPB) in a teaching hospital, assessing the influence of endoscopist experience as a risk factor. METHOD: All colonoscopies performed between 1995 and 2008 were reviewed. Demographic data, endoscopic procedure information, incidence of CP and PPB, and endoscopist experience were recorded. RESULTS: In the 14-year period, 25,214 endoscopic colonic procedures were performed, and 3991 patients underwent polypectomy. The overall CP risk was 0.51/1000 procedures; and PPB 14.7/1000. The relative risk (RR) ratio of complications was 2.8/1000 procedures. The RR rate was highest for endoscopists performing less than 591 procedures per year (4.0/1000 [95% CI, 3.7-4.3] vs 2.9/1000 [95% CI, 2.6-3.2]), P < 0.001). CONCLUSION: The complication rate after colonoscopy was comparable to that previously reported. Colonoscopy carried out by a low-volume endoscopist was independently associated with bleeding and perforation.

Appropriateness of colonoscopy in Europe (EPAGE II). Functional bowel disorders: pain, constipation and bloating.

BACKGROUND AND STUDY AIMS: To summarize the published literature on assessment of appropriateness of colonoscopy for the investigation of functional bowel symptoms, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. METHODS: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of functional bowel symptoms was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. RESULTS: Much of the evidence for use of colonoscopy in evaluation of chronic abdominal pain, and/or constipation and/or abdominal bloating is modest. Major limitations include small numbers of patients and lack of adequate characterization of these patients. Large community-based follow-up studies are needed to enable better definition of the natural history of patients with functional bowel disorders. Guidelines stress that alarm features ("red flags"), such as rectal bleeding, anemia, weight loss, nocturnal symptoms, family history of colon cancer, age of onset > 50 years, and recent onset of symptoms should all lead to careful evaluation before a diagnosis of functional bowel disorder is made. EPAGE II assessed these symptoms by means of 12 clinical scenarios, rating colonoscopy as appropriate, uncertain and inappropriate in 42 % (5/12), 25 % (3/12), and 33 % (4/12) of these, respectively. CONCLUSIONS: Evidence to support the use of colonoscopy in the evaluation of patients with functional bowel disorders and no alarm features is lacking. These patients have no increased risk of colon cancer and thus advice on screening for this is not different from that for the general population. EPAGE II criteria, available online (http://www.epage.ch), consider colonoscopy appropriate in patients of > 50 years with chronic or new-onset bowel disturbances, but not in patients with isolated chronic abdominal pain.

[Epidermiology of alcohol withdrawal syndrome. Mortality and factors of poor prognostic]. / Epidemiología del síndrome de abstinencia alcohólica. Mortalidad y factores de mal pronóstico.

INTRODUCTION: Patients with alcoholism and alcohol withdrawal syndrome (AWS) have a worse prognostic. METHODS: We have performed a retrospective analysis of the hospital discharges in with diagnosis include AWS from 1 of January of 1997 to the 31 of December of 2002. RESULTS: We identified 924 hospital stays with 2.4% of mortality (1.6% in Internal Medicine). Mortality is associated with greater age (57 years +/-15 vs. 49+/- 13, p < 0.005), with the diagnostic of hepatic cirrhosis (6.2 vs. 1.8%, p < 0.005), bacteraemia (10 vs. 1.8%, p < 0.001) and respiratory infection (9.6 vs. 1.8%, p < 0,001), with a lower mortality when AWS was secondary diagnosis (1.2 vs. 4.2%, p < 0.005). In multivariant analysis were associated with more mortality age (OR 1.03), hepatic cirrhosis (OR 3.4), bacteriemia (OR 4.5) and respiratory infection (OR 3.6). CONCLUSION: Alcohol withdrawal syndrome mortality could to benefit from treatment in an Internal Medicine Service.

[Diagnosis by cranial computer tomography of sphenoidal sinusitis]. / Diagnóstico por tomografía axial computarizada de sinusitis esfenoidal.

Sphenoidal sinusitis is an uncommon pathology potentially dangerous condition, that we can find in young population. Clinically it is very difficult to diagnose because of its nonspecific symptoms, but cranial computer tomography confirms the diagnosis. The most cases were treated with antibiotics and recovered completely. We present a young man with isolated sphenoidal sinusitis who was managed in our medical centre, and a review of the literature.

[Epidemiologic analyses of elderly patients in an Internal Medicine department]. / Análisis epidemiológico de los pacientes ingresados en un servicio de medicina interna.

OBJECTIVES: To study the characteristics of the entered patients in an Internal Medicine department. PATIENTS AND METHODS: Descriptive and observational study with admissions elder than 65 years old in an Internal Medicine Department during the year 2002. The variables analyzed were: age, sex, intake date, discharge date, days of hospital stay, chronic disease previous, reason for admission (guide symptom), deceased and diagnosis at discharge. The statistical analysis was performed with measures of central tendency and of standard deviation, Chi-squared Mann-Whitney-Wilcoxon. RESULTS: 770 patients were accepted for the study. The distribution in sex is similar, although the women show greater median age. The most frequent chronic disease was ischemic hypertensive heart disease (25.7%) and the 64.9% of the patients have some cardiovascular risk factor. The men show more cardiovascular risk factor and more chronic disease (p < 0.01). The most frequent was dyspnea (42.7%). The most frequent diagnosis was cardiac failure (20.6%). 16.6% of the patients died in the hospital, and the most frequent diagnosis was respiratory tract infection (49.5%). CONCLUSIONS: The most frequent pathologies are the cardiopulmonary chronic disease of developed countries. The primary and secondary prevention and an improvement of chronic cardiopulmonary disease would be an effective way of cost control in these disease.

[Control of hypertension in elderly patients admitted in internal medicine]. / Grado de control de hipertensión arterial en población mayor de 65 años ingresada en un servicio de Medicina Interna.

OBJECTIVES: To investigate hypertension control in elderly patients. To identify the cardiovascular risk factors and cardiovascular diseases associated with poor control of hypertension. To evaluate the pharmacologic treatment needed for the good control of hypertension. To analyse the existence of date in the medical history to evaluate the cardiovascular risk. METHODS: A cross-sectional study of elderly hypertensive patients intaked between 1 to January 2002 to 31 December 2002 in a Internal Medicine Service. Blood pressure was measured in the standard manner. Blood pressure control was regarded as optimum if pressure averaged less than 140/90 mmHg or, in diabetics, less than 130/80 mmHg. RESULTS: The study included 484 hypertensive patients. In the hypertensive patients, both systolic and diastolic blood pressures were well controlled in 53.9% of patients, systolic blood pressure alone in 2,1% and diastolic blood pressure alone in 30.8%. The isolated systolic arterial hypertension prevalence is bigger in the group with poor control, p < 0.001. The 77% of hypertensive patients associated other cardiovascular risk factor, and the 69% associated any cardiovascular disease. The 64% of hypertensive patients needed pharmacologic treatment. CONCLUSIONS: Arterial blood pressure control was optimum in only one out of two hypertensive patients. Diabetes is the most influential variable in poor control. The diuretics are the active ingredients more used in the hypertension therapeutic.

[Bacteraemia due to Leuconostoc spp. in a patient without immunological disorders]. / Bacteriemia por Leuconostoc spp. en paciente sin factores de riesgo.

Leuconostoc spp are gram-positive coccobacilli, catalase and oxidase negative, vancomycin resistant. Causes of infection have been reported previously but it has not been described confirmed bacteremia due to Leuconostoc spp in patient without other immunological disorders. We describe a case of bacteremia in a 64-years-old man with a prosthetic valve 7 months before to begin fever of unknown origin. We confirmed bacteremia due Leuconostoc spp and the treatment with respective antibiotics permits the cure. Leuconostoc spp should be considered as a potential cause of bacteraemia, but we would be observant to the bacteremias due vancomycin resistant germs, because in most cases the laboratory do not find the sensitivity to this antibiotic.

[Gasometric alterations in hospitalized cirrhotic patients]. / Alteraciones gasométricas en pacientes cirróticos hospitalizados.

BACKGROUND AND OBJECTIVES: Gas exchange alterations have been described in cirrhotic patients; but by the moment, a few prospective studies have focused in them. The aim of this study was to describe the frequency and severity of gasometric alterations in hospitalized cirrhotic patients, a their correlation with hepatocellular disfunction. PATIENTS AND METHODS: 50 consecutive cirrhotic patients (41 males) admitted for liver decompensation (ascites, liver encephalopathy, alcoholic hepatitis and upper gastrointestinal bleeding) without acute or chronic cardiopulmonary disfunction were included in the study. Patients were classified according with Child-Pugh score (A, n = 13; B, n = 21; C, n = 16). Severe alcoholic hepatitis (SAH) was confirmed in 7 patients. Arterial gasometry was performed in all patients before discharge. Contrast echocardiography was performed in any case of suspicion of hepatopulmonary syndrome (HPS). RESULTS: Light hypoxemia was observed (80.9 mmHg), without differences with Child-Pugh. Hypocapnia was significantly more evident in Child C than in A and B (31.2 +/- 3.1 vs. 38.1 +/- 4.3 y 36.3 +/- 5 mmHg; p < 0,05), respectively. Cirrhotic patients with SAH showed a significantly higher hypocapnia by comparison with others (31.2 +/- 3.1 vs. a 36.3+/-5 mmHg; p < 0.05). In multivariate analysis, independent prognostic variables for hypocapnica were plasmatic levels of protrombin time, albumin and sodium. HPS was confirmed in 8 patients (16%). CONCLUSIONS: The most prevalent gas exchange abnormality in cirrhosis was the alteration of alveolar-arterial oxygen tension gradient, directly correlated with hepatocellur disfunction. Hypocapnia could be a compensatory mechanism or the result of the activation of central respiratory centres by non-depurated substances by the liver.

Occult liver involvement by polyarteritis nodosa.

The diagnosis of panarteritis nodosa is usually difficult because of the variability of clinical manifestations. Herein is presented a case of occult liver involvement by polyarteritis nodosa. Several biopsies were performed but the diagnosis was made with the contribution of a hepatic arteriography.

[Toxic hepatitis from cinchophen: report of 3 cases]. / Hepatitis tóxica por cincofeno: descripción de tres enfermos.

Three cases of hepatic toxicity due to cincophen (a uricosuric drug used for the treatment of gout) are reported. The three patients were females aged 57, 60 and 67 years, respectively, who were treated with cincophen because of renoureteral urate stones. The mean dose was 300 mg/day for a mean duration of 3-4 months before the hepatotoxic features first developed. Cincophen induces hepatic necrosis through a hypersensitivity or metabolic idiosyncrasy mechanism with histologic abnormalities similar to those due to isoniazid, anticonvulsants, halothane and methyldopa. In two patients the disease presented as acute hepatitis. One had severe hepatic failure and died. Cincophen had been widely used in Europe and severe hepatotoxicity reactions have been reported since then (with a mortality rate of about 50%). It is still commercially available in Spain in two preparations as lithium cincophenate and piperacine. The present study has the aim of recalling the severe problems associated with cincophen hepatotoxicity, so that new cases can be prevented.

[Presinusoidal portal hypertension due to portal thrombosis in a patient with Alagille's syndrome]. / Hipertensión portal presinusoidal por trombosis portal en una paciente con síndrome de Alagille.

We present the case of a 16-year old woman with Alagille's syndrome, who had upper gastrointestinal bleeding due to rupture of esophageal varices secondary to presinusoidal portal hypertension without liver fibrosis. Portal thrombosis is a manifestation previously unreported in association to this syndrome.

[Usefulness of skin tests (tuberculin and delayed-type hypersensitivity reaction) in patients with HIV infection]. / Utilidad de los tests cutáneos (mantoux y prueba de hipersensibilidad retardada) en la infección por el VIH.

The aim of this study is to asses the management and application of skin tests (tuberculin and delayed-type hypersensitivity reaction) in patients with HIV-infection.

[Risk of tuberculosis in a cohort of HIV positive IVDA patients in relation to the degree of immunodeficiency and tuberculosis skin test]. / Riesgo de tuberculosis en una cohorte de pacientes UDVP VIH+ en relación con el grado de inmunodeficiencia y la prueba de la tuberculina.

OBJECTIVE: The aim of this study was to assess risk for developed active tuberculosis in HIV infected IDU oblation and relate with immunodeficiency degree. METHODS: Longitudinal follow-up was realized, the period of study was 9 years, in HIV seropositive IDU patients. Control group was HIV seronegative IDU. CD4+ lymphocytes count and cutaneous test (PPd and DHT) were performed at baseline and each three months, them screening from active tuberculosis. RESULTS: Study's population was 165 patients and control group was 69. The average age was 26 and 23.8 respectively. The medium follow-up was 25 months. Active tuberculosis was developed in 9.26 cases per one hundred persons and year from follow-up. It was between 4.92 in cases with more than 500 CD4+ lymphocytes and 3.08 for them with lymphocytes between 50 and 200 per mm3. The incidence tests was 3.99 in PPD negative normoergic patients and 15.87 in PPD negative anergic patients. CONCLUSIONS: Risk from active tuberculosis was relactioned with latent infection and immunodeficiency degree. We constated high risk in low CD4+ lymphocytes counts; and degrees from DHT let an approach to tuberculosis production mechanism.

[Drug interactions and their management in patients with human immunodeficiency virus infection]. / Interacciones medicamentosas y su manejo en pacientes infectados con el virus de la inmunodeficiencia humana.

In fact patients with human immune deficiency virus infection are in treatment with multidrugs regimen, also in antiretrovirical therapy as profilaxis and treatment opportunist infections and other problems, in other fact the high tase of intravenous drugs users in meta-done programming (one of the principal transmission cause). Consequently is necessary an rational approximation to this problem also in the deepth knowledgment of his mechanisms and his management in the daily clinical practice.

[Upper digestive tract findings in elderly patients with iron-deficiency anemia. A comparison between users and non-users of non-steroidal anti-inflammatory drugs]. / Patología digestiva alta en pacientes de edad avanzada con anemia ferropénica: comparación entre usuarios y no usuarios de anti-inflamatorios no esteroideos.

BACKGROUND: Iron-deficiency anemia is common in the elderly. Chronic upper gastrointestinal bleeding is its most frequent cause. The use of non-steroidal antinflammatory drugs (NSAID) is common in older people. Gastrointestinal complications of NSAID may be also more frequent among the elderly. AIMS: The study was aimed to evaluate if a history of regular NSAID use in elderly patients with iron-deficiency anemia is associated to characteristic findings on esophagogastroduodenoscopy. MATERIALS AND METHODS: A total of 91 patients (40% of males and 60% females) older than 65 years (mean age 77 years, range 65-90 years) entered the study. All of them had been admitted to our Hospital for study of iron-deficiency anemia. Thirty-eight patients were regular users of NSAID. Esophagogastroduodenoscopy was performed in all patients. RESULTS: The prevalences of peptic ulcer, erosive gastritis/duodenitis, and esophagitis were similar in NSAID users and non-users (13 vs 11%, 18 vs 15%, and 26 vs 26%, respectively). A trend to a higher prevalence of gastric adenocarcinoma was observed the group of NSAID non-users (8% vs 23%, p = 0.05). Esophagogastroduodenoscopy was entirely normal in 39% of NSAID users and 34% of NSAID non-users. CONCLUSIONS: Upper gastrointestinal lesions in elderly patients with iron-deficiency anemia are similar in NSAID users and non-users, with the exception of gastric adenocarcinoma which can be more common in NSAID non-users.

[Treatment with indomethacin for the control of the metabolic disorder caused by a villous adenoma of the rectum]. / Tratamiento con indometacina para el control del trastorno metabólico producido por un adenoma velloso de recto.

A 79 year old patient with a previous history of 10 months of mucous diarrhea is admitted due to pre-renal insufficiency, hyponatremia, hypokalemia and metabolic alkalosis secondary to rectal villous adenoma. The volume of the rectal discharge was 2.500 cc/day. Sodium level of the rectal secretion was 145 mEq/L and potassium 20 mEq/L. E2 prostaglandin: 1500 pg/ml. After hydroelectrolytic treatment, a PG synthetase inhibitor (indomethacin) was added to a dosage of 25 mg q/d PO. Rectal discharge was reduced to 500 cc/day, as well as sodium and prostaglandin levels. It has been proved that the use of PG synthetase inhibitors can facilitate the preparatory metabolic control in patients with villous adenoma.

[Correlation between mantoux and tuberculin's fraction from delayed hypersensitivity skin test, in a cohort from HIV-1 positive patients, in function of immunodeficiency level, and active tuberculosis incidence]. / Correlación entre el mantoux y la fracción tuberculínica de la prueba de hipersensibilidad retardada, en una cohorte de pacientes VIH+, en función de su nivel de inmunodeficiencia, e incidencia de tuberculosis activa.

OBJECTIVES: The aim of this work was to assess cellular immunity using the multitest CMI and relate its results with lymphocyte CD4 counts, and the risk to developed active tuberculosis if the multi-test's tuberculosis pápula was positive. METHODS: Prospective longitudinal follow-up of 342 IDU patients, 210 infected with HIV-1 and seronegative 132 patients. The cohort study was 165 IDU HIV-1 positive patients (128 men, 37 female). Ages was 18 to 45 years. Study time were 25 months (8-25). Tuberculin skin tests and multitest IMC were performed at baseline and each three months, and screening from active tuberculosis were performed all study when necessary was considered. RESULTS: Actived tuberculosis developed in 9.25 cases per one hundred persons and year from follow-up in the ranges with better immunologic status (Score from PHR > 10 mm). There are an significative correlation between tuberculosis skin test diameter and PHR tuberculin fraction papula. CONCLUSIONS: PHR performed with Multitest IMC is an useful test to evaluate cellular immune system, and HIV-1 positive patients with energy in this test or positive tuberculine fraction must be considered to isoniazid (9 months) prophylaxis.

[Endocarditis caused by Stenotrophomonas maltophilia: report of a case and review of literature]. / Endocarditis caused by stenotrophomonas maltophilia: report of a case and review of literature.

We report a case of a 65 year-old woman with late endocarditis of prosthetic aortic valve and paravalvular abscess by Stenotrophomonas maltophilia, which had an acute presentation for the memtionated abscess broken, with fever, bacteremia and congestive heart failure secondary to severity aortic regurgitation. Itacute;s a rare cause of endocarditis with only 22 cases descripted in medical literature, the most of them in parenteral drug addict and as complication of cardiac valve replacement. The literature is reviewed and relate the epidemiology, clinical and prognosis characteristics of this disease, the same as his treatment and prevention.