Determination of synthetic cannabinoids in oral fluids by liquid chromatography with fluorescence detection after solid-phase extraction.

Synthetic cannabinoids are one of the most consumed new psychoactive substances, being absolutely necessary the development of analytical methodologies for the determination of these substances in biological fluids. In this study, a liquid chromatography with fluorescence detection (LC-FD) method has been developed for the analysis of 8 synthetic cannabinoids in oral fluids. The method has been validated in terms of linearity, precision and extraction recoveries, giving limits of detection as low as 0.7 µg L-1, and limits of quantification of 2.6 µg L-1. Different silica and polymeric commercial solid sorbents such as C18, Supel-Select HLB, EB2 ExtrabondⓇ and SampliQ-OPT were tested, concluding that Supel-Select HLB provided quantitative recoveries for the extraction of synthetic cannabinoids in oral fluids.•Analysis of synthetic cannabinoids in oral fluids.•Analytical procedure based on liquid chromatography with fluorescence detection.•Sample treatment based on solid phase extraction with HLB cartridges.

[Anorectal manifestations in systemic diseases]. / Manifestations ano-rectales des maladies systémiques.

Numerous systemic diseases (vasculitis, connective tissue disease or sarcoidosis) can display an involvement of the perianal skin, the rectum and/or the anus. Such knowledge is important in order to treat these complications specifically when possible. Lesions of the anorectum arising from systemic diseases can sometimes cause perforations in the peritoneal cavity (if concerning the higher portion of the rectum) and/or fistulization to the anal margin. Differential diagnosis, mostly infectious or inflammatory (Crohn's disease) must be ruled out in every case. Other systemic diseases can display specific manifestations as this is the case in scleroderma which can lead to anal incontinence. Despite the relative rarity of these manifestations, their ignorance would forbid global management of these complex diseases. It should thus be detected in each consultation and a regular follow-up must be provided with a proctologist and/or a gastroenterologist when needed.

Particular aspects of proctology for anoperineal lesions in Crohn's disease.

All practitioners caring for patients with Crohn's disease (CD) must know all the various aspects of anoperineal lesions in this singular entity. Suppuration in CD does not follow the classic routes and spaces of diffusion and is often associated with endolumenal lesions that can evolve on their own. Abscesses and fistulas require specific medico-surgical management where seton drainage, staged operative and sphincter-sparing procedures have a dominant place. The variability of associated lesions and the particularly individualized efficacy of drugs call for case-by-case management, thus, making standardization and comparisons difficult. Recent therapeutic progress has led to modifications of the minimally invasive management policies practiced in the last decades.

Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases.

AIM: The aim of this study was to analyse the characteristics of horseshoe tract formation in anal fistula. METHOD: We retrospectively analysed the data from all consecutive patients who underwent surgery for an anal fistula from November 2004 to March 2011. A horseshoe tract was defined as a circumferential extension connecting both sides of the anorectum. RESULTS: During the period of analysis, 1876 patients were operated on for a fistula. Of these, 82 (4.4%) had a horseshoe extension. The majority (72%) were male and the median age was 46 (17-84) years. The primary tract was high transsphincteric in 90% of cases and the primary opening was posterior in 65% of cases. The location of the horseshoe extension was posterior in 66% of cases with spread in the deep perianal space in 62%. In all, 71% were cryptoglandular and 24% were seen in Crohn's disease (20). Of the 62 non-Crohn's patients previous treatment was common and included surgery (42), antibiotics alone (41) and non-steroidal anti-inflammatory drugs (21). CONCLUSION: Horseshoe extension in anal fistula is uncommon. With Crohn's disease excepted, the majority had had previous treatment.

Ajuste rápido de dosis de tapentadol en el tratamiento del dolor mal controlado / No disponible

Introducción: el tapentadol es un nuevo fármaco de acción dual MOR/NRI, que actúa a nivel central, efectivo en el tratamiento del dolor moderado e intenso, que presenta un perfil de tolerabilidad mas favorable que otros opiáceos. Esto podría permitir una titulación rápida que permita un control precoz del dolor. Material y métodos: presentamos dos casos clínicos en los que se realiza una titulación rápida de la dosis de tapentadol en pacientes hospitalizados con dolor mal controlado. Este ajuste rápido, permitió controlar el dolor, en ausencia de efectos secundarios, acortando el tiempo de estancia hospitalaria de estos pacientes. Conclusiones: el perfil favorable de efectos secundarios mostrado por el tapentadol, permite un ajuste rápido de la dosis, que consigue un control eficaz del dolor en un menor lapso de tiempo (AU)

Background: tapentadol is a new drug with a centrally acting, dual action mechanism on MOR/NRI. It is effective on moderate to severe pain and shows a favourable side effects profile in comparison to other major opiates. This could allow a fast dose titration to achieve an earlier pain control. Material and methods: we present two cases on which we have performed a fast dose titration in hospitalised patients with bad pain control. This fast titration allowed an early control of the pain, in absence of side effects, achieving a shortening in their hospital stay. Conclusions: the favourable side effects profile of tapentadol, allows a fast dose titration, achieving an efficacious pain control in a shorter time lapse (AU)

Endorectal advancement flap with muscular plication: a modified technique for rectovaginal fistula repair.

AIM: Endorectal advancement flap is the most used treatment for acquired rectovaginal fistula but is liable to failure. We describe our experience with a modified technique. METHOD: Patients were included who had an acquired rectovaginal fistula. Exclusions included patients with Crohn's disease with proctitis, malignant or radiation-related fistula, stricture of the anorectum or those with an external sphincter defect. Surgery included closure of the internal opening with a figure-of-eight reabsorbable suture, plication of the anorectal muscular layer and mucosal flap advancement. Total parenteral nutrition was administered postoperatively for seven days. RESULTS: Between March 2003 and July 2008, 23 consecutive women (mean age 45.5 [28-78] years) were treated. The cause of fistulation included obstetric injury (n = 5), cryptoglandular disease (n = 11) and Crohn's disease (n = 7). Thirteen (57%) patients had a previous failed repair. At a mean follow-up of 14 (2-67) months, success was achieved in 65% (15/23) of patients. The mean Wexner incontinence scores pre- and postoperatively were 1.3 (0-15) and 0.6 (0-6), respectively. CONCLUSION: The success rate was promising with no deterioration of anal continence.

Cryptoglandular anal fistula.

Fistula arising from the glands of the anal crypts is the most common form of anoperineal sepsis. It is characterized by a primary internal orifice in the anal canal, a fistulous tract, and an abscess and/or secondary perineal orifice with purulent discharge. Antibiotics are not curative. The treatment of an abscess is urgent and consists, whenever possible, of incision and drainage under local anesthesia. Definitive treatment of the fistulous tract can await a second stage. The primary aim is to control infection without sacrificing anal continence. Fistulotomy is the basis for all treatments but the specific technique depends on the height of the fistula in relation to the sphincteric mechanism. Overall results of fistulotomy are excellent but there is some risk of anal incontinence. This explains the growing interest in sphincter sparing techniques such as the mucosal advancement flap, the injection of fibrin glue, and the plug procedure. However, results of these procedures are not yet good enough and leave much room for improvement.

Seton drainage and fibrin glue injection for complex anal fistulas.

OBJECTIVE: The study aimed to evaluate the efficacy of fibrin glue in the treatment of complex anal fistula. METHOD: Thirty consecutive patients with a complex anal fistula underwent glue instillation after an 8 week period of seton drainage. Cure was defined as complete closure of any secondary opening, absence of fistula seepage, and no abscess formation. RESULTS: The mean age of the patients (15 males) was 40.5 (range, 22.8-69.1) years. The mean duration of follow-up was 11.7 (range, 0.2-33.5) months. Complete closure of the fistula was achieved in 17 patients at 1 month but in two patients a delayed abscess occurred. At the end of follow-up, 15 (50%) patients were considered to have been cured. The success rate was no different in cases of Crohn's disease or when postoperative antibiotic therapy was given. There was, however, a significant difference in success following regional vs general anaesthesia (68.4 vs 18.2% success, P = 0.02). CONCLUSION: Fibrin glue cured 50% of our first 30 patients, and regional anaesthesia was predictive of success.

Stapled haemorrhoidopexy: 6 years' experience of a referral centre.

AIM: To prospectively evaluate the long-term results and assess patient satisfaction after stapled haemorrhoidopexy (HS). METHOD: A total of 150 patients (121 male patients) with symptomatic grade II (n = 50) or III (n = 100) haemorrhoids underwent stapled HS. Patients were followed up during consultations at regular intervals, allowing prospective data collection. A final telephone follow up was also undertaken. RESULTS: Follow up data were obtained for 130 of 150 patients (86.6%). After a median follow up of 39 months (range, 12-72), 90% of the patients were fully satisfied and 92% were free of haemorrhoidal symptoms. There were no intraoperative complications. Postoperative bleeding that required operation was observed in five patients (3.3%). Most late postoperative complications were benign and easily resolved: unexplained pain for over a month (n = 1), external haemorrhoidal thrombosis (n = 2), anal fissure (n = 6) one with hypertrophic papilla, anal fistula (n = 1), rectal stenosis (n = 1), anal incontinence for (n = 1). Eight patients needed rubber band ligation to treat persistent or recurrent symptomatic prolapse. Four patients (2.6%) were reoperated on during the follow up period but none for haemorrhoidal pathology. CONCLUSION: Stapled HS procedure is effective and has low morbidity, high patient satisfaction and provided good long-term control of haemorrhoidal symptoms in the treatment of second and third-degree haemorrhoids.

Sufrimiento al final de la vida / No disponible

Durante el 6º Congreso Nacional de la Sociedad Española de Cuidados Paliativos, celebrado en San Sebastián del 7 al 10 de Junio de 2006, tuvo lugar una mesa interactiva sobre el tema «Sufrimiento al final de la vida». Objetivo: el objetivo del presente artículo es exponer las respuestas de 175 profesionales sanitarios presentes en la sala a las preguntas formuladas desde la mesa. Método: cuestionario anónimo de tipo categórico presentado a la audiencia a través de un sistema interactivo. Resultado y conclusiones: se exponen los datos facilitados por los 175 profesionales así como los comentarios que los mismos suscitaron en los componentes de la mesa, sobre diversos temas de actualidad en el campo de los cuidados paliativos, desde los miedos y sentimientos de culpa de los enfermos hasta la espiritualidad, la sedación y la eutanasia (AU)

During the 6th National Congress of the Spanish Society of Palliative Care, that took place in San Sebastian from the 7th to the 10th of June of 2006, a symposium on «Suffering at the end of life» was held. Objective: the objetive of the present paper is to show the answers of 175 sanitary professionals who answered relevant questions coming from the table experts invited. Method: an anonymous categoric questionnaire present through an interactive system. Results and conclusions: answers from the audience and commentaries made by the table membres about different themes suchs as fears and guilt thoughts of patients, spirituality, sedation and euthanasia are shown (AU)

Meningitis por listeria monocytogenes tras anestesia subaracnoidea / Meningitis due to Listeria monocytogenes after spinal anesthesia

No disponible

Anal sphincter injury after forceps delivery: myth or reality? A prospective ultrasound study of 93 females.

PURPOSE: This study was designed to estimate the prevalence of anal sphincter injury after forceps delivery in a large population of females managed by trained obstetricians in a French hospital and to identify factors predictive for anal sphincter injury. METHODS: We performed a prospective study of healthy females older than 18 years with no history of anal incontinence, anorectal abnormalities, or anorectal surgery after their first vaginal delivery. All females were interviewed using a standardized questionnaire concerning intestinal transit and continence status. Physical examination and endoanal ultrasonography were performed after delivery. RESULTS: Between November 1999 and November 2000, 93 females were included in the study after their first forceps delivery. Eleven patients (11.8 percent) had a partial defect involving the external sphincter, visible on ultrasonography. One patient (1.1 percent) had a partial defect of external sphincter with complete defect of internal sphincter (sequelae of primary repair of a third-degree perineal tear). Seventeen patients (18.2 percent) had flatus incontinence, and four patients (4.3 percent) had liquid stool incontinence. A high daily number of stools was significantly associated with sphincter defect visible on ultrasonography (P=0.02). The development of anal incontinence was not related to sphincter defect on ultrasonography. There was a strong association between perineal tear and sphincter defect visible on ultrasonography (odds ratio, 4.5 (range, 1.2-16.7)). CONCLUSIONS: Anal sphincter injury after forceps delivery was identified in <13 percent of our large population of healthy females. Our study does not confirm previous observations that anal sphincter injury is common after forceps delivery; previously published studies may have overestimated the prevalence of this condition. The only factor with significant predictive value for anal sphincter injury was perineal tear. Anal endosonography should be recommended after obstetric perineal tear.

Anoperineal tuberculosis: diagnostic and management considerations in seven cases.

PURPOSE: Anoperineal tuberculosis is a rare extrapulmonary form of the disease that we must learn to recognize because it requires specific treatment. METHODS: Data from seven patients with anoperineal tuberculosis observed in a Parisian proctology unit between 1982 and 1999 were reviewed. RESULTS: All the patients were male (median age, 55 years); five were born in underdeveloped countries, and two were still living there. The average length of time between first manifestation of the disease and diagnosis was three years (range, 3 months to 9 years); all patients had undergone surgery previously. There were six recurring anal fistulas (complex in 5 cases) and one recurring abscess. In every case, the diagnosis had been suspected or confirmed by systematic histologic study of the surgically excised tissue. An association with pulmonary tuberculosis was found in each case. Treatment included two parts: conventional surgical treatment of anal sepsis and specific medical antituberculosis treatment. Evolution was favorable in all cases, with no recurrence of disease. Human immunodeficiency virus infection did not increase the incidence of anoperineal tuberculosis. CONCLUSION: Tuberculosis should be suspected in all recurrent fistulas. Histologic examination of the excised tissue and a lung x-ray should be performed to avoid delay in diagnosing an easily curable disease.

Análisis de la demanda de actuación de un Equipo de Soporte de Atención Domiciliaria (ESAD) / Analisys of consultations of a home support team (HCST)

Objetivo. Describir el trabajo realizado durante el primer año de funcionamiento de un equipo de soporte de atención domiciliaria en un área de salud. Diseño. Estudio descriptivo transversal. Emplazamiento. Áreas 2 y 5 de la provincia de Zaragoza (ámbito urbano). Pacientes. Todos los pacientes (n = 151) incluidos en el programa de atención domiciliaria con equipo de soporte de INSALUD durante el año 2000.Mediciones y resultados principales. La edad media de los pacientes atendidos fue de 77 años, un 63 por ciento eran mujeres. Las principales enfermedades que presentaban los pacientes fueron neurológicas (37,3 por ciento) y neoplásicas (35 por ciento). La captación de los casos fue en un 88 por ciento desde el equipo de atención primaria (EAP). El EAP continuó el seguimiento del paciente en un 47,7 por ciento de los casos, principalmente pacientes inmovilizados. El ESAD lo hizo en un 14 por ciento, en este caso pacientes en situación terminal (p < 0,001). El seguimiento fue conjunto en un 38,3 por ciento. Se notificó el fallecimiento del 43,7 por ciento del total de pacientes atendidos, de los que el 53 por ciento fallecieron en su domicilio. Conclusiones. La atención domiciliaria es un modelo de asistencia en progresión. En este contexto, los ESAD son un recurso que puede resultar útil en el desarrollo de la labor de los EAP en el tratamiento del paciente complejo (AU)

[Analysis of the demand for a home care support team (HCST)]. / Análisis de la demanda de actuación de un equipo de soporte de atención domiciliaria (ESAD).

OBJECTIVES: To describe the clinical activity of the home care support team (HCST) over the first year of implementation in a health area. DESIGN: A descriptive, cross-sectional study. SETTING: Health Area 2 and 5 of Zaragoza (urban environment). PARTICIPANTS: All the patients (n = 151) included in the home care programme over the year 2000. MEASUREMENTS AND MAIN RESULTS: The mean age of attended patients was 77 years; sixty-three percent were woman. The most frequent medical disorders of the patients were neurologic (37.3%) and oncologic disorders (35%). The majority (88%) were referred from the primary care team (PCT). Subjects admitted from primary care of health (family physician or nurse) were 88%. The follow-up of these patients was carried out by the PCT (47.7%), mainly disabled patients, and 14% by HCST (significantly more frequent terminal ill patients). In 38.3% of the patients, follow-up was performed by both teams. Forty two percent of the patients attended died over the year 2000, 53% of them at home. CONCLUSIONS: Home care is an assistance model in progress. HCST are a resource that can become usefull in the development of the PCT work with all the hard to treat complex patients

Prosthetic rectopexy to the pelvic floor and sigmoidectomy for rectal prolapse.

BACKGROUND: Full thickness rectal prolapse in young adults with normal pelvic floor is a disease in which the rectum is exceedingly long and mobile. Surgical treatment should correct both anatomical defects by combined rectopexy and colonic resection, which is expected to be less constipating than rectopexy alone. The aim of this study was to describe an original procedure of rectopexy to the pelvic floor with prosthetic material combined with sigmoid resection, and to evaluate prospectively anatomical and functional results. METHODS: Thirty-five patients (30 women) of median age 44 years (range 18 to 74) were operated on for full thickness rectal prolapse with normal pelvic floor. The rectum was mobilized posteriorly without division of the lateral ligaments and attached to the pelvic floor previously repaired with a nonabsorbable mesh. The sigmoid colon was resected with hand-sewn anastomosis. Clinical results were assessed by a questionnaire. RESULTS: There were no deaths or any septic or anastomotic complications. Small bowel obstruction was corrected laparoscopically in 1 patient. Mean hospital stay was 8 days (range 6 to 14). Mean follow-up was 34 months (range 10 to 93). No recurrence was seen. Preoperatively, 33 patients (94%) complained of constipation mainly with emptying problems (21 patients) and 25 patients (71.5%) were incontinent. Postoperatively, no constipated or incontinent patient's condition worsened. Rectal emptying was restored in 17 patients (81%). Eighteen incontinent patients (72%) regained full continence. On the other hand, 2 patients with normal bowel function worsened and 1 patient with an altered rectal compliance after Delorme's operation became incontinent. CONCLUSIONS: In young adults with rectal prolapse and normal pelvic floor undergoing prosthetic rectopexy and sigmoid resection (a) morbidity was low, (b) anatomical control was obtained in all cases, (c) emptying problems were corrected, and (d) deleterious effects are likely to occur if they had no constipation before operation or if rectal compliance was previously altered.