Subclinical synovitis impact on the progression of lupus joint disease: A 10-year longitudinal multicenter study.

OBJECTIVE: To determine the effect of subclinical synovitis on the progression of joint disease in a cohort of patients with systemic lupus erythematosus over a mean follow-up of 10 years. METHODS: A longitudinal follow-up of 96 patients diagnosed with lupus was performed. All patients were considered clinically free of joint disease or with minimal joint impairment at baseline and were studied through ultrasound study of their dominant hand to assess the prevalence of subclinical synovitis. Now, over 10 years after we contacted them and reviewed their evolution to determine the impact of had or had not been diagnosed with subclinical synovitis in their current joint condition. RESULTS: Thirty-one of the 91 reached patients developed clinical progression in their joint manifestations (at least one ordinal degree of worsening). Of these, 23 (74,9%) had demonstrated subclinical synovitis at baseline. In the group of patients who did not progress clinically, 46 (76,6%) did not have this finding at the start of follow-up (p < .01, OR 9,44 95%CI 3,46-25,74). The patients in whom clinical progression was demonstrated had worse combined ultrasound scores than the rest of the patients: 6,41 SD 1,45 vs. 1,15 SD 0,97 (p < .01). CONCLUSIONS: The finding of subclinical synovitis in patients with systemic lupus erythematosus is associated with the development of joint disease progression both clinically and ultrasonographically.

HLA-Cw6 allele and biologic therapy are protective factors against liver fibrosis in psoriatic arthritis patients.

OBJECTIVES: To evaluate the association between liver fibrosis and the HLACw6 allele in psoriatic arthritis (PsA) patients. METHODS: A retrospective longitudinal study involving PsA patients with determination of the HLA-Cw6 allele was performed. Liver fibrosis was estimated by using the FIB-4 (fibrosis-4) score. A multivariate logistic model was undertaken to assess the odds ratio (OR), with its 95% confidence interval, of liver fibrosis after adjustment for potential confounding factors. RESULTS: A total of 209 PsA patients were included: 25.3% HLA-Cw6 were positive, 59.8% were receiving biological disease-modifying anti-rheumatic drugs (bDMARDs), 29.6% had arterial hypertension (AHT), 24% dyslipidaemia, and 4.2% acute myocardial infarction (AMI). The HLA-Cw6 allele was more frequent in PsA patients with normal FIB-4 values (p=0.024), as opposed to AHT (p=0.002), AMI (p=0.023) and dyslipidaemia (p=0.030), which were found more frequently in subjects with altered FIB-4 values. The presence HLA-Cw6 and the use of bDMARDs were confirmed as protective factors against liver fibrosis (OR 0.210, 0.062-0.707, p=0.012 and OR 0.397, 0.166-0.949, p=0.038, respectively). Conversely, AHT emerged as a risk factor (OR 2.973, 1.125-7.858, p=0.028). CONCLUSIONS: In PsA, the HLA-Cw6 allele and bDMARDs behave as protective factors for liver fibrosis, while AHT is an independent risk factor.

Epidemiology and clinical characteristics of psoriatic arthritis-related uveitis in Madrid, Spain.

PURPOSE: To describe the epidemiology and clinical characteristics of psoriatic arthritis (PsA) related uveitis in Madrid, Spain. METHODS: A case series nested in a retrospective single-center cohort of 494 patients with PsA was performed. Patients older than 18 years old whit a clinical diagnosis PsA-related uveitis who attended the Ramon y Cajal University Hospital in Madrid, Spain, between 1st January 2017 and 31st December 2019 were included in the study. Epidemiological and clinical data were retrieved from the electronic medical records. RESULTS: Thirteen cases of psoriatic arthritis-related uveitis (6 men and 7 women) were included. PsA-related uveitis showed an incidence of 0.05 cases per 100,000 persons/year (CI95 0.00-0.35), and a prevalence of 2.19 cases per 100,000 persons (CI95 1.24-3.79). The prevalence of active uveitis in the cohort of PsA patients was 2.6%. The first episode of uveitis (mean age of 48.15 ± 15.41 years) was anterior and unilateral in 92.31% of the cases. Most of the patients had a recurrent course (69.2%) with 0.92 flare-ups per patient/year (CI95 0.85-0.96). The uveitis preceded the diagnosis of psoriatic arthritis in 62.5% of the patients. In patients with PsA-related uveitis, HLA-B27 was present in 23.1%, HLA-Cw6 in 7.7%. CONCLUSIONS: Uveitis is a PsA manifestation that affects roughly 1 in 37 PsA patients, and that may precede the articular symptoms. It generally presents as a unilateral acute anterior uveitis and has a recurrent course. The most frequent observed complications are elevated intraocular pressure and cataracts.

Prevalence of subclinical synovitis of the hand in patients with systemic lupus erythematosus.

OBJECTIVES: To determine the prevalence of subclinical synovitis in Lupus patients without peripheral joint symptoms, in those with arthralgias without arthritis and those with episodic arthritis but without radiological structural damage. METHODS: We conducted a multicentre cross-sectional study. Patients with lupus from those three categories were recruited to take part in a greyscale ultrasound scan performed by an expert blinded rheumatologist. Data from a historical control group from a previous study was also included for comparisons. Images were assessed separately in order to determine the presence and level of synovitis following Eular recommendations. RESULTS: Ninety-six patients (88.5% female) with an average age of 40 ± 6.2 years old, were included. SLICC/ACR score was 0.6 ± 0.3 in the group without joint symptoms (group 0), 0.8 ± 0.3 in the group with arthralgias (group I) and 1.1 ± 0.4 in the group with episodic arthritis. The global prevalence of subclinical synovitis was 38.5%. In group 0, that prevalence was 30%. The time since onset of symptoms of patients with subclinical synovitis was longer than the rest of the patients (9.4 ± 2.2 vs 6.5 ± 4.0 years, P < 0.001). No other remarkable association was founded with clinical features of the disease. CONCLUSIONS: This is the first study focused on subclinical synovitis in patients with lupus. Other previous studies had included patients with different levels of arthropathy. Subclinical synovitis does exist in lupus patients in over a third of patients. Its meaning remains unclear and must be a topic of further studies.

Management of non-surgical pneumoperitoneum.

Percutaneous endoscopic gastrostomy (PEG) is the best approach to feeding patients not eligible for oral nutrition who have a functioning digestive system. Pneumoperitoneum after PEG is a relatively common complication. As regards management, the most important decision is whether conservative therapy or an exploratory laparotomy should be indicated. We report the case of a patient with giant pneumoperitoneum following PEG, who was successfully managed with percutaneous air drainage.

Manejo del neumoperitoneo no quirúrgico / Management of non-surgical pneumoperitoneum

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[Pneumoperitoneum due to splenic abscess: a diagnostic challenge. Case Report]. / Neumoperitoneo por absceso esplénico: un reto diagnóstico. Reporte de un caso.

BACKGROUND: Splenic abscess is a rare clinic entity, its incidence has increased due to the rising number of clinical conditions involving immunosuppression. Endocarditis is the most frequent cause, and gram-positive aerobes are the main causal agents. Its clinical presentation is non-specific and delays diagnosis. Computed tomography scan is the method of choice, and the treatment is based on antibiotics and drainage, radiological or surgical, involving splenectomy in special cases that require it. CLINICAL CASE: A 55-year-old man with abdominal pain and fever. The analysis revealed leukocytosis 14,000/mm3, prothrombin activity 53%, and metabolic acidosis. Computed tomography scan showed a peri-hepatic pneumoperitoneum, liquid fluid, and peri-splenic bubbles, and slight trabeculation of fat around the duodenal bulb with pneumoperitoneum in this area. Patient underwent a median laparotomy, finding a purulent peritonitis due to a ruptured abscess in the spleen, splenectomy was performed. Fluid culture showed polymorphonuclears, with no microorganisms identified. The patient progressed and was discharged on the 5th post-operative day. CONCLUSIONS: Splenic abscess is an uncommon condition, in which the diagnosis is delayed and mortality, in untreated patients, is high. Its association with pneumoperitoneum may confuse the diagnosis towards viscera perforation. Thus it must be suspected in the finding of unknown cause of pneumoperitoneum by complementary examinations. The treatment of choice is splenectomy, because the capsular rupture is the norm in all of them.

Acute mediastinitis due to extravasation of parenteral nutritional formula via a central venous catheter.

Mediastinitis is a complication generally associated with thoracic surgery. Its occurrence after placement of a central venous catheter is uncommon, and only a few cases have been reported. An 83-year-old man who had mediastinitis due to extravasation of parenteral nutritional formula via a central venous catheter is presented. The signs and symptoms, diagnosis, and treatment of this unusual complication are described. This complication should be included in the differential diagnosis of mediastinitis in patients with a central venous catheter in place who have not had thoracic surgery.

Enterolitiasis no obstructiva: presentación de 2 casos / Non-obstructive enterolithiasis: Report of two cases

La enterolitiasis o coprolitiasis, cálculos formados primariamente en el intestino, es una rara enfermedad en humanos asociada, generalmente, con estasis intestinal. Es sin embargo muy frecuente en algunos animales como los caballos. Suele cursar sin síntomas en la mayoría de los casos, pero puede presentar oclusión intestinal y debe ser tenida en cuenta como posible causa de la misma. Presentamos 2 casos de enterolitiasis cuyo diagnóstico fue establecido por imágenes de radiografía simple de abdomen y tomografia computarizada (TC). Aunque ambos pacientes presentaban factores favorecedores para enterolitiasis, no se puede descartar un sustrato genético que predisponga al desarrollo de esta infrecuente entidad clínica (AU)

Abstract Enterolithiasis, or coprolithiasis, stones formed mainly in the intestine, is uncommon in humans and is generally associated with intestinal stasis. This entity is highly common in some animals, such as horses. Enterolithiasis is usually asymptomatic but may lead to intestinal occlusion and should be considered as a possible cause of this event. We report two cases of enterolithiasis, in which the diagnosis was established by simple abdominal radiography and computed tomography. Although both patients had factors favoring the development of enterolithiasis, a genetic substrate predisposing them to this uncommon clinical entity cannot be excluded (AU)

[Non-obstructive enterolithiasis: report of two cases]. / Enterolitiasis no obstructiva: presentación de 2 casos.

Enterolithiasis, or coprolithiasis, stones formed mainly in the intestine, is uncommon in humans and is generally associated with intestinal stasis. This entity is highly common in some animals, such as horses. Enterolithiasis is usually asymptomatic but may lead to intestinal occlusion and should be considered as a possible cause of this event. We report two cases of enterolithiasis, in which the diagnosis was established by simple abdominal radiography and computed tomography. Although both patients had factors favoring the development of enterolithiasis, a genetic substrate predisposing them to this uncommon clinical entity cannot be excluded.

BELM: Bayesian extreme learning machine.

The theory of extreme learning machine (ELM) has become very popular on the last few years. ELM is a new approach for learning the parameters of the hidden layers of a multilayer neural network (as the multilayer perceptron or the radial basis function neural network). Its main advantage is the lower computational cost, which is especially relevant when dealing with many patterns defined in a high-dimensional space. This brief proposes a bayesian approach to ELM, which presents some advantages over other approaches: it allows the introduction of a priori knowledge; obtains the confidence intervals (CIs) without the need of applying methods that are computationally intensive, e.g., bootstrap; and presents high generalization capabilities. Bayesian ELM is benchmarked against classical ELM in several artificial and real datasets that are widely used for the evaluation of machine learning algorithms. Achieved results show that the proposed approach produces a competitive accuracy with some additional advantages, namely, automatic production of CIs, reduction of probability of model overfitting, and use of a priori knowledge.

[Laparoscopic cholecystectomy in a patient with situs inversus totalis]. / Colecistectomía laparoscópica en una paciente con situs inversus totalis.

OBJECTIVE: To report a case with situs inversus totalis (SIT) and chronic cholelithiasis solved by laparoscopic surgery, outlining the utility of minimal invasive surgery and specific considerations in patients with anatomic variations. CASE REPORT: A case of a 46 year-old female who presented with a six-month history of abdominal colic pain at the left hypochondrium, accompanied with nausea and vomiting, is presented. On examination she had epigastric tenderness. Blood tests, including liver function tests, were normal. Electrocardiogram showed right axis deviation and right ventricular hypertrophy, in keeping with dextrocardia. Chest-X-Ray confirmed the diagnosis of dextrocardia. An ultrasound scan of the upper abdomen identified the gallbladder containing stones in the left upper quadrant. A CT scan visualized the spleen and the gastric camera in the right upper quadrant. Barium gastrointestinal transit, barium enema and abdominal-X-Ray were used as complementary diagnostic studies. A magnetic resonance cholangiography was not performed because the patient suffered from claustrophobia. Cholecystectomy and transcystic cholangiography were performed by laparoscopic route, taking care to set-up the operating theatre in the mirror image of the normal set-up for cholecystectomy. The patient completed a successful procedure without complications and was discharged 48 hours after the procedure. Histological exam diagnosed a chronic lithiasic cholecystitis. CONCLUSIONS: Laparoscopic cholecystectomy is an adequate surgical procedure for patients with total situs inversus and cholelithiasis, having a high security range. Detailed clinical examination is important for the diagnosis of previously unknown anatomic variations. Transcystic cholangiography is mandatory when a magnetic resonance cholangiography can not be performed. Furthermore, perhaps in this situation a left-handed surgeon is better prepared than a right-handed one to comfortably carry out the procedure.

[Quality assessment and improvement in the indication and management of parenteral nutrition in a general surgery unit]. / Evaluación y mejora de la calidad en la indicación y el manejo de la nutrición parenteral en un servicio de cirugía general.

OBJECTIVE: To analyze the degree of compliance with a variety of internationally accepted standards defined for Total Parenteral Nutrition (TPN) quality control in our Surgery Department. PATIENTS AND METHOD: Prospective study of patients treated with TPN over two years in the department of surgery of a university teaching hospital (n = 72). Assessment of quality was performed by measurements of compliance using 19 criteria. The criteria were divided into three groups according to characteristics of TPN standardisation: this must be "appropriate" to the nutritional requirements of the patient, "safe" in order to prevent complications and "accurate" in its daily programming. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria over six months, paying particular attention to those criteria which had the highest percentage of errors in the study carried out using a Pareto analysis. During a third period of six months the information on all 19 criteria was gathered again and the improvement with regard to the standard values and to the compliance in the first period (using the value of z) was evaluated. RESULTS: The compliance with seven criteria was significantly below standard values: all those of the "appropriate" group, except the criteria "type of diet" and "composition of the diet", and the criteria "absence of complications" of the "safe" group, which was also the one with the highest number of grouped non-compliances. In the second period all the below standard criteria improved with compared to the first period. The criteria "time of fasting", "concordance" and "duration" were significantly improved. The criteria "time of fasting", "duration" and "latency" reached the standard. The rest of criteria that reached their standard in the first evaluation maintained the same results. CONCLUSIONS: Corrective measures introduced were effective since all the below standard criteria improved, including metabolic complications. Notwithstanding, it is necessary to continue in this line to improve the criteria still below standard.

Evaluación y mejora de la calidad en la indicación y el manejo de la nutrición parenteral en un servicio de cirugía general / Quality assessment and improvement in the indication and management of parenteral nutrition in a general surgery unit

Objetivo. Aplicar un ciclo de evaluación y mejora del cumplimiento de diversos criterios de calidad en la indicación y manejo de la nutrición parenteral total (NPT) en un servicio quirúrgico. Pacientes y método. Estudio prospectivo en 72 pacientes tratados con NPT durante 2 años en el Servicio de Cirugía General del Hospital General Universitario Reina Sofía de Murcia. El ciclo de mejora se realizó en dos períodos: en el primero, de 1 año de duración, se analizó el cumplimiento (porcentaje e intervalo de confianza [IC] del 95%) de 19 criterios respecto a sus estándares internacionalmente aceptados (significación estadística según valor de z para el modelo de una cola) en todas las dietas de NPT prescritas en nuestro servicio de cirugía general. Dichos estándares estaban divididos en tres grupos, “ajustada” (indicación correcta de la nutrición), “segura” (ausencia de complicaciones) y “exacta” (correspondencia de la dieta administrada con la prescrita). Durante los 6 meses siguientes, tras analizar las posibles causas de los incumplimientos, se aplicaron las medidas oportunas para intentar solucionarlos. En un segundo periodo de 6 meses se recogieron nuevamente los datos de los 19 criterios y se evaluó la mejora tanto respecto al estándar como respecto al cumplimiento del primer período (mediante el valor de z para una cola). Resultados. Siete criterios se encontraban significativamente por debajo del estándar: todos los del grupo “ajustada”, salvo los criterios “tipo de dieta” y “composición de la dieta”, y el criterio “ausencia de complicaciones” del grupo “segura”, que era además el que mayor número de incumplimientos agrupaba. En el segundo período, todos los criterios por debajo de su estándar mejoraron respecto al primero y en especial los criterios “tiempo de ayuno”, “concordancia” y “duración” mejoraron de forma estadísticamente significativa. Alcanzaron su estándar los criterios “tiempo de ayuno”, “duración” y “latencia”. El resto de los criterios, que alcanzaron su estándar en la primera evaluación, continuaban con los mismos resultados. Conclusiones. Las medidas correctoras introducidas fueron eficaces, ya que se mejoró en todos los criterios por debajo de sus estándares, incluidas las complicaciones metabólicas. A pesar de ello es necesario continuar en la línea de actuación para mejorar los criterios aún por debajo de su estándar The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Objective. To analyze the degree of compliance with a variety of internationally accepted standards defined for Total Parenteral Nutrition (TPN) quality control in our Surgery Department. Patients and method. Prospective study of patients treated with TPN over two years in the department of surgery of a university teaching hospital (n = 72). Assessment of quality was performed by measurements of compliance using 19 criteria. The criteria were divided into three groups according to characteristics of TPN standardisation: this must be “appropriate” to the nutritional requirements of the patient, “safe” in order to prevent complications and “accurate” in its daily programming. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria over six months, paying particular attention to those criteria which had the highest percentage of errors in the study carried out using a Pareto analysis. During a third period of six months the information on all 19 criteria was gathered again and the improvement with regard to the standard values and to the compliance in the first period (using the value of z) was evaluated. Results. The compliance with seven criteria was significantly below standard values: all those of the “appropriate” group, except the criteria “type of diet” and “composition of the diet”, and the criteria “absence of complications” of the “safe” group, which was also the one with the highest numer of grouped non-complinces. In the second period all the below standard criteria improved with compared to the first period. The criteria “time of fasting”, “concordance” and “duration” were significantly improved. The criteria “time of fasting”, “duration” and “latency” reached the standard. The rest of criteria that reached their standard in the first evaluation maintained the same results. Conclusions. Corrective measures introduced were effective since all the below standard criteria improved, including metabolic complications. Notwithstanding, it is necessary to continue in this line to improve the criteria still below standard The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Evaluación y mejora del cumplimiento de la normativa sobre consentimiento informado para la transfusión de hemoderivados en un servicio de cirugía general / Assessment of improvements in compliance with the guidelines on informed consent for the transfusion of blood derivatives in a general surgery department

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