Utilidad de la monitorización transcutánea de CO2 durante el registro polisomnográfico en una unidad de sueño / The usefulness of transcutaneous monitoring of CO2 during a sleep study in the sleep disorder unit

Los trastornos respiratorios del sueño son frecuentes en la población general y generan un alto consumo de recursos por ingresos, consultas y uso crónico de las terapias ventilatorias. La medición de CO2 transcutánea (tcCO2 ) ha mostrado buena correlación con la presión arterial de CO2 (PCO2 ) y es superior al pulsioxímetro para detectar hipoventilación. Su uso está poco extendido en nuestro medio. Nuestro objetivo fue valorar su utilidad en estudios de sueño basales y en titulaciones de CPAP y BIPAP, aplicadas a pacientes con síndrome de apneas del sueño (SAHS) y síndrome de obesidad-hipoventilación (SOH). Usamos el medidor tcCO2 en polisomnografías (PSG) basales de pacientes con sospecha de patología respiratoria del sueño y en titulaciones de CPAP o BIPAP de pacientes ya diagnosticados. Se realizaron 102 estudios a 89 pacientes. Hubo 45 estudios basales, 21 titulaciones de CPAP y 34 de BIPAP. La patología más frecuente fue el SAHS. La presión media de las titulaciones de CPAP fue de 9,6 cmH2 O. En las titulaciones de BIPAP la IPAP media fue de 15,7 y la EPAP media de 7,4. El índice de desaturación (IDH) medio fue de 27. La SpO2 media fue de 91,8% y el CT90 del 22,9%. La tcCO2 media fue de 45,6 y la máxima de 49,2. No hubo efectos secundarios a la monitorización tcCO2 . Conclusiones: observamos hipercapnia latente en muchos pacientes y el medidor fue bien tolerado. Creemos que la monitorización tcCO2 puede ser útil como método no invasivo para detectar hipoventilación, aun con cifras normales de SpO2

The transcutaneous CO2 (tcCO2 ) monitoring has demonstrated a good correlation with the arterial CO2 value, and is better than pulsioxymeter for to detect hypoventilation episodes. The tcCO2 monitoring is not routine in our environment. The aim of our study was to evaluate the utility of tcCO2 monitoring in our sleep unit, in basal studies and in non invasive ventilation settings. We performed a prospective study. We measured the tcCO2 values in basal polisomnografies (PSG) and in CPAP or BIPAP settings in patients with diagnosis of OSAS, obesity-hypoventilation Syndrome and COPD. We included 102 studies in 89 patients. There were 45 basal studies, 21 CPAP settings and 34 BIPAP settings. The most frequent pathology was OSAS. The mean pressure in CPAP settings was 9.6 H2 Ocm, while in BIPAP settings the mean IPAP was 15.7 and the mean EPAP was 7.4. The mean desaturation index was 27, the mean peripheral O2 value was 91.8%, and the mean cumuled time under 90% (CT90) of O2 peripheral saturation was 22.9%. The mean tcCO2 was 45.6 and the maximum was 49.2. Conclusions: tcCO2 monitoring is a non invasive method for to detect hypoventilation episodes in patients with sleep pathology and in non invasive ventilation settings, although the peripheral oxygen saturation remains in normal values

Enfermedad poliquística hepática / Polycystic liver disease

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[Splanchnic hemodynamic effects of somatostatin and octreotide in cirrhotic patients. A Doppler ultrasonographic study]. / Efecto hemodinámico esplácnico de somatostatina y octreótido en cirróticos. Estudio con ultrasonografía Doppler.

AIM: Doppler-ultrasound assessment of the splanchnic hemodynamic effects of intravenous somatostatin and octreotide administration. MATERIAL AND METHOD: Forty-five cirrhotic patients with esophageal varices were randomized to receive 1-hour intravenous somatostatin (SOM, 250 mg), octreotide (OCT, 50 mg), or placebo (PLA). In baseline and at 15, 30, 45 and 60 minutes of infusion, mean velocity, congestion index, flow volume and diameter of the portal vein, as well as the superior mesenteric artery resistivity index, were measured. Plasma bradykinine and vasoactive intestinal peptide (VIP) concentrations were also measured at baseline and at 30 and 60 minutes. RESULTS: While placebo caused no changes in any of the venous and arterial parameters, SOM and OCT caused a sustained decrease in portal vein velocity (-19.41 vs. -11.19%) and flow (-22.79 vs. -12.33%), and an increase in the congestion index (+17.5 vs. +7.5%) and resistivity index of the superior mesenteric artery (+7.18 vs. +6.16%) with respect to baseline (p < 0.05). These changes were already evident at 15 minutes and remained unchanged during the time of the study period. With respect to OCT, SOM caused a higher reduction in mean velocity and flow of the portal vein, with no significant differences for congestion index and mesenteric artery resistivity index, both increased by SOM and OCT. Plasma bradykinine and VIP concentrations remained unchanged in the three groups. CONCLUSIONS: At therapeutic doses, intravenous somatostatin and octreotide reduce portal vein velocity and flow, and increase portal vein congestion index and superior mesenteric artery resistivity index. Somatostatin causes a higher portal flow reduction than octreotide in spite of a similar splanchnic arterial effect.

Granulocitoaféresis en la enfermedad inflamatoria intestinal. Eficacia a 32 semanas con protocolo de inducción y sesiones de mantenimiento / Granulocytapheresis in inflammatory bowel disease. Efficacy of an induction plus maintenance sessions protocol at 32 weeks

Introducción: la granulocitoaféresis (GCAF) retira de la circulacióngranulocitos-monocitos activados, modificando el pool circulantee induciendo una reducción en la inflamación intestinal.Objetivo: valorar la eficacia de la GCAF en la enfermedad inflamatoriaintestinal (EII) mediante sesiones de inducción y mantenimiento.Material y método: análisis retrospectivo en pacientes conEII activa corticodependiente y corticorrefractaria. Aplicamos 5sesiones de inducción en colitis ulcerosa (CU) y 7 en enfermedadde Crohn (EC) y 1 sesión mensual hasta semana 32. Evaluamosindices clínicos de actividad y empleo de corticoides.Resultados: incluimos a 18 pacientes (10 CU, 8 EC), 10 deellos corticodependientes y 8 corticorrefractarios. Catorce pacienteseran refractarios y 4 intolerantes a inmunosupresores (IS). No completaronla inducción 2-CU (brotes graves) y 1-EC (secundarismos).Abandonaron el mantenimiento 1-CU y 3-EC. De aquellos quecompletaron inducción alcanzaron respuesta o remisión el 87,5%de las CU (2 y 5 pacientes), y el 71,4% de EC (1 y 4 pacientes) respectivamente.Estos resultados a 32 semanas eran del 75% en CU(3 y 3 pacientes) y del 42,8% en EC (1 y 2 pacientes) respectivamente.De los que completaron la inducción, suprimieron corticoidesel 14,2% de EC por el 62,5% de CU (25% de estas en remisióny 37,5% en respuesta). Registramos 2 secundarismos graves (tromboflebitisy síncope). Ninguna CU que completó inducción sufrió colectomíatras 97,6 (72-128) semanas de seguimiento.Conclusiones: tanto CU como EC responden bien a induccióncon GCAF pero mientras la CU mantiene tras 32 semanastasas similares de respuesta-remisión (87,5 vs. 75%) casi 1/3 delos pacientes con EC recaen tras alcanzar respuesta. La granulocitoaféresises una alternativa de tratamiento para inducir y mantenerremision en CU, ahorrando corticoides, pero en la EC se precisauna adecuada selección de pacientes y un esquema demantenimiento aún por definir

Introduction: granulocytapheresis (GCAP) eliminates activatedgranulocytes-monocytes from peripheral blood, thus modifyingthe circulating pool of leukocytes and reducing intestinal inflammation.Objective: tto evaluate the efficacy of GCAP in inflammatorybowel disease (IBD) using an induction and maintenance protocol.Material and method: a retrospective study including patientswith active corticosteroid-dependent or refractory IBD. Inductionincluded 5 sessions in ulcerative colitis (UC) and 7 sessionsin Crohn´s disease (CD); one monthly session was usedthereafter until week 32. Clinical activity indices and use of corticosteroidswere monitored.Results: eighteen patients were included (10 with UC, 8 withCD), 10 of them dependent on and 8 refractory to corticosteroids.Fourteen of them were refractory and a further 4 were intolerantto immunosuppressants (IS). Induction was not completedin 2 UC (severe relapses) and 1 CD (side-effects) patients. OneUC and 3 CD patients withdrew during maintenance. Among patientswho completed induction, response or remission wasachieved in 87.5% of UC cases (2 and 5 patients) and 71.4% ofCD cases (1 and 4 patients), respectively. At week 32 responseremissionrates reached 75% in CU (3 and 3 patients) and 42.8%in CD (1 and 2 patients) cases, respectively. Corticosteroid withdrawalwas possible in 14.2% of CD and in 62.5% of UC patients(25% in remission and 37.5% with response). There were twomajor side effects (thrombophlebitis and syncope). No colectomieswere performed for UC patients who completed GCAP inductionafter a mean follow-up of 97.6 weeks (range: 72-128).Conclusions: both UC and CD respond well to GCAP induction.At 32 weeks UC patients maintain similar response-remissionrates (87.5 vs. 75%), whereas almost one-third of CD patientsloose response. Granolocytapheresis is an alternative,steroid-sparing treatment modality to induce and maintain remissionin UC, while good patient selection and a maintenance protocolnot well defined yet are needed for CD (AU)

Intrahepatic arteriovenous fistula resulting from needle biopsy

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Hematemesis y vómitos persistentes en paciente anticoagulada / Hematemesis and persistent vomiting in an anticoagulated patient

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Abdomen agudo en la enfermedad celiaca: yeyunoileítis ulcerativa / Acute abdomen in celiac disease: Ulcerative jejunoileitis

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Esclerosis hepatoportal, una causa infrecuente de hipertensión portal / Hepatoportal sclerosis, an unfrequent cause of portal hypertension

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[Granulocytapheresis in inflammatory bowel disease. Efficacy of an induction plus maintenance sessions protocol at 32 weeks]. / Granulocitoaféresis en la enfermedad inflamatoria intestinal. Eficacia a 32 semanas con protocolo de inducción y sesiones de mantenimiento.

INTRODUCTION: Granulocytapheresis (GCAP) eliminates activated granulocytes-monocytes from peripheral blood, thus modifying the circulating pool of leukocytes and reducing intestinal inflammation. OBJECTIVE: To evaluate the efficacy of GCAP in inflammatory bowel disease (IBD) using an induction and maintenance protocol. MATERIAL AND METHOD: A retrospective study including patients with active corticosteroid-dependent or refractory IBD. Induction included 5 sessions in ulcerative colitis (UC) and 7 sessions in Crohn's disease (CD); one monthly session was used thereafter until week 32. Clinical activity indices and use of corticosteroids were monitored. RESULTS: Eighteen patients were included (10 with UC, 8 with CD), 10 of them dependent on and 8 refractory to corticosteroids. Fourteen of them were refractory and a further 4 were intolerant to immunosuppressants (IS). Induction was not completed in 2 UC (severe relapses) and 1 CD (side-effects) patients. One UC and 3 CD patients withdrew during maintenance. Among patients who completed induction, response or remission was achieved in 87.5% of UC cases (2 and 5 patients) and 71.4% of CD cases (1 and 4 patients), respectively. At week 32 response-remission rates reached 75% in CU (3 and 3 patients) and 42.8% in CD (1 and 2 patients) cases, respectively. Corticosteroid withdrawal was possible in 14.2% of CD and in 62.5% of UC patients (25% in remission and 37.5% with response). There were two major side effects (thrombophlebitis and syncope). No colectomies were performed for UC patients who completed GCAP induction after a mean follow-up of 97.6 weeks (range: 72-128). CONCLUSIONS: both UC and CD respond well to GCAP induction. At 32 weeks UC patients maintain similar response-remission rates (87.5 vs. 75%), whereas almost one-third of CD patients lose response. Granolocytapheresis is an alternative, steroid-sparing treatment modality to induce and maintain remission in UC, while good patient selection and a maintenance protocol not well defined yet are needed for CD.

[Liver biopsy in patients with chronic hepatitis C virus infection: experience in a district hospital]. / Biopsia hepática en pacientes con infección crónica por el VHC: experiencia de un hospital comarcal.

INTRODUCTION: Liver biopsy is a highly useful tool in the evaluation of patients with chronic hepatitis C. However, the technique is not free of complications and presents a series of limitations (lack of representativity and interobserver variability in sample interpretation). Due to these limitations and the development of new noninvasive techniques, the role of liver biopsy is currently being reevaluated. MATERIAL AND METHOD: We performed a descriptive retrospective study of liver biopsies performed in patients with chronic hepatitis C virus (HCV) infection from January 2002 to January 2005. Age, gender, genotype, histology of the hepatic cylinder, and the percentage of patients who received treatment after liver biopsy was analyzed. The indications for biopsy in our patients and the reasons for nontreatment after biopsy were identified. We also analyzed whether the decision to start treatment was influenced by the histological grade of the lesion and whether there is any association between histological grade and transaminase levels. RESULTS: A total of 156 patients were included and 72% received treatment after biopsy. Transaminase levels were elevated in 86%. Alanine aminotransferase (ALT) levels were elevated in 92.30% of treated patients and in 66% of untreated patients. The most frequent cause of nontreatment after biopsy was fibrosis stage < 2. The histological results were as follows: G0 in 2%, G1 in 26.8%, G2 in 47.7%, G3 in 22.2% and G4 in 1.3%; stage of fibrosis was F0 in 7.2%, F1 in 30.1%, F2 in 37.9%, F3 in 19.6%, and F4 in 5.2%. Fibrosis was advanced (F >= 2) in 41% of the patients with normal ALT levels and was mild (< F2) in 33% of those with elevated ALT levels. CONCLUSION: Liver biopsy could be useful in patients with indication for treatment but a high risk of treatment-related adverse effects, as well as in those with normal transaminase levels, in whom the degree of fibrosis observed could influence the therapeutic approach.