Prevalence of Primary Resistance of Helicobacter pylori to Clarithromycin and Levofloxacin in Southern Spain.

BACKGROUND: The eradication of Helicobacter pylori (HP) using clarithromycin (CLA)-based triple therapy depends on the resistance of HP to antibiotics. The Maastricht III conference recommends the implementation of locoregional surveillance programmes for primary resistance of HP to CLA. In Andalusia, there are no previous data in this respect. The aim of this study was to determine the prevalence of the primary resistance of HP to CLA and levofloxacin (LF) in southern Spain. METHODS: Multicentre cross sectional study was carried out in 6 hospitals in Andalusia. Patients of both sexes numbering 401 were included (male 48%), aged 18-80 years and naïve to HP eradication. Resistance of HP to CLA (CLAr) and LF (LFr) was assessed by determining mutations by PCR: mutations of the 23S rRNA gene define CLAr and mutations of the gene gyrA define LFr. Four hundred one gastric samples were collected. CLAr was detected in 72 patients (17.9%) and LFr was detected in 56 patients (13.9%). Heteroresistance was detected for both antibiotics: CLA 37/72 (51.3%) and LF 28/56 (50%). Variability for CLAr was detected among the centres, ranging from 11.5% to 24.7% without statistical significance (p = 0.12). Female sex was related to CLAr. CONCLUSIONS: In Andalusia, there is a high rate of primary CLAr and LFr. CLA-based triple therapy should be avoided as the primary eradication regimen in this region. There is a wide variability in the rate of CLAr among centres.

Lactose tolerance test shortened to 30 minutes: An exploratory study of its feasibility and impact.

INTRODUCTION: Lactose malabsorption (LM) is a very common condition with a high prevalence in our setting. Lactose tolerance test (LTT) is a basic, affordable test for diagnosis that requires no complex technology. It has been recently shown that this test can be shortened to 3 measurements (baseline, 30 min, 60 min) with no impact on final results. The purpose of our study was to assess the feasibility and benefits of LTT simplification and shortening to 30 min, as well as the financial impact entailed. MATERIAL AND METHODS: A multicenter, observational study of consecutive patients undergoing LTT for LM suspicion. Patients received 50 g of lactose following a fasting period of 12 h, and had blood collected from a vein at all 3 time points for the measurement of blood glucose (mg/dl). Differences between the shortened and complete test forms were analyzed using McNemar´s test. A comparison of blood glucose levels between patients with normal and abnormal results was performed using Student´s T-test for independent mean values. Consistency was assessed using the kappa index. A p < 0.05 was considered to be statistically significant. RESULTS: A total of 270 patients (69.6 % females) were included, with a mean age of 39.9 ± 16 years. LTT was abnormal for 151 patients (55.9 %). We observed no statistically significant differences in baseline blood glucose levels between patients with normal and abnormal LTT results (p = 0.13); however, as was to be expected, such differences were obvious for the remaining time points (p < 0.01). Deleting blood glucose measurements at 60 minutes only led to overdiagnose LM (false positive results) in 6 patients (2.22 %), with a kappa index of 0.95 (95 % CI: 0.92-0.99) (p < 0.001) versus the complete test. Suppressing measurements at 60 min would have saved at least € 7,726. CONCLUSION: The shortening of LTT to only 2 measurements (baseline and 30-min) hardly leads to any differences in final results, and would entail savings in time, materials, and personnel.

Test de tolerancia a la lactosa reducido a 30 minutos: un estudio exploratorio de su factibilidad e impacto / Lactose tolerance test shortened to 30 minutes: an exploratory study of its feasibility and impact

Introducción: la malabsorción a la lactosa (ML) es una patología muy frecuente con alta prevalencia en nuestro medio. El test de tolerancia a la lactosa (TTL) es una prueba básica y económica que permite su diagnóstico sin precisar tecnología compleja. Recientemente se ha demostrado que este test puede reducirse a 3 determinaciones (basal, 30 y 60 min) sin afectar al resultado final. El propósito de nuestro estudio fue el valorar la factibilidad y ventajas de poder acortar y simplificar el TTL a 30 min, así como el impacto económico que conllevaría. Material y métodos: estudio multicéntrico y observacional de pacientes consecutivos a los que se les realiza un TTL ante la sospecha de ML. Los enfermos reciben 50 g de lactosa tras 12 h de ayuno y se les realiza extracción de sangre venosa en los 3 tiempos para la medición de la glucemia (mg/dl). La diferencia entre el test reducido y el completo se analizaron con el test de McNemar. La comparación de los niveles de glucemia entre los pacientes con test normal y patológico fue realizada usando el test t-Student para comparación de medias independientes. La concordancia fue evaluada con el índice Kappa. Se consideró p < 0,05 como estadísticamente significativo. Resultados: se incluyeron 270 pacientes (69,6 % mujeres) con edad media de 39,9 ± 16 años. El TTL fue patológico en 151 casos (55,9 %). No observamos diferencias estadísticamente significativas entre las glucemias basales de los pacientes con TTL normal o patológico (p = 0,13), sin embargo, como cabía esperar, estas diferencias fueron evidentes en los demás tiempos (p < 0,01). La eliminación de la determinación de glucemia a los 60 min tan solo sobrevaloró el diagnóstico de ML (falsos positivos) en 6 enfermos (2,22 %), con índice kappa de 0,95 (IC 95 %: 0,92- 0,99) (p < 0.001) respecto al test completo. Si se hubiera suprimido la determinación de los 60 min, se podría haber ahorrado al menos 7.726 euros. Conclusión: el reducir el TTL a 2 determinaciones (basal y 30 min) no implica apenas cambios en el resultado final del test, sin embargo conllevaría un ahorro de tiempo, material y personal (AU)

Introduction: Lactose malabsorption (LM) is a very common condition with a high prevalence in our setting. Lactose tolerance test (LTT) is a basic, affordable test for diagnosis that requires no complex technology. It has been recently shown that this test can be shortened to 3 measurements (baseline, 30 min, 60 min) with no impact on final results. The purpose of our study was to assess the feasibility and benefits of LTT simplification and shortening to 30 min, as well as the financial impact entailed. Material and methods: A multicenter, observational study of consecutive patients undergoing LTT for LM suspicion. Patients received 50 g of lactose following a fasting period of 12 h, and had blood collected from a vein at all 3 time points for the measurement of blood glucose (mg/dl). Differences between the shortened and complete test forms were analyzed using McNemar’s test. A comparison of blood glucose levels between patients with normal and abnormal results was performed using Student’s T-test for independent mean values. Consistency was assessed using the kappa index. A p < 0.05 was considered to be statistically significant. Results: A total of 270 patients (69.6 % females) were included, with a mean age of 39.9 ± 16 years. LTT was abnormal for 151 patients (55.9 %). We observed no statistically significant differences in baseline blood glucose levels between patients with normal and abnormal LTT results (p = 0.13); however, as was to be expected, such differences were obvious for the remaining time points (p < 0.01). Deleting blood glucose measurements at 60 minutes only led to overdiagnose LM (false positive results) in 6 patients (2.22 %), with a kappa index of 0.95 (95 % CI: 0.92-0.99) (p < 0.001) versus the complete test. Suppressing measurements at 60 min would have saved at least Euros 7,726. Conclusion: The shortening of LTT to only 2 measurements (baseline and 30-min) hardly leads to any differences in final results, and would entail savings in time, materials, and personnel (AU)

Pancreatitis aguda asociada a levofloxacino / Acute pancreatitis associated with levofloxacin

No disponible

No disponible

[Gastric pneumatosis and gas in the portal venous system secondary to peptic ulcer]. / Neumatosis gástrica y gas en el sistema venoso portal secundario a una úlcera péptica.

A 72-year-old woman presented to the emergency department with recurrent vomiting without abdominal pain. On physical examination, the patient was afebrile and her abdomen was soft and nontender with a giant abdominal-wall hernia. Upper endoscopy showed a deep, 3-cm ulcer at the gastric angulus. Computed tomography (CT) of the abdomen showed gastric dilatation with gas in the wall and a large part of the digestive tract within the hernia sac. CT imaging also revealed gas throughout the portal venous system. The patient declined surgery. Management was conservative and included correction of fluid and electrolyte balance, and nasogastric drainage for gastric decompression with good response.

Neumatosis gástrica y gas en el sistema venoso portal secundario a una úlcera péptica / Gastric pneumatosis and gas in the portal venous system secondary to peptic ulcer

Presentamos el caso de una mujer de 72 años, que acudió aurgencias tras presentar vómitos de repetición, sin dolor abdominal.En la exploración presentaba una gran hernia abdominalsin datos de complicación, no dolorosa y afebril. Laendoscopia digestiva alta (EDA) mostró una úlcera profundade unos 3 cm de tamaño en la incisura angularis. En latomografía computarizada abdominal se apreció una dilatacióngástrica, con neumatosis de toda la pared y gas en elsistema venoso portal. La paciente rechazó el tratamientoquirúrgico de la hernia abdominal. Se realizó un tratamientoconservador con reposición de volumen y del balanceelectrolítico, y una descompresión gástrica con sonda nasogástrica,con buena respuesta por parte de la paciente

A 72-year-old woman presented to the emergency departmentwith recurrent vomiting without abdominal pain. Onphysical examination, the patient was afebrile and her abdomenwas soft and nontender with a giant abdominal-wallhernia. Upper endoscopy showed a deep, 3-cm ulcer at thegastric angulus. Computed tomography (CT) of the abdomenshowed gastric dilatation with gas in the wall and a largepart of the digestive tract within the hernia sac. CT imagingalso revealed gas throughout the portal venous system.The patient declined surgery. Management was conservativeand included correction of fluid and electrolyte balance, andnasogastric drainage for gastric decompression with goodresponse

[Diagnostic value of colonoscopy indication as predictor of colorectal cancer: is it possible to design a fast track diagnosis?]. / Valor de la indicación de la colonoscopia como predictor de diagnóstico de cáncer colorrectal. Se puede diseñar un circuito rápido de diagnóstico?

BACKGROUND: Diagnostic delay in patients with colorectal cancer (CRC) is a quality indicator and its reduction could improve prognosis of the disease. OBJECTIVE: To analyze the diagnostic value of different colonoscopy indications in CRC and to select the signs or symptoms that, if prioritized in a rapid diagnostic circuit, would be most efficient. MATERIAL AND METHODS: A retrospective analysis of 2219 outpatients who underwent colonoscopy from 2000 to 2007 was performed. For each indication we calculated the sensitivity (S), positive predictive value (PPV), positive likelihood ratio (LR+), and number of colonoscopies needed to diagnose a case of CRC (NND). RESULTS: A total of 179 patients were diagnosed with CRC. The indications with greatest PPV were liver metastases (35.3%), suspicious radiological image (20.8%), and non-distal rectal bleeding (22%). Iron deficiency anemia (11%), constitutional syndrome (10%), any rectal bleeding (9.4%) and rectal syndrome (9%) had intermediate PPV. Constipation (6.3%), alternating constipation-diarrhea (3.3%), changes in bowel habits (3%), distal rectal bleeding (2.1%), diarrhea (1.8%) and abdominal pain (1.1%) had low PPV. The NND was 4 in liver metastases, 7 in non-distal bleeding and 8 in suspicious radiological image. Distal bleeding (13), diarrhea (14), abdominal pain (14), changes in bowel habits (15) and alternating constipation-diarrhoea (21) had negative NND. The subgroup of patients aged >or= 50 years showed lower NND in non-distal rectal bleeding (5), suspicious radiological image (5) and any rectal bleeding (16). CONCLUSIONS: Patients with non-distal rectal bleeding should be prioritized over other indications in a strategy of rapid diagnosis of CRC. Age equal to or more than 50 years should also be considered because this factor seems to reduce NND. Distal bleeding, abdominal pain and changes in bowel habits had low PPV and were associated with other diagnoses than CRC. Consequently, prioritization of these factors would be inefficient.

Valor de la indicación de la colonoscopia como predictor de diagnóstico de cáncer colorrectal. ¿Se puede diseñar un circuito rápido de diagnóstico? / Diagnostic value of colonoscopy indication as predictor of colorectal cancer: Is possible to be designed a fast tracking for diagnosis?

INTRODUCCIÓN: La demora diagnóstica en los pacientes concáncer colorrectal (CCR) es un indicador de calidad, y su reducciónpuede suponer un beneficio en el pronóstico de la enfermedad.OBJETIVOS: Analizar el valor diagnóstico para CCR de las indicacionesde colonoscopia y seleccionar aquellas cuya priorizaciónen un circuito rápido de diagnóstico es más eficiente.MATERIAL Y MÉTODOS: Análisis retrospectivo de 2.219 colonoscopiasambulatorias de 2000 a 2007. Para cada indicaciónse calcularon la sensibilidad (S), el valor predictivo positivo(VPP), el cociente de probabilidad positivo (LR+) y el númerode colonoscopias para diagnosticar un caso de CCR (NND).RESULTADOS: Fueron diagnosticados de CCR 179 pacientes.Las indicaciones con mayor VPP fueron las metástasis hepáticas(35,3%), la imagen radiológica sospechosa (20,8%) y larectorragia no distal (22%). La anemia ferropénica (11%), elsíndrome constitucional (10%), cualquier rectorragia (9,4%)y el síndrome rectal (9%) tuvieron un VPP intermedio. El estreñimiento(6,3%), la alternancia estreñimiento-diarrea(3,3%), la alteración del hábito intestinal (3%), la rectorragiadistal (2,1%), la diarrea (1,8%) y el dolor abdominal (1,1%)presentaron un VPP bajo. El NND fue de 4 en las metástasis,de 7 en la rectorragia no distal y de 8 en la imagen radiológicasospechosa, mientras que la rectorragia distal (–13), la diarrea(–14), el dolor abdominal (–14), la alteración del hábitointestinal (–15) y la alternancia (–21) tuvieron NND negativos.Los pacientes con una edad 50 años mostraron menorNND en la rectorragia no distal (5), la imagen radiológica sospechosa(5) y cualquier rectorragia (16).(..) (AU)

BACKGROUND: Diagnostic delay in patients with colorectalcancer (CRC) is a quality indicator and its reduction couldimprove prognosis of the disease.OBJECTIVE: To analyze the diagnostic value of different colonoscopyindications in CRC and to select the signs or symptomsthat, if prioritized in a rapid diagnostic circuit, wouldbe most efficient.MATERIAL AND METHODS: A retrospective analysis of 2219outpatients who underwent colonoscopy from 2000 to 2007was performed. For each indication we calculated the sensitivity(S), positive predictive value (PPV), positive likelihoodratio (LR+), and number of colonoscopies needed to diagnosea case of CRC (NND).RESULTS: A total of 179 patients were diagnosed with CRC.The indications with greatest PPV were liver metastases(35.3%), suspicious radiological image (20.8%), and non-distalrectal bleeding (22%). Iron deficiency anemia (11%),constitutional syndrome (10%), any rectal bleeding (9.4%)and rectal syndrome (9%) had intermediate PPV. Constipation(6.3%), alternating constipation-diarrhea (3.3%), changesin bowel habits (3%), distal rectal bleeding (2.1%), diarrhea(1.8%) and abdominal pain (1.1%) had low PPV. TheNND was 4 in liver metastases, 7 in non-distal bleeding and8 in suspicious radiological image. Distal bleeding (–13),diarrhea (–14), abdominal pain (–14), changes in bowel habits(–15) and alternating constipation-diarrhoea (–21) hadnegative NND. The subgroup of patients aged 50 yearsshowed lower NND in non-distal rectal bleeding (5), suspiciousradiological image (5) and any rectal bleeding (16). (..) (AU)

Valor de la indicación de la colonoscopia como predictor de diagnóstico de cáncer colorrectal. ¿Se puede diseñar un circuito rápido de diagnóstico? / Diagnostic value of colonoscopy indication as predictor of colorectal cancer: is possible to be designed a fast tracking for diagnosis?

INTRODUCCIÓN: La demora diagnóstica en los pacientes concáncer colorrectal (CCR) es un indicador de calidad, y su reducciónpuede suponer un beneficio en el pronóstico de la enfermedad.OBJETIVOS: Analizar el valor diagnóstico para CCR de las indicacionesde colonoscopia y seleccionar aquellas cuya priorizaciónen un circuito rápido de diagnóstico es más eficiente.MATERIAL Y MÉTODOS: Análisis retrospectivo de 2.219 colonoscopiasambulatorias de 2000 a 2007. Para cada indicaciónse calcularon la sensibilidad (S), el valor predictivo positivo(VPP), el cociente de probabilidad positivo (LR+) y el númerode colonoscopias para diagnosticar un caso de CCR (NND).RESULTADOS: Fueron diagnosticados de CCR 179 pacientes.Las indicaciones con mayor VPP fueron las metástasis hepáticas(35,3%), la imagen radiológica sospechosa (20,8%) y larectorragia no distal (22%). La anemia ferropénica (11%), elsíndrome constitucional (10%), cualquier rectorragia (9,4%)y el síndrome rectal (9%) tuvieron un VPP intermedio. El estreñimiento(6,3%), la alternancia estreñimiento-diarrea(3,3%), la alteración del hábito intestinal (3%), la rectorragiadistal (2,1%), la diarrea (1,8%) y el dolor abdominal (1,1%)presentaron un VPP bajo. El NND fue de 4 en las metástasis,de 7 en la rectorragia no distal y de 8 en la imagen radiológicasospechosa, mientras que la rectorragia distal (–13), la diarrea(–14), el dolor abdominal (–14), la alteración del hábitointestinal (–15) y la alternancia (–21) tuvieron NND negativos.Los pacientes con una edad >= 50 años mostraron menorNND en la rectorragia no distal (5), la imagen radiológica sospechosa(5) y cualquier rectorragia (16).CONCLUSIONES: En una estrategia de diagnóstico rápido deCCR, los casos de rectorragia no distal deberían priorizarsesobre el resto de indicaciones de colonoscopia. La edad >= 50años debe tenerse en cuenta, ya que disminuye el NND. Larectorragia distal, el dolor abdominal y la alteración del hábitointestinal tuvieron bajos VPP, por lo que su priorizaciónresulta ineficiente

BACKGROUND: Diagnostic delay in patients with colorectalcancer (CRC) is a quality indicator and its reduction couldimprove prognosis of the disease.OBJECTIVE: To analyze the diagnostic value of different colonoscopyindications in CRC and to select the signs or symptomsthat, if prioritized in a rapid diagnostic circuit, wouldbe most efficient.MATERIAL AND METHODS: A retrospective analysis of 2219outpatients who underwent colonoscopy from 2000 to 2007was performed. For each indication we calculated the sensitivity(S), positive predictive value (PPV), positive likelihoodratio (LR+), and number of colonoscopies needed to diagnosea case of CRC (NND).RESULTS: A total of 179 patients were diagnosed with CRC.The indications with greatest PPV were liver metastases(35.3%), suspicious radiological image (20.8%), and non-distalrectal bleeding (22%). Iron deficiency anemia (11%),constitutional syndrome (10%), any rectal bleeding (9.4%)and rectal syndrome (9%) had intermediate PPV. Constipation(6.3%), alternating constipation-diarrhea (3.3%), changesin bowel habits (3%), distal rectal bleeding (2.1%), diarrhea(1.8%) and abdominal pain (1.1%) had low PPV. TheNND was 4 in liver metastases, 7 in non-distal bleeding and8 in suspicious radiological image. Distal bleeding (–13),diarrhea (–14), abdominal pain (–14), changes in bowel habits(–15) and alternating constipation-diarrhoea (–21) hadnegative NND. The subgroup of patients aged >= 50 yearsshowed lower NND in non-distal rectal bleeding (5), suspiciousradiological image (5) and any rectal bleeding (16). CONCLUSIONS: Patients with non-distal rectal bleeding shouldbe prioritized over other indications in a strategy of rapiddiagnosis of CRC. Age equal to or more than 50 years shouldalso be considered because this factor seems to reduce NND.Distal bleeding, abdominal pain and changes in bowel habitshad low PPV and were associated with other diagnoses thanCRC. Consequently, prioritization of these factors would be inefficient

Hepatitis aguda colestásica inducida por amoxicilina-clavulánico / Acute cholestatic hepatitis induced by amoxicillin-clavulanic acid

No disponible

ERCP in patients 90 years of age and older.

BACKGROUND: Biliary diseases represent particular diagnostic and therapeutic problems in elderly patients. METHODS: Patients 90 years of age or older who underwent ERCP from January 1993 to September 2001 were studied retrospectively. RESULTS: A total of 126 patients underwent 147 ERCP procedures (range 1-5 per patient). Twelve additional ERCPs were performed in 9 of the patients during follow-up because of recurrent symptoms. A total of 159 procedures were, therefore, available for analysis. The most frequent indications were suspicion of bile duct stones (46.8%) and obstructive jaundice (35.7%). Midazolam (95.6%) was used for conscious sedation and hyoscine (74.8%) for duodenal ileus. Patient tolerance of the procedure was good in 92.4% of sessions. Diagnoses included bile duct stones (54%), bile duct dilatation without any apparent obstruction (11.9%), and malignant stenosis (9.5%). Therapeutic procedures were indicated in 95.6% of diagnosed patients and completed in 96.3% of cases. Complications occurred in association with 2.5% of the ERCP procedures; the procedure-related mortality rate was 0.7%. CONCLUSIONS: ERCP in elderly patients is practicable. The complication rate is low, and therapeutic efficacy is good.