Treatment variability and its relationships to outcomes among patients with Wernicke's encephalopathy: A multicenter retrospective study.

BACKGROUND: Despite guidelines and recommendations, Wernicke's encephalopathy (WE) treatment lacks evidence, leading to clinical practice variability. AIMS: Given the overall lack of information on thiamine use for WE treatment, we analyzed data from a large, well-characterized multicenter sample of patients with WE, examining thiamine dosages; factors associated with the use of different doses, frequencies, and routes; and the influence of differences in thiamine treatment on the outcome. METHODS: This retrospective study was conducted with data from 443 patients from 21 centers obtained from a nationwide registry of the Spanish Society of Internal Medicine (from 2000 to 2012). Discharge codes and Caine criteria were applied for WE diagnosis, and treatment-related (thiamine dosage, frequency, and route of administration) demographic, clinical, and outcome variables were analyzed. RESULTS: We found marked variability in WE treatment and a low rate of high-dose intravenous thiamine administration. Seventy-eight patients out of 373 (20.9%) received > 300mg/day of thiamine as initial dose. Patients fulfilling the Caine criteria or presenting with the classic WE triad more frequently received parenteral treatment. Delayed diagnosis (after 24h hospitalization), the fulfillment of more than two Caine criteria at diagnosis, mental status alterations, and folic acid deficiency were associated significantly with the lack of complete recovery. Malnutrition, reduced consciousness, folic acid deficiency, and the lack of timely thiamine treatment were risk factors for mortality. CONCLUSIONS: Our results clearly show extreme variability in thiamine dosages and routes used in the management of WE. Measures should be implemented to ensure adherence to current guidelines and to correct potential nutritional deficits in patients with alcohol use disorders or other risk factors for WE.

Alcoholic Liver Disease Among Patients with Wernicke Encephalopathy: A Multicenter Observational Study.

BACKGROUND: data regarding the association between Wernicke encephalopathy (WE) and alcoholic liver disease (ALD) are scarce in spite of alcohol consumption being the main risk factor for WE. AIMS: to describe the frequency of ALD in a cohort of patients diagnosed with WE and alcohol use disorders (AUDs) and to compare the characteristics of WE patients with and without ALD. METHODS: we conducted an observational study in 21 centers through a nationwide registry of the Spanish Society of Internal Medicine. WE Caine criteria were applied and demographic, clinical, and outcome variables were analyzed. RESULTS: 434 patients were included in the study, of which 372 were men (85.7%), and the mean age was 55 ± 11.8 years. ALD was present in 162 (37.3%) patients and we found a higher percentage of cases with tremor, flapping and hallucinations in the ALD group. A total of 22 patients (5.0%) died during admission (7.4% with ALD vs 3.7% without ALD; P = 0.087). Among the ALD patients, a relationship between mortality and the presence of anemia (Odds ratio [OR]=4.6 Confidence interval [CI]95% 1.1-18.8; P = 0.034), low level of consciousness (OR=4.9 CI95% 1.1-21.2; P = 0.031) and previous diagnosis of cancer (OR=10.3 CI95% 1.8-59.5; P = 0.009) was detected. Complete recovery was achieved by 27 patients with ALD (17.8%) and 71 (27.8%) without ALD (P = 0.030). CONCLUSION: the association of WE and ALD in patients with AUDs is frequent and potentially linked to differences in clinical presentation and to poorer prognosis, as compared to alcoholic patients with WE without ALD.

Role of microRNAs in alcohol-induced liver disorders and non-alcoholic fatty liver disease.

MicroRNAs (miRNAs) are small non-coding RNAs that regulate multiple physiological and pathological functions through the modulation of gene expression at the post-transcriptional level. Accumulating evidence has established a role for miRNAs in the development and pathogenesis of liver disease. Specifically, a large number of studies have assessed the role of miRNAs in alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD), two diseases that share common underlying mechanisms and pathological characteristics. The purpose of the current review is to summarize and update the body of literature investigating the role of miRNAs in liver disease. In addition, the potential use of miRNAs as biomarkers and/or therapeutic targets is discussed. Among all miRNAs analyzed, miR-34a, miR-122 and miR-155 are most involved in the pathogenesis of NAFLD. Of note, these three miRNAs have also been implicated in ALD, reinforcing a common disease mechanism between these two entities and the pleiotropic effects of specific miRNAs. Currently, no single miRNA or panel of miRNAs has been identified for the detection of, or staging of ALD or NAFLD. While promising results have been shown in murine models, no therapeutic based-miRNA agents have been developed for use in humans with liver disease.

Compliance with current VTE prophylaxis guidelines and risk factors linked to complications of VTE prophylaxis in medical inpatients: a prospective cohort study in a Spanish internal medicine department.

OBJECTIVES: To evaluate the degree of compliance with the current guidelines regarding venous thromboembolism (VTE) prophylaxis in medical patients during admission and to identify risk factors linked to complications of VTE prophylaxis. DESIGN: Prospective cohort study. SETTING: The Internal Medicine Department of the University Hospital of Santiago de Compostela (tertiary referral hospital). PARTICIPANTS: A total of 396 hospitalised, elderly patients who did not undergo surgery and had no active or previous oral anticoagulation or low molecular weight heparin (LMWH) treatment (during the previous year) and who received VTE prophylaxis during admission. PRIMARY AND SECONDARY OUTCOME MEASURES: The degree of compliance with the current guidelines was estimated by calculating PADOVA and IMPROVE indexes in all cases. We analysed the development of the following complications: major and minor bleeding, major and minor haematoma and decrease of platelet count. RESULTS: We found that VTE prophylaxis was correctly indicated in 88.4% of patients. We found two (0.5%) cases with major bleeding, 17 (4.3%) with minor bleeding, 30 (7.6%) with decreased platelet count, 29 (7.3%) with major haematoma and 82 (20.7%) with minor haematoma. After multivariate logistic regression analysis, the presence of major haematomas was linked to obesity (OR 4.1; 95% CI 1.8 to 9.2, p=0.001), concomitant antiplatelet treatment (OR 2.7; 95% CI 1.1 to 6.5, p=0.03) and enoxaparin use (OR 3.5; 95% CI 1.1 to 10.9, p=0.029), and the presence of minor haematomas was associated with PADOVA index <4 points (OR 3.1; 95% CI 1.5 to 6.4, p=0.003) and diabetes mellitus (OR 2; 95% CI 1.1 to 3.7, p=0.031). CONCLUSIONS: Complications during VTE prophylaxis in elderly hospitalised medical patients are frequent even with correct application of current guidelines. The main factors linked to haematomas were obesity and concomitant antiplatelet treatment, the presence of which should lead physicians to exercise extreme caution. The use of tinzaparin for VTE prophylaxis in these patients could have a better safety profile.

Differences Between Alcoholic and Nonalcoholic Patients With Wernicke Encephalopathy: A Multicenter Observational Study.

OBJECTIVE: To analyze the differences in characteristics and prognosis between alcoholic and nonalcoholic patients with Wernicke encephalopathy (WE). PATIENTS AND METHODS: A retrospective observational cohort of 468 patients diagnosed with WE with at least 2 Caine criteria was selected from all patients discharged with a diagnosis of WE from 21 medical centers in Spain from January 1, 2000, through December 31, 2012. Demographic, clinical, and outcome variables were described. RESULTS: Among the 468 patients, the most common risk factor was alcoholism (n=434 [92.7%]). More than one-third of patients (n=181 [38.7%]) had the classic WE triad of symptoms (ocular signs, cerebellar dysfunction, and confusion). Among 252 patients for whom magnetic resonance imaging data were available, 135 (53.6%) had WE-related lesions and 42 (16.7%) had cerebellar lesions. Of the 468 patients, 25 (5.3%) died during hospitalization. Alcoholic patients presented more frequently than nonalcoholic patients with cerebellar signs (P=.01) but less frequently with ocular signs (P=.02). Alcoholic patients had a significantly higher frequency of hyponatremia (P=.04) and decreased platelet count (P=.005) compared with nonalcoholics. Alcoholic patients were diagnosed earlier than nonalcoholics (median time to diagnosis, 1 vs 4 days; P=.001) and had shorter hospitalizations (13 vs 23 days; P=.002). CONCLUSION: Compared with nonalcoholic patients, alcoholic patients with WE are more likely to present with cerebellar signs and less likely to have ocular signs. Diagnosis may be delayed in nonalcoholic patients. Mortality in the present series was lower than described previously.

Alcoholic liver disease and hepatitis C virus infection.

Alcohol consumption and hepatitis C virus (HCV) infection have a synergic hepatotoxic effect, and the coexistence of these factors increases the risk of advanced liver disease. The main mechanisms of this effect are increased viral replication and altered immune response, although genetic predisposition may also play an important role. Traditionally, HCV prevalence has been considered to be higher (up to 50%) in alcoholic patients than in the general population. However, the presence of advanced alcoholic liver disease (ALD) or intravenous drug use (IDU) may have confounded the results of previous studies, and the real prevalence of HCV infection in alcoholic patients without ALD or prior IDU has been shown to be lower. Due to the toxic combined effect of HCV and alcohol, patients with HCV infection should be screened for excessive ethanol intake. Patients starting treatment for HCV infection should be specifically advised to stop or reduce alcohol consumption because of its potential impact on treatment efficacy and adherence and may benefit from additional support during antiviral therapy. This recommendation might be extended to all currently recommended drugs for HCV treatment. Patients with alcohol dependence and HCV infection, can be treated with acamprosate, nalmefene, topiramate, and disulfiram, although baclofen is the only drug specifically tested for this purpose in patients with ALD and/or HCV infection.

Pylephlebitis: Incidence and prognosis in a tertiary hospital / Pileflefitis: incidencia y prognosis en un hospital terciario

OBJECTIVES: Septic thrombophlebitis of the portal vein or its branches, most often secondary to intra-abdominal infection is known as pylephlebitis. The frequency and the prognosis of this complication are unknown. The aim of this study was to determine the global and relative incidence of the most frequent intra-abdominal infections and the real prognosis of this disease. Methods An observational retrospective study was conducted in a tertiary care hospital (University Hospital of Salamanca, Spain) from January 1999 to December 2008.ResultsA total of 7796 patients with intra-abdominal infection were evaluated, of whom 13 (0.6%) had been diagnosed with pylephlebitis. Diverticulitis was the most frequent underlying process, followed by biliary infection. Early mortality was 23%. Survivors had no recurrences, but one of them developed portal cavernomatosis. Conclusions Pylephlebitis is a rare complication of intra-abdominal infection, with a high early mortality, but with a good prognosis for survivors

OBJETIVOS: La tromboflebitis séptica de la vena porta o de sus ramas se conoce como pileflebitis. En la mayoría de ocasiones es secundaria a infecciones intraabdominales. La frecuencia y el pronóstico deesta complicación infecciosa no son conocidas. El objetivo de este estudio es describir la incidenciaglobal, relativa y el pronóstico real de esta enfermedad respecto a las infecciones intraabdominales más frecuentes. MÉTODOS: Estudio observacional retrospectivo en un hospital de tercer nivel (Hospital Universitario de Salamanca) desde enero de 1999 a diciembre de 2008.RESULTADOS: Se evaluó a 7.796 pacientes con infecciones intraabdominales. Trece (0,6%) fueron diagnosticados de pileflebitis. La diverticulitis fue el proceso subyacente más frecuente, seguida de la infección biliar. La mortalidad precoz fue del 23%. Los pacientes que sobrevivieron no presentaron recurrencias, pero uno de ellos desarrolló una cavernomatosis portal. CONCLUSIONES: La pileflebitis es una complicación poco frecuente de las infecciones intraabdominales. Presenta una elevada mortalidad precoz, pero tiene un buen pronóstico vital para los pacientes que sobreviven

Pylephlebitis: incidence and prognosis in a tertiary hospital.

OBJECTIVES: Septic thrombophlebitis of the portal vein or its branches, most often secondary to intra-abdominal infection is known as pylephlebitis. The frequency and the prognosis of this complication are unknown. The aim of this study was to determine the global and relative incidence of the most frequent intra-abdominal infections and the real prognosis of this disease. METHODS: An observational retrospective study was conducted in a tertiary care hospital (University Hospital of Salamanca, Spain) from January 1999 to December 2008. RESULTS: A total of 7796 patients with intra-abdominal infection were evaluated, of whom 13 (0.6%) had been diagnosed with pylephlebitis. Diverticulitis was the most frequent underlying process, followed by biliary infection. Early mortality was 23%. Survivors had no recurrences, but one of them developed portal cavernomatosis. CONCLUSIONS: Pylephlebitis is a rare complication of intra-abdominal infection, with a high early mortality, but with a good prognosis for survivors.

Safety of the combined use of praziquantel and albendazole in the treatment of human hydatid disease.

There is still no well-established consensus about the clinical management of hydatidosis. Currently, surgery continues to be the first therapeutic option, although treatment with anti-parasitic drugs is indicated as an adjuvant to surgery to decrease the number of relapses and hydatid cyst size. When surgery is not possible, medical treatment is indicated. Traditionally, albendazole was used in monotherapy as the standard treatment. However, combined therapy with albendazole plus praziquantel appears to improve anti-parasitic effectiveness. To date, no safety studies focusing on such combined therapy have been published for the treatment of hydatidosis. In this work, we analyze the adverse effects seen in 57 patients diagnosed with hydatidosis who were treated with praziquantel plus albendazole combined therapy between 2006 and 2010.

Study of hydatidosis-attributed mortality in endemic area.

BACKGROUND: Cystic hydatid disease is still an important health problem in European Mediterranean areas. In spite of being traditionally considered as a "benign" pathology, cystic echinococcosis is an important cause of morbidity in these areas. Nevertheless, there are few analyses of mortality attributed to human hydatidosis. OBJECTIVE: To describe the epidemiology, the mortality rate and the causes of mortality due to E. granulosus infection in an endemic area. METHODOLOGY: A retrospective study followed up over a period of 14 years (1998-2011). PRINCIPAL FINDINGS: Of the 567 patients diagnosed with hydatid disease over the period 1998-2011, eleven deaths directly related to hydatid disease complications were recorded. Ten patients (90.9%) died due to infectious complications and the remaining one (9.1%) died due to mechanical complications after a massive hemoptysis. We registered a case fatality rate of 1.94% and a mortality rate of 3.1 per 100.000 inhabitants. CONCLUSIONS: Hydatidosis is still a frequent parasitic disease that causes a considerable mortality. The main causes of mortality in patients with hydatidosis are complications related to the rupture of CE cysts with supurative collangitis. Therefore, an expectant management can be dangerous and it must be only employed in well-selected patients.

Fever of unknown origin as the first manifestation of colonic pathology.

Fever of unknown origin (FUO) is an entity caused by more than 200 diseases. Haematologic neoplasms are the most common malignant cause of FUO. Fever as a first symptom of colonic tumour pathology, both benign and malignant, is a rare form of presentation. Our work is a descriptive study of a series of 23 patients with colonic tumoral pathology who presented with fever of unknown origin. The mean age was 67.6 years; 56.5% of patients were men and 43.5% were women. Primary malignant neoplasia was the most common diagnosis. Blood cultures were positive in 45% of the samples. Coagulase-negative staphylococci were the most common cause of bacteraemia. Nine of 10 faecal occult blood tests performed were positive. Fever secondary to colon neoplasms, both benign and malignant, usually presents with a bacteraemic pattern, with positive results for blood-culture tests in a high percentage of cases.

Cavitary pneumonia and skin lesions.

Tularemia is a worldwide zoonosis caused by Francisella tularensis. The most frequent forms of tularemia are ulceroglandular, followed by typhoidal forms, glandular, and oculoglandular. Respiratory involvement is an uncommon presentation. Cutaneous lesions secondary to respiratory infections occur in 30% of cases. We present a case of tularemia with cavitary pneumonia and skin lesions.

Spontaneous pneumothorax in Wegener's granulomatosis: case report and literature review.

BACKGROUND: Pulmonary manifestations of Wegener's granulomatosis (WG) are present in 45% of cases at the onset of the disease, and they reach 85% of the patients during its evolution. Pulmonary affection usually starts with unspecific symptoms such as cough, dyspnea, hemoptysis, and pleuritis. Pulmonary nodules are 1 of the most common manifestations. The prevalence of pleural affection is 10 to 20%. However, spontaneous pneumothorax is extremely rare. Although its real incidence is unknown, according to different classic series, it ranges between 3 and 5% of the cases. OBJECTIVE: To present a new case of spontaneous pneumothorax in a patient suffering WG and a brief review on this subject. METHODS: We report our experience in a case of spontaneous pneumothorax due to WG. We also review the literature through a PubMed search between 1960 and 2010, using a broad range of keywords related to WG and spontaneous pneumothorax. Publications were evaluated for the demographic features of patients, manifestations of the disease, and outcome. RESULTS: Despite the large prevalence of the respiratory involvement, spontaneous pneumothorax is extremely rare, with only 21 cases reported in the literature. CONCLUSION: Pneumothorax is a rare complication in WG cases, without a clear pathogenic mechanism involved.