Enfermedad inflamatoria intestinal en pacientes mayores de 60 años: ¿es una enfermedad diferente? / Differences by age in clinical features of inflammatory bowel disease

Background: Approximately, 15% of patients with Inflammatory Bowel Disease (IBD) are diagnosed at 60 years of age or more. Aim: To characterize and compare clinical variables between patients with IBD aged 60 years or more and their younger counterparts. Material and Methods: Retrospective study based on a registry of IBD patients diagnosed between the years 1976 and 2014. Results: Four hundred and nine IBD patients were included. Among them, 294 had Ulcerative Colitis (UC), 104 had Crohn s Disease (CD) and eleven had an indeterminate IBD. Forty-six patients (11.2%) were older than 60 years and 16 (3.9%) had been diagnosed after this age. When comparing patients by age, those aged 60 years or more had a higher frequency of CD and indeterminate IBD (p < 0.01) and a lower ileocolic location in CD (p = 0.02). Both groups were similar in terms of hospitalization due to IBD flare, surgery, use of steroids, immunosuppressive or biological therapies and drug-related adverse events. When analyzing age at diagnosis of IBD, patients diagnosed at ages of 60 years or more had a lower frequency of UC (p < 0.01), a higher frequency of exclusive colonic involvement (p = 0.01), and lower use of mesalamine (p < 0.01). There were no differences in drug-related adverse events, hospitalizations due to IBD flares and surgery according to age at diagnosis. Conclusions: In this population, clinical features of IBD in older patients were similar to those in younger patients.

Eventos adversos en la terapia farmacológica de la enfermedad inflamatoria intestinal / Adverse events associated with the treatment of inflammatory bowel disease

Background: The purpose of inflammatory bowel disease (IBD) treatment is to achieve resolution of symptoms and remission of disease with a minimum of adverse events (AE). Aim: To report AE of different prescriptions used for the treatment of IBD. Material and Methods: Analysis of a registry of patients with IBD held at a private clinic from 1976 to 2013. All used medications, the occurrence and severity of AE were recorded. Results: The records of 346 patients aged 16 to 86 years, 74% with ulcerative colitis, were analyzed. The most commonly type of medications prescribed were 5-aminosalicylates (5-ASAs) in 329 patients (92%), followed by adrenal steroids in 218 (61%). Forty nine AE were recorded in the same number of patents (14%). These were more common in patients with Crohn disease (n = 19, 21%). An univariate analysis, demonstrated that extra-intestinal manifestations, hospitalizations secondary to IBD crisis, requirement of surgery and treatment with steroids, immunosuppressants or biologic agents were significantly associated with the presence of AE. AEs were more common with immunosuppressants, followed by 5-ASAs and steroids. Discontinuation of therapy was required in 79, 100 and 43% of patients taking these medications, respectively. Twenty percent of AEs were severe. Leukopenia and pancytopenia along with alopecia were the most common AEs attributable to azathioprine. Conclusions: The occurrence of AEs in patients with IBD is uncommon. Even inmunosuppressants or biologic agents have a low rate of AE and most of them mild.

Enfermedad inflamatoria intestinal a partir de una experiencia local / Inflammatory bowel disease. Experience in 316 patients

Background: The incidence and prevalence of Inflammatory Bowel Disease (IBD) has increased. Aim: To determine demographic and clinical characteristics of patients with IBD in a Chilean private hospital. Patients and Methods: Review of a prospective registry of patients with IBD, started on 2012. It includes clinical, imaging, endoscopical and pathological information of patients. Results: Data of 316 patients with IBD, aged 16 to 86 years (56% females), were analyzed. Ulcerative Colitis (UC), Crohn´s and non-classifiable IBD were diagnosed in 230, 77 and 9 patients, respectively. The disease was diagnosed in 82% of patients in the period between 2002 and 2012. There was a peak in the diagnosis of both UC and CD between 20 and 39 years of age, without gender differences. The disease switched from UC to CD in six patients. In four, there was a change in disease behavior. Thirty eight patients were treated with biological therapy. The median lapse between the diagnosis and the use of biological therapy was 1 year in patients diagnosed after 2007, compared with 5.5 years among those patients diagnosed before 2007 (p = 0.001). There was a trend towards a higher requirement of surgery until 2006. Subsequently there was a stabilization of the requirement, concomitant with the incorporation of biological therapy. Conclusions: An adequate registry of IBD patients is necessary to improve demographic and clinical characteristics. A national registry is needed to assess the epidemiological changes of IBD in Chile.

Rol de infliximab en enfermedad inflamatoria intestinal: Experiencia local / Treatment of inflammatory bowel disease with infliximab: Experience in 25 patients

Background: Biological therapy has an important role in the treatment of Inflammatory Bowel Disease (IBD). However, the use of these drugs is resisted due to fears about their side effects. Aim: To report the experience with the use of Infliximab in patients with IBD. Material and Methods: Descriptive study of a historical cohort of patients with IBD treated between 2007 and 2012 with Infliximab. A favorable clinical response was considered when general, intestinal and extra-intestinal symptoms subsided after the second or third dose of the drug. Endoscopic or imaging response was evaluated between three and six months of treatment. Results: Twenty five patients aged 18 to 61 years (12 women) were included. Sixteen had Cohn’s Disease and 9 had Ulcerative Colitis. Treatment was indicated due to refractory disease in 13 patients, perianal involvement in nine, stenosis in two and pyoderma gangrenosum in one. Ten patients initiated Infliximab within less than two years of diagnosis. Twenty-two patients received combined treatment with immunosuppressive medications and the other three patients were treated exclusively with Infliximab. A favorable clinical response was observed in 88% after the second dose and 64% had endoscopic or imaging remission after 3-6 months. Twelve patients discontinued Infliximab, due to bad response to treatment in three patients, economic cost in three patients, and patient/doctor decision in six. Only three patients had side effects (herpes zoster and sinusitis). None of these motivated the discontinuation of treatment. Conclusions: In this cohort of patients with IBD, the use of Infliximab was associated with endoscopic or imaging remission in 64% of cases after 3-6 months of treatment with no major side effects.

Características de los egresos de atención de dengue: Costa Rica, 1999-2002 / Characteristics of hospitalized patients in a dengue unit: Costa Rica, 1999-2002

Objetivo: Caracterizar la población de pacientes egresados de la Unidad de Atención al Dengue del Hospital Monseñor Sanabria de Puntarenas. Materiales y métodos: Se reunieron datos descriptivos del período de enero de 1999 a diciembre de 2002, así como los hallazgos clínicos y hematológicos de 267 pacientes egresados. Resultados: Los principales motivos de ingreso hospitalario fueron el mal estado general (35,0 por ciento), conteo de plaquetas inferior a 100000/ul (31,5 por ciento) y el torniquete positivo (21,3 por ciento). El dengue afectó por igual a hombres y mujeres; fundamentalmente a adultos, con un promedio de 31 años de edad, así como a trabajadores remunerados, amas de casa y estudiantes (89,5 por ciento). La mayor parte de pacientes provenían del área de mayor urbanización (75,7 por ciento). El día promedio de ingreso, desde el inicio de los síntomas, fue de 3,7 días, y los síntomas más frecuentes fueron: fiebre, cefalea, mialgias, artralgias y dolor retroocular. El 39,7 por ciento presentó algún tipo de manifestación hemorrágica, fuera provocado (26,2 por ciento) o espontáneo (22,8 por ciento), de los cuales el 7,2 sangraron por más de un sitio. El principal sitio de sangrado fue la piel (52,4 por ciento), seguido de las mucosas de nariz y la encías (35,7 por ciento). La trombocitopenia se presentó en el 68,0 por ciento de los casos. No hubo diferencia en el recuento plaquetario el día de ocurrencia de las manifestaciones hemorrágicas, entre los que sangraron y los que no. Se presentó leucopenia en el 40,5 por ciento de los casos. La estancia hospitalaria promedio fue de 3,3 días (rango: 1-12). Conclusión: Los hallazgos de este estudio deben considerarse para estimular la aplicación de la epidemiología descriptiva en el estudio de eventos como el dengue que afectan a nivel local, nacional o regional, y así contribuir al conocimiento de ellos.

Objective: To characterize the patients at the Dengue Unit of the Monseñor Sanabria Hospital, Puntarenas; during the dengue fever (DEN-2) outbreak in the Central Pacific Region of Costa Rica, from 1999 to 2002. Materials and methods: Descriptive data, clinical findings and hematological results from 267 patients, were collected. Results: The main causes for hospitalization were: poor general condition (35,0%), platelet count under 100000/ul (31,5%) and a positive tourniquet test (21,3 %). Dengue fever affected both men and women, adults (31 years old average) and workers, housewives and students (89,5 %). Most patients came from the areas with the higher urbanization (75,7 %). The average day of admission, since onset of symptoms, was 3,7. The most frequent symptoms were: fever, headache, muscle and joint pain and retroocular pain. Almost 40% of patients had some hemorrhagic manifestation, provoked (26,2 %) or spontaneous (22,8 %), with 7,2 % that bled from more than one body site. The main locations of bleeding were the skin (52,4 %), nose and gums (35,7 %). Sixty-eight percent of cases presented thrombocytopenia. There was no difference in platelet count at the day of hemorrhagic manifestations between the cases that bled and those without bleeding. Leucopenia was reported in 40,5 % of cases. The average number of days of hospitalization was 3,3, ranging from 1 to 12. Conclusion: The findings of this study must be considered in order to foster the use of descriptive epidemiology in the study of events that affect populations even at local, regional or national level, thus contributing to the understanding of these diseases.

Prueba de torniquete como predictiva de sangrado espontáneo en casos de dengue clásico por den-2 / Tourniquet test as predictive of spontaneous bleeding in classic dengue, den-2, cases

Objetivo: Determinar el valor de la prueba de torniquete como predictiva de sangrado espontáneo en pacientes afectados por dengue clásico en un brote por el virus DEN-2. Materiales y métodos: Se realizó un estudio caso-control con una población de 267 pacientes egresados de la Unidad de Atención del Dengue del Hospital Monseñor Sanabria en Puntarenas, con diagnóstico de dengue clásico, en el periodo de julio de 1999 a junio de 2002, durante el brote de virus DEN-2 en la Región Pacífico Central de Costa Rica. Hubo un total de 61 pacientes con sangrado espontáneo, casos, y 181 pacientes sin el evento, controles. Se calculó la capacidad predictiva de la prueba de torniquete mediante una tabla de contingencia con la que se determinaron las características diagnósticas de la prueba así como la razón de posibilidades, Odds ratio y la fracción etiológica, tomando como prueba de oro la condición de sangrado espontáneo. Resultados: La sensibilidad y especificidad de la prueba fueron 41.0 por ciento y 75.1 por ciento, respectivamente; asimismo, el valor predictivo positivo fue de 35.7 por ciento, mientras que el valor predictivo negativo fue de 79.1 por ciento. Los pacientes con diagnóstico de dengue por DEN-2 con la prueba de torniquete positivo tuvieron el doble de posibilidad de sufrir de sangrado espontáneo que aquellos con resultado negativo a la prueba, OR igual 2.1; IC 95 por ciento: 1.1-3.9. Conclusión: La prueba de torniquete no es confiable para indicar fragilidad capilar y no debería utilizarse de manera definitiva para clasificar al paciente que requiere hospitalización por DEN-2.

Objective: To determine the significance of the tourniquet test as predictive of spontaneous bleeding in classic dengue fever patients in an DEN-2 virus outbreak. Materials and methods: A casecontrol study on 267 patients at the Dengue Unit of the Monseñor Sanabria Hospital in Puntarenas, diagnosed as classic dengue fever, between July 1999 and June 2002, during the Central Pacific Area DEN-2 virus outbreak. There were a total of 61 patients with spontaneous bleeding (cases) and 181 controls. The predictive ability of the tourniquet test, the odds ratio and the etiologic fraction were assessed using a 2x2 table, using the spontaneous bleeding condition as golden standard. Results: Sensitivity and specificity of the positive tourniquet were 41.0% and 75.1%, respectively; besides, the predictive positive value was 35.7% while the predictive negative value was 79.1%. Patients diagnosed with dengue by DEN-2 virus, with a tourniquet positive test had two times the chance of spontaneous bleeding than those with a negative test (OR= 2.1, 95% IC: 1.1-3.9). Conclusion: The tourniquet test is not reliable to predict capillary fragility; hence it should not be used to classify patients that require hospitalization in cases of dengue fever caused by DEN-2 virus.

Estudio prospectivo de erradicación de helicobacter pylori en ulcerosos duodenales: análisis de biopsias de antro y cuerpo gástrico / Prospective study of helicobacter pylori erradication in duodenal ulcer patients: analysis of antral and gastric body biopsies

Omeprazole may not eradicate helicobacter pylori from the stomach but rather displace it from the antrum to the stomach body. This fact could interfere with colonization studies in patients receiving the drug. The aim of this study was to assess the presence of helicobacter pylori, defined as a positive wrease test, culture or microscopical examination, in antral and gastric body biopsies in patients receiving treatment with omeprazole. Sixty four paired antral and gastric body biopsies obtained at the end of a 28 day course of omeprazole, 62 obtained 4 months later, 40 obtained 8 months later and 23 obtained 12 months later were analized. there was a 92 percent concordance between antral and gastric body biopsies for the presence of helicobacter pylori. However, 9 of the samples obtained at 28 days (14 percent) were negative for H. pylori in the antrum but positive in the gastric body. It is concluded that for early assessment of helicobacter pylori eradication after omeprazole treatment, paired biopsies of antral and gastric body are needed