[Changes in the etiology, outcome, and characteristics of patients with acute gastrointestinal bleeding between 1999 and 2005]. / Cambios en la etiología, resultados y características de los pacientes con hemorragia digestiva aguda grave a lo largo del perido 1999-2005.

OBJECTIVES: To analyze the evolution of the following variables in patients admitted to a Blood Unit for gastrointestinal bleeding throughout 1999-2005: etiology, comorbid diseases, use of NSAIDs/anticoagulants, and mortality. MATERIAL AND METHODS: We analyzed the evolution of the following causes of GIB that required admission to the Blood Unit from 1999 to 2005: duodenal ulcer (DU), gastric ulcer (GU), portal hypertension (PHT), and others. We also analyzed changes in the percentage of patients admitted with comorbid disease, use of NSAIDs/anticoagulants, and mortality. RESULTS: 1,611 Patients with a mean age of 60.45 years (59.7-61.2) were included in this study; 76.41% were males (74.3-78.5). DU was the cause of bleeding in 22.20% of cases (20.2-24.3), GU in 18.40% of cases (16.6-20.4), and PHT in 33.60% of cases (31.3-36.0). In all, 34.5% (32.6-37.3) of patients were taking NSAIDs, 7.1% (6.0-8.6) were receiving anticoagulant therapy, 72.6% (70.4-74.8) presented with comorbid disease, and overall mortality was 6.27% (5.16-7.59). Throughout the 1999-2005 period there was an increase in the number of patients with comorbid diseases (p < 0.02), and a decrease in cases of DU (p < 0.04), without significant differences in the remaining variables. CONCLUSIONS: DU, GU and PHT account for three quarters of admissions to our Blood Unit. Over the last seven years, there has been a decrease in cases due to DU, and an increase in patients with comorbid disease; overall mortality rates have remained stable.

Transfusion requirements in patients with gastrointestinal bleeding: a study in a Blood Unit at a referral hospital.

OBJECTIVES: 1. To study transfusion requirements in the Department of Gastroenterology of a Tertiary Referral Hospital, and their evolution over the last seven years. 2. To analyze risk factors associated with greater erythrocyte transfusion requirements. PATIENTS AND METHODS: erythrocyte transfusion requirements were compared for patients admitted to the Department of Gastroenterology at Hospital Virgen del Rocío, Seville, from 1999 to 2005. Clinical data of interest have been analyzed in order to determine factors associated with greater transfusion requirements. RESULTS: 1,611 patients with a mean age of 60.45 years (59.7-61.2) were included in this study; 76.41% were males. Gastric ulcers were the cause of bleeding in 18.4% of cases (with 69% requiring transfusions); duodenal ulcers caused 22.2% of cases (with 52.9% requiring transfusions), and portal hypertension caused 33.6% of cases (with 90.2% requiring transfusions). Upper and lower gastrointestinal bleeding of unknown origin requires transfusions in 88.9 and 96.2% of cases, respectively.A multivariate logistic regression analysis showed that clinical presentations such as hematemesis (odds ratio = 3.12), hematochezia (odds ratio = 33.17), gastrointestinal hemorrhage of unknown origin (odds ratio = 6.57), and hemorrhage as a result of portal hypertension (odds ratio = 3.43) were associated with greater transfusion requirements for erythrocyte concentrates. No significant differences were observed between the percentages of patients who received transfusions from 1999 to 2005. CONCLUSIONS: 1. No differences have been observed between the percentages of patients who received transfusions over the last seven years at our Department of Gastroenterology. 2. Patients presenting with hematemesis or hematochezia, in addition to those with bleeding of unknown origin or from portal hypertension, are prone to have greater transfusion requirements.

Epidemiology of chronic inflammatory bowel disease in the Northern area of Huelva.

OBJECTIVE: To know the different epidemiologic aspects of chronic inflammatory bowel disease (IBD) in the Northern area of the province of Huelva. MATERIAL AND METHODS: we carried out a retrospective (1980-1996) and prospective (1996-2003) study of all patients diagnosed with IBD in the Northern area of Huelva, with 77,856 inhabitants. The distribution of Crohn s disease (CD) and ulcerative colitis (UC) was analyzed, as well as sex, age and smoking habit at the time of diagnosis, familial aggregation, appendicectomy rate, phenotype (anatomical site and clinical types), extraintestinal manifestations, and immunosuppressive therapy or surgical requirements. RESULTS: 70 patients with IBD were studied, 40 with UC and 30 with CD. Sex distribution was 39 (55.7%) males (55% with CD vs 56.6% with UC; NS) and 31 (44.3%) females (45% with CD vs 43.3% with UC; NS). Mean age at presentation was 44.7 +/- 19.32 years in UC vs 32.3 +/- 16.43 in CD; p < 0.001. Familial association was 7.1%. Previous appendicectomy was referred in 2.5% of patients with UC vs 36.7% of those with CD (p < 0.001), and the percentage of smokers was also higher in CD 66.7% vs CU 12.5% (p < 0.001). Anatomical site in UC was: proctitis, 20%; proctosigmoiditis/left colon, 42.5%; extensive colitis, 25%; and pancolitis, 12.5%; in CD was: terminal ileum, 43.3%; colon, 20%; and ileo-colon, 36.7%. The disease patterns were: inflammatory 56.7%, obstruction 26.7%, and fistulization 16.7%. Extraintestinal manifestations were diagnosed in 7.5% of patients with UC vs 16.6% patients with CD; surgery was performed in one patient with UC vs 10 with CD, and one patient with UC required immunosuppressive treatment vs 12 with CD. A multivariant analysis showed that younger age and smoking habit were risk factors for CD vs advanced age in UC, in which case, the smoking habit was a protective factor. The mean incidence rate of IBD starting from 1996 and expressed in cases/100,000 inhabitants/year was 5.2 for UC and 6.6 for CD. CONCLUSIONS: The mean incidence of UC in our area was 5.2 cases/100,000/inhabitants/year, and 6.6 for CD. Patients presenting with CD are diagnosed at a significantly younger age that those with UC; the smoking habit is a risk factor for CD while it protects from UC. The characteristics of IBD in our geographical area do not differ substantially from those in other regions of Spain.

Estudio epidemiológico de la enfermedad inflamatoria intestinal en la zona norte de Huelva / Epidemiology of chronic inflammatory bowel disease in the Northern area of Huelva

Objetivo: conocer los distintos aspectos epidemiológicos de la enfermedad inflamatoria intestinal (EII) en la zona norte de la provincia de Huelva. Material y métodos: se realizó un estudio retrospectivo (1980-1996) y prospectivo (1996-2003) sobre los pacientes diagnosticados de EII en la zona norte de Huelva con 77.856 habitantes. Se ha analizado la distribución de enfermedad de Crohn (EC) y colitis ulcerosa (CU), sexo, edad y hábito tabáquico en el momento del diagnóstico, agregación familiar, antecedentes de apendicetomía, fenotipo (extensión y tipos clínicos), manifestaciones extraintestinales y necesidad de tratamiento inmunosupresor y/o quirúrgico. Resultados: se estudiaron 70 pacientes con EII, 40 con CU y 30 con EC. Un total de 39 (55,7 por ciento) eran varones (55 por ciento en EC frente a 56,6 por ciento en CU; NS) y 31 (44,3 por ciento) mujeres (45 por ciento en EC frente a 43,3 por ciento en CU; NS). La media de edad en el momento de diagnóstico fue de 44,7ñ19,32 para CU frente a 32,3ñ16,43 para EC (p<0,001). La asociación familiar fue del 7,1 por ciento. Referían apendicectomía previa el 2,5 por ciento de los pacientes con CU frente a 36,7 por ciento de los pacientes con EC (p < 0,001), igualmente el hábito tabáquico era más frecuente en la EC 66,7 por ciento que en la CU 12,5 por ciento (p < 0,001).La extensión de la CU fue: proctitis 20 por ciento; proctosigmoiditis/colitis izquierda 42,5 por ciento; colitis extensa 25 por ciento y pancolitis 12,5 por ciento; en la EC, el 43,3 por ciento presentaba afección de íleon terminal, el 20 por ciento afección del colon y el 36,7 por ciento afección de colon e intestino delgado. El patrón fue inflamatorio en el 56,7 por ciento de los pacientes, estenosante en el 26,7 por ciento y fistulizante en el 16,7 por ciento. Se presentaron manifestaciones extraintestinales en el 7,5 por ciento de los pacientes con CU, 1 caso precisó cirugía y 1 tratamiento inmunosupresor; el 16,8 por ciento de los pacientes con EC presentaron manifestaciones extraintestinales, 10 precisaron cirugía y 12 tratamiento inmunosupresor o biológico.El análisis de regresión logística multivariante mostró que la menor edad y el hábito tabáquico fueron factores de riesgo para EC, frente a mayor edad en CU, en la que además el tabaco se mostró como factor de protección. La tasa de incidencia media de EII a partir de 1996 y expresada en casos/100.000 habitantes/año fue de 5,2 para CU y 6,6 para EC. Conclusiones: la tasa media de incidencia en nuestro medio es de 5,2 casos/100.000/habitantes/año para CU y 6,6 para EC. Los pacientes afectos de EC se diagnostican a una edad significativamente menor que aquellos con CU; el hábito tabáquico es un factor de riesgo para la EC mientras que protege de la CU. Las características de la EII en nuestro medio no difieren sustancialmente de las de otras regiones de España (AU)

[Diagnosis and treatment of refractory sprue]. / Diagnóstico y tratamiento del esprúe refractario.

Celiac disease is a gluten-sensitive enteropathy characterized by villous atrophy that is reversed by gluten withdrawal. A minority of these patients is resistant to a gluten-free diet or, after a period of remission, they experience relapse despite continued adherence to treatment, which is called unclassified sprue or refractory sprue.The prognosis of refractory sprue may be poor: patients may die of severe malabsorption or from the development of an enteropathy-associated T-cell lymphoma. We report a 72-year-old-woman with a diagnosis of refractory sprue who responded well to treatment with corticosteroids and a gluten-free diet.

Disminución de la talla en mujeres con diabetes mellitus no insulinodependiente (DMNID) / Decrease size in women with thype 2 diabetes

No disponible

Parenteral infusions as culture media from a viewpoint of nosocomial bacteremia.

OBJECTIVE: To assess the growth patterns of selected organisms in common parenteral solutions, in order to ascertain implications for nosocomial bacteremia. DESIGN: A microbial suspension of approximately 300 CFU/mL was sequentially inoculated into common parenteral infusions from three different manufacturers and incubated at room temperature. Initially, 11 bacterial isolates and one Candida species from clinical specimens were studied. Eight gram-negative rods (GNR) were tested at varying pH's. Species variability was examined by testing an additional 39 isolates. RESULTS: The eight GNR grew in Ringer's lactate (RL) from two manufacturers and only two grew in dextrose 5% in water (D5/W) (Klebsiella pneumoniae and Serratia marcescens). No organism grew in saline or dextrose 5% in saline. The gram-positive cocci and Candida did not grow in any solution. No significant changes in growth were found after modifying the pH of solutions. Significant inter- and intra-species growth variability was noted. CONCLUSIONS: RL is a good culture media for GNR and D5/W is a poor culture media with the exception of some bacteria of the Tribe Klebsielleae. We recommend to follow high standards of nursing practice for administering intravenous infusions and to avoid nutrient-containing solutions for prolonged parenteral use, when possible.

[Serologic response against hepatitis C virus as a predictive factor to the treatment with interferon]. / Respuesta serológica frente al virus de la hepatitis C como factor predictivo al tratamiento con interferón.

AIM: Serologic response of patients with chronic hepatitis C (CHC) was studied as a predictor of response to IFN therapy and we evaluated the correlation between such response with gender, risk factor, serum ferritin, GGT, Knodell's index and fibrosis. MATERIALS AND METHODS: A study was carried out in 40 patients with CHC who were treated with interferon-alpha 3 MU 3 times weekly 48 weeks. The diagnosis of hepatitis C was made based upon Inmuno-Blot (core, NS3, NS4 y NS5) and confirmed by detection of HCV-RNA in serum. Responses were evaluated (normal ALT and undetectable HCV-RNA in serum) at three months, at the end of treatment and six months after treatment. RESULTS: No significant differences were observed in responses at three months with regard to gender (47% males responded versus 55% females, n.s.), source of infection (50% intravenous drug users versus 50% non intravenous drug users; n.s.) and GGT level (50% with high levels versus 50% with normal levels, n.s.); however 25% of patients with high level of serum iron responded versus 59% with normal values (p = 0.04) and 28% of patients with fibrosis at liver histopathology responded versus 82% without fibrosis (p = 0.0006). No differences were observed at the response rates with regard to levels of core (20.1 SD:4 versus 19.5 SD:2.2, n.s.), NS3 (18.6 SD:7 versus 17.1 SD:7.3, n.s.) and NS4 (14.3 SD:7.7 versus 10.5 SD:9.2, n.s.). However NS5 levels in responders were 2.5 (0-16) versus 5.2 (0-16.5) in nonresponders (p < 0.05) and score in Knodell's index was 6.1 SD:2.6 in responders versus 9.2 SD:2.4 in nonresponders (p = 0.006). 47% of responders relapsed 6 months after the end of treatment with IFN. CONCLUSIONS: Titers of anti-NS5 showed predictive value of response as opposed to anti-core, anti-NS3 and anti-NS4 and it may justify its determination in the assessment of a patient with CHC at centers without capacity for measuring genotype and viral load. Low level of serum iron and Knodell's index like absence of fibrosis at liver histopathology were also variables with predictive value of response, as opposed to gender, GGT level and source of infection.

[Control of pediatric nosocomial bacteremia by a program based on culturing of parenteral solutions in use]. / Control de bacteriemia nosocomial pediátrica mediante un programa de cultivo de soluciones parenterales en uso.

OBJECTIVE: As Klebsiella, Enterobacter and Serratia are capable of growth in i.v. fluids and these bacteria are commonly implicated in nosocomial bacteremia, a control strategy through microbiological surveillance of in-use parenteral solutions is proposed. MATERIAL AND METHODS: A second level general teaching hospital, serving low-income patients. Through four consecutive strategies, a continuous surveillance program of i.v. fluids sterility in pediatric wards was stablished in 1992. During the first stage all of the in-use solutions were cultured. During the second stage randomly selected samples were studied. Third stage was designed as a case-control study. The last stage included samples drawn in convenience. Positive cultures point out eventual infusion mishandling, as well as high-risk areas and patients. RESULTS: After culturing 1940 parenteral solutions, infusion contamination rates decreased from 29.6% in 1992 to 12.9% in 1997 (p < 0.001). The proportion of Gram-negative rods isolated from blood cultures went from 72.7% to 40.85% (p < 0.0001), and the nosocomial bacteremia rate dropped from 3.12 to 1.54 per 100 discharges. CONCLUSIONS: The program has enabled us to: 1) Detect and control eventual bacteremia outbreaks; 2) Assess the endemic infusion contamination rate; 3) Arouse healthcare workers awareness about infusion line precautions; 4) Have a suitable surveillance strategy according to our laboratory's workload.

Parenteral infusions bacterial contamination in a multi-institutional survey in Mexico: considerations for nosocomial mortality.

BACKGROUND: Parenteral infusions can be contaminated during administration (extrinsic contamination). A previous survey found that extrinsic contamination was not uncommon in a hospital in Mexico with lapses in aseptic techniques. To determine whether this problem exists in other similar institutions, we undertook a multi-institutional study. METHODS: We surveyed 6 hospitals (A to F) lacking an infection control committee to determine the level of extrinsic contamination. We visited each hospital and obtained samples of all the parenteral infusions in use, drawing 0.5-1 mL from the tubing injection port. Quantitative and qualitative bacterial cultures were performed. Chlorine levels of the tap water were measured. Visits were repeated until the survey was completed. RESULTS: A total of 751 infusions were cultured, of which 16 (2.13%) were contaminated. Hospital contamination rates varied from zero to 5.56%. Klebsiella pneumoniae was the most common isolate (10 cases). During the first sampling day in hospital C, the 7 infusions from the pediatric ward were found to be contaminated with a similar K pneumoniae strain. In-service education was started in this hospital. Infusion contamination was eliminated followed by a reduction in mortality rate. Overall, a higher risk for infusion contamination was noted for pediatric patients (P =.01, odds ratio = 3.28, 95% CI, 1.10-9.91) and in wards with inadequate water chlorine levels (P =. 02, odds ratio = 3.64, 95% CI, 1.08-13.51). CONCLUSIONS: If the hospitals surveyed are representative of others in developing countries, an endemic level of parenteral infusion contamination could exist in many hospitals throughout the world.

[The epidemiology of Q fever in the northern area of Huelva, Spain]. / Epidemiología de la fiebre Q en la zona norte de Huelva.

OBJECTIVE: The aim of the present study is to know the prevalence, incidence and clinical presentation of the acute Q fever in the north of the Huelva district. METHODOLOGY: a) Prevalence: 1,654 serum were randomly collected from the health district and distributed by their origin, age and sex. The methodology used was the indirect immunofluorescence, Coxiella burnetii phase II as antigen. Were regarded as positives those serum whose titles were equal or higher to 80; b) Incidence: prospective study of every case treated in hospital during 1996-1997 plus every referred patient from the different "Health Centers". An acute case of Q fever was established as a feverish syndrome of more than 2 days plus a title equal or higher to 320 against C. burnetti phase II antigen, and c) Clinical data: all the patients were clerked and similar form was filled up including the following items: pneumonia, hepatitis, headache, persistent fever, etc. RESULTS: a) Prevalence: it was 5.08%, more frequent in men than in women; b) Incidence: 21 new cases over two years, an incidence of 12.70 cases per 100,000 population, and c) CLINICAL PRESENTATION: feverish syndrome plus hepatitis in 100% of the cases, just two pneumonia were recorded and in 4 cases the clinical picture was associated to immunological symptoms with persistent fever. CONCLUSION: A discrepancy between incidence and prevalence has been pointed out which makes us think that the majority of the Q fever cases in this area debut as a self restricted feverish syndrome which does not require specialized treatment.

[Eradication of Helicobacter pylori by triple therapy in ulcerous patients: the role of endoscopy and antibiotic sensitivity]. / Erradicación mediante triple terapia de Helicobacter pylori en pacientes ulcerosos: papel de la endoscopia y sensibilidad antibiótica.

BACKGROUND: A protocol was conducted to evaluate the compliance and results of Helicobacter pylori infection treatment in patients with ulcer disease. To know the metronidazole, clarithromycin and amoxicillin activities of Helicobacter pylori strains from such patients. PATIENTS AND METHODS: 35 patients with ulcer disease (27 duodenal ulcer and 8 gastric ulcer) were studied. Diagnosis of Helicobacter pylori infection was performed by urease test and culture of mucosal gastric samples from patients undergoing endoscopy. The patients received the following treatment during 7 days: omeprazole (20 mg bid), clarithromycin (500 mg bid) and amoxicillin (1 g bid), OCA x 7. Susceptibility was determined by E-test system on Wilkins-Chalgren blood agar and read after 5 days. RESULTS: 22/24 patients who had completed the protocol design eradicated Helicobacter pylori (91.7%), 11 patients (31.4%) refused second endoscopy to verify control of eradication. After treatment 10 patients presented with pyrosis "de novo" (28%). The overall metronidazol, claritromycin and amoxicillin resistance rate was 50%, 1.5% and 0% respectively. CONCLUSIONS: OCA x 7 treatment obtains a eradication rate higher than 90% in our patients with ulcer disease, despite smoking habit, but with a significative number of patients presenting pyrosis after treatment. We recommend a non-endoscopy method to verify eradication rate, because of its poor acceptance. 3. Metronidazol resistance rate is high in our series but clarithromycin susceptibility is maintained.