Enfermedad obstructiva del intestino delgado en el paciente geriátrico: diagnóstico diferencial / Obstructive disease of small bowell disease in the eldery: differential diagnosis

La enfermedad obstructiva del intestino delgado en el paciente mayor, es una entidad frecuente, pero debido a los efectos del envejecimiento y las enfermedades asociadas, el cuadro clínico generalmente es confuso y el diagnóstico diferencial difícil, en consecuencia, se debe tener un mayor índice de sospecha que en los pacientes jóvenes. Se presenta a un paciente varón de 77 años de edad, que consultó por un cuadro de suboclusión intestinal, secundario a una estenosis inflamatoria del íleon terminal. Se realizó resección de la lesión y el estudio histológico de la pieza quirúrgica resultó ser una enfermedad de Crohn. No se consideró necesario tratamiento complementario y el paciente está libre de enfermedad seis meses después. Motivados por este caso clínico, los autores intentamos describir, los diversos procesos implicados en el diagnóstico diferencial, de la enfermedad obstructiva del intestino delgado en el paciente mayor e incluimos una puesta al día de los nuevos métodos diagnósticos

Obstructive disease of the small bowel in the elderly patient is a frequent entity, but due to the effect of aging and the associated diseases, the clinical picture generally is confusing and differential diagnosis is very difficult, inconsequence physicians caring for elderly patients must have a high index of suspicion for the same gastrointestinal diseases that afflict young adults. We present a 77year-old male that showed a clinical picture of an incomplete bowel obstruction secondary to inflammatory stricture of the terminal ileum. We performed a surgical resection of the affected ileum and the histological study of the surgical piece was compatible with Crohn´s disease. We did not consider necessary a complementary treatment and the patient is free of disease six months later. The authors attempt to describe the multiple disorders implicated in the differential diagnosis of the obstructive disease of the small bowel in the elderly patient, including an update on the newer methods of diagnosis

Late complications in patients with pectoral defibrillator implants with transvenous defibrillator lead systems: high incidence of insulation breakdown.

As the majority of ICDs with transvenous leads are now implanted in the pectoral region, complications associated with the technique are being identified. To determine the incidence of lead complications in patients with transvenous defibrillator leads and ICDs implanted in the pectoral region, 132 unselected consecutive patients with transvenous defibrillator leads had ICDs implanted in the pectoral region. Three lead systems were used: (1) lead system 1 (45 patients) consisted of a transvenous pacing sensing lead and a superior vena cava coil with a submuscular patch used for defibrillation; (2) lead system 2 (36 patients) utilized a CPI Endotak lead system; and (3) lead system 3 (51 patients) utilized a Medtronic Transvene lead system. Patients were followed for 3-54 months (cumulative 2,269, mean 18 months). The average duration of follow-up with the three systems was 32, 12 and 11 months, respectively. At 30 months follow-up, all three lead systems had a low incidence of complications. However, there was a 13% overall incidence (45% actuarial incidence) of erosion of the insulation of the pacing sensing lead of system 1 at 50 months of follow-up. All lead complications were seen in patients with ICDs whose weights were > 195 g and volumes > 115 cc. The erosion was probably a consequence of the pressure by the large ICD against the lead in the pectoral pocket. Follow-up with lead systems 2 and 3 is relatively short (average 12 months) but no lead erosions were seen. Pectoral implantation of ICDs with long transvenous leads and large generators is associated with a moderate risk of late complications in the form of insulation breaks caused by pressure of the generator against the leads. The use of less redundant leads coupled with smaller ICDs will probably eliminate this complication.

Use of single lead VDD pacing in children.

The development of transvenous ventricular pacing leads with proximal electrodes capable of atrial sensing and the recent availability of smaller generators has created the opportunity to treat children with complete AV block and normal sinus node function with a transvenous single lead VDD pacing system. Studies in adults have demonstrated this system to be efficacious with low complication rates. Transvenous single lead VDD pacemakers were implanted in ten children, aged 5-15 years, between December 1993 and April 1996, in our institution. The indications were complete AV block with severe bradycardia in 5 patients, second-degree or complete AV block following congenital heart surgery in 3, complete AV block with long QT syndrome in 1, and second-degree AV block and syncope in 1. There were no complications related to the procedure in any case. P and R wave amplitudes were measured and thresholds were determined intraoperatively on all patients. Amplitudes and thresholds were remeasured on seven patients with a mean follow-up of 17 months; Holter monitors were performed on seven patients with mean follow-up of 16 months. P and R wave amplitudes were generally diminished at follow-up compared to initial values but remained within an acceptable range for all patients. Four patients required reprogramming after pacemaker insertion, 1 received an atrial lead for dual chamber pacing, 1 required reposition for lead dislodgment, and 1 patient required a new lead for an inadequate ventricular pacing threshold. No patient had evidence of failure to sense or capture as evaluated by Holter monitoring at last follow-up. Single lead VDD pacing systems can be successfully used in properly selected children with high degree or complete AV block with normal sinus node function.

The value of Hughes-Cardiff classification in the management of perianal Crohn's disease.

PURPOSE: The aim of this study was to assess the value of Hughes' pathogenic classification in the prognosis and management of perianal Crohn's disease (CD). PATIENTS AND METHODS: This classification differentiates between purely inflammatory lesions and their mechanical or septic complications, and defines the presence of ulceration (U), fistula (F) and stricture (S), which are assigned a score of 0, 1 or 2 according to the severity and associated conditions, proximal intestinal involvement and disease activity (A, P and D). Of a series of 96 patients with CD, 12 underwent 16 procedures involving anesthesia to treat symptomatic anal lesions. Patients presenting with severe pain were explored and treated by surgical drainage or, in cases in which there was no demonstrable sepsis, by gentle dilation or infiltration with steroids. For superficial, non-specific fistulas, conventional fistulotomy was performed, and long-term seton drainage was implanted for complex fistulas. Strictures were treated by gentle dilation. Uncontrolled sepsis or proctocolitis was managed by proximal stoma creation or proctocolectomy. RESULTS: The association of cavitating ulcers (U2) and contiguous active rectal involvement (P1) was a contraindication for rectal preservation, making proctectomy or stoma creation the most feasible therapeutic option. The etiology of most, but not all, complex fistulas (F2) was the progressive cavitation of U2, whilst F1 was either of cryptoglandular origin or the result of epithelialized fissures (U1). The treatment was also adjusted to this association, and it was confirmed that most of the severe lesions (F2) and S2) were secondary to U2. CONCLUSIONS: Hughes' pathogenic classification: 1) makes it possible to set up an easily stored registry of anal and perianal Crohn's disease; 2) identifies predefined lesions, allowing the individualization of therapeutic procedures and the comparison of results, and 3) provides prognostic information.

Predictors of long-term survival in patients with malignant ventricular arrhythmias.

The study consisted of 369 patients (age 62 +/- 13 years) who presented to our institution from April 1984 to April 1994 for malignant ventricular arrhythmias presenting as sustained ventricular tachycardia (VT) in 57% of patients, ventricular fibrillation in 25% of patients, and syncope due to VT in 17% of patients. Coronary artery disease was present in 74% of patients, cardiomyopathy in 19% of patients, and no evident heart disease in 7% of patients. Two hundred twenty-one patients were given drug, therapy, 47 patients underwent arrhythmia surgery, and 75 patients had an implantable cardioverter-defibrillator (ICD). During a mean follow-up of 30 months (range 1 to 101), 66 patients (18%) died from a cardiac death of which 26 (39%) were sudden. Cox regression analysis was conducted utilizing a total of 19 variables (clinical and therapeutic) in the entire population and separately in patients with coronary artery disease and cardiomyopathy. The most significant variables (multivariate analysis) of survival from cardiac mortality in the entire population were: congestive heart failure (CHF) class (p = 0.0003), ejection fraction (p = 0.02), and the use of drug therapy (p = 0.03); in patients with coronary artery disease, CHF class (p = 0.0001) and ejection fraction (p = 0.0006); and in patients with cardiomyopathy, CHF class (p = 0.009) and sustained VT on Holter monitoring (p = 0.007). Kaplan-Meier survival rates from cardiac death were: significantly lower (p = 0.005) in patients with CHF class III and IV compared with CHF class I and II (25% vs 58%, p = 0.005) with drug therapy; marginally significant (47% vs 88%, p = 0.06) from 20 to 40 months in patients with an ICD; and nonsignificant in patients who underwent arrhythmia surgery (63% vs 71%). Patients with an ICD had a better expected survival (82%) than patients who had arrhythmia surgery (69%) and drug therapy (65%). Thus, in patients with malignant ventricular arrhythmias, CHF class was the most significant independent predictor of survival from cardiac mortality over all disease substrates, and therapy influenced survival depending on the CHF class. Patients in CHF class III and IV who underwent arrhythmia surgery or had an ICD had a better expected survival than those taking drug therapy, and the negative impact of antiarrhythmic therapy was most prominent in patients with CHF class III and IV.

Evaluation of serum carcinoembryonic antigen monitoring in the follow-up of colorectal cancer patients with metastatic lymph nodes and a normal preoperative serum level.

The value of serial serum carcinoembryonic antigen (CEA) assay in the follow-up of colorectal cancer patients with metastatic lymph nodes and normal (< or = 5 ng/ml) preoperative CEA levels, was examined in this study. Thirty-eight patients were studied and compared with 22 patients with elevated CEA levels. The overall sensitivity of CEA for the diagnosis of recurrence was 36%. Postoperative CEA was strongly influenced by the site of recurrence. CEA monitoring showed the best results in patients who developed hepatic metastases (sensitivity 60%, specificity 94%, positive predictive value 60%, and negative predictive value 94%), and was ineffective for the detection of locoregional or pulmonary metastases. The results indicate that elevation of CEA in the postoperative course of these patients is an indicator of the presence of hepatic metastases. Postoperative CEA monitoring should not be omitted in Dukes C patients with normal preoperative levels, and is more reliable for the detection of liver metastases.

Medical factors in the morbidity and mortality associated with emergency colorectal cancer surgery.

OBJECTIVE: To review the results of the analysis and quantification of the influence of medical factors on the morbidity and mortality associated with emergency surgery for colorectal cancer. PATIENTS AND METHODS: We analyze retrospectively the data for 51 patients who underwent emergency surgery: 34 (67%) to treat acute obstruction and 17 (33%) for perforation. The median follow-up period was 18.5 months (3 to 62 months). RESULTS: The main tumor was located in the right colon in 13 patients (25%), in the left colon in 35 (69%) and in, the rectum in 3 (6%). Primary resection was performed in 94% of the patients: without anastomosis in 35% (18 of 51) and with primary anastomosis in 59% (30 of 51); 6% of the tumors were not resectable. The postoperative morbidity was 41%: 29% (10 of 34) occurring in obstructions and 65% (11 of 17) in perforations. The mortality rate was 14% (9% and 23%, respectively). There were statistically significant associations between mortality and the American Society of Anesthesia grading (p < 0.01) and between both the mortality and morbidity and the score for the acute physiology component of APACHE II (p = 0.01, respectively) and the total APACHE II score (p < 0.01 in both cases). The rate of actuarial disease-free survival was 26% at 36 months. Overall survival was 15% at 62 months. A recurrence rate of 48% (14 of 29) has been recorded. CONCLUSIONS: Emergency surgery for colorectal cancer is associated with a high postoperative morbidity and mortality rate, which correlate with the medical status and, particularly, with the acute physiology score of the APACHE II risk stratification system.

Permanent pacemaker lead implantation via the transhepatic route.

A 4-year-old male with transposition of the great arteries, status post-Senning repair, required placement of an atrial pacemaker for sinus node dysfunction and atrial flutter. Multiple systemic venous occlusions precluded conventional transvenous lead implantation. A transhepatic approach resulted in successful placement of an endocardial atrial pacing lead.

[A comparative study on the prognostic value of the nuclear expression of protein p53 vis-à-vis histopathology in colorectal cancer]. / Estudio comparativo sobre el valor predictivo de la expresión nuclear de la proteína p53 frente a la histopatología en el cáncer colorrectal.

OBJECTIVE: To determine the predictive value of p53 nuclear overexpression in comparison with established prognostic pathological features in colorectal adenocarcinoma. PATIENTS AND METHODS: 61 patients operated on for cure between January 1989 an December 1991 were included. Expression of p53 protein was examined by immunohistochemistry in paraffin-embedded sections. Tumor localization, depth of bowel wall involvement, lymph nodes metastasis, vascular invasion and PCNA Labelling index were studied in all patients. RESULTS: Nuclear staining was detected in 27 (44.2%) cases. Positivity was more frequent in tumors with venous invasion and in rectal cancer. p53-positive tumours exhibited a higher likelihood of relapse and lower survival. After adjustment for the other covariates, p53 overexpression was the only factor showing independent prognostic significance on the risk of recurrence. None of the factors analysed evinced independent significant relationship with the risk of death. CONCLUSION: Nuclear p53 protein overexpression is closely related to the development of postoperative recurrences and has higher predictive value than standard pathological variables.

Prediction of recurrence in B-C stages of colorectal cancer by p53 nuclear overexpression in comparison with standard pathological features.

This study investigated the predictive value of p53 nuclear overexpression on recurrence of colorectal adenocarcinomas compared with established prognostic pathological features. Sixty-one paraffin-embedded sections from primary tumours were examined by immunohistochemistry. Specific nuclear staining was detected in 27 (44.2%) cases. Positivity was more frequent in tumours with venous invasion (76.9%) (P = 0.06) and in rectal cancer (68.4%) (P = 0.06). After a median observation time of 46 months, p53-positive tumours exhibited a higher percentage of recurrence (40.7% vs 11.7%) (P = 0.03), and a higher likelihood of relapse at 5-year follow-up (46% vs 13%) (P = 0.006). Among the pathological variables analysed, only the extent of bowel wall invasion showed a relationship with recurrence. After adjustment for the other covariates in a Cox's regression model, p53 overexpression was the only factor showing independent prognostic significance (hazard ratio: 4.96; 95% Confidence Interval (CI): 1.47-16.71) (P = 0.012). The results of this study show that nuclear p53 protein overexpression has higher predictive value than standard pathological variables.

Incidence of malposition of polyvinylchloride and red rubber left-sided double-lumen tubes and clinical sequelae.

Currently, fiberoptic bronchoscopy (FB) is recommended for correct positioning of double-lumen endobronchial tubes (DLTs) because of the high incidence of malpositions not appreciated by clinical signs. The aims of this study were to assess whether clinical signs allow accurate confirmation of adequate positioning with left red rubber (RR) or polyvinyl-chloride (PVC) double-lumen tubes and to compare the incidence of malpositions between the two tubes. Another goal was to assess whether these malpositions, not appreciated by clinical assessment, adversely affected outcome. Twenty-one adult patients scheduled for elective thoracic surgery were randomly assigned to the RR (11 patients) or PVC group (10 patients). After endobronchial intubation, the position of the tubes was adjusted until clinically satisfactory lung separation had been achieved. A single investigator performed all the FB assessments were performed in the supine (SUP) and lateral positions. The anesthesiologists responsible for the clinical evaluation were "blinded" to the bronchoscopic findings. While in the SUP position, the tube was "too deep" to permit visualization of the carina during tracheal bronchoscopy in 5 patients (2 RR, 3 PVC). In 17 of 21 (10 RR, 7 PVC), the bronchial cuff could not be visualized, although in 1 patient (RR group), the cuff was overinflated and bulged out to partially obstruct the right main bronchus orifice. Bronchial bronchoscopy showed 4 of 11 patients in the RR group in whom the left upper lobe orifice was occluded compared with 1 only in the PVC group.(ABSTRACT TRUNCATED AT 250 WORDS)

Subpectoral implantation of ICD generators: long-term follow-up.

A nonthoracotomy surgical approach using an endocardial electrode and combined implantation of a subcutaneous patch and the implantable cardioverter defibrillator (ICD) generator in a subpectoral pocket has been described. We report the long-term follow-up results in patients undergoing implantation using this approach. The patient population consisted of 28 patients (22 men and 6 women) with a mean age of 59 +/- 12 years. The underlying heart disease consisted of coronary artery disease in 20 patients and dilated cardiomyopathy in 8 patients. Sustained ventricular tachycardia was the mode of presentation in 16 patients and sudden cardiac death in 12 patients. The mean left ventricular ejection fraction was 31% +/- 6%. The lead system consisted of an 8 French bipolar passive fixation rate sensing lead positioned at the right ventricular apex, an 11 French spring coil electrode positioned at the superior vena cava-right atrial junction (surface area 700 mm2), and submuscular placement of a large patch (surface area 28 cm2) on the anterolateral chest wall near the cardiac apex via a submammary incision. A defibrillation threshold of < or = 15 joules (J) was required for implantation. This criterion was not satisfied in five patients; thus, a limited thoracotomy was performed via the submammary incision, and the large patch was placed epicardially. The mean R wave amplitude was 12 +/- 3 mV, the mean pacing threshold was 1.0 +/- 0.5 V at 0.5 msec, and the mean defibrillation threshold was 12.6 +/- 3 J. ICD generators implanted were the Ventak-P in 17, PCD-7217 in 5, and the Cadence V-100 in 6 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Profile of health services utilization during the XVII Central American and Caribbean Sport Games: Delegation of Puerto Rico, Ponce 1993]. / Perfil de utilización de los servicios de salud durante los XVII Juegos Deportivos Centroamericanos y del Caribe: Delegación de Puerto Rico, Ponce 1993.

During the XVII Central American and Caribbean Sports Games held in Ponce in 1993 the health services offered to the Puerto Rico Delegation included medical, dental and psychological assistance, physical therapy and services on the playing field. Information about the use of these services was obtained from the encounter sheets. The Puerto Rican delegation of 750 members had 1,800 encounters with the health team; 612 (34.0%) individual consults; 896 (54.8%) physical therapy sessions; 166 (9.2%) encounters in the sports venues; and 36 (20%) group therapies. The most common diagnoses were athletic injuries (304; 58.2%) and diseases of the respiratory system (76; 14.5%). The most frequent athletic injuries were first degree strains (75; 24.7%) and tendinitis (73, 24.0%). This pattern is similar to that observed in other sports games and delegations with mild conditions prevailing. An interdisciplinary work and biopsychosocial approach will be important for the better health and performance of our athletes.

Patterns of injuries in athletes evaluated in an interdisciplinary clinic.

The pattern of sports injuries appears to be population-specific. The purpose of the present study is to describe 1750 injuries evaluated between April 1988 and April 1994 in our Olympic Training Center Interdisciplinary Sports Injury Clinic. Our patient population included elite and recreational athletes of both sexes between the ages of 7 and 71 years. Males comprised 73% of the patient population and approximately 80% of the injuries corresponded to the 10 to 29 age range. The most frequent sports in males were baseball (21.9%) and basketball (15.9%) and in females were track and field (17.1%) and gymnastics (15.1%). Most injuries (52%) were traumatic in nature, chronic (71.6%), and occurred during training sessions (57.4%). The most commonly affected anatomical areas were the knee (31.2%) and shoulder (15.5%). The most common diagnoses were tendinitis (25.4%), and first degree strains (11.8%) and sprains (9.3%). Finally, treatment strategies included medications (61.0%), physical therapy (48.9%), relative rest (35.7%), and home exercise programs (35.2%). The variety of musculoskeletal disorders seen in combination with the frequent use of conservative treatment confirms the importance of an interdisciplinary approach to sports injuries.

[Morbidity during the XVI Central American and Caribbean Games: Puerto Rican delegation, Mexico 1990]. / Morbilidad durante los XVI Juegos Deportivos Centroamericanos y del Caribe: Delegación de Puerto Rico, México 1990.

The health services offered to the Puerto Rican Delegation during the XVI Central American and Caribbean Sports Games in México in 1990 included: medical, dental and psychological assistance, physical therapy and services on the playing field. From the consultation sheets completed during the Games we obtained information about the use of these services. The 336 members of the Puerto Rico Delegation in the village at México City had 1,838 encounters with the health team. Of these, 991 were medical consults, 55 group therapies, 466 physical therapy sessions and 326 encounters in the sports venues. Among the encounters for medical evaluation the most frequent problems were athletic injuries (318; 32.1%), respiratory problems (240; 24.2%), gastrointestinal conditions (126; 12.7%) and dental services (119; 12.0%). The most frequent athletic injuries were first degree strains (83; 26.1%), tendinitis (56; 17.6%), contusions (42; 13.2%), myositis (40; 12.6%) and first degree sprains (28; 8.8%). The health problems found were diversed and in the majority of cases mild in character, which can be attend by adequately trained on sports health primary health professionals.

Total pectoral implantation: a new technique for implantation of transvenous defibrillator lead systems and implantable cardioverter defibrillator.

We describe a new approach to total pectoral implantation of cardioverter defibrillators with an endocardial defibrillation lead system. Endocardial lead configuration used was an FDA approved right atrial-superior vena cava defibrillation spring electrode, right ventricular bipolar sensing electrode, and a pectoral patch. Endocardial leads were implanted via a cephalic or an axillary venesection. Pectoral patch was placed in a submuscular position. In case of failure to obtain satisfactory thresholds, a small intercostal thoracotomy was performed via the same skin incision and patch placed over the epicardium instead of submuscular position and used with the right atrial spring electrode. The device was implanted in the pectoral region, submuscularly, over the patch. Sixteen consecutive patients underwent this approach. With a submuscular patch, adequate defibrillation thresholds (< or = 15 joules [J]) were obtained in 14 (87.5%) patients. In the other two, defibrillation thresholds of < or = 15 J were obtained with a epicardial patch. Pectoral implantation of the device was feasible in all 16 patients and none needed repositioning. Average postimplant hospital stay was 5 days. During follow-up period (average 5 months), none of the patients reported any major local symptoms and no problems have been encountered in device interrogation. Thus, total pectoral implantation of the cardioverter defibrillator including the patch, leads, and the device is feasible. Furthermore, in case of failure to obtain adequate defibrillation thresholds with submuscular patch, an epicardial patch can easily be implanted and allows 100% successful defibrillation at energy levels of < or = 15 J with right atrial patch configuration.