Levels of endothelial and platelet microparticles and their interactions with leukocytes negatively correlate with organ dysfunction and predict mortality in severe sepsis.

OBJECTIVE: Mortality in sepsis is believed to be associated with exaggerated inflammatory responses, but recent evidence suggests that poor outcome is associated with reduced inflammation. To test this hypothesis, we measured several inflammatory markers to determine whether any of them or any combinations are associated with mortality or organ dysfunction. DESIGN: Clinical study. SETTING: School of medicine. PATIENTS: Thirty-five patients with severe sepsis. INTERVENTIONS: Markers of endothelial, platelet, and leukocyte activation were measured on days 1, 2, and 3 after enrollment. The markers were a) endothelial microparticles (EMPs) and their conjugates with monocytes (EMP/MONO); b) platelet microparticles (PMPs) and platelet activation marker CD62P; c) platelet-leukocyte conjugates (PLT/LEU) and leukocyte activation marker CD11b; and d) intracellular nitric oxide in leukocytes. MEASUREMENTS AND MAIN RESULTS: The 28-day mortality rate was 51% (18 of 35). Significant differences between survivors and nonsurvivors on day 1 were found in PLT/LEU (p = .001), CD11b (p = 0.02), and EMP/MONO (p = .02) groups. Using logistic regression to assess if these markers predict mortality on day 1, we found that PLT/LEU had the best predictive value among the markers used (area under receiver operating characteristics curve = 0.82). All markers of cell activation and inflammation were significantly higher among survivors on days 2 and 3, except nitric oxide, which was lower. This marker showed significant negative correlation with the Sequential Organ Failure Assessment score throughout the study. CONCLUSIONS: Our data support the hypothesis that early increased, not decreased, inflammatory response as measured by our markers is associated with improved survival rate. A high negative correlation was found between some of these markers and Sequential Organ Failure Assessment score.

Elevation of endothelial microparticles, platelets, and leukocyte activation in patients with venous thromboembolism.

OBJECTIVES: The purpose of this research was to determine the levels of platelet, leukocyte, and endothelial activation and markers of cellular interactions in patients with venous thromboembolism (VTE). BACKGROUND: The details of interactions between endothelium, platelets, and leukocytes in VTE are not well understood. METHODS: We studied 25 patients with VTE and compared 25 healthy controls. We used flow cytometry to measure: 1) endothelial microparticles (EMP) identified by CD31+/CD42b- (EMP(31)) or E-selectin (EMP(62E)); 2) platelet microparticles (CD31+/CD42b+); 3) surface expression of P-selectin in platelets and CD11b in leukocytes; 4) EMP-monocyte conjugates (percentage of monocytes positive for E-selectin); and 5) platelet-leukocyte conjugates (PLC) expressed as percentage of leukocytes positive for CD41. RESULTS: Patients with VTE had marked elevations of EMP(31) (2,193 vs. 383 counts/microl; p = 0.003), EMP(62E) (368 vs. 223 counts/microl; p = 0.001), and EMP-monocyte conjugates (3.3% vs. 2.5%; p = 0.002), as well as increased activation of platelets (35.2 vs. 5.0 fluorescence intensity units for P-selectin; p < 0.0001) and leukocytes (13.9 vs. 7.7 U for CD11b; p = 0.004). Also elevated in VTE were PLC (61.7% vs. 39.6%; p = 0.01). Expression of CD11b in leukocytes strongly correlated with PLC (r = 0.74; p < 0.0001). CONCLUSIONS: Marked activation of endothelium, platelets, and leukocytes occurs in VTE, and VTE, or the accompanying inflammatory process, involves the release of EMP and formation of EMP-monocyte conjugates and PLC. These findings support prior studies suggesting that release of EMP and their binding to monocytes are key events in thrombogenesis. Our findings also support the concept that the formation of PLC regulates leukocyte activation and participates in linking thrombosis with inflammation.

Percutaneous stenting of bilateral pulmonary artery stenosis caused by malignant extrinsic compression.

Percutaneous stenting of the pulmonary arteries (PAs) represents a potential option in cases of PA compression due to a variety of conditions. We present the first reported case of successful bilateral percutaneous stenting of the PAs in a patient with non-small cell lung cancer and severe right ventricular hypertension due to mediastinal lymphadenopathy compressing both PAs. Although the natural course of the disease was not altered, the patient had significant symptomatic relief without adverse effects. Additionally, there was objective evidence of improvement. This case suggests that endovascular stenting is a feasible palliative management option in patients with right ventricular failure due to malignant extrinsic compression of the PAs.

¿Es útil la relación urea/creatinina para diferenciar hemorragia digestiva alta de baja? / It is useful the urea/creatinine rate for differentiation of upper from lower gastrointestinal bleeding?

La hemorragia digestiva constituye un tercio de las hospitalizaciones de nuestro servicio. A veces es difícil diferenciar clínicamente la localización del sitio de sangrado. Se ha señalado que la relación urea/creatinina puede ayudar a definir el sitio de sangrado, pero que existe una gran superposición de resultados. Estudiamos 154 pacientes con hemorragia digestiva en forma prospectiva. Tuvieron hemorragia digestiva alta 123 (79.9 por ciento) pacientes con una relación urea/creatinina promedio de 62.27ñ29.13 y hemorragia digestiva baja 31 (20.1 por ciento) con una relación urea/creatinina de 39.49ñ13.83, diferencia estadísticamente significativa pero con una gran superposición de resultados. Definiendo hemorragia digestiva alta cuando existe una relación urea/creatinina mayor de 60, encontramos una gran especificidad (96.77 por ciento) pero una sensibilidad baja (51.22 por ciento); cuando tomamos los casos de enterorragia, que generalmente son los que pueden dar problema de diagnóstico, la especificidad alcanza 96.42 por ciento y la sensibilidad 46.15 por ciento. En conclusión, un valor de urea/creatinina mayor de 60 nos indica generalmente una hemorragia del tracto digestivo alto, pero un valor por debajo de 60 no es de valor diagnóstico.

[IT IS USEFULL THE UREA/CREATININE RATE FORDIFFERENTIATION OF UPPER FROM LOWER GASTROINTESTINAL BLEEDING?] / ?Es útil la relación Urea\Creatininapara diferenciar Hemorragia Digestiva Alta de Baja¿

Gastrointestinal bleeding constitutes a third part of the hospitalizations in our service. Some times is difficult to clinically distinguish the site of bleeding. It was pointed that the urea/creatinine ratio can help to define the site of bleeding, but there is a lot of superposition in the results. We studied prospectively 154 patients with gastrointestinal bleeding. 123 (79.9%) patients had upper gastrointestinal bleeding with an urea/creatinine ratio of 62.27 +/- 29.13 and 31(20.1%) patients had lower gastrointestinal bleeding with an urea/creatinine ratio of 39.49 +/- 13.83. This difference is statistically significant but has a lot of overlap results. Defining gastrointestinal bleeding as an urea/creatinine ratio greater than 60, we found a great specificity (96.77%) but a low sensibility (51.22). In addition, when we only took hematochezia cases, that usually is a diagnostic problem, the specificity was 96.42% and the sensitivity 46.15%. In conclusion, an urea/creatinine ratio greater than 60 usually indicate us an upper gastrointestinal bleeding, but values below of 60 isn't of diagnostic value.

Manejo exitoso de hemorragia por várice yeyunal con escleroterapia y endoligadura: reporte de un caso / Successful handling of hemorrhages due to jejunal variceal vein with sclerotherapy and endoligature: a report on one case

Se reporta el caso de un paciente cirrótico, sometido previamente a escleroterapia de várices esofágicas y gastrectomía total, que presentó una hemorragia activa de várice yeyunal, en quien el tratamiento con escleroterapia y posterior endoligadura fue exitoso resolviendo el problema variceal.

[SUCCESSFUL HANDLING OF HEMORRHAGES DUE TO JEJUNALVARICEAL VEIN WITH SCLEROTHERAPY AND ENDOLIGATURE: A REPORT ON ONE CASE] / Manejo exitoso de hemorragia por váriceyeyunal con escleroterapia y endoligadura: Reporte de un caso.

A case of jejunal bleeding is reported. A 68-year-o1d man, who suffered previous gastrectomy and sclerotherapy for esophageal varices presented jejunal variceal bleeding. These varices were sclered and banded with good results.

Hemobilia: reporte de dos casos / Hemobilia: report of two cases

La hemobilia, definida como hemorragia dentro del árbol biliar, es una entidad rara. La comunicación anormal entre los vasos sanguíneos y el árbol biliar puede ser debida a trauma, desórdenes inflamatorios, infecciones, litiasis vesicular, tumores y trastornos de la coagulación. Presentamos el reporte de dos casos, cuyo diagnóstico se realizó por Pancreatocolangiografía Retrógrada Endoscópica (PCRE).

Hemobilia is defined as the hemorrhage within the biliary tree. Maybe, the abnormal communication between blood vessels and the biliary tree, is due to trauma, inflammatory disorders, infections, gallstones, tumors and coagulation disorders. Two cases, which diagnosis were made with retrograde endoscopic cholangio pancreatography, are reported here.

Tratamiento con inyección endoscópica de la úlcera péptica sangrante / Endoscopic injection treatment of bleeding peptic ulcer

Objetivos: Fueron dos, 1)Determinar la eficacia de la terapia de inyección endoscópica (TIE) en pacientes con sangrado por úlcera péptica con .alto riesgo de recurrencia, y 2)Reconocer los factores de riesgo clínico-endoscópicos que influyen en la recurrencia de hemorragia y la mortalidad por esta patología. Métodos: Es un estudio retrospectivo que incluye 121 pacientes admitidos a una unidad especializada en el manejo de hemorragia digestiva debido a una úlcera péptica con sangrado activo o vaso visible no sangrante, entre Marzo de 1994 y Febrero de 1996, y a los que se les realizó TIEcon adrenalina. Resultados: Se logró éxito en la hemostasia endoscópica inicial en 119 pacientes (99.1 por ciento), en un paciente la hemorragia persistió (0.9 por ciento), y en otro no se pudo realizar la TIE por inaccesibilidad. La hemostasia definitiva se alcanzó en 93 pacientes (77.5 por ciento), y hubo recurrencia en 28 (23.5 por ciento).Se remitió a cirugía a 26 pacientes (21.5 por ciento). El examen univariado demostró que la recurrencia de la hemorragia estuvo relacionada con la presencia de shock (p=0.002), hematemesis (p=0.02),edad mayor de 60 años (p=0.009), número de unidades transfundidas (p=O.OOOOO) y tamaño de la úlcera mayor de 2cm (p=0.018). La mortalidad global en nuestros pacientes fue de 10 por ciento, y la mortalidad operatoria de 34.6 por ciento. Los factores asociados significativamente con la mortalidadfueron la recurrencia de la hemorragia (p=0.000003), presencia de enfermedad concomitante (p=0.05), la presencia de úlcera gástrica (p=0.021), además de la edad (mayores de 60años), presencia de.shock y tamaño de la úlcera mayor de 2cm (P=0.05). Conclusiones: La TIE es un procedimiento útil en el tratamiento de la hemorragia por úlcera péptica con alto riesgo de recurrencia (hemorragia activa o vaso visible), habiéndose obtenido la hemostasia definitiva en el 77.5 por ciento...

Background: Objectives were two. (1) to determine the efficiency of the endoscopic injection therapy (EIT) in patients suffering from bleeding caused by peptic ulcer disease with high risk of recurrence, and (2) to recognize clinical and endoscopical risk factors that influence recurrence of hemorrhage and mortality from this pathology. Methods: This is a retrospective study that included 121 patients, who were admitted by a unit specialized in managing gastrointestinal hemorrhage owing to peptic ulcer with active bleeding or non-bleeding visible vessel, and who underwent EIT with epinephrine between March, 1994 and February, 1996. Results: Initial success was achieved in 119 patients who underwent EIT (99.1 per cent). Bleeding persisted in one patient (0.9 per cent), and in another one, EIT was not successful because of inaccessible location. Definite hemostasis was achieved in 93 patients (77.5 per cent) and there was recurrence in 28 cases (23.5 per cent). Twenty-six patients underwent surgical therapy (21.5 per cent).The univariable analysis showed that hemorrhage recurrence was related to the presence of shock (p=0.002), hematemesis (p=0.2), age over 60 (p=0.009), number of blood units transfused (p=O.OOOOO) and ulcer diameter larger than 2 cm (p=0.018). The global mortality in our patients was of 10 per cent, and surgical mortality was of 34.6 per cent. Factors significantly related to mortality were hemorrhage recurrence (p=0.000003), presence 01concomitant disease (p=0.05), and presence of gastric ulcer (p=0.021), in addition to age (over 60), presence of shock and ulcer diameter larger than 2 cm (p=0.05). Conclusion: EIT is a valuable procedure for the treatment of hemorrhage caused by peptic ulcer with high risk of recurrence (active hemorrhage or visible vessel), with a definite hemostasis of 77.5 per cent...

[ENDOSCOPIC INJECTION TREATMENT OF BLEEDING PEPTIC ULCER] / Tratamiento con Inyección endoscópicade la úlcera péptica sangrante.

BACKGROUND: Objectives were two. (1) to determine theefficiency of the endoscopic injection therapy (EIT) in patients suffering from bleeding caused by peptic ulcer disease with high risk of recurrence, and (2) to recognize clinical and endoscopical risk factors that influence recurrence of hemorrhage and mortality from this pathology. METHODS: This is a retrospective study that included 121 patients, who were admitted by a unit specialized in managing gastrointestinal hemorrhage owing to peptic ulcer with active bleeding or non-bleeding visible vessel, and who underwent EIT with epinephrine between March, 1994 and February, 1996.RESULTS: Initial success was achieved in 119 patients who underwent EIT (99,1%). Bleeding persisted in one patient (0,9%), and in another one, EIT was not sucessful because of inaccessible location. Definite hemostasis was achieved in 93 patients (77,5%) and there was recurrence in 28 cases (23,5%). Twenty-six patients underwent surgical therapy (21,5%). The univariable analysis showed that hemorrhage recurrence was related to the presence of shock (p = 0,002), hematemesis (p = 0,2), age over 60 (p = 0,009), number of blood units transfused (p = 0,00000) and ulcer diameter larger than 2 cm (p = 0,018). The global mortality in our patients was of 10%, and surgical mortality was of 34,6%. Factors significantly related to mortality were hemorrhage recurrence (p = 0,000003), presence of concomitant disease (p = 0,05), and presence of gastric ulcer (p = 0,021), in addition to age (over 60), presence of shock and ulcer diameter larger than 2 cm (p = 0,05).CONCLUSION: EIT is a valuable procedure for the treatment of hemorrhage caused by peptic ulcer with high risk of recurrence (active hemorrhage or visible vessel), with a definite hemostasis of 77,5%. The presence of shock, hematemesis, age over 60, transfusion requirements of more than 3 blood units, and ulcer diameter of more than 2 cm are factors that increase the probability of hemorrhage recurrence after EIT. Mortality is significantly related to the presence of hemorrhage recurrence, concomitant diseases and gastric ulcer in addition to clinical and endoscopical factors mentioned above, with the exception of hematemesis and transfusion requirement. A prompt surgery after detection of a major bleeding recurrence in patients with the risk factor already described and a coordinate action with a surgery team experienced in digestive hemorrhage would influence favorably the mortality rate of this disease.

[HEMOBILIA: REPORT OF TWO CASES] / Hemobilia: Reporte de Dos Casos.

Hemobilia is defined as the hemorrhage within the biliary tree. Maybe, the abnormal communication between blood vessels and the billiary tree, is due to trauma, inflammatory disorders, infections, gallstones, tumors and coagulation disorders. Two cases, which diagnosis were made with retrograde endoscopic cholangio pancreatography, are reported here.

Pancreatocolangiografía retrograda endoscópica y esfinterotomía en las parasitosis / Endoscopic retrograde colangio pancreatography and esphinterotomy in parasitic diseases

Presentamos seis pacientes con obstrucción de la vía billar debida a parásitos (Fasciola hepática, Ascaris lumbricoides y quiste hidatídico) que se diagnosticaron y manejaron endoscópicamente. Este es el primer trabajo nacional que resalta la importancia de la pancreatocolangiografía retrógrada endoscópica en el manejo de estas parasitosis. Por otro lado se destaca que no obstante la litiasis coledociana es la causa más común de ictericia extrahepática; debe considerarse a la parasitosis de la vía biliar en el diagnóstico diferencial.

We report six patients with billary duct obstruction due to parasites (Fasciola hepatica, ascarlasis and hydatid cyst) that were diagnosed and managed with the endoscopic approach. This is the first national paper which relevants the importance of endoscopic retrograde cholangio pancreatography in the management of this parasitosis. Despite choledocholithiasis is the most common cause of extrahepatic jaundice, biliary tree parasitosis must be considered in the differential diagnosis.

Famotidina en el tratamiento de la úlcera péptica / Famotidine in peptic duodenal ulcer treatment

Este estudio abierto, multicéntrico, estuvo destinado a evaluar la eficacia, tolerancia y seguridad del nuevo antagonista de los receptores H2, Famotidina, en el tratamiento de la úlcera péptica duodenal. Treinticuatro pacientes con úlcera péptica duodenal, demostrada endoscópicamente, recibieron una tableta de Famotidina, 40mg. noche, hasta por seis semanas. Se mantuvo el tratamiento hasta documentar cicatrización de la lesión, mediante endoscopía realizada a la segunda, cuarta y sexta semana. Un paciente fue excluído por desviación del protocolo. La curación acumulativa en los 33 pacientes evaluables fue de 48.5 por ciento, 91 por ciento y 97 por ciento a la segunda, cuarta y sexta semana de tratamiento, respectivamente. El 52 por ciento de los pacientes se tornó asintomático a las 72 horas y el 79 por ciento al finalizar la primera semana. La droga fue bien tolerada y no se registraron reacciones adversas clínicas, ni de laboratorio en los treinticuatro pacientes estudiados. Se concluye que Famotidina es eficaz y bien tolerada en el tratamiento de la mayoría de pacientes con úlcera péptica duodenal