Enfermedades vasculares del hígado. Guías Clínicas de la Sociedad Catalana de Digestología y de la Asociación Española para el Estudio del Hígado / Vascular diseases of the liver. Clinical Guidelines from the Catalan Society of Digestology and the Spanish Association for the Study of the Liver

Las enfermedades vasculares hepáticas, a pesar de su relativamente baja prevalencia, representan un problema de salud importante en el campo de las enfermedades hepáticas. Una característica común a muchas de estas enfermedades es que pueden causar hipertensión portal, con la elevada morbimortalidad que ello conlleva. Con frecuencia estas enfermedades se diagnostican en pacientes jóvenes y el retraso en su diagnóstico y/o un tratamiento inadecuado pueden reducir de forma importante la esperanza de vida. El presente artículo revisa la evidencia actual en el síndrome de Budd-Chiari, la trombosis venosa portal en pacientes no cirróticos, la hipertensión portal idiopática, el síndrome de obstrucción sinusoidal, las malformaciones vasculares hepáticas en la telangiectasia hemorrágica hereditaria, la trombosis portal en la cirrosis, otras patologías vasculares menos frecuentes como las fístulas arterioportales, así como un apartado sobre el diagnóstico por imagen de las enfermedades vasculares hepáticas y su tratamiento desde el punto de vista hematológico (estudio de la diátesis trombótica y tratamiento anticoagulante). Las recomendaciones se han realizado de acuerdo a los estudios publicados extraídos de Pubmed. La calidad de la evidencia y la intensidad de las recomendaciones fueron graduadas de acuerdo al sistema Grading of Recommendations Assessment Development and Evaluation (GRADE). Cuando no existían evidencias suficientes, las recomendaciones se basaron en la opinión del comité que redactó la guía.

Despite their relatively low prevalence, vascular diseases of the liver represent a significant health problem in the field of liver disease. A common characteristic shared by many such diseases is their propensity to cause portal hypertension together with increased morbidity and mortality. These diseases are often diagnosed in young patients and their delayed diagnosis and/or inappropriate treatment can greatly reduce life expectancy. This article reviews the current body of evidence concerning Budd-Chiari syndrome, non-cirrhotic portal vein thrombosis, idiopathic portal hypertension, sinusoidal obstruction syndrome, hepatic vascular malformations in hereditary haemorrhagic telangiectasia, cirrhotic portal vein thrombosis and other rarer vascular diseases including arterioportal fistulas. It also includes a section on the diagnostic imaging of vascular diseases of the liver and their treatment from a haematological standpoint (study of thrombotic diathesis and anticoagulation therapy). All recommendations are based on published studies extracted from PubMed. The quality of evidence and strength of recommendations were rated in accordance with the GRADE system (Grading of Recommendations, Assessment Development and Evaluation). In the absence of sufficient evidence, recommendations were based on the opinion of the committee that produced the guide.

Visual hallucinations in patients with acute stroke: a prospective exploratory study.

BACKGROUND AND PURPOSE: The incidence, underlying physiopathology, features and association with lesion topography of visual hallucinations in acute stroke have scarcely been investigated. METHODS: Patients with a diagnosis of acute stroke (ischaemic or haemorrhagic) in any vascular territory, admitted within 24 h after the onset of symptoms, were consecutively included in the study. Patients with a previous history of psychosis or cognitive impairment were excluded. They and/or their caregivers answered a structured hallucination and sleep questionnaire at admission, within the first 15 days and at the clinical follow-up 3-6 months after discharge. Lesion location (IMAIOS online atlas) and leukoaraiosis (Wahlund scale) were determined by magnetic resonance imaging or computed tomography scan. Subsets of patients also underwent a neuropsychological evaluation (N = 50) and an electroencephalogram (N = 33) before discharge. RESULTS: In all, 77 patients with a mean age of 71 ± 12 years were included of whom 57.1% were men. The incidence of visual hallucinations was 16.7%. These hallucinations were mostly complex, in black and white and self-limited. The appearance of hallucinations was not influenced by age, sex, neuropsychological performance during admission or modified Rankin scale score at discharge. Visual hallucinations were associated with occipital cortex lesions (P = 0.04), and with sleep disturbances during and before admission (P = 0.041 and P = 0.03 respectively). CONCLUSIONS: Visual hallucinations are relatively frequent in patients with acute stroke and they are self-limited. Patients with occipital lesions and sleep disturbances are more likely to suffer them.

Severe anaemia related to oseltamivir during treatment of chronic hepatitis C: a new drug interaction?

Treatment for hepatitis C virus is often complicated by anaemia from ribavirin-related haemolysis and bone marrow suppression because of peginterferon alfa. An extensive literature search revealed no reports of drug interactions between ribavirin and oseltamivir. We report the case of a patient with chronic hepatitis C infection who developed severe anaemia during antiviral treatment with peginterferon alfa/ribavirin when oseltamivir was added to treat influenza. The adverse events related to ribavirin and drug-drug interactions during therapy for hepatitis C are discussed.

Hyperkalemic distal renal tubular acidosis caused by immunosuppressant treatment with tacrolimus in a liver transplant patient: case report.

Nephrotoxicity is one of the most common side effects of long-term immunosuppressive therapy with calcineurin inhibitors. We describe a case of distal renal tubular acidosis secondary to tacrolimus administration. A 43-year-old man with end-stage liver disease due to hepatitis C and B virus infections and alcoholic cirrhosis received a liver transplantation under immunosuppressive treatment with tacrolimus and mycophenolate mofetil. In the postoperative period, the patient developed hyperkalemic hyperchloremic metabolic acidosis, with a normal serum anion gap and a positive urinary anion gap, suggesting distal renal tubular acidosis. We excluded other causes of hyperkalemia. Administration of intravenous bicarbonate, loop diuretics, and oral resin exchanger corrected the acidosis and potassium levels. Distal renal tubular acidosis is one of several types of nephrotoxicity induced by tacrolimus treatment, resulting from inhibition of potassium secretion in the collecting duct. Treatment to correct the acidosis and hyperkalemia should be promptly initiated, and the tacrolimus dose adjusted when possible.

Insuficiencia hepática por enfermedad hepática crónica agudizada / No disponible

No disponible

[Opinion of university professors on the suitability of specific primary care training in medical students]. / Opinión de los profesores universitarios acerca de la conveniencia de una formación específica sobre atención primaria en los alumnos de medicina.

OBJECTIVE: To find the opinion of teachers at the University of Alicante about the appropriateness of a Primary Care Theory-Practice programme within the Medicine curriculum. DESIGN: A descriptive observation study of a crossover nature. SETTING: Teachers of the Departments of Medicine and Public Health who had had contact with the Primary Care Theory-Practice programme. PARTICIPANTS: 44 out of 71 teachers (62%) replied. INTERVENTION: An 11-question survey was answered anonymously between October 1993 and June 1994. MEASUREMENTS AND MAIN RESULTS: 77.3% (95% Confidence Interval 64.9-89.7%) considered appropriate the theoretical content at undergraduate level, where there was an average 18.5 hours teaching (C.I. 15.8-21.2); and 95.5% (C.I.89.4-100%), the practicals at a Health Centre, where there was an average 65.2 hours (C.I. 43.1-87.3) work. 43.9% thought it was appropriate to form a separate subject and 39% favored integrating these themes into other subjects. Theoretical contents would be basically teaching general information about Primary Care; and practical work would be clinical activities. The greatest advantages regarding carrying out practical work in Health Centres were: the student finds pathology more prevalent and learns to provide practical answers. The greatest disadvantages were: the low methodological knowledge and teaching preparation of the Teams. CONCLUSIONS: Those interviewed considered that the teaching at undergraduate level of a Primary Care subject with theoretical-practical content would be useful. The advantages, its contents and some difficulties were noted.

[The benefits of auditing clinical histories. Our experience over 5 years]. / Interés de las auditorías de historias clínicas. Nuestra experiencia en cinco años.

OBJECTIVE: To evaluate how our clinical records (CR) are filled in and to observe the impact of measures taken to correct faults found over a five-year follow-up period. DESIGN: Three descriptive studies (auditing methodologies) on representative samples of CR selected at random. Four quality indicators were fixed: internal communication (i.e. legibility and comprehensibility), external communication, manageability and the quality of the activity at attendances measured by the SOAP. The optimum standards (OS) were agreed by the team (technique of nominal group). SETTING: "Florida" Health Centre, Alicante. PATIENTS AND OTHERS PARTICIPANTS: Periodic team meetings to analyse results and agree activities. In 1986, N of CR = 367; in 1988, 370; and in 1990, 372. MAIN MEASUREMENTS AND RESULTS: During the follow-up period, the filling-in of all the variables, except the address, the test carried out and blood pressure, improved. But the following did not reach the OS: code, affiliation, origin, instruction, habits, allergies, working activity, socio-economic data, age and gender, family/personal background, test carried out, blood pressure and analytical data. The following all reached the OS: legibility, which went up from 88% to 96.5%, comprehensibility from 62 to 75.3%, external communication from 81 to 88.9%, manageability from 53 to 79.6% and SOAP from 62 to 82.5%. CONCLUSIONS: Auditing allows the level of the filling-in of the CR to be measured. Deficiencies which appear to be due to the design of the record itself can be detected. The efficacy of corrective measures to improve records can also be assessed.

[Medicine at the primary care level (optional undergraduate subject at the University of Alicante): 2 years of experience]. / Medicina en atención primaria (asignatura optativa de pregrado en la Universidad de Alicante): dos años de experiencia.

OBJECTIVE: We want to put on record two years' experience of undergraduate teaching of an optional subject, "Medicine at the Primary Care level". This was given to sixth-year students by Family and Community Medicine specialist doctors within the Department of Medicine. DESIGN AND SETTING: A crossover study carried out at the University of Alicante. PARTICIPANTS: In the first year, 73 out of the 102 students making up the complete course took part (71.6%); and in the second year, 33 out of 93 (35.5%). MEASUREMENTS AND MAIN RESULTS: The methodology employed, the teaching staff and the documents handed out were given high marks by the students in both cases; as were the course contents in the second year. Deficiencies were noted in the presentation of practical hypotheses. In the first course the students criticised the lack of certain points, basically the tackling of the more common chronic pathologies, something which was corrected in the second year. The survey identified students' wishes to spend longer on the subject. CONCLUSIONS: The students valued positively the existence of a theoretical content specific to Primary Care Medicine. In particular, they requested to be taught performance patterns for prevalent pathologies and for seminars to be organised around practical hypotheses.