Bayesian heterogeneity in a meta-analysis with two studies and binary data.

The meta-analysis of two trials is valuable in many practical situations, such as studies of rare and/or orphan diseases focussed on a single intervention. In this context, additional concerns, like small sample size and/or heterogeneity in the results obtained, might make standard frequentist and Bayesian techniques inappropriate. In a meta-analysis, moreover, the presence of between-sample heterogeneity adds model uncertainty, which must be taken into consideration when drawing inferences. We suggest that the most appropriate way to measure this heterogeneity is by clustering the samples and then determining the posterior probability of the cluster models. The meta-inference is obtained as a mixture of all the meta-inferences for the cluster models, where the mixing distribution is the posterior model probability. We present a simple two-component form of Bayesian model averaging that is unaffected by characteristics such as small study size or zero-cell counts, and which is capable of incorporating uncertainties into the estimation process. Illustrative examples are given and analysed, using real sparse binomial data.

Colonic adenosquamous carcinoma and mucinous adenocarcinoma with microsatellite instability.

A 43-year-old man presented with two-month history of fatigue, weakness, paleness, rectal bleeding, sweating, and weight loss of 10 kg in the past one month. A complete blood count revealed anaemia. The patient underwent a right hemicolectomy. The microscopic examination revealed an adenosquamous carcinoma associated with a mucinous adenocarcinoma in a patient with microsatellite instability due to loss of MLH1 and PMS2 expression and retention of MSH2 and MSH6 expression in both the squamous and glandular components. We also observed an atypical immunohistochemical phenotype in the adenocarcinoma component showing CK7 expression and reduced CK20 and CDX2 expression.

Role of primary care in the follow-up of patients with obstructive sleep apnoea undergoing CPAP treatment: a randomised controlled trial.

OBJECTIVE: To evaluate whether follow-up of patients with obstructive sleep apnoea (OSA) undergoing CPAP treatment could be performed in primary care (PC) settings. DESIGN: Non-inferiority, randomised, prospective controlled study. SETTINGS: Sleep unit (SU) at the University Hospital and in 8 PC units in Lleida, Spain. PARTICIPANTS: Patients with OSA were randomised to be followed up at the SU or PC units over a 6-month period. MAIN OUTCOMES MEASURED: The primary outcome was CPAP compliance at 6 months. The secondary outcomes were Epworth Sleep Scale (ESS) score, EuroQoL, patient satisfaction, body mass index (BMI), blood pressure and cost-effectiveness. RESULTS: We included 101 patients in PC ((mean±SD) apnoea-hypopnoea index (AHI) 50.8±22.9/h, age 56.2±11 years, 74% male) and 109 in the SU (AHI 51.4±24.4/h, age 55.8±11 years, 77% male)). The CPAP compliance was (mean (95% CI) 4.94 (4.47 to 5.5) vs 5.23 (4.79 to 5.66) h, p=0.18) in PC and SU groups, respectively. In the SU group, there were greater improvements in ESS scores (mean change 1.79, 95% CI +0.05 to +3.53, p=0.04) and patient satisfaction (-1.49, 95% CI -2.22 to -0.76); there was a significant mean difference in BMI between the groups (0.57, 95% CI +0.01 to +1.13, p=0.04). In the PC setting, there was a cost saving of 60%, with similar effectiveness, as well as a decrease in systolic blood pressure (-5.32; 95% CI -10.91 to +0.28, p=0.06). CONCLUSIONS: For patients with OSA, treatment provided in a PC setting did not result in worse CPAP compliance compared with a specialist model and was shown to be a cost-effective alternative. TRIAL REGISTRATION NUMBER: Clinical Trials NCT01918449.

Objective Bayesian meta-analysis for sparse discrete data.

This paper presents a Bayesian model for meta-analysis of sparse discrete binomial data, which are out of the scope of the usual hierarchical normal random-effect models. Treatment effectiveness data are often of this type. The crucial linking distribution between the effectiveness conditional on the healthcare center and the unconditional effectiveness is constructed from specific bivariate classes of distributions with given marginals. This assures coherency between the marginal and conditional prior distributions utilized in the analysis. Further, we impose a bivariate class of priors that is able to accommodate a wide range of heterogeneity degrees between the multicenter clinical trials involved. Applications to real multicenter data are given and compared with previous meta-analysis.

Importancia de una unidad de cirugía mayor ambulatoria en la formación del residente de cirugía general: experiencia en el Hospital General Universitario de Elche / No disponible

Introducción: La cirugía mayor ambulatoria o cirugía sin ingreso permite, en pacientes seleccionados, realizar un tratamiento quirúrgico eficaz, eficiente y seguro sin la necesidad de ingreso hospitalario. Material y método: El Hospital General Universitario de El checuenta con una unidad de cirugía sin ingreso, con 2 quirófanos propios, y un total de 10 sesiones mensuales destinadas al servicio de cirugía general. En dichos quirófanos se realizan intervenciones de pared abdominal, proctología y patología mamaría benigna. Nuestros residentes tienen establecida una rotación continua durante todos los años de la especialidad. Describimos el tipo y número de intervenciones en las que ha participado cada residente, como cirujano o ayudante, comparando los resultados con los mínimos establecidos en el programa de la especialidad durante el periodo2005-2010.Resultados: Durante el periodo a estudio, el total de intervenciones en las que participaron los residentes fue de 3905 (media de154,41 intervenciones por año y residente). De estas intervenciones el 15% como segundo ayudante, el 35% como primer ayudante y el restante 50% como cirujano principal. Discusión: La participación de los residentes en las actividades de cirugía mayor ambulatoria debe estar presente en los programas de formación de los médicos en formación. Estamos ante una parte importante de la cirugía moderna, y como tal, debe ser igualmente parte importante en la formación del futuro cirujano (AU)

Patients and method: The University General Hospital of Elchehas a unit of major ambulatory surgery, 2 own operating rooms, and a total of 10 monthly meetings destined for the general surgery service. In the above mentioned operating rooms there are realized interventions of abdominal wall, proctology and benign breast pathology. Our residents have a constant rotation established during every year of the specialty. We describe the type and number of interventions in which, every resident, has taken part, as surgeon or assistant, comparing the results with the minimums established in the program of the specialty during the period2005-2010.Results: During the period to study, the total of interventions in which the residents took part was of 3905 (average of 154,41 interventions per year and resident). Of these interventions, 15 % like the second assistant, 35 % like the first assistant and the remaining50 % like principal surgeon. Discussion: The participation of the residents in ambulatory surgery activities must be present in the programs of formation of the doctors in formation. We are before an important report of the modern surgery, and as such, it is necessary to be equally an important part in the formation of the future surgeon (AU)

Posterior polymorphous dystrophy associated with nonkeratoconic steep corneal curvatures.

PURPOSE: To report a case series of eyes with posterior polymorphous corneal dystrophy and steep nonkeratoconic corneas. METHODS: Retrospective, descriptive, nonrandomized case series. RESULTS: Thirty-five eyes of 18 patients (14 cases from 6 families and 4 isolated cases) with diffuse posterior polymorphous corneal dystrophy had mean topographic simulated keratometry readings of 52.21 diopters (D), with a range of 46.47 D to 59.86 D and an SD of 3.69 D, with no slit-lamp or topographic findings suggestive of keratoconus. CONCLUSIONS: The patients in this series demonstrate diffuse posterior polymorphous corneal dystrophy and nonkeratoconic steep corneas.

Pla 1 1 and Ole e 1 pollen allergens share common epitopes and similar ultrastructural localization.

BACKGROUND: English plantain (Plantago lanceolata L.) and olive (Olea europaea L.) pollens are important causes of pollinosis in large areas of North America, Australia, and the Mediterranean basin. The major pollen allergens of both plants, Pla I 1 and Ole e 1, share 38.7% of their amino acid sequences. OBJECTIVE: To analyze putative cross-reactivity between these 2 proteins. METHODS: Several antibodies and patients' sera were used in immunoblot and immunocytochemistry experiments. RESULTS: Two anti-Pla I 1 antibodies were able to bind to 3 polypeptides from olive pollen protein extracts, which correspond to the 3 glycosylation isoforms of Ole e 1 (18-22 kDa) previously described. Moreover, Pla I 1 protein was found in the cytoplasm of both the vegetative and the generative cells of P lanceolata mature pollen. On olive pollen sections, these anti-Pla I 1 antibodies displayed significant labeling in the cytoplasm of the vegetative cell and in both the exine and the material adhering to this outer layer of the pollen wall. In addition, the anti-Ole e 1 antibody 10H1 was found to cross-react with proteins of similar masses (16-20 kDa) to Pla I 1 variants. In Plantago pollen sections, the 10H1 antibody recognized proteins located in the cytoplasm of both the vegetative and generative cells. Cross-reaction was confirmed using sera from patients allergic to either plant pollen. CONCLUSION: Both allergens share common epitopes, which can be cross-recognized by different antibodies and sera from different patients, although this antigenic similarity seems to have little clinical relevance.

Neuromodulación de raíces sacras como tratamiento de la incontinencia fecal. Resultados preliminares / Sacral root neuromodulation as treatment for fecal incontinence. Preliminary results

Presentamos nuestra experiencia inicial en el tratamiento de laincontinencia fecal (IF) mediante neuromodulación de raíces sacras(NRS), a través de los resultados de un estudio prospectivo realizadocon 26 pacientes en el que se comparan los valores basales enla escala de continencia de Wexner-Cleveland y en la capacidadpara el retraso de la defecación, con los obtenidos tras un año deterapia con NRS. El estudio inicial de cada paciente incluía anamnesis,exploración general, ecografía y manometría rectal, así comounos diarios de continencia y de calidad de vida específicos para laIF de 3 semanas. Antes de la terapia con NRS, el valor medio en laescala Wexner-Cleveland fue de 15,00 ± 1,81 y el 62,50% de lospacientes tenía una capacidad de retraso de la defecación menorde 1 minuto. Tras un año de terapia con NRS, el valor medio en laescala de Wexner-Cleveland fue de 4,87 ± 2,54 (p = 0,0031) y el75,01% de los pacientes presentaba una capacidad de retraso defecatoriomayor de 15 minutos (p = 0,0018). Hacemos, además,una descripción detalla de la técnica quirúrgica de la NRS, haciendoreferencia a sus indicaciones y finalizamos revisando las distintasopciones terapéuticas para la IF mostrando nuestro algoritmo terapéuticopara esta patología. La NRS es una técnica eficaz para eltratamiento de la IF en pacientes seleccionados que no han respondidoa tratamiento conservador, biofeedback o correcciones anatómicas(esfinteroplastia), con una mínima morbilidad y susceptible derealizarse en un programa de cirugía ambulatoria

We present our initial experience in the treatment of fecal incontinence (FI) with sacral root neuromodulation (SRN) by reporting the results of a prospective study with 26 patients where baselineWexner-Cleveland scale scores and ability to delay defecationwere compard to results after one year with SRN. The initial studyof patients included history taking, general examination, anal ultrasonography,and manometry, and a three-week diary of continenceand quality of life specific for FI was used. Before SRN themean baseline Wexner-Cleveland score was 15.00 ± 1.81, and62.50% of patients could only delay defecation for less than aminute. After a year with NRS the mean Wexner-Cleveland scorewas 4.87 ± 2.54 (p = 0.0031), and 75.01% of patients could delaydefecation above fifteen minutes (p = 0.0018). We also describethe surgical technique and its indications, and finally reviewthe various therapeutical options for FI and show our algorithmfor this condition. SRN is an effective technique for the treatmentof FI in properly selected patients with no response to medicaltherapies (including biofeedback) or anatomic correction (sphincteroplasty),with efficacy, little morbidity, and a short hospital stay

[Sacral root neuromodulation as treatment for fecal incontinence. Preliminary results]. / Neuromodulación de raíces sacras como tratamiento de la incontinencia fecal. Resultados preliminares.

We present our initial experience in the treatment of fecal incontinence (FI) with sacral root neuromodulation (SRN) by reporting the results of a prospective study with 26 patients where baseline Wexner-Cleveland scale scores and ability to delay defecation were compared to results after one year with SRN. The initial study of patients included history taking, general examination, anal ultrasonography, and manometry, and a three-week diary of continence and quality of life specific for FI was used. Before SRN the mean baseline Wexner-Cleveland score was 15.00 +/- 1.81, and 62.50% of patients could only delay defecation for less than a minute. After a year with NRS the mean Wexner-Cleveland score was 4.87 +/- 2.54 (p = 0.0031), and 75.01% of patients could delay defecation above fifteen minutes (p = 0.0018). We also describe the surgical technique and its indications, and finally review the various therapeutical options for FI and show our algorithm for this condition. SRN is an effective technique for the treatment of FI in properly selected patients with no response to medical therapies (including biofeedback) or anatomic correction (sphincteroplasty), with efficacy, little morbidity, and a short hospital stay.

[Treatment of proctalgia fugax with botulinum toxin: results in 5 patients]. / Tratamiento de la proctalgia fugax con toxina botulínica: resultados en 5 pacientes.

INTRODUCTION: Proctalgia fugax can be defined as transitory but recurrent anal pain. Although its etiology remains unknown, an internal anal sphincter spasm seems to be the most likely, so that the different treatments focus on reducing the pressure of the internal anal sphincter. This study is aimed at evaluating the effectiveness of botulinum A toxin in the treatment of proctalgia fugax. PATIENTS AND METHODS: Prospective clinical trial of patients with proctalgia fugax treated with botulinum A toxin at the Outpatient Clinic attached to the Coloproctogy Unit, University Hospital of Elche, from January 1999 to January 2002. The patients included in the study underwent rectal digital examination, anuscopy, rectoscopy, anal manometry and ultrasonography, barium enema and pelvic CT scan to rule out any organic cause for anal pain. The treatment consisted of 25 IU of botulinum A toxin, with a supplementary dose of 50 IU in those patients with persistence of anal pain episodes within the next two months. The patients were reviewed on the first week, second month, sixth month and first and second year. Anal pain was measured by the patients, using a linear analogue scale from 0 to 10, and continence was assessed at every visit using the Cleveland Continence Grading Scale. RESULTS: Five patients were recluted for the study, with a predominance of females (4 vs. 1). Mean age was 45 years. Length of symptoms prior to the treatment was 13 months (range: 6-18 months). Only one female patient required a second dose of botulinum A toxin to handle the anal pain. All the patients healed and remained free of pain up to finishing the follow-up. There were no local complications. Anal manometry showed an increased MRP (mean resting pressure) in comparison to a control group of patients (114 mmHg vs. 66 mmHg; p < 0.001) that restore to normal values after the treatment (75.65 mmHg). As for the MSP (mean squeeze pressure), it showed no difference with respect to the control group nor did it vary after the treatment. CONCLUSION: Botulinum A toxin offers a high rate of healing with no associate morbidity in the treatment of proctalgia fugax.

Tratamiento de la proctalgia fugax con toxina botulínica: resultados en 5 pacientes / Treatment of proctalgia fugax with botulinum toxin: results in 5 patients

Introducción. La proctalgia fugax es un dolor pasajero en la región anal cuya etiología no está clara, siendo la más defendida el espasmo del esfínter anal interno. Así, están indicados tratamientos que inducen una relajación del esfínter. El objetivo de este trabajo ha sido evaluar la eficacia de la toxina botulínica como tratamiento de la proctalgia fugax. Material y métodos. Estudio prospectivo de pacientes diagnosticados de proctalgia fugax en la consulta de Coloproctología del Servicio de Cirugía General y del Aparato Digestivo del Hospital General Universitario de Elche desde enero de 1999 a enero de 2002. A todos los pacientes se les realizó una exploración física, tacto rectal, anuscopia, rectoscopia, enema opaco, ecografía endoanal, manometría anal y tomografía computarizada (TC) pélvica para descartar cualquier tipo de patología orgánica. Como tratamiento se realizaron infiltraciones con 25 U de toxina botulínica y se reinyectaron 50 U más a aquellos pacientes en los que al segundo mes persistía la proctalgia. Se revisó a la primera semana, al segundo mes, sexto mes, al año y al segundo año. El dolor fue evaluado mediante escala visual analógica de 0 a 10. La continencia se determinó con el Cleveland Score Incontinence. Resultados. Se incluyeron 5 pacientes (4 mujeres y un hombre). La edad media fue de 45 años. La duración de los síntomas previa al tratamiento fue de 13 meses (rango: 6-18 meses). Sólo una paciente requirió una segunda dosis de toxina botulínica, desapareciendo el dolor tras esta segunda infiltración. Todos los pacientes curaron, manteniéndose sin dolor al final del seguimiento. No hubo complicaciones locales. Los hallazgos manométricos mostraron un incremento en la presión máxima basal (PMB) en comparación con el grupo control (114 mmHg frente a 66 mmHg; p < 0,001), recuperándose a valores normales tras el tratamiento (75,65 mmHg). La presión máxima de contracción voluntaria (PMCV) no mostró diferencias con respecto a los valores del grupo control tanto previo al tratamiento como en el seguimiento. Conclusión. La toxina botulínica puede ser considerada como una potencial terapia para la proctalgia fugax dada la alta tasa de curación con mínima morbilidad

Introduction. Proctalgia fugax can be defined as transitory but recurrent anal pain. Although its etiology remains unknown, an internal anal sphincter spasm seems to be the most likely, so that the different treatments focus on reducing the pressure of the internal anal sphincter. This study is aimed at evaluating the effectiveness of botulinum A toxin in the treatment of proctalgia fugax. Patients and methods. Prospective clinical trial of patients with proctalgia fugax treated with botulinum A toxin at the Outpatient Clinic attached to the Coloproctogy Unit, University Hospital of Elche, from January 1999 to January 2002. The patients included in the study underwent rectal digital examination, anuscopy, rectoscopy, anal manometry and ultrasonography, barium enema and pelvic CT scan to rule out any organic cause for anal pain. The treatment consisted of 25 IU of botulinum A toxin, with a supplementary dose of 50 IU in those patients with persistence of anal pain episodes within the next two months. The patients were reviewed on the first week, second month, sixth month and first and second year. Anal pain was measured by the patients, using a linear analogue scale from 0 to 10, and continence was assessed at every visit using the Cleveland Continence Grading Scale. Results. Five patients were recluted for the study, with a predominance of females (4 vs. 1). Mean age was 45 years. Length of symptoms prior to the treatment was 13 months (range: 6-18 months). Only one female patient required a second dose of botulinum A toxin to handle the anal pain. All the patients healed and remained free of pain up to finishing the follow-up. There were no local complications. Anal manometry showed an increased MRP (mean resting pressure) in comparison to a control group of patients (114 mmHg vs. 66 mmHg; p < 0.001) that restore to normal values after the treatment (75.65 mmHg). As for the MSP (mean squeeze pressure), it showed no difference with respect to the control group nor did it vary after the treatment. Conclusion. Botulinum A toxin offers a high rate of healing with no associate morbidity in the treatment of proctalgia fugax

Utilidad de las prótesis autoexpandibles recubiertas en la enfermedad benigna gastroesofágica / Utility of covered self-expanding prostheses in benign gastroesophageal disease

No disponible

Uso de pegamento y clips metálicos para el sellado endoscópico de perforación gástrica yatrógena / Use of glue and metal clips for endoscopic sealing of iatrogenic gastric perforation

No disponible

Bacteriemia por Campylobacter jejuni asociada a pancreatitis aguda / Campylobacter jejuni bacteriemia associated with acute pancreatitis

No disponible

1,3-beta-glucanases as candidates in latex-pollen-vegetable food cross-reactivity.

BACKGROUND: 1,3-beta-glucanases (group 2 of pathogenesis-related proteins) are enzymes widely distributed among higher plants and have been recently proven to be significant allergens. OBJECTIVE: The aim of this work was to study the potential implication of 1,3-beta-glucanases in cross-reactivities among latex, pollen and vegetable foods. METHODS: The cDNA encoding the N-terminal domain (NtD) of Ole e 9, a major allergenic 1,3-beta-glucanase from olive pollen, was amplified by polymerase chain reaction and produced as a recombinant protein in Pichia pastoris (recombinant N-terminal domain, rNtD). Circular dichroism, ELISA, immunoblotting and immunoblotting inhibition experiments were carried out. Sera from olive pollen allergic patients and a rNtD-specific polyclonal antiserum were used. RESULTS: The NtD of Ole e 9 has been produced at high yield in the yeast P. pastoris and possesses 1,3-beta-glucanase activity. The expressed polypeptide conserves IgE and IgG immunodominant epitopes of the whole Ole e 9. A rNtD-specific polyclonal antiserum and sera from olive pollen allergic patients allowed detection of IgG and IgE reactive peptidic epitopes common to 1,3-beta-glucanase Ole e 9 in extracts from ash and birch pollen, tomato, potato, bell-pepper, banana and latex. CONCLUSION: rNtD and homologous glucanases are new molecules to be used in diagnostic protocols as they could help to identify allergic pollen patients who are at risk for developing allergic symptoms to fruits, vegetables and latex.

Using covariates to reduce uncertainty in the economic evaluation of clinical trial data.

As part of their practice, policymakers have to make economic evaluations using clinical trial data. Recent interest has been expressed in determining how cost-effectiveness analysis can be undertaken in a regression framework. In this respect, published research basically provides a general method for prognostic factor adjustment in the presence of imbalance, emphasizing sub-group analysis. In this paper, we present an alternative method from a Bayesian approach. We propose the use of covariates in Bayesian health technology assessment in order to reduce uncertainty about the effect of treatments. We show its advantages by comparison with another published method that do not adjust for covariates using simulated data.